Pediatric Hypertension - Insights into Etiology, Diagnosis and Progression of Target Organ Damage

Statement of Problem: Over the last several decades the prevalence of pediatric hypertension has increased fourfold, thought to be partially attributable to the concurrent rise in pediatric obesity. Hypertensive children are at increased cardiovascular disease risk as they often manifest other cardiovascular disease risk factors such as obesity, dyslipidemia, and insulin resistance. Further, up to 40% have target organ damage in the form of left ventricular hypertrophy at initial diagnosis. Left ventricular hypertrophy, a pathological remodeling of the heart thought to be secondary to increased left ventricular afterload as seen in hypertension, causes arrhythmias, heart failure and myocardial infarction in adults. Its striking prevalence at initial diagnosis suggests that elevated blood pressure detection and hypertension diagnosis in children may be delayed or because other factors, specifically obesity, play a more substantial role in its development among hypertensive children. Methods: We conducted two studies: 1) a pre-post evaluation of a quality improvement initiative to improve elevated blood pressure recognition among children and adolescents seen for primary care. The intervention consisted of a one-time provider educational session and implementation of an ongoing real-time electronic medical record alert; and 2) a prospective, observational study of hypertensive children to investigate the association of obesity and obesity-related risk factors with the presence of left ventricular hypertrophy and with the change in left ventricular mass over a 12-month period of anti-hypertensive therapy. Results: We found that recognition of elevated blood pressure among patients seen for pediatric primary care was poor overall but increased from 12.5% pre-intervention to 42% during the intervention period (p<0.001). Recognition was no different by educational session attendance status. During both pre-intervention and intervention periods, systolic BP ≥120mmHg was associated with greater recognition. However, the prevalence ratio (PR) was smaller in the intervention period: intervention PR 1.3, 95% confidence interval (CI) 1.2 – 1.5 (p<0.001) versus pre-intervention PR 2.4, 95% CI 1.4-3.9 (p=0.001). Similar relationships were observed for other cardiovascular disease risk factors. Acute care visit encounters were associated with decreased recognition in the intervention period (PR 0.6, 95% CI 0.5- 0.7; p