Enter department name here
What is the Impact of the New Hypertension Guidelines?
Joseph T Flynn, MD, MSRobert O. Hickman Endowed Professor of PediatricsSeattle Children’s Hospital/University of WashingtonPediatric Nephrology Seminar 46 – March 9, 2019
Enter department name here
Disclosures
• Consultant, Silvergate Pharmaceuticals
• Royalties – Springer, Up To Date
• Grant Support – NIDDK, American Heart Association
Enter department name here
Major Changes From the Fourth Report
• More rigorous evidence-based methodology
• Revised definitions of BP categories
• New normative BP tables based on BPs from normal-weight children
• Simplified screening table
• Emphasis on use of 24-hr ABPM to confirm HTN diagnosis
• Revised recommendations for performance of echocardiography
• Lower treatment goals for primary HTN; ABPM goal for CKD
Enter department name here
What may have the greatest impact?
• Revised BP classification system
• New normative BP tables
Enter department name here
Revised Childhood BP Classification
Flynn et al, Pediatrics 2017; 140:e20171904
Enter department name here
Classification of HTN
• Changes in HTN classification compared to the Fourth Report:– BP >90th percentile now termed
‘elevated BP’– BP cut-points for stage 1 and 2 HTN
simplified– BP cut-points for adolescents ≥13 years
old no longer percentile-based
Enter department name here
New Normative BP Tables
• 4th Report BP tables generated from BP values in ~70,000 healthy children• Many children had overweight or
obesity• Inclusion of these children likely
biased normative BP values upward
Enter department name hereMuntner et al, JAMA 2004; 291:2107
Enter department name here
New Normative BP Tables
• New normative BP tables commissioned for the 2017 CPG, based only on BP readings from ~50,000 normal-weight children
• “New” normal BP values are ~2-3 mmHg lower than values in Fourth Report• Similar to International standard BP values published
by Xi et al, Circulation 2016;133:398• Could lead to increased numbers of children &
adolescents diagnosed with abnormal BP
Enter department name here
Potential impacts
• Lower normative BP values• Increased numbers of children identified w/high BP
• Revised classification• Teens with BP below adult thresholds classified as
having elevated BP or hypertension
Enter department name here
Prevalence of high BP using 2017 AAP normative BP values
• Houston school BP screening program data used to assess the prevalence of high BP using new 2017 AAP CPG normative BP values and updated BP classifications• Data on ~22,000 children available (13.8±1.6 y/o)• BP measured using Spacelabs 90217 ABP or
Dinamap oscillometric devices• Minimum of 2 readings obtained on each student;
96% had 3 or more readings• Those with high BP on first screening asked to return
for repeat BP measurement
Bell et al, Hypertension 2019;73:148
Enter department name here
Prevalence of high BP using 2017 AAP normative BP values
• Increase in percentage of children with elevated BP
• Similar prevalence of stage 1/2 HTN
• Differences emerged based on age/height
Bell et al, Hypertension 2019;73:148
Enter department name here
Prevalence of high BP using 2017 AAP normative BP values
Bell et al, Hypertension 2019;73:148
Enter department name here
Prevalence of high BP using 2017 AAP normative BP values
• Their summary:• Prevalence of elevated blood pressure in
children increased by 1.5% by AAP compared with Fourth Report.
• Children <13 years and taller, older teens are more likely to have confirmed hypertension by AAP guidelines, particularly boys.
• Results highlights need for outcomes-based definition of HTN in children
Bell et al, Hypertension 2019;73:148
Enter department name hereDong et al, Jnl Hypertension 2019;37:297
Enter department name here
Reclassification of BP based on 2017 AAP CPG
• Analyzed BP data from ~16,000 children included in 1999-2014 NHANES Surveys
• Used normative BP data from 2004 Fourth Report and 2017 AAP CPG to classify BP values as normal, elevated or hypertensive
• Also examined anthropometric and laboratory data to determine any associations with other CV risk factors like obesity, dyslipidemia, etc.
Sharma et al, JAMA Pediatrics 2018;172:557
Enter department name here
Reclassification of BP based on 2017 AAP CPG
Sharma et al, JAMA Pediatrics 2018;172:557
• Prevalence of high BP increased from 11.8% to 14.2%• 5.8% had an increase in the stage of hypertension or a new
hypertension diagnosis• Children whose BP reclassified upward more likely to have
overweight/obesity, dyslipidemia or elevated hemoglobin A1c
Enter department name here
Sensitivity of detecting hypertensive TOD using 2017 AAP CPG
Khoury et al, Pediatrics 2018; 142:e20180245
• Examined data from 364 children with obesity or T2DM who had been evaluated for hypertensive TOD with echocardiography, PWV and carotid IMT
• Prevalences of increased LV mass, diastolic dysfunction, thicker carotid arteries and faster PWV were compared using classifications based on Fourth Report vs. 2017 CPG normative BP values
Enter department name here
Sensitivity of detecting hypertensive TOD using 2017 AAP CPG
Khoury et al, Pediatrics 2018; 142:e20180245
• Prevalence of hypertension increased from 8% using Fourth Report BP values to 13% using 2017 CPG values
• 25% of those with pre-HTN by Fourth Report criteria were reclassified as having stage 1 HTN; these were all >13 y/o
• 2017 CPG classification was more sensitive for detecting hypertensive TOD than the Fourth Report classification
Enter department name here
In Summary
• As expected, the new normative data and changes in BP classification resulted in changes in HTN prevalence in children• Effect varies by age, height, sex
• Use of the CPG BP values and classification may be more useful for identifying children and adolescents with increased CV risk
• However, still need an outcomes-based definition of childhood HTN
Enter department name here
