Cv System Exam 2_19: Pediatric Htn

Front 1

Normal BP

Back 1

is defined as SBP & DBP that are <90th percentile for gender, age, and height.

Front 2

Hypertension

Back 2

is defined as average SBP or DBP that is >95th percentile for gender, age, & height on at least 3 separate occasions.

Front 3

JNC 7: prehypertension

Back 3

BP level that is 120/80 mmHg & recommends the application of therapeutic lifestyle changes. It is now recommended that, as with adults, children and adolescents with BP levels 120/80 mm Hg but <95th percentile should be considered prehypertensive.

Front 4

where did 120/80 come from?

Back 4

insurance data

Front 5

Children >____ years old who are seen in a medical setting should have their BP measured.

Back 5

3 years old

Front 6

are electric BP machines good for kids?

Back 6

nope... auscultaion is preffered method

Front 7

Elevated BP must be ________ before characterizing a child as having hypertension

Back 7

confirmed on repeated visits

Front 8

Conditions Under Which Children <3 Years Old Should Have BP Measured 1.

Back 8

-History of prematurity, VLBW, or other neonatal complication requiring ICU
-Congenital heart disease (repaired or nonrepaired)
-Recurrent UTIs, hematuria, or proteinuria
-Known renal disease or urologic malformations
-Family history of congenital renal disease

Front 9

Conditions Under Which Children <3 Years Old Should Have BP Measured 2.

Back 9

-Solid-organ transplant
-Malignancy or bone marrow transplant
-Treatment with drugs known to raise BP
-Other systemic illnesses associated with hypertension (neurofibromatosis, tuberous sclerosis, etc)
-Evidence of elevated intracranial pressure

Front 10

Ideally, the child whose BP is to be measured should:

Back 10

-Have avoided stimulant drugs -or foods,
-Have been sitting quietly for 5 minutes,
-Be seated with his or her back supported, feet on the floor
-Have the right arm supported and cubital fossa at heart level.

Front 11

BP at high levels tends to fall on measurement as the result of:

Back 11

-an accommodation effect (ie, reduction of anxiety by the patient from one visit to the next)
-regression to the mean.
**BP level is not static but varies even under standard resting conditions.

Front 12

BP standards based on ___,____ and ____ provide a precise classification of BP according to body size.

Back 12

gender, age, and height
**The revised BP tables now include the 50th, 90th, 95th, and 99th percentiles (with standard deviations) by gender, age, and height.

Front 13

The child is normotensive if the BP is <____ percentile

Back 13

90th percentile

Front 14

If the BP is >90th percentile, the BP measurement should be ___________.

Back 14

repeated at that visit to verify an elevated BP.

Front 15

BP measurements between the 90th & 95th percentiles indicate

Back 15

prehypertension.

In addition, if an adolescent's BP is >120/80 mm Hg, the patient should be considered to be prehypertensive even if this value is <90th percentile.
This BP level typically occurs for SBP at 12 years old & for DBP at 16 years old

Front 16

Stage 1 Hypertension

Back 16

95th–99th percentile plus 5 mm Hg
Frequency of BP monitoring:
Recheck in 1–2 wk or sooner if the patient is symptomatic;
if persistently elevated on 2 additional occasions, evaluate or refer to source of care within 1 mo
TLCs:
Weight-management counseling if overweight;
Introduce physical activity and diet management
Pharmacotherapy:
Initiate therapy based on indications or if compelling indications

Front 17

Indications for Antihypertensive Drug Therapy in Children

Back 17

Symptomatic hypertension
Secondary hypertension
Hypertensive target-organ damage
Diabetes (types 1 and 2)
Persistent hypertension despite nonpharmacologic measures

Front 18

Stage 2 Hypertension

Back 18

>99th percentile plus 5 mm Hg
Frequency:
Evaluate or refer to source of care within 1 wk or immediately if the patient is symptomatic
TLCs:
Weight-management counseling if overweight;
Introduce physical activity and diet management
Pharmacotherapy
**Initiate Therapy

Front 19

Using the BP Tables

Back 19

Use the standard height charts to determine the height percentile.
Measure & record the child's SBP & DBP.
Use the correct gender table for SBP & DBP.
Find the child's age on the left side of the table.
Follow the age row horizontally across the table to the intersection of the line for the height percentile (vertical column).
There, find the 50th, 90th, 95th, & 99th percentiles for SBP in the left columns & for DBP in the right columns

Front 20

Overweight & high BP are also components of the _______, a condition of multiple metabolic risk factors for CVD as well as for type 2 diabetes

Back 20

metabolic syndrome

Front 21

CVD Risk Factors

Back 21

High BP
Overweight
Low HDL cholesterol,
Elevated plasma triglyceride,
Abnormal glucose tolerance.

Front 22

Evaluating CVD Risk Factors

Back 22

Fasting plasma insulin is generally elevated,
elevated insulin concentration may be reflective only of obesity & is *not diagnostic* of the insulin-resistance syndrome.
To identify other risk factors, a fasting lipid panel & fasting glucose level should be obtained in children who are overweight & have BP between the 90th & 94th percentile & in all children with BP >95th percentile

Front 23

Approximately ____% of children snore, & at least 1% to 3% have sleep-disordered breathing.

Back 23

15%

Because of the associations with hypertension & the frequency of occurrence of sleep disorders, particularly among overweight children, a history of sleeping patterns should be obtained in a child with hypertension

Front 24

BEARS

Back 24

Bedtime problems,
Excessive daytime sleepiness,
Awakenings during the night,
Regularity and duration of sleep,
Sleep-disordered breathing (snoring).

Front 25

Secondary Hypertension

Back 25

Secondary hypertension is more common in children than in adults.
Because overweight is strongly linked to hypertension, BMI should be calculated as part of the physical examination.
Once hypertension is confirmed, BP should be measured in both arms and a leg. (coarctated aorta)**
Very young children, children with stage 2 hypertension, & children or adolescents with signs that suggest systemic conditions associated with hypertension should be evaluated more completely than in those with stage 1 hypertension

Front 26

Secondary Hypertension

Back 26

It is important to seek signs & symptoms suggesting:
Renal disease
gross hematuria, edema, fatigue,
Heart disease
chest pain, exertional dyspnea, palpitations
Diseases of other organ systems
endocrinologic, rheumatologic

Front 27

Past Medical History

Back 27

Should focus the subsequent evaluation & uncover definable causes of hypertension.
Questions should be asked about:
prior hospitalizations,
trauma,
urinary tract infections,
Snoring
other sleep problems

Front 28

Family History

Back 28

Hypertension,
Diabetes,
Obesity,
Sleep apnea,
Renal disease,
Other CVD (hyperlipidemia, stroke),
Familial endocrinopathies.

Front 29

Drugs

Back 29

-lots of kids on stimulants, increase BP
-Illicit drugs
-Supplements!

Front 30

Normally, BP is _______ mm Hg higher in the legs than the arms.

Back 30

10 to 20 mmHg

Front 31

BMP / UA

Back 31

Measurement of serum BUN, creatinine, and electrolytes, and collection of urine for urinalysis and culture.
These tests permit quick assessment of renal function and abnormalities in glucose or potassium homeostasis.

Front 32

Complete Blood Count

Back 32

Looking for anemia that may reflect chronic diseases such as vasculitis and chronic renal disease.

Front 33

Renal Ultrasonography

Back 33

Detect any renal scar, congenital anomaly, or difference in renal size.
A possible exception is the adolescent with documented gradual and mild increase in BP that is associated with an increase in BMI
Such children are highly likely to have essential hypertension.

Front 34

Fasting Plasma Glucose & Lipids

Back 34

Should be performed in prehypertensive children who are:
obese,
have a family history of HTN or CVD
have chronic renal disease.

Front 35

LVH

Back 35

LVH is the most prominent clinical evidence of target-organ damage caused by hypertension in children & adolescents.
With the use of echocardiography to measure left ventricular mass, LVH has been reported in 34% to 38% of children and adolescents with mild, untreated BP elevation

Front 36

LVH

Back 36

Echocardiography is recommended as a primary tool for evaluating patients for target-organ abnormalities by assessing the presence or absence of LVH.
Left ventricular mass is determined from standard echocardiographic measurements of the left ventricular end-diastolic dimension, the intraventricular septal thickness, and the thickness of the left ventricular posterior wall

Front 37

primary therapy for obesity-related hypertension.

Back 37

Weight reduction

Front 38

Indications for antihypertensive drug therapy in children

Back 38

include secondary hypertension & insufficient response to TLCs.... start with one drug at a time!

Front 39

Acceptable drug classes for use in children include:

Back 39

ACE inhibitors,
angiotensin-receptor blockers,
ß-blockers,
calcium channel blockers,
diuretics.

Front 40

The goal for antihypertensive treatment in children

Back 40

should be reduction of BP to <95th percentile unless concurrent conditions are present, in which case BP should be lowered to <90th percentile.
Severe, symptomatic hypertension should be treated with IV antihypertensive drugs