Top Things to Know: Ambulatory Blood Pressure Monitoring in Children and Adolescents
Published: May 23, 2022
Prepared by Barbara Entl, MD, Science and Medicine Advisor
- This statement presents a succinct review of new evidence, guidance on optimal application of ambulatory blood pressure monitoring (ABPM) in the clinical setting, and an updated classification scheme for the interpretation of ambulatory blood pressure monitoring in children and adolescents.
- ABPM is used to confirm whether a patient with high office blood pressure (BP) truly has hypertension (HTN). Ambulatory BP (ABP) – i.e., multiple BP readings obtained over an entire 24-hour period – is better able to distinguish true BP status; and compare to clinic BP is a better predictor of target organ damage in adults and is a better target for therapeutic goals in high-risk pediatric populations.
- There has been significant expansion of the evidence base for use of ABPM in the pediatric population, including new data linking ambulatory blood pressure levels with development of blood pressure-related target organ damage.
- Individuals with persistently elevated BP during childhood and adulthood have a greater relative risk for higher carotid intima-media thickness (CIMT) and pulse wave velocity as adults than those with normal BP. Importantly, adults with a history of elevated childhood BP that later normalizes do not have a significant increase in CIMT as adults, supporting the importance of treating pediatric HTN to decrease future risk.
- The major advantages of ABPM are to mitigate spuriously elevated BP from measurement anxiety (i.e., white coat HTN), and to assess circadian BP patterns. Classification of patients into different BP phenotypes helps to stratify risk and guide therapy.
- When clinic BP and ABP are both normal, the patient is considered normotensive. When the opposite is true, the patient has ambulatory HTN. When the BP as measured by the two techniques differ, the patient has either white coat or masked HTN. White coat HTN is diagnosed when the clinic BP is in the hypertensive range, but ABP is normal. Masked HTN is diagnosed when the clinic BP is normal, but ABP is elevated.
- Some children with medical diagnoses, such as kidney disease, often thought to have a more benign prognosis have normal office BP but significant abnormalities noted on ABPM.
- ABPM is designed to evaluate BP across many functional dimensions, including position (supine, sitting, standing), level of physical activity, sleep, and stress, to provide a more complete view of an individual’s BP during normal daily activities.
- When establishing normal ABP values in pediatric patients, various characteristics that may impact systolic and diastolic BP should be considered. Sex is a predictor of higher ABP, with male sex associated with a greater prevalence of high ABP. Overweight and obesity status are also associated with increased ABP.
- This statement provides updated guidance on the application and interpretation of ABPM in pediatric patients; specifically, it addresses: 1) indications for routine performance of ABPM; 2) type of ABPM device suitable for use in children; 3) standard approach to obtaining ABP studies; 4) monitoring criteria; and 5) methods for performing ABPM.
Citation
Flynn JT, Urbina EM, Brady TM, Baker-Smith C, Daniels SR, Hayman LL, Mitsnefes M, Tran A, Zachariah JP; on behalf of the Atherosclerosis, Hypertension, and Obesity in the Young Committee of the American Heart Association Council on Lifelong Congenital Heart Disease and Heart Health in the Young; Council on Cardiovascular Radiology and Intervention; Council on Epidemiology and Prevention; Council on Hypertension; and Council on Lifestyle and Cardiometabolic Health. Ambulatory blood pressure monitoring in children and adolescents: 2022 update: a scientific statement from the American Heart Association [published online ahead of print May 23, 2022]. Hypertension. 2022;79:e•••–e•••. doi: 10.1161/HYP.0000000000000215