20 Arterial Hypertension
20.1.1 Basics
Definition
Arterial hypertension is defined as an increase in systolic and/or diastolic blood pressure over the gender-specific 95th percentile for the age or size of the patient (Table 20.1). At least three independent measurements are needed.
Mean values for boys (mmHg) | ||||||
Daytime | Nighttime | 24 hours | ||||
Height (cm) | 50th percentile | 95th percentile | 50th percentile | 95th percentile | 50th percentile | 95th percentile |
120 | 112/73 | 123/85 | 95/55 | 104/63 | 105/65 | 113/72 |
130 | 113/73 | 125/85 | 96/55 | 107/65 | 105/65 | 117/75 |
140 | 114/73 | 127/85 | 97/55 | 110/67 | 107/65 | 121/77 |
150 | 115/73 | 129/85 | 99/56 | 113/67 | 109/66 | 124/78 |
160 | 118/73 | 132/85 | 102/56 | 116/67 | 112/66 | 126/78 |
170 | 121/73 | 135/85 | 104/56 | 119/67 | 115/67 | 128/77 |
180 | 124/73 | 137/85 | 107/56 | 122/67 | 120/67 | 130/77 |
Mean values for girls (mmHg) | ||||||
Daytime | Nighttime | 24 hours | ||||
Height (cm) | 50th percentile | 95th percentile | 50th percentile | 95th percentile | 50th percentile | 95th percentile |
120 | 111/72 | 120/84 | 96/55 | 107/66 | 103/65 | 113/73 |
130 | 112/72 | 124/84 | 97/55 | 109/66 | 105/66 | 117/75 |
140 | 114/72 | 127/84 | 98/55 | 111/66 | 108/66 | 120/76 |
150 | 115/73 | 129/84 | 99/55 | 112/66 | 110/66 | 122/76 |
160 | 116/73 | 131/84 | 100/55 | 113/66 | 111/66 | 124/76 |
170 | 118/74 | 131/84 | 101/55 | 113/66 | 112/66 | 124/76 |
180 | 120/74 | 131/84 | 103/55 | 114/66 | 113/66 | 124/76 |
The following formulas can be used as a rule of thumb for the upper blood pressure limits:
Children age 1 to 10 years:
Systolic blood pressure (mmHg): 100 + (age in years × 2)
Diastolic blood pressure (mmHg): 60 + (age in years × 2)
Children and adolescents age 11 to 17 years:
Systolic blood pressure (mmHg): 100 + (age in years × 2)
Diastolic blood pressure (mmHg): 70 + (age in years)
Epidemiology
The incidence of arterial hypertension in children and adolescents in Germany is at present 1 to 3% but increasing.
Classification and Etiology
Arterial hypertension is classified as primary (essential) hypertension or secondary hypertension. Secondary hypertension is due to a treatable cause.
Primary (Essential) Hypertension
The cause of essential hypertension is unknown. It is assumed that there are multiple factors, among them genetic predisposition, environmental factors, lifestyle, and ethnic origin. Studies in the United States show that essential hypertension is on the increase, even in children and adolescents. Many of these patients are obese and have a positive family history of hypertension. This form of hypertension is often associated with lipid metabolism disorders and impaired glucose tolerance (metabolic syndrome), especially in overweight patients.
Secondary Hypertension
Renal disease: Kidney diseases constitute around 90% of secondary hypertension:
Renovascular diseases: Renovascular disease is found in about half of neonates with hypertension. Examples:
Congenital renal artery stenosis
Complex anomaly of the entire aorta (mid-aortic syndrome)
Renal artery stenosis due to a fibromuscular dysplasia (association with neurofibromatosis type I)
Renal vascular thrombosis (especially after umbilical vessel catheters)
After kidney transplantation
Renal parenchymal diseases: Renal parenchymal diseases are the most common causes of secondary hypertension in infants and school-age children. Examples:
Focal segmental glomerulosclerosis
Mesangial proliferative glomerulonephritis
Membranoproliferative glomerulonephritis
Rapid progressive glomerulonephritis
IgA nephritis
Diabetic nephropathy
HIV nephropathy
Renal parenchymal scarring and reflux nephropathy
Vasculitis (systemic lupus erythematosus, Wegener granulomatosis, polyangiitis)
Hemolytic uremic syndrome
Polycystic kidney disease (in autosomal recessive forms, severe hypertension is often already present at birth)
Alport syndrome
Renal hypoplasia/dysplasia
Metabolic diseases (cystinosis, oxalosis)
Cardiovascular diseases:
Coarctation of the aorta—leading symptom: increased blood pressure in the upper limbs, decreased blood pressure in the lower limbs. (Even after surgery or interventional catheterization, hypertension often persists in the upper limbs.)
Rarely:
Hypoplastic aortic arch
Mid-aortic syndrome
Takayasu arteritis
Aortic aneurysm
Stenosis of the carotid artery
After Kawasaki disease
Endocrine diseases:
Cushing syndrome, steroid treatment
Adrenogenital syndrome
Pheochromocytoma (rare in childhood, usually associated with neurofibromatosis type I)
Neuroblastoma (however, usually no hypertension present)
Hyperthyroid crisis
Hyperaldosteronism, Liddle syndrome (hypokalemia, alkalosis)
Neurogenic diseases:
Intracranial pressure (brain tumors, trauma)
CNS inflammation (Guillain–Barré syndrome, encephalitis)
Drugs and toxic causes:
Drugs: steroids, cyclosporine A, sympathomimetics, caffeine
Excessive consumption of liquorice
Mercury poisoning
Other causes:
Bronchopulmonary dysplasia
Hypercalcemia
Porphyria
Turner Syndrome
Marfan syndrome
Sickle cell anemia
Sleep apnoe
Note
Essential hypertension is a diagnosis of exclusion. The younger the patient and the higher the blood pressure, the more likely secondary hypertension is. In children, more than 75% of cases are secondary hypertension. About half of cases among adolescents involve secondary hypertension.
The most common cause of secondary hypertension is kidney disease. The most common cardiovascular cause is coarctation of the aorta.
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