Pediatric hypertension predisposes children to adult hypertension and early markers of cardiovascular disease. No large-scale studies have examined diagnosis and initial medication management of pediatric hypertension and prehypertension. The objective of this study was to evaluate diagnosis and initial medication management of pediatric hypertension and prehypertension in primary care.
Retrospective cohort study aggregating electronic health record data on >1.2 million pediatric patients from 196 ambulatory clinics across 27 states. Demographic, diagnosis, blood pressure (BP), height, weight, and medication prescription data extracted. Main outcome measures include proportion of pediatric patients with ≥3 visits with abnormal BPs, documented hypertension and prehypertension diagnoses, and prescribed antihypertensive medications. Marginal standardization via logistic regression produced adjusted diagnosis rates.
Three hundred ninety-eight thousand seventy-nine patients, ages 3 to 18, had ≥3 visits with BP measurements (48.9% girls, 58.6% <10 years old). Of these, 3.3% met criteria for hypertension and 10.1% for prehypertension. Among practices with ≥50 eligible patients, 2813 of 12 138 patients with hypertension (23.2%; 95% confidence interval, 18.2%–28.2%) and 3990 of 38 874 prehypertensive patients (10.2%; 95% confidence interval, 8.2%–12.2%) were diagnosed. Age, weight, height, sex, and number and magnitude of abnormal BPs were associated with diagnosis rates. Of 2813 diagnosed, persistently hypertensive patients, 158 (5.6%) were prescribed antihypertensive medication within 12 months of diagnosis (angiotensin-converting enzyme inhibitors/angiotensin receptive blockers [35%], diuretics [22%], calcium channel blockers [17%], and β-blockers [10%]).
Hypertension and prehypertension were infrequently diagnosed among pediatric patients. Guidelines for diagnosis and initial medication management of abnormal BP in pediatric patients are not routinely followed.
Comments
RE: Chinese Guideline for Hypertension in Children: Reality and Necessity
Blood pressure cutoff for hypertension in children is important to pediatric clinicians to make a definite diagnosis for their patients. In china, the most widely accepted clinical criteria for the diagnosis of hypertension in children is the Fourth Report on the Evaluation of the Diagnosis, Evaluation, and Treatment of High Blood Pressure in Children and Adolescents published by the U.S. National High Blood Pressure Education Program(NHBPEP) [1]. I wonder whether the U.S.-based data may be accurately applied in China because different racial and ethnic groups have diffrent features of BP level and prevalence of hypertension[2,3].In recent years, Chinese scholars have attempted to develop our own BP tables for diagnosing hypertensionin children and adolescents. In 2010, Mi J et al reviewed the large Chinese epidemiological surveys involving 112227 children and developped the blood pressure reference standards for Chinese children[4]. In 2015, Bo X et al established international blood pressure references among non-overweight children and adolescents aged 6-17 years based on seven nationally representative data (China, India, Iran, Korea, Poland, Tunisia and USA)[5]. Anyhow, it is a dilemma because there is no concensus on the diagnosis criteria. The reality is the recommended standards for assessing blood pressure in Chinese children is still a major focus. And I believe, our task is not to examine the guidelines for diagnosis and initial medication management of abnormal BP in pediatric patients are routinely followed or not, which is discussed by Kaelber DC et al[6].Instead, we shoud rethink our Chinese guidelines for diagnosis, and I believe that is a necessity.
References
[1]National High Blood Pressure Education Program Working Group on High Blood Pressure in Children and Adolescents. The fourth report on the diagnosis, evaluation, and treatment of high blood pressure in children and adolescents. Pediatrics. 2004;114(2 suppl 4th report):555-576
[2]Rosner B, Cook N, Portman R, Daniels S, Falkner B: Blood pressure differences by ethnic group among United States children and adolescents. Hypertension 2009, 54(3):502-508.
[3]Suglia SF, Clark CJ, Gary-Webb TL.Adolescent Obesity, Change in Weight Status, and HypertensionNovelty and Significance Racial/Ethnic Variations.Hypertension 2013, 61(2):290-295.
[4]Mi J, Wang T, Meng L, ,et al.Development of blood pressure reference standards for Chinese children.Chin J Evid Based Pediatr 2010, 5(1):4-14.
[5]Xi B, Zong X, Kelishadi R,et al. Establishing International Blood Pressure References Among Non-Overweight Children and Adolescents Aged 6-17 Years. Circulation 2015 Dec15. Epub 2015 Dec 15.
[6]Kaelber DC, Liu W, Ross M,et al. Diagnosis and Medication Treatment of Pediatric Hypertension: A Retrospective Cohort Study.Pediatrics Dec 2016, 138 (6) e2016219.