Hypertension, Chronic

Description

Diagnostic criteria

General and supportive measures

Medicine treatment

Referral

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ICD-10 code: I10

DESCRIPTION

Primary/Essential hypertension

Occurs most commonly in adolescents.
The patient is often asymptomatic and well.
It is diagnosed by excluding underlying causes of hypertension.
Hypertension is confirmed by sustained high blood pressure measured on 3 follow-up occasions.

Chronic secondary hypertension

All children with incurable forms of persistent secondary hypertension require medicine treatment over and above general and supportive measures.

DIAGNOSTIC CRITERIA

Investigations

• Urine dipstick test.
• Urine MCS.
• Blood urea, calcium, creatinine and electrolytes.
• Chest X-ray, ECG and abdominal ultrasound.

If all tests are negative, start lifestyle intervention.

GENERAL AND SUPPORTIVE MEASURES

• Introduce physical activity, diet management and weight reduction, if obese.
• Advise teenagers against smoking.
• Follow up to monitor blood pressure and educate patient on hypertension:
  • if blood pressure decreases, continue with non-drug management and followup;
  • if BP is increasing progressively, reinvestigate to exclude secondary causes or refer;
  • if BP is stable but persistently > 95th percentile and secondary causes have been excluded, start medicine treatment after failed non-drug management for 6 months.
•  Consider earlier initiation of medicine treatment if positive family history for cardiovascular disease, essential hypertension or diabetes mellitus.

MEDICINE TREATMENT

The goal of treatment in uncomplicated primary hypertension with no target-organ damage is to achieve BP < 95th percentile. For chronic renal disease, diabetes or hypertension with target-organ damage, the target is BP < 90th percentile. Medicine treatment is initiated for Stage 2 hypertension. Consider therapy in Stage 1 hypertension if there is a family history of cardiovascular disease, hypertension or diabetes.

Aim to achieve control of BP over 48–72 hours in symptomatic patients.

For ambulatory patients start at the lowest dose of the preferred medicine and increase the dose until control is achieved.

Once the highest recommended dose is reached or if the patient experiences adverse effects from the medicine, add a second medicine from a different class. For patients with persistent hypertension despite the use of first-line medicine, add a second/third medicine.There is no specific order in which medicine should be added.

There is no evidence of superiority of specific classes of drugs, however, daily dose improves compliance.

ACE inhibitor

ACE-inhibitors are contraindicated in bilateral renal artery stenosis, coarctation of the aorta, aortic stenosis and mitral stenosis.

• Enalapril, oral, 0.04 mg/kg/dose 12 hourly.
  • Maximum dose: 0.3 mg/kg/dose up to 40 mg/day.

OR

For young children less than 10 kg body weight:

• Captopril, oral:
  • Initial dose: 0.1 mg/kg/dose 8 hourly.
  • Maximum dose: 2 mg/kg/dose.

β-blocker

Contraindicated in severe heart failure and asthma.

• Atenolol, oral, 0.5–1 mg/kg/dose once daily.
  • Maximum dose: 2 mg/kg/day.

OR

If child less than 10 kg body weight:

• Propranolol, oral, 0.25–1 mg/kg/dose 8–12 hourly.
  • Maximum dose: 1.5 mg/kg/dose.

Calcium channel blocker

• Amlodipine, oral, 0.1–0.2 mg/kg/dose once daily.
  • Maximum daily dose: 10 mg/day

Diuretic

• Hydrochlorothiazide, oral, 0.5–1 mg/kg/dose once daily.
  • May cause hypokalaemia.

OR

• Furosemide, oral, 0.5–1.5 mg/kg/dose 12–24 hourly.
  • Maximum dose: 6 mg/kg/day. o May cause hypokalaemia.

α-blocker

May be indicated in patients with phaeochromocytoma-associated hypertension.
Consult a specialist and refer for management of phaeochromocytoma-associated hypertension.

REFERRAL

• All children with chronic hypertension for specific diagnosis, planning of treatment and long-term follow-up.
• Patients with phaechromocytoma-associated hypertension.

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Standard Treatment Guidelines And Essential Medicines List For South Africa, Hospital Level, Paediatrics, 2023 Edition

Chapter 4: Cardiovascular System,  4.11 Hypertension In Children,  4.11.2 Hypertension, Chronic