The Journal of Pediatrics
Volume 152, Issue 4 , Pages 455-456, April 2008

Removing the Mask: The Danger of Hidden Hypertension

  • Elaine M. Urbina, MD (Director)

      Affiliations

    • Corresponding Author InformationReprint requests: Elaine M. Urbina, MD, Director, Preventive Cardiology, Cincinnati Children’s Hospital Medical Center & Department of Pediatrics, University of Cincinnati, 3333 Burnet Ave, MLC 7002, Cincinnati, OH 45229.

Preventive Cardiology, Cincinnati Children’s Hospital Medical Center, Department of Pediatrics, University of Cincinnati, Cincinnati, Ohio

Article Outline

Abbreviations: ABPM, Ambulatory blood pressure monitoring, BP, Blood pressure, HTN, Hypertension, LVH, Left ventricular hypertrophy, LVM, Left ventricular mass

 

Evaluation of blood pressure is now established as an essential feature of a complete well-child visit.1 However, not merely the presence of an abnormal “number,” but also the risk for development of hypertension (HTN)-related target organ damage, should be of concern to pediatricians. Sufficient data are now available demonstrating an increased prevalence of left ventricular hypertrophy (LVH), microalbuminuria, and vascular abnormalities related to HTN in both adults2, 3, 4 and children.5, 6, 7 Prevention of LVH, an independent risk factor for adverse cardiovascular outcomes in adults,8 is becoming even more important as the obesity epidemic is driving an increase in the diagnosis of clinical HTN in youth.9, 10

See related article, p 489

Identification of patients at risk for BP-related cardiac thickening may be improved with the addition of ambulatory blood pressure monitoring (ABPM) to the clinical evaluation. ABPM has been shown to be a more powerful predictor of LVH than resting clinic BP measurments.11, 12 In this issue of The Journal, Maggio et al13 extend these observations by demonstrating the contribution of obesity to abnormalities in ABPM and left ventricular mass (LVM) in prepubertal children.

Not surprisingly, measures of adiposity and ABPM were more strongly correlated with LVM compared with lean body mass and resting BP. However, an unexpected but important additional finding was that 26.2% of the study subjects exhibited masked HTN, defined as elevated ABPM in the setting of normal clinic BP. This is a substantially higher prevalence than reported previously in children.12, 14, 15, 16 Although the precise prevalence of masked HTN is not known, in adults it has been estimated from 8% to 38%, with the wide range attributed to heterogeneity in study designs.17

Regardless of the prevalence of masked HTN, the real question is whether masked HTN causes target organ damage. A study of more than 3000 adults found that the subjects with masked HTN had a higher prevalence of LVH than normotensive subjects, although those subjects with sustained HTN were the most likely to demonstrate LVH (prevalence of LVH: normotensive, 4%; masked HTN, 14%; HTN, 26%).18 Furthermore, subjects with masked HTN appear at increased risk of developing sustained HTN requiring medication.19 Although little data are available in youth relating masked HTN to future sustained HTN, children with masked HTN are 2.5 times more likely to report a history of parental HTN14 and children with persistent masked HTN have been found to have greater LVM16 and higher prevalence of LVH12 compared with normotensive controls.

Taken together, these data suggest that masked HTN is not a benign process, but instead carries a prognosis similar to that of sustained HTN. It may be that masked HTN is a peculiar phenotypic variant of HTN possibly associated with heightened BP variability17 that may be related to alterations in autonomic tone.20 Unfortunately, there are no clear criteria for identifying patients with masked HTN during office visits. Adult studies suggest that these patients are more often males with high central adiposity.17 However, pediatric studies have been equivocal, with 1 study finding higher body mass index in children with “white coat” HTN (high clinic blood pressure but normal ABPM)16 but another finding more obesity in subjects with masked HTN.14 The findings of Maggio et al support the importance of obesity as a contributing factor, because none of the lean subjects had masked HTN.

Less controversial is the conclusion that masked HTN is more prevalent in patients with stage 1 HTN than in those with more severe HTN.21 Consequently, pediatric HTN experts suggest using ABPM in the following circumstances: (1) a child with resting office BP levels consistently in the prehypertensive range, especially if the child has other cardiovascular risk factors, such as obesity or a positive family history of HTN; (2) if multiple care providers report HTN yet resting BP levels are normal in the clinic setting; or (3) if there is evidence of target organ damage.22 Unfortunately, insufficient data are available to support a more evidence-based approach. Clearly, more research is needed regarding the mechanisms and potential predictors of masked HTN. It is time to remove the mask and recognize that hidden HTN indeed carries dangers.

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References 

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PII: S0022-3476(07)01174-2

doi:10.1016/j.jpeds.2007.12.045

Refers to article:

  • Associations among Obesity, Blood Pressure, and Left Ventricular Mass , 21 December 2007

    Albane B.R. Maggio, Yacine Aggoun, Laetitia M. Marchand, Xavier E. Martin, François Herrmann, Maurice Beghetti, Nathalie J. Farpour-Lambert
    The Journal of Pediatrics April 2008 (Vol. 152, Issue 4, Pages 489-493)

The Journal of Pediatrics
Volume 152, Issue 4 , Pages 455-456, April 2008

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