Examining hypertension in children and adolescents: Clinical implications of the differences between the European and American Guidelines

array:23 ["pii" => "S2341287918301558" "issn" => "23412879" "doi" => "10.1016/j.anpede.2018.08.005" "estado" => "S300" "fechaPublicacion" => "2018-10-01" "aid" => "2510" "copyright" => "Asociación Española de Pediatría" "copyrightAnyo" => "2018" "documento" => "article" "crossmark" => 1 "licencia" => "http://creativecommons.org/licenses/by-nc-nd/4.0/" "subdocumento" => "fla" "cita" => "An Pediatr (Barc). 2018;89:255.e1-5" "abierto" => array:3 [ "ES" => true "ES2" => true "LATM" => true ] "gratuito" => true "lecturas" => array:2 [ "total" => 1395 "formatos" => array:3 [ "EPUB" => 122 "HTML" => 558 "PDF" => 715 ] ] "itemAnterior" => array:19 [ "pii" => "S2341287918301546" "issn" => "23412879" "doi" => "10.1016/j.anpede.2018.08.004" "estado" => "S300" "fechaPublicacion" => "2018-10-01" "aid" => "2498" "copyright" => "Asociación Española de Pediatría" "documento" => "article" "crossmark" => 1 "licencia" => "http://creativecommons.org/licenses/by-nc-nd/4.0/" "subdocumento" => "fla" "cita" => "An Pediatr (Barc). 2018;89:254.e1-7" "abierto" => array:3 [ "ES" => true "ES2" => true "LATM" => true ] "gratuito" => true "lecturas" => array:2 [ "total" => 1632 "formatos" => array:3 [ "EPUB" => 123 "HTML" => 1078 "PDF" => 431 ] ] "en" => array:13 [ "idiomaDefecto" => true "cabecera" => "Spanish Association of Paediatrics" "titulo" => "Recommendations for the diagnosis and followup of the foetus and newborn child born to mothers with autoimmune thyroid disease" "tienePdf" => "en" "tieneTextoCompleto" => "en" "tieneResumen" => array:2 [ 0 => "en" 1 => "es" ] "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "254.e1" "paginaFinal" => "254.e7" ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Recomendaciones para el diagnóstico y seguimiento del feto y del recién nacido hijo de madre con patología tiroidea autoinmune" ] ] "contieneResumen" => array:2 [ "en" => true "es" => true ] "contieneTextoCompleto" => array:1 [ "en" => true ] "contienePdf" => array:1 [ "en" => true ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1777 "Ancho" => 1760 "Tamanyo" => 339015 ] ] "descripcion" => array:1 [ "en" => "Approach to the management of an infant born to a mother with GD or hyperthyroidism (current or past). Pregnant mother: measure TRAb levels in the second to third trimester of pregnancy. Inform the neonatologist of results. If TRAb status positive or unknown: high-risk NB. If TRAb status negative: low-risk NB. Newborn (NB): measure TRAb in cord blood (hormone levels not useful) and monitor." ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "Susana Ares Segura, Carmen Temboury Molina, María Jesús Chueca Guindulain, Gema Grau Bolado, María Jesus Alija Merillas, María Caimari Jaume, Paula Casano Sancho, José Carlos Moreno Navarro, José Manuel Rial Rodríguez, Amparo Rodríguez Sánchez" "autores" => array:11 [ 0 => array:2 [ "nombre" => "Susana" "apellidos" => "Ares Segura" ] 1 => array:2 [ "nombre" => "Carmen" "apellidos" => "Temboury Molina" ] 2 => array:2 [ "nombre" => "María Jesús" "apellidos" => "Chueca Guindulain" ] 3 => array:2 [ "nombre" => "Gema" "apellidos" => "Grau Bolado" ] 4 => array:2 [ "nombre" => "María Jesus" "apellidos" => "Alija Merillas" ] 5 => array:2 [ "nombre" => "María" "apellidos" => "Caimari Jaume" ] 6 => array:2 [ "nombre" => "Paula" "apellidos" => "Casano Sancho" ] 7 => array:2 [ "nombre" => "José Carlos" "apellidos" => "Moreno Navarro" ] 8 => array:2 [ "nombre" => "José Manuel" "apellidos" => "Rial Rodríguez" ] 9 => array:2 [ "nombre" => "Amparo" "apellidos" => "Rodríguez Sánchez" ] 10 => array:1 [ "colaborador" => "en representación del Grupo de trabajo de tiroides de la Sociedad Española de Endocrinología Pediátrica" ] ] ] ] ] "idiomaDefecto" => "en" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2341287918301546?idApp=UINPBA00005H" "url" => "/23412879/0000008900000004/v1_201810020628/S2341287918301546/v1_201810020628/en/main.assets" ] "en" => array:19 [ "idiomaDefecto" => true "cabecera" => "Special Article" "titulo" => "Examining hypertension in children and adolescents: Clinical implications of the differences between the European and American Guidelines" "tieneTextoCompleto" => true "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "255.e1" "paginaFinal" => "255.e5" ] ] "autores" => array:1 [ 0 => array:3 [ "autoresLista" => "Empar Lurbe i Ferrer" "autores" => array:1 [ 0 => array:4 [ "nombre" => "Empar" "apellidos" => "Lurbe i Ferrer" "email" => array:1 [ 0 => "empar.lurbe@uv.es" ] "referencia" => array:3 [ 0 => array:2 [ "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "b" "identificador" => "aff0010" ] 2 => array:2 [ "etiqueta" => "c" "identificador" => "aff0015" ] ] ] ] "afiliaciones" => array:3 [ 0 => array:3 [ "entidad" => "Servicio de Pediatría, Consorcio Hospital General Universitario de Valencia, Valencia, Spain" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "CIBER Fisiopatología Obesidad y Nutrición (CB06/03), Instituto de Salud Carlos III, Madrid, Spain" "etiqueta" => "b" "identificador" => "aff0010" ] 2 => array:3 [ "entidad" => "INCLIVA, Instituto de Investigación, Valencia, Spain" "etiqueta" => "c" "identificador" => "aff0015" ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "La hipertensión arterial en niños y adolescentes a examen: implicaciones clínicas de las diferencias entre la Guía Europea y la Americana" ] ] "textoCompleto" => "Advances in the field of high blood pressure, or hypertension (HTN), in children and adolescents have highlighted the need for documents summarising the evidence on the aetiology, assessment, treatment and outcomes of HTN in this age group.<a class="elsevierStyleCrossRef" href="#bib0090">1</a> Our knowledge of blood pressure (BP) in children and adolescents has increased considerably in the past two decades. The first guidelines on the control of BP in this age group were published in 1997,<a class="elsevierStyleCrossRef" href="#bib0095">2</a> as there had previously been no consistent definition of HTN in the paediatric population, and measurement of BP was not performed in asymptomatic children and adolescents.<a class="elsevierStyleCrossRefs" href="#bib0100">3,4</a> Although the association between BP and cardiovascular disease is well established in adults, this association in children and adolescents is not well defined, as the development of cardiovascular complications results from the interaction of various risk factors and age. Consequently, the definition of reference values in the paediatric population is based on the percentile distribution of BP values.Advances in the knowledge of high BP in children and adolescentsThe awareness that HTN may be present in seemingly healthy children and that HTN in adults may have its roots in childhood has spurred interest and demonstrated the need to include measurement of BP in the medical care of children and adolescents. Furthermore, we have gained a deeper understanding of the impact of BP values on the development of subclinical damage in target organs through the use of recently developed methods with a much higher specificity and sensitivity. We are also aware that the prevalence of HTN is increasing as a consequence of the obesity epidemic, which has become a significant public health problem. Early detection of the roots of HTN is crucial for the early implementation of interventions aimed at reducing the elevation of BP and its subsequent impact on cardiovascular morbidity and mortality in adulthood.Evolution of guidelines for the diagnosis and management of HTNThe current widespread interest in clinical practice guidelines for HTN stems from the desire of health-care professionals to offer, and of patients to receive, the best possible care, that is, care that is consistent, effective and narrows the gap between clinical practice and evidence-based recommendations. The guidelines published throughout the years have significantly expanded the knowledge in this field and stimulated a growing interest not only in epidemiologists, but also in paediatricians and basic researchers.<a class="elsevierStyleCrossRefs" href="#bib0110">5,6</a>New guidelines have been published in the past 2 years.<a class="elsevierStyleCrossRefs" href="#bib0120">7,8</a> The first ones were developed by the Working Group on Hypertension in Children and Adolescents of the European Society of Hypertension, recognising the need to update the 2009 European guidelines to integrate the evidence gathered over the past few years.<a class="elsevierStyleCrossRefs" href="#bib0115">6,7</a> This was followed by the publication of the updated version of the United States guidelines on HTN in the paediatric population,<a class="elsevierStyleCrossRef" href="#bib0125">8</a> which had last been updated in 2004.<a class="elsevierStyleCrossRef" href="#bib0110">5</a>The European and United States guidelines, published 1 year apart, agree on some aspects, but also have marked disagreements on other essential aspects that influence everyday clinical practice.Agreement between European and United States GuidelinesThe European and the United States guidelines<a class="elsevierStyleCrossRefs" href="#bib0120">7,8</a> agree on several aspects, including:<ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005">•BP screening. BP should be measured starting at age 3 years, and in younger children if they are at risk of developing HTN.</li><li class="elsevierStyleListItem" id="lsti0010">•Methods for measurement of BP. The auscultatory method is recommended, using Korotkoff sounds K1 and K5 to assess systolic blood pressure (SBP) and diastolic blood pressure (DBP), respectively. The guidelines also find the use of oscillometric devices validated in the paediatric population acceptable to measure BP.<a class="elsevierStyleCrossRef" href="#bib0130">9</a> However, whenever high BP readings are found by the oscillometric method, the auscultatory method must be used for confirmation.</li><li class="elsevierStyleListItem" id="lsti0015">•24-h ambulatory BP monitoring (ABPM). It is considered useful both for diagnosis of HTN and to monitor pharmacological treatment.</li><li class="elsevierStyleListItem" id="lsti0020">•Treatment. Once HTN is diagnosed, both guidelines agree that lifestyle changes should be introduced and BP rechecked repeatedly, initiating pharmacological treatment if these measures do not achieve adequate control. In cases where the elevation of BP is such that it poses a risk of organ damage, pharmacological treatment should be initiated immediately.</li></ul>Differences between the European and the United States guidelinesMethodological differencesThe main methodological differences involve the criteria for diagnosis and classification of HTN. This is due to: (a) differences in reference values; (b) difference in the age used to apply the adult criteria for definition of HTN, replacing the traditional approximation by BP percentiles and (c) differences in the classification of HTN.<ul class="elsevierStyleList" id="lis0010"><li class="elsevierStyleListItem" id="lsti0025">a)The reference values for BP come from the same source in both guidelines, the 2004 US Task Force cohort.<a class="elsevierStyleCrossRef" href="#bib0110">5</a> While the European guidelines maintain the percentiles of the original cohort, the United States guidelines calculate the percentiles based only on children with normal weight. The exclusion of children with overweight or obesity, which were included in the original cohort, was founded on the risk of bias that could lead to underdiagnosis of HTN.</li><li class="elsevierStyleListItem" id="lsti0030">b)For the diagnosis of HTN, both guidelines use BP percentiles for age, sex and height, until the age of 16 years in the European guidelines and the age of 13 years in the United States guidelines. Starting from these ages, adult criteria are applied to define HTN: 140/90mmHg in the European guidelines<a class="elsevierStyleCrossRef" href="#bib0135">10</a> and 130/80mmHg in the United States guidelines,<a class="elsevierStyleCrossRef" href="#bib0140">11</a> thresholds that are not free from controversy (<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>).<a class="elsevierStyleCrossRefs" href="#bib0145">12,13</a><elsevierMultimedia ident="tbl0005"></elsevierMultimedia></li><li class="elsevierStyleListItem" id="lsti0035">c)The definitions of stages 1 and 2 also differ between the European and the United States guidelines, as the latter applies the criteria of the published guidelines for the adult population (<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>).<a class="elsevierStyleCrossRefs" href="#bib0120">7,8</a></li></ul>The choice of age 16 years in the European guidelines is based on the fact that in adolescents aged 16 and 17 years, with the exception of males aged 17 years at or above the 95th percentile for height, all the specific values for the 95th percentile for BP are below the threshold used to define HTN in adults. When adolescents become adults, this difference may lead to an adolescent previously considered to have HTN to be considered a normotensive adult on turning 18 years old due to discrepancies in definition criteria.The United States guidelines lower the age for application of adult BP criteria to 13 years. It could be argued that simplifying this criterion for the diagnosis of HTN would facilitate the identification of children at higher risk of cardiovascular disease. When the threshold of 130mmHg is applied at the age of 13 years, it is below the 95th percentile for age, sex and height in male adolescents, whereas the opposite is true of female adolescents, in whom the 95th percentile does not reach 130mmHg in any instance.Impact on diagnosis and treatmentThe first consequence of these differences involves the prevalence of HTN. The United States guidelines result in a greater proportion of children considered to have HTN, although not in a greater proportion needing pharmacological treatment.This greater prevalence leads to increases in:<ul class="elsevierStyleList" id="lis0015"><li class="elsevierStyleListItem" id="lsti0040">a)The patients requiring clinical monitoring.</li><li class="elsevierStyleListItem" id="lsti0045">b)The use of 24-h ABPM, due to the recommendation that “ABPM should be performed for the confirmation of HTN in children and adolescents with office BP measurements in the elevated BP category for 1 year or more or with stage 1 HTN over 3 clinic visits (Grade C, moderate recommendation).”<a class="elsevierStyleCrossRef" href="#bib0125">8</a> Both guidelines<a class="elsevierStyleCrossRefs" href="#bib0120">7,8</a> recognise the usefulness of ABPM for the identification of white-coat HTN and masked HTN and that it is the sole method available for diagnosis of nocturnal HTN, which carries risks that are independent of the daytime ambulatory and office BP values. The reported frequency of white-coat and masked HTN varies as a result of the office and ambulatory BP criteria used to establish the diagnosis. In this context, the lower office BP values established by the United States guidelines for the definition of HTN will result in a marked increase in the proportion of individuals with white-coat HTN, as the reference used to define HTN by the ABPM method continues to be the distribution tables obtained for the European population.<a class="elsevierStyleCrossRef" href="#bib0155">14</a></li><li class="elsevierStyleListItem" id="lsti0050">c)Performance of diagnostic tests to assess early organ damage. The timing of the evaluation of potential target organ damage has considerable clinical relevance. The assessment of left ventricular mass continues to be the key in the investigation of early signs of organ damage. Children and adolescents with HTN may have left ventricular hypertrophy even in the early stages of disease,<a class="elsevierStyleCrossRefs" href="#bib0120">7,8</a> and delaying evaluation may lead to errors in risk stratification. The European guidelines recommend monitoring target organ damage after HTN is diagnosed and considers its presence as an indication for initiating pharmacological treatment; the United States guidelines recommend assessment of left ventricular mass only at the time that pharmacological treatment is considered. Thus, the European guidelines promote the assessment and detection of target organ damage as a way to establish the need of pharmacological treatment in children and adolescents with HTN.</li><li class="elsevierStyleListItem" id="lsti0055">d)The ongoing debate on the BP targets to pursue in treatment is also considered in the recommendations of both guidelines. In children, the evidence supporting specific BP targets is scarce, and there is also uncertainty regarding the specific impact of drugs on cardiovascular and renal outcomes. In the absence of prospective, long-term studies on the impact of different BP levels in intermediate or final cardiovascular or renal goals, the 95th percentile is considered the BP target, as this was the threshold used to define HTN in children and adolescents, although lowering BP below the 90th percentile would be preferable as long as the treatment is well tolerated. In individuals aged 16 years or more, the European guidelines recommend establishing targets using the cutoff for clinically significant BP in adults, that is, of less than 140/90mmHg, without discouraging the goal of less than 130/80mmHg. Conversely, the United States guidelines recommend reducing BP to less than 130/80mmHg starting at the age of 13 years.</li><li class="elsevierStyleListItem" id="lsti0060">e)When it comes to patients with chronic kidney disease (CKD), the European guidelines recommend a BP target below the 75th percentile in children with nonproteinuric renal disease and a BP target below the 50th percentile in those with proteinuric disease.<a class="elsevierStyleCrossRef" href="#bib0160">15</a> This recommendation differs from the United States guidelines, which recommend a BP target below the 50th percentile in nonproteinuric patients, too, although there is no evidence that this measure provides additional protection against renal events in nonproteinuric CKD.<a class="elsevierStyleCrossRef" href="#bib0165">16</a></li></ul>The importance of isolated systolic HTNFinally, isolated systolic HTN, the most frequent type of HTN in adolescents, has been specifically considered by the European guidelines<a class="elsevierStyleCrossRef" href="#bib0120">7</a> (<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>) but not the United States guidelines.<a class="elsevierStyleCrossRef" href="#bib0125">8</a> In a high proportion of cases, elevation of SBP with a normal DBP is associated with normal BP in the aortic root. Various mechanisms may be involved in these discrepancies, but this phenomenon nevertheless affects clinical decision-making. At present, we accept the recommendation that patients with isolated systolic HTN undergo measurement of central aortic BP by indirect, non-invasive methods, as this allows the detection of left ventricular mass abnormalities. In patients with normal central BP and left ventricular mass, it is possible to apply a watchful waiting approach without initiating treatment.<a class="elsevierStyleCrossRef" href="#bib0170">17</a>Future needsAll published guidelines acknowledge and lament the lack of robust evidence from clinical trials on which to base the recommendations for the diagnosis and management of paediatric HTN. To fill this gap, action must be taken to gather data that will result in relevant evidence in upcoming years. To determine the usefulness and appropriateness of the new BP threshold, future studies ought to analyse the effects, both in the short and the long term. The long-term analysis involves the challenge of assessing the incidence of cardiovascular complications of HTN over many years. On the other hand, in the short term, we need to explore new strategies for improving control of BP without significantly increasing the cost, work burden and side effects of treatment. Future studies must attempt to answer all the questions that remain unresolved to date.Conflicts of interestThe author has no conflict of interest to declare." "textoCompletoSecciones" => array:1 [ "secciones" => array:11 [ 0 => array:3 [ "identificador" => "xres1089603" "titulo" => "Abstract" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0005" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec1033015" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres1089602" "titulo" => "Resumen" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0010" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec1033014" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Advances in the knowledge of high BP in children and adolescents" ] 5 => array:2 [ "identificador" => "sec0010" "titulo" => "Evolution of guidelines for the diagnosis and management of HTN" ] 6 => array:2 [ "identificador" => "sec0015" "titulo" => "Agreement between European and United States Guidelines" ] 7 => array:3 [ "identificador" => "sec0020" "titulo" => "Differences between the European and the United States guidelines" "secciones" => array:3 [ 0 => array:2 [ "identificador" => "sec0025" "titulo" => "Methodological differences" ] 1 => array:2 [ "identificador" => "sec0030" "titulo" => "Impact on diagnosis and treatment" ] 2 => array:2 [ "identificador" => "sec0035" "titulo" => "The importance of isolated systolic HTN" ] ] ] 8 => array:2 [ "identificador" => "sec0040" "titulo" => "Future needs" ] 9 => array:2 [ "identificador" => "sec0045" "titulo" => "Conflicts of interest" ] 10 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2018-08-07" "fechaAceptado" => "2018-08-09" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec1033015" "palabras" => array:4 [ 0 => "Clinical guidelines" 1 => "Arterial hypertension" 2 => "Children" 3 => "Teenagers" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec1033014" "palabras" => array:4 [ 0 => "Guía clínica" 1 => "Hipertensión arterial" 2 => "Niños" 3 => "Adolescentes" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:2 [ "titulo" => "Abstract" "resumen" => "Over the past 2 years, new guidelines for hypertension in children and adolescents have been published. The first, developed by the 2009 European Hypertension Society Working Group on Hypertension in Children and Adolescents, recognised the need for an update of the European Guidelines in order to incorporate the new information acquired over the last few years. Subsequently, an update of the American guidelines (the most recent of which was in 2004) has been published. In both guidelines, there are aspects which are agreed on, and in others, there are marked differences in the basic elements that have an influence on daily clinical practice. The main differences are centred on the criteria for the diagnosis and classification of hypertension, with the subsequent impact on its prevalence. Future studies should offer responses to all the questions that still remain unresolved." ] "es" => array:2 [ "titulo" => "Resumen" "resumen" => "En los 2 últimos años se han publicado nuevas guías de hipertensión arterial en niños y adolescentes. La primera de ellas, desarrollada por el Grupo de Trabajo de hipertensión arterial en niños y adolescentes de la Sociedad Europea de Hipertensión, recogía la necesidad de una actualización de la Guía Europea de 2009 para incorporar la información adquirida durante los últimos años. Con posterioridad, se ha publicado la actualización de la Guía Americana, cuyo antecedente más reciente se encuentra en 2004. En ambas guías se encuentran aspectos en los que existe acuerdo y otros en los que hay marcadas diferencias en elementos fundamentales que influyen en la práctica clínica diaria. Las principales diferencias se centran en los criterios para el diagnóstico y clasificación de la hipertensión arterial, con el consiguiente impacto en su prevalencia. Ambas guías reconocen y lamentan la falta de evidencia sólida, basada en ensayos para las recomendaciones sobre el diagnóstico y el manejo de la hipertensión arterial pediátrica. Estudios futuros deben ofrecer respuestas a todos los interrogantes que a día de hoy permanecen por resolver." ] ] "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "Please cite this article as: Lurbe i Ferrer E, La hipertensión arterial en niños y adolescentes a examen: implicaciones clínicas de las diferencias entre la Guía Europea y la Americana. Ann Pediatr (Barc). 2018;89:256." ] ] "multimedia" => array:1 [ 0 => array:8 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at1" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:2 [ "leyenda" => "P90th, 90th percentile; P95th, 95th percentile; P99th, 99th percentile.* or 120/80, whichever is lowest.¥ or 130/80 and 139/89, whichever is lowest.§ or 140/90, whichever is lowest." "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " align="" valign="top" scope="col"> \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " colspan="2" align="center" valign="top" scope="col" style="border-bottom: 2px solid black">European guidelines<a class="elsevierStyleCrossRef" href="#bib0120">7</a></th><th class="td" title="table-head " colspan="2" align="center" valign="top" scope="col" style="border-bottom: 2px solid black">United States guidelines<a class="elsevierStyleCrossRef" href="#bib0125">8</a></th></tr><tr title="table-row"><th class="td" title="table-head " align="" valign="top" scope="col" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black"><16 years \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">≥16 years and adults \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black"><13 years \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">≥13 years and adults \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Normal BP \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top"><130/85 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top"><120/<80 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Normal-elevated \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">≥P90th to \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">130–139/85–89 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">≥P90th to* \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">120–129/<80 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="5" align="left" valign="top">HTN</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Stage 1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">≥P95th to P99th+5mmHg \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">140–159/90–99 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">≥P95th to <P95th+12mmHg¥ \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">130/80 to 139/89 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Stage 2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">>P99th+5mmHg \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">160–179/100–109 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">≥P95th+12mmHg§ \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">≥140/90 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Isolated systolic \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">SBP≥P95th and DBP<P90th \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">SBP≥140 and DBP<90 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Not discussed \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1862810.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Definition of normal BP and HTN in children and adults." ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0015" "bibliografiaReferencia" => array:17 [ 0 => array:3 [ "identificador" => "bib0090" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "2016—Guías europeas para el manejo de la hipertensión arterial en niños y adolescentes: nuevos conceptos para un viejo problema" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:1 [ 0 => "E. 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Examining hypertension in children and adolescents: Clinical implications of the differences between the European and American Guidelines

La hipertensión arterial en niños y adolescentes a examen: implicaciones clínicas de las diferencias entre la Guía Europea y la Americana

Empar Lurbe i Ferrera,b,c

a Servicio de Pediatría, Consorcio Hospital General Universitario de Valencia, Valencia, Spain

b CIBER Fisiopatología Obesidad y Nutrición (CB06/03), Instituto de Salud Carlos III, Madrid, Spain

c INCLIVA, Instituto de Investigación, Valencia, Spain

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    "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0135" class="elsevierStylePara elsevierViewall">Advances in the field of high blood pressure&#44; or hypertension &#40;HTN&#41;&#44; in children and adolescents have highlighted the need for documents summarising the evidence on the aetiology&#44; assessment&#44; treatment and outcomes of HTN in this age group&#46;<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">1</span></a> Our knowledge of blood pressure &#40;BP&#41; in children and adolescents has increased considerably in the past two decades&#46; The first guidelines on the control of BP in this age group were published in 1997&#44;<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">2</span></a> as there had previously been no consistent definition of HTN in the paediatric population&#44; and measurement of BP was not performed in asymptomatic children and adolescents&#46;<a class="elsevierStyleCrossRefs" href="#bib0100"><span class="elsevierStyleSup">3&#44;4</span></a> Although the association between BP and cardiovascular disease is well established in adults&#44; this association in children and adolescents is not well defined&#44; as the development of cardiovascular complications results from the interaction of various risk factors and age&#46; Consequently&#44; the definition of reference values in the paediatric population is based on the percentile distribution of BP values&#46;</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Advances in the knowledge of high BP in children and adolescents</span><p id="par0010" class="elsevierStylePara elsevierViewall">The awareness that HTN may be present in seemingly healthy children and that HTN in adults may have its roots in childhood has spurred interest and demonstrated the need to include measurement of BP in the medical care of children and adolescents&#46; Furthermore&#44; we have gained a deeper understanding of the impact of BP values on the development of subclinical damage in target organs through the use of recently developed methods with a much higher specificity and sensitivity&#46; We are also aware that the prevalence of HTN is increasing as a consequence of the obesity epidemic&#44; which has become a significant public health problem&#46; Early detection of the roots of HTN is crucial for the early implementation of interventions aimed at reducing the elevation of BP and its subsequent impact on cardiovascular morbidity and mortality in adulthood&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Evolution of guidelines for the diagnosis and management of HTN</span><p id="par0015" class="elsevierStylePara elsevierViewall">The current widespread interest in clinical practice guidelines for HTN stems from the desire of health-care professionals to offer&#44; and of patients to receive&#44; the best possible care&#44; that is&#44; care that is consistent&#44; effective and narrows the gap between clinical practice and evidence-based recommendations&#46; The guidelines published throughout the years have significantly expanded the knowledge in this field and stimulated a growing interest not only in epidemiologists&#44; but also in paediatricians and basic researchers&#46;<a class="elsevierStyleCrossRefs" href="#bib0110"><span class="elsevierStyleSup">5&#44;6</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">New guidelines have been published in the past 2 years&#46;<a class="elsevierStyleCrossRefs" href="#bib0120"><span class="elsevierStyleSup">7&#44;8</span></a> The first ones were developed by the Working Group on Hypertension in Children and Adolescents of the European Society of Hypertension&#44; recognising the need to update the 2009 European guidelines to integrate the evidence gathered over the past few years&#46;<a class="elsevierStyleCrossRefs" href="#bib0115"><span class="elsevierStyleSup">6&#44;7</span></a> This was followed by the publication of the updated version of the United States guidelines on HTN in the paediatric population&#44;<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">8</span></a> which had last been updated in 2004&#46;<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">5</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">The European and United States guidelines&#44; published 1 year apart&#44; agree on some aspects&#44; but also have marked disagreements on other essential aspects that influence everyday clinical practice&#46;</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Agreement between European and United States Guidelines</span><p id="par0030" class="elsevierStylePara elsevierViewall">The European and the United States guidelines<a class="elsevierStyleCrossRefs" href="#bib0120"><span class="elsevierStyleSup">7&#44;8</span></a> agree on several aspects&#44; including&#58;<ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005"><span class="elsevierStyleLabel">&#8226;</span><p id="par0035" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">BP screening&#46;</span> BP should be measured starting at age 3 years&#44; and in younger children if they are at risk of developing HTN&#46;</p></li><li class="elsevierStyleListItem" id="lsti0010"><span class="elsevierStyleLabel">&#8226;</span><p id="par0040" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Methods for measurement of BP&#46;</span> The auscultatory method is recommended&#44; using Korotkoff sounds K1 and K5 to assess systolic blood pressure &#40;SBP&#41; and diastolic blood pressure &#40;DBP&#41;&#44; respectively&#46; The guidelines also find the use of oscillometric devices validated in the paediatric population acceptable to measure BP&#46;<a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">9</span></a> However&#44; whenever high BP readings are found by the oscillometric method&#44; the auscultatory method must be used for confirmation&#46;</p></li><li class="elsevierStyleListItem" id="lsti0015"><span class="elsevierStyleLabel">&#8226;</span><p id="par0045" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">24-h ambulatory BP monitoring &#40;ABPM&#41;&#46;</span> It is considered useful both for diagnosis of HTN and to monitor pharmacological treatment&#46;</p></li><li class="elsevierStyleListItem" id="lsti0020"><span class="elsevierStyleLabel">&#8226;</span><p id="par0050" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Treatment&#46;</span> Once HTN is diagnosed&#44; both guidelines agree that lifestyle changes should be introduced and BP rechecked repeatedly&#44; initiating pharmacological treatment if these measures do not achieve adequate control&#46; In cases where the elevation of BP is such that it poses a risk of organ damage&#44; pharmacological treatment should be initiated immediately&#46;</p></li></ul></p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Differences between the European and the United States guidelines</span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Methodological differences</span><p id="par0055" class="elsevierStylePara elsevierViewall">The main methodological differences involve the criteria for diagnosis and classification of HTN&#46; This is due to&#58; &#40;a&#41; differences in reference values&#59; &#40;b&#41; difference in the age used to apply the adult criteria for definition of HTN&#44; replacing the traditional approximation by BP percentiles and &#40;c&#41; differences in the classification of HTN&#46;<ul class="elsevierStyleList" id="lis0010"><li class="elsevierStyleListItem" id="lsti0025"><span class="elsevierStyleLabel">a&#41;</span><p id="par0060" class="elsevierStylePara elsevierViewall">The reference values for BP come from the same source in both guidelines&#44; the 2004 US Task Force cohort&#46;<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">5</span></a> While the European guidelines maintain the percentiles of the original cohort&#44; the United States guidelines calculate the percentiles based only on children with normal weight&#46; The exclusion of children with overweight or obesity&#44; which were included in the original cohort&#44; was founded on the risk of bias that could lead to underdiagnosis of HTN&#46;</p></li><li class="elsevierStyleListItem" id="lsti0030"><span class="elsevierStyleLabel">b&#41;</span><p id="par0065" class="elsevierStylePara elsevierViewall">For the diagnosis of HTN&#44; both guidelines use BP percentiles for age&#44; sex and height&#44; until the age of 16 years in the European guidelines and the age of 13 years in the United States guidelines&#46; Starting from these ages&#44; adult criteria are applied to define HTN&#58; 140&#47;90<span class="elsevierStyleHsp" style=""></span>mmHg in the European guidelines<a class="elsevierStyleCrossRef" href="#bib0135"><span class="elsevierStyleSup">10</span></a> and 130&#47;80<span class="elsevierStyleHsp" style=""></span>mmHg in the United States guidelines&#44;<a class="elsevierStyleCrossRef" href="#bib0140"><span class="elsevierStyleSup">11</span></a> thresholds that are not free from controversy &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#41;&#46;<a class="elsevierStyleCrossRefs" href="#bib0145"><span class="elsevierStyleSup">12&#44;13</span></a></p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia></li><li class="elsevierStyleListItem" id="lsti0035"><span class="elsevierStyleLabel">c&#41;</span><p id="par0070" class="elsevierStylePara elsevierViewall">The definitions of stages 1 and 2 also differ between the European and the United States guidelines&#44; as the latter applies the criteria of the published guidelines for the adult population &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#41;&#46;<a class="elsevierStyleCrossRefs" href="#bib0120"><span class="elsevierStyleSup">7&#44;8</span></a></p></li></ul></p><p id="par0075" class="elsevierStylePara elsevierViewall">The choice of age 16 years in the European guidelines is based on the fact that in adolescents aged 16 and 17 years&#44; with the exception of males aged 17 years at or above the 95th percentile for height&#44; all the specific values for the 95th percentile for BP are below the threshold used to define HTN in adults&#46; When adolescents become adults&#44; this difference may lead to an adolescent previously considered to have HTN to be considered a normotensive adult on turning 18 years old due to discrepancies in definition criteria&#46;</p><p id="par0080" class="elsevierStylePara elsevierViewall">The United States guidelines lower the age for application of adult BP criteria to 13 years&#46; It could be argued that simplifying this criterion for the diagnosis of HTN would facilitate the identification of children at higher risk of cardiovascular disease&#46; When the threshold of 130<span class="elsevierStyleHsp" style=""></span>mmHg is applied at the age of 13 years&#44; it is below the 95th percentile for age&#44; sex and height in male adolescents&#44; whereas the opposite is true of female adolescents&#44; in whom the 95th percentile does not reach 130<span class="elsevierStyleHsp" style=""></span>mmHg in any instance&#46;</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Impact on diagnosis and treatment</span><p id="par0085" class="elsevierStylePara elsevierViewall">The first consequence of these differences involves the prevalence of HTN&#46; The United States guidelines result in a greater proportion of children considered to have HTN&#44; although not in a greater proportion needing pharmacological treatment&#46;</p><p id="par0090" class="elsevierStylePara elsevierViewall">This greater prevalence leads to increases in&#58;<ul class="elsevierStyleList" id="lis0015"><li class="elsevierStyleListItem" id="lsti0040"><span class="elsevierStyleLabel">a&#41;</span><p id="par0095" class="elsevierStylePara elsevierViewall">The patients requiring clinical monitoring&#46;</p></li><li class="elsevierStyleListItem" id="lsti0045"><span class="elsevierStyleLabel">b&#41;</span><p id="par0100" class="elsevierStylePara elsevierViewall">The use of 24-h ABPM&#44; due to the recommendation that &#8220;ABPM should be performed for the confirmation of HTN in children and adolescents with office BP measurements in the elevated BP category for 1 year or more or with stage 1 HTN over 3 clinic visits &#40;Grade C&#44; moderate recommendation&#41;&#46;&#8221;<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">8</span></a> Both guidelines<a class="elsevierStyleCrossRefs" href="#bib0120"><span class="elsevierStyleSup">7&#44;8</span></a> recognise the usefulness of ABPM for the identification of white-coat HTN and masked HTN and that it is the sole method available for diagnosis of nocturnal HTN&#44; which carries risks that are independent of the daytime ambulatory and office BP values&#46; The reported frequency of white-coat and masked HTN varies as a result of the office and ambulatory BP criteria used to establish the diagnosis&#46; In this context&#44; the lower office BP values established by the United States guidelines for the definition of HTN will result in a marked increase in the proportion of individuals with white-coat HTN&#44; as the reference used to define HTN by the ABPM method continues to be the distribution tables obtained for the European population&#46;<a class="elsevierStyleCrossRef" href="#bib0155"><span class="elsevierStyleSup">14</span></a></p></li><li class="elsevierStyleListItem" id="lsti0050"><span class="elsevierStyleLabel">c&#41;</span><p id="par0105" class="elsevierStylePara elsevierViewall">Performance of diagnostic tests to assess early organ damage&#46; The timing of the evaluation of potential target organ damage has considerable clinical relevance&#46; The assessment of left ventricular mass continues to be the key in the investigation of early signs of organ damage&#46; Children and adolescents with HTN may have left ventricular hypertrophy even in the early stages of disease&#44;<a class="elsevierStyleCrossRefs" href="#bib0120"><span class="elsevierStyleSup">7&#44;8</span></a> and delaying evaluation may lead to errors in risk stratification&#46; The European guidelines recommend monitoring target organ damage after HTN is diagnosed and considers its presence as an indication for initiating pharmacological treatment&#59; the United States guidelines recommend assessment of left ventricular mass only at the time that pharmacological treatment is considered&#46; Thus&#44; the European guidelines promote the assessment and detection of target organ damage as a way to establish the need of pharmacological treatment in children and adolescents with HTN&#46;</p></li><li class="elsevierStyleListItem" id="lsti0055"><span class="elsevierStyleLabel">d&#41;</span><p id="par0110" class="elsevierStylePara elsevierViewall">The ongoing debate on the BP targets to pursue in treatment is also considered in the recommendations of both guidelines&#46; In children&#44; the evidence supporting specific BP targets is scarce&#44; and there is also uncertainty regarding the specific impact of drugs on cardiovascular and renal outcomes&#46; In the absence of prospective&#44; long-term studies on the impact of different BP levels in intermediate or final cardiovascular or renal goals&#44; the 95th percentile is considered the BP target&#44; as this was the threshold used to define HTN in children and adolescents&#44; although lowering BP below the 90th percentile would be preferable as long as the treatment is well tolerated&#46; In individuals aged 16 years or more&#44; the European guidelines recommend establishing targets using the cutoff for clinically significant BP in adults&#44; that is&#44; of less than 140&#47;90<span class="elsevierStyleHsp" style=""></span>mmHg&#44; without discouraging the goal of less than 130&#47;80<span class="elsevierStyleHsp" style=""></span>mmHg&#46; Conversely&#44; the United States guidelines recommend reducing BP to less than 130&#47;80<span class="elsevierStyleHsp" style=""></span>mmHg starting at the age of 13 years&#46;</p></li><li class="elsevierStyleListItem" id="lsti0060"><span class="elsevierStyleLabel">e&#41;</span><p id="par0115" class="elsevierStylePara elsevierViewall">When it comes to patients with chronic kidney disease &#40;CKD&#41;&#44; the European guidelines recommend a BP target below the 75th percentile in children with nonproteinuric renal disease and a BP target below the 50th percentile in those with proteinuric disease&#46;<a class="elsevierStyleCrossRef" href="#bib0160"><span class="elsevierStyleSup">15</span></a> This recommendation differs from the United States guidelines&#44; which recommend a BP target below the 50th percentile in nonproteinuric patients&#44; too&#44; although there is no evidence that this measure provides additional protection against renal events in nonproteinuric CKD&#46;<a class="elsevierStyleCrossRef" href="#bib0165"><span class="elsevierStyleSup">16</span></a></p></li></ul></p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">The importance of isolated systolic HTN</span><p id="par0120" class="elsevierStylePara elsevierViewall">Finally&#44; isolated systolic HTN&#44; the most frequent type of HTN in adolescents&#44; has been specifically considered by the European guidelines<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">7</span></a> &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#41; but not the United States guidelines&#46;<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">8</span></a> In a high proportion of cases&#44; elevation of SBP with a normal DBP is associated with normal BP in the aortic root&#46; Various mechanisms may be involved in these discrepancies&#44; but this phenomenon nevertheless affects clinical decision-making&#46; At present&#44; we accept the recommendation that patients with isolated systolic HTN undergo measurement of central aortic BP by indirect&#44; non-invasive methods&#44; as this allows the detection of left ventricular mass abnormalities&#46; In patients with normal central BP and left ventricular mass&#44; it is possible to apply a watchful waiting approach without initiating treatment&#46;<a class="elsevierStyleCrossRef" href="#bib0170"><span class="elsevierStyleSup">17</span></a></p></span></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0060">Future needs</span><p id="par0125" class="elsevierStylePara elsevierViewall">All published guidelines acknowledge and lament the lack of robust evidence from clinical trials on which to base the recommendations for the diagnosis and management of paediatric HTN&#46; To fill this gap&#44; action must be taken to gather data that will result in relevant evidence in upcoming years&#46; To determine the usefulness and appropriateness of the new BP threshold&#44; future studies ought to analyse the effects&#44; both in the short and the long term&#46; The long-term analysis involves the challenge of assessing the incidence of cardiovascular complications of HTN over many years&#46; On the other hand&#44; in the short term&#44; we need to explore new strategies for improving control of BP without significantly increasing the cost&#44; work burden and side effects of treatment&#46; Future studies must attempt to answer all the questions that remain unresolved to date&#46;</p></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Conflicts of interest</span><p id="par0130" class="elsevierStylePara elsevierViewall">The author has no conflict of interest to declare&#46;</p></span></span>"
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              "titulo" => "Impact on diagnosis and treatment"
            ]
            2 => array:2 [
              "identificador" => "sec0035"
              "titulo" => "The importance of isolated systolic HTN"
            ]
          ]
        ]
        8 => array:2 [
          "identificador" => "sec0040"
          "titulo" => "Future needs"
        ]
        9 => array:2 [
          "identificador" => "sec0045"
          "titulo" => "Conflicts of interest"
        ]
        10 => array:1 [
          "titulo" => "References"
        ]
      ]
    ]
    "pdfFichero" => "main.pdf"
    "tienePdf" => true
    "fechaRecibido" => "2018-08-07"
    "fechaAceptado" => "2018-08-09"
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        0 => array:4 [
          "clase" => "keyword"
          "titulo" => "Keywords"
          "identificador" => "xpalclavsec1033015"
          "palabras" => array:4 [
            0 => "Clinical guidelines"
            1 => "Arterial hypertension"
            2 => "Children"
            3 => "Teenagers"
          ]
        ]
      ]
      "es" => array:1 [
        0 => array:4 [
          "clase" => "keyword"
          "titulo" => "Palabras clave"
          "identificador" => "xpalclavsec1033014"
          "palabras" => array:4 [
            0 => "Gu&#237;a cl&#237;nica"
            1 => "Hipertensi&#243;n arterial"
            2 => "Ni&#241;os"
            3 => "Adolescentes"
          ]
        ]
      ]
    ]
    "tieneResumen" => true
    "resumen" => array:2 [
      "en" => array:2 [
        "titulo" => "Abstract"
        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Over the past 2 years&#44; new guidelines for hypertension in children and adolescents have been published&#46; The first&#44; developed by the 2009 European Hypertension Society Working Group on Hypertension in Children and Adolescents&#44; recognised the need for an update of the European Guidelines in order to incorporate the new information acquired over the last few years&#46; Subsequently&#44; an update of the American guidelines &#40;the most recent of which was in 2004&#41; has been published&#46; In both guidelines&#44; there are aspects which are agreed on&#44; and in others&#44; there are marked differences in the basic elements that have an influence on daily clinical practice&#46; The main differences are centred on the criteria for the diagnosis and classification of hypertension&#44; with the subsequent impact on its prevalence&#46; Future studies should offer responses to all the questions that still remain unresolved&#46;</p></span>"
      ]
      "es" => array:2 [
        "titulo" => "Resumen"
        "resumen" => "<span id="abst0010" class="elsevierStyleSection elsevierViewall"><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">En los 2 &#250;ltimos a&#241;os se han publicado nuevas gu&#237;as de hipertensi&#243;n arterial en ni&#241;os y adolescentes&#46; La primera de ellas&#44; desarrollada por el Grupo de Trabajo de hipertensi&#243;n arterial en ni&#241;os y adolescentes de la Sociedad Europea de Hipertensi&#243;n&#44; recog&#237;a la necesidad de una actualizaci&#243;n de la Gu&#237;a Europea de 2009 para incorporar la informaci&#243;n adquirida durante los &#250;ltimos a&#241;os&#46; Con posterioridad&#44; se ha publicado la actualizaci&#243;n de la Gu&#237;a Americana&#44; cuyo antecedente m&#225;s reciente se encuentra en 2004&#46; En ambas gu&#237;as se encuentran aspectos en los que existe acuerdo y otros en los que hay marcadas diferencias en elementos fundamentales que influyen en la pr&#225;ctica cl&#237;nica diaria&#46; Las principales diferencias se centran en los criterios para el diagn&#243;stico y clasificaci&#243;n de la hipertensi&#243;n arterial&#44; con el consiguiente impacto en su prevalencia&#46; Ambas gu&#237;as reconocen y lamentan la falta de evidencia s&#243;lida&#44; basada en ensayos para las recomendaciones sobre el diagn&#243;stico y el manejo de la hipertensi&#243;n arterial pedi&#225;trica&#46; Estudios futuros deben ofrecer respuestas a todos los interrogantes que a d&#237;a de hoy permanecen por resolver&#46;</p></span>"
      ]
    ]
    "NotaPie" => array:1 [
      0 => array:2 [
        "etiqueta" => "&#9734;"
        "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as&#58; Lurbe i Ferrer E&#44; La hipertensi&#243;n arterial en ni&#241;os y adolescentes a examen&#58; implicaciones cl&#237;nicas de las diferencias entre la Gu&#237;a Europea y la Americana&#46; Ann Pediatr &#40;Barc&#41;&#46; 2018&#59;89&#58;256&#46;</p>"
      ]
    ]
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          "leyenda" => "<p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">P90th&#44; 90th percentile&#59; P95th&#44; 95th percentile&#59; P99th&#44; 99th percentile&#46;</p><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">&#42; or 120&#47;80&#44; whichever is lowest&#46;</p><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">&#165; or 130&#47;80 and 139&#47;89&#44; whichever is lowest&#46;</p><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">&#167; or 140&#47;90&#44; whichever is lowest&#46;</p>"
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                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " align="" valign="top" scope="col">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " colspan="2" align="center" valign="top" scope="col" style="border-bottom: 2px solid black">European guidelines<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">7</span></a></th><th class="td" title="table-head  " colspan="2" align="center" valign="top" scope="col" style="border-bottom: 2px solid black">United States guidelines<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">8</span></a></th></tr><tr title="table-row"><th class="td" title="table-head  " align="" valign="top" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">&#60;16 years&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">&#8805;16 years and adults&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">&#60;13 years&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#60;130&#47;85&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#60;120&#47;&#60;80&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Normal-elevated&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#8805;P90th to&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">130&#8211;139&#47;85&#8211;89&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#8805;P90th to<span class="elsevierStyleSup">&#42;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">120&#8211;129&#47;&#60;80&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="5" align="left" valign="top"><span class="elsevierStyleItalic">HTN</span></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Stage 1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#8805;P95th to P99th<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>5<span class="elsevierStyleHsp" style=""></span>mmHg&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">140&#8211;159&#47;90&#8211;99&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#8805;P95th to &#60;<span class="elsevierStyleHsp" style=""></span>P95th<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>12<span class="elsevierStyleHsp" style=""></span>mmHg<span class="elsevierStyleSup">&#165;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">130&#47;80 to 139&#47;89&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Stage 2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#62;P99th<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>5<span class="elsevierStyleHsp" style=""></span>mmHg&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">160&#8211;179&#47;100&#8211;109&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#8805;P95th<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>12<span class="elsevierStyleHsp" style=""></span>mmHg<span class="elsevierStyleSup">&#167;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#8805;140&#47;90&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Isolated systolic&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">SBP<span class="elsevierStyleHsp" style=""></span>&#8805;<span class="elsevierStyleHsp" style=""></span>P95th and DBP<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>P90th&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">SBP<span class="elsevierStyleHsp" style=""></span>&#8805;<span class="elsevierStyleHsp" style=""></span>140 and DBP<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>90&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Not discussed&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
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          "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Definition of normal BP and HTN in children and adults&#46;</p>"
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      "titulo" => "References"
      "seccion" => array:1 [
        0 => array:2 [
          "identificador" => "bibs0015"
          "bibliografiaReferencia" => array:17 [
            0 => array:3 [
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              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "2016&#8212;Gu&#237;as europeas para el manejo de la hipertensi&#243;n arterial en ni&#241;os y adolescentes&#58; nuevos conceptos para un viejo problema"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
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                            0 => "E&#46; Lurbe i Ferrer"
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                    ]
                  ]
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                      "Revista" => array:5 [
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            1 => array:3 [
              "identificador" => "bib0095"
              "etiqueta" => "2"
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                      "titulo" => "Report of the task force on blood pressure control in children"
                      "autores" => array:1 [
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                          "etal" => true
                          "autores" => array:6 [
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                            1 => "R&#46;P&#46; Epps"
                            2 => "R&#46; Heavenrich"
                            3 => "R&#46;M&#46; Lauer"
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                          ]
                        ]
                      ]
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                  ]
                  "host" => array:1 [
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                ]
              ]
            ]
            2 => array:3 [
              "identificador" => "bib0100"
              "etiqueta" => "3"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:1 [
                      "titulo" => "Report of the Second Task Force on Blood Pressure Control in Children&#8212;1987&#46; Task Force on Blood Pressure Control in Children&#46; National Heart&#44; Lung&#44; and Blood Institute&#44; Bethesda&#44; Maryland"
                    ]
                  ]
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                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "Pediatrics"
                        "fecha" => "1987"
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                            "web" => "Medline"
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                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Update on the 1987 Task Force Report on High Blood Pressure in Children and Adolescents&#58; a working group report from the National High Blood Pressure Education Program"
                      "autores" => array:1 [
                        0 => array:2 [
                          "colaboracion" => "National High Blood Pressure Education Program Working Group on Hypertension Control in Children and Adolescents"
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                        ]
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                    ]
                  ]
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                    0 => array:1 [
                      "Revista" => array:6 [
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                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "The fourth report on the diagnosis&#44; evaluation&#44; and treatment of high blood pressure in children and adolescents"
                      "autores" => array:1 [
                        0 => array:2 [
                          "colaboracion" => "National High Blood Pressure Education Program Working Group on High Blood Pressure in Children and Adolescents"
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            5 => array:3 [
              "identificador" => "bib0115"
              "etiqueta" => "6"
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                  "contribucion" => array:1 [
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                      "autores" => array:1 [
                        0 => array:3 [
                          "colaboracion" => "European Society of Hypertension"
                          "etal" => true
                          "autores" => array:6 [
                            0 => "E&#46; Lurbe"
                            1 => "R&#46; Cifkova"
                            2 => "J&#46;K&#46; Cruickshank"
                            3 => "M&#46;J&#46; Dillon"
                            4 => "I&#46; Ferreira"
                            5 => "C&#46; Invitti"
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                        ]
                      ]
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                  ]
                  "host" => array:1 [
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                      "titulo" => "2016 European Society of Hypertension guidelines for the management of high blood pressure in children and adolescents"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
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                            0 => "E&#46; Lurbe"
                            1 => "E&#46; Agabiti-Rosei"
                            2 => "J&#46;K&#46; Cruickshank"
                            3 => "A&#46; Dominiczak"
                            4 => "S&#46; Erdine"
                            5 => "A&#46; Hirth"
                          ]
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                  ]
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                      "Revista" => array:6 [
                        "tituloSerie" => "J Hypertens"
                        "fecha" => "2016"
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              "identificador" => "bib0125"
              "etiqueta" => "8"
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                0 => array:3 [
                  "comentario" => "pii&#58; e20171904"
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Clinical practice guideline for screening and management of high blood pressure in children and adolescents"
                      "autores" => array:1 [
                        0 => array:3 [
                          "colaboracion" => "Subcommittee on Screening and Management of High Blood Pressure in Children"
                          "etal" => true
                          "autores" => array:6 [
                            0 => "J&#46;T&#46; Flynn"
                            1 => "D&#46;C&#46; Kaelber"
                            2 => "C&#46;M&#46; Baker-Smith"
                            3 => "D&#46; Blowey"
                            4 => "A&#46;E&#46; Carroll"
                            5 => "S&#46;R&#46; Daniels"
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                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1542/peds.2017-0685"
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                        "tituloSerie" => "Pediatrics"
                        "fecha" => "2017"
                        "volumen" => "140"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/28924060"
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Article information

ISSN: 23412879
Original language: English

DOI:10.1016/j.anpede.2018.08.005

The statistics are updated each day

Year/Month	Html	Pdf	Total

2024 November	7	4	11
2024 October	39	39	78
2024 September	31	29	60
2024 August	30	41	71
2024 July	32	28	60
2024 June	29	23	52
2024 May	28	23	51
2024 April	28	24	52
2024 March	25	20	45
2024 February	22	23	45
2024 January	23	18	41
2023 December	13	16	29
2023 November	21	18	39
2023 October	23	22	45
2023 September	34	25	59
2023 August	24	13	37
2023 July	35	27	62
2023 June	29	31	60
2023 May	28	18	46
2023 April	11	17	28
2023 March	32	22	54
2023 February	20	22	42
2023 January	22	36	58
2022 December	40	41	81
2022 November	39	35	74
2022 October	49	45	94
2022 September	24	27	51
2022 August	41	43	84
2022 July	45	45	90
2022 June	29	32	61
2022 May	33	34	67
2022 April	24	27	51
2022 March	48	48	96
2022 February	27	31	58
2022 January	28	24	52
2021 December	36	36	72
2021 November	32	33	65
2021 October	48	68	116
2021 September	24	30	54
2021 August	19	28	47
2021 July	14	61	75
2021 June	37	40	77
2021 May	38	45	83
2021 April	95	86	181
2021 March	43	33	76
2021 February	40	12	52
2021 January	23	29	52
2020 December	34	9	43
2020 November	33	17	50
2020 October	12	16	28
2020 September	20	15	35
2020 August	14	7	21
2020 July	13	14	27
2020 June	15	9	24
2020 May	22	21	43
2020 April	14	16	30
2020 March	12	12	24
2020 February	21	5	26
2020 January	18	13	31
2019 December	23	20	43
2019 November	19	7	26
2019 October	11	8	19
2019 September	17	7	24
2019 August	18	15	33
2019 July	34	26	60
2019 June	22	18	40
2019 May	25	10	35
2019 April	43	21	64
2019 March	29	13	42
2019 February	25	13	38
2019 January	25	9	34
2018 December	46	27	73
2018 November	73	31	104
2018 October	76	459	535
2018 September	39	18	57

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