Using simplified blood pressure tables to avoid underdiagnosing childhood hypertension

Abstract

T he prevalence of paediatric hypertension has significantly increased as a result of the childhood obesity epidemic (1). To evaluate for hypertension, office blood pressure (OBP) measurements are interpreted using the Task Force OBP reference thresholds (also known as the fourth report blood pressure [BP] tables) (2). One-third of children, however, with OBP-based hypertension have 'white coat' hypertension, which does not require the same treatment (3,4). In addition, OBP measurements are insensitive to masked and night-time hypertension, which can independently influence target organ damage (4,5).In clinical practice, the diagnosis of 'white coat', masked and night-time hypertension is made by 24 h ambulatory BP monitoring (ABPM) (3)(4)(5). This assessment involves specialized instrumentation (for continuous and timed ABP measurements), trained staff and costs that are nonreimbursable in many regions. Those diagnosed with OBP-based hypertension as per fourth report BP thresholds are referred for ABPM assessment (6-8).While the fourth report BP tables are widely available, two large North American studies found that hypertension remained undiagnosed by care providers in 74% to 87% of children, even though their recorded OBP exceeded fourth report OBP thresholds (9,10). This underdiagnosis of hypertension was largely due to the logistics of applying the fourth reports BP tables in clinical practice. The fourth report BP tables require a patient's height percentile to interpret his or her OBP. Height percentile is not always plotted in many patient care settings. Moreover, 476 OBP . OBP classified as abnormal by the simplified BP thresholds and by the fourth report BP thresholds performed similarly for correctly identifying abnormal ABP measurements as per ABP references (overlapping 95% CIs of the sensitivity, specificity and predictive values and likelihood ratios). CONCLUSIONS: Simplified BP tables, proposed to reduce the underdiagnosis of hypertension in children, can serve as a useful screening tool to decide a referral for ABP monitoring. Future prospective studies are needed to establish these findings.

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

“…This was a single-center, retrospective, cross-sectional study that was performed as a post hoc analysis from previously performed studies. 8,9 The study involved the retrospective review of existing clinical data and was therefore considered to be exempt from the need for individual informed consent. The records of children and adolescents up to 18 years of age referred to a tertiary care outpatient hypertension clinic (London, ON, Canada) between January 2003 and December 2008 were collected.…”

“…A standard protocol recommended by the fourth-report guidelines have been used to evaluate patients for secondary hypertension. 1,8,9 Those who had an ABP assessment as a part of initial evaluation for hypertension were included. Those who were already on an antihypertensive medication, had less than 2 OBP recordings, had an inadequate ABPM study, or manifested a secondary etiology of hypertension on workup were excluded.…”

“…7 A trained staff member chose an appropriate-sized cuff and supervised the ABPM per a standard protocol. 1,8,9 The ABPM recording was considered to be successful if at least 80% valid ABPM readings, with a minimum of 1 reading per hour, were obtained during day and night. The ABP on each patient was analyzed for mean ABP and ABP load during 24 hours, and separate day and night periods.…”

Diagnosis of hypertension: Ambulatory pediatric American Heart Association/European Society of Hypertension versus blood pressure load thresholds

“…In those with multiple ABPM assessments, their first ABPM recording was included for this analysis. The data was collected between January, 2003 and December, 2008 ( n = 159) as a part of previous studies 16 , 17 , 18 , 19 and recently between January, 2018 and September, 2020 (n = 291). During both the study periods, there was a uniformity in the protocol regarding offering ABPM to patients older than 5 years and for evaluating secondary hypertension (Fourth Report guidelines 20 during the first study period and similar recommendations by the American Academy of Pediatrics‐AAP‐guidelines during the second period 1 ).…”

Late referrals of pediatric patients with elevated blood pressure

“…Without the support of an EMR that automatically calculates blood pressure z-scores from age, height, and gender, the busy primary care physician or emergency room physician may not be able to quickly classify a blood pressure reading as abnormal. Simplified blood pressure tables may serve as simpler tool to accurately classify office blood pressure [15]. Furthermore, the use of smart phone apps such as Ped(z) (https://www.pedz.de/en/welcome.html) may help identify elevated blood pressure readings, but this requires another step for the already overloaded clinical practitioners.…”