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Hypertension
HTN Evaluation
Systolic blood pressure (SBP): the pressure in the arteries immediately after the left heart has contracted (systole) and ejected blood out into the arteries
Diastolic blood pressure (DBP): the pressure exerted by the blood against the artery walls while the heart is relaxed and the ventricles are filling with blood
Note: Definitions can vary by country - these definitions are for the United States
🤏 Elevated blood pressure:
Ages 1 to <13: SBP and DBP both ≥90th percentile but <95th percentile
Ages ≥13: SBP 120-129 and DBP <80
1️⃣ Stage 1 hypertension:
Ages 1 to <13: SBP and/or DBP ≥95th percentile but <12 mmHg above the 95th percentile
Ages ≥13: SBP 130-139 and/or DBP 80-89
2️⃣ Stage 2 hypertension:
Ages 1 to <13: SBP and/or DBP ≥12 mmHg above the 95th percentile
Ages ≥13: SBP ≥140 and/or DBP ≥90
Primary hypertension: hypertension (as defined above) that is not attributable to a medical condition
Formerly known as "essential" hypertension
Diagnosis of exclusion
Secondary hypertension: hypertension (as defined above) for which an underlying cause can be identified
Hypertensive crisis: an episode of severely elevated blood pressure with the potential for end-organ damage, although no cutoff is specified. Typically, this is subcategorized as either "urgency" (severe asymptomatic hypertension) or "emergency." May be chronic, acute, or acute-on-chronic.
Hypertensive urgency (severe asymptomatic hypertension): severely elevated BP without evidence of end-organ damage (e.g., symptoms, laboratory abnormalities)
Depending on how reliable the BP measurement is, you will likely send these kids to ER as well. They may not get admitted if BPs can be controlled, but often they are so we can get them set up with home BP cuff, med prescriptions, teaching on BP measurement and some initial workup.
Hypertensive emergency: severely elevated BP with evidence of end-organ damage, including symptoms (e.g., dizziness, headache, vision changes, chest pain, shortness of breath, altered mentation, bleeding, etc.)
Ensure the cuff is correctly sized, placed on the upper extremity, the patient is calm, and the measurement is repeated if elevated
📏 Correctly sized:
Measure the mid upper arm circumference (MUAC) to ensure that an appropriately sized cuff is used (cuffs should be labeled with the appropriate circumference ranges)
The bladder of the cuff (i.e., just the part fills with air, not the entire wrap) should encircle 80%-100% of the upper arm circumference
The width should be 40% of the MUAC
Using an inappropriately small cuff can cause spuriously high BPs, while an inappropriately large cuff may result in spuriously low BPs
💪 Upper extremity:
Right arm is typically preferred for consistency and because of the possibility of coarctation (which can result in falsely low BPs in the left arm)
The arm should be supported and the arm should be at heart level
The arm should be bare above the cuff; do not place the cuff over clothing
🧘 Calm:
Rested for at least 5 minutes in a quiet room while in a seated position with back supported and feet flat on the floor
Bear in mind that watching videos or playing video games can certainly raise some kids' blood pressures
Sometimes resting for longer than 5 minutes is necessary, in which cases repeating at the end of the office visit may be helpful
The room should be quiet (including talking) while the measurement is being taken
🔁 Repeated:
If the first measurement is >90th percentile, repeat it twice (at least 1 minute apart) and average these two measurements:
If an oscillometric ("automatic") technique was used, the measurement is still elevated (>90th percentile) on repeat, and the child is old/calm enough to cooperate, then repeat the measurement twice using the auscultatory ("manual") technique and average these two measurements to get your final BP
🩺 Auscultatory ("manual") method:
Place the bell of the stethoscope (not the diaphragm) over the brachial artery in the antecubital fossa, 2-3 cm below the cuff
Inflate the cuff 20-30 mmHg above the point at which the Korotkoff sounds disappear (or the estimated systolic value)
Deflate at a rate of 2-3 mmHg per second
SBP = the first point at which sounds are heard (phase I Korotkoff)
DBP = the point at which sounds are no longer audible (phase 5 Korotkoff)
🦵 Leg BP measurements:
Use an appropriately sized cuff placed at the midthigh
For auscultation, place the bell of the stethoscope over the popliteal artery
🚫 Wrist/forearm measurements:
Not recommended for diagnosis or for home BP monitoring
Very little data in children, and there is more more variability in measurements than in adults (particularly with diastolic measurements)
Hypertensive kids are likely to go on to become hypertensive adults
Clinical trials in adults show that treatment of HTN reduces risk of cardiovascular morbidity and mortality
Identify any treatable conditions that can cause/contribute to hypertension
Identify patients who would benefit from antihypertensive drug therapy
Office setting:
<3 years of age: patients with risk factors for hypertension should be screened annually at routine health supervision visits (well child checks)
Patients <3 years of age without risk factors do not need routine screening for hypertension
Risk factors for hypertension in children <3 years of age
Perinatal risk factors:
Born at <32 weeks gestation (moderate preterm)
Small for gestational age (SGA)
Very low birth weight <1500 g (VLBW)
Neonatal complications requiring NICU stay and/or umbilical artery catheterization
Congenital anomaly of kidney or ureter tract [CAKUT]
Congenital urologic malformation
Family history of congenital kidney disease
Recurrent urinary tract infection (UTI)
Persistent hematuria or proteinuria
Solid organ or hematopoietic stem cell transplant
Malignancy or other systemic illness associated with hypertension (e.g., neurofibromatosis, tuberous sclerosis complex, sickle cell disease)
Treatment with medications that can increase blood pressure (e.g., caffeine, nonsteroidal anti-inflammatory drugs [NSAIDs], glucocorticoids)
Evidence of elevated intracranial pressure (intracranial hypertension)
≥3 years of age: all patients regardless of risk factors should be screened annually at routine health supervision visits (well child checks)
If patients ≥3 years have risk factors for hypertension, they should be screened at all healthcare encounters, not just routine checkups
Risk factors for hypertension in children ≥3 years of age
Obesity
Diabetes (type 1 or type 2)
History of aortic arch obstruction or coarctation
Substances/medications that can increase blood pressure:
Decongestants (pseudoephedrine)
Nonsteroidal anti-inflammatory drugs (NSAIDs)
Glucocorticoids
Stimulants (e.g., methylphenidate, amphetamines)
Oral contraceptives
Tricyclic antidepressants
Calcineurin inhibitors (cyclosporine, tacrolimus)
Caffeine
Recreational drugs (e.g., methamphetamine, cocaine, anabolic steroids)
Ambulatory blood pressure monitor (ABPM) screening:
Patients with elevated BP (defined above) for ≥1 year
Patients with stage 1 HTN for ≥3 clinic visits
Patients with certain high-risk conditions
Patients with hypertension who are on antihypertensive therapy
Secondary HTN
Genetic syndromes associated with HTN (e.g., neurofibromatosis [NF], Turner syndrome, Williams syndrome, coarctation)
Chronic kidney disease (CKD), including structural renal abnormalities
Diabetes (type 1 and type 2)
Solid-organ transplant
Obesity
Obstructive sleep apnea (OSA)
Aortic coarctation s/p repair
History of prematurity
Ensure there is no concern for hypertensive emergency
Identify risk factors for primary and secondary hypertension
Confirm the patient has persistent hypertension
Proceed with a basic laboratory and imaging evaluation
Symptoms that can suggest end-organ damage: headache, seizures, changes in mental status (confusion, lethargy, coma), irritability (in infants), vomiting, focal neurologic complaints (facial nerve palsy, hemiplegia), visual disturbances, left-heart failure symptoms including chest pain, palpitations, cough, shortness of breath
Even if hypertensive emergency is not suspected, it is useful to document a thorough review of these "red flag" symptoms to use as a baseline for comparison in the future
Primary hypertension
More likely in patients who are postpubertal
More likely in patients who are overweight/obese
More common in patients of African American descent
Often have a family history of primary hypertension
Patients with primary hypertension are typically asymptomatic
Patients may be predisposed to high blood pressure based on being overweight/obesity, diet, and/or family history of hypertension
Secondary hypertension
More likely in young children (especially <6 years of age)
More likely to cause diastolic hypertension
More likely to cause nocturnal hypertension
More likely to cause severe hypertension
May have a family history of secondary hypertension (e.g., ADPKD)
May have symptoms related to underlying disease
E.g., pheochromocytoma (paroxysms of headache, sweating, tachycardia)
Pertinent review of systems (and associated diseases):
📝 Want to make this into a note template? Get a head start with [Note template components for Hypertension: Initial Evaluation]General:
fatigue (intracranial hypertension, obstructive sleep apnea [OSA])
hyperactivity (OSA)
anxiety; may also ask if they become anxious with doctor's appointments
pregnancy (preeclampsia)
Skin:
rash (vasculitis, systemic lupus, thyroid dysfunction)
sweating (thyroid dysfunction)
pallor (thyroid dysfunction, anemia of CKD, sickle cell anemia)
recent impetigo (postinfectious glomerulonephritis [GN])
paroxysms of pallor, flushing, diaphoresis (pheochromocytoma [PCC])
Head: headaches, seizures (intracranial hypertension)
Eyes: visual disturbances
Ears: hearing loss (Alport syndrome, lead poisoning)
Throat: recent pharyngitis (postinfectious GN)
Respiratory: snoring, apnea (obstructive sleep apnea [OSA])
Cardiovascular:
Gastrointestinal:
vomiting, especially in the morning or after naps (intracranial hypertension)
bloody stools (hemolytic uremic syndrome [HUS])
Genitourinary:
Musculoskeletal:
joint swelling (systemic lupus, vasculitis)
Other pertinent items in the history:
Medications: sympathomimetics (stimulants like amphetamines, methylphenidate), oral contraceptives, corticosteroids, NSAIDs, tricyclic antidepressants, calcineurin inhibitors (cyclosporine, tacrolimus)
Medical history:
recurrent UTI or episodes of unexplained fever (hydronephrosis, vesicoureteral reflux [VUR])
abdominal trauma (direct trauma to kidney/urinary system)
recent head trauma, seizures (intracranial hypertension)
anxiety
perinatal complications:
other conditions associated with increased risk of cardiovascular disease: obesity, diabetes (type 1 or type 2), dyslipidemia, CKD, organ transplantation, cardiac disease (including repaired coarctation), cancer, Kawasaki disease, autoimmune disease, HIV infection, depression, bipolar disorder
Social history:
dietary intake:
typical daily food intake, snacking habits (obesity, primary hypertension)
ask about home cooked vs processed foods
salty foods (primary hypertension)
ask about table salt (free access to salt shaker), salty seasonings used in foods
recreational drugs: methamphetamine, cocaine, phencyclidine (PCP), anabolic steroids, ephedra (in some weight loss "supplements;" illegal in US)
smoking or vaping
activity level, exercise habits
stressors at home/school
tobacco smoke exposure in the home (primary hypertension)
Family history: hypertension (primary or secondary), early myocardial infarction [MI], stroke, diabetes, OSA, hearing loss (Alport syndrome), kidney disease, need for dialysis/kidney transplant
Vitals:
Take blood pressures on all four extremities ("4-point BPs")
A significant drop in BP from upper to lower extremities (often cited as >20 mmHg) is suggestive of coarctation of the aorta
Typically the BP in the legs is about 20 mmHg higher than in the arms
Assess for tachycardia (hyperthyroidism, pheochromocytoma [PCC], neuroblastoma)
Pertinent physical exam findings (and associated diseases):
Head/face:
elfin facies (Williams syndrome)
broad forehead, flattened nasal bridge, wide-spaced eyes, long philtrum, small and widely-spaced teeth, wide mouth, small chin
moon facies (Cushing syndrome)
rounded face (lower face/sides)
Eyes:
proptosis (hyperthyroidism)
non-dilated ophthalmoscopic exam:
retinal changes: arteriovenous nicking, retinal hemorrhages, cotton wool patches (suggestive of severe [more often secondary] hypertension)
papilledema: obscured optic disc margins (intracranial hypertension)
Throat:
tonsillar hypertrophy (obstructive sleep apnea)
Neck:
thyromegaly/goiter (hyperthyroidism)
webbed neck (Turner syndrome)
Chest wall:
widely spaced nipples (Turner syndrome)
Cardiovascular (CV):
heart murmur (coarctation of the aorta)
friction rub (collagen vascular disease; pericarditis in systemic lupus)
apical heave (left ventricular hypertrophy [LVH] as seen in severe/chronic hypertension)
diminished or delayed lower extremity pulses (coarctation of the aorta)
Abdomen:
abdominal mass/palpable kidneys (Wilms tumor, neuroblastoma, polycystic kidney disease, hydronephrosis, multicystic dysplastic kidney)
bruit over the epigastrium or flank (renal artery stenosis [RAS])
obesity (more common in primary hypertension)
truncal obesity (Cushing syndrome, corticosteroid therapy)
Genitourinary:
ambiguous/virilized genitalia (congenital adrenal hyperplasia)
precocious puberty (intracranial tumors)
Extremities/musculoskeletal:
joint swelling (collagen vascular disease, systemic lupus, vasculitis)
edema (chronic kidney disease, glomerulonephritis, heart failure)
muscle weakness (Liddle syndrome, hyperaldosteronism)
Skin:
pallor (anemia of CKD, sickle cell anemia)
acne, hirsutism, striae (Cushing syndrome, corticosteroid therapy, anabolic steroid abuse)
café-au-lait spots, neurofibromas (neurofibromatosis [NF])
ash leaf spots, adenoma sebaceum (tuberous sclerosis [TS])
malar rash (systemic lupus)
palpable purpura (vasculitis)
acanthosis nigricans (type 2 diabetes mellitus)
Historical data to review:
Growth history: excessive weight gain/loss, change in growth percentiles (obesity, thyroid dysfunction)
Blood pressure data from other healthcare encounters
Home BP data if available (ask if family has a home BP cuff or anyone at home who is trained to measure blood pressures)
Prior episodes of UTI or unexplained fever suspicious for UTI/pyelonephritis
Prior imaging data
Kidney/bladder ultrasound (cystic kidney disease, congenital anomalies, hydronephrosis, evidence of scarring from pyelonephritis or VUR, nephrocalcinosis, etc.)
VCUGs (to evaluate for VUR)
Echocardiography (to evaluate for left ventricular hypertrophy)
Sidebar: Why isn't this step number one?
Demonstrating a patient does not have persistent hypertension in the outpatient setting may take days, weeks or months depending on setting and what resources are available
While no further workup is necessary if the patient is not hypertensive, reviewing an individual's risk factors for hypertension will help guide future blood pressure screening
If available, review historical data
Ensure historical BPs are contextualized: review them against the appropriate blood pressure percentiles for the patient's age and height at the time the data was collected
Educate on lifestyle modifications (e.g., healthy diet, sleep, physical activity), and schedule another office visit to recheck the blood pressure:
Elevated BP: recheck BP in 6 months
If still in elevated range, check upper and lower extremity BPs (same visit), and repeat BP check in 6 months
If still elevated, perform 24-hour ABPM (if available), start diagnostic evaluation, and consider subspecialty referral
Continue to monitor at annual checkups: significant risk for progression to HTN in adolescence/adulthood
Stage 1 HTN: repeat in 1-2 weeks
If still in stage 1 range, check upper and lower extremity BPs (same visit), and repeat BP check in 3 months
If still in stage 1 range, perform 24-hour ABPM (if available), start diagnostic evaluation, initiate treatment, and consider subspecialty referral
Stage 2 HTN: check upper and lower extremity BPs (same visit), and repeat BP check in 1 week
If still in stage 2 range, perform 24-hour ABPM (if available), start diagnostic evaluation, initiate treatment, and refer for subspecialty evaluation
All children with persistent hypertension should have:
Lipid testing, nonfasting (non-HDL cholesterol or full lipid profile)
In children with hypertension who are obese, also evaluate for comorbidities:
Hemoglobin A1c to screen for diabetes mellitus (DM)
Alanine aminotransferase (ALT) to screen for nonalcoholic fatty liver disease (NAFLD)
If risk factors are present based on history, examination, initial labs, consider obtaining:
Thyroid stimulating hormone (TSH)
Urine drug screen
Sleep study (polysomnogram)
Complete blood count (CBC), especially in those with growth delay and/or abnormal kidney function
Not routinely recommended for HTN evaluation, but may be considered if risk factors present: serum uric acid, urine microalbumin
Kidney bladder ultrasound (KBUS)
Useful for determining presence of congenital anomalies (including solitary kidney) or abnormalities in kidney parenchyma (e.g., thinning or discrepancies in kidney length) which may suggest scarring
At a minimum, guidelines recommend a screening ultrasound in any of the following:
All patients <6 years of age
Abnormal urinalysis (UA)
Abnormal kidney function
Practice will vary by institution, but an ultrasound may be obtained:
At the time of initial evaluation for patients referred for hypertension
After the diagnosis of hypertension is confirmed
Only in select patients, based on the above criteria and/or if other risk factors are present
Consider doppler ultrasound of the renal arteries:
Sensitivity is variable but may be done to avoid more invasive testing
Best results in children ≥8 years of age who are of normal weight and able to cooperate with the exam when performed at a center with pediatric experience
If these criteria are not met, doppler ultrasound may have poor sensitivity; consider CTA/MRA
In the case of abnormally low resistive indices and/or tardus parvus waveforms, consider a narrowing of the suprarenal aorta [PMID 24037085]
CT angiography (CTA), MR angiography (MRA):
Poorly studied in children, but one study including both adults and children showed a sensitivity and specificity ≥90% [PMID 17497443]
Renal angiography (digital subtraction angiography)
Consider if is a strong concern for renal artery stenosis/renovascular hypertension, even if doppler US/CTA/MRA were negative
Factors that raise suspicion for RAS/renovascular hypertension:
Stage 2 HTN, particularly if no other risk factors
Difficult to control HTN (despite ≥2 medications)
Significant diastolic HTN
Severe HTN after kidney transplant
Significant rise (>30%) in creatinine after ACE inhibitor initiation (if suprarenal/bilateral RAS)
Discrepant kidney sizes
Unexplained hypokalemia
Presence of bruit on exam
Disease associated with RAS (vasculitis or genetic syndrome)
Echocardiography
Should be performed to evaluate for left ventricular hypertrophy (LVH), geometry (concentric vs eccentric), and function (ejection fraction)
Defining left ventricular hypertrophy (LVH):
≥8 years: LV mass index (LVMI) >51 g/m2.7 (boys and girls) for children and adolescents ≥8 years
<8 years:
Boys: LV mass >115 g/BSA
Girls: LV mass >95 g/BSA
If abnormalities present, repeat every 6 months to monitor for improvement/progression
If no abnormalities present, consider repeating every 12 months if: HTN persists despite treatment