hypertension guidelines what s new -...

Clinical Research Facility

Central Manchester University Hospitals

NHS Foundation Trust

Supported by

Hypertension guidelines – what’s new

Professor Nick Webb DM FRCP FRCPCHRoyal Manchester Children’s Hospital, Manchester UK

NIHR Manchester Clinical Research Facility

International Congress on Hypertension in Children and Young Adults, Valencia Feb 2018

Overview

Importance of hypertension Guideline history New American Academy of

Pediatrics Clinical Practice Guideline Nov 2017

New US adult hypertension guidelines Nov 2017

European Society of Hypertension guidelines 2016

Implications for practice

Sound rationale for classification and treatment of hypertension in adults

BP relationship to risk of CVD is continuous, consistent and independent of other risk factors

Each increment of 20/10mmHg doubles the risk of CVD across the entire BP range starting from 115/75mmHg

In stage 1 hypertension, achieving a sustained 12mmHg reduction in SBP over 10 years will prevent 1 death for every 11 patients treated

Elevated BP in childhood and adolescence is a strong predictor of hypertension and metabolic syndrome in adult life

Hypertension in children is a significant problem

Flynn J. Pediatr Nephrol 2013; 28: 1059-1066

Hypertension in children is a significant problem

Lurbe E et al. J Hypertens 2016; 34: 1887-1920

Hypertension is strongly associated with obesity

Lo JC et al. Pediatrics 2013;131:e415-e424

Rates of obesity are rising

van Jaarsveld CHM et al Arch Dis Child 2015;100:214-219

History of guideline development

Pre 1977 No good definition of HT in children

BP rarely routinely measured

1977: First major clinical practice

guideline

NHBPEP report

Defined HT as BP>95C

Detection, evaluation and management

1987: Second Task Force Update

1996: Update on 1987 report Update

2004: Fourth Taskforce Comprehensive normal data classified

according to sex, age and height

2009: 1st European Society

Hypertension guidelines

2016: 2nd European Society

Hypertension guidelines

2017: AAP Clinical Practice Guidelines

Pediatrics 2017 Nov 30th

Flynn JT et al. Pediatrics 2017 Nov 30th

Adopted rigorous evidence based approach, including detailed systematic review

30 Key Action Statements (KAS) – graded based on strength

Approx 2 dozen additional clinical recommendations based upon expert opinion (where insufficient evidence for KAS)

Normal range data

4th Report BP tables generated from BP values from 63,227 children at 83091 physician visits Many children had overweight or obesity

Inclusion of these children likely biased normative BP values upwards

Took only those with normal weight (<85C) (49,967)

BP values 2-3mm lower than in 4th report

Normal range data

New normative BP tables in the 2017 CPG

are based only on these BP readings from

49,967 normal-weight children

Will likely lead to increased numbers of

children and adolescents diagnosed with

abnormal BP

Presentation of BP tables

4th Report 2017 AAP CPG

≥95th +12mmHg represents new definition of stage 2 hypertension

Simplification of presentation

Simplified table for screening purposes

90C values

Recognises common use of automated devices but need for confirmation by auscultation

Diagnosis and management

Diagnosis of hypertension still based on demonstration of elevated or hypertension level BP at 3 separate encounters unless the patient is symptomatic

Auscultation remains preferred method

Detailed recommendations on measurement including link to video

Clear advice on BP measurement

AAP: Measuring BP in children video

Change in definition of hypertension

BP between 90 and 95C now termed ‘elevated blood pressure’

‘Pre-hypertension’ felt to be confusing

Simplification of cut-off between stage 1 and stage 2 hypertension

Single value for elevated BP and hypertension in ≥13s

New paediatric guidelines for ≥13s in line with this new adult guideline

Highlights

‘Prehypertension’ in 2003 JNC guideline (120-139/80-89) replaced with ‘Elevated’ and Stage 1 hypertension

Stage 2 hypertension lowered from ≥160/100 to ≥140/90

New Stage 1 hypertension This group has 2 x CV risk

compared to normal BP

Recent RCTs have shown benefit of treatment

Will result in 14% increase in prevalence of BP in US and 1.9% increase in antihypertensive use

Highlights

Greater use of out of office BP measurement

Ambulatory BP monitoring

Recommendations include

Confirmation of diagnosis where high BP for >12m or on 3 separate occasions

Evaluation of masked hypertension in children with repaired coarctation

Evaluation of BP pattern and risk for target organ damage in those with high risk conditions e.g. CKD

Evaluation for possible hypertension in OSAS

Evaluation of BP in heart and kidney recipients

Assessment of treatment effectiveness

Monitoring of treatment efficacy and possible masked hypertension in CKD

Ambulatory BP monitoring

Focus is same as other recent consensus recommendations in adults e.g. NICE

However whilst NICE and others offer home BP monitoring as an alternative, these guidelines do not recommend this as insufficient evidence in children

May have implications as many primary care providers do not have ready access to paediatric ABPM

German working group on paediatric hypertension; data viewed as best

Other highlights: Echocardiography Panel of cardiologists convened

Different recommendations from 4th

report

LV mass >51g/m2 – as in 4th report

BUT could also be defined as LV mass >115g/BSA in boys and >95g/BSA in girls

Echo should be performed at time of diagnosis REPLACED WITH echo at time that initiation of pharmacological treatment is considered

Repeat echo should be performed where this was initially normal in those with stage 2 HTN, secondary HT and incompletely treated stage 1 HTN

Drug therapy and treatment goals

Indications for medications Persistent HT despite lifestyle

modification, especially with an abnormal echo: Symptomatic HT

Stage 2 HT without a modifiable risk factor

Any stage of HT in children with diabetes or CKD

RAAS blockers, Ca channel blockers and thiazide diuretics recommended initial therapy

Strong recommendation for RAAS blockade in CKD, diabetes or proteinuria

Treatment goals

<90th centile or 130/80, whichever is lower

In CKD BP should be measured by ABPMRecommended goal is 24h mean <50th centile

European Society of Hypertension 2016: Highlights

BP should be measured in all children starting at 3y

Minimal cost and time input / no invasive or expensive tests

If normal, repeat every 2y

If high normal and no target organ damage, repeat in 1y

Use US 4th task force normal data

Definition of hypertension

Revised for ≥16y to be in line with adult guidelines

European Society of Hypertension 2016


Auscultatory method recommended

AAP 2017 guideline

specifically states lack of

evidence of support home BP

monitoring


AAP 2017 guideline does not

recommend routine cIMT

measurement

Achievability of guidelines: a UK perspective

No uniform system of routine medicals for children

British GPs generally unaware of paediatric BP guidelines

Availability of appropriate BP measuring equipment is a significant issue

Nearly all BP measurement in UK children takes place in secondary and tertiary care

103 primary care practices within 6.4km of RMCH

Information collected Practice demographics Availability of equipment to measure BP in

children of all ages Availability and confidence in interpreting

normal range data in children of all ages Inspection of BP measuring equipment

Range of cuff sizes available Whether machine BHS validated

95/103 (92%) practices participated 40 practices had total of 70 paediatric BP cuffs

available 24 had one, 11 had two, 5 had >two 51 different measurement devices

35 (69%) validated for use in children

Confidence (IQR) in interpreting paediatric BP data 3 (2-6)/10 Improved to 8 (6-9) if normal range data provided

Plumb LA et al. Arch Dis Child 2014

SurveyMonkey of GPs in SW of UK

100 responses

78% would never routinely measure child’s BP in primary care setting

Only 15% responded correctly re how to size an appropriate cuff

Summary

Hypertension is a significant and growing problem in children and adolescents

US and European guidelines are helpful well written documents Will increase awareness of diagnosis and treatment of

hypertension in this population

New US paediatric hypertension guidelines Much lower threshold for diagnosis of hypertension

In line with new US adult guidelines

Will increase number of children diagnosed and requiring treatment Significant increase in workload and healthcare expenditure Great need for prospective studies in this population, including

rigorous health-economic evaluation

Thank you

[email protected]

hypertension guidelines what s new -...

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