Hypertension in adolescents： diagnosis， treatment
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www.thelancet.com/child-adolescent Vol 5 May 2021
357
Review
Lancet Child Adolesc Health 2021;
5: 357–66
Published Online
March 9, 2021
https://doi.org/10.1016/
S2352-4642(20)30344-8
Department of Pediatrics,
University of Alberta,
Edmonton, AB, Canada
(M Khoury MD); Heart Institute,
Cincinnati Children’s Hospital
Medical Center, Cincinnati, OH,
USA (Prof E M Urbina MD)
Correspondence to:
Asst Prof Michael Khoury,
Department of Pediatrics, Stollery
Children’s Hospital, University of
Alberta, Edmonton T6G 2B7, AB,
Canada
khoury1@ualberta.ca
Hypertension in adolescents: diagnosis, treatment,
and implications
Michael Khoury, Elaine M Urbina
Hypertension is a major modifiable cardiovascular disease risk factor and its presence in childhood is associated
with the presence and burden of atherosclerosis. Moreover, hypertension tracks from childhood to adulthood and is
associated with adverse cardiac changes and vascular damage that in turn are associated with premature cardiovascular
disease in adulthood. Therefore, the early identification and eective treatment of hypertension in children and
adolescents is key in the primordial and primary prevention of cardiovascular disease, particularly for at-risk
individuals, such as those with obesity, diabetes, or chronic kidney disease, among others. Unfortunately, hypertension
can be dicult to diagnose in children and adolescents and is as such frequently under-recognised. In this Review,
we provide an overview of hypertension in adolescents, with a focus on its prevalence and diagnosis, the rationale for
early identification and treatment, and current knowledge gaps.
Introduction
Hypertension is a major risk factor for the development
of heart failure and cardiovascular disease, tracks from
childhood to adulthood,
1
and is associated with adverse
cardiac and vascular changes that in turn can be associated
with manifest cardiovascular disease events in adulthood.
2
Thus, the early diagnosis and appropriate treatment of
hypertension in children and adolescents is of paramount
importance for the prevention of premature cardiovascular
disease, particularly for at-risk populations, including
those with obesity, obstructive sleep apnoea, a history of
prematurity, chronic kidney disease, diabetes, specific
forms of congenital heart disease, and children who have
received a solid organ transplant.
3,4
Herein, we provide a
review of hypertension in adolescents, with a focus on
current literature and existing knowledge gaps regarding
diagnostic approaches and the rationale and strategies for
treatment. For a detailed review of the clinical evaluation
and approach to hypertensive paediatric patients, readers
are directed to the American Academy of Pediatrics (AAP)
clinical practice guideline
3
and the European Society of
Hypertension (ESH) guideline.
4
Definition and prevalence of hypertension in
adolescents
There are several challenges inherent to defining hyper-
tension and evaluating its global prevalence. Blood
pressure increases naturally with age and height, and
a specific blood pressure cuto point in childhood or
adolescence that results in increased cardiovascular risk
in adulthood has not been determined.
3
Thus, paediatric
hypertension has traditionally been defined on the basis
of age-specific, sex-specific, and height-specific normative
values. The two most commonly referenced guidelines,
the 2017 AAP guideline
3
and the 2016 ESH guideline,
4
also include static cuto points to define hypertension
for adolescents aged 13 years or older and adolescents
aged 16 years or older, respectively. These cuto points
are the same as the cuto points in these guidelines’
respective adult guideline counterparts, and so promote
seamless transition from care provided in adolescence to
care provided in adulthood. Moreover, static cuto points
facilitate the interpretation of blood pressure values in
children and adolescents, removing the need to refer to
detailed normative value tables. The removal of this
time-consuming process is of critical importance given
the known underdiagnosis of hypertension in clinical
settings.
5
The AAP and ESH guidelines have key dierences
in their hypertension definitions (table). In the AAP
guide line, the normative values did not include data from
individuals who were classified as overweight or obese
due to the known associations between overweight and
obesity and blood pressure. The exclusion of these data
resulted in reference tables with a 1–4 mm Hg decrease in
threshold cuto points for elevated blood pressure and
hypertension compared with the ESH guideline (which
uses previous normative values provided by the US Task
Force
6
). In addition, the static cuto points in the AAP
guideline are lower than the ESH cuto points, and are in
Key messages
• Paediatric hypertension tracks into adulthood and is associated with increased
atherosclerotic burden in childhood, cardiovascular and renal target organ damage,
and manifest cardiovascular disease in adulthood.
• Paediatric hypertension has historically been greatly underdiagnosed due to a number
of important barriers, including difficulties with measurement, the need for repeated
measurements, and the need to refer to detailed tables of normative values.
• Key differences exist between current European and American paediatric hypertension
definitions. These differences have important implications when interpreting
prevalence data on a global scale.
• Ambulatory blood pressure monitoring is an invaluable tool in the confirmation of
paediatric hypertension and is essential in the diagnosis of white coat and masked
hypertension.
• Head-to-head trials and long-term safety evaluations of antihypertensive therapy in
the paediatric population have not yet been done.
• Numerous other key research gaps remain in the study of paediatric hypertension,
including the need for updated cutoff points for ambulatory blood pressure
monitoring, standardised protocols and normative values for home blood pressure
monitoring, and the clinical implications of various paediatric hypertension definitions.
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