Arterial Hypertension in children

Question 1

Definition

Answer 1

> 140/90 mmHg
SBP and / or DBP> 95th percentile for
age, sex and height at measurements on 3
different occasions.

Question 2

Prehypertension

Answer 2

• SBP or DBP between percentiles 90-95.
• Adolescents with BP 120/80 mm Hg will be considered prehypertension.

Question 3

Indications for ABP measurements
< 3 years – in special cases:

Answer 3

◼ Affections from neonatal period,
◼ Congenital cardiac malformations,
◼ Renal affections or family history of familial renal disease,
◼ Intracranial hypertension,
◼ transplant,
◼ malignancy,
◼ Treatment with drugs that increase the BP,
◼ Other systemic diseases asociated with AHT (neurofibromatosis, tuberose sclerosis, etc).

Question 4

Recommendations of BP
measurement in children

Answer 4

 PREVIOUSLY: -RELAXATION, recreation min 5’.

 NOT: food, drink exciting min 30 min prior

 POSITION: seated with the arm supported at heart level, REST min 5’

 WIDTH cuff
- 40% of the arm length and
80-100% of the circumference

 Stethoscope: a brachial K1 and K5 (appearance and disappearance)

BOTH ARMS
3 measurements x 3.
Attention tachycardia.

Question 5

Anamnesis

Answer 5

 Family history of Essential AH
 History of chronic renal disease, transplant
 Other issues considered risk factors:
- low birth weight,
- malnutrition,
- smoking in adolescents,
- excessive consumption of energy drinks, - sleep apnea syndrome
 Medication: sympathomimetic, oral contraceptives, steroids

 Cocaine

Question 6

Symptomatology

Answer 6

 nonspecific

 headache, vertigo, dizziness,
epistaxis, faintness, visual
disturbances, tinnitus, etc.

Question 7

DGN
PREHYPERTENSION
AH STD I
AH STD II

Answer 7

PREHYPERTENSION - > Measure BP in 6 months

AH STD I - > X 2, in 1-2 weeks
Investigation

AH STD II -> Confirmation in 1 week
Investigation

Question 8

Most common cause of HTN in neonates

Answer 8

1) Thrombosis/stenosis of the renal artery, 2) kidney malformations,
3) Co Ao,
4) bronchopulmonary dysplasia

Question 9

Most common causes of HTN in Infant-6ys

Answer 9

1) renal parenchymal disease,
2) coarctation of the aorta,
3) renal artery stenosis

Question 10

Most common causes of HTN in 6-10 ys

Answer 10

1) renal parenchymal disease,
2) renal artery stenosis,
3) essential HT

Question 11

Most common causes of HTN in Adolescent

Answer 11

1) renal parenchymal disease,
2) essential HT,
3) obesity

Question 12

Renal AHT

Answer 12

 3 - 30% AHT in adult,
and between 1⁄2 - 2/3 in
children, being the most frequent
secondary AHT.
 There are 2 forms:
◼ renoparenchimal AHT
◼ renovascular AHT

Question 13

Renoparenchimal AHT

Answer 13

◼ In acute and chronic nephropathy
◼ There is a
- good corelation between volemy and ABP,
the diminished or absence of the plasmatic renin and high total peripheral resistence.

Question 14

The most frequent renoparenchimal AHT are due to:

Answer 14

 Acute or chronic glomerulonephrites
 Chronic atrophic pielonephrites,
 Renal polycystic disease
 Hydronephrosis
 Wilms and juxtaglomerular cell tumors
(hemangiopericitom)
 Collagen diseases and others

Question 15

Renovascular AHT

Answer 15

 1-2 % in all AHT in adult.
↑in children
 Low renal irigation due to the
- stenosis,
- trombosis,
- oclusion or compresive tumor at the renal artery,
- ↑ plasmatic renin,
- hipovolemy and high neurogen activity.

Question 16

Renovascular AHT in children:

Answer 16

◼ Fibromuscular dysplasia, predominant in female, at the 1/3 median or distal.
◼ In Recklinghausen neurofibromatosis with AH – stenosis due to focal proliferation, predominant intimal, at the renal and intrarenal artery.

Question 17

Endocrine AHT

Answer 17

 Feocromocitoma
 Primary hyperaldosteronism (Conn
disease)
 Suprarenalian enzymatic deficits
 Hipercorticism
 Hiper and hipothyroidism
 Hiperparathyroidism
 Primary reninism

Question 18

Pheochromocytoma

Answer 18

 Neuroectodermal tumor
 With paroxistic high release of
cathecolamines
 In children – more frequent permanent
AHT and not intermittent

Question 19

Variable clinical manifestations of feochromocitoma

Answer 19

◼ norepinefrins,
most frequent- α adrenergic manifestations (SHT,DHT, tahicardia),

◼ epinefrins
- β adrenergic manifestations (SHT, tahicardia, hipermetabolism, hiperglicemia, anxiety, sometimes hypotension)
◼ dopamin, very rare, with normal or even low ABP, tahicardia, diarhea, poliuria and nausea.

Question 20

Aortic coarctation

Answer 20

= variable stenosis
of the aortic arch with the eccentric
lumen.

Question 21

Types of Aortic coarctation

Answer 21

◼ Postductal or adult type, the most
frequent, with tight stenosis under the
arterial channel origin
◼ Preductal or infantil type, between the
subclavicular artery and arterial channel.
This type is frequent associated with
severe cardiovascular anomalies.

Question 22

Investigations

Answer 22

Basic tests:
◼ blood count,
◼ urea and serum
◼ creatinine,
◼ Urine,
◼ ENT examination,
◼ Chest X rays,
◼ ECG
◼ Ophtalmology examination
◼ Metab carbohydrate, lipid,
◼ ionogram serum, and urine possibly
◼ urine culture

Question 23

Investigations
 Specific tests

Answer 23

◼ cardiac ultrasound,
◼ abdominal and renal Doppler aa ultrasound,
◼ arteriography,
◼ Hormonal Dosage:
- thyroid,
plasma renin,
plasma aldosterone,
urinary ionogram,
cortisol levels,
urinary free cortisol,
dexamethasone suppression test,
serum or urinary catecholamine dosage (Vanil mandelic acid),
◼ Computed Tomography

Question 24

Indications for treatment
ST I

Answer 24

 Symptomatic hypertension
 Secondary hypertension
 Hypertension with target organ damage
 Association of type 1 or 2 diabetes

 AH despite persistent non-
pharmacological measures

Question 25

Antihypertensive medication

Answer 25

 Initiation - an antihypertensive at
minimum recommended dose,
preferably angiotensin converting
enzyme inhibitor (ACEI)
 ACEI (captopril, enalapril) - obesity
associated with AH
 Calcium channel blockers
 Thiazides diuretics

Question 26

Antihypertensive medication

Answer 26

 “step-up” therapy
 Associations
 After achieving BP control -
measuring 6 months is a
candidate for “step down”
 Specific treatment

Question 27

Pharmacological treatment (1)

Answer 27

One drug at minimum dose
 β adrenergic non-/selective antagonist
◼ propranolol (1-4 mg/kg/day)
◼ metoprolol (1-6 mg/kg/day)
 IECA - ACEi
◼ captopril,0,3-6 mg/kg/day,
◼ enalapril-0,1-0,5 mg/kg/day,
 Calcium channels blockers
◼ nifedipin SR 0,25-3 mg/kg/day

Question 28

Pharmacological treatment (2)

Answer 28

 Then the “step up” therapy

 In 2 weeks the BP – not controlled
◼ The second antihypertensive drug
 If the second drug is not enough
◼ The third even the fourth drug

 Diuretics can be associated:
- clorotiazid (20-30 mg/kg/day),
- hidroclorotiazid, 1-3 mg/kg/day,
- spironolactone (1-3 mg/kg/day),
- furosemide (0,5-6 mg/kg/dose).

 Other classes of antihypertensive drugs can be used now in children:
- blocker of the angiotensin II receptors,
- losartan (0,7-1,4 mg/kg/day),
- irbesartan

 After stabilization ABP must be measured at 6 months and the „step down” can be tried.

Question 29

Treatment of the emergency
hypertension

Answer 29

 Admitted
 DABP ≥120 mmHg.
 ABP must be reduced with 20-25% in first 8 hours, then ↓ gradualy, in weeks.
 Can be used the 2 ways
◼ parenteral or
◼ oral – calcium channel blockers, nifedipin, 0,2-0,5 mg/kg/dose (10 mg/dose)

 Parenteral:
◼ labetalol, in bolus 0,2-1 mg/kg/dose in 2 minutes or in pev, 0,4-3 mg/kg/h
◼ Associated, if necessary, with sodiu nitroprusate, 0,3-10 μg/kg/min in pev
◼ Others.