When to measure BP?When to measure BP?

Routine PERoutine PE

Headache, vertigoHeadache, vertigo

Decrease Level of ConsciousnessDecrease Level of Consciousness

Facial PalsyFacial Palsy

ConvulsionConvulsion

HemiparesisHemiparesis

Unexplained AnemiaUnexplained Anemia

FTT,Irritability, VomitingFTT,Irritability, Vomiting

Suspected Renal or Vascular DiseasesSuspected Renal or Vascular Diseases

DM, Abdominal massDM, Abdominal mass

Heart Failure, Respiratory DistressHeart Failure, Respiratory Distress

Family history of HTNFamily history of HTN

Case 1Case 1

A 5 Yr old girl referred for check-upA 5 Yr old girl referred for check-up

PE: WNL Except BP=140/90PE: WNL Except BP=140/90

Lower limb BP=110/70Lower limb BP=110/70

Cardiac Echo: NormalCardiac Echo: Normal

Angiography: COAAngiography: COA

Treatment: Ballon DilatationTreatment: Ballon Dilatation

Case 2Case 2

A 4 month old infant, admitted due to A 4 month old infant, admitted due to uncontrolled convulsionuncontrolled convulsion

PE: BP=90/70 Palpable liver & spleenPE: BP=90/70 Palpable liver & spleen

Sono: Unilateral Cystic kidneySono: Unilateral Cystic kidney

Second BP=140/90Second BP=140/90

BP control also controlled convulsionBP control also controlled convulsion

Final Diagnosis: Tuberous SclerosisFinal Diagnosis: Tuberous Sclerosis

Case 3Case 3

A 14 yr old girl, with headache, visited by A 14 yr old girl, with headache, visited by internist with normal lab finding and sono. internist with normal lab finding and sono. HTN was controlled by 2 drugsHTN was controlled by 2 drugs

PE: Tall girl, Normal BP,NL PE (except PE: Tall girl, Normal BP,NL PE (except low BP of lower limbs)low BP of lower limbs)

Her father was hypertensive (?Essential)Her father was hypertensive (?Essential)

Echo & Angiography Revealed COA Echo & Angiography Revealed COA

Case 4Case 4

A 4 Yr old boy with VP Shunt (due to A 4 Yr old boy with VP Shunt (due to hydrocephalus) was consulted due to hydrocephalus) was consulted due to uncontrollable convulsions in Surgery uncontrollable convulsions in Surgery Ward. The shunt was not working well and Ward. The shunt was not working well and HTN was not controllable with drug.HTN was not controllable with drug.

Changing the shunt catheter was followed Changing the shunt catheter was followed by normal BP and controlling convulsion.by normal BP and controlling convulsion.

Case 5Case 5

A 12 Yr old boy was followed by a A 12 Yr old boy was followed by a neurosurgeon due to headache and was neurosurgeon due to headache and was scheduled for brain CT scan. He scheduled for brain CT scan. He developed hemiparesis few months later.developed hemiparesis few months later.

PE: 180/120PE: 180/120

Outcome: BP was controlled but Outcome: BP was controlled but hemiparesis was irreversible.hemiparesis was irreversible.

Case 6Case 6

A 10 Yr old girl from Ahwaz was wondered A 10 Yr old girl from Ahwaz was wondered due to anemia for 3 years. BP was not due to anemia for 3 years. BP was not measured & in-spite of a lot of work-ups, measured & in-spite of a lot of work-ups, BUN was not checked.BUN was not checked.

PE: Wt= 15 Kg, Ht=115, BP=140/100PE: Wt= 15 Kg, Ht=115, BP=140/100

Final Diagnosis: CRFFinal Diagnosis: CRF

Case 7Case 7

A 12 Yr old boy was followed for unexplained anemia (with low A 12 Yr old boy was followed for unexplained anemia (with low MCV) for 10 years. Neither BP was measured nor BUN was MCV) for 10 years. Neither BP was measured nor BUN was checked.checked.Blood sample was sent abroad for more evaluation. Result: Alfa- Blood sample was sent abroad for more evaluation. Result: Alfa- ThalassemiaThalassemiaHe referred due to facial palsy. The third specialist who visited him, He referred due to facial palsy. The third specialist who visited him, noticed HTN.noticed HTN.The cause of HTN was CRF. After successful renal TX, Hb raised to The cause of HTN was CRF. After successful renal TX, Hb raised to 12, but MCV was less than 70.12, but MCV was less than 70.

Case 8Case 8

An 11 Yr old boy, with facial palsy, was admitted in neurosurgery An 11 Yr old boy, with facial palsy, was admitted in neurosurgery ER with impression of pseudotumor cerebri. Daily LP was done for ER with impression of pseudotumor cerebri. Daily LP was done for one week and was discharged with BUN=20. A neurologist one week and was discharged with BUN=20. A neurologist recommended carbamazepine. Before starting treatment, he recommended carbamazepine. Before starting treatment, he developed edema, blindness, pallor and oliguria.developed edema, blindness, pallor and oliguria.

Findings: anemia, thrombocytopenia, renal failure and BP= Findings: anemia, thrombocytopenia, renal failure and BP= 160/120.160/120.

Case 9Case 9

This 5 YR old girl was admitted with This 5 YR old girl was admitted with impression of febrile convulsion. BP was impression of febrile convulsion. BP was not measured at admission, but later on not measured at admission, but later on incidentally it was found to be 160/120.incidentally it was found to be 160/120.

Final Diagnosis: Hypertensive Final Diagnosis: Hypertensive Encephalopathy secondary to AGN.Encephalopathy secondary to AGN.

Definition of HTNDefinition of HTN

- Borderline: 90-95 percentile Borderline: 90-95 percentile

- Mild: 5-9 mmHg above 95 percentile Mild: 5-9 mmHg above 95 percentile

- Moderate: 10-15 mmHg above 95 Moderate: 10-15 mmHg above 95 percentile percentile

- Severe: More than 15 mmHg above 95 Severe: More than 15 mmHg above 95 percentile or vital organ damage percentile or vital organ damage

Definition of HTNDefinition of HTNNormal BP — Both systolic and diastolic BP Normal BP — Both systolic and diastolic BP <90th percentile.<90th percentile.

Prehypertension — Systolic and/or diastolic Prehypertension — Systolic and/or diastolic BP ≥90th percentile but <95th percentile or if BP ≥90th percentile but <95th percentile or if BP exceeds 120/80 mmHg (even if <90th BP exceeds 120/80 mmHg (even if <90th percentile for age, gender, and height).percentile for age, gender, and height).

DEFINITIONDEFINITION

Hypertension — HTN is defined as either Hypertension — HTN is defined as either systolic and/or diastolic BP ≥95th percentile systolic and/or diastolic BP ≥95th percentile measured upon three or more separate measured upon three or more separate occasions. The degree of HTN is further occasions. The degree of HTN is further delineated by the two following stages.delineated by the two following stages.

- Stage 1 HTN — Systolic and/or diastolic BP - Stage 1 HTN — Systolic and/or diastolic BP between the 95th percentile and 5 mmHg above between the 95th percentile and 5 mmHg above the 99th percentile.the 99th percentile.

- Stage 2 HTN — Systolic and/or diastolic BP - Stage 2 HTN — Systolic and/or diastolic BP ≥99th percentile plus 5 mmHg.≥99th percentile plus 5 mmHg.

Differences in children and adults Differences in children and adults

- Incidence Incidence

- BP is not measured routinely BP is not measured routinely

- Difficulties in BP measurement Difficulties in BP measurement

- Vital organ damage Vital organ damage

- Etiology Etiology

- Symptoms Symptoms

Upper limit of BPUpper limit of BP

Age (yr)Age (yr) BPBP

1-51-5 110/70110/70

6-96-9 120/80120/80

10-1310-13 125/85125/85

14-1814-18 135/90135/90

Causes of transient HTNCauses of transient HTN

- Renal (AGN, HUS, Surgery, Renal TX)Renal (AGN, HUS, Surgery, Renal TX)

- Acute hypovolemia (Burn, relapse of NS)Acute hypovolemia (Burn, relapse of NS)

- CNS (trauma, tumor, infection, …)CNS (trauma, tumor, infection, …)

- Endocrine (hypercalcemia, Endocrine (hypercalcemia, hyperthyroidism) hyperthyroidism)

- Drugs (steroids, sympathomimetics) Drugs (steroids, sympathomimetics)

Causes of sustained HTNCauses of sustained HTN

- Renin-dependent (Renovascular, renal Renin-dependent (Renovascular, renal parenchymal disease, renal tumors)parenchymal disease, renal tumors)

- CRFCRF- Coarctation of aortaCoarctation of aorta- ↑↑Catecholamine (pheochromocytoma, Catecholamine (pheochromocytoma,

neuroblastoma)neuroblastoma)- ↑↑Corticosteroids (CAH, Cushing Corticosteroids (CAH, Cushing

syndrome, …)syndrome, …)- Essential HTN Essential HTN

Etiology and AgeEtiology and Age

Infants: RV, congenital anomalies, PCKD, Infants: RV, congenital anomalies, PCKD, MCDK,HUS, ATN, COA, CAH.MCDK,HUS, ATN, COA, CAH.

1-6 yr: RPD, RV, endocrine diseases, 1-6 yr: RPD, RV, endocrine diseases, COA, essential.COA, essential.

6-12 yr: RPD, essential, RV, endocrine 6-12 yr: RPD, essential, RV, endocrine diseases, COA.diseases, COA.

12-18 yr: Essential, RPD, RV, endocrine 12-18 yr: Essential, RPD, RV, endocrine diseases, COA.diseases, COA.

Renal diseases Renal diseases

- The most common cause of HTN (75-The most common cause of HTN (75-80%)80%)

- The most common renal disease:The most common renal disease:

reflux – nephropathy (25-50%)reflux – nephropathy (25-50%)

- The most common type of RVH:The most common type of RVH:

fibromuscular dysplasia (70%)fibromuscular dysplasia (70%)

Symptoms in infants Symptoms in infants

- CHFCHF (56%)(56%)

- Respiratory distressRespiratory distress (36%)(36%)

- FTT, vomiting FTT, vomiting (29%)(29%)

- Irritability Irritability (20%)(20%)

- Convulsion Convulsion (11%)(11%)

Symptoms in older children Symptoms in older children

- Headache Headache (30%)(30%)

- Nausea, VomitingNausea, Vomiting (13%)(13%)

- Hypertensive encephalopathy Hypertensive encephalopathy (10%)(10%)

- Polyuria, enuresis, visual defect, facial Polyuria, enuresis, visual defect, facial palsy, epistaxis, etc. palsy, epistaxis, etc.

Guiding points in P.EGuiding points in P.E

- Obesity, HtObesity, Ht

- Difference in BP of extrimities Difference in BP of extrimities

- BruitBruit

- Abnormal genitalia Abnormal genitalia

- Skin lesion Skin lesion

- Abdominal massAbdominal mass

- etc etc

Investigations Investigations

Mild- CBC, BUN, creatinine, electrolytes, ca, Mild- CBC, BUN, creatinine, electrolytes, ca, uric acid, cholestrol, urinalysis uric acid, cholestrol, urinalysis

Moderate- Abdominal sono, DMSA scan, Moderate- Abdominal sono, DMSA scan, urine VMA, renin, aldostrone or urine VMA, renin, aldostrone or catecholamines, chest X-ray, ECG±VCUGcatecholamines, chest X-ray, ECG±VCUG

Severe- Angiography, segmental renal vein Severe- Angiography, segmental renal vein renin and IVC catecholamine, urine steroid renin and IVC catecholamine, urine steroid analysis, echo, DTPAanalysis, echo, DTPA