Cardiovascular Medicine Book

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Hypertension in ChildrenAka: Hypertension in Adolescents, Pediatric Hypertension

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  1. See Also
    1. Hypertension in Infants
    2. Hypertension
  2. Criteria
    1. See Hypertension Criteria
    2. Routine Blood Pressure screening over age 3 years
  3. Causes
    1. See Hypertension Causes in Children
    2. Renovascular disease is most common cause in children
    3. Features most suggestive of secondary Hypertension
      1. Hypertension under age 10 years
      2. Stage 2 Hypertension in children
  4. Risk Factors
    1. Obesity or Metabolic Syndrome
    2. Black ethnicity
    3. Snoring or other findings of Sleep Apnea
    4. Family History
      1. CAD, Hyperlipidemia or htn: Essential Hypertension
      2. Kidney disease or deafness: Renovascular disease
      3. Diabetes, Thyroid or adrenal disease: Endocrinopathy
  5. History
    1. See Family History above
    2. See Medication Causes of Hypertension
    3. General: Weight change
    4. Lung: Dyspnea on exertion
    5. Cardiovascular: Chest Pain, Palpitations
    6. Renal: Hematuria, Recurrent Urinary Tract Infection
    7. Extremities: Edema, joint pain or swelling, myalgias
    8. Neurologic: Headaches
    9. Endocrine: Profuse sweating, hot or cold intollerance
  6. Examination: Secondary Hypertension clues
    1. General
      1. Growth delay (Chronic Kidney Disease)
    2. Eyes
      1. Fundoscopic exam
    3. Throat
      1. Tonsil or adenoid hypertrophy (Sleep Apnea)
    4. Neck
      1. Thyromegaly (Hyperthyroidism)
    5. Cardiovascular
      1. Tachycardia (Hyperthyroidism, Pheochromocytoma)
    6. Abdomen
      1. Abdominal mass (renal lesion)
      2. Abdominal bruit (Renal Artery Stenosis)
    7. Extremities
      1. Cold legs with diminished pulses (Aortic Coarctation)
      2. Joint swelling (Systemic Lupus Erythematosus)
    8. Skin
      1. Acne Vulgaris, Hirsutism (Cushing's Disease)
      2. Malar Rash (Systemic Lupus Erythematosus)
      3. Profuse sweating (Pheochromocytoma)
    9. Neurologic
      1. Motor weakness (Hyperaldosteronism)
    10. Endocrine
      1. Truncal Obesity, moon facies (Cushing's Syndrome)
  7. Diagnosis
    1. See Hypertension Criteria
    2. Obtain 3 elevated Blood Pressures on different days
    3. Consider Ambulatory Blood Pressure Monitoring
  8. Labs
    1. Complete Blood Count
      1. Includes Leukocyte differential and Platelet Count
    2. Chemistry panel
      1. Electrolytes
      2. Serum Glucose (consider obtaining with Insulin)
      3. Blood Urea Nitrogen
      4. Serum Creatinine
      5. Serum Calcium
      6. Serum Phosphorus
      7. Serum Uric Acid
    3. Urine testing
      1. Urinalysis
      2. Urine drug screen (if indicated)
      3. Urine Culture
      4. Consider 24 hour urine
        1. Creatine clearance
        2. 24 Hour Urine Protein Collection
    4. Endocrine tests
      1. Thyroid Stimulating Hormone (TSH)
      2. Consider 24 hour Urine Cortisol
      3. Consider plasma renin level
      4. Consider 24 hour Urine VMA and metanephrines
  9. Diagnostics
    1. Electrocardiogram
    2. Other studies to consider
      1. Echocardiogram
      2. MRA of renal arteries
  10. Imaging
    1. Renal ultrasound
  11. Management: Non-pharmacologic
    1. Weight loss if overweight
    2. Regular Exercise program
    3. Low Fat Diet
    4. Low sodium diet (e.g. DASH Diet)
    5. Tobacco Cessation
    6. Avoid Alcohol
  12. Management: Pharmacologic
    1. Indications
      1. Symptomatic Hypertension
      2. Secondary Hypertension
      3. Stage 1 Hypertension refractory to general measures
      4. Stage 2 Hypertension
      5. End-organ involvement
        1. Proteinuria
        2. Retinopathy
        3. Left Ventricular Hypertrophy
    2. Goal Blood Pressures
      1. Less than 95%: No end organ damage
      2. Less than 90%: End-organ involvement or comorbidity
    3. Agents FDA approved in children
      1. Propranolol 1-2 mg/kg/day (max: 4 mg/kg, 640 mg)
      2. Hydrochlorothiazide 1 mg/kg/day (max: 3 mg/kg, 50 mg)
      3. Amlodipine 2.5 to 5 mg/day (max: 10 mg/day)
      4. ACE Inhibitors (age 6 and over)
        1. Lisinopril 0.07 mg/kg/day (max: 0.6/mg/kg, 40 mg)
        2. Benzapril, Enalapril, Fusinopril also FDA approved
      5. Angiotensin Receptor Blockers (age 6 and over)
        1. Losartan 0.7 mg/kg/day (max: 1.4 mg/kg, 100 mg)
        2. Irbesartan (Avapro) also FDA approved
          1. Ages 6-12 are given 75 to 150 mg daily maximum
          2. Age 13 and older are given adult dosing
  13. References
    1. (2004) Pediatrics 114:555
    2. Bartosh (1999) Pediatr Clin North Am 46:235
    3. Flynn (2005) Adolesc Med Clin 16:11
    4. Luma (2006) Am Fam Physician 73(9):1558

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