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cute Hypertension and Hypertensive Crisis in Children

Dr A. George Koshy, Govt Medical College ,Thiruvananthapuram

Introduction:

Pediatric Hypertension is defined as systolic or diastolic blood pressure


(BP) exceeding the 95th percentile for gender, age and height. The risk of
hypertension increases with the Body Mass Index (BMI). Approximately
30% of children with BMI greater than 95th percentile have
hypertension. The spectrum of hypertension that presents to the
Emergency Department ranges from mild and asymptomatic to a true
hypertensive emergency.
A definition of hypertension ideally is based on a threshold level of blood
pressure that divides those at risk for adverse outcomes from those who
have no increased risk. The important conclusions of the fourth report
on the diagnosis, evaluation and treatment of high blood pressure in
children and adolescents of The National High Blood Pressure Education
Program Working Group on High Blood Pressure in Children and
Adolescents. (Pediatrics 2004; 114: 555-576) are as follows:

• Hypertension is defined as average systolic and /or diastolic blood


pressure >95th percentile for gender, age and height on > 3 occasions.
• Pre hypertension is defined as average systolic or diastolic pressures
between 90- 95th percentile. These children should be observed carefully
and evaluated if risk factors like obesity are present; tracking data
suggest that this subgroup is more likely to develop overt hypertension
over time than normotensive children.
• Adolescents with blood pressure levels more than 120/80 mm Hg
should be considered pre hypertensive.
• A patient with blood pressure levels >95th percentile in a physician’s
office or clinic, who is normotensive outside a clinical setting, has white-
coat hypertension. Ambulatory blood pressure monitoring is helpful for
confirmation.
• If the blood pressure is >95th percentile, it should be staged. If stage 1
(95th percentile to the 99th percentile plus 5 mm Hg), measurements
should be repeated on 2 more occasions. If hypertension is confirmed,
evaluation should proceed. If blood pressure is stage 2 (>99th percentile
plus 5 mm Hg), prompt referral should be made for evaluation and
therapy. If the patient is symptomatic, immediate referral and treatment
are indicated.

• All children should have yearly blood pressure evaluation beyond 3


years of age. There is an increased risk of hypertension in children with
history of hypertension in family members, those who are obese, had
IUGR or have urinary infections and renal scars.

Evaluation:

When confronted with newly diagnosed hypertension in the child, the


physician should consider three important issues: 1) Is the hypertension
primary or secondary? 2) Is there evidence of target organ damage? and
3) Are there associated risk factors that would worsen the prognosis if
the hypertension were not treated immediately?.
A brief, but careful history and physical examination should be
performed. Some key features in the history would be the duration and
onset of hypertension, degree of compliance with any drug therapy, and
possibility of renal disease (any history of urinary tract infections,
hematuria, edema, or umbilical artery catheterization). One should also
enquire for any history of joint pain, palpitations, weight loss, flushing,
weakness, drug ingestion, headaches, nausea, vomiting and a family
history of renal disease or hypertension.
After several determinations of the blood pressure, a focused physical
examination should be performed immediately. One should check for any
evidence of neurologic dysfunction and left ventricular dysfunction /
cardiac failure. Fundoscopy should be performed looking for hemorrhage,
infarcts or papilledema. The peripheral pulses should be palpated
carefully. Weak and delayed femorals suggest coarctation of aorta. Any
discrepancy in the upper and lower extremity BP measurements should
be noted. The presence of an abdominal bruit suggests renovascular
hypertension.
An improper cuff size can significantly record a wrong blood pressure. By
convention, an appropriate cuff size is a cuff with an inflatable bladder
width that is at least 40% of the arm circumference at a point midway
between the olecranon and the acromion. For such a cuff to be optimal
for an arm, the cuff bladder length should cover 80% to 100% of the
circumference of the arm. Blood pressure measurements are
overestimated to a greater degree with a cuff that is too small than they
are underestimated by a cuff that is too large. If a cuff is too small, the
next largest cuff should be used, even if it appears large

Etiology

Hypertension is usually described as primary (essential) or secondary


due to a definable cause. The secondary cause will be found more likely
when the patient is younger and hypertension is more severe. Most acute
hypertension in childhood is due to glomerulonephritis. Chronic
hypertension is commonly associated with renal parenchymal disease
and only a small proportion have renovascular hypertension,
pheochromocytoma or coarctation of the aorta . Late in the first decade
and into the second decade of life, primary hypertension begins to
predominate. Coarctation of the aorta accounts for one third cases of
hypertension in neonatal period and infancy. Renovascular causes are
amongst the curable forms of hypertension.

Common causes of Hypertension in different age groups


Hypertensive Crisis in Children.

Hypertensive emergency is distinguished from hypertensive urgency by


the presence of acute end-organ dysfunction discovered in the history,
physical examination or investigations, and not by the height of the BP.

Hypertensive Emergency

Hypertension associated with evidence of end-organ dysfunction


constitutes hypertensive emergency.
Malignant hypertension is characterized by marked elevations in systolic
and/or diastolic BP (e.g., 160 mm Hg or higher systolic/ 105 mm Hg or
higher diastolic for those less than 10 years of age; 170 mm Hg or higher
systolic/ 110 mm Hg or higher diastolic for those more than 10 years of
age) and is often associated with spasm and tortuosity of the retinal
arteries, papilledema, and hemorrhages and exudates on fundoscopic
examination.
Hypertensive encephalopathy(an example of hypertensive emergency) is
seen often in malignant hypertension and consists of a combination of
symptoms and signs that often vary from patient to patient (nausea,
vomiting, headaches, altered mental status, visual disturbances,
seizures, stroke).

Patients with hypertensive emergency/ malignant hypertension usually


are admitted to an intensive care unit for continuous cardiac monitoring
and frequent assessment of neurologic status and urine output. An IV
line is started for fluids and medications. Patients typically have altered
blood pressure autoregulation, and overzealous reduction of blood
pressure to reference range levels may result in organ hypoperfusion.
The initial goal of therapy is to reduce the mean arterial pressure by
approximately 25% over the first 8 to 12 hours. An intra- arterial line is
helpful for continuous titration of blood pressure. Sodium and volume
depletion may be severe, and volume expansion with isotonic sodium
chloride must be considered. Urine output should be monitored from the
outset. Any serious complications must be recognized and managed
along with the treatment for hypertension. Anti convulsants should be
administered to a child with seizure.
A number of medications are available for hypertensive emergencies. The
choice of drugs depend on several factors such as the clinical condition
of the patient, the presumed cause, whether there is a change in cardiac
output or total peripheral resistance and whether there is end-organ
involvement. It is important to select an agent with a rapid and
predictable onset of action and to monitor the blood pressure carefully as
is being reduced. Because hypertensive encephalopathy is a possible
complication of hypertensive emergencies, antihypertensive agents with
minimal CNS side effects should be chosen to avoid confusion between
symptoms of disease and adverse effects of the drug. Centrally acting
drugs like Alpha Methyl Dopa and Clonidine are usually not preferred
because of the CNS side effects. Intravenous administration is generally
preferred in order to carefully titrate the fall in blood pressure. Too rapid
reduction in blood pressure can interfere with adequate organ perfusion
and hence a stepwise reduction should be planned. Hypertensive
emergencies should be treated by an intravenous antihypertensive that
can produce a controlled reduction in the blood pressure, aiming to
decrease the pressure by 25% over the first 8 hours after presentation
and then gradually normalizing the BP over the next 48 hours. Each of
the most commonly used medications offers distinct advantages and
disadvantages and each clinical situation requires its own mode of
management. However, some general guidelines are usually helpful.

Sodium nitroprusside is an arteriolar and venous vasodilator that is


invariably effective. BP decreases with little change in cardiac output,
and reflex tachycardia is not usually an important problem. It is
administered by constant infusion. Its effect is immediate, and lasts only
as long as the infusion is continued. Its use requires intensive
observation and therefore may not be indicated in the ED. Other
disadvantages are that the drug requires 10 minutes to prepare and is
photosensitive, and there is a potential for cyanide accumulation. The
infusion bottle and tubing should be covered and protected from light.

Diazoxide is an arteriolar vasodilator, has little effect on capacitance


vessels and has no direct cardiac effect. It is very potent with a rapid
onset, and the effect can be dramatic. It may provide a long duration of
BP control (8 to 12 hours). It causes marked salt and water retention,
and in patients with edema, it should be followed with a diuretic agent. It
also causes reflex tachycardia and hyperglycemia.

Hydralazine is an arteriolar vasodilator that is not as potent as diazoxide


or nitroprusside. However, it has an excellent safety profile. The half-life
is short (3 to7 hours), necessitating frequent dosing. Reflex tachycardia
often occurs, and may require the introduction of a beta blocker.

-adrenergic blocker.βLabetalol is an alpha 1 and nonselective Dosing is


independent of renal function. It has been reported to be effective in the
management of severe hypertension that results from
pheochromocytoma and coarctation of the aorta and is a reasonable
alternative in the treatment
of hypertensive crises in patients with end stage renal disease.

Nifedipine, a calcium channel blocker, reduces peripheral vascular


resistance and does not affect cardiac output. It can be administered
sublingually, but biting the capsule and swallowing its contents achieves
measurable blood levels more rapidly than the sublingual route. Its use
depends on the patient’s state of consciousness. It is contraindicated in
the presence of intracerebral bleeding.

Nicardipine, another calcium channel blocker is an excellent drug for use


in emergencies, since it can be administered as an infusion that can be
easily prepared and titrated.

-adrenergic blocker used almostαPhentolamine is a pure exclusively for


the treatment of catecholamine crisis (as seen in patients with
pheochromocytoma or ingestion of sympathomimetic agents such as
cocaine). The effect is immediate. There is a high risk of hypotension
after
the primary lesion (e.g. pheochromocytoma) is excised, and care should
be exercised and the surgeons should be alerted to this possibility.
Most children with hypertensive crisis have chronic or acute renal
disease. In these patients, management of blood pressure also requires
careful attention to fluid balance and diuresis. Intravenous Frusemide is
usually effective even though glomerular filtration may be impaired.

Hypertensive Urgency:

A hypertensive urgency is defined as severe hypertension without


evidence of end-organ involvement. Patients with known hypertension
who present in an urgent hypertensive crisis may not require
hospitalization if the therapy in the emergency department is successful,
and adequate follow-up can be ensured. Often, oral antihypertensive
agents are sufficient, although there are occasions when parenteral
therapy is indicated.

Other Drug Therapy:

Calcium channel blockers like amlodipine, felodipine, isradipine,


intravenous nicardipine and nitrendipine have been studied in children.
They are well tolerated, effective and safe. Enalapril, an angiotensin
converting enzyme inhibitor is a commonly used pediatric
antihypertensive agent. The maximum serum concentration occurs
approximately 1 hour after administration, and that of the metabolite,
enalaprilat peaks between 4 and 6 hours after the first dose, and 3 and 4
hours after multiple doses. Intravenous Enalaprilat is available for
management of hypertensive crisis but only limited data are available in
children. Captopril has shorter duration of action and can be given
sublingually for faster action. Limited data are available on the efficacy
and safety of Angiotensin Receptor Blockers like Losartan.
Conclusions:

Most children who present with hypertensive crisis have secondary


hypertension. Renal parenchymal disease is the commonest underlying
etiological factor .With the increase in the prevalence of obesity in
children, the incidence of hypertension among children is also on rise.

Hypertensive encephalopathy and acute left ventricular failure are


frequent modes of presentation.

Intracranial hemorrhage and renal failure are less frequent and often
overlooked modes of clinical presentation. Hypertensive emergencies in
symptomatic children should be treated without delay to avoid further
damage to vital organs. BP should be brought down by no more than
25% within the first 8 hours. Asymptomatic children with hypertensive
urgency require less aggressive approach and blood pressure can be
brought down more gradually. Once the acute phase has been tackled,
extensive work up is required to identify the underlying etiological factor.

One should not forget that many cases of secondary hypertension are
eminently curable.