Hypertension
1
At no time should the systolic pressure in the arm exceed that in the foot. If it does, pressures in both arms and legs should be measured. Consistent recording of higher arm systolic pressure indicates aortic coarctation. High pressure in only the right arm suggests that an obstruction is present proximal to the origin of the left subclavian artery. Interpretation of blood pressure values Hypertension is defined as an average systolic or diastolic BP above the 9th percentile. Any child !ith a BP exceeding the 9"th percentile re#uires scrutiny. Patients !ith severe hypertension and target$organ damage re#uire immediate attention. %or other patients, several measurements of BP should be made at !ee&ly intervals to determine if the elevation is sustained. 'he average of multiple measurements should be plotted on an appropriate percentile chart. If the average measurement is bet!een the 9"th and 9th percentiles (ie, the patient is prehypertensive) the child*s BP should be monitored at +$month intervals. If the average BP is greater than the 9th percentile, the child should be evaluated further and therapy considered. Patients !ith stage I hypertension should be seen again in $- !ee&s. 'hose !ith stage II hypertension s hould be reevaluated in !ee& or sooner if the patient is symptomatic. o$called !hite$coat hypertension is diagnosed in a patient !ho has a BP above the 9th percentile !hen measured in the physician*s office but !ho is normotensive outside the clinical setting. Ambulatory monitoring of BP usually is re#uired to diagnose !hite$coat hypertension. Identification of signs of secondary hypertension A primary ob/ectiv e of the physical examination is to identify signs of secondary hypertension. 'he follo!ing should be evaluated to assess for potential causes of the hypertension0 • Body mass index may lead to an evaluation for metabolic syndrome • 'achycardia may indicate hyperthyroidism, pheochromocytoma, andneuroblastoma • 1ro!th retardation may suggest chronic renal failure • Caf2 au lait spots may point to neurofibromatosis • An abdominal mass may lead to an evaluation for 3ilms tumor and polycystic &idney disease • 4pigastric or abdominal bruit may lead to the diagnosis of coarctation of the abdominal aorta or renal artery stenosis • BP difference bet!een the upper and lo!er extremities indicates coarctation of the thoracic aorta • 'hyromegaly may suggest hyperthyroidism • 5irili6ation or ambiguity may suggest adrenal hyperplasia • tigmata of Bardet$Biedl, von Hippel$7indau, 3illiams, or 'urner syndromes • Acanthosis nigricans may indicate metabolic syndrome 'he complete blood count (CBC) may indicate anemia due to chronic renal disease. Blood chemistry s tudies may be helpful. An increased serum creatinineconcentration indicates renal disease. Hypo&alemia suggests hyperaldosteronism (see potassium). Blood hormone levels may be measured. High plasma renin activity indicates renal vascular hypertension, including coarctation of the aorta, !hereas lo! activity indicates glucocorticoid$remediable aldosteronism, 7iddle syndrome, or apparent mineralocorticoid excess. A high plasma aldosterone concentration is diagnostic of hyperaldosteronism. High values of catecholamines (eg, epinephrine, norepinephrine, or dopamine) are diagnostic of pheochromocytoma or neuroblastoma.
description
hypertension in children
Transcript of Hypertension
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At no time should the systolic pressure in the arm exceed that in the foot. If it does, pressures in both arms andlegs should be measured. Consistent recording of higher arm systolic pressure indicates aortic coarctation.High pressure in only the right arm suggests that an obstruction is present proximal to the origin of the leftsubclavian artery.
Interpretation of blood pressure values
Hypertension is defined as an average systolic or diastolic BP above the 9th percentile. Any child !ith a BPexceeding the 9"th percentile re#uires scrutiny.
Patients !ith severe hypertension and target$organ damage re#uire immediate attention. %or other patients,several measurements of BP should be made at !ee&ly intervals to determine if the elevation is sustained.
'he average of multiple measurements should be plotted on an appropriate percentile chart. If the averagemeasurement is bet!een the 9"th and 9th percentiles (ie, the patient is prehypertensive) the child*s BP shouldbe monitored at +$month intervals. If the average BP is greater than the 9th percentile, the child should beevaluated further and therapy considered.
Patients !ith stage I hypertension should be seen again in $- !ee&s. 'hose !ith stage II hypertension shouldbe reevaluated in !ee& or sooner if the patient is symptomatic.
o$called !hite$coat hypertension is diagnosed in a patient !ho has a BP above the 9th percentile !henmeasured in the physician*s office but !ho is normotensive outside the clinical setting. Ambulatory monitoringof BP usually is re#uired to diagnose !hite$coat hypertension.
Identification of signs of secondary hypertension
A primary ob/ective of the physical examination is to identify signs of secondary hypertension. 'he follo!ingshould be evaluated to assess for potential causes of the hypertension0
• Body mass index may lead to an evaluation for metabolic syndrome
• 'achycardia may indicate hyperthyroidism, pheochromocytoma, andneuroblastoma
• 1ro!th retardation may suggest chronic renal failure
• Caf2 au lait spots may point to neurofibromatosis
• An abdominal mass may lead to an evaluation for 3ilms tumor and polycystic &idney disease
• 4pigastric or abdominal bruit may lead to the diagnosis of coarctation of the abdominal aorta or renal
artery stenosis
• BP difference bet!een the upper and lo!er extremities indicates coarctation of the thoracic aorta
• 'hyromegaly may suggest hyperthyroidism
• 5irili6ation or ambiguity may suggest adrenal hyperplasia
• tigmata of Bardet$Biedl, von Hippel$7indau, 3illiams, or 'urner syndromes
• Acanthosis nigricans may indicate metabolic syndrome
'he complete blood count (CBC) may indicate anemia due to chronic renal disease. Blood chemistry studies
may be helpful. An increased serum creatinineconcentration indicates renal disease. Hypo&alemia suggests
hyperaldosteronism (see potassium).
Blood hormone levels may be measured. High plasma renin activity indicates renal vascular hypertension,
including coarctation of the aorta, !hereas lo! activity indicates glucocorticoid$remediable aldosteronism,
7iddle syndrome, or apparent mineralocorticoid excess. A high plasma aldosterone concentration is diagnostic
of hyperaldosteronism. High values of catecholamines (eg, epinephrine, norepinephrine, or dopamine) are
diagnostic of pheochromocytoma or neuroblastoma.
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8n urine dipstic& testing (see urinalysis), a positive result for blood or protein indicates renal disease. rine
cultures are used to evaluate the patient for chronic pyelonephritis. High urinary excretion of catecholamines
and catecholamine metabolites (metanephrine) indicates pheochromocytoma or neuroblastoma. rine
sodium levels reflect dietary sodium inta&e and may be used as a mar&er to follo! a patient after dietary
changes are attempted.
%asting lipid panels and oral glucose$tolerance tests are performed to evaluate metabolic syndrome in obesechildren. :rug screening is performed to identify substances that might cause hypertension.
7eft ventricular hypertrophy (75H) results from chronic hypertension. 'he finding of 75H on echocardiography
confirms the chronicity of the hypertension and is an absolute indication for starting or intensifying treatment.
75H is symmetric, consisting of e#uivalent increases in in thic&ness for both the left ventricular portion of the
ventricular septum and the left ventricular posterior !all. 7eft ventricular function must also be assessed.
4chocardiography is essential in the evaluation of suspected aortic coarctation. 'he aortic arch and its
branches must be examined in precise anatomic detail.
Abdominal ultrasonography may reveal tumors or structural anomalies of the &idneys or renal vasculature.
;enal scarring suggests excessive renin release. Asymmetry in renal si6e suggests renal dysplasia or renal
artery stenosis. ;enal or extrarenal masses suggest a 3ilms tumor or neuroblastoma, respectively.
8n :oppler studies, asymmetry in renal artery blood flo! suggests renal artery stenosis.
