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Pediatric Hypertension: Prevalence, Complications, and Medication Use
Study Questions:
What is the prevalence of hypertension diagnosis in children of US military members, and what is the frequency of echocardiography evaluations, cardiac complications, and antihypertensive prescriptions in the post-2004 guideline era?
Methods:
Using billing data from military health insurance (TRICARE) enrollees, hypertension cases were defined as two or more visits with a primary or unspecified hypertension diagnosis during any calendar year or one such visit if with a cardiologist or nephrologist. Incidence of hypertension, frequency of echocardiograms, associated cardiovascular diagnostic codes, and information on medication treatment for hypertension were obtained.
Results:
During 2006-2011, 16,322 out of 1.3 million individuals aged 2-18 years met the definition of hypertension (2.6/1,000). The incidence of hypertension increased by 17% between 2006 and 2011 (from 2.3/1,000 to 2.7/1,000; p < 0.001) and was more common in adolescents aged 12-18 years than in younger children (5.4/1,000 vs. 0.9/1,000). Echocardiography was performed in 5,585 (34%) individuals with hypertension. The frequency of annual echocardiograms increased from 22.7% to 27.7% (p < 0.001), and among those individuals, 8.0% had left ventricular hypertrophy (LVH) or dysfunction. Among the patients with hypertension, only 6,353 (38.9%) received an antihypertensive medication.
Conclusions:
The prevalence of the diagnosis of hypertension has increased; however, compliance with national clinical guidelines remains poor. Of children with a diagnosis of hypertension who had an echocardiogram, 1 in 12 was abnormal, highlighting the importance of the use of echocardiography in children with hypertension; however, only 34% of children with a diagnosis of hypertension, rather than the recommended 100% received an echocardiogram. LVH was more prominent in younger children (aged 2-11 years) with hypertension, and points to additional potential complications in this cohort as they age. Unfortunately, the rate of medication use was near 40%, but still considerably low for established diagnosis of hypertension in children.
Perspective:
With the recognition that adult cardiovascular disease begins in childhood, there has been a national effort to develop guidelines for the diagnosis, evaluation, and treatment of high blood pressure in children and adolescents. These results emphasize the need for increased awareness of the frequency of pediatric hypertension, and highlight the concerning relatively high risk of cardiovascular complications (LVH and heart failure). Although lifestyle modification may be appropriate, the low rates of echocardiography in established hypertension are evidence of lack of implementation of clinical guidelines. Fortunately, among the patients with hypertension, a known echocardiogram, and LVH diagnosis, 78.7% were prescribed an antihypertensive medication. However, the increasing trend of hypertension diagnosis combined with the poor percentage of individuals receiving treatment suggests that in addition to education, active efforts to aid clinicians in implementation of these guidelines may be essential to significantly improving evaluation and treatment of pediatric hypertension.
Keywords: Antihypertensive Agents, Blood Pressure, Echocardiography, Heart Defects, Congenital, Heart Failure, Hypertension, Hypertrophy, Left Ventricular, Pediatrics, Prevalence, Primary Prevention
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