New AHA Statement on Pediatric Primary Hypertension

Megan Brooks

April 03, 2023

Amplified by the childhood obesity epidemic, primary hypertension is now the leading type of pediatric hypertension, especially in adolescence, yet the condition is "underrecognized," the American Heart Association (AHA) says in a new scientific statement.

Dr Bonita Falkner

"Children can have secondary hypertension that is caused by an underlying condition such as chronic kidney disease, endocrine disorders, cardiac anomalies, and some syndromes. However, primary hypertension is now recognized as the most common type of hypertension in childhood," Bonita Falkner, MD, chair of the writing group and emeritus professor of medicine and pediatrics, Thomas Jefferson University, Philadelphia, Pennsylvania, told | Medscape Cardiology.

And hypertensive children are "highly likely" to become hypertensive adults and to have measurable target organ injury, particularly left ventricular hypertrophy and vascular stiffening, the writing group notes. 

The AHA statement on primary pediatric hypertension was published online March 30 in Hypertension.

Primary or essential hypertension occurs in up to 5% of children and adolescents in the US and other countries.

The American Academy of Pediatrics (AAP), European Society of Hypertension and Hypertension Canada all define hypertension as repeated BP readings at or above the 95th percentile for children, but the thresholds differ by age.

The AAP adopts 130/80 mm Hg starting at age 13 years; the European Society of Hypertension adopts 140/90 mm Hg starting at age 16 years; and Hypertension Canada adopts 120/80 mm Hg for those aged 6-11 years and 130/85 mm Hg for those aged 12-17 years.

Adolescents entering adulthood with a BP <120/80 mm Hg is an optimal goal, the writing group advises.

They recommend that healthcare professionals be trained on evidence-based methods to obtain accurate and reliable BP values with either auscultatory or oscillometric methods.

When the initial BP measurement is abnormal, repeat measurement by auscultation is recommended, within the same visit if possible, and then within weeks if the screening BP is hypertensive, or months if the screening BP is elevated.

Because BP levels are variable, even within a single visit, "best practice" is to obtain up to three BP measurements and to record the average of the latter two measurements unless the first measurement is normal, the writing group says. Further confirmation of diagnosis of hypertension can be obtained with 24-hour ambulatory BP monitoring (ABPM).

"Primary hypertension in youth is difficult to recognize in asymptomatic, otherwise healthy youth. There is now evidence that children and adolescents with primary hypertension may also have cardiac and vascular injury due to the hypertension," Falkner told | Medscape Cardiology.

"If not identified and treated, the condition can progress to hypertension in young adulthood with heightened risk of premature cardiovascular events," Falkner said.

The writing group says "primordial prevention" is an important public health goal because a population with lower BP will have fewer comorbidities related to hypertension and CVD.

Modifiable risk factors for primary hypertension in childhood include obesity, physical inactivity and poor diet/nutrition, disturbed sleep patterns and environmental stress.

A healthy lifestyle in childhood — including eating healthy food; encouraging physical activity that leads to improved physical fitness and healthy sleep; and avoiding the development of obesity — may help mitigate the risk of hypertension in childhood, the writing group says.  

Looking ahead, they say efforts to improve recognition and diagnosis of high BP in children, as well as clinical trials to evaluate medical treatment and recommend public health initiatives, are all vital to combat rising rates of primary hypertension in children.

This scientific statement was prepared by the volunteer writing group on behalf of the American Heart Association’s Council on Hypertension; the Council on Lifelong Congenital Heart Disease and Heart Health in the Young; the Council on Kidney in Cardiovascular Disease; the Council on Lifestyle and Cardiometabolic Health; and the Council on Cardiovascular and Stroke Nursing.

Hypertension. Published online March 30, 2023. Scientific Statement

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