Comparative Analysis of American Heart Association and European Society of Hypertension Ambulatory Blood Pressure Thresholds for Diagnosing Hypertension in Children

Abstract

Introduction: The influence of using 24-hour ambulatory blood pressure (ABP) thresholds recommended by the American Heart Association (AHA) (24-hour mean ABP >95th percentile and ABP load >25%) or the European Society of Hypertension (ESH) (mean 24-hour ABP >95th percentile or >130/80 mm Hg if mean ABP 95th percentile exceeds 130/80 mm Hg) on the diagnosis of pediatric hypertension has been understudied.Methods: In a cross-sectional, retrospective study of 159 children from a tertiary care outpatient clinic, we classified office blood pressure (OBP) as normotension or hypertension based on the OBP thresholds recommended by the American Academy of Pediatrics (AAP) and the fourth report on the diagnosis, evaluation, and treatment of high blood pressure in children and adolescents (herein referred to as the fourth report) by the National High Blood Pressure Educational Program Working Group on High Blood Pressure in Children and Adolescents separately. Thereafter, we evaluated the agreement between the ambulatory AHA and ESH thresholds for diagnosing normotension, white-coat hypertension (WCH), masked hypertension (MH), and hypertension based on the patient's ABP and OBP hypertension pattern.Results: With office hypertension as per the AAP thresholds, the AHA and ESH thresholds classified 85% of subjects similarly into normotension, WCH, MH, and hypertension (k ¼ 0.78; 95% CI, 0.67-0.89). The agreement between the AHA and ESH thresholds did not change when OBP was reclassified by the fourthreport OBP thresholds (k ¼ 0.77; 95% CI, 0.65-0.88). With OBP classified by either AAP or fourth-report thresholds, the ESH thresholds diagnosed 6% to 7% more children as hypertensive, whereas the AHA threshold classified 11% more children as normotensive. Conclusion:The AHA and ESH thresholds have good agreement in classifying OBP. However, the ESH threshold classifies more OBP as hypertensive and the AHA threshold classifies more OBP as normotensive.Kidney Int Rep (2020) 5, 611-617; https://doi.

Reclassification of adolescent hypertension by ambulatory blood pressure monitoring using adult norms and association with left ventricular hypertrophy

“…regardless of which adult norms were applied. This is similar to previous studies 16,17 wherein applying different norms resulted in significant reclassification. Perhaps the most clinically significant reclassification is of those patients reclassified from no-HTN to HTN as these are the patients who are missed when using the current pediatric norms.…”

“…15 We found significant misclassification or rather reclassification (since pediatric standards are not necessarily evidence-based) regardless of which adult norms were applied. This is similar to previous studies 16,17 Previous studies have evaluated the impact of reclassification of clinic BP when applying various normative data to a pediatric population, 5,6 but few have evaluated the impact on ABPM classification. 16,17 Two previous studies evaluated the impact of ABPM reclassification using pediatric norms and ESH norms.…”

“…Study participantsThis was a retrospective study of all patients[13][14][15][16][17] years old who wore an ABPM between 9/2018 and 5/2019 in the Renal, Cardiology, and Multi-Disciplinary Hypertension Clinics at a large pediatric hospital-based outpatient center. All patients with complete ABPM data were included for the analysis of blood pressure classification (HTN vs. no-HTN) based on ABPM alone and the classification of white coat HTN (WCH) vs. no-WCH and masked HTN (MH) vs. no-MH using ABPM and clinic BP.…”

Controversy and Agreement Among Guidelines Defining Ambulatory Hypertension in Children

“…In light of these discrepancies, it is important to understand the impact of using different systems of classifying hypertension. Hence, the value of work by Sharma et al 9 published in this issue of Kidney International Reports. They report a cross-sectional study that includes 159 children seen in a tertiary hospital hypertension clinic, using office BP and ABPM measurements to classify participants into normotensive, whitecoat hypertension, masked hypertension, and hypertension categories according to both AAP and ESH guidelines.…”

Automated Office Blood Pressure Measurement for the Diagnosis of Hypertension

“…8 Abnormal ABPM readings and confirmation of end-organ damage serve as the gold standard for the diagnosis of hypertension. Although there are some differences when applying either the American or European guidelines, 9 all of them call for the use of ABPM for the confirmation of hypertension. Furthermore, routine ABPM is strongly recommended to regularly assess severity and determine circadian BP patterns.…”