A 17-year-old female presented to the Hypertension and Vascular Evaluation (HAVE) Program for high blood pressure (BP) during multiple office visits in the setting of morbid obesity and type 2 diabetes mellitus. Family history was significant for high blood pressure and high cholesterol. On exam, her weight was 176.9 kg (99th percentile) and her BMI was 60.92 kg/m2 (99.7th percentile). She had acanthosis nigricans with an otherwise unremarkable cardiac exam. We assessed for target-organ abnormalities associated with hypertension on the same day of the visit. Her cardiac status was evaluated by echocardiogram, which demonstrated an elevated LV mass index of 82 g/m2 (>95th percentile). The health of her arteries was evaluated by measuring the pulse wave velocity (PWV) in the aorta, which was elevated to 7.5 m/s. Her carotid artery intima-media thickness (cIMT) was increased to 0.72 mm. An ambulatory blood pressure monitor (ABPM) demonstrated sustained systolic hypertension on antihypertensive medication.
Over the last 5 decades, there has been a steady rise in obesity in children. In conjunction with this epidemiologic shift, prevalence of other cardiovascular co-morbidities, including systemic hypertension, has also increased. These risk factors track into adulthood. Therefore, early recognition and treatment of hypertension in childhood has the potential to reduce adverse cardiovascular events later in life.
Blood pressure should be measured annually in patients > 3 years of age and in those at risk for secondary hypertension < 3 years of age. Multiple high BP readings, along with certain medical conditions (see below), may warrant referral to the HAVE Program, a joint clinical program between the Cardiac Center and the Division of Nephrology. At the initial visit, a comprehensive history and physical exam is performed for clues to the cause of hypertension. A work-up for a secondary cause of hypertension may include a renal ultrasound, urinalysis, and blood work to assess for renal and endocrine causes and an echocardiogram to assess for aortic arch obstruction. Placement of 24-hour ABPM further assesses for hypertension outside the healthcare setting.
Medical conditions that put children at risk for hypertension*
- Chronic kidney disease
- Renal artery stenosis
- Coarctation of the aorta
- Solid organ transplant (eg, heart, kidney)
- Obesity Diabetes, type 1 and type 2
- Lipid disorders (eg, homozygous FH)
- Kawasaki disease (with or without coronary artery involvement)
- Chronic inflammatory disease (eg, vasculitis, Lupus)
- Sickle cell disease
- Cancer treatment survivors
* Cardiovascular risk reduction in high-risk pediatric patients. Circulation. 2006;12;114(24):2710-2738.
We also assess cardiovascular impact of chronically elevated BP using simple, non-invasive tests. These results aid in assessing overall risk, tailoring treatment strategies, making recommendations for activity levels, and in counseling patients and families. On echocardiogram, left ventricular hypertrophy and increased left ventricular mass index (LVMI) are associated with hypertension and contribute to the adverse cardiovascular profile in these patients. In addition, evidence suggests that fatty streaks are present in the intimal layer of arteries as early as 3 years of age and can progress to atherosclerotic plaque in adolescence—a process further stimulated by the presence of risk factors such as hypertension. One marker of subclinical atherosclerotic disease easily measured by ultrasound is cIMT (see Figure 1). Hypertension also alters the structure of the arteries and increasing the vascular load to the heart. Pulse wave velocity (PWV) in the aorta measured by Doppler technology evaluates one component of vascular structure: arterial stiffness. An increased cIMT and elevated aortic PWV are noted in children with cardiovascular risk factors and can improve with interventions.
To round out our comprehensive evaluation, we counsel on healthy diet and exercise. In addition to caring for patients with primary hypertension, we have diagnosed hypertension and guided treatment in patients with high-risk conditions, such as solid organ transplant, rheumatologic disease, and coarctation of the aorta. Our team recognizes the critical role that primary care providers play in the treatment of hypertension. Communication and collaboration with the patient’s primary team remains an important part of our care for each patient.
Despite optimizing BP medications, our patient continued to have hypertension and was unable to lose weight. She underwent a sleeve gastrectomy. At a recent HAVE Program visit, her BMI decreased to 47 kg/m2, her BP was normal, echocardiography demonstrated a normal LVMI of 46 g/m2, and vascular profile included a normal PWV at 6.2 m/s and decreased cIMT to 0.68 mm. We decreased her anti-hypertensive medications. We relayed encouraging results to the patient and her care team, which suggest that markers of cardiovascular risk were slowly improving with efforts to address her co-morbidities. Hopefully, this information will motivate our patient to pursue further weight loss, adhere to her medication regimen, and continue to develop a healthy lifestyle.
References and suggested readings
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.
Expert Panel on Integrated Guidelines for Cardiovascular Health and Risk Reduction in Children and Adolescents: Summary Report, Pediatrics. 2011;128 Suppl 5:S213-256.