Pediatric Hypertension Underdiagnosed and Undertreated

Troy Brown, RN

November 22, 2016

Pediatric hypertension and prehypertension are largely undiagnosed, and clinicians do not routinely follow diagnosis and medication management guidelines, according to a retrospective cohort study of almost 400,000 patients.

"The finding that only 1 in 20 children with diagnosed, persistent hypertension for ≥1 year were prescribed antihypertensive medication indicates poor compliance with current pediatric hypertension guidelines recommending pharmacological treatment if no improvement occurs at least within 3 to 6 months," the researchers write.

David C. Kaelber, MD, PhD, MPH, from the Comparative Effectiveness Research Through Collaborative Electronic Reporting Consortium Research Team, Elk Grove Village, Illinois, and the departments of Internal Medicine, Pediatrics, Epidemiology, and Biostatistics at Case Western Reserve University in Cleveland, Ohio, and colleagues report their findings in an article published online November 22 in Pediatrics.

"[T]hese findings are compelling and highlight the shortcomings of our current practice. As pediatricians, we must carefully consider whether we are appropriately diagnosing and managing hypertension in our patients," Kevin D. Hill, MD, MSCI, and Jennifer S. Li, MD, MHS, from Duke Clinical Research Institute and Division of Pediatric Cardiology, Department of Pediatrics, Duke University School of Medicine, Durham, North Carolina, write in an accompanying editorial.

The researchers analyzed electronic health record data, including demographics, diagnosis, blood pressure (BP), height, weight, and medication prescriptions, for more than 1.2 million pediatric patients as part of the Comparative Effectiveness Research Through Collaborative Electronic Reporting Consortium. The American Academy of Pediatrics coordinates the consortium, which consists of seven healthcare organizations and includes 196 primary care sites across 27 states with more than 2000 pediatric primary care clinicians.

The main outcome measures included the proportion of pediatric patients with abnormal BPs at three or more visits, documented hypertension and prehypertension (defined as three or more systolic and/or diastolic BP measurements between the 90th and 95th percentiles for sex, age, and height or higher than 120/80 mm Hg) diagnoses, and prescribed antihypertensive medications.

A total of 398,079 patients aged 3 to 18 years had three or more visits at which their BP was measured and were included in the study. Of those, 13,080 children (3.3%) met criteria for hypertension and 40,076 (10.1%) for prehypertension. The researchers dropped practice sites with fewer than 50 eligible patients to allow for multivariable modeling.

Among the remaining practices, the researchers found that just 23.2% (2813 of 12,138) of patients with hypertension had been diagnosed. Similarly, only 10.3% (3990 of 38,874) of those with prehypertension had been diagnosed. Among the 4996 children with stage 2 hypertension, 1612 (32.4%) had been diagnosed.

"Some underdiagnosis may be explained by the fact that identifying hypertensive children is complicated by the variation in normal BP ranges across sex, height percentile, and age, with hundreds of abnormal BP threshold values for pediatric patients," the authors write. "When abnormal BP identification becomes a core functionality in pediatric [electronic health records], recognition of abnormal BPs and hypertension or prehypertension may improve."

A hypertension diagnosis was more likely in children who were older, heavier, tall, or male; who had one or more BP measurement in the stage 2 BP range; or who had additional readings beyond the three required for diagnosis.

Only 158 (5.6%) of the 2813 diagnosed, persistently hypertensive patients received antihypertensive medication within 12 months of diagnosis (angiotensin-converting enzyme inhibitors/angiotensin receptive blockers [35%], diuretics [22%], calcium channel blockers [17%], and β-blockers [10%]).

"Current guidelines state that children with stage 2 hypertension or symptomatic stage 1 hypertension should be started on antihypertensive medication at the time of diagnosis, and children with asymptomatic stage 1 hypertension should be started on antihypertensive medication if their hypertension persists after 3 to 6 months without pharmacological intervention," the researchers explain.

"A prevalence of 3.3% suggests that 2.2 million children and adolescents require evaluation and possible treatment of hypertension. These patient numbers exceed the capacity of subspecialist providers in the United States and, therefore, primary care pediatricians will have to become more comfortable prescribing antihypertensive drugs," Dr Hill and Dr Li write. "This burden could be eased if the next iteration of pediatric hypertension guidelines were to provide expert consensus to guide treatment initiation."

The authors and editorialists have disclosed no relevant financial relationships.

Pediatrics. Published online November 22, 2016. Article abstract, Editorial extract

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