–Editorialists say pediatric hypertension in children is ready for a ‘paradigm shift’
Last year’s influential— and highly controversial— SPRINT trial should be used to better inform and influence our understanding and management of hypertension in children, write two influential physicians who have played a key role in the cardiovascular guidelines for children and adolescents. They argue that a careful interpretation of the trial lends support for increased attention to achieving optimal blood pressure early in life.
In an editorial published in Hypertension., Bonita Falkner (Thomas Jefferson University) and Samuel Gidding (Alfred I duPont Hospital for Children) acknowledge that SPRINT, which evaluated the effect of standard or aggressive blood pressure treatment in older adults with high cardiovascular risk, “seems far removed from a pediatric setting.” But, they argue, the long term consequences of high blood pressure starting in childhood or adolescence will result in a significant increase in adults with cardiovascular disease, similar to those studied in SPRINT, which demonstrates that “hypertension accelerates cardiovascular disease.
Falkner and Gidding also acknowledge that “there are no data that link a BP threshold in childhood with cardiovascular events decades later in adulthood.” In the existing guidelines optimal blood pressure is defined as 120/80 mm Hg or lower for adolescents and 110/70 mm Hg or lower for children under 12 years of age. Approximately 10% of adolescents have blood pressure above 120/80 mm Hg which, the authors argue, leaves them more likely to develop early cardiovascular target organ damage.
The main thrust of the editorial is to “support a paradigm shift on the approach to childhood BP from primary prevention to primordial prevention,” which would lead to a greater focus on “interventions to prevent development of prehypertension/hypertension.” Primordial prevention “should focus on conserving normal BP.” Weight control, physical activity, and sodium restriction are key elements in primordial prevention. The authors do not offer any specific recommendations for antihypertensive drug treatment in this context. In an email exchange Gidding said that the editorial “points to the value of lifelong BP less than 120/80 achieved through lifestyle means.” The current pediatric guidelines are now being revised. For now, he said, he follows the current guidelines, which recommend drug therapy for some pediatric patients with elevated high blood pressure when lifestyle changes have not been successful.
… or Slippery Slope?
I asked Sanjay Kaul (Cedars Sinai) for a comment. “On the surface,” he wrote, “this seems like a reasonable proposal as it is based on several supportive epidemiological studies, and the editorialists are not specifically calling for pharmacological treatment to target these risk factors. However, what is not clear is the actual BP target for primordial prevention. How low is too low? Extrapolating the BP targets achieved in the SPRINT trial via pharmacological treatment in patients at moderate to high risk for CV disease to adolescents without disease is a slippery slope.” He also pointed that “while the editorialists focus on the potential benefits of lower BP targets in the adolescents, potential risks of such a strategy need also be considered.”