Screening and Management of Pediatric High Blood Pressure-Challenges to Implementing the Clinical Practice Guideline.

PURPOSE OF REVIEW: Elevated blood pressure (BP) and hypertension in childhood convey risk for hypertension and cardiovascular events in adulthood. Early recognition of abnormal BPs is key to preventing or lessening this risk. However, the process for making the diagnosis of hypertension is complex, and overall adherence to the 2017 American Academy of Pediatrics Clinical Practice Guidelines (CPG) is poor. We will review obstacles to adherence to the CPG and approaches designed to improve the diagnosis and management of hypertension in children. RECENT FINDINGS: Baseline data from the multi-center quality improvement intervention, "Boosting Primary Care Awareness and Treatment of Hypertension" (BP-CATCH), demonstrate that childhood hypertension remains underdiagnosed. Other studies confirm a lack of compliance with the process outlined in the CPG. The provision of electronic prompts, coaching, and education results in modest improvements. The combination of embedded medical record tools and education seems to offer the most hope for improvement.

Tobacco exposure in adults and children with proteinuric glomerulopathies: a NEPTUNE cohort study.

BACKGROUND: Tobacco exposure has been recognized as a risk factor for cardiovascular disease (CVD) and progression of kidney disease. Patients with proteinuric glomerulopathies are at increased risk for cardiovascular morbidity and mortality. Multiple studies have linked tobacco exposure to CVD and chronic kidney disease, but the relationships between smoking and proteinuric glomerulopathies in adults and children have not been previously explored. METHODS: Data from the Nephrotic Syndrome Study Network (NEPTUNE), a multi-center prospective observational study of participants with proteinuric glomerulopathies, was analyzed. 371 adults and 192 children enrolled in NEPTUNE were included in the analysis. Self-reported tobacco exposure was classified as non-smoker, active smoker, former smoker, or exclusive passive smoker. Baseline serum cotinine levels were measured in a sub-cohort of 178 participants. RESULTS: The prevalence of active smokers, former smokers and exclusive passive smoking among adults at baseline was 14.6%, 29.1% and 4.9%, respectively. Passive smoke exposure was 16.7% among children. Active smoking (reference non-smoking) was significantly associated with greater total cholesterol among adults (ß 17.91 95% CI 0.06, 35.76, p = 0.049) while passive smoking (reference non-smoking) was significantly associated with greater proteinuria over time among children (ß 1.23 95% CI 0.13, 2.33, p = 0.03). Higher cotinine levels were associated with higher baseline eGFR (r = 0.17, p = 0.03). CONCLUSION: Tobacco exposure is associated with greater risk for CVD and worse kidney disease outcomes in adults and children with proteinuric glomerulopathies. Preventive strategies to reduce tobacco exposure may help protect against future cardiovascular and kidney morbidity and mortality in patients with proteinuric glomerulopathies.

Association of Childhood Blood Pressure with Left Atrial Size and Function: Study of High Blood Pressure in Pediatrics-Adult Hypertension in Youth (SHIP AHOY).

OBJECTIVE(S): To evaluate the cross-sectional association of cardiovascular disease risk factors with left atrial (LA) size and function among healthy youth, aged 11-18 years, with a wide range of blood pressures (BPs). STUDY DESIGN: Echocardiographic images of youth enrolled in the Study of High Blood Pressure in Pediatrics: Adult Hypertension Onset in Youth study were analyzed for LA measurements. The association of casual BP, ambulatory BP, and other cardiovascular disease risk factors with LA size and function were determined using descriptive statistics and multivariable regression. Regression models adjusting for age, sex, race, and body mass index z score determined the independent association between ambulatory systolic BP indices (mean systolic BP/50th %ile systolic BP) and BP phenotypes with LA outcomes while exploratory analyses investigated for additional predictors of LA outcomes. RESULTS: The study population consisted of 347 youth: median age 15.7 years, 60% male and 40% non-White. Greater-risk casual systolic BP groups had worse cardiometabolic profiles but no differences in LA size and function. Each 0.1 increase in ambulatory systolic BP day or night index was associated with a 9.9 mL/m2 increase in LA volume/body surface area (LAV/BSA; 95th% CI 2.8-17.0, P = .006) and a 6.8 mL/m2 increase in LAV/BSA (95th% CI 0.8-12.8, P = .03), respectively. Ambulatory hypertension was associated with greater odds of abnormal LAV/BSA, defined as >75th %ile (2014 ambulatory BP monitoring criteria: OR 3.2 [95th% CI 1.4-7.2; P = .002]; 2022 ambulatory BP monitoring criteria: OR 2.1 [95th% CI 1.0-4.1; P = .008]). CONCLUSIONS: Increasing ambulatory systolic BP and ambulatory hypertension are independently associated with LAV/BSA.

HEARTS en las Américas: un ejemplo mundial del uso de dispositivos automatizados de medición de la presión arterial validados clínicamente en la prevención y el manejo de las enfermedades cardiovasculares en entornos de atención primaria de salud

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Simplified blood pressure measurement approaches and implications for hypertension screening: the Atherosclerosis Risk in Communities study.

OBJECTIVES: Averaging multiple blood pressure (BP) measurements is recommended for hypertension (HTN) screening but can be impractical, especially in resource-constrained settings. We aimed to explore the implications of fewer BP measurements on BP classification and subsequent cardiovascular disease (CVD) risk. METHODS: We studied 8905 middle-aged participants without diagnosed HTN and quantified misclassified HTN (≥140/90 mmHg) by simplified BP approaches (e.g. single 1st BP, single 2nd BP, mainly 1st but 2nd BP if 1st was in a certain range) vs. the reference standard of the average of 2nd and 3rd BP. We also assessed CVD risk related to HTN status. RESULTS: There were 823 participants classified as HTN by the standard approach. With single 1st BP, 2.8% of non-HTN were overidentified as HTN, and 18.3% of HTN were identified as not having HTN. The corresponding estimates with single 2nd BP were 2.1 and 6.4%. Similar estimates were seen when 2nd BP was used if 1st BP at least 130/80 (1.9 and 8.1%), with only 27.8% requiring 2nd BP. Two thousand, one hundred and seventy-eight CVD cases were documented in this population over 30 years. HTN by either the standard approach or any of the simplified approaches conferred higher CVD risk vs. consistent no HTN by both approaches. CONCLUSION: In those without diagnosed HTN, a simplified BP measurement approach using the 2nd BP only when the 1st BP is at least 130/80 could reduce the total number of BP measurements by more than 50%, identify HTN with limited misclassification (2-8%), and predict CVD risks reasonably well.

Blood pressure measurement device selection in low-resource settings: Challenges, compromises, and routes to progress.

High blood pressure (BP) is the single leading preventable cardiovascular disease (CVD) risk factor across the world. In order to decrease the global burden of CVD, broad hypertension screening programs that facilitate early hypertension diagnosis and treatment are essential. Accurate BP devices are a key element of hypertension control programs. With the overwhelming number of devices available now on the market, most of which have not been tested for accuracy, it can be challenging to select the optimal BP measurement device for clinical settings. This review details essential factors to consider when selecting a good-quality BP device, particularly for use in low-resource settings. Barriers to the procurement and use of good-quality devices are reviewed and practical solutions proposed.

An exploratory study on the quality of patient screening and counseling for hypertension management in Tanzania.

BACKGROUND: The global burden of hypertension, currently estimated at 1 billion, is a leading Non-Communicable Disease (NCD) in Sub Saharan Africa. In Tanzania, the reported prevalence of hypertension is 25%. Inherent limitations of the healthcare system to control hypertension include inadequate provider knowledge, system capacity, medication access, and patient awareness, all of which hinder effective screening and disease management. To assess the quality of hypertension screening and patient counseling, we conducted a study in an ambulatory setting in Tanzania. METHODS: Observations of patient screening were conducted on 69 adult patients during routine outpatient care and screening camps. In addition, 33 healthcare providers participated in a pre-post knowledge assessment after observing instructional training videos. RESULTS: Patient observations indicated that blood pressure (BP) measurement was explained to 65% of patients, and 77% of the measurements were made with mercury sphygmomanometers. For several aspects of BP measurement, nurses performed better than doctors: patient's arm supported on a flat surface (doctors, 58% vs nurses 67%, p<0.05), and patient's back was supported (doctors, 50% vs nurses 88%, p<0.01). Among those diagnosed with hypertension, 7% were prescribed medications, 14% were advised on reduced salt during cooking, 29% on reduced salt consumption, 21% on reduced consumption of sodium rich foods, 21% on reducing caloric intake, 21% on increasing physical activity, and 43% were informed about follow up appointments. Provider knowledge assessments showed critical gaps in consequences of hypertension, 1st line medicines, and awareness of guidelines at baseline. Following the instructional videos there were improvements in some aspects: diagnostic criteria for hypertension (pre 45% vs post 91%, p<0.001) and counseling for controlling hypertension (pre 30% vs post 58%, p<0.01). CONCLUSION: Enhancing knowledge and performance competencies of health providers at the primary care level is a critical prerequisite for effective hypertension management in low resource settings.

Real-World Strategies to Treat Hypertension Associated with Pediatric Obesity.

PURPOSE OF REVIEW: To review the most recent literature on current strategies for the treatment of hypertension associated with pediatric obesity. RECENT FINDINGS: Over the last three decades, childhood and adolescent overweight and obesity prevalence in the USA has continued to rise. Unsurprisingly but rather disturbingly, this rising prevalence has been paralleled by an increase in cardiovascular disease (CVD) risk factors in childhood such as hypertension, dyslipidemia, and diabetes that become manifest earlier than previously reported. These childhood CVD risk factors are not only associated with target organ damage in childhood but also track into adulthood, increasing the risk of long-term CVD morbidity and mortality. There have been several mechanisms proposed to explain the role of obesity on the development of hypertension in childhood. However, central to the management of obesity-related hypertension is a multifaceted approach targeting lifestyle modifications and weight loss. Effective treatment often also requires a pharmacologic approach and rarely bariatric surgery.

Antenatal exposure to nonsteroidal anti-inflammatory drugs and risk of neonatal hypertension.

Nonsteroidal anti-inflammatory drugs (NSAIDs) are used as tocolytics, which are medications that suppress uterine contractions for preterm birth prevention. Their effect on cerebral/systemic vascular beds poses the question of whether antenatal NSAID exposure is associated with neonatal hypertension. We performed a retrospective case-control study in a tertiary neonatal intensive care unit, including 40 hypertension cases (hospitalized neonates ≥ 35 weeks with systolic BP > 100 mm Hg on three consecutive days) compared to 134 controls matched by gestational age at delivery, plurality, and delivery date. Cases and controls were compared by antenatal NSAID exposure, other common tocolytics, and maternal/neonatal characteristics and complications. Multivariable logistic regression was used to estimate the odds of hypertension among those with prenatal exposure to NSAIDs versus those without exposure. Newborns with hypertension had a lower gestational age at delivery and increased incidence of neonatal complications, including respiratory distress syndrome, bronchopulmonary dysplasia, surfactant administration, longer duration of ventilation, and history of umbilical artery catheterization. Days of indomethacin exposure were positively associated with greater odds of neonatal hypertension (OR 1.17 [1.00 to 1.38], P = 0.055), even after adjustment for other factors associated with neonatal hypertension. Newborns with hypertension were less likely to have been exposed to calcium channel blockers as a tocolytic. The results of our study suggest an association between prenatal exposure to nonsteroidal anti-inflammatory drugs and neonatal hypertension. Furthermore, our data suggest that prenatal calcium channel blocker exposure may protect against the development of neonatal hypertension. Future multicenter studies are needed to understand the risks of tocolytics and subsequent consequences in preterm infants.

Diagnostic Errors in Primary Care Pediatrics: Project RedDE.

OBJECTIVE: Diagnostic errors (DEs), which encompass failures of accuracy, timeliness, or patient communication, cause appreciable morbidity but are understudied in pediatrics. Pediatricians have expressed interest in reducing high-frequency/subacute DEs, but their epidemiology remains unknown. The objective of this study was to investigate the frequency of two high-frequency/subacute DEs and one missed opportunity for diagnosis (MOD) in primary care pediatrics. METHODS: As part of a national quality improvement collaborative, 25 primary care pediatric practices were randomized to collect 5 months of retrospective data on one DE or MOD: elevated blood pressure (BP) and abnormal laboratory values (DEs), or adolescent depression evaluation (MOD). Relationships between DE or MOD proportions and patient age, gender, and insurance status were explored with mixed-effects logistic regression models. RESULTS: DE or MOD rates in pediatric primary care were found to be 54% for patients with elevated BP (n = 389), 11% for patients with abnormal laboratory values (n = 381), and 62% for adolescents with an opportunity to evaluate for depression (n = 400). When examining the number of times a pediatrician may have recognized an abnormal condition but either knowingly or unknowingly did not act according to recommended guidelines, providers did not document recognition of an elevated BP in 51% of patients with elevated BP, and they did not document recognition of an abnormal laboratory value without a delay in 9% of patients with abnormal laboratory values. CONCLUSIONS: DEs and MODs occur at an appreciable frequency in pediatric primary care. These errors may contribute to care delays and patient harm.

Blood Pressure and Visit-to-Visit Blood Pressure Variability Among Individuals With Primary Proteinuric Glomerulopathies.

Hypertension and blood pressure variability (BPV; SD and average real variability) in primary proteinuric glomerulopathies are not well described. Data were from 433 participants in the NEPTUNE (Nephrotic Syndrome Study Network). Hypertensive BP status was defined as previous history of hypertension or BP ≥140/90 mm Hg for adults/≥95th percentile for children at baseline. BPV was measured in participants with ≥3 visits in the first year. Two-hundred ninety-six adults (43 years [interquartile range, 32-57.8 years], 61.5% male) and 147 children (11 years [interquartile range, 5-14 years], 57.8% male) were evaluated. At baseline, 64.8% of adults and 46.9% of children were hypertensive. Histological diagnosis was associated with hypertensive status in adults (P=0.036). In adults, hypertensive status was associated with lower hazard of complete remission (hazard ratio, 0.36; 95% confidence interval, 0.19-0.68) and greater hazard of achieving the composite end point (end-stage renal disease or estimated glomerular filtration rate decline >40%; hazard ratio, 4.1; 95% confidence interval, 1.4-12). Greater systolic and diastolic SD and average real variability were also associated with greater hazard of reaching the composite end point in adults (all P<0.01). In children, greater BPV was an independent predictor of composite end point (determined by systolic SD and average real variability) and complete remission (determined by systolic and diastolic average real variability; all P<0.05). Hypertensive status was common among adults and children enrolled in NEPTUNE. Differences in hypertensive status prevalence, BPV, and treatment were found by age and histological diagnosis. In addition, hypertensive status and greater BPV were associated with poorer clinical outcomes.

Cystatin C and Cardiac Measures in Children and Adolescents With CKD.

BACKGROUND: Cardiovascular disease (CVD) is highly prevalent among children with chronic kidney disease (CKD). Cystatin C is an established marker of kidney function and an emerging biomarker for CVD events. We quantified the relationship between cystatin C level and cardiac structure and function over time among children with CKD and assessed whether cystatin C level and diastolic function retained an association after accounting for kidney function. STUDY DESIGN: Prospective cohort study. SETTING & PARTICIPANTS: 678 children and adolescents with mild to moderate CKD enrolled in the CKD in Children (CKiD) Study with 1,228 echocardiographically obtained cardiac structure and function measurements. PREDICTOR: Serum cystatin C (mg/L) measured annually. OUTCOMES: Cardiac structure (left ventricular mass index [g/m2.7]) and cardiac function (shortening fraction; E/A, E'/A', E/E' ratios) measured every other year. MEASUREMENTS: Demographics and anthropometrics, measured glomerular filtration rate (mGFR), heart rate, blood pressure, hemoglobin z score, serum albumin level, and calcium-phosphorus product. RESULTS: Independent of time, each 1-mg/L increase in cystatin C level was independently associated with a concurrent 7.7% (95% CI, 5.3%-10.0%) increase in left ventricular mass index, a -4.7% (95% CI, -7.0% to -2.4%) change in E/A ratio, a -6.6% (95% CI, -9.0% to -4.2%) change in E'/A' ratio, and a 2.5% (95% CI, 0.3%-4.7%) increase in E/E' ratio. mGFR was also independently associated with E'/A' ratio. When cystatin C level and mGFR were included in the same model, cystatin C level remained independently associated with E'/A' ratio, whereas mGFR was not. LIMITATIONS: 24% of the cohort was missing data for outcomes of interest or measurements; study population includes only children and adolescents with mild to moderate CKD. CONCLUSIONS: In this study of children and adolescents with mild to moderate CKD, cystatin C level was independently associated with cardiac structure and diastolic function. Cystatin C level remained able to predict diastolic function decline via E'/A' ratio even after adjusting for mGFR, suggesting that cystatin C level may have an independent role in CVD risk stratification among children and adolescents with CKD.

Complete Remission in the Nephrotic Syndrome Study Network.

BACKGROUND AND OBJECTIVES: This analysis from the Nephrotic Syndrome Study Network (NEPTUNE) assessed the phenotypic and pathology characteristics of proteinuric patients undergoing kidney biopsy and defined the frequency and factors associated with complete proteinuria remission (CRever). DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS: We enrolled adults and children with proteinuria ≥0.5 g/d at the time of first clinically indicated renal biopsy at 21 sites in North America from April 2010 to June 2014 into a prospective cohort study. NEPTUNE central pathologists assigned participants to minimal-change disease (MCD), FSGS, membranous nephropathy, or other glomerulopathy cohorts. Outcome measures for this analysis were (1) CRever with urine protein-to-creatinine ratio (UPC) <0.3 g/g with preserved native kidney function and (2) ESRD. Continuous variables are reported as median and interquartile range (IQR; 25th, 75th percentile). Cox proportional hazards modeling was used to assess factors associated with CRever. RESULTS: We enrolled 441 patients: 116 (27%) had MCD, 142 (32%) had FSGS, 66 (15%) had membranous nephropathy, and 117 (27%) had other glomerulopathy. The baseline UPC was 4.1 g/g (IQR, 1.9, 7.7) and the eGFR was 81 ml/min per 1.73 m(2) (IQR, 50, 105). Median duration of observation was 19 months (IQR, 11, 30). CRever occurred in 46% of patients, and 4.6% progressed to ESRD. Multivariate analysis demonstrated that higher prebiopsy proteinuria (hazard ratio, 0.3; 95% confidence interval, 0.2 to 0.5) and pathology diagnosis (FSGS versus MCD; hazard ratio, 0.2; 95% confidence interval, 0.1 to 0.5) were inversely associated with CRever. The effect of immunosuppressive therapy on remission varied by pathology diagnosis. CONCLUSIONS: In NEPTUNE, the high frequency of other pathology in proteinuric patients affirms the value of the diagnostic kidney biopsy. Clinical factors, including level of proteinuria before biopsy, pathology diagnosis, and immunosuppression, are associated with complete remission.

Screening blood pressure measurement in children: are we saving lives?

Blood Pressure screening in children and adolescents is currently recommended by several prominent medical organizations, including the American Heart Association, the National High Blood Pressure Education Program, the National Heart, Lung, and Blood Institute, the European Society of Hypertension, and the American Academy of Pediatrics. This practice was recently subject to intense scientific review by the U.S. Preventive Services Task Force. The conclusion of the Task Force was that "current evidence is insufficient to assess the balance of benefits and harms of screening for primary hypertension in asymptomatic children and adolescents." This commentary provides an alternate interpretation of current evidence for blood pressure screening in children and adolescents and highlights its importance as a part of routine medical care.