What are the causes and management of adolescent hypertension?

From the Guidelines

Adolescent hypertension should be managed with lifestyle modification as the initial treatment, and ACE inhibitors or angiotensin receptor blockers should be started for confirmed hypertension, with a goal of blood pressure <90th percentile for age, sex, and height or <130/80 mmHg in adolescents ≥13 years. According to the most recent guidelines from 2024 1, lifestyle modification focused on healthy nutrition, physical activity, sleep, and weight management is recommended for elevated blood pressure. In addition to lifestyle modification, ACE inhibitors or angiotensin receptor blockers should be started for treatment of confirmed hypertension, defined as blood pressure consistently ≥95th percentile for age, sex, and height or ≥130/80 mmHg in adolescents ≥13 years.

Some key points to consider in the management of adolescent hypertension include:

• Lifestyle modifications such as weight management, regular physical activity, and a diet rich in fruits, vegetables, and low-fat dairy products
• Pharmacological therapy with ACE inhibitors or angiotensin receptor blockers for confirmed hypertension
• Target blood pressure of <90th percentile for age, sex, and height or <130/80 mmHg in adolescents ≥13 years
• Regular monitoring with follow-up every 3-6 months
• Consideration of secondary causes of hypertension, particularly in severe cases or those resistant to treatment.

It's worth noting that the 2021 guidelines 1 also recommend lifestyle modification as the initial treatment, but the 2024 guidelines 1 provide more specific guidance on the use of ACE inhibitors and angiotensin receptor blockers for confirmed hypertension. The most recent and highest quality study should be prioritized, and in this case, the 2024 guidelines 1 provide the most up-to-date recommendations for the management of adolescent hypertension.

From the FDA Drug Label

The antihypertensive effect of losartan was studied in one trial enrolling 177 hypertensive pediatric patients aged 6 to 16 years old. The sitting diastolic blood pressure (SiDBP) on entry into the study was higher than the 95th percentile level for the patient’s age, gender, and height. At the end of three weeks, losartan reduced systolic and diastolic blood pressure, measured at trough, in a dose-dependent manner Overall, the two higher doses (25 mg to 50 mg in patients <50 kg; 50 mg to 100 mg in patients ≥50 kg) reduced diastolic blood pressure by 5 to 6 mmHg more than the lowest dose used (2.5 mg in patients <50 kg; 5 mg in patients ≥50 kg). In a clinical study involving 115 hypertensive pediatric patients 6 to 16 years of age, patients who weighed < 50 kg received either 0.625 mg, 2.5 mg or 20 mg of lisinopril once daily and patients who weighed > 50 kg received either 1.25 mg, 5 mg, or 40 mg of lisinopril once daily. At the end of 2 weeks, lisinopril lowered trough blood pressure in a dose-dependent manner with antihypertensive efficacy demonstrated at doses > 1.25 mg (0.02 mg per kg).

Adolescent Hypertension Treatment:

• Losartan and lisinopril have been studied in pediatric patients with hypertension.
• Losartan reduced systolic and diastolic blood pressure in a dose-dependent manner in patients aged 6 to 16 years old.
• Lisinopril also lowered trough blood pressure in a dose-dependent manner in patients aged 6 to 16 years old.
• The effective doses of losartan were 25 mg to 50 mg in patients <50 kg and 50 mg to 100 mg in patients ≥50 kg.
• The effective doses of lisinopril were > 1.25 mg (0.02 mg per kg) in patients aged 6 to 16 years old. 2 and 3

From the Research

Definition and Prevalence of Adolescent Hypertension

• Hypertension is a major modifiable cardiovascular disease risk factor, and its presence in childhood is associated with the presence and burden of atherosclerosis 4.
• Hypertension tracks from childhood to adulthood and is associated with adverse cardiac changes and vascular damage that in turn are associated with premature cardiovascular disease in adulthood 4.

Diagnosis of Adolescent Hypertension

• Hypertension can be difficult to diagnose in children and adolescents and is frequently under-recognised 4.
• A thorough and sequential clinical and diagnostic evaluation must be undertaken, including screening urinalysis, blood chemistries, and renal sonography 5.
• There are pitfalls in interpreting casual blood pressure measurements in adolescents, and the role of ambulatory blood pressure monitoring is evolving 5.

Treatment of Adolescent Hypertension

• Lifestyle modifications, including diet, exercise, and limitation of sodium intake, remain the foundation of treatment 5.
• Commonly used medications include calcium channel blockers, angiotensin receptor blockers and converting enzyme inhibitors, beta blockers, and diuretics 5.
• First-line therapy for hypertension is lifestyle modification, including weight loss, healthy dietary pattern that includes low sodium and high potassium intake, physical activity, and moderation or elimination of alcohol consumption 6.

Lifestyle Interventions for Hypertension

• Growing evidence supports the use of lifestyle interventions for the prevention and adjuvant treatment of hypertension 7.
• Regular physical exercise, body weight management and healthy dietary patterns are major lifestyle interventions that can help prevent and treat hypertension 7.
• Other less traditional recommendations such as stress management and the promotion of adequate sleep patterns coupled with circadian entrainment can also be beneficial 7.