Hypertension (HTN) is common in children and often associated with pathologic progression to end ... more Hypertension (HTN) is common in children and often associated with pathologic progression to end organ damage, specifically left ventricular hypertrophy (LVH). The primary goal of this retrospective chart review is to determine if patients with higher blood pressure were more likely to complete echocardiogram (ECHO) and more likely to have LVH, among a pediatric population referred for hypertension evaluation before the 2017 American Academy of Pediatrics (AAP) guidelines. To meet this goal, the number of patients evaluated by ECHO and prevalence of LVH was examined for independent associations with blood pressure and BMI categories by logistic regression. It was found that higher blood pressure was associated with having an ECHO evaluation (p = 0.012). Among patients evaluated by ECHO, one-third had LVH but the presence of LVH was not associated with blood pressure severity or use of anti-hypertensive medication. Instead, BMI was the only factor associated with LVH cardiac remodeling in our population (p = 0.025). Newly updated AAP practice guidelines recommend evaluation of HTN via ABPM, with ECHO performed only at the initiation of pharmaceutical therapy. It is notable that BMI, the only risk factor of LVH found in this study, is not addressed in the current AAP guidelines for ECHO evaluation among hypertensive children. This study suggests that ECHO evaluation may be warranted in a larger subset of children as is recommended by current European Society of Hypertension pediatric guidelines.
Purpose Nurse practitioners (NPs) are valued members of the interdisciplinary PICU team. The NPs ... more Purpose Nurse practitioners (NPs) are valued members of the interdisciplinary PICU team. The NPs manage critically ill patients and perform procedures, although their role as educators to the residents has not been well described. The PICU resident curriculum was redesigned to incorporate more procedural teaching opportunities by the NPs. A checklist of common procedures in the PICU was distributed to each resident at the beginning of their rotation. The residents were encouraged to work with the NPs to seek out any procedure opportunities. We hypothesize that utilizing PICU NPs to …
Background: Increased blood pressure variability (BPV) has been associated with development of hy... more Background: Increased blood pressure variability (BPV) has been associated with development of hypertensive target organ damage in adults, including left ventricular (LV) hypertrophy and increased vascular stiffness. Whether similar relationships can be seen in youth is unknown. Methods: We assessed short-term BPV and its relation to LV mass and carotid-femoral pulse wave velocity (cfPWV) in 374 participants (mean age 15.5 years, 60% male) in the SHIP-AHOY cohort. Short-term BPV was assessed by examining the differences in systolic and diastolic blood pressure (S/DBP) between 2 SHIP-AHOY study visits. Average time between visits was 25 days. BP was measured by auscultation; 4 BP measurements were conducted at each visit and averaged. BPV was calculated as the difference between the mean BP measurements at the 2 visits. LV mass was measured by m-mode echocardiography and cfPWV was assessed using plethysmography. Results: Mean SBP was 123.1 ± 13.0 mmHg on day 1, and 122.3 ± 12.8 mmHg on day 2, with a mean difference of 0.9 ± 7.5 mmHg between the visits. Mean DBP was 71.6 ± 11.6 mmHg on day 1, and 72.0 ± 11.7 mmHg on day 2, with a mean difference of 0.5 ± 10.4 mmHg between the visits. Participants were then divided into 2 groups according to whether their BPV was above (n = 198) or below (n = 176) the median BPV of the entire cohort. LV mass was similar between the groups: 32.7 ± 7.3 gram/ht^2.7 for those above the median vs. 32.8 ± 6.7 for those below the median (P = NS), but cfPWF was significantly higher in those with BPV above the median: 5.2 ± 0.9 meters/second vs. 5.0 ± 0.8 m/s for those below the median, P = 0.03. Conclusions: These data suggest that increased short-term BPV may be associated with the development of increased vascular stiffness in youth.
Archives of Pediatrics & Adolescent Medicine, 1981
The material in this book is derived from presentations made at an international symposium on juv... more The material in this book is derived from presentations made at an international symposium on juvenile hypertension held in Italy in 1979. The contents consist of contributions by more than 100 internationally recognized experts in the field. In fact, the title of the contributor list could well read "Who's Who in the World of Juvenile Hypertension." The subject matter is divided into six major sections: (1) a discussion of the magnitude of the problem, (2) related aspects of blood pressure in childhood, (3) pathophysiology of juvenile hypertension, (4) clinical aspects of juvenile hypertension, (5) therapy for hypertension, and (6) a series of brief communications of unrelated specific topics. The publishers earn high praise for the easily readable print, as well as for reproduction of illustrations and photographs, which clearly reflect a high level of expertise. However, the 19 blank pages, most of which are interspersed throughout the text and are
Ambulatory BP (ABP) is increasingly used to confirm the diagnosis of hypertension. Pediatric but ... more Ambulatory BP (ABP) is increasingly used to confirm the diagnosis of hypertension. Pediatric but not adult guidelines consider BP load (% readings above 95 th %ile) in risk-stratification of the ABP phenotype. We compared ABP sex- and height- specific percentile and BP load as predictors of left ventricular hypertrophy (LVH) in youth. We measured casual BP, ABP, anthropometrics, and calculated LV mass by echo as (g)/height (m) 2.7 (LVMI) in 357 adolescents (mean age 15.5 + 1.7 years, 63% white, 59% male). ABPM was performed with the Ontrak device (Spacelabs Inc., Snoqualmie, WA). ABP index was defined as mean ABP/sex- and height-specific 95 th %ile. LVH was defined as LVMI ≥38.6 (pediatric cut-point). Logistic regression was used to assess different ABP measures as predictors of LVH. Sensitivity and specificity of different ABP cut points as predictors of LVH were calculated. Seventy (19.6%) participants had LVH. Systolic 24-hour, wake and sleep ABP indices as well as 24-hour SBP load were all significantly associated with LVH, while wake and sleep SBP load were not. When adjusted for BMI percentile and sex, only the associations between ABP indices and LVH remained statistically significant (table). SBP percentiles also had better balanced sensitivities and specificities in predicting LVH (24-hour 65 th percentile: 63% and 59%; wake 70 th percentile: 54% and 62%; sleep 75 th percentile: 60% and 61%). There was no significant association between diastolic BP measures and LVH. We conclude that there is no significant contribution of BP load in predicting LVH in youth. Systolic ABP percentiles lower than the commonly used 95 th percentile are the best predictors of LVH in this population.
Hypertension in children and adolescents is becoming a greater problem in the developed world. Al... more Hypertension in children and adolescents is becoming a greater problem in the developed world. Although traditionally thought of as usually secondary to renal, vascular, or endocrine causes, primary hypertension is becoming the most common form seen in childhood. This changing epidemiology is related to the recent obesity epidemic. The evaluation of high blood pressure in children is more involved than in adults and is aimed both at identifying secondary causes and to identify other co-morbidities of cardiovascular risk. Treatment of hypertension in childhood and adolescence is aimed at reducing cardiovascular risk. While there are a growing number of antihypertensive agents with FDA labeling for children, there remain far fewer options than for adults. This paper reviews the epidemiology, definitions, evaluations, and management of elevated blood pressure in children and adolescents.
BACKGROUND: Nocturnal hypertension is a risk factor for chronic kidney disease (CKD) progression ... more BACKGROUND: Nocturnal hypertension is a risk factor for chronic kidney disease (CKD) progression among adults. In children, effects of nocturnal hypertension on CKD progression is less studied. METHODS: We investigated the relationships between nocturnal, daytime, or sustained hypertension and progression to kidney replacement therapy in children using Cox proportional hazards models. Nocturnal and diurnal hypertension respectively defined as: mean blood pressure >95th percentile and/or load >25% for either systolic or diastolic blood pressure within sleep or wake periods. RESULTS: One thousand five hundred seventy-seven ambulatory blood pressure monitoring studies from 701 CKiD participants were reviewed. Nighttime, daytime, and both types of hypertension were 19%, 7%, and 33%, respectively. Participants with both daytime and nocturnal hypertension had the highest risk of kidney replacement therapy. Among children with CKD, compared with those who were normotensive, those with isolated nocturnal hypertension had a hazard ratio of 1.49 ([CI, 0.97–2.28]; P =0.068) while those with both daytime and nocturnal hypertension had a HR of 2.23 ([CI, 1.60–3.11]; P <0.001) when adjusted for age, race, sex, and baseline proteinuria and glomerular filtration. Estimates for risk were similar among glomerular and nonglomerular participants but not significant in glomerular due to smaller sample size. CONCLUSIONS: The presence of both daytime and nocturnal hypertension is significantly associated with risk of kidney replacement therapy. Our study confirms the utility of ambulatory blood pressure monitoring in children with CKD. Identifying and controlling both daytime and nocturnal hypertension using ambulatory blood pressure monitoring may improve outcomes and delay CKD progression in this population.
Hypertension is associated with left ventricular hypertrophy (LVH), a risk factor for cardiovascu... more Hypertension is associated with left ventricular hypertrophy (LVH), a risk factor for cardiovascular events. Since cardiovascular events in youth are rare, hypertension has historically been defined by the 95th percentile of the normal blood pressure (BP) distribution in healthy children. The optimal BP percentile associated with LVH in youth is unknown. We aimed to determine the association of systolic BP (SBP) percentile, independent of obesity, on left ventricular mass index (LVMI), and to estimate which SBP percentile best predicts LVH in youth. We evaluated SBP, anthropometrics, and echocardiogram in 303 adolescents (mean age 15.6 years, 63% white, 55% male) classified by SBP as low-risk (L=141, <80th percentile), mid-risk (M=71, 80–<90th percentile), or high-risk (H=91, ≥90th percentile) using the mean of 6 measurements at 2 visits according to the 2017 guidelines. Logistic regression was used to determine the sensitivity and specificity of various SBP percentiles associated with LVH. Results: BP groups did not differ by age or demographics but differed slightly by body mass index. Mean BP, LVMI, and prevalence of LVH increased across groups (BP: L=111/75, M=125/82, and H=133/92 mm Hg; LVMI: L=31.2, M=34.2, and H=34.9 g/m 2.7 ; LVH: L=13%, M=21%, H=27%, all P <0.03). SBP percentile remained a significant determinant of LVMI after adjusting for covariates. The 90th percentile for SBP resulted in the best balance between sensitivity and specificity for predicting LVH (LVMI≥38.6 g/m 2.7 ). Abnormalities in cardiac structure in youth can be found at BP levels below those used to define hypertension.
Ambulatory hypertension (HT) is more strongly related to cardiac target organ damage (TOD) than c... more Ambulatory hypertension (HT) is more strongly related to cardiac target organ damage (TOD) than clinic BP. Therefore, correct classification of ambulatory blood pressure (ABP) phenotype is needed to determine which patients to refer for imaging. Pediatric ABPM interpretation is based on percentiles of ABP while adult ABPM interpretation is based on static cut-points. We sought to determine which ABP classification system was the best predictor of TOD in adolescents. We measured adiposity, LV mass index (LVMI), systolic and diastolic function (strain, E/e’ ratio) in 315 adolescents (15.9 + 1.4 years, 64% white, 59% male). BP phenotype was determined by mean of 6 casual aneroid SBPs, and 24-hour SBP on ABP (Spacelabs Inc., Snoqualmie, WA) 1) by age, sex and height specific pediatric cut-points and 2) by adult ABPM cut-points (day <130, night < 110, 24-hour < 125 mmHg). We evaluated concordance in classification and prevalence of TOD with Chi square and kappa statistic for agreement. For daytime SBP, 5% of all subjects (16 of 315) reclassified from normotensive (NT) to masked hypertension (MH) and 8% (24 of 315) reclassified from white coat (WC) to HT. Results were similar for night and 24-hour ABP. Fewer NT and WC subjects had any form of TOD by adult vs pediatric cut-point (NT 32 vs 36%, WC 8 vs 13%; chi square < 0.0001, kappa 0.73). The only significant differences in cardiac TOD by ABP phenotype were found using adult ABP cut-points (LVMI higher and strain lower HT vs NT, diastolic E/e’ higher HT and MH vs NT all p <=0.05). We conclude that classification of ABP by adult cut-points is superior in identifying adolescents at risk for cardiac TOD. These findings may inform future pediatric ABP guidelines.
Background Blood pressure (BP) is often inadequately controlled in children treated for hypertens... more Background Blood pressure (BP) is often inadequately controlled in children treated for hypertension, and personalized (n-of-1) trials show promise for tailoring treatment choices. We assessed whether patients whose treatment choices are informed by an n-of-1 trial have improved BP control compared to usual care. Methods A randomized clinical trial was conducted in a pediatric hypertension clinic in Houston from April 2018 to September 2020. Hypertensive adolescents and young adults 10–22 years old were randomized 1:1 to a strategy of n-of-1 trial using ambulatory BP monitoring to inform treatment choice or usual care, with treatment selected by physician preference. The primary outcome was the proportion of patients with ambulatory BP control at 6 months in a Bayesian analysis. Results Among 49 participants (23 randomized to n-of-1 trials and 26 to usual care), mean age was 15.6 years. Using skeptical priors, we found a 69% probability that n-of-1 trials increased BP control at 6 months (Bayesian odds ratio (OR) 1.24 (95% credible interval (CrI) 0.51, 2.97), and 74% probability using neutral informed priors (OR 1.45 (95% CrI 0.48, 4.53)). Systolic BP was reduced in both groups, with a 93% probability of greater reduction in the n-of-1 trial group (mean difference between groups = −3.6 mm Hg (95% CrI −8.3, 1.28). There was no significant difference in side effect experience or caregiver satisfaction. Conclusions Among hypertensive adolescents and young adults, n-of-1 trials with ambulatory BP monitoring likely increased the probability of BP control. A large trial is needed to assess their use in clinical practice. ClinicalTrials.gov NCT03461003 Clinical trial registry ClinicalTrials.gov; NCT 03461003
Hypertension (HTN) is common in children and often associated with pathologic progression to end ... more Hypertension (HTN) is common in children and often associated with pathologic progression to end organ damage, specifically left ventricular hypertrophy (LVH). The primary goal of this retrospective chart review is to determine if patients with higher blood pressure were more likely to complete echocardiogram (ECHO) and more likely to have LVH, among a pediatric population referred for hypertension evaluation before the 2017 American Academy of Pediatrics (AAP) guidelines. To meet this goal, the number of patients evaluated by ECHO and prevalence of LVH was examined for independent associations with blood pressure and BMI categories by logistic regression. It was found that higher blood pressure was associated with having an ECHO evaluation (p = 0.012). Among patients evaluated by ECHO, one-third had LVH but the presence of LVH was not associated with blood pressure severity or use of anti-hypertensive medication. Instead, BMI was the only factor associated with LVH cardiac remodeling in our population (p = 0.025). Newly updated AAP practice guidelines recommend evaluation of HTN via ABPM, with ECHO performed only at the initiation of pharmaceutical therapy. It is notable that BMI, the only risk factor of LVH found in this study, is not addressed in the current AAP guidelines for ECHO evaluation among hypertensive children. This study suggests that ECHO evaluation may be warranted in a larger subset of children as is recommended by current European Society of Hypertension pediatric guidelines.
Purpose Nurse practitioners (NPs) are valued members of the interdisciplinary PICU team. The NPs ... more Purpose Nurse practitioners (NPs) are valued members of the interdisciplinary PICU team. The NPs manage critically ill patients and perform procedures, although their role as educators to the residents has not been well described. The PICU resident curriculum was redesigned to incorporate more procedural teaching opportunities by the NPs. A checklist of common procedures in the PICU was distributed to each resident at the beginning of their rotation. The residents were encouraged to work with the NPs to seek out any procedure opportunities. We hypothesize that utilizing PICU NPs to …
Background: Increased blood pressure variability (BPV) has been associated with development of hy... more Background: Increased blood pressure variability (BPV) has been associated with development of hypertensive target organ damage in adults, including left ventricular (LV) hypertrophy and increased vascular stiffness. Whether similar relationships can be seen in youth is unknown. Methods: We assessed short-term BPV and its relation to LV mass and carotid-femoral pulse wave velocity (cfPWV) in 374 participants (mean age 15.5 years, 60% male) in the SHIP-AHOY cohort. Short-term BPV was assessed by examining the differences in systolic and diastolic blood pressure (S/DBP) between 2 SHIP-AHOY study visits. Average time between visits was 25 days. BP was measured by auscultation; 4 BP measurements were conducted at each visit and averaged. BPV was calculated as the difference between the mean BP measurements at the 2 visits. LV mass was measured by m-mode echocardiography and cfPWV was assessed using plethysmography. Results: Mean SBP was 123.1 ± 13.0 mmHg on day 1, and 122.3 ± 12.8 mmHg on day 2, with a mean difference of 0.9 ± 7.5 mmHg between the visits. Mean DBP was 71.6 ± 11.6 mmHg on day 1, and 72.0 ± 11.7 mmHg on day 2, with a mean difference of 0.5 ± 10.4 mmHg between the visits. Participants were then divided into 2 groups according to whether their BPV was above (n = 198) or below (n = 176) the median BPV of the entire cohort. LV mass was similar between the groups: 32.7 ± 7.3 gram/ht^2.7 for those above the median vs. 32.8 ± 6.7 for those below the median (P = NS), but cfPWF was significantly higher in those with BPV above the median: 5.2 ± 0.9 meters/second vs. 5.0 ± 0.8 m/s for those below the median, P = 0.03. Conclusions: These data suggest that increased short-term BPV may be associated with the development of increased vascular stiffness in youth.
Archives of Pediatrics & Adolescent Medicine, 1981
The material in this book is derived from presentations made at an international symposium on juv... more The material in this book is derived from presentations made at an international symposium on juvenile hypertension held in Italy in 1979. The contents consist of contributions by more than 100 internationally recognized experts in the field. In fact, the title of the contributor list could well read "Who's Who in the World of Juvenile Hypertension." The subject matter is divided into six major sections: (1) a discussion of the magnitude of the problem, (2) related aspects of blood pressure in childhood, (3) pathophysiology of juvenile hypertension, (4) clinical aspects of juvenile hypertension, (5) therapy for hypertension, and (6) a series of brief communications of unrelated specific topics. The publishers earn high praise for the easily readable print, as well as for reproduction of illustrations and photographs, which clearly reflect a high level of expertise. However, the 19 blank pages, most of which are interspersed throughout the text and are
Ambulatory BP (ABP) is increasingly used to confirm the diagnosis of hypertension. Pediatric but ... more Ambulatory BP (ABP) is increasingly used to confirm the diagnosis of hypertension. Pediatric but not adult guidelines consider BP load (% readings above 95 th %ile) in risk-stratification of the ABP phenotype. We compared ABP sex- and height- specific percentile and BP load as predictors of left ventricular hypertrophy (LVH) in youth. We measured casual BP, ABP, anthropometrics, and calculated LV mass by echo as (g)/height (m) 2.7 (LVMI) in 357 adolescents (mean age 15.5 + 1.7 years, 63% white, 59% male). ABPM was performed with the Ontrak device (Spacelabs Inc., Snoqualmie, WA). ABP index was defined as mean ABP/sex- and height-specific 95 th %ile. LVH was defined as LVMI ≥38.6 (pediatric cut-point). Logistic regression was used to assess different ABP measures as predictors of LVH. Sensitivity and specificity of different ABP cut points as predictors of LVH were calculated. Seventy (19.6%) participants had LVH. Systolic 24-hour, wake and sleep ABP indices as well as 24-hour SBP load were all significantly associated with LVH, while wake and sleep SBP load were not. When adjusted for BMI percentile and sex, only the associations between ABP indices and LVH remained statistically significant (table). SBP percentiles also had better balanced sensitivities and specificities in predicting LVH (24-hour 65 th percentile: 63% and 59%; wake 70 th percentile: 54% and 62%; sleep 75 th percentile: 60% and 61%). There was no significant association between diastolic BP measures and LVH. We conclude that there is no significant contribution of BP load in predicting LVH in youth. Systolic ABP percentiles lower than the commonly used 95 th percentile are the best predictors of LVH in this population.
Hypertension in children and adolescents is becoming a greater problem in the developed world. Al... more Hypertension in children and adolescents is becoming a greater problem in the developed world. Although traditionally thought of as usually secondary to renal, vascular, or endocrine causes, primary hypertension is becoming the most common form seen in childhood. This changing epidemiology is related to the recent obesity epidemic. The evaluation of high blood pressure in children is more involved than in adults and is aimed both at identifying secondary causes and to identify other co-morbidities of cardiovascular risk. Treatment of hypertension in childhood and adolescence is aimed at reducing cardiovascular risk. While there are a growing number of antihypertensive agents with FDA labeling for children, there remain far fewer options than for adults. This paper reviews the epidemiology, definitions, evaluations, and management of elevated blood pressure in children and adolescents.
BACKGROUND: Nocturnal hypertension is a risk factor for chronic kidney disease (CKD) progression ... more BACKGROUND: Nocturnal hypertension is a risk factor for chronic kidney disease (CKD) progression among adults. In children, effects of nocturnal hypertension on CKD progression is less studied. METHODS: We investigated the relationships between nocturnal, daytime, or sustained hypertension and progression to kidney replacement therapy in children using Cox proportional hazards models. Nocturnal and diurnal hypertension respectively defined as: mean blood pressure >95th percentile and/or load >25% for either systolic or diastolic blood pressure within sleep or wake periods. RESULTS: One thousand five hundred seventy-seven ambulatory blood pressure monitoring studies from 701 CKiD participants were reviewed. Nighttime, daytime, and both types of hypertension were 19%, 7%, and 33%, respectively. Participants with both daytime and nocturnal hypertension had the highest risk of kidney replacement therapy. Among children with CKD, compared with those who were normotensive, those with isolated nocturnal hypertension had a hazard ratio of 1.49 ([CI, 0.97–2.28]; P =0.068) while those with both daytime and nocturnal hypertension had a HR of 2.23 ([CI, 1.60–3.11]; P <0.001) when adjusted for age, race, sex, and baseline proteinuria and glomerular filtration. Estimates for risk were similar among glomerular and nonglomerular participants but not significant in glomerular due to smaller sample size. CONCLUSIONS: The presence of both daytime and nocturnal hypertension is significantly associated with risk of kidney replacement therapy. Our study confirms the utility of ambulatory blood pressure monitoring in children with CKD. Identifying and controlling both daytime and nocturnal hypertension using ambulatory blood pressure monitoring may improve outcomes and delay CKD progression in this population.
Hypertension is associated with left ventricular hypertrophy (LVH), a risk factor for cardiovascu... more Hypertension is associated with left ventricular hypertrophy (LVH), a risk factor for cardiovascular events. Since cardiovascular events in youth are rare, hypertension has historically been defined by the 95th percentile of the normal blood pressure (BP) distribution in healthy children. The optimal BP percentile associated with LVH in youth is unknown. We aimed to determine the association of systolic BP (SBP) percentile, independent of obesity, on left ventricular mass index (LVMI), and to estimate which SBP percentile best predicts LVH in youth. We evaluated SBP, anthropometrics, and echocardiogram in 303 adolescents (mean age 15.6 years, 63% white, 55% male) classified by SBP as low-risk (L=141, <80th percentile), mid-risk (M=71, 80–<90th percentile), or high-risk (H=91, ≥90th percentile) using the mean of 6 measurements at 2 visits according to the 2017 guidelines. Logistic regression was used to determine the sensitivity and specificity of various SBP percentiles associated with LVH. Results: BP groups did not differ by age or demographics but differed slightly by body mass index. Mean BP, LVMI, and prevalence of LVH increased across groups (BP: L=111/75, M=125/82, and H=133/92 mm Hg; LVMI: L=31.2, M=34.2, and H=34.9 g/m 2.7 ; LVH: L=13%, M=21%, H=27%, all P <0.03). SBP percentile remained a significant determinant of LVMI after adjusting for covariates. The 90th percentile for SBP resulted in the best balance between sensitivity and specificity for predicting LVH (LVMI≥38.6 g/m 2.7 ). Abnormalities in cardiac structure in youth can be found at BP levels below those used to define hypertension.
Ambulatory hypertension (HT) is more strongly related to cardiac target organ damage (TOD) than c... more Ambulatory hypertension (HT) is more strongly related to cardiac target organ damage (TOD) than clinic BP. Therefore, correct classification of ambulatory blood pressure (ABP) phenotype is needed to determine which patients to refer for imaging. Pediatric ABPM interpretation is based on percentiles of ABP while adult ABPM interpretation is based on static cut-points. We sought to determine which ABP classification system was the best predictor of TOD in adolescents. We measured adiposity, LV mass index (LVMI), systolic and diastolic function (strain, E/e’ ratio) in 315 adolescents (15.9 + 1.4 years, 64% white, 59% male). BP phenotype was determined by mean of 6 casual aneroid SBPs, and 24-hour SBP on ABP (Spacelabs Inc., Snoqualmie, WA) 1) by age, sex and height specific pediatric cut-points and 2) by adult ABPM cut-points (day <130, night < 110, 24-hour < 125 mmHg). We evaluated concordance in classification and prevalence of TOD with Chi square and kappa statistic for agreement. For daytime SBP, 5% of all subjects (16 of 315) reclassified from normotensive (NT) to masked hypertension (MH) and 8% (24 of 315) reclassified from white coat (WC) to HT. Results were similar for night and 24-hour ABP. Fewer NT and WC subjects had any form of TOD by adult vs pediatric cut-point (NT 32 vs 36%, WC 8 vs 13%; chi square < 0.0001, kappa 0.73). The only significant differences in cardiac TOD by ABP phenotype were found using adult ABP cut-points (LVMI higher and strain lower HT vs NT, diastolic E/e’ higher HT and MH vs NT all p <=0.05). We conclude that classification of ABP by adult cut-points is superior in identifying adolescents at risk for cardiac TOD. These findings may inform future pediatric ABP guidelines.
Background Blood pressure (BP) is often inadequately controlled in children treated for hypertens... more Background Blood pressure (BP) is often inadequately controlled in children treated for hypertension, and personalized (n-of-1) trials show promise for tailoring treatment choices. We assessed whether patients whose treatment choices are informed by an n-of-1 trial have improved BP control compared to usual care. Methods A randomized clinical trial was conducted in a pediatric hypertension clinic in Houston from April 2018 to September 2020. Hypertensive adolescents and young adults 10–22 years old were randomized 1:1 to a strategy of n-of-1 trial using ambulatory BP monitoring to inform treatment choice or usual care, with treatment selected by physician preference. The primary outcome was the proportion of patients with ambulatory BP control at 6 months in a Bayesian analysis. Results Among 49 participants (23 randomized to n-of-1 trials and 26 to usual care), mean age was 15.6 years. Using skeptical priors, we found a 69% probability that n-of-1 trials increased BP control at 6 months (Bayesian odds ratio (OR) 1.24 (95% credible interval (CrI) 0.51, 2.97), and 74% probability using neutral informed priors (OR 1.45 (95% CrI 0.48, 4.53)). Systolic BP was reduced in both groups, with a 93% probability of greater reduction in the n-of-1 trial group (mean difference between groups = −3.6 mm Hg (95% CrI −8.3, 1.28). There was no significant difference in side effect experience or caregiver satisfaction. Conclusions Among hypertensive adolescents and young adults, n-of-1 trials with ambulatory BP monitoring likely increased the probability of BP control. A large trial is needed to assess their use in clinical practice. ClinicalTrials.gov NCT03461003 Clinical trial registry ClinicalTrials.gov; NCT 03461003
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