Hypertension | Boston Children’s Hospital

What is hypertension?

Hypertension means “high blood pressure.” This refers to how hard the blood is pushing against the walls of the artery through which it flows—not how quickly it flows. In hypertension, the level of pressure is higher than normal.

How is blood pressure measured?

Blood pressure is measured in millimeters of mercury (mm Hg). A typical normal blood pressure in an adult is 120/80 mm Hg, or “120 over 80.” The top number refers to the pressure when the heart is pushing blood out through the arteries (systolic). The bottom number refers to the pressure when the heart is at rest—“between beats” (diastolic).

It’s easy to tell whether an adult has hypertension, because there’s a standard set of measurements:

• Normal blood pressure—systolic < 120 mmHg and diastolic < 80 mm Hg
• Pre-hypertension—systolic 120-139 mmHg or diastolic 80-89 mmHg
• Stage 1 hypertension—systolic 140-159 mmHg or diastolic 90-99 mmHg
• Stage 2 hypertension—systolic ≥160 or diastolic ≥100 mmHg

But it’s harder with children. That’s because there are no universal cut-offs as there are for adults; instead, whether a child has hypertension depends on how his blood pressure compares to his peers (determined by gender, height, and age).

• Pre-hypertension—90^th to 95^th percentile
• Stage 1 hypertension—95^th – 99^th (plus 5 mm mercury)
• Stage 2 hypertension—anything higher than 99^th plus 5 mm mercury

How common is hypertension in children?

Hypertension is becoming increasingly common in children and adolescents. A recent study that looked at 15,000 adolescents found that nearly one in five had hypertension. And there’s reason to believe that hypertension is vastly underdiagnosed in children, since:

• it can be difficult to measure in infants and young children
• it’s sometimes challenging to identify
• it’s often thought of as not something that really affects kids

The rise in the number of children with primary hypertension in the United States is thought to correlate with the rise of obesity.

What complications are associated with hypertension?

While kids with hypertension are unlikely to have heart attacks and strokes, it still has significant risks. Hypertension causes changes in the structures of the blood vessels and heart. Since hypertension in children has historically been understudied, there isn’t a lot of data about exactly what these changes mean. But we do know that in adults, hypertension increases the chance of complications in the heart, blood vessels, and kidneys. There’s also compelling evidence that some of these changes are seen in children with high blood pressure.

These changes affect:

Blood vessels—high blood pressure can damage blood vessels throughout the body, which makes it harder for organs to work efficiently.

Kidneys—if the blood vessels in the kidneys are damaged, they may stop removing waste and extra fluid from the body. This extra fluid can raise blood pressure even more.

Other organs—if left untreated, hypertension makes it harder for blood to reach many different parts of the body, including the eyes and the brain, and can lead to blindness and strokes.

Can primary hypertension be prevented?

Pediatricians are making great efforts to prevent obesity and stem the tide of problems that accompany it. We believe that promoting healthy lifestyle choices will help combat this trend and will go a long way towards preventing primary hypertension in children (and keep adults healthier, too).

Some things are being done—nutritional information is being made more readily available, there’s one push to provide healthy options in schools and another to remove soft drinks from them—but still, it often comes down to families making the right decisions. We are dedicated to educating families to assist with appropriate dietary and activity choices to improve overall health and reduce the risk of hypertension.

What is “white coat hypertension”?

“White coat hypertension” is when a child’s blood pressure readings are high at the doctor’s office (mostly because she’s anxious, which can cause blood pressure to rise), but normal outside of the office (for example at home or at school).

This is pretty common in kids. By some estimations, between 30 and 40 percent of kids who have high blood pressure in the office actually have white-coat hypertension.

White coat hypertension is still a risk. Everyone’s blood pressure changes from time to time—it’s lower when you’re asleep, for example­­­­­—but if a child’s blood pressure continually rises when she’s anxious (such as before a test), it can be sign of high blood pressure at other times and potentially cause the same kinds of damage that standard hypertension causes.

White coat hypertension is diagnosed by taking the child’s blood pressure outside of the doctor’s office. This can be done in different ways:

• Some parents feel comfortable doing it at home.
• Sometimes we make arrangements for a school nurse to check the child’s blood pressure.
• Your child’s doctor might recommend that she wear an ambulatory blood pressure monitoring device—a blood pressure cuff attached to a small device that sits on her belt , and measures her blood pressure at regular intervals over the course of 24 hours. This device is about the size of a deck of cards and is usually tolerated very well.

If your child is diagnosed with white coat hypertension, her doctor may still want to follow her, since some children with white coat hypertension will develop actual hypertension in the future.

Causes of hypertension in children

1. Primary hypertension

Primary hypertension means that the hypertension does not seem to be caused by some other underlyng medical condition. Many doctors think that the incidence of childhood or adolescent hypertension has been rising along with the obesity epidemic. The majority of teens and children over age 6 with hypertension have a family history of hypertension and/or are overweight.

2. Secondary hypertension

Secondary hypertension is caused by a known underlying medical condition. Of these, about

• 80 percent of children have some kind of kidney disease or blood vessel abnormalities
• 5 percent have an endocrinological disorder
• 2 to 5 percent have heart disease

Hypertension in infants with hypertension almost always has a secondary cause. In addition, premature infants have a higher incidence of hypertension.

Among kids with hypertension, especially those who are very young, secondary hypertension is more common than primary hypertension. But among children who are older than 6 to 8 years old, the ratio of primary to secondary hypertension is approaching 50/50.

Signs and symptoms of hypertension

Often, kids and teens with pre-hypertension or stage 1 hypertension won’t show any symptoms at all. If your child has stage 2 hypertension, she might experience one or more of the following symptoms:

• headaches
• loss of vision
• double-vision
• chest pain
• abdominal pain
• breathing problems

An infant with stage 2 hypertension may seem irritable, not be feeding properly, or vomiting. Sometimes these infants are diagnosed with “failure to thrive.”

Frequently Asked Questions (FAQ) about Hypertension

Q: If left untreated, does hypertension get worse?

A: It’s hard to say. Researchers are starting to see that kids and adolescents with pre-hypertension are more likely to develop stage 1 hypertension, but we don’t know if  or when stage 1 hypertension will progress to stage 2.

Q: Can hypertension be cured?

A: In some cases, secondary hypertension can be “fixed.” For example, if:

• it’s caused by a narrowing in a blood vessel that the doctors are able to widen
• it’s caused by a rare endocrine tumor that doctors are able to treat successfully

There are also cases in which hypertension might be transient; for example, if it’s caused by a temporary inflammation of the filters in the kidney.

Even when hypertension can’t be “fixed,” it can almost always be well-controlled, with diet and exercise and/or medication.

Q: If my child is being treated for hypertension, what should I watch out for?

A: Keep an eye out for:

• chest pains
• severe headaches that don’t seem to respond to at-home treatment
• changes in vision
• nausea
• swelling of hands and feet
• shortness of breath with limited exertion
• changes in her urine (such as lack of urine production, urine that is brown or tea-colored)

Call your child’s doctor if she experiences any of these symptoms.

Q: Will my child need to go on medication?

A: Only a fraction of kids with hypertension require medication. Frequently, it’s treated with diet and exercise modification first. And if the child is overweight, every kilogram (around 2 pounds) of weight she loses, her blood pressure could bring her blood pressure down by about a point.

Q: Will my child have hypertension as an adult?

A: While children with hypertension are more likely to have it as adults, it’s not necessarily always the case. This depends on factors including the cause of the hypertension and how it responds to treatment.

Q: What is the most common treatment?

A: For children with pre-hypertension or stage 1 hypertension, changing to a more healthful diet and exercising more is often enough to manage the hypertension. For children with more severe hypertension, medication is often necessary.

Q: If my child is taking medication for hypertension, will she have to take it for the rest of her life?

A: Not necessarily. If your child has primary hypertension, appropriate lifestyle modifications may allow for medications to be stopped. In addition, if a secondary cause is identified and successfully treated, medications may not be necessary.

Back to top.

Blood Pressure Profile in School Children (6–16 Years) of Southern India: A Prospective Observational Study

Introduction

The measurement of blood pressure (BP) is firmly established as an important component of routine pediatric physical examination (1). BP is considerably lower in children than in adults but usually increases steadily throughout the first two decades of life (2–5). The BP is continuously distributed and BP profile in children varies with age, sex, weight, height, body mass index (BMI) (obesity), family history of hypertension, social economic status, and dietary habits. Local reference values have to be established to understand the BP variable (2, 6, 7). The prevalence of hypertension in children has been reported to be approximately 1–3%. Elevated BP in children and adolescents may be an early expression of essential hypertension in adulthood (2, 8, 9). Juvenile BP has been reported as among one of the several predictors of adult BP (10, 11). As it is not possible to record reliable BP by conventional methods in children below 6 years, hence the ideal age would be 6–16 years, i.e., school children. NIH of USA has recommended that BP measurement should be part with weight and height measurement, which is done in children at least once a year. But even today in many parts of world including India, this practice has not been implemented due to unknown reasons. Most of the studies have established the standards for children of western world but presently there are no such standards available for Indian children, and the western standards cannot be applied to Indian children, because of difference in factors such as ethnic, socioeconomic, dietetic, environmental, and emotional factors between Indian and Western countries. Hence, there is need to establish the normal BP standards for Indian children and to find out the prevalence of hypertension among them. Hence, the present study was taken up to determine normal BP in apparently healthy, asymptomatic school children in the age group of 6–16 years, and to determine the correlation of BP values with different sex, weight, height, and BMI and also to find out prevalence of hypertension in school going population.

Materials and Methods

This was a community based prospective, observational study done in Department of Pediatrics, South Central Railway Hospital, Secunderabad, India. The study sample consisted of 3,302 (1,658 boys and 1,644 girls) apparently healthy school children, in the age group of 6–16 years, and the study was conducted from January 2010 to October 2010. The study was approved by the Institutional Ethical Committee and Institutional Research Board (IRB) and written consent was taken from child’s care taker or parents before enrollment. A short history about febrile illnesses, burning micturition, cough, and dyspnea/breathlessness was taken. A complete general physical examination from head to toe was done of all enrolled child. Vital parameter and temperature were recorded. Child was clinically assessed for anemia, jaundice, cyanosis, clubbing, lymphadenopathy, and edema and was looked for any congenital anomalies. A detailed systemic examination of all systems (respiratory system, cardiovascular system, gastro-intestinal system, nervous system) was done to exclude the systemic disorders like congenital heart disease, renal disorders, and liver diseases. The parameters that were studied included age, sex, weight, and height, BMI (kg/m²), systolic blood pressure (SBP), diastolic blood pressure (DBP). The inclusion criteria included healthy school children, in the age group of 6–16 years and the exclusion criteria included children <6 years and more than 16 years and failure to obtain consent from parents or care giver.

A written pro forma was sent home with the child to collect information about family history of hypertension (father/mother). Dietary history (vegetarian/non-vegetarian) and socioeconomic status (per capita income) and the performa were collected after 2 days. Age in completed years was recorded as per school admission registers. Measurements were made by a single person (who was trained prior for taking all measurement) and same equipment was used to obtain accurate measurement and to increase the sensitivity of the results. Weight was measured in kilograms using a dial type of weighing machine and all recordings including BP measurements was done by a single individual to eliminate observers subjective bias. Height was measured to nearest 1 cm with subject standing without shoes using a non-stretchable metallic tape.

Measurement of Blood Pressure

Before recording BP, the procedure was explained to children and sufficient time was given to allay anxiety and fears. BP was measured in supine position using diamond mercury manometer with a set of different sized cuffs as per the recommendation given by the fourth report on the diagnosis, evaluation, and treatment of high BP in children and adolescents (2004) (2). The cuff bladder was wide enough to cover at least 2/3rd of arm and long enough to encircle arm completely. Auscultatory method was used and the first and fifth Korotkoff’s sounds were taken as indicative of the SBP and DBP, respectively. BP was recorded three times with 2 min interval between each measurement. In children, where a higher range of BP was observed, the factors like anxiety and fear were removed and rerecorded after 1 h. Average of three BP readings was taken, BMI was calculated using the formula [BMI = Weight (kg)/Height² (m)].

Definition

There is no agreed definition of hypertension since BP is a continuous variable within a population (12, 13). Thus, hypertension is defined as “average systolic blood pressure and or diastolic blood pressure that is >95 percentile for gender, age, and height on ≥3 occasions” (2). Normal BP is defined as SBP and DBP that are <90 percentile for gender, age, and height (2).

Statistical Analysis

All the data were entered in Microsoft excel sheet and SPSS version 16 for window’s was used for analysis. Correlation coefficient and simple linear regression analysis was done for predicting BP (SBP and DBP) separately for age, sex, weight, height, and BMI. Norms were established for each individual age height, weight and BMI (kg/m²). The data were analyzed by Karl–Pearson’s coefficient of co-relation and regression.

Results

In the present study, the prevalence of hypertension was found to be 2.42% (95th percentile for age and sex was cut-off point).

Variation with Age

In the study, 3,302 urban children [1,658 (50.2%) boys and 1,644(49.8%) girls] in the age group of 6–16 years were clinically examined and their BP was recorded. The correlation coefficient for relationship between age and SBP in males and females was 0.89 and 0.91, respectively, with significant P-value (P < 0.001). The mean DBP in males at 11 years is 65.03 ± 0.86 mm of Hg and at 16 years was 74 ± 1.08 mm of Hg (Table 1). The correlation coefficient for relationship between age and DBP in males and females was 0.92 and 0.90, respectively, with significant P-value (P < 0.001).

Table 1. Table showing systolic blood pressure and diastolic blood pressure according to age and sex.

Variation with Height

Based on height of the individual student, eight groups were made independent of age and weight with a difference of 10 cm between the groups. It was observed that there is not much increase in mean SBP up to 130 cm (both in males and females) and SBP increased significantly and gradually in children above 130 cm of height. The correlation coefficient for relationship between height and SBP in males and females was 0.91 and 0.93, respectively, with significant P-value (P < 0.001). The same findings were seen in the case of mean diastolic BP (Table 2). The correlation coefficient for relationship between height and DBP in males and females was 0.92 and 0.88, respectively, with significant P-value (P < 0.001).

Table 2. Relation of mean systolic blood pressure and mean diastolic blood pressure to height.

Variation with Weight

The weight of students was divided into nine groups, independent of age and height of the children with a difference of 5 kg between each group. The mean SBP and DBP were calculated. In this study, it was observed that the mean SBP and mean DBP in both males and females increased gradually from 15 to 60 kg weight (Table 3). The correlation coefficient for relationship between weight and SBP in males and females is 0. 92 and 0.92, respectively, with a significant P-value (P < 0.001). The correlation coefficient for relationship between weight and DBP in males and females was 0.94 and 0.91, respectively, with a significant P-value (P < 0.001).

Table 3. Relation of mean systolic blood pressure and mean diastolic blood pressure to weight.

Variation with BMI

The BMI of students was divided into five groups, with a difference of 2 kg/m² between each group. The mean SBP and DBP were calculated. It was observed that as BMI increased, both SBP and DBP increased gradually and significantly (Table 4). The correlation coefficient for relationship between BMI and SBP in males and females is 0.83 and 0.82, respectively, with significant P-value (P < 0.001). The correlation coefficient for relationship between BMI and DBP in males and females was 0.89 and 0.85, respectively, with significant P-value (P < 0. 001).

Table 4. Relation of mean systolic blood pressure and mean diastolic blood pressure to BMI.

As per the information received through the pro forma sent home with each child to collect about family history of hypertension (father/mother), 146 (9%) of male and 84 (5%) females students had positive family history of hypertension. The mean SBP of males and females with positive family history of hypertension at 6 years was 104.4 ± 1.04 and 100.7 ± 1.26 mm of Hg, respectively, and for that of 10 years 116.8 ± 0.85 mm of Hg (males) and 113.3 ± 1.13 mm of Hg (females). The mean DBP of males and females with positive family history of hypertension at 6 years was 64.50 ± 0.98 and 62.19 ± 1.34 mm of Hg, respectively, and for that of 16 years was 73.56 ± 1.13 mm of Hg (males) and 71 ± 1.42 mm of Hg (females). The nomogram charts were made for both male and female as per age with mean SBP ± 2SD and mean DBP ± 2SD (Figures 1–4). The 95% of the study population falls between these two limits.

Figure 1. Norms of mean SBP according to age in boys (6–16 years).

Figure 2. Norms of mean DBP according to age in boys (6–16 years).

Figure 3. Norms of mean SBP according to age in girls (6–16 years).

Figure 4. Norms of mean DBP according to age in girls (6–16 years).

Discussion

In the present study, the data concerning the readings of BP of children at different age group are presented. The SBP and DBP measurements in our study according to age and sex, obtained by auscultation using the sphygmomanometer are comparable to studies done by Sharma et al. (5), Krishna et al. (8), Gupta et al. (14), and Rosner et al. (15).

In the present study, both SBP and DBP show a positive correlation with increase in age, consistent with the findings reported by several studies (5, 16–18). Male students had 1–2 mm of Hg of higher BP when compared with their female counterparts at all ages. This is similar to the average annual increase of 2 mm of Hg in boys and about 1 mm of Hg in girls reported by World Health Organization study group (18). Thus, it can be concluded that the males had slightly higher values of BP (1–2 mm of Hg) when compared to the females for that age. This could be explained because boys are heavier and taller when compared to females for that age which results in this observation. It was also observed from the results of mean SBP for different ages (in either sex) that there is not much increase (1–2 mm of Hg/year) in the SBP between age groups 6–10 years. But the rise is steeper (2–3 mm of Hg/year) during adolescence (>11 years) when compared with the rise of SBP between age group of 6–10 years. In the present study, there was a minimal increase of 4–5 mm of Hg in diastolic BP from age 6 to 10 years in both sexes. But diastolic BP showed a spurt from 11 years (adolescence) and it increased for 8–10 mm of Hg, which correlated with results obtained by Sharma et al. (5) and Krishna et al (8). The spurt in SBP and DBP may be possibly due to age related hormonal, physical, and psychological changes occurring in the body during puberty (>11 years). For DBP, a rising trend with age was also present, although this rise was much less marked than the SBP and this similar finding was reported in other studies (5, 18). Height is related to BP and is an independent variable for BP (2, 17). In our study, the mean SBP and DBP in both sexes increased 3–5 mm of Hg for every 10 cm increase in height, independent of age, and weight. It was also observed that mean SBP and DBP showed an increase of 3–4 mm of Hg up to an height of 130 cm in both sex and BP increment was more pronounced (4–5 mm of Hg) in students whose height was more than 130 cm (in either of sex). This probably could be explained as BP does not have a simple linear correlation with height as it is thought to be or other factors like hormonal, emotional factors can be credited for this observation. In our study, the relation of SBP and DBP with height was independent of age. Similar results were shown by various studies conducted till now (5, 8, 17, 19). Hence height has to be considered independent of age before classifying the child as pre-hypertensive/hypertensive, which means taller children are allowed higher normal BP when their height is taken into consideration than when age is used alone. On the other hand, shorter children and adolescents are identified as having high normal or mildly elevated BP when only age and sex derived data is used. Thus, the BP nomogram obtained according to height should is always recommended to be used in pediatric practice.

In our study, there was an increase in 2.5–3 mm of Hg in DBP an every weight group up to 60 kg. The study done by Agarwal et al. (17) also showed a similar trend, but the increase in mean SBP and DBP was 1–1.5 mm of Hg and 1.5–2 mm of Hg, respectively, with increase of every 5 kg weight. The difference was possibly due to the present study was done in an urban private school where all the students belong to higher socioeconomic status (Grade I modified Prasad classification). It is known that higher BP values are described in families belonging to higher socioeconomic status due to nutritional and psychological factors. The other reason could be that Agarwal et al. (17) used Korotkoff’s phase IV to determine DBP, but we used Korotkoff’s phase V as DBP. In our study, it was also noted that the increase in DBP according to weight was more pronounced than increase in SBP (2 versus 3 mm of Hg), which was unexplainable. Heart size is closely associated with the body size (2, 20). The body size is objectively measured by BMI, which is a measure of obesity. It is well known that obesity is associated with stroke, atherosclerosis, coronary artery disease, and endocrinal disorders. The association between hypertension and obesity in adults is well established. But relationship between hypertension and obesity in childhood has been noted, but less extensively evaluated (2, 21, 22). In our study, the mean SBP and DBP increased by 3–4 mm of Hg with increase in every 2 kg/m² of BMI (each group). This study shows a positive linear association of BMI with SBP and DBP in both sexes and these results were comparable to other studies (5, 8, 14, 19). Thus, concluding that obese children have higher levels of BP when compared to their normal counterparts. However, there is paucity of information about the possible mechanism to relate obesity and higher BP values. The postulation, which have been given, includes increased cardiac output, increased blood volume, excessive sodium intake as a consequence of excessive calorie intake, increased steroid production, and alteration in receptors in various pressure substances but these hypothesis still requires firm scientific basis to validate them (14, 21, 22).

In our observation, the mean values of SBP and DBP for age in males and females with positive family history of hypertension is 2–3 mm of Hg higher for each group when compared to the mean values of SBP and DBP of general study population (from 6 to 16 years). Thus, the BP values are at higher range in both sexes when compared to general population. Similar results were shown by studies done by others (14, 18). Thus, proving that the familial tendency of elevated BP can be detected early in life (first and second decade). This could be attributed to the nutritional habits, life style of the family members, and genetic predisposition. Thus, it is recommended to modify the life style and dietary habits of children with positive family history of hypertension to prevent the disastrous complications of hypertension during adulthood. Based on the predictive equation, norms were obtained for both SBP and DBP based on the observed readings and the upper and lower limits of SBP and DBP for that age was obtained for the local population from 6 to 16 years age group.

The limitation of the study includes as the study population was from higher socioeconomic class, hence we cannot extrapolate the results to lower and middle income group children. There was a lack of follow up of the children’s who had hypertension. We did not perform multi-regression analysis on the data; hence there could have been some unseen confounders in the study.

Conclusion

Blood pressure in an important vital sign, which reflects the integrity of the cardiovascular system, renal, endocrinal system, and other systems in the body. After critically analyzing the results of the present study and comparing the results with other studies, it can be concluded that BP, both systolic and diastolic gradually increases with age, the increase being more pronounced in SBP than in DBP. The increase in the BP with increase in the age is not uniform with a wide range of fluctuations, between different age groups and with a spurt in SBP with the onset of puberty. There is no significant difference in BP of the two sexes when the values are corrected for maturation status. There is a strong correlation between BP and weight and BP and height in both sexes (R > 0.7 and P < 0.001). When BP values are arranged according to weight and height criteria, the correlation with age disappears. Hence body weight and height are the principle determinants of BP.

Author Contributions

MS wrote the first draft of the manuscript. DS and AP helped in writing manuscript and did primary corrections in the manuscript. TS and SS made final corrections of manuscript before submission. All the authors approved the submission of this version of the manuscript and takes full responsibility for the manuscript. There was no external funding, honorarium, grant, or other form of payment given to anyone to produce the manuscript.

Conflict of Interest Statement

There are no prior publications or submissions with any overlapping information, including studies and patients. The manuscript has not been and will not be submitted to any other journal while it is under consideration by Frontiers in Pediatrics. The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

References

1. Sinaiko AR. Hypertension in children. N Engl J Med (1996) 335(26):1968–73. doi:10.1056/NEJM199612263352607

Pubmed Abstract | Pubmed Full Text | CrossRef Full Text | Google Scholar

2. National High Blood Pressure Education Program Working Group on High Blood Pressure in Children and Adolescents. The fourth report on the diagnosis, evaluation, and treatment of high blood pressure in children and adolescents. Pediatrics (2004) 114(2 Suppl 4th Report):555–76. doi:10.1542/peds.114.2.S2.555

Pubmed Abstract | Pubmed Full Text | CrossRef Full Text | Google Scholar

3. Leonard GF. Hypertension in childhood. Pediatr Rev (2007) 28(8):283–97. doi:10.1542/pir.28-8-283

CrossRef Full Text | Google Scholar

4. Lauer RM, Clarke WR, Beaglehole R. Level, trend, and variability of blood pressure during childhood: the Muscatine study. Circulation (1984) 69(2):242–9. doi:10. 1161/01.CIR.69.2.242

Pubmed Abstract | Pubmed Full Text | CrossRef Full Text | Google Scholar

5. Sharma BK, Sagar S, Wahi PL, Talwar KK, Singh S, Kumar L. Blood pressure in school children in northwest India. Am J Epidemiol (1991) 134(12):1417–26.

Google Scholar

6. Nelson MJ, Ragland DR, Syme SL. Longitudinal prediction of adult blood pressure from juvenile blood pressure levels. Am J Epidemiol (1992) 136(6):633–45.

Pubmed Abstract | Pubmed Full Text | Google Scholar

7. Freedman DS, Goodman A, Contreras OA, DasMahapatra P, Srinivasan SR, Berenson GS. Secular trends in BMI and blood pressure among children and adolescents: the Bogalusa Heart Study. Pediatrics (2012) 130(1):e159–66. doi:10.1542/peds.2011-3302

Pubmed Abstract | Pubmed Full Text | CrossRef Full Text | Google Scholar

8. Krishna P, PrasannaKumar KM, Desai N, Thennarasu K. Blood pressure reference tables for children and adolescents of Karnataka. Indian Pediatr (2006) 43(6):491–501.

Pubmed Abstract | Pubmed Full Text | Google Scholar

9. Bagga A, Jain R, Vijayakumar M, Kanitkar M, Ali U. Evaluation and management of hypertension. Indian Pediatr (2007) 44(2):103–21.

Google Scholar

10. Shear CL, Burke GL, Freedman DS, Berenson GS. Value of childhood blood pressure measurements and family history in predicting future blood pressure status: results from 8 years of follow-up in the Bogalusa Heart Study. Pediatrics (1986) 77(6):862–9.

Pubmed Abstract | Pubmed Full Text | Google Scholar

11. Toschke AM, Kohl L, Mansmann U, von Kries R. Meta-analysis of blood pressure tracking from childhood to adulthood and implications for the design of intervention trials. Acta Paediatr (2010) 99(1):24–9. doi:10.1111/j.1651-2227.2009.01544.x

Pubmed Abstract | Pubmed Full Text | CrossRef Full Text | Google Scholar

12. Badeli H, Sajedi SA. Childhood hypertension: new concepts, definitions, and diagnostic evaluations. Iran J Kidney Dis (2008) 2(3):123–6.

Google Scholar

13. Ardissino G, Bianchetti M, Braga M, Calzolari A, Daccò V, Fossali E, et al. Recommendations on hypertension in children: the CHI/d project. Pediatr Med Chir (2004) 26(6):408–22.

Google Scholar

14. Gupta AK, Ahmad AJ. Normal blood pressures and the evaluation of sustained blood pressure elevation in childhood. Indian Pediatr (1990) 27(1): 33–42.

Pubmed Abstract | Pubmed Full Text | Google Scholar

15. Rosner B, Prineas RJ, Loggie JM, Daniels SR. Blood pressure nomograms for children and adolescents, by height, sex, and age, in the United States. J Pediatr (1993) 123(6):871–86. doi:10.1016/S0022-3476(05)80382-8

Pubmed Abstract | Pubmed Full Text | CrossRef Full Text | Google Scholar

16. Gillman MW, Cook NR, Rosner B, Evans DA, Keough ME, Taylor JO, et al. Identifying children at high risk for the development of essential hypertension. J Pediatr (1993) 122(6):837–46. doi:10.1016/S0022-3476(09)90005-1

Pubmed Abstract | Pubmed Full Text | CrossRef Full Text | Google Scholar

17. Agarwal VK, Sharan R, Srivastava AK, Kumar P, Pandey CM. Blood pressure profile in children of age 3-15 years. Indian Pediatr (1983) 20(12): 921–5.

Google Scholar

18. Maggio AB, Aggoun Y, Marchand LM, Martin XE, Herrmann F, Beghetti M, et al. Associations among obesity, blood pressure, and left ventricular mass. J Pediatr (2008) 152(4):489–93. doi:10.1016/j.jpeds.2007.10.042

Pubmed Abstract | Pubmed Full Text | CrossRef Full Text | Google Scholar

19. Blood pressure studies in children. Report of a WHO Study Group. World Health Organ Tech Rep Ser (1985) 715:1–36.

Pubmed Abstract | Pubmed Full Text | Google Scholar

20. Norton GR, Majane OH, Libhaber E, Maseko MJ, Makaula S, Libhaber C, et al. The relationship between blood pressure and left ventricular mass index depends on an excess adiposity. J Hypertens (2009) 27(9):1873–83. doi:10.1097/HJH.0b013e32832dca53

Pubmed Abstract | Pubmed Full Text | CrossRef Full Text | Google Scholar

21. Muntner P, He J, Cutler JA, Wildman RP, Whelton PK. Trends in blood pressure among children and adolescents. JAMA (2004) 291(17):2107–13. doi:10.1001/jama.291.17.2107

Pubmed Abstract | Pubmed Full Text | CrossRef Full Text | Google Scholar

22. Redon J. Hypertension in obesity. Nutr Metab Cardiovasc Dis (2001) 11(5):344–53.

Pubmed Abstract | Pubmed Full Text | Google Scholar

High normal blood pressure: prevalence and predictive value

The continuous nature of the relationship between blood pressure (BP) and cardiovascular and renal events makes it difficult to choose a borderline BP level that would separate normal from elevated BP. A meta-analysis of 61 prospective studies showed that mortality from coronary heart disease and stroke in people aged 40 to 89 years begins to increase from a systolic BP level of 115 mmHg. and diastolic BP 75 mm Hg. [12].

The concept of prehypertension (PH) was introduced in 1939 when BP levels between 120-139 mmHg were first noticed. (systolic) and 80-89 mm Hg. (diastolic), as having value in the development of stable arterial hypertension (AH). The term “borderline hypertension” has been used for almost three decades, the name “prehypertension” was given in 2003. In the European guidelines for hypertension, the upper limit of the PH range is designated as high normal blood pressure (HNAP). The need to distinguish this category is due to the fact that the risks of cardiovascular complications and mortality with a given increase in blood pressure significantly increase compared to optimal blood pressure.

VNAD is not a disease and is not even considered by all specialists as an independent risk factor (FR), but this is the condition in which early primary prevention of hypertension and related complications is possible. Identification of the category of persons with VNAD will increase awareness of the risk factors for hypertension, reduce the risk of cardiovascular complications, and possibly reduce the rate of progression of hypertension or prevent it.

Epidemiology of high normal blood pressure

A number of studies have been carried out [3-6] on the detection of VNAD, the data of which have shown that its prevalence is significant and varies widely. In 2006, the first results were obtained on the prevalence of this category of AD in the United States (up to 28%). It has been established that within 5 years, IAD transforms into AH of various degrees, which significantly increases the risk of morbidity and mortality.

In the United States, every third citizen has a GNI [3], while 50% of them have three more F.R. The prevalence of VNAD in Russia is 1.7 times less; additional three risk factors are present in 73.2% of cases [4]. These data suggest that the presence of VNAD and a combination of three or more RFs more often forms hypertension and its cardiovascular complications. Thus, modern preventive cardiology should actively study the mechanisms of formation and develop new methods for monitoring the effectiveness of treatment and prevention of cardiovascular complications in the early stages of AH, since in this case complications are formed among full health.

In the Russian study “EPOKHA-AG” it was found that the maximum number of respondents with VNAD occurs in the age group from 40 to 59 years. This pattern was present in 2002 and persisted in 2007. Regardless of the year of the study, men had the maximum age-specific prevalence of VNAD in the middle age group (from 40 to 59 years) – 22.0%.

Increased blood pressure within 135-139/85-89 mm Hg. associated with other risk factors [3, 4]. An analysis of 1379 young (20-44 years old) representatives of the general population included in the Bogalusa Heart Study registry [7] showed that 27% of them had VNAD, significantly more often in men (35% vs. 22% in women) and in African Americans (29% versus 27% for whites). The main determinants of VNAD were the increase in body mass index (BMI) and male gender. Several studies have also shown that high BMI is a strong predictor of prehypertension among conventional risk factors [8, 9]. It has been established that obesity is an independent determinant of the development of VNP in women: as body weight increases by 1 kg, its risk increases to the same extent as with an increase in age by a year [10].

In the Japanese epidemiological study Jichi Medical School Cohort Study [11], which included 4706 men and 7342 women aged 18 to 90 years, a high prevalence of VNAD was stated, amounting to 34.8% in men and 31.8% in women. Even formally normal BMI values ​​(23.0–24.9 kg/m ² ) were associated with an increase in the probability of increased normal blood pressure by 1.47 times. Explicit obesity (BMI ≥ 30 kg/m ² ) led to an increase in the probability of VNAD in men by 3.39 times, in women by 4.23 times. Dyslipoproteinemia and advanced age also predisposed to PG – an increase in age by every 10 years was associated with an increase in the likelihood of increased normal blood pressure by 12% in men and by 48% in women. Impaired glucose tolerance, diabetes mellitus (DM) and the presence of AH in both parents increased the risk of VNAD in women, and alcohol abuse in men.

In large populations, people with HNAD were also more likely to have DM [12], impaired fasting glucose, dyslipidemia, and metabolic syndrome (MS) [13] than people with normal BP.

Increased levels of tumor necrosis factor-α, homocysteine, low-density lipoprotein cholesterol, γ-glutamyltransferase, microalbuminuria were associated with VNAD, which indicates the role of inflammation in the development of this condition.

VNI and CVD risk

Despite the prevalence of VNAD, its significance, including in predicting risk, remains controversial. Some studies have shown HNAP to be an independent risk factor for cardiovascular disease (CVD), while others have not shown the same result after adjusting for other risk factors [14, 15].

Data from the Framingham study [16] showed that during the follow-up of a representative sample of 6859 respondents for 11 years, individuals with VNA had 397 cases of cardiovascular events, of which 72 deaths, 190 myocardial infarctions, 85 cases of strokes, 50 people developed chronic heart failure. At the same time, the risks of complications developed more aggressively in the IBP zone compared to the normal level of blood pressure. In women with blood pressure levels from 130/85 to 139/89 mm Hg, for 4 years, life prognosis is significantly worse compared to those who have normal blood pressure. A similar pattern is formed in men after 6 years. In patients with DM, IAD increases the risk of cardiovascular complications by 1.8 times.

Data from an American study of 32,000 patients aged 25-74 years who were followed up for 18 years showed that in patients with VNAD, the odds ratio for myocardial infarction, stroke, congestive heart failure (adjusted for other risk factors) is 1 .32 (1.05-1.65) versus 1.0 for normotensives. It should be noted that all participants had at least one additional cardiovascular risk factor. It was important to identify the “heterogeneity” of PG, so VNIAP (130-139/85-89 mm Hg) acted as an independent predictor of increased CVD and mortality, while patients with BP 120-129/80-84 mm Hg. no longer had increased risks after taking into account other risk factors [17].

Another meta-analysis of 18 prospective cohort studies, including more than 468,000 participants, showed that after controlling for other cardiovascular risk factors, there is a significant association between IAD and CVD. Moreover, even for the low range of PG, the risk of CVD increased compared to that with optimal blood pressure [18].

Certain predictors of ABP transformation into A.G. have now been identified. The risk of developing hypertension significantly increased at baseline age of at least 65 years, fasting glycemia of at least 110 mg/dl, HOMA index of at least 2.5, and the presence of MS [19]. In the ATTICA study, age, male gender, higher education, increased waist circumference and serum C-reactive protein level determined the increased risk of hypertension after 5 years [20]. The results of a 26-year follow-up of Framingham Heart Study participants [16] showed that 54.2% of men and 60. 6% of women develop AH at baseline HBP (23.6% of men and 36.2% of women at baseline normotension) . Thus, the risk of AH with baseline IAD increased 2.25 times ( p <0.0001) and 1.89 times ( p <0.0001). Elevated baseline SBP and weight gain were the main risk factors for the development of hypertension.

It should be noted that subclinical lesions of the heart and blood vessels were already detected in HNAD [7].

Data from the NHANES III population registry [21] indicates that VNAP causes a 2.13-fold increase in the likelihood of microalbuminuria. According to a survey of 2678 adults with HNAD [22] who did not suffer from DM, microalbuminuria is significantly more common in them than in truly normotensive patients (4.9and 2.8% respectively; p \u003d 0.009). VNAD caused an increase in the frequency of persistent microalbuminuria by 1.7 times, which indicates not only the initial stage of hypertensive nephropathy, but is also a marker of endothelial dysfunction.

The relationship of IAD with left ventricular hypertrophy, its concentric remodeling and impaired diastolic function was confirmed in the large epidemiological project MONICA/KORA [23]. S. Stabouli. and co-authors [24] demonstrated that in adults and children with HNAD, the value of myocardial mass index was significantly higher than in optimal normal BP (34.1±3.4 and 29.5±8.3 g/m ² ; p <0.05).

VNAD may be associated with signs of vascular damage, reflecting both the prevalence of the atherosclerotic process and an increase in the stiffness of the aortic wall and its main branches. It has been demonstrated that in individuals with elevated normal blood pressure, especially in combination with impaired glucose tolerance, there are significantly greater thicknesses of the intima-media complex of the common carotid arteries compared to normotensives [25]. It has been established that IBP is an independent determinant of the increase in pulse wave velocity, the value of which, like the augmentation index, is significantly higher when it is present compared to that in normotensives [26].

Thus, the prevalence of VNAD and data on its role in the development of hypertension, target organ damage, and cardiovascular complications make further study of this condition relevant. From a practical point of view, interest in this problem is dictated by the possibility of early preventive measures in this category of people.

No conflict of interest.

Contributors :

Participation in the collection of literary sources, preparation of an article for publication – O.A.

Analysis and synthesis of material — O.A., I.O.

Editing the article – I.O.

GBUZ Design Bureau named after. NN Burdenko – The level of blood pressure makes it possible to judge the state of the human body

Blood pressure is one of the main indicators of the state of the human body. Its value allows you to directly judge the functioning of the cardiovascular system, indirectly – about the work of other organs and systems.

Blood pressure is the force with which blood presses from the inside against the walls of the arteries.

“Optimal (up to 120/80) and normal (120-129/80-84) blood pressure does not require constant monitoring. For people with such indicators of blood pressure, it is enough to measure it periodically, during scheduled medical examinations, medical examinations, visits to the doctor for other reasons, ”explains the chief freelance cardiologist of the Ministry of Health of the Penza Region, head of the cardiological dispensary, cardiologist of the Penza Regional Clinical Hospital named after N .N. Burdenko Elena Nikolaevna Volodina.

High normal blood pressure (130-139/85-89) is an independent disease or risk factor, but is considered as a condition in which early primary prevention of arterial hypertension and its associated complications is possible.

“Maximum predisposition to high normal blood pressure is found in men aged 40 to 59 with an elevated body mass index. They are advised to control blood pressure somewhat more often than standard recommendations, get rid of bad habits, normalize weight, ”advises Elena Nikolaevna.

Arterial hypertension is a chronic disease characterized by high blood pressure.

Arterial hypertension of the 1st degree (140-159/90-99) is often asymptomatic and goes unnoticed for a long time.

“In case of accidental detection of its signs, for example, during a routine examination, the patient is recommended to conduct daily monitoring of blood pressure in order to exclude the “white coat” syndrome – increased pressure due to excitement, fear of doctors. When confirming the diagnosis, the patient needs regular monitoring by a local doctor, periodic self-measurement of blood pressure, ”the cardiologist notes.

According to Elena Nikolaevna, arterial hypertension of the 1st degree requires regular medication and lifestyle modification. “Often, lifestyle correction helps to stabilize blood pressure: proper nutrition and normalization of weight, rejection of bad habits, moderate physical activity, lack of stress,” advises the specialist.

With arterial hypertension of 2 and 3 degrees (160 and above / 100 and above), isolated systolic hypertension (more than 140 / less than 90), daily self-monitoring of blood pressure is required.

“To correct these conditions, in addition to lifestyle changes, drug therapy is required, which is carried out only on prescription and under the supervision of a doctor,” Elena Nikolaevna clarifies.

Young people under 35 often do not notice the symptoms of high blood pressure. However, they may also develop arterial hypertension, therefore, periodic monitoring with existing risk factors, the appearance of complaints is mandatory for timely diagnosis, prevention and treatment if necessary.

Prevention of deviations in blood pressure from normal values ​​primarily consists in correcting lifestyle that can prevent the development of the disease. Recommendations must be adhered to by people with a burdened heredity who are at risk (overweight, frequent stress).

“To prevent hypotension, night sleep should be normalized – it should be at least 8 hours, include dishes with a high content of calcium, potassium and magnesium in the menu, eat often in small portions, limit animal fats and fast carbohydrates, ensure sufficient physical activity”, – says the doctor.