is white coat hypertension benign in children and...
TRANSCRIPT
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
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.
The prevalence of WCH in young people with persistently elevated casual BP to be between 13 and 88%. (2)
ADOLESCENT WHITE COAT HYPERTENSION
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.
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)
ADOLESCENT WHITE COAT HYPERTENSION
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.
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 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)
ADOLESCENT WHITE COAT HYPERTENSION
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.
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 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 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)
ADOLESCENT WHITE COAT HYPERTENSION
85 children – OBPM, ABPM, ECHO, US of the carotid
WCH - 12.9%; MH - 9.4%
Pediatr Nephrol, 20:1151-55, 2005.
85 children – OBPM, ABPM, ECHO, US of the carotid
WCH - 12.9%; MH - 9.4%
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.
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.
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
18% had WCH and 11% MH
64 boys, mean age: 12.8±2.9 years
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.
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.
Pediatr Cardiol, 37:345-352, 2016.
There was a progressive increase in 24-h PP from normotension, WCH, MH, to hypertension.
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
Pall D, Juhasz M, Lengyel S, Molnar C, Paragh G, Fulesdi B, Katona E. J Hypertens, 28(10):2139-44; 2010.
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
Normotensives WCH Sustained HTN
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
Normotensives WCH Sustained HTN
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
Pall D, Juhasz M, Lengyel S, Molnar C, Paragh G, Fulesdi B, Katona E. J Hypertens, 28(10):2139-44; 2010.
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
Pall D, Juhasz M, Lengyel S, Molnar C, Paragh G, Fulesdi B, Katona E. J Hypertens, 28(10):2139-44; 2010.
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
• 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.
• 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.
• 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.
• 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.
• LVMI of the normotensives and white coat hypertensives didn’t differed.