Roundtable

Discu s s i o n

Hypertension in Children and Adolescents Marvin Moser, MD; Thomas D. Giles, MD; Bonita Falkner, MD; Allan B. Schwartz, MD; Raymond R. Townsend, MD

Following a hypertension symposium held in Philadelphia, PA, on June 8, 2004, a roundtable discussion was held to discuss the treatment of hypertension in adolescents and children. The participants included Thomas D. Giles, MD, of Louisiana State College of Medicine, New Orleans, LA; Bonita Falkner, MD, of the Department of Medicine and Pediatrics, Thomas Jefferson University, Philadelphia, PA; Allan B. Schwartz, MD, of the Division of Nephrology and Hypertension, Drexel University College of Medicine, Philadelphia, PA; Raymond R. Townsend, MD, of the Department of Medicine, University of Pennsylvania School of Medicine, Philadelphia, PA; and Marvin Moser, MD, of the Department of Medicine/Cardiology, Yale University School of Medicine, New Haven, CT. (J Clin Hypertens. 2005;7:24–30) ©2005 Le Jacq Ltd.

DR. MOSER: Let’s start by asking Dr. Falkner, who chaired the recent committee, to summarize the recommendations of the pediatric task force on the management of hypertension in adolescents and children (National High Blood Pressure Education Program Working Group on High Blood Pressure in Children and Adults). First, Bonnie, it’s a very confusing issue for physicians to look at complicated tables and be told that if someone falls in the 95th or the 99th percentile of a blood pressure range, he or she should be considered hypertensive. Give us an idea, as best you can, of some round blood pressure (BP) numbers that you might consider as elevated in children, for example, an 8-year old, a 10-year old, a 12-year old, and a 14-year old. Roughly, what are the 95th percentile numbers? DR. FALKNER: First, one does not expect physicians to be able to memorize what BP is normal or elevated for a child at a given age or size. The tables are there to guide, just like the height and weight tables. Physicians who take care of children generally use developmental charts with height; weight; body mass index; and, more recently, BPs to assess what’s normal and what’s abnormal. A systolic BP level that would be abnormal for an 8-year-old boy of average height would be ≈116–120 mm Hg systolic. This BP

www.lejacq.com 24

THE JOURNAL OF CLINICAL HYPERTENSION

ID: 3851

level is about the 95th percentile of the normal distribution, which is the top level; this child would need to have BP measurements repeated. DR. MOSER: Would a 10-year old with an 120 mm Hg systolic be considered above the norm? DR. FALKNER: A systolic BP of 120 mm Hg is above the normal range in a 10-year-old boy. The normal distributions of BP increase with age for both boys and girls. At about age 13 in girls, it tends to level off, which is about the time girls reach their maximum stature. With adolescent boys, there continues to be a rise in BP until they reach about 18 or 19 years, which corresponds with the continued linear growth of boys. Within that normal shift in BP, as children grow older and taller, we use the BP level that is at or above the 95th percentile to define high BP. DR. MOSER: Then for girls of 8- or 10-years old, a systolic BP of 120 mm Hg would certainly be considered on the high side. DR. FALKNER: Yes. DR. MOSER: What about an average height and weight 13-year-old boy and a 13-year-old girl? DR. FALKNER: The 95th percentile for systolic BP in a 13-year-old boy of average height is 126 mm Hg. For a 13-year-old girl of average height, the 95th percentile is 124 mm Hg. Throughout adolescence, a girl who has systolic BP measurements that are repeatedly ≥130 mm Hg has hypertension. VOL. VII NO. I JANUARY 2005

The Journal of Clinical Hypertension (ISSN 1524-6175) is published monthly by Le Jacq Ltd., Three Parklands Drive, Darien, CT 06820-3652. Copyright ©2005 by Le Jacq Ltd., All rights reserved. No part of this publication may be reproduced or transmitted in any form or by any means, electronic or mechanical, including photocopy, recording, or any information storage and retrieval system, without permission in writing from the publishers. The opinions and ideas expressed in this publication are those of the authors and do not necessarily reflect those of the Editors or Publisher. For copies in excess of 25 or for commercial purposes, please contact Sarah Howell at [email protected] or 203.656.1711 x106.

DR. MOSER: OK. Are we going to ignore diastolic pressures? DR. FALKNER: We consider them. While some children can have diastolic hypertension, it’s more likely for them to have systolic hypertension. DR. MOSER: Dr. Giles, isn’t it still true that, in younger people, the diastolic pressure has a prognostic value? I know that at over the age of 50 we tend to ignore the diastolic pressure in estimating risk and deciding on therapy, but in younger groups, should we still pay attention to the diastolic pressure? DR. GILES: I think you still need to look at it. It’s probably one of the most poorly measured BP components. But isolated diastolic elevations are not common. DR. MOSER: Then what if we had levels of 120/88 mm Hg in a 10-year-old child? DR. GILES: It would make you wonder. It’s a narrow pulse pressure. You have to start looking at reasons that give you a narrow pulse pressure. Quite honestly, except for cardiac failure and a few other similar entities, it’s not a common finding. What I think we’re going to be stuck with here, and this is why I’m glad that we had an opportunity to chat with Bonnie, is that at some point these children or adolescents are handed off to the family practitioner or the internist, who should have a good idea of what is normal or abnormal BP in the transitional age groups. DR. FALKNER: It’s a key issue, particularly in girls. A systolic pressure of 130 mm Hg is hypertension in girls from ages 13 to about 18. It’s pretty steady at these levels, so a girl with a systolic pressure at 132 mm Hg could switch from hypertension to normotension just by having her 18th birthday because, once she moves past what we consider to be the pediatric age of approximately 18, she’ll flip onto the adult definition, which you know is >140 mm Hg. So you have to ask, what is high BP in young women? DR. MOSER: Bonnie, you’ve had a chance to follow children and adolescents for a number of years. As you’ve seen them change their body habitus, how do you adjust for a normal range of BP in someone who is going through adolescence and adding increased fat or muscle weight? DR. FALKNER: Some, but not all, adolescents will have an increase in BP as they grow heavier or if they become overweight. For these adolescents, the best possible treatment is to get them to lose weight; if that goal is achieved, then the BP will frequently decrease. But not every overweight adolescent has high BP. Some of them can have substantially excess body weight and have a normal BP, so it’s more than

VOL. VII NO. I JANUARY 2005

just weight that causes hypertension. There must be some predisposition to hypertension in individuals who show an increase in BP as they gain weight in excess of what is appropriate for their height. DR. MOSER: Could someone gain weight and have his or her pressure go up and still not exceed the 95th percentile definition? For example, a 14year old with a systolic BP of 100 mm Hg who gains substantial weight in a year or so might now have a BP of 130 mm Hg. Is he still within an acceptable 95th percentile? DR. FALKNER: That kind of increase in BP is more than what is expected within a year of growing older and taller. It would indicate someone who has obesity hypertension, where rapid accrual of excess weight has a pressor effect. DR. GILES: Yes. It’s a good thing to bring up again. Fat per se, independent of all the things associated with visceral fat, in point of fact lowers your BP, so if you’re “hypertensive,” it’s a problem. Whatever it is in that syndrome that predisposes you to an increase in BP, you have that additional factor. Are we talking about a chubby kid with fat around the middle, or are we discussing the metabolic syndrome? DR. FALKNER: It is very hard to be certain about visceral adiposity in children and in adolescents; it’s difficult to make the distinction of total adiposity, as compared with visceral adiposity, in adolescents and to isolate a type of fat and determine whether it’s more toxic than another type of fat. DR. MOSER: Returning to definitions, we can agree that a systolic BP >120 mm Hg is elevated in an 8-year old and probably 120 mm Hg or 125 mm Hg is high in a 10- or 12-year old. Readings >130 mm Hg are considered high in a 13- or 14-year old. Ray, could you give us a range of diastolic pressures? I still can’t forget that we should pay some attention to this in young people, especially in people with renal disease. DR. TOWNSEND: Before I answer that question, could you define which Korotkoff (K) sound you’re using? DR. FALKNER: Since 1996, the pediatric guidelines on BP have used K5 to define diastolic BP in all children. Years ago, K5 was just for adolescents, but now it’s for all children. It is based on a substantial amount of data. In some children, you can hear beats down to near zero. When that happens, you can be certain they do not have diastolic hypertension; it is then reasonable to use K4 to estimate diastolic pressure. DR. MOSER: What about the diastolic? What are the upper limits for children at 8-, 10-, or 12-years old?

THE JOURNAL OF CLINICAL HYPERTENSION

25

The Journal of Clinical Hypertension (ISSN 1524-6175) is published monthly by Le Jacq Ltd., Three Parklands Drive, Darien, CT 06820-3652. Copyright ©2005 by Le Jacq Ltd., All rights reserved. No part of this publication may be reproduced or transmitted in any form or by any means, electronic or mechanical, including photocopy, recording, or any information storage and retrieval system, without permission in writing from the publishers. The opinions and ideas expressed in this publication are those of the authors and do not necessarily reflect those of the Editors or Publisher. For copies in excess of 25 or for commercial purposes, please contact Sarah Howell at [email protected] or 203.656.1711 x106.

DR. FALKNER: A diastolic pressure >78–80 mm Hg is elevated for an 8–10-year old; a diastolic pressure >80 mm Hg is elevated in a 12–14-year old. DR. MOSER: Ray, what would you do about a child of 10 or 11 with a BP of 130/85 mm Hg? Gerald Berenson has collected a great deal of follow-up data, and he is convinced that risk is considerably increased even with this level of BP. DR. TOWNSEND: Some of us are disciples of Arthur Guyton, who believed that ultimately the kidney is the significant contributor to the development of sustained elevated levels of BP. Many of the kids I’ve seen from the renal group have kidney disease, even if their creatinines are still within the normal range. Protecting further loss of kidney function has been one of the main reasons we treat them. DR. MOSER: Do these kids come to you with proteinuria? DR. TOWNSEND: No. DR. MOSER: Or diabetes? DR. TOWNSEND: Sometimes. They don’t usually have renal problems from diabetes. This happens more in the 20s and 30s. They may have an uretero-vesical reflux problem or a congenital aplastic type of kidney disorder, or sometimes just high BP with some renal involvement from a chronic glomerulonephritis. We treat them and typically use a regimen similar to an adult treatment. We use a diuretic, an angiotensin-converting enzyme (ACE) inhibitor, or an angiotensin receptor blocker (ARB) and, if we need it to lower BP, a calcium channel blocker. Most of the kids I’ve seen have an increased body mass index. DR. MOSER: Tom, as a non-nephrologist, let’s assume that you had a referral from a school physician for a 14-year-old kid going out for basketball or baseball with a BP of 135–140/85–90 mm Hg. The school physician has read Dr. Falkner’s report and concluded that the BP is too high. The school decided that they did not want to risk having this kid play basketball. What do you do? What do you tell the parents? I’m going to ask Allan the same question in a minute. DR. GILES: If I see an increased systolic BP in a young person, it means to me that something is probably wrong, particularly with his or her central arterial blood vasculature. You need to consider risk factor modification. Does this kid have lipid problems? If the kid is an athlete, the question is what does he do? If he plays offensive tackle, and he’s 280 lb, it’s one thing; if he’s a lean tennis player who plays singles and doesn’t have a lot of body fat, then it’s something else.

26

THE JOURNAL OF CLINICAL HYPERTENSION

DR. MOSER: Let’s take the two cases. This kid is 6’2”, he obviously grew very quickly, he’s skinny as a rail, and he’s playing basketball. His lipid profile is normal; there is no diabetes in the family. He just has an elevated pressure. His echocardiogram does not suggest a cardiac myopathy. Tell me exactly what you tell him, his coach, and his family. DR. GILES: First, I’d screen him for all of the other comorbidities. DR. MOSER: He doesn’t have any. DR. GILES: I would put him on a treadmill, not to look for ischemic heart disease, but to see what happens with his BP. If his systolic pressure goes >200 mm Hg, I would tell him not to play competitive sports. I probably would delve into his history. Is he on steroids? Does he use any weight-reducing substances? DR. MOSER: No steroids, no substance abuse. DR. GILES: Does he have an elevated homocysteine level? You’ve got to look at all possibilities in a patient this age. Something is wrong with his blood vessels. Is his C-reactive protein normal? DR. MOSER: Homocysteine levels and C-reactive protein are normal. DR. GILES: If you’re telling me that a casual office BP is elevated and he is absolutely normal in everything else, then I’m probably going to put a 24-hour ambulatory BP monitor on him and see what his pressures are outside the office. Maybe the kid doesn’t even have high BP. DR. MOSER: By the way, both his parents had hypertension when they were 35- and 40-years old. DR. GILES: You can’t really diagnose hypertension by casual office BPs. How many times, when we were screening people for the military, did we have them go off in a room to rest and then a corpsman takes their BP and finds that it isn’t high? Maybe some of those people really had hypertension. I wouldn’t say that they didn’t, but clearly these are people that you would take a very careful look at. If this boy is playing competitive sports and he’s having these levels of increase from BP with exercise, I’d be very cautious about letting him participate. DR. MOSER: I’m trying to really pin you down. He’s had six BPs with his physician at school, he has four with you, he takes home a BP cuff and the pressures are a little lower at home, but still above the 95th percentile at 135/85 mm Hg. The kid’s a great athlete, and his parents say he needs to keep playing ball because it’s the only way he’s going to college. Forget the treadmill for a minute. You just have him jump up and down for 10 minutes, and his pressure goes to 180/80 mm Hg. Have you changed your mind about what you would like to do?

VOL. VII NO. I JANUARY 2005

The Journal of Clinical Hypertension (ISSN 1524-6175) is published monthly by Le Jacq Ltd., Three Parklands Drive, Darien, CT 06820-3652. Copyright ©2005 by Le Jacq Ltd., All rights reserved. No part of this publication may be reproduced or transmitted in any form or by any means, electronic or mechanical, including photocopy, recording, or any information storage and retrieval system, without permission in writing from the publishers. The opinions and ideas expressed in this publication are those of the authors and do not necessarily reflect those of the Editors or Publisher. For copies in excess of 25 or for commercial purposes, please contact Sarah Howell at [email protected] or 203.656.1711 x106.

DR. GILES: Well, 180 mm Hg has prognostic significance. It’s better than >200 mm Hg. DR. MOSER: Let’s say it does go to 200 mm Hg. Are you going to let him play basketball? I hate to spend so much time on this, but it is a common problem, especially with teenage boys. DR. GILES: I see a lot of athletes. You’re describing somebody whom I don’t run into too often. This kid is too normal. DR. FALKNER: Actually, in fact, I see a number of these kids too, and what we may forget is how big they are. The school nurses and doctors just have regular adult BP cuffs. They may be unable to take the BP with a cuff that is large enough and may encounter a false reading because the BP cuff is not large enough for a very big adolescent. DR. SCHWARTZ: And some of them are on steroids. DR. FALKNER: At least with a proper cuff you find the BP may not be as high as the readings taken in school. DR. MOSER: What we’re saying is that you want to make sure that you take the BP with a big enough cuff. You want to make certain that the pressure is elevated and not just on a casual one or two readings. It is important to recognize this, but let’s assume that we took all these factors into consideration and we even checked his pressure after 4–5 minutes of playing basketball, for example, and the systolic pressure did go up to 180–200 mm Hg. Are we going to stop him from playing ball? Are we going to treat him? Many times you can’t get anywhere with weight reduction, especially if the sport is football. The kid probably eats pizza and lots of salty foods, so you might influence that aspect of the problem. If he is on steroids or other performance-enhancing substances, then stopping them may help to lower his BP. But what if these efforts aren’t effective? What then? DR. GILES: I would have a very careful look at this kid, and if he really “looks that great,” I would discuss it with the family. It’s a personal decision, and the risk/benefit equation enters. DR. MOSER: Allan, what would you do if he were your brother’s son? DR. SCHWARTZ: My thoughts tend to run in three directions. I want to give an example before I go into it. We actually had a similar situation in Philadelphia a few years ago when a very tall, lean, young man from the Caribbean presented as a prime prospect for one of our local basketball teams as a newly-enrolled freshman. He, in fact, on further evaluation, did have systolic hypertension and, on aortic evaluation, ended up having aortic

VOL. VII NO. I JANUARY 2005

disease. He probably also had Marfan’s syndrome. He was rejected from college basketball and, in fact, lost his scholarship. It was a major disappointment to the coach, who had heavily recruited him. Young people with hypertension should have a thorough evaluation for the etiology of hypertension. DR. MOSER: I think that we all would agree with this. DR. SCHWARTZ: Whenever I see a juvenile or adolescent who’s athletically involved, and we’re sure that his or her repetitive BP readings are high, I always wonder if I am going to miss something that’s genetic. I tend to look for chronic kidney disease, renal artery stenosis, and coarctation of the aorta, and make certain to use an appropriatelysized BP cuff. One of these kids is going to turn out to have an aortic or a renal artery abnormality. If you’re looking for kidney disease, then you’re probably going to see some people with congenital abnormalities, and they’re going to wind up with hypertension as the first detectable problem. DR. MOSER: I’m still looking for an answer. You look at all of the possibilities, and there are no aortic abnormalities. There’s no proteinuria. DR. SCHWARTZ: I want to stress the steroid issue. It is more frequent in wrestlers. They’ve also been known to use tremendous amounts of adrenergic stimulants, such as ordinary cold remedy preparations, to build their level of awareness and their responsiveness. DR. MOSER: No one wants to answer my question. DR. GILES: I’ll answer it for you. It’s just like every other clinical decision. There’s a risk benefit. As a physician, all that you can do is give advice. Now my advice to such an individual is that if he or she is going to make $10 million in the first 4 or 5 years of playing pro sports and then retire, then the benefit may outweigh the risk, however, if you treat the BP, his or her performance ability may decrease. I tend to be cautious about doing anything or giving advice that I think could cause some harm. In the end, it is the parents’ decision if the youngster is an adolescent. DR. SCHWARTZ: If you put the young person on medication because you know that there are long-term benefits to BP reduction, you have to consider whether or not the medication is going to alter the performance of the individual. With health care regulations being what they are today, it may not be the physician’s decision as to whether the patient plays or doesn’t play. The physician’s decision will be whether or not to cooperate with the family in developing a medication program after all of the proper evaluations.

THE JOURNAL OF CLINICAL HYPERTENSION

27

The Journal of Clinical Hypertension (ISSN 1524-6175) is published monthly by Le Jacq Ltd., Three Parklands Drive, Darien, CT 06820-3652. Copyright ©2005 by Le Jacq Ltd., All rights reserved. No part of this publication may be reproduced or transmitted in any form or by any means, electronic or mechanical, including photocopy, recording, or any information storage and retrieval system, without permission in writing from the publishers. The opinions and ideas expressed in this publication are those of the authors and do not necessarily reflect those of the Editors or Publisher. For copies in excess of 25 or for commercial purposes, please contact Sarah Howell at [email protected] or 203.656.1711 x106.

DR. GILES: Let me clarify my position. What I said was it’s a risk benefit for the patient, and he or she needs to decide based on that point because, by any criteria we possess now, with a person with no other risk factors and a systolic BP of 130– 135 mm Hg, nobody has clinical trial data showing that treating with medication is actually going to do anything. We don’t know that answer yet. I rather suspect it would, but I don’t know it yet. DR. MOSER: To summarize at the moment, the feeling I’m getting from at least two of the panelists is that, barring some secondary causes, or some other comorbidities, in a young man who’s healthy, lean, active, and not using steroids or other compounds, with systolic BPs of 130–135 mm Hg or thereabouts, rising to 180, 200 mm Hg on exercise, you would probably advise that person not to involve himself in vigorous sports, such as basketball, or sports that involve isometric pushing and tugging, like football. Is this a reasonable summary? DR. GILES: I think that the competitive nature of sports often makes people push beyond what any reasonable limit would be. DR. MOSER: All right. Ray and Bonnie, your comments, and then let’s try to summarize what some other people might do. As we’ve mentioned, this is a very important problem, and it is not uncommon. Remember, we’re not always looking at high-level performing athletes. Sometimes these are just kids who want to play football, basketball, tennis, or soccer for the fun of it. DR. MOSER: Ray, what would you do? He’s your cousin. DR. TOWNSEND: I’m going to differ. I would treat him with a β blocker, and I’d let him play. DR. MOSER: Okay. Bonnie? You’re the world’s leading expert on pediatric hypertension. What would you do? DR. FALKNER: With a systolic BP ≈130–135 mm Hg, which goes up to ≈180–200 mm Hg on vigorous exercise? DR. MOSER: Right. And we have carried out all of the evaluations that have been mentioned, and they are all within normal limits. DR. FALKNER: The systolic BP of 130–135 mm Hg in an older adolescent is not particularly high. It is not at the level where I would consider treating him with drugs, yet. I would tell him to go play sports, not to gain weight, not to start smoking, and not to become involved in any drugs. I would monitor his BP, and, if it tended to rise further, I would treat with medication. DR. MOSER: Then if it went up to 145–150 mm Hg and to 200 mm Hg on exercise?

28

THE JOURNAL OF CLINICAL HYPERTENSION

DR. FALKNER: That would be different. I would treat his BP, most probably with an ACE or an ARB. DR. MOSER: Not a β blocker, as Ray would do? DR. FALKNER: No. DR. MOSER: Afraid of the decrease in performance? DR. FALKNER: Yes, and I’m afraid he wouldn’t take it if he didn’t like the way he felt or if he was concerned that the medication was effecting his sports performance. DR. MOSER: Obviously there are differences of opinion. What we have done is very similar to what has been discussed. If there were no other diseases, we would try to convince the coach or physician to take his BPs after a practice session, whether it’s football, soccer, basketball, etc. If his BPs rose significantly, we would do what Ray suggested: We would start the kid on small doses of a β blocker. I think that an ACE inhibitor or an ARB would also be appropriate therapy. Most often, BPs are reduced, and the kids continue to participate. Now maybe that approach is wrong. We certainly have no data on outcomes. DR. GILES: I don’t even know what the goal is with kids. DR. MOSER: The goal is to possibly reduce risk and allow the person to enjoy sports. DR. GILES: All right. He’s a young guy. He becomes depressed, and his ability to perform decreases on a β blocker. It does happen. DR. MOSER: Absolutely, but often a small dose may effectively prevent a BP increase without symptoms. If it doesn’t, then an ACE inhibitor or an ARB will be effective. DR. GILES: An ARB probably wouldn’t give him any side effects, but the question again is what are we trying to achieve? DR. MOSER: Fun. He wants to play soccer for fun. DR. GILES: But we all know that treatment doesn’t necessarily mean a molecule. DR. MOSER: As you gather from this discussion, there is a real difference of opinion. Some of us will treat the numbers, recognizing that there probably is something wrong with this person’s vascular system, although we can’t detect it. We will lower the BP in the hope that we might prevent progression and prevent a cardiovascular event that might occur years later. Bonnie, what was the conclusion in the Pediatric report? DR. FALKNER: First, all children and adolescents with hypertension should have a basic evaluation for some identifiable cause; that basic evaluation is a chemistry panel, urinalysis, and a renal ultrasound. In addition…

VOL. VII NO. I JANUARY 2005

The Journal of Clinical Hypertension (ISSN 1524-6175) is published monthly by Le Jacq Ltd., Three Parklands Drive, Darien, CT 06820-3652. Copyright ©2005 by Le Jacq Ltd., All rights reserved. No part of this publication may be reproduced or transmitted in any form or by any means, electronic or mechanical, including photocopy, recording, or any information storage and retrieval system, without permission in writing from the publishers. The opinions and ideas expressed in this publication are those of the authors and do not necessarily reflect those of the Editors or Publisher. For copies in excess of 25 or for commercial purposes, please contact Sarah Howell at [email protected] or 203.656.1711 x106.

DR. MOSER: Even in a 13- or 14-year old? DR. FALKNER: Right. DR. MOSER: But the expectation of finding a specific disease in a 13- or 14-year old is quite small. Isn’t it? DR. FALKNER: Yes, but you still have a good chance of finding some renal scarring residual as a sequela of a urinary tract infection, so there’s enough reason to justify doing a renal ultrasound as part of the basic evaluation. It is now recommended to also evaluate for comorbidities in children, including lipid abnormalities. In kids above the 95th percentile (1%–3% of children), an echocardiogram is suggested to rule out left ventricular hypertrophy (LVH). If LVH is found, of course, intervention is more immediate. DR. MOSER: I think that we would all agree to treat if LVH is present. DR. GILES: But you need to remember, even in the inherited form of cardiomyopathy, that a fair percentage of those people have concentric, and not asymmetric, septal hypertrophy, so you are not always going to pick up on a case of cardiomyopathy with septal hypertrophy on an echocardiogram. DR. MOSER: But you would treat and reduce the BP with medication that may include a diuretic. It would not, however, eliminate the risk of sudden death during vigorous activity. DR. GILES: You’re right. You don’t know who those people are going to be. DR. MOSER: What do the recommendations suggest in the case that we have presented without LVH? DR. FALKNER: Treatment should include therapeutic lifestyle changes, particularly for obese children and adolescents; weight control; diet modification; and increasing physical activity, which is not relevant for this particular case. Children who should be treated with pharmacologic drugs are children or adolescents who have stage 2 hypertension or who have evidence of diabetes or chronic renal disease. In addition, individuals who don’t have any response to the therapeutic lifestyle changes, and who have continuing BP elevations, may benefit from medication. If there is LVH medication is clearly indicated. DR. MOSER: The recommendations are very similar for children and adults. We really don’t know the exact dosages for children. We always say that it’s one half of the adult dose based on very little data. DR. FALKNER: Right. The only data we have now is a substantial amount of clinical experience from case series and small clinical trials with newer agents. We don’t have comparative drug data at all.

VOL. VII NO. I JANUARY 2005

DR. MOSER: But are you suggesting half the dose that we use in an adult? DR. FALKNER: Not really. We actually have some dosing recommendations based on milligrams per kilogram. In a 13-year old, for example, we would probably start out at the lowest dose, which would be 25 mg/d for an ARB such as losartan, or 12.5 mg/d for hydrochlorothiazide. The dose should be titrated upward until you achieve BP control as close to the ideal as possible. There is no specific recommendation for a choice of initial medication. You can use diuretics, β blockers, ARBs, ACEs, or calcium channel blockers. DR. MOSER: Ray, how would you proceed in a 13–14-year old? What if the patient was black and had minimal LVH? DR. TOWNSEND: I’m sorry, but I’m still something of a diuretic believer. I’d probably give this kid a diuretic first. DR. MOSER: Don’t apologize. DR. TOWNSEND: I’d start with 12.5 mg/d of hydrochlorothiazide and might push it to 25 depending upon how he responds. Then I would add something to block the renin-angiotensin system if the diuretic was inadequate. DR. MOSER: Allan, how would you treat it? DR. SCHWARTZ: In considering the same patient, I would probably stay away from diuretics at the onset. I would be concerned about the uncomfortable side effects, especially cramps, in an athlete or someone who wants to perform actively. I’m much more of an ACE inhibitor and an ARB advocate, and, as things have gone in the last few years, I’ve tended to usually take the smallest tablet that’s made, break it in half, and have the individual back in the office in 2 weeks, and then go to the smaller tablet. The titration then becomes one of trying to achieve some kind of appropriate numerical control of a patient’s BP. If I have to go to a diuretic in addition to an ACE inhibitor or an ARB, it usually means that it is a fairly complicated case. In a person with LVH, it is more important to reduce the BP than it is to have a totally comfortable choice of medication. DR. GILES: In a young black patient, you probably have to use a diuretic. DR. SCHWARTZ: Yes. DR. MOSER: And Tom, any difference in your approach to this patient? DR. GILES: Not really. I think that we’re talking about somebody who’s probably going to wind up on several drugs. I would also emphasize sodium restriction. It is not uncommon to see kids consuming 20 grams of sodium chloride a day. If

THE JOURNAL OF CLINICAL HYPERTENSION

29

The Journal of Clinical Hypertension (ISSN 1524-6175) is published monthly by Le Jacq Ltd., Three Parklands Drive, Darien, CT 06820-3652. Copyright ©2005 by Le Jacq Ltd., All rights reserved. No part of this publication may be reproduced or transmitted in any form or by any means, electronic or mechanical, including photocopy, recording, or any information storage and retrieval system, without permission in writing from the publishers. The opinions and ideas expressed in this publication are those of the authors and do not necessarily reflect those of the Editors or Publisher. For copies in excess of 25 or for commercial purposes, please contact Sarah Howell at [email protected] or 203.656.1711 x106.

Table. Average Blood Pressures for Average-Height Children Under Age 18

AGE (YR) 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17

BOYS (MM HG) 85/37 88/42 91/46 93/50 95/53 96/55 97/57 99/59 100/60 102/61 104/61 106/62 108/62 111/63 113/64 116/65 118/67

GIRLS (MM HG) 86/40 88/45 89/49 91/52 93/54 94/56 96/57 98/58 100/59 102/60 103/61 105/62 107/63 109/64 110/65 111/66 111/66

Adapted with permission from Kluger J, Adams M. Blowing a gasket. Time. December 6, 2004.

they cut it in half, they’re down to 10 grams; even this might help. I just want to ask, by the way, what is your concept of what an optimal BP is going to be in your evaluation of kids? You were telling us about the upper percentile, but what is the ideal BP for an average kid of average height and weight at their age? DR. FALKNER: The new pediatric BP tables provide the BP level at the 90th percentile and the 95th percentile, which have been done before, with the 95th percentile designating the cutpoint for hypertension. High-normal was the designation for BP between the 90th and 95th percentile. That terminology is now switching to prehypertension. The BP value for the 50th percentile has been added to the table. The numbers are there to determine what is prehypertension, what is hypertension, and what the average BP level is at that age.

30

THE JOURNAL OF CLINICAL HYPERTENSION

DR. GILES: An optimal systolic BP then for most children would be ≈90–100 mm Hg. DR. MOSER: The last question, Bonnie. We used to consider that anybody younger than 13 should be studied for renovascular disease and other secondary causes of hypertension. Then, because the probabilities were so minimal, recommendations suggested that these tests should only be performed in children younger than 6 or 7. What were the recommendations of the new task force? DR. FALKNER: It still holds. The younger the child and the higher the BP, the more likely it is that there’s going to be some secondary cause. DR. MOSER: Like under the age of 10? 5? 7? Where? DR. FALKNER: About under the age of 8. DR. MOSER: All right, let’s offer some last comments about the diagnosis and management of adolescents’ or kids’ hypertension. DR. SCHWARTZ: I think it’s important to look for underlying causes, whether genetic or acquired, in children and teenagers. Recognition of the abuse of various medications is important. A thorough history should include all drugs, from steroids to adrenergic agonists to nonsteroidal anti-inflammatory drugs, and even asthma types of medications. DR. MOSER: Tom? DR. GILES: Mine’s really more philosophical. I just want to stress the importance of marginal BPs in younger people. Controlling the BP along with the other risk factors in these young kids, especially with nonpharmacological measures, may save a generation. DR. MOSER: Bonnie? DR. FALKNER: I think we have a big burden to try to identify children at risk. It’s not only the BP level we need to consider. We also need to consider the effect of multiple risk factors in individuals, and we need to do something about them. Obesity and lipid abnormalities are two other areas of concern and should be taken into account in children or adolescents with an elevated BP.

VOL. VII NO. I JANUARY 2005

The Journal of Clinical Hypertension (ISSN 1524-6175) is published monthly by Le Jacq Ltd., Three Parklands Drive, Darien, CT 06820-3652. Copyright ©2005 by Le Jacq Ltd., All rights reserved. No part of this publication may be reproduced or transmitted in any form or by any means, electronic or mechanical, including photocopy, recording, or any information storage and retrieval system, without permission in writing from the publishers. The opinions and ideas expressed in this publication are those of the authors and do not necessarily reflect those of the Editors or Publisher. For copies in excess of 25 or for commercial purposes, please contact Sarah Howell at [email protected] or 203.656.1711 x106.