UCSF specialists in pediatric kidney and heart disease present the latest guidelines on evaluating patients with possible hypertension, including a key first step for establishing the diagnosis. Noting that the condition is increasingly common in kids and has serious consequences, they provide a blueprint for management that includes when to begin a diagnostic workup, when to start interventions, and when to refer.
nice to meet everybody. I'm fall break been I'm a pediatric nephrologist. I work in Oakland and SAn Francisco and I also run the pediatric kidney transplant program. And I've got a longstanding interest in high blood pressure and I'm here with Howard and uh because we're kind of, we work in tandem cardiology nephrology and want to sort of review the specifics of blood pressure management and then also sort of powder or for and when to refer to our groups. So Howard maybe you can introduce yourself? Sure. Hi. Um, I think I know many if not all of you. I'm Howard Rosenfeld, I'm the co director of the division here, pediatric cardiology in Oakland and Paul is going to be doing the lion's share of this particular talk. And as we move along you'll see why. So thanks all for attending. And um I'm here for a portion of the talk and to answer questions. Okay. So Howard has no disclosures and I have a couple of financial relationships with some companies that actually are doing mostly transplant work. So here are the learning objectives for this talk. I wanted to find pediatric hypertension and I want to talk about how we utilize current hypertension guidelines to make diagnostic decisions, hoping that you will take away from this um, how to apply those guidelines in your own practices and then I want to prevent the present the information that you can so you can apply diagnostic and treatment strategies for elevated blood pressure based on the patient's age and access to care and some recommended referral workflows. I think the first question for me actually, as a pediatric nephrologist when I started about 20 years ago was, you know, did I really care about it? A teenager specifically with what we would call primary hypertension or essential hypertension wasn't really relevant to treat that patient. And I think over the last 20 years, we've accumulated some data that indicates that hypertension in young patients does predisposed to cardiovascular mortality. So this is a study of Young adults aged 20 to 25 Where they were looking at the incidence of cardiovascular disease over time. And what they found was if you if you had a young adult with high blood pressure, that there was a substantially higher chance of having a cardiovascular event over the next 10-20 years. And I think this data represents that probably the cardiovascular damage that we see frequently in adults from hypertension is probably happening in pediatric patients. But it takes a while to see the effect. So I think of this as an area under the curve effect where the longer a young patient is hypertensive, the more likely they are to have a cardiovascular event later. And so I think they're really Is an onus on us as pediatricians to identify these patients. And I think normalizing blood pressure in a 15 year old or an 18 year old Probably does have a payout in lower cardiovascular events as they get older. That's a very hard thing to prove. So it's important to recognize we don't have randomized controlled trial evidence that treating a 17 year old who's overweight with the antihypertensive will prevent them from dying or having a stroke later. But I think it makes sense that the cardiovascular morbidity um starts when patients are young and accumulates over time. In addition, there's actually evidence that hypertension at the time that the child is hypertensive actually impairs cognition. So this is a study looking at different um cognitive test, testing strategies in Children who are hypertensive and basically there's four things listed here block design, digit span, mathematics, reading, um and those things were tested and found at least three of them. The block design, digit span and mathematics were found to be affected when in hypertensive Children compared to normals. A multi varied analysis actually, um sort of eliminated block design and mathematics and came up with digit span as a primary driver of this. And this interestingly when they took these patients who were hypertensive and had abnormal digit span thinking and trying to treat their hypertension, they couldn't quite show an effect. But it was only because they didn't actually achieve control in the study. If you actually looked at the patients who achieved good control of their blood pressure. This digit span defect actually disappeared. So I think this is more evidence that treating hypertension can can help our pediatric patients think better. And also I think was, you know, 20, years ago when I was starting, it wasn't so clear how many patients were hypertensive and in the literature before about 2000, the quoted number was about 1% of all pediatric patients were hypertensive. And then this was a study, An observational study done in Houston, looking at more than 5000 Children aged 10-19 years. That actually uncovered a hypertension rate of 4.5% for the entire population in 20% in the overweight pediatric population. So of these pediatric patients in Houston had about a 20% rate of hypertension. So this certainly establishes this as a common disease in Children. And I think we've continued to see high blood pressures and we've also continued to see a high rate of obesity in our patient population. There are these large task force reports that come out about every decade and the most recent one was called the 5th Task Force report. This came out three years ago. It identified sort of the the current standards for identifying and treating pediatric hypertension. And then the main difference in this specific task force report compared to others was it actually created a new database of normals. So they took the old database and they eliminated overweight Children. So they created a new database of normals. Um that has normal blood pressures based on height and weight and you can find these normals by just googling normal pediatric blood pressure. And it comes up as a CDC website. And that's often times what I do in clinic to if I want to quickly find a blood pressure norm for a certain age and height. I do that And then it made some further revisions. But that was the main difference. Was it redefined the normals? And frankly the effect of that was some patients that were would have been quote unquote normal. In the fourth task force report all of a sudden became abnormal in the fifth task Force report. So one of the basic recommendations for measuring blood pressure and Children and the reality is obviously the primary care positions do most of this. And the the real simple um recommendation is that patients who are three years old or older should have their blood pressure is measured dearly. And that's you know I recognize that that's non trivial in a lot of three year olds and four year olds. And the reason this recommendation starts at age three is because it's really hard to measure blood pressure is less than three. Um But there are some patients who should have their blood pressure measured when they're less than three years old. So patients who are born premature or in the I. C. N. For significant portions of time. Um You know I think it's reasonable to try to start measuring their blood pressures when they're a year older when you can do it. Um Congenital heart disease patients where they may actually have problems if their blood pressures are too high or they may suffer from low blood pressure's deserve measurement. I think if you've got a patient to your monitoring because they've had one or two urinary tract infections, I think blood pressure is one sign that the kidneys might have been affected by a urinary tract infection. Or if you're monitoring monitoring a patient who has mild microscopically material or mild protein area, That's another patient population where you probably want to check if you have a clear family history of renal disease. Specifically things that are known to affect smaller for younger patients, such as also more dominant polycystic kidney disease. That's another population that deserves measuring and then solid organ or bone marrow transplant patients. Uh If there are less than three years old, it can still be very helpful to us as specialist managing those patients. If a primary care doctor measures measures blood pressure in the office and then other diseases that are associated with hypertension like neurofibromatosis or tuberous sclerosis would be tuberous sclerosis would be great if if we get some primary care blood pressures to help us know whether patients have had high blood pressure because frankly, sometimes a 1.5 year old or a two year old with neurofibromatosis comes to my clinic visit and I can't get a blood pressure that day because they are screaming the entire time. So it's it's helpful if anybody can try and get a blood pressure in those patients and then the other population that I think is very helpful is any patient of mine where I'm managing them with some antihypertensive. It's very helpful if a primary care doctor sees them and can try to get a blood pressure for that same reason. It's pretty hard to measure blood pressures. And so if a primary care doctor can obtain obtain one successfully that helps me as a specialist. Um so some further recommendations on how and when to measure blood pressure. The the key thing here is that Children should really be have their blood pressure measured after they've been sitting in a quiet room for 3-5 minutes. Now that's really hard to achieve in most situations. Um but certainly in a regular screening situation if a patient walks directly into the vitals room and they sit down and the blood pressure is high. It's important to teach your office staff that will let them sit there for a couple of minutes and then recheck it. And the measures the blood pressure should be measured on a right arm with the patient's seated when possible. Oscar rotation is the preferred method Using the K5 sound for the for the blood pressure measurement and then the appropriate size cuff is important if a cuff is too small routinely the blood pressure will be too high. Um And then the key here is actually repeating. So if the blood pressure is high it should be confirmed on a repeated measurements in the same visit. Um and then specifically if it's over over the 90th%ile it's good to repeat using your own years or having a trained staff member who can do it. And then finally I think the most important thing is in the primary care setting when blood pressures are identified that are over the 95th% off rage or but not stage two hypertension. The key thing there is to repeat them over. Typically two more visits based out at least a week apart before calling the that patient was having high blood pressure because routinely a patient come in on a on a single day and have a high blood pressure and will in a week or two may have a normal blood pressure. And that patient doesn't necessarily need anymore evaluation. So this is just a picture of what the size of the blood pressure cuff and the key here is to look at the circumference of the midline of the arm and then the look at the cuff bladder link and they usually will state the centimeters that they're good for on the actual cuff. And then of course we've all been in the situation of trying to get a blood pressure reading off of a small infant. Um And I think this is just a simple question which is when is the blood pressure reading on a calf the same as the blood pressure reading on an arm and a is never be it's only it's only similar if you can't get an arm blood pressure depends on age. And and the answer is really that it's not really going to be the same as an arm blood pressure, which is why pretty much all recommendations on pediatric blood pressure are written on off of arm blood pressure readings that are Oscar story. I'll say that in patients less than two Oscar Tory blood pressures are very hard to obtain. And so using a machine is actually standard but we still like to see an arm blood pressure on a patient less than two um when possible, recognize that it's not always possible. The charts for blood pressure normals. Like I said, you can find them by googling, that's how I do it. They basically come up as a as a gender and age and then a height percentile and you can read across and find sort of the 90th%ile in less than 90 it is considered normal. And then there's some definitions of hypertension and they change the language a little bit. This latest task force report has defined the mildly high blood pressure as they used to be called prehypertension. Now it's called elevated blood pressure. So for patients over the 90th%ile we don't consider that normal. We call that elevated blood pressure. And then if they're over the 95th percentile there called stage one and if they're over the 95th percentile plus 12 there over Stage two notice for patients 13 and over their their absolute numbers. I will I will say though that I think it's a little bit unclear what to do with a very tall 11 or 12 year old because they probably should be treated more like a 13 year old. So the patient who hits puberty and is five ft eight at age 12 probably should be treated like a 13 and up patient. So what does this actually look like in? Well actually it's in I'm putting an example what it looks like in my office because this patient has obviously been seen by a PCP PCP before. So it's a pretty common thing that I see a 17 year old female has had excessive weight gain for the last six years. She reports no symptoms, no headache, no chest pain and exercising but her blood pressure is high, it's 1 40/95. And then you, the primary care pediatrician has repeated over three separate visits and it's been high all three times. And so you referred her on and the patient actually has already received lifestyle modification counseling and has been trying to eat healthier and exercise for three months and really hasn't lost any weight. So I have this patient in my office and you know, for me um I have sort of a pretty clear idea in my mind what the next step is. So you know I listed a couple of things that are possible. Should I order an echocardiogram? Should I get your onions here? Um Cata cola means sort of do a more complete work up. Should I do an ambulatory blood pressure monitoring to rule out white coat hypertension? Or should I just repeat the blood pressure again at the next visit? You know you the you the good pediatricians have already ruled out D and then we'll talk a little bit more about the rest of these. But the basic answer is that in these patients we perform an ambulatory blood pressure monitoring to rule out white coat hypertension. And that's because this in this population of teenagers, even overweight teenagers White coat hypertension is common. It's about 20-25% of the patients. And it really negates the need for further evaluation. Howard will get his chance to talk about ordering at the carter games in a bit. So what does this ambulatory blood pressure monitoring look like? Um So this is just a picture of the machine, it's pretty small. It's about the size of two decks of cards stacked up. Um and what it does is that it's just a miniaturized version of what we all use in our offices. It's an Osceola metric device. We set it to fire off every 20 minutes during the day and every 30 minutes at night. It's actually pretty impressive but most patients can sleep at night? I definitely have patients that come in and they've taken it off at night because they couldn't sleep but mostly it works. Um And it has normative values for by height for Children aged about 6-18 years. So we can't really use it less than about six. The height cut off is about 120cm cm for the normative values. There's some situations where it's specifically useful. So in patients who have secondary hypertension. So the patient population that ends up in my clinic and that I'm managing they tend to actually have a high rate of nocturnal hypertension so they can be well controlled in the office and still be hypertensive at home. And then in chronic kidney disease. It's the same thing. There's a something we call mass hypertension where they can be normal in the office and be hypertensive a significant percentage of the rest of the day and you know, including being hypertensive at night. The type one diabetes patients in the type two diabetes patients definitely have abnormal A BPM at a high rate. And those abnormal ap PMS do correlate with cardiac changes like L. V. H. And then in my solid organ transplant population they are essentially chronic kidney disease. But this also applies to liver and heart transplants. They have a high rate of nocturnal hypertension that you can't see in an office, Patients with obesity will frequently have actually have white coat hypertension. So even though they look hypertensive in the office like I was saying 20-25% don't need to be treated with antihypertensive obstructive sleep apnea patients can show non dipping or abnormal blood pressure's at night. Um And then I you know I've got a couple of other things and then I generally used ambulatory blood pressure monitoring for my treated hypertensive patients just to make sure I've actually achieved control. I think this is especially true in patients who have abnormal echocardiograms. So these are the patient populations where we I think ambulatory blood pressure monitoring is really that's important and we actually repeat it typically at some interval usually one or two times a year. So I talked about this with this briefly. But the A Bpm is is actually really well uh the best predictor of LV. H. And if you look at the things we want to prevent for our patients by treating high blood pressure preventing cardiac changes is pretty high on my list. And so the ambulatory blood pressure monitoring is the best predictor of that and when it has been normalized is the best predictor of normalization of heart function in the adult literature. The ambulatory blood pressure monitoring is an independent predictor of cardiovascular events. So being normal in the office is important. But having a normal ambulatory blood pressure monitor conveys some cardiac protection interestingly in diabetics, it actually can predict the onset of micro albumin urea. Which implies that the vascular deregulation in diabetes that causes micro albumin urea can be picked up by an 80 P. M. And then it's an interesting question whether this is required to replace home monitoring. And the answer is that it's actually it does give a different answer than home monitoring as well as office monitoring. So I think it is not unreasonable. And I routinely do have patients obtain a blood pressure monitor and go home and check their blood pressure at home as a way to augment what I measure in my office. But it turns out the 24 hour monitor actually gives different results even than home monitoring. Probably because it goes off enough over the course of a day that the patient really does start to ignore it and you get a truly relaxed blood pressure. As I said, one of the drawbacks is it doesn't really have validated data for small kids. In other talks I've given, I've had primary care doctors asked about what other series, what do we recommend for home monitoring? So um the Omron company puts out a series of good monitors that this is a picture from amazon but they're also available in Walgreens CVS. Um and walmart. This is a contact machine and this one is unique because it's really the only machine that has smaller cuff. So it comes with an infant and neonatal cuff and a child cuff. Um It's a little bit more expensive. I can really only find it on amazon. But you know, for my smaller patients, this is what we use. And then the standard Walgreens cuff actually works pretty well. It's interesting that the rating here is 1.8 stars. But in independent studies these are shown to be reasonably accurate. Um so that you know that those are a totally reasonable option. All of these cuffs are arm cuffs, not wrist cuffs. Every now and then I'll have a really tough infant or newborn or toddler where I'll actually use a wrist cuff on an arm. But in general we avoid wrist cuffs. I think that uh I'm gonna spend some time talking about the evaluation of hypertension. But I think the key thing here is that the higher the blood pressure and the younger the patient, the more likely the hypertension is to be secondary. This is a really old statement from the 70s, but it definitely holds true today. And you know, I think the most common thing we see is essential hypertension or primary hypertension. Usually this is mild, very hypertension, adolescent where the, you know, the adults in the room also have high blood pressure. And so I routinely ask the parents or guardians in the room and ask if they have high blood pressure if they say they do. I actually ask them what medicine they have they're taking because it can give some hints about some of the things that could be causing it. Obviously primary hypertension is associated with obesity. 20% of obese patients with DM. I over 95th percentile are hypertensive and then the primary hypertension clusters with the other metabolic syndrome. Risk factors hipaa lipid e mia, glucose intolerance, et cetera. When I start looking for secondary hypertension causes in Children, these are the most common and interesting. You know, the hypertension. I see a lot of high blood pressure patients because a lot of the secondary causes of hypertension are related to the kidneys. So reflex naturopathic is common glow Maryland. Fire districts have to be fairly common polycystic kidney disease, both recessive and dominant eye pick up in my practice and treat their hypertension. Renal vascular disease is listed as 12% here. This was a study of all comers as you get younger in age. The reno vascular disease goes up. So uh Mhm. Infant or a toddler who has high blood pressure. You know, reno vascular diseases. Probably half those patients cohabitation is actually relatively uncommon. And howard will address that in a little bit. Things like the field crisis chromosomes item A or other endocrine screening tumors are not very common individually, but we certainly look at them. And patients who have no other cause for their high blood pressure. And I'm gonna actually turn it over to Howard here to talk a little about a little bit about cohabitation. Thanks paul. Um yeah, so the reason why cardiology is here is because a lot of the referrals for hypertension come into cardiology and clearly the heart is an integral part of making the blood pressure. But it turns out that there's really only one primary cardiac cause for hypertension. And that's co optation of the thoracic aorta. And in Paul's last slide it was listed at 2% of overall hypertension um which is not an insignificant number but is relatively small. The incidence of cohabitation in the US is about four and 10,000 live births And that allows for about 2000 babies born with lactation per year. The vast majority of those you're all picking up as newborns or infants. Um partly because of cardiac screening patients presenting with saturation differential with higher saturation in the arm than in the legs are then screened for correct ation. So many are picked up uh that way and and others present symptomatically with congestive heart failure or shock if they have neonatal critical correct ation. I think Paul's prior slide listing consultation at 2%. I don't know what the date on that study was but my guess is go ahead paul. If you know, Do you remember whether that study was from the 90s or more recently, it's from the 90s. It was definitely an older population so it's probably lower now. Yeah the only reason why I mentioned it because we're seeing so many more hypertensive patients in the setting of obesity that um I think the overall incidence of cohabitation is probably quite a bit lower than that now. Um connotations associated with bicuspid aortic valve and some genetic syndromes. So clearly if you have a patient with a known bicuspid valve, they need to be screened. Patients with Williams syndrome and Turner syndrome clearly need to be screened. Um And the reason why it's important to pick up these patients is because the prevalence of long term hypertension in the correct population is not insignificant and it's improved if we treat it earlier in the child. Next slide. So these are the two ways that cohabitation will present. The picture on the left is a patient whose doctor started Rios is still open. And so the baby. The baby. This baby would have good femoral pulses but would have de saturation in the lower extremities. So this is a baby that you would pick up on your cardiac screening prior to discharge from the hospital. Not by necessarily delayed or absent femoral pulses but by lower saturation in the feet than in the right arm. The that's a picture of an older child on the right with has developed some collaterals between the upper and lower portion of the aorta. But you can envision in the setting of a closed doctors arteriosclerosis. The lower extremity will be fully saturated but femoral pulses will either be absent or significantly decreased and delayed. So most of our young Children with cohabitation can be picked up by a good screening physical exam and saturation in the nursery and obviously any child who has high blood pressure in the office should have their femoral pulse is checked to be sure that they have strong femoral pulses. Um If even better is blood pressure Uh in the arm and lower legs. For patients who have that concern. And just to remind people blood pressures in the legs generally should be about 10 of mercury higher than in the right arm. Um And so blood pressures in the thigh that are significantly lower than break your blood pressures should you know um be referred for rollout consultation. That next slide. This is just to remind me to mention that E. K. G. There's really no indication for an E. K. G. In the evaluation of hypertension that the sensitivity with respect to left ventricular hypertrophy is quite poor. The specificity is not particularly good and the positive predictive value of L. V. H. On an E. K. G. Is is poor. And so um as far as getting you kgs prior to referral that's not not necessary. And I think that part of the the the reason for this lecture is just to stress that the algorithm for management doesn't need a primary cardiac referral and doesn't need an echocardiogram until we've documented that the child has significant persistent elevation in blood pressure. Probably by ambulatory blood pressure monitoring. Next slide. I think that might be it for cardiology indications for an echocardiogram. So obviously if you have concerns for consultation those patients should be referred. We do look for left ventricular hypertrophy um in the setting of severe or chronic disease but that's generally after documentation of persistent elevation and blood pressure by amateur he blood pressure monitoring. As paul said L. B. H. Can help guide anti hypertension therapy. We'd like to see a regression of left ventricular hypertrophy on appropriate medication. And so just the bottom line cardiology evaluation isn't indicated as part of the initial evaluation of the hypertensive child except under rare circumstances. Alright I'm gonna I'm gonna take it back and obviously if you have questions we can discuss those those concepts a little more. So what do I do when I evaluate a hypertensive child? So the first thing is that I confirm the hypertension in multiple visits and measurements. Now I will say that I think enough primary care providers have seen this talk and have been educated themselves that I rarely have a patient who shows up in my office after a single high blood pressure unless it's a very high blood pressure. So stage two hypertension I always you know isn't it? Now they're always sending that right over. But the mildly high blood pressure you know definitely bears repeating. And then like like howard said I usually do an A. B. P. M. Unless there's symptoms. So a patient who has clear symptomatic hypertension or who because the blood pressure is very high and sees howard and already has L. V. H. Those are patients who will treat them with medicine before doing E. V. P. M. And I've got a full slide with kind of a flow flow diagram of this. Um And then the other thing I do is part of my evaluation is I try to determine whether there's been hypertensive end organ damage. So once I established a patient's got high blood pressure typically by a Bpm. Then I look for other things like L. D. H. By referring to howard for an echocardiogram. I look for retinopathy when I can. It's pretty hard to do a good exam one's own self. But I tried and then I look for protein urea and other signs of potentially CKD. And then I try to identify some of the risk factors associated with primary hypertension. Um And then I have some testing that I do to look for secondary hypertension. And then I also work on sort of the modifiable risk factors for cardiovascular disease in all patients. Um So specifically that there's a series of recommended screening tests and at the basic level all patients who have confirmed stage one hypertension should have a your analysis the chemistry panel lipid profile. There's some hypertensive diseases that segregate with lipid diseases. And then interestingly ultrasonography recommendation is is to do it for sure on patients less than six years of age or if there's some some other measured abnormality. I will tell you that I usually get ultrasounds because I have a low false positive rate and I have plenty of obese teenagers who I think have a primary hypertension and turn out to have only one kidney or one small kidney. So I definitely think that um overweight can uncover um remind all real abnormalities. So I generally do do ultrasonography because it's also um it's not a great screen but it is a screen for renal renal artery stenosis and bigger patients. So I tend to do that as well. And these things I've highlighted in yellow are things that can definitely be done. I think before referring a patient even to nephrology it helps it helps us to have this data in hand when the patient arrives. It's very useful for me to already know that they have a normal urine and a normal creating because it changes what I do next. Um And then sort of we have more advanced or sort of not necessary, more advanced, but different studies that we can perform. So usually a thyroid screen is reasonable drug screen depending on the history and age. And many times I actually will screen for sleep abnormalities. And I oftentimes either refer directly to pulmonary for a sleep study or have the PCP do it. Um And then cbC is kind of a here. Nor there. Sometimes they can pick up things that might otherwise be missed. If I already have a needle in an arm, I will typically send a cbc with my BMP. Because actually the main cost of testing there is the lobotomy not the actual blood test itself. Um And then there's some other imaging imaging tests and sort of secondary evaluations that I'll do on the patients who doesn't obviously fit into um primary hypertension. So the patient who is not overweight or the patient who has stage two hypertension that's more severe or a younger patient and you know anybody who's younger than about age 12 will generally get one or more of these tests. So um depending on the history obtained I might actually do a nuclear scan and look for scars with the kidneys sort of patient who has multiple U. T. I. S. In their past and is hypertensive now um Sometimes that can be useful to identify um which medicine would be best especially if if there's if it's a thin patient with not obvious primary hypertension. I get a history of U. T. I. S. I might actually do a D. M. S. A. Scan and look for scars. I think RTR arterial graffiti has a has a role to play for because ultrasounds only about 70% sensitive in the hands of a good technologist for picking up renal renal artery stenosis. So I will routinely do MRHS occasionally CTS but I try to do m ras to avoid radiation and mara is actually aren't perfect. So there's definitely a very small population of patients with very high blood pressure where we're suspicious of something internal that you can't pick. You know a small vessel that's abnormal inside the kidney. They would do they would benefit from invasive arterial graffiti by an interventional radiologist. But that's pretty rare in terms of looking for endocrine secreting tumors. Some of that's based on the level of blood pressure and the history obtains. I've seen a few of these patients and most of them had very high blood pressure and it's sort of a clear history of category I mean like effects but I will send those these for patients who don't have a better explanation for the high blood pressure. And as we talked about echocardiogram it's not necessarily a diagnostic test here but it's certainly a staging in terms of the end organ damage. And sometimes I will use echocardiogram to direct um sort of medication therapy because I definitely have a group of patients who have stage one hypertension feel normal and they don't want to take medicine. Even though I kind of think it's a good idea at this point. And I think echocardiogram at that point can help define whether they actually have end organ damage and how hard to push them to take medicine. And if you look at why I actually treat patients I'm really trying to prevent an organ abnormalities. We already talked about L. V. H. But it's actually pretty prevalent in the hypertensive pediatric patients. It's between 20 and 40%. Um in the higher the stage of blood pressure the more likely they already have L. V. H. So I typically do an echocardiogram when I'm starting medication and diagnosis and then I'll do it every 1 to 2 years and thereafter depending on how severe their hypertension is and how successful I am in controlling their blood pressure. And I use LVMH's indication to intensify drug therapy. So instead of trying to get somebody to 90% off rage if they have L. V. H. I tried to get the 50th percentile for age and as I mentioned um high blood pressure can cause impaired cognitive function. It also can cause headaches. It's not necessarily the only thing that causes a headache but it can certainly contribute to headaches. So if I'm taking care of a 15 year old who's got stage one hypertension it's not really that bad. But they have high headache frequency. You know I might start a medicine earlier on them as opposed to giving them 3 to 6 months to lose weight and do more exercise Because I think that sometimes it can be the the added factor that triggers triggers migraines or contributes to frequency and then a lot of patients will actually report disordered sleep. So one of my screening questions is whether they wake up rested and I you know I ask the ask the parent if they wake up rested. If they can get out of bed to go to school. I asked the family members that the patient snores because I do want to pick up obstructive sleep apnea. And then, you know, ultimately we want to prevent long term cardiovascular morbidity and mortality. And like I said, there's no actual randomized controlled evidence that we we do reduce long term cardiovascular morbidity, morbidity and mortality. But I'm pretty, I'm pretty sure that that's the case. I'm a 50 year old male and I definitely know that I have a much lower chance of having a heart attack or a stroke Or cardiovascular death of my blood pressure is completely normal. And I think that's a cumulative effect over what's happened for the past 30 years for me, um, you know, I think that the fact if you look at the recommendations for how to deal with blood pressure. So for patients with a normal blood pressure, they should do all the things that we should all do. So they should have a healthy diet. They should sleep well. They should have increased physical activity. For patients in the elevated blood pressure range where they don't really qualify for medication use. You know, weight management counseling if they're overweight, increasing physical activity. Diet management can make some some inroads. Not many patients are salt sensitive and I'll come back to that if they're smoking, they should stop, you know, stress actually can play into this. Um, and then for stage one and stage two hypertension even when I've got a patient on medicines, I still continue with weight management and exercise counseling. Um to try to optimize my treatment. If you look at the actual effect of lifestyle changes, there's very good evidence that weight reduction works, but it can be a decent amount of weight. It's usually 15 to £20. So if you drop the B. M. I. Buy 10 percentile for so if they're in the 99th percentile for B. M. I. And they can drop to the 90th percentile that's associated with about a 10 millimeter drop in blood pressure, which is pretty substantial sodium restrictions. Pretty hit and miss. So some patients will be more soft sensitive than others. But in reality it's a relatively mild effect. I think everybody's heard that african, the african american population is likely to be more to be more likely to be salt sensitive than a white population, which is real um exercise. There's not a lot of data for exercise alone, you know, the six millimeter reduction in mercury that I quote here was actually a study where they did weight reduction combined with or without exercise and they got an extra six millimeters drop for the patients that were doing intensive exercise. And we're talking about 4-5 days a week. It's kind of two, plus minutes of sweaty exercise a week, which is a decent amount. But that's what I counsel my patients is like, you know, they want, I want them to sweat for 200 minutes. Um and then for drug treatment I actually try to avoid medications for just quote unquote elevated blood pressure unless they have specific compelling factors. So in chronic kidney disease your chronic kidney disease progresses slower. If you're at the 50th%ile for age rather than the 92nd%ile for age, diabetes, the complications are reduced. If you can have a truly normal blood pressure. Obviously in heart failure patients or patients with L. V. H. We might target a truly 50th%ile blood pressure and then stage one hypertension. Usually we'll start drug therapy. Typically if there is that if it's a primary hypertension patient where they might have the chance of losing weight or doing exercise and changing their blood pressure. That's the treatment of choice and will continue to be the treatment of choice. Even if they're on medicine Stage two Hypertension. We pretty much just start a drug therapy and then work on the other things afterwards. I have about five minutes left. Um I'm gonna do this slide and then I'm gonna move on to sort of the sort of a overview of a workflow for patients with high blood pressure. I've got some antihypertensive slides that will be in the talk. But you know these are the main medicines that I use as a nephrologist. I have diuretics like furosemide or hydrochlorothiazide or clara Caledon I have some direct phase of villagers that really aren't. First choice for outpatients um I use sympathetic blockers like cloNIDine is actually a fairly commonly used by me as a second choice medicine. And then there's um angiotensin blockade with aces and arbs and there's calcium channel blockers like my feta peen and little pain in my card up in um you know, if I look at what I choose for a typical primary hypertensive patients, so the 17 year old is overweight. If it's a male, I pretty much always use an ace inhibitor. So I typically would use an al april or listen to people for females right? There is a clear problem with being pregnant on an ace inhibitor and since it's very hard to guarantee good um pregnancy prevention in adolescent females. Oftentimes we'll use a calcium channel blocker mostly because angiotensin blockade and calcium channel blockade have the lowest side effects. Um They don't really have caused exercise intolerance, they don't really cause sleepiness. Whereas if you put something on a beta blockade. Oftentimes they'll report some exercise intolerance. If you put people on Canadian they'll routinely have a little bit of fatigue. But many times. Typically I will end up on a second medicine that's not either an angiotensin converting enzyme inhibitor or calcium channel blocker. So you know, if I was in a primary care office and I'm looking at treating a patient and load a pine or like Cinderella and Alice. There would be reasonable first choices that's typically what I use and then in the interest of leaving plenty of time for questions. I'm going to go through this workflow, it's super complex, but I'm going to run through it specifically because I want to talk about places to refer. So, you know, the patients sitting in the primary care doctor's office, the blood pressure is taken and they kind of falls into either normal tents in which we don't have to talk about elevated blood pressure, which I did talk about a little bit. So if they have something that they can change, if you know that they're sedentary because they've been doing home school for covid for a year, you know, that's something that a primary care doctor can and will and does treat routinely. I think If there's stage one hypertension, then I think you actively have to bring them back for a couple more visits and double check that it's the blood pressure is really over the 95th%ile. And then a diagnostic work up should begin. And I say that I say should begin. And if you see I've actually got consider referral to nephrology here. I don't think necessarily that a patient has to be sent to a nephrologist who is overweight and adolescent and stage one hypertension because I think the primary care doctor can do the initial work up rule out and Oregon, you know, rule out the obvious target damage of you know protein urea or high creatinine would trigger a referral to me. And then the primary care doctor can and should do the therapeutic lifestyle change intervention and and and start taking care of those that patients hypertension. I think that by the time by the time a patient has tried and failed at losing weight and you're ready to start a medicine, I think that's a reasonable time to refer to nephrology for sure because I would do an ambulatory blood pressure monitor and rule out white coat hypertension at that point before starting a medication. And right now the way to access the ambulatory blood pressure monitoring is to refer to nephrology. I think in a patient where your initial diagnostic work up picks up a cause of secondary hypertension. Maybe you get a high creatinine, maybe in a younger patient you get an ultrasound that shows a single kidney. I think that's the time to refer to nephrology and we can work on figuring out the right medicine for that secondary cause of hypertension. I think for stage two hypertension, those patients should be started on medication and usually that's a good time to refer a patient to nephrology. But many times you have the patient in front of you in your office and their blood pressure is very high and then you know, a phone call directly to the nephrologist and starting them on medication is probably the real first thing to do at that point. And by the time we get down to um putting that patient on medication I think that's another time to involve a nephrologist and do an ambulatory blood pressure monitor. I think it's perfectly reasonable to refer a patient where you've established they have stage one hypertension. I think it's perfectly reasonable to refer them to the nephrology at that point and we can manage the evaluation and the therapeutic lifestyle interventions. But but I'm not sure it's required. And frankly as primary care doctors you'll probably do as good or better job of those interventions as I will. Um I do have access to potentially a little bit more resources. I do have a dietician. You can see patients and follow up on dietary changes. So I think you know if I look at this workflow I've put now in yellow all the things that primary care doctors can manage manage and actually that they do manage. Because notice even in the bottom here for for a stage one hypertension. Once they're on drugs therapy, if I send a patient back to you and they're on a little bit of licensure pearl and you see them in your office and their blood pressure is too high you should feel free to increase the dose of the medication. I think that's definitely you know a good thing um in the same way if they come back to me and I increased the dose I'll send you a letter and let you know what I did. Um So I think that we can co manage these patients outside of the specialist's office and do a lot of work in the primary care office. And frankly probably do it better because I think many times primary care doctors have great relationships with their patients, mm hmm.