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Canadian Journal of Cardiology

Evidence Gaps in the Identification and Treatment of Hypertension in Children

  • Janis M. Dionne
    Correspondence
    Corresponding author: Dr Janis M. Dionne, Division of Nephrology, 4480 Oak Street, Vancouver, British Columbia V6H 3V4, Canada. Tel.: +1-604-875-2272; fax: +1-604-875-3649.
    Affiliations
    Division of Nephrology, Department of Pediatrics, University of British Columbia, BC Children’s Hospital, Vancouver, British Columbia, Canada
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Published:February 21, 2020DOI:https://doi.org/10.1016/j.cjca.2020.02.076

      Abstract

      The ultimate goal of recognizing and treating hypertension in childhood is to prevent target-organ damage during childhood and to reduce the risk of adulthood cardiovascular disease. The quality of evidence to guide blood pressure management in children is lower than in adult medicine, yet some common findings support clinical practice recommendations. Oscillometric devices are increasingly replacing manual blood pressure measurements, but evidence shows that readings are not equivalent between the 2 methods. In addition, multiple blood pressure readings are needed before diagnosing a child with hypertension, but the optimal number and timing are still being determined. The recent American Academy of Pediatrics blood pressure guideline has revised the normative data tables and included threshold blood pressure limits which seem to identify children with higher cardiovascular risks. Threshold limits vary between guidelines, and the most accurate threshold has yet to be determined. Lifestyle modifications are a cornerstone of hypertension management, but the optimal diet and physical activity changes for beneficial effect are not known. When pharmacotherapy is needed, physicians have used drugs from all antihypertensive classes in children, yet only a few classes have been systematically studied. The long-term cardiovascular consequences of elevated blood pressure during childhood are under investigation and it seems that the lower the childhood blood pressure the better and that the rate of change during childhood is predictive of adulthood disease. With much still to learn, this article summarizes the evidence and the evidence gaps for the diagnosis, investigation, management, and outcomes of pediatric hypertension.

      Résumé

      L’objectif ultime du dépistage et du traitement de l’hypertension chez l’enfant est de prévenir les atteintes des organes cibles durant l’enfance et de réduire le risque de maladie cardiovasculaire à l’âge adulte. La qualité des données probantes sur la prise en charge de la pression artérielle des enfants est inférieure à celle que l’on retrouve en médecine pour adultes. Néanmoins, certains résultats communs étayent les recommandations de pratique clinique. Les appareils d’oscillométrie remplacent de plus en plus les mesures manuelles de la pression artérielle, mais les données probantes montrent que les 2 méthodes n’offrent pas des lectures équivalentes. De plus, de nombreuses lectures de la pression artérielle sont nécessaires avant de poser le diagnostic d’hypertension chez un enfant, mais le nombre et le moment optimaux ne sont pas encore déterminés. L’American Academy of Pediatrics blood pressure guideline a passé en revue les tables de données normatives et a spécifié les valeurs limites de la pression artérielle qui semblent permettre de repérer les enfants exposés à des risques cardiovasculaires plus élevés. Les valeurs limites varient selon les lignes directrices et des seuils plus précis restent à déterminer. Les modifications du mode de vie sont la pierre angulaire de la prise en charge de l’hypertension, mais on ne connaît pas les changements à adopter dans le régime alimentaire et l’activité physique pour obtenir des effets bénéfiques. Lorsque la pharmacothérapie était nécessaire, les médecins ont utilisé les médicaments de toutes les classes d’antihypertenseurs chez les enfants, mais seules quelques classes ont fait l’objet d’études systématiques. Les conséquences à long terme d’une pression artérielle élevée durant l’enfance sur la santé cardiovasculaire font l’objet d’une étude. Il semble que plus la pression artérielle est basse durant l’enfance plus c’est préférable et que le taux de variation durant l’enfance permet de prédire la maladie à l’âge adulte. En dépit de tout ce qui reste à apprendre, le présent article récapitule les données probantes et les lacunes en matière de données probantes sur le diagnostic, l’évaluation, la prise en charge et les issues de l’hypertension de l’enfant.
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