Pediatric hypertension criteria should reflect overweight and obesity

Criteria to classify children and young adults as hypertensive should be changed to reflect the status of overweight and obese children with high blood pressure who don’t meet current guidelines, according to a recent report.

The recommendation was made in a study published in the European Journal of Preventive Cardiology, and suggests that the European Society of Hypertension (ESH) criteria-last updated in 2016-must be updated again to address the increased cardiovascular risk faced by overweight and obese teenagers currently considered nonhypertensive under current ESH guidelines.

The study evaluated children and teenagers aged 6 to 16 years who were overweight or obese and classified as nonhypertensive under current ESH guidance. Researchers applied both ESH criteria from 2016 and American Academy of Pediatrics (AAP) guidelines from 2017 to these children and teenagers, considering additional cardiovascular and health information. When AAP criteria were applied to the study group, 11% were classified as hypertensive. These participants tended to be older with lower high-density lipoprotein levels, higher body mass index, and other risk factors when compared with those participants who were classified as nonhypertensive under both current ESH and AAP criteria.

Additionally, researchers note that children and adolescents who fell into the hypertensive group when AAP criteria were applied-but continued to be nonhypertensive under ESH criteria-had greater insulin resistance, high total cholesterol to HDL-C ratios, and higher rates of left ventricular hypertrophy.

The researchers suggest that by adapting ESH criteria to better match current AAP criteria, more high-risk children and teenagers could benefit from early identification of hypertension and better avoidance of the progression of cardiovascular damage.

Hypertension and cardiovascular risk

Giuliana Valerio, MD, PhD, associate professor of pediatrics at the Parthenope University of Naples, Italy, and one of the study authors, says that the lower blood pressure threshold to classify children and teenagers as hypertensive in the AAP guidelines helped to classify more children and adolescents with high risk factors.

“As a result of the lowered blood pressure cutoffs, the 2017 AAP criteria allowed us to identify more obese children and teenagers with insulin-resistance and atherogenic dyslipidemia who would have been missed using the ESH criteria,” she says. “In addition, children and adolescents reclassified as hypertensive by the 2017 AAP criteria, but normotensive by the old criteria, also have higher odds of left ventricular hypertrophy than individuals classified as nonhypertensive by both criteria.”

The plan now is to request ESH to officially update its criteria, noting that having 2 different sets of criteria for hypertension in children is both “confusing and detrimental.” The ability to identify these children and adolescents early and accurately is essential, she adds.

“The association between obesity, abnormal cardiometabolic risk factors, hypertension, and left ventricular hypertrophy represents a threatening cluster in children and adolescents and should not be overlooked because appropriate management can decrease cardiovascular risk,” Valerio says.