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Clinical Research Facility
Central Manchester University Hospitals
NHS Foundation Trust
Supported by
Hypertension guidelines – what’s new
Professor Nick Webb DM FRCP FRCPCHRoyal Manchester Children’s Hospital, Manchester UK
NIHR Manchester Clinical Research Facility
International Congress on Hypertension in Children and Young Adults, Valencia Feb 2018
Overview
Importance of hypertension Guideline history New American Academy of
Pediatrics Clinical Practice Guideline Nov 2017
New US adult hypertension guidelines Nov 2017
European Society of Hypertension guidelines 2016
Implications for practice
Sound rationale for classification and treatment of hypertension in adults
BP relationship to risk of CVD is continuous, consistent and independent of other risk factors
Each increment of 20/10mmHg doubles the risk of CVD across the entire BP range starting from 115/75mmHg
In stage 1 hypertension, achieving a sustained 12mmHg reduction in SBP over 10 years will prevent 1 death for every 11 patients treated
Elevated BP in childhood and adolescence is a strong predictor of hypertension and metabolic syndrome in adult life
History of guideline development
Pre 1977 No good definition of HT in children
BP rarely routinely measured
1977: First major clinical practice
guideline
NHBPEP report
Defined HT as BP>95C
Detection, evaluation and management
1987: Second Task Force Update
1996: Update on 1987 report Update
2004: Fourth Taskforce Comprehensive normal data classified
according to sex, age and height
2009: 1st European Society
Hypertension guidelines
2016: 2nd European Society
Hypertension guidelines
2017: AAP Clinical Practice Guidelines
Flynn JT et al. Pediatrics 2017 Nov 30th
Adopted rigorous evidence based approach, including detailed systematic review
30 Key Action Statements (KAS) – graded based on strength
Approx 2 dozen additional clinical recommendations based upon expert opinion (where insufficient evidence for KAS)
Normal range data
4th Report BP tables generated from BP values from 63,227 children at 83091 physician visits Many children had overweight or obesity
Inclusion of these children likely biased normative BP values upwards
Took only those with normal weight (<85C) (49,967)
BP values 2-3mm lower than in 4th report
Normal range data
New normative BP tables in the 2017 CPG
are based only on these BP readings from
49,967 normal-weight children
Will likely lead to increased numbers of
children and adolescents diagnosed with
abnormal BP
Presentation of BP tables
4th Report 2017 AAP CPG
≥95th +12mmHg represents new definition of stage 2 hypertension
Simplification of presentation
Simplified table for screening purposes
90C values
Recognises common use of automated devices but need for confirmation by auscultation
Diagnosis and management
Diagnosis of hypertension still based on demonstration of elevated or hypertension level BP at 3 separate encounters unless the patient is symptomatic
Auscultation remains preferred method
Detailed recommendations on measurement including link to video
Change in definition of hypertension
BP between 90 and 95C now termed ‘elevated blood pressure’
‘Pre-hypertension’ felt to be confusing
Simplification of cut-off between stage 1 and stage 2 hypertension
Single value for elevated BP and hypertension in ≥13s
Highlights
‘Prehypertension’ in 2003 JNC guideline (120-139/80-89) replaced with ‘Elevated’ and Stage 1 hypertension
Stage 2 hypertension lowered from ≥160/100 to ≥140/90
New Stage 1 hypertension This group has 2 x CV risk
compared to normal BP
Recent RCTs have shown benefit of treatment
Will result in 14% increase in prevalence of BP in US and 1.9% increase in antihypertensive use
Ambulatory BP monitoring
Recommendations include
Confirmation of diagnosis where high BP for >12m or on 3 separate occasions
Evaluation of masked hypertension in children with repaired coarctation
Evaluation of BP pattern and risk for target organ damage in those with high risk conditions e.g. CKD
Evaluation for possible hypertension in OSAS
Evaluation of BP in heart and kidney recipients
Assessment of treatment effectiveness
Monitoring of treatment efficacy and possible masked hypertension in CKD
Ambulatory BP monitoring
Focus is same as other recent consensus recommendations in adults e.g. NICE
However whilst NICE and others offer home BP monitoring as an alternative, these guidelines do not recommend this as insufficient evidence in children
May have implications as many primary care providers do not have ready access to paediatric ABPM
Other highlights: Echocardiography Panel of cardiologists convened
Different recommendations from 4th
report
LV mass >51g/m2 – as in 4th report
BUT could also be defined as LV mass >115g/BSA in boys and >95g/BSA in girls
Echo should be performed at time of diagnosis REPLACED WITH echo at time that initiation of pharmacological treatment is considered
Repeat echo should be performed where this was initially normal in those with stage 2 HTN, secondary HT and incompletely treated stage 1 HTN
Drug therapy and treatment goals
Indications for medications Persistent HT despite lifestyle
modification, especially with an abnormal echo: Symptomatic HT
Stage 2 HT without a modifiable risk factor
Any stage of HT in children with diabetes or CKD
RAAS blockers, Ca channel blockers and thiazide diuretics recommended initial therapy
Strong recommendation for RAAS blockade in CKD, diabetes or proteinuria
Treatment goals
<90th centile or 130/80, whichever is lower
In CKD BP should be measured by ABPMRecommended goal is 24h mean <50th centile
European Society of Hypertension 2016: Highlights
BP should be measured in all children starting at 3y
Minimal cost and time input / no invasive or expensive tests
If normal, repeat every 2y
If high normal and no target organ damage, repeat in 1y
Use US 4th task force normal data
Definition of hypertension
Revised for ≥16y to be in line with adult guidelines
European Society of Hypertension 2016: Highlights
Auscultatory method recommended
AAP 2017 guideline
specifically states lack of
evidence of support home BP
monitoring
European Society of Hypertension 2016: Highlights
AAP 2017 guideline does not
recommend routine cIMT
measurement
Achievability of guidelines: a UK perspective
No uniform system of routine medicals for children
British GPs generally unaware of paediatric BP guidelines
Availability of appropriate BP measuring equipment is a significant issue
Nearly all BP measurement in UK children takes place in secondary and tertiary care
103 primary care practices within 6.4km of RMCH
Information collected Practice demographics Availability of equipment to measure BP in
children of all ages Availability and confidence in interpreting
normal range data in children of all ages Inspection of BP measuring equipment
Range of cuff sizes available Whether machine BHS validated
95/103 (92%) practices participated 40 practices had total of 70 paediatric BP cuffs
available 24 had one, 11 had two, 5 had >two 51 different measurement devices
35 (69%) validated for use in children
Confidence (IQR) in interpreting paediatric BP data 3 (2-6)/10 Improved to 8 (6-9) if normal range data provided
Plumb LA et al. Arch Dis Child 2014
SurveyMonkey of GPs in SW of UK
100 responses
78% would never routinely measure child’s BP in primary care setting
Only 15% responded correctly re how to size an appropriate cuff
Summary
Hypertension is a significant and growing problem in children and adolescents
US and European guidelines are helpful well written documents Will increase awareness of diagnosis and treatment of
hypertension in this population
New US paediatric hypertension guidelines Much lower threshold for diagnosis of hypertension
In line with new US adult guidelines
Will increase number of children diagnosed and requiring treatment Significant increase in workload and healthcare expenditure Great need for prospective studies in this population, including
rigorous health-economic evaluation