Heart Dis­ease

An in­creas­ing num­ber of chil­dren are de­vel­op­ing hypertension, a ma­jor risk fac­tor for heart dis­ease

Newsweek International - - NEWS - BY CAR­RIE ARNOLD @ed­bite

Old at Heart

“BE­ING YOUNG” is not a typ­i­cal risk fac­tor that comes to mind when think­ing about dan­ger­ous heart con­di­tions, nor do we ex­pect the pe­di­a­tri­cian to test for signs of such prob­lems at an an­nual checkup. But in Au­gust, the Amer­i­can Academy of Pe­di­atrics re­vised its guide­lines for the screen­ing, di­ag­no­sis and treat­ment of high blood pres­sure in youth, the rst time these stan­dards have been up­dated since 2004. The new rec­om­men­da­tions sim­pli ed the di­ag­nos­tic pro­ce­dures for pe­di­atric and ado­les­cent high blood pres­sure, made the de ni­tion for hypertension more sim­i­lar to adult guide­lines and changed the term “pre­hy­per­ten­sion” to “el­e­vated blood pres­sure.” The changes make it eas­ier for doc­tors to spot a grow­ing health threat that seems un­be­liev­able: Chil­dren and ado­les­cents are in­creas­ingly at risk for a heart con­di­tion that has al­ways been tied to ag­ing. “We think of some­one with hypertension as be­ing that 50-year-old man down the street, but it’s be­com­ing more and more com­mon even in young chil­dren,” says Dr. David Kael­ber, a pe­di­atric and in­ter­nal medicine physi­cian at Case Western Re­serve Uni­ver­sity.

The shift hints at prob­lems to come. Hypertension a ects 3.5 per­cent of U.S. chil­dren, or more than 2.5 mil­lion peo­ple un­der 18. That num­ber may seem puny com­pared with the one-third of U.S. adults with high blood pres­sure, but Kael­ber says it is still wor­ri­some. High blood pres­sure rates in chil­dren and ado­les­cents have risen in line with higher rates of child­hood obe­sity. With­out in­ter­ven­tion, chil­dren with high blood pres­sure are likely to be­come adults with high blood pres­sure, a risk fac­tor for po­ten­tially fatal heart dis­ease.

Thou­sands of stud­ies have linked hypertension in adults to heart at­tack, stroke, angina and pe­riph­eral artery dis­ease. This threat is why ad­e­quate screen­ing in young peo­ple is so im­por­tant, says Janet de Je­sus, a pro­gram o cer at the Na­tional Heart, Lung, and Blood In­sti­tute. “Kids de nitely aren’t as healthy as they

used to be, and these guide­lines are go­ing to be a huge as­set to the eld.”

There are a va­ri­ety of causes of high blood pres­sure in chil­dren and adults. El­e­vated blood lipids can form plaque de­posits on ar­ter­ies, mak­ing them nar­rower and sti er, which can in­crease blood pres­sure. Peo­ple with higher body weights have more blood, rais­ing the amount of pres­sure on the walls of ar­ter­ies. Smok­ing dam­ages ar­ter­ies and leads to in am­ma­tion. Kid­ney prob­lems, ob­struc­tive sleep ap­nea and even med­i­ca­tions and thy­roid is­sues can all lead to hypertension.

But high blood pres­sure isn’t just a sign that some­thing is wrong in the body—it’s a prob­lem in and of it­self. Hypertension fur­ther dam­ages ar­ter­ies, and the ex­cess strain on the heart can cause that mus­cle to grow thicker, which can in­ter­fere with its abil­ity to de­liver blood, oxy­gen and nu­tri­ents to the body. This cas­cade of mal­adies makes hypertension one of the ma­jor risk fac­tors for heart dis­ease, along with obe­sity, high choles­terol, smok­ing, phys­i­cal in­ac­tiv­ity and di­a­betes.


The prob­lem, ac­cord­ing to Dr. Carissa Bak­er­smith, an epi­demi­ol­o­gist at the Uni­ver­sity of Maryland and the lead data sci­en­tist on the new Amer­i­can Academy of Pe­di­atrics guide­lines, is that many of these is­sues go un­de­tected un­til dis­as­ter strikes. She points to sev­eral stud­ies that pro­vided the de ni­tive ev­i­dence that although heart dis­ease of­ten may not be­come ap­par­ent un­til adult­hood, its seeds are planted in child­hood. A study called Patho­bi­o­log­i­cal Deter­mi­nants of Atheroscle­ro­sis in Youth in the 1990s and the on­go­ing Bo­galusa Heart Study have mea­sured the preva­lence of nar­rowed and hard­ened ar­ter­ies (atheroscle­ro­sis) in ado­les­cents and young adults who died ac­ci­den­tally. Both stud­ies show strong as­so­ci­a­tions be­tween atheroscle­ro­sis—a lead­ing pre­dic­tor of heart dis­ease—and smok­ing, choles­terol lev­els and hypertension. “I re­ally want peo­ple, es­pe­cially par­ents, to un­der­stand that high blood pres­sure does oc­cur in kids. We’re see­ing adult dis­ease in chil­dren,” Baker-smith says.

These re­sults chal­lenge the now-out­dated no­tion that hypertension in kids was pri­mar­ily the result of con­gen­i­tal con­di­tions that a ected the kid­ney and heart. Although ge­net­ics ac­counts for one- fth of all high blood pres­sure cases in kids un­der 18, the re­main­der are “adult-style” hypertension is­sues, caused by a con­ver­gence of bi­o­log­i­cal and en­vi­ron­men­tal fac­tors. Large epi­demi­o­log­i­cal stud­ies by the Cen­ters for Dis­ease Con­trol and Pre­ven­tion have doc­u­mented a rise in sys­tolic blood pres­sure and in di­as­tolic blood pres­sure in chil­dren be­tween 1988 and 2000, which sug­gests the in­crease in pe­di­atric hypertension isn’t just the result of height­ened aware­ness. Although adults have a sin­gle cuto for po­ten­tial blood pres­sure prob­lems, de­ter­min­ing that point is more com­plex for pe­di­a­tri­cians be­cause blood pres­sure in grow­ing chil­dren varies by age, height and sex. Even when doc­tors were vig­i­lant about screen­ing for blood pres­sure is­sues in chil­dren, they strug­gled to in­ter­pret those re­sults. “A lot of doc­tors were very confused,” says Dr. Suzanne La­zorick, a pe­di­a­tri­cian and pre­ven­tive medicine physi­cian at Eastern Carolina Uni­ver­sity.

Kael­ber puts it more starkly. “If you re­viewed elec­tronic med­i­cal records [for chil­dren], you could see blood pres­sures recorded, but the pe­di­a­tri­cian never di­ag­nosed hypertension,” he says. Physi­cians were un­clear about what blood pres­sure level was too high, so the con­di­tion in chil­dren went un­no­ticed.


These chal­lenges led Kael­ber and Dr. Joseph Flynn, a nephrol­o­gist at the Uni­ver­sity of Washington, to call for a re­vi­sion of the 2004 guide­lines they had au­thored. Baker-smith led a re­view of the 15,000-plus stud­ies pub­lished since 2004 to cre­ate a rigorous base from which to dis­till nd­ings. From there, they re­viewed how well the cur­rent stan­dards were work­ing and what sci­en­tists were learn­ing about high blood pres­sure in chil­dren and ado­les­cents. The nal doc­u­ment con­tains sev­eral ma­jor changes from pre­vi­ous rec­om­men­da­tions, in­clud­ing how to mea­sure blood pres­sure and how doc­tors di­ag­nose hypertension, as well as the ter­mi­nol­ogy to use.

In­stead of screen­ing for high blood pres­sure at ev­ery health care visit, the new guide­lines say to screen only at an­nual well-child vis­its be­gin­ning at age 3. Many tran­sient fac­tors can a ect blood pres­sure, in­clud­ing stress and ca eine, which could lead to in­ac­cu­rate data and unnecessary test­ing. And doc­tors need sev­eral blood pres­sure read­ings to make a di­ag­no­sis of hypertension.

The panel also al­tered the tran­si­tion from pe­di­atric blood pres­sure ta­bles to the 120/80 mmhg cuto used for adults. The tran­si­tion used to come at age 18, so a child could have ab­nor­mal blood pres­sure at the age of 17 years and 364 days and

then be ne the next day, Kael­ber says. The new ta­bles be­gin tran­si­tion­ing chil­dren to adult mark­ers at age 13, de­pend­ing on height and weight. This pro­vides more con­sis­tency and will ease the tran­si­tion to adult blood pres­sure stan­dards.

To de Je­sus, the im­por­tance of the new guide­lines in en­sur­ing ad­e­quate di­ag­no­sis and treat­ment of child­hood hypertension can’t be over­stated. When kids are young, they can com­pletely re­verse car­dio­vas­cu­lar dam­age from hypertension or high choles­terol. By the time they reach adult­hood, how­ever, this abil­ity di­min­ishes.

Kael­ber, Flynn, Baker-smith and col­leagues also re­cal­i­brated the blood pres­sure ta­bles to in­clude only chil­dren with normal weights. Pe­di­a­tri­cians de­cide if a child’s blood pres­sure is high by com­par­ing it with those of a group of healthy chil­dren. But the grow­ing num­bers of chil­dren who are over­weight and obese, two traits strongly linked to in­creased blood pres­sure, have skewed that bench­mark data. Us­ing only normal-weight chil­dren pro­vides a better de ni­tion for a healthy blood pres­sure, Baker-smith says. The team also elim­i­nated the need for echocar­dio­grams (an ul­tra­sound of the heart) un­less the child re­quires med­i­ca­tion, a change that re ects the grow­ing num­ber of hy­per­ten­sive chil­dren with­out un­der­ly­ing con­gen­i­tal heart is­sues. For those with more se­vere hypertension in need of med­i­ca­tion, echocar­dio­grams have re­vealed car­diac com­pli­ca­tions more usu­ally seen in adults, such as left ven­tric­u­lar hy­per­tro­phy, a thick­en­ing of the heart mus­cle.

Lastly, the guide­line re­vi­sion group changed the term “pre-hypertension,” used to in­di­cate chil­dren whose blood pres­sure was a con­cern but who didn’t meet clin­i­cal de ni­tions of hypertension, to “el­e­vated blood pres­sure.” The new lan­guage is in­tended to sound an alarm. “Par­ents tend to hear pre-hypertension and think it’s not a prob­lem be­cause it’s be­fore a dis­ease, but that’s not what we’re try­ing to say,” La­zorick says.

The in­creas­ing re­liance on am­bu­la­tory blood pres­sure mon­i­tor­ing de­vices could pose a chal­lenge. Although these mon­i­tors pro­vide in­creased ac­cu­racy, not all pe­di­a­tri­cians have ac­cess to them. Ramp­ing up the avail­abil­ity of am­bu­la­tory mon­i­tor­ing will be key to putting the rec­om­men­da­tions into prac­tice, La­zorick says.

Although some of these guide­lines may seem more con­ser­va­tive—hypertension screen­ing only at reg­u­lar pre­ven­tive care vis­its, re­duced


rec­om­men­da­tions for echocar­dio­gram—they ac­tu­ally de­crease the po­ten­tial for over­diag­no­sis of pe­di­atric hypertension. “No one wants to give kids a di­ag­no­sis they don’t have or a treat­ment they don’t need,” Baker-smith says.

No stan­dards can elim­i­nate the risk of over­diag­no­sis. But given that rst-line treat­ment for chil­dren with high blood pres­sure is di­etary and phys­i­cal ac­tiv­ity changes, Baker-smith says this advice is low-risk and can bene t many chil­dren, even those with­out hypertension. Mak­ing these changes isn’t easy, es­pe­cially in a cul­ture awash in salty, fatty foods. By start­ing early and mod­el­ing healthy be­hav­iors, de Je­sus says, par­ents can teach their kids to make good de­ci­sions about food and ex­er­cise as they get older and have more au­ton­omy. “Even adults strug­gle to choose wa­ter over soda or juice. How can we ex­pect a 10-yearold to do that?” La­zorick asks.

But for chil­dren di­ag­nosed with high blood pres­sure, hav­ing an adult dis­ease re­quires grow­ing up fast.


GET­TING PUMPED: The new guide­lines call for pe­di­a­tri­cians to start screen­ing an­nu­ally for high blood pres­sure be­gin­ning when a child is 3.

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