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Acute Hypertension and Hypertensive Crisis in Children

Dr A. George Koshy, Govt Medical College ,Thiruvananthapuram

Introduction:
Pediatric Hypertension is defined as systolic or diastolic blood pressure (BP)
exceeding the 95th percentile for gender, age and height. The risk of
hypertension increases with the Body Mass Index (BMI). Approximately 30% of
children with BMI greater than 95th percentile have hypertension. The
spectrum of hypertension that presents to the Emergency Department ranges
from mild and asymptomatic to a true hypertensive emergency.
A definition of hypertension ideally is based on a threshold level of blood
pressure that divides those at risk for adverse outcomes from those who have
no increased risk. The important conclusions of the fourth report on the
diagnosis, evaluation and treatment of high blood pressure in children and
adolescents of The National High Blood Pressure Education Program Working
Group on High Blood Pressure in Children and Adolescents. (Pediatrics 2004;
114: 555-576) are as follows:
Hypertension is defined as average systolic and /or diastolic blood pressure
>95th percentile for gender, age and height on > 3 occasions.
Pre hypertension is defined as average systolic or diastolic pressures between
90- 95th percentile. These children should be observed carefully and evaluated
if risk factors like obesity are present; tracking data suggest that this subgroup
is more likely to develop overt hypertension over time than normotensive
children.
Adolescents with blood pressure levels more than 120/80 mm Hg should be
considered pre hypertensive.
A patient with blood pressure levels >95th percentile in a physicians office
or clinic, who is normotensive outside a clinical setting, has white-coat
hypertension. Ambulatory blood pressure monitoring is helpful for
confirmation.
If the blood pressure is >95th percentile, it should be staged. If stage 1 (95th
percentile to the 99th percentile plus 5 mm Hg), measurements should be
repeated on 2 more occasions. If hypertension is confirmed, evaluation should
proceed. If blood pressure is stage 2 (>99th percentile plus 5 mm Hg), prompt
referral should be made for evaluation and therapy. If the patient is
symptomatic, immediate referral and treatment are indicated.
All children should have yearly blood pressure evaluation beyond 3 years of
age. There is an increased risk of hypertension in children with history of
hypertension in family members, those who are obese, had IUGR or have
urinary infections and renal scars.
Evaluation:
When confronted with newly diagnosed hypertension in the child, the
physician should consider three important issues: 1) Is the hypertension
primary or secondary? 2) Is there evidence of target organ damage? and 3) Are
there associated risk factors that would worsen the prognosis if the
hypertension were not treated immediately?.
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A brief, but careful history and physical examination should be performed.

Some key features in the history would be the duration and onset of
hypertension, degree of compliance with any drug therapy, and possibility of
renal disease (any history of urinary tract infections, hematuria, edema, or
umbilical artery catheterization). One should also enquire for any history of
jo i n t pain, palpitations, weight loss, flushing, weakness, drug ingestion,
headaches, nausea, vomiting and a family history of renal disease or
hypertension.
After several determinations of the blood pressure, a focused physical
examination should be performed immediately. One should check for any
evidence of neurologic dysfunction and left ventricular dysfunction / cardiac
failure. Fundoscopy should be performed looking for hemorrhage, infarcts or
papilledema. The peripheral pulses should be palpated carefully. Weak and
delayed femorals suggest coarctation of aorta. Any discrepancy in the upper
and lower extremity BP measurements should be noted. The presence of an
abdominal bruit suggests renovascular hypertension.
An improper cuff size can significantly record a wrong blood pressure. By
convention, an appropriate cuff size is a cuff with an inflatable bladder width
that is at least 40% of the arm circumference at a point midway between the
olecranon and the acromion. For such a cuff to be optimal for an arm, the cuff
bladder length should cover 80% to 100% of the circumference of the arm.
Blood pressure measurements are overestimated to a greater degree with a cuff
that is too small than they are underestimated by a cuff that is too large. If a
cuff is too small, the next largest cuff should be used, even if it appears large
Etiology
Hypertension is usually described as primary (essential) or secondary due to a
definable cause. The secondary cause will be found more likely when the
patient is younger and hypertension is more severe. Most acute hypertension
in childhood is due to glomerulonephritis. Chronic hypertension is commonly
associated with renal parenchymal disease and only a small proportion have
renovascular hypertension, pheochromocytoma or coarctation of the aorta .
Late in the first decade and into the second decade of life, primary
hypertension begins to predominate. Coarctation of the aorta accounts for one
third cases of hypertension in neonatal period and infancy. Renovascular
causes are amongst the curable forms of hypertension.
Common causes of Hypertension in different age groups

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Hypertensive Crisis in Children.

Hypertensive emergency is distinguished from hypertensive urgency by the
presence of acute end-organ dysfunction discovered in the history, physical
examination or investigations, and not by the height of the BP.
Hypertensive Emergency
Hypertension associated with evidence of end-organ dysfunction constitutes
hypertensive emergency.
Malignant hypertension is characterized by marked elevations in systolic
and/or diastolic BP (e.g., 160 mm Hg or higher systolic/ 105 mm Hg or higher
diastolic for those less than 10 years of age; 170 mm Hg or higher systolic/ 110
mm Hg or higher diastolic for those more than 10 years of age) and is often
associated with spasm and tortuosity of the retinal arteries, papilledema, and
hemorrhages and exudates on fundoscopic examination.
Hypertensive encephalopathy(an example of hypertensive emergency) is seen
often in malignant hypertension and consists of a combination of symptoms
and signs that often vary from patient to patient (nausea, vomiting, headaches,
altered mental status, visual disturbances, seizures, stroke).
Patients with hypertensive emergency/ malignant hypertension usually are
admitted to an intensive care unit for continuous cardiac monitoring and
frequent assessment of neurologic status and urine output. An IV line is started
for fluids and medications. Patients typically have altered blood pressure
autoregulation, and overzealous reduction of blood pressure to reference range
levels may result in organ hypoperfusion. The initial goal of therapy is to
reduce the mean arterial pressure by approximately 25% over the first 8 to 12
hours. An intra- arterial line is helpful for continuous titration of blood
pressure. Sodium and volume depletion may be severe, and volume expansion
w ith isotonic sodium chloride must be considered. Urine output should be
monitored from the outset. Any serious complications must be recognized and
managed along with the treatment for hypertension. Anti convulsants should
be administered to a child with seizure.

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A number of medications are available for hypertensive emergencies. The

choice of drugs depend on several factors such as the clinical condition of the
patient, the presumed cause, whether there is a change in cardiac output or
total peripheral resistance and whether there is end-organ involvement. It is
important to select an agent with a rapid and predictable onset of action and to
monitor the blood pressure carefully as is being reduced. Because hypertensive
encephalopathy is a possible complication of hypertensive emergencies,
antihypertensive agents with minimal CNS side effects should be chosen to
avoid confusion between symptoms of disease and adverse effects of the drug.
Centrally acting drugs like Alpha Methyl Dopa and Clonidine are usually not
preferred because of the CNS side effects. Intravenous administration is
generally preferred in order to carefully titrate the fall in blood pressure. Too
rapid reduction in blood pressure can interfere with adequate organ perfusion
and hence a stepwise reduction should be planned. Hypertensive emergencies
should be treated by an intravenous antihypertensive that can produce a
controlled reduction in the blood pressure, aiming to decrease the pressure by
25% over the first 8 hours after presentation and then gradually normalizing
the BP over the next 48 hours. Each of the most commonly used medications
offers distinct advantages and disadvantages and each clinical situation
requires its own mode of management. However, some general guidelines are
usually helpful.
Sodium nitroprusside is an arteriolar and venous vasodilator that is invariably
effective. BP decreases with little change in cardiac output, and reflex
tachycardia is not usually an important problem. It is administered by constant
infusion. Its effect is immediate, and lasts only as long as the infusion is
continued. Its use requires intensive observation and therefore may not be
indicated in the ED. Other disadvantages are that the drug requires 10 minutes
to prepare and is photosensitive, and there is a potential for cyanide
accumulation. The infusion bottle and tubing should be covered and protected
from light.
Diazoxide is an arteriolar vasodilator, has little effect on capacitance vessels
and has no direct cardiac effect. It is very potent with a rapid onset, and the
effect can be dramatic. It may provide a long duration of BP control (8 to 12
hours). It causes marked salt and water retention, and in patients with edema,
it should be followed with a diuretic agent. It also causes reflex tachycardia and
hyperglycemia.
Hydralazine is an arteriolar vasodilator that is not as potent as diazoxide or
nitroprusside. However, it has an excellent safety profile. The half-life is short
(3 to7 hours), necessitating frequent dosing. Reflex tachycardia often occurs,
and may require the introduction of a beta blocker.
Labetalol is an alpha 1 and nonselective -adrenergic blocker. Dosing is
independent of renal function. It has been reported to be effective in the
management of severe hypertension that results from pheochromocytoma and
coarctation of the aorta and is a reasonable alternative in the treatment
of hypertensive crises in patients with end stage renal disease.
Nifedipine, a calcium channel blocker, reduces peripheral vascular resistance
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and does not affect cardiac output. It can be administered sublingually, but
biting the capsule and swallowing its contents achieves measurable blood
levels more rapidly than the sublingual route. Its use depends on the patients
state of consciousness. It is contraindicated in the presence of intracerebral
bleeding.
Nicardipine, another calcium channel blocker is an excellent drug for use in
emergencies, since it can be administered as an infusion that can be easily
prepared and titrated.
Phentolamine is a pure -adrenergic blocker used almost exclusively for the
treatment of catecholamine crisis (as seen in patients with pheochromocytoma
or ingestion of sympathomimetic agents such as cocaine). The effect is
immediate. There is a high risk of hypotension after
the primary lesion (e.g. pheochromocytoma) is excised, and care should be
exercised and the surgeons should be alerted to this possibility.
Most children with hypertensive crisis have chronic or acute renal disease. In
these patients, management of blood pressure also requires careful attention to
fluid balance and diuresis. Intravenous Frusemide is usually effective even
though glomerular filtration may be impaired.
Hypertensive Urgency:
A hypertensive urgency is defined as severe hypertension without evidence of
end-organ involvement. Patients with known hypertension who present in an
urgent hypertensive crisis may not require hospitalization if the therapy in the
emergency department is successful, and adequate follow-up can be ensured.
Often, oral antihypertensive agents are sufficient, although there are occasions
when parenteral therapy is indicated.

Other Drug Therapy:

Calcium channel blockers like amlodipine, felodipine, isradipine, intravenous
nicardipine and nitrendipine have been studied in children. They are well
tolerated, effective and safe. Enalapril, an angiotensin converting enzyme
inhibitor is a commonly used pediatric antihypertensive agent. The maximum
serum concentration occurs approximately 1 hour after administration, and
that of the metabolite, enalaprilat peaks between 4 and 6 hours after the first
dose, and 3 and 4 hours after multiple doses. Intravenous Enalaprilat is
available for management of hypertensive crisis but only limited data are
available in children. Captopril has shorter duration of action and can be given
sublingually for faster action. Limited data are available on the efficacy and
safety of Angiotensin Receptor Blockers like Losartan.
Conclusions:
Most children who present with hypertensive crisis have secondary
hypertension. Renal parenchymal disease is the commonest underlying
etiological factor .With the increase in the prevalence of obesity in children,
the incidence of hypertension among children is also on rise. Hypertensive
encephalopathy and acute left ventricular failure and are frequent modes of
presentation. Intracranial hemorrhage and renal failure are less frequent and
often overlooked modes of clinical presentation. Hypertensive emergencies in
symptomatic children should be treated without delay to avoid further damage
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to vital organs. BP should be brought down by no more than 25% within the
first 8 hours. Asymptomatic children with hypertensive urgency require less
aggressive approach and blood pressure can be brought down more gradually.
Once the acute phase has been tackled, extensive work up is required to
identify the underlying etiological factor. One should not forget that many
cases of secondary hypertension are eminently curable.
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