IS WHITE COAT HYPERTENSION BENIGN IN CHILDREN AND...

IS WHITE COAT HYPERTENSION BENIGN IN CHILDREN AND ADOLESCENTS?

Dénes Páll MD, PhD, DSci

Department of Medicine, University of Debrecen

Debrecen, HUNGARY

First data was reported in 1991: prevalence of adolescent WCH is 44%. (1)

1. Hornsby JL. J Fam Pract 1991; 33: 617–623., 2. Stabouli S. Pediatr Nephrol 2005; 20: 1151–1155.3 Matsuoka S, Pediatr Nephrol 2002; 17: 950–953., 4. Parati G. J Hypertens 2006; 24: 29–31.

5. Morić VB.Acta Med Croatica 2008; 62(suppl 1):3–6., 6. Floriańczyk T. Kardiol Pol 2008; 66: 12–17.

ADOLESCENT WHITE COAT HYPERTENSION




The prevalence of WCH in young people with persistently elevated casual BP to be between 13 and 88%. (2)






In a study of Japanese young people under 25, WCH was diagnosed in 47% of those who had been found to be hypertensive based on office measurements. (3)





The white coat effect (the difference between the office value and the daytime mean is 10 mmHg) was observed in 50% of hypertensives and 25% of normotensives. (4)







The white coat effect (the difference between the office value and the daytime mean is 10 mmHg) was observed in 50% of hypertensives and 25% of normotensives. (4)



The prevalence of WCH in a study involving Croatian adolescents was21% (5), while in a corresponding Polish study it was found to be 32.6%. (6)


85 children – OBPM, ABPM, ECHO, US of the carotid

WCH - 12.9%; MH - 9.4%

Pediatr Nephrol, 20:1151-55, 2005.

Pediatr Nephrol, 20:1151-55, 2005.

119 consecutive children age 6 to 18 years, (65% male) referred for HBP.

Prevalence of WCH: 52%

J Pediatr, 150:491-7, 2007.

119 consecutive children age 6 to 18 years, (65% male) referred for HBP.

Prevalence of WCH: 52%

Treadmill exercise

J Pediatr, 150:491-7, 2007.

- increased LV mass in 35%

- exaggerated BP response to TE in 38%

- at least one of them: 62%

J Pediatr, 150:491-7, 2007.

112 adolescents, referred for elevated blood pressure

64 boys, mean age: 12.8±2.9 years

112 adolescents, referred for elevated blood pressure

18% had WCH and 11% MH

64 boys, mean age: 12.8±2.9 years

Curr Hypertens Rep, 15:143-149, 2013.

WCH: 46%, pre-HT: 19%, HT: 35%.

J Am Soc Hypertens, 10(2):108-114; 2016.

Untreated 69 children, 6-20 years

ABPM: WCH, pre-HT, HT.

Obese children in all three groups may be at a greater risk for end organ damage.

J Am Soc Hypertens, 10(2):108-114; 2016.

Correlation between the magnitude of white-coat effect (WCE) or reverse WCE

(RWCE) and

- 24-h pulse pressure (PP) - an indicator of target organ damage and arterial

stiffness, in children and young adults.

- BP variability - another predictor of clinical outcomes.

Pediatr Cardiol, 37:345-352, 2016.

189 subjects were studied.


There was a progressive increase in 24-h PP from normotension, WCH, MH, to hypertension.

DHSDebrecen Hypertension Study

D E B R E C E N

RESULTS OF THE DEBRECEN HYPERTENSION STUDY

1 occasion - 3 measurements DO WE EXCLUDE HYPERTENSION?

by age, gender and height syst. and diast. BP <90th percentile

n=10359

NO (n=1641)

YES (n=8708)

Further measurements are

needed

3 occasions - 3x3 measurements

DO WE CONFIRM HYPERTENSION?

by age, gender and height

syst. and/or diast. BP >95th percentile

n=1461

NO (n=1245)

HYPERTENSIVE (n=216)

Katona E, Zrinyi M, Lengyel S, Paragh G, Zatik J, Fulesdi B, Pall D. Blood Press, 20(3):134-9; 2011.

PREVALENCE2.53%

DHS

ABPM 120 cases

DHSHYPERTENSION WAS CONFIRMED BY ABPM

Pall D, Juhasz M, Lengyel S, Molnar C, Paragh G, Fulesdi B, Katona E. J Hypertens, 28(10):2139-44; 2010.

normotension

borderline HT

hypertension sustained hypertension

60 %

17 %

23 % 13 %

70 %

17 % 16 %

34 %50 %

n=120

females: n=56males: n=64

white coat hypertension

ABPM 120 cases

HYPERTENSION WAS CONFIRMED BY ABPM DHS


RESULTS OF THE ABPM

White coat HTN Sustained HTN p-value

Number 47 73

Systolic BP average (mmHg) 125.29.3 130.89.5 <0.01

Diastolic BP average (mmHg) 68.16.9 70.26.40 0.37

Average heart rate (1/min) 78.710.9 78.59.4 0.94

Systolic PTE (%) 27.120.1 39.925.1 <0.01

Diastolic PTE (%) 8.39.9 8.68.4 0.87

Systolic HTN load (mmHgxh) 69.670.9 129.6114.9 <0.001

Diastolic HTN load (mmHgxh) 15.920.4 14.718.1 0.73

DHS

Normotensives WCH Sustained HTN

Number 59 47 73

Gender (F/M) 29/30 28/19 29/44

Age (years) 15.8±0.6 16.3±1.1 16.5±1.0

Height (cm) 169.0±9.2 170.5±9.9 170.5±9.9

Body weight (kg) 58.3±11.5 64.1±13.8 71.6±15.5

BMI (kg/m2) 20.22.7 21.83.5 23.44.2

BMI < 25 kg/m2 (%) 93.2 85.1 68.5

BMI 25-30 kg/m2 (%) 5.1 12.8 23.3

BMI > 30 kg/m2 (%) 1.7 2.1 8.2

CHARACTERISTICS OF THE ADOLESCENTSDHS


Number 59 47 73

Se glucose (mmol/l) 5.30.7 5.40.7 5.61.5

Se cholesterol (mmol/l) 4.2±0.7 4.3±0.7 4.2±0.8

Se triglyceride (mmol/l) 0.86±0.44 0.93±0.45 1.08±0.65

HDL-cholesterol (mmol/l) 1.5±0.2 1.5±0.2 1.4±0.3

LDL-cholesterol (mmol/l) 2.3±0.5 2.4±0.6 2.4±0.7

LABORATORY FINDINGS OF THE ADOLESCENTS

DHS


Number 59 47 73

Systolic BP (mmHg) 114.910.1 138.311.4 144.811.1

Diastolic BP (mmHg) 66.88.9 82.511.0 82.48.3

Mean BP (mmHg) 83.08.4 101.17.9 103.26.4

Pulse rate (1/min) 81.916.6 84.819.7 81.117.2

CASUAL BLOOD PRESSURE OF THE ADOLESCENTS

DHS

NITRIC OXIDE (NOx) IN ADOLESCENTS

0

10

20

30

40

50

Normotensive WCH Sustained HT

Seru

m N

Ox

(µm

ol/

l)

** NS** p<0.01

**

DHS

Páll D, Lengyel S, Komonyi É, Molnár C, Paragh G, Fülesdi B, Katona É. Eur J Neurol, 18(4):584-9; 2011.Lengyel S, Katona É, Zatik J, Molnár C, Paragh G, Fülesdi B, Páll D. Blood Press, 21(1):39-44; 2012.

LEFT VENTRICULAR MASS INDEX IN ADOLESCENTS

0

10

20

30

40

50

Normotensive WCH Sustained HTLeft

ven

tric

ula

r m

ass

ind

ex (

g/m

2.7

)

*NS *** p<0.001

* p<0.05

***

35.5±10.3 37.7±11.2 44.1±14.1

DHS


INTIMA-MEDIA THICKNESS OF THE COMMON CAROTID ARTERIES IN ADOLESCENTS

0

0,01

0,02

0,03

0,04

0,05

0,06

Normotensive WCH Sustained HT

Inti

ma-

med

ia t

hic

knes

s (c

m)

** NS

** p<0.01

**

0.048±0.01 0.056±0.01 0.054±0.02

DHS


MEAN BLOOD FLOW VELOCITY OF ARTERIA CEREBRI MEDIA AT WHITE COAT HYPERTENSIVE ADOLESCENTS

Páll D, Lengyel S, Komonyi É, Molnár C, Paragh G, Fülesdi B, Katona É. Eur J Neurol, 18(4):584-9; 2011.

At rest Breath-holding

NT WCH HTN

CONCLUSION 1.

• The imbalance of the endothelial factors may play a determinant role in

the development of the disease and its target organ damage, which

warrants further exploration.

CONCLUSION 2.

• An increased IMT can be demonstrated not only in the sustained, but also

in white coat form of adolescent hypertension.




CONCLUSION 2.

• LVMI of the normotensives and white coat hypertensives didn’t differed.

• Target-organ damage develops in a stepwise fashion in adolescent

hypertension.

• An increased IMT can be demonstrated not only in the sustained, but also

in white coat form of adolescent hypertension.




CONCLUSION 2.

• LVMI of the normotensives and white coat hypertensives didn’t differed.

IS WHITE COAT HYPERTENSION BENIGN IN CHILDREN AND ADOLESCENTS?

NT WCH MH HTN

CONCLUSION 3.

Journal of Hypertension 2016, 34:1887–1920

IS WHITE COAT HYPERTENSION BENIGN IN CHILDREN AND...

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