Hypertension in adolescents

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Dinesh Shah, M.B.B.S, José Eduardo Riceto Loyola Junior, M.D.[2]

Synonyms and keywords:

Hypertension in adolescents is an increasingly recognized condition and is associated with both current target-organ injury and future adult cardiovascular risk. In adolescents, primary hypertension is now the predominant form of hypertension, particularly in those with obesity, excess adiposity, family history of hypertension, and other cardiometabolic risk factors. Accurate blood pressure measurement, confirmation of persistent elevation, and appropriate evaluation for secondary causes and target-organ damage are essential because childhood and adolescent hypertension often tracks into adulthood.

Pediatric hypertension may be classified according to the AAP (American Academy of Pediatrics):^[1]

• The pathophysiology of hypertension can be either primary, which is multifactorial, or secondary, in which hypertension develops as a consequence of other diseases.
• Essential hypertension can be triggered by multiple factors such as: obesity, insulin resistance, activation of sympathetic nervous system, changes in sodium homeostasis, renin-angiotensin-aldosterone system changes, disorders in the vascular smooth muscle structure or function, elevated uric acid levels, fetal programming and genetic factors.^[2]

Based on etiology, hypertension in children can be classified into 2 groups:^[3]

• 1. Primary hypertension - No specific cause known
• 2. Secondary hypertension - Common causes include:^[4]

• Renal diseases
• Renal artery stenosis
• Obstructive sleep apnea^[5]
• Related to drugs - glucocorticoids, CNS stimulants
• Congenital adrenal hyperplasia
• Pheochromocytoma
• Hyperthyroidism
• Coarctation of the aorta

These conditions are displayed in order of prevalence^[6][7][8]

One to six years:

• Renal parenchymal disease; renal vascular disease; endocrine causes; coarctation of the aorta; essential hypertension

Six to twelve years:

• Renal parenchymal disease; essential hypertension; renal vascular disease; endocrine causes; coarctation of the aorta; iatrogenic illness

Twelve to eighteen years

• Essential hypertension; iatrogenic illness; renal parenchymal disease; renal vascular disease; endocrine causes; coarctation of the aorta

Hypertension in adolescents may be a symptom of other underlying and undiagnosed conditions. Thus, these patients require a detailed medical assessment. Secondary causes were discussed above and include: renal diseases, drugs, adrenal diseases and hyperthyroidism.

• According to the WHO, an estimated 1.13 billion people worldwide have hypertension.
• Hypertension commonly affects individuals older than 65 years of age, especially living in low or middle-income countries.
• In a study from the University of Texas' McGovern Medical School, the prevalence of pediatric elevated hypertension from 10 to 17 years of age was 16.3%, stage 1 hypertension was 10.6% and stage 2 hypertension 2.4%.^[9]
• Higher prevalence was noted in patients who were classified as obese or overweight.^[9]
• Prevalence of childhood hypertension has increased from 1994 to 2018.^[10]
• A systematic review estimated that in 2015, the prevalence of childhood hypertension was 4.32% among children aged 6 years. Patients aged 19 years had a prevalence of 3.28%. The peak of prevalence in hypertension occurred at age 14 years.^[10]

• The most common risk factor in the development of hypertension in adolescents is obesity.
• Other important risk factors include family history of hypertension, low birth weight, chronic kidney disease, diabetes, sleep-disordered breathing, and exposure to medications or substances that raise blood pressure.^[1]
• A focused medication and substance history should specifically assess stimulants, glucocorticoids, hormonal therapies, decongestants, bronchodilators, illicit substances, and other agents that may elevate blood pressure.^[1]

• The U.S. Preventive Services Task Force concludes that the current evidence is insufficient to assess the balance of benefits and harms of screening for high blood pressure in asymptomatic children and adolescents aged 3 to 18 years.^[11]
• The 2017 American Academy of Pediatrics guideline recommends measuring blood pressure annually beginning at 3 years of age and at every health care encounter in children and adolescents with obesity, kidney disease, diabetes, a history of aortic arch obstruction or coarctation, or use of medications known to increase blood pressure.^[1]
• According to the 2016 European Society of Hypertension guidelines, screening for hypertension in asymptomatic children and adolescents is recommended every two years beginning at three years of age.^[12]

• If left untreated, children with hypertension may progress to develop atherosclerotic heart disease in adulthood. They have also increased risk of cardiovascular disease and mortality as well as left ventricular hypertrophy.
• Renal complications such as chronic kidney disease may develop.
• Ophthalmologic compromise is also a possible with hypertensive retinopathy being a potential complication.
• Children and adolescents with severe hypertension are at risk of developing hypertensive encephalopathy, seizures, cerebrovascular accidents, and congestive heart failure.^[13]

• Hypertension in adolescents should be suspected on the basis of properly performed office blood pressure measurements and confirmed with ambulatory blood pressure monitoring when indicated.^[14]
• Office blood pressure should be measured in the right arm with an appropriately sized cuff after the patient has been seated quietly, and elevated oscillometric readings should be confirmed by auscultation.^[1][11]
• Ambulatory blood pressure monitoring is recommended to confirm hypertension in children and adolescents with persistent elevated office readings or stage 1 hypertension across repeated visits, and it is particularly useful for identifying white-coat hypertension, masked hypertension, and abnormal nocturnal blood pressure patterns.^[1][15]

• The history should assess birth history, growth, renal and urologic disease, sleep-disordered breathing, medication and substance exposures, diet and physical activity, and family history of hypertension, kidney disease, and premature cardiovascular disease.^[1]
• Common symptoms of hypertensive emergencies include headache, altered sensorium, seizures, vomiting, focal neurologic complaints and visual disturbances.^[1]
• The physical examination should include height, weight, body mass index, repeat blood pressure measurement with correct cuff size, pulse examination, and focused assessment for coarctation of the aorta, endocrine disease, and other secondary causes.^[1]

• Common physical examination findings of hypertension include retinal vascular changes on fundoscopy, cardiac heave, and laterally displaced point of maximal impulse (PMI) due to left ventricular hypertrophy (LVH).^[1]
• The physical examination should include height, weight, body mass index, repeat blood pressure measurement with correct cuff size, pulse examination, and focused assessment for coarctation of the aorta, endocrine disease, and other secondary causes.^[1]

• There are no laboratory tests that by themselves diagnose hypertension.^[1]
• Initial evaluation commonly includes urinalysis, serum electrolytes, blood urea nitrogen, creatinine, and a lipid profile.^[1]
• In adolescents with obesity, additional evaluation for cardiometabolic comorbidity should include screening for abnormal glucose metabolism and liver disease.^[1]
• Renin, aldosterone, thyroid testing, drug screening, sleep evaluation, and other specialized tests should be obtained selectively when the history, physical examination, age, or severity of hypertension suggests a secondary cause.^[1]
• Renal ultrasonography is recommended in younger children and in those with abnormal urinalysis, impaired renal function, or suspicion for renovascular or structural renal disease.^[1]

• Electrocardiography is not recommended as the primary method to assess left ventricular hypertrophy in pediatric hypertension because of limited sensitivity.^[1]
• Findings on an ECG suggestive of hypertension include left ventricular hypertrophy, ST depression and T wave inversion.

• Chest radiography is not part of the routine evaluation of hypertension in adolescents and should be reserved for specific clinical indications.^[1]

• Echocardiography is not diagnostic of hypertension, but it is useful for evaluation of hypertension-mediated target-organ damage, particularly left ventricular hypertrophy, and should be considered when pharmacologic therapy is being considered.^[1]
• Repeat echocardiography may be used selectively to monitor persistent hypertension or previously documented target-organ injury.^[1]

• CT or MRI is not used to diagnose hypertension itself but may be used selectively to evaluate suspected secondary causes such as coarctation of the aorta, renovascular disease, or adrenal pathology.^[1]

• There are no other imaging findings associated with hypertension.

• There are no other diagnostic studies associated with hypertension.

The AAP guideline recommends keeping systolic and diastolic pressure under 90th percentile or <130/80 mmHg in patients aged 13 or older to prevent any cardiovascular events.

• All children and adolescents with hypertension should change their lifestyle for the better.^[12]
• Such changes include: weight reduction if obese or overweight, regular physical activity, healthy diet (DASH diet), avoidance of substance use, stress reduction, family-based interventions (involving the whole family on such lifestyle changes can dramatically increase therapeutic adherence).^[12]

• Lifestyle modification is the foundation of treatment for adolescents with elevated blood pressure or hypertension, especially in primary hypertension associated with excess adiposity and other cardiometabolic risk factor.^[1]
• Recommended nonpharmacologic therapy includes weight reduction when indicated, regular physical activity, a healthy dietary pattern such as the DASH diet, sodium reduction, sleep optimization, and avoidance of tobacco, alcohol, and other substances that can increase blood pressure.^[1][16][14]
• Pharmacologic therapy is indicated for adolescents with symptomatic hypertension, stage 2 hypertension without a clearly modifiable factor, persistent hypertension despite lifestyle intervention, or hypertension associated with chronic kidney disease or diabetes.^[1]
• Recommended first-line antihypertensive agents include angiotensin-converting enzyme inhibitors, angiotensin receptor blockers, long-acting calcium channel blockers, and thiazide diuretics.^[1]
• Antihypertensive medication should generally be started at a low dose and titrated every 2 to 4 weeks until the blood pressure goal is achieved or dose-limiting adverse effects occur.^[1]
• Calcium channel blockers and hydrochlorothiazide are appropriate choices for female adolescents at risk for pregnancy.^[12]
• Start at the lowest dose and titrate every 2 to 4 weeks until blood pressure goal is reached.^[12]
• Home blood pressure monitoring may be a useful adjunct in follow-up, but ambulatory blood pressure monitoring remains the preferred out-of-office method for confirming hypertension and distinguishing white-coat from masked hypertension in children and adolescents.^[1][15][14]

Surgery is not the first-line treatment option for children with hypertension. Surgery is usually reserved for children with select adrenal disease or coarctation of aorta.

Effective measures for the primary prevention of primary hypertension in children include low sodium intake, adhering to the DASH diet, maintaining appropriate body weight, and regular physical activities.

After diagnosis, secondary prevention focuses on sustained blood pressure control, treatment adherence, repeated assessment for target-organ damage when indicated, and management of associated cardiovascular risk factors such as obesity, dyslipidemia, diabetes, and sleep-disordered breathing.^[1]

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