Treatment for high blood pressure in African-Americans needs to start sooner and be more aggressive, according to a consensus statement by the International Society on Hypertension in Blacks (ISHIB) that is published in Hypertension: Journal of the American Heart Association.

"Evidence from several recently completed studies converged to convince our committee that we were waiting a little bit too long to start treating hypertension in African-Americans," said lead author John M. Flack, MD, of the Department of Internal Medicine at Wayne State University in Detroit, MI, in an online report of the study.

The update to the ISHIB's 2003 consensus statement—for which Flack and colleagues reviewed hypertension and cardiovascular disease prevention and treatment guidelines, pharmacological hypertension clinical end point trials, and blood pressure-lowering trials in African-Americans—includes two major recommendations:

* The thresholds at which treatment is initiated in African-American patients should be lowered.
* Physicians should move quickly from single-drug therapy to multi-drug therapy to keep a patient's blood pressure comfortably below the thresholds

"We believe that these recommendations will lead to better blood pressure control, and a better outlook for African-Americans with high blood pressure," Flack said.

Currently, blood pressure below 120/80 is considered normal for healthy adults. However, the ISHIB is proposing that physicians recommend lifestyle changes to lower blood pressure in otherwise healthy African-Americans with blood pressure at or above 115/75. Those changes include reduced dietary sodium and increased potassium from eating more fruits and vegetables, as well as losing weight, getting regular aerobic exercise, and consuming alcohol in moderation, Flack said.

"Epidemiological data shows that 115/75 is the critical blood pressure number for adults, and every time that figure goes up by 20/10 the risk of cardiovascular disease essentially doubles. We think it makes perfect sense to start lifestyle changes at that lower threshold," he said, pointing out that from age 50 and up, Americans have a 90% chance of developing hypertension.

The ISHIB also recommends that physicians tighten the primary prevention threshold to 135/80 for African-Americans, and begin secondary prevention when blood pressure is at or above 130/80, according to the statement, which provides step-by-step guidance on the best second, third, and fourth drugs to add based on individual patient characteristics, along with charts with alternate multi-drug combinations so physicians have several options for keeping patients' blood pressure under targets.

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As the chair of pediatrics at the Mount Sinai School of Medicine, Dr. Lisa Satlin is a kidney specialist who sees patients from birth to age 21. Since starting her career as a pediatric nephrologist in 1982, she has treated children and their families for problems like hypertension.

Who’s at risk

Hypertension, or high blood pressure, is an extremely common health risk familiar to any American over the age of 50. But it can be present in childhood and adolescence as well.

Blood pressure measurements are reported as two numbers: systolic blood pressure (blood pressure when the heart contracts) over diastolic blood pressure (blood pressure when the heart is relaxed). "In a pediatric patient, hypertension is defined as at least three readings showing a blood pressure level above the 95% percentile" higher than 95 out of 100 children of the same age, gender, and height, says Satlin.

"Having a blood pressure below 90% is normal, and between 90% and 95% is considered prehypertension." According to national guidelines, blood pressure measurements should be a routine in office visits for children over age 3.

"For children, we almost never make a diagnosis of hypertension based on a single casual blood pressure measurement, unless it is extremely high. Instead, this diagnosis usually is made only if the blood pressure is above 95% on three separate occasions, because many situations can lead to a single or temporary elevated blood pressure," says Satlin.

"Children may be in pain from an illness or get anxious or frightened going into the doctor’s office, and the blood pressure might be normal at other times."

Checking the blood pressure at home when the child is more relaxed can help determine whether a child has true hypertension or whether it is only high when seeing a doctor — "White Coat Hypertension." Satlin’s team often has a child use a take-home, wearable, "mini"- blood pressure machine to check the pressure during an entire day.

There are two main types of hypertension. "Primary, or essential, hypertension has no identifiable cause and is most common in children beyond puberty," says Satlin. "Often these children have a family history of high blood pressure and are overweight or obese."

"Secondary hypertension is due to an underlying cause like kidney, hormonal or heart disease, or medication," says Satlin. "This is more common in younger children, under the age of 5-10 years."

Elevated blood pressure in secondary hypertension cases tends to be more severe and consistent than in primary hypertension and may require a variety of special diagnostic tests for identification.

Risk factors for pediatric hypertension include obesity and family history. Up to 80% of children with primary hypertension have a family history of the disease.

Gender and ethnicity also can be risk factors. "We have learned from studies of children in their second decade of life that boys are twice as likely to have prehypertension as girls," says Satlin. "Blood pressures tend to be higher in Hispanic and African-American children, compared to Caucasian children."

Signs and symptoms

One of the difficulties of treating childhood hypertension is that it is frequently a silent disease. "Hypertension typically does not present with any major symptoms in children, except perhaps headache," says Satlin. "This is a big problem, because hypertension that begins in childhood and goes untreated can persist into adulthood, increasing the risk of heart disease, stroke and kidney disease." Because pediatric hypertension is often asymptomatic, it’s usually diagnosed through routine screening.

If pediatric hypertension is severe, it can lead to a variety of symptoms and in rare cases cause seizures, kidney disease, eye disease or heart failure.

Traditional treatment

When a child is diagnosed with hypertension, it is important to determine if there is an underlying cause. "The evaluation usually includes a full history and physical exam, blood pressure measurements in both arms and legs, blood and urine tests, and frequently ultrasounds of the heart and kidneys," says Satlin.

In children, secondary hypertension is often the result of kidney, heart or
hormonal conditions. "Depending on what is found, besides a nephrologist, a child might see a pediatric cardiologist or endocrinologist," says Satlin.

For children with primary prehypertension or hypertension, lifestyle modification can be enough to reduce blood pressure. "The key steps are a healthy diet with low salt intake and more fruits and vegetables, avoiding obesity and getting regular exercise," says Satlin. "Children with more severe hypertension also need to do these things, but their doctor might also need to treat the blood pressure with medications until the blood pressure improves or if it does not improve enough."

Children with an identifiable cause may need a specific treatment. For instance, children with the kidney disease called nephrotic syndrome, which can cause hypertension, often respond well to temporary use of diuretics or oral corticosteroids. "If we can treat the underlying disease, the blood pressure will usually return to normal" says Satlin, "and since the long-term consequences of hypertension can be very significant, it’s important to identify and treat this early in life."

Research breakthroughs

Scientists have vastly enhanced our understanding of the causes of hypertension in children as well as adults by studying patients with extreme elevations of blood pressure or a family history.

"It has become clear that high blood pressure is the end product of an interaction of genes and environment," says Satlin. "Thanks to major research breakthroughs, we’ve finally uncovered the genetic basis for a number of causes of hypertension."

Questions for your doctor

A good way for some parents to start a conversation with their child’s pediatrician is, "I have high blood pressure. Is my child at risk?"

Parents also may want to ask specifically about their child’s blood pressure percentile. If your child is at risk or already has higher-than-normal blood pressure, ask, "What can I do to lower my child’s blood pressure?" There is a lot that doctors and parents can do to prevent or treat childhood hypertension, so get prepared to ask the right questions.

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