From the Guidelines
The workup for adolescent hypertension should begin with confirming the diagnosis through multiple blood pressure measurements on separate occasions, using appropriate cuff size and proper technique, as recommended by the most recent guidelines 1. Initial evaluation includes a thorough history focusing on risk factors like family history, obesity, sleep disorders, and medication use, followed by a physical examination looking for signs of secondary causes. Some key points to consider in the initial evaluation include:
- Family history of hypertension
- Obesity or overweight
- Sleep disorders
- Medication use that may contribute to hypertension Laboratory testing should include:
- Urinalysis
- Complete blood count
- Electrolytes
- Blood urea nitrogen
- Creatinine
- Lipid profile
- Fasting glucose Additional tests may include thyroid function tests, plasma renin activity, and aldosterone levels if clinically indicated. Imaging studies should include renal ultrasound to rule out structural abnormalities, particularly in younger patients or those with severe hypertension. Echocardiography is recommended to assess for target organ damage, specifically left ventricular hypertrophy. Ambulatory blood pressure monitoring is valuable to confirm the diagnosis and rule out white coat hypertension. Management begins with lifestyle modifications including:
- Weight reduction
- Regular physical activity
- Dietary sodium restriction
- Increased fruit and vegetable consumption If blood pressure remains elevated despite lifestyle changes, pharmacologic therapy should be considered, typically starting with ACE inhibitors (like enalapril 0.08-0.6 mg/kg/day), ARBs (such as losartan 0.7-1.4 mg/kg/day), or calcium channel blockers (amlodipine 0.1-0.6 mg/kg/day) as recommended by recent guidelines 1. The goal blood pressure is generally <90th percentile for age, sex, and height, or <130/80 mmHg in adolescents ≥13 years. Secondary causes of hypertension are more common in children and adolescents than adults, so a thorough evaluation is essential to identify potentially treatable conditions like renal disease, endocrine disorders, or coarctation of the aorta. It is also important to consider the potential risks and benefits of different treatment options, including the potential teratogenic effects of certain medications, and to provide reproductive counseling to individuals of childbearing age 1.
From the Research
Adolescent Hypertension Workup
- The workup for adolescent hypertension involves a thorough and sequential clinical and diagnostic evaluation, including screening urinalysis, blood chemistries, and renal sonography 2.
- Identifying the hypertensive adolescent and intervening with risk factors such as obesity is important for the clinician treating adolescents 2.
- Lifestyle modifications, including diet, exercise, and limitation of sodium intake, remain the foundation of treatment for adolescent hypertension 2.
- Commonly used medications for adolescent hypertension include calcium channel blockers, angiotensin receptor blockers, converting enzyme inhibitors, beta blockers, and diuretics 2.
Diagnosis and Screening
- Hypertension can be difficult to diagnose in children and adolescents and is frequently under-recognized 3.
- The US Preventive Services Task Force concludes that the evidence to support screening for high blood pressure in children and adolescents is insufficient and that the balance of benefits and harms cannot be determined 4.
- Screening for hypertension in children and adolescents should include the use of normative blood pressure tables for diagnosis and classification 5.
Risk Factors and Treatment
- Factors associated with an increased prevalence of elevated BP and hypertension in adolescents include a family history of hypertension, obesity, minority race/ethnicity, physical inactivity, high dietary intake of sodium, and poor sleep quality 6.
- Lifestyle changes, such as adhering to the Dietary Approaches to Stop Hypertension diet, are a central component of effectively reducing BP and have been shown to reduce target organ damage 6.
- Pharmacologic treatment using angiotensin-converting enzyme inhibitors and angiotensin receptor blockers is an effective and safe method for reducing BP among children with uncontrolled BP after implementing lifestyle changes 6.