Left Ventricular Hypertrophy in Pediatric Hypertension. When damage is at sight. 

img_2190-2This is an excerpt of a publication of mine sent to a peer review journal by me to be published.

Since the publication in 1977 of the First American Task Force for the diagnosis, evaluation and treatment of high blood pressure (BP) in children and adolescents, updated in 1987, 1996 and more comprehensibly in 2004 (as Fourth Report) has been stressed out the importance of HTN related organ damage being, in this context, LVH a paradigm. Likewise, the latest European Society of HTN guidelines for the management of HTN in children and adolescents published in 2016 has highlighted the assessment of subclinical organ damage as an intermediate stage in the continuum of vascular disease as well, targeting predominantly LVH (2) Woroniecki and colleagues’ article (1) exposed the somehow puzzling issue when it comes to defining LVH in pediatric population on the basis of the existence of diverse criteria with pros and cons. These arguments are not new and have made very difficult over years to ascertain a reliable standardization of LVH definition at the early stages of life in children and adolescents suffering from HTN. Although, the authors of the article do not mention the connection of prehypertension with LVH, this association exists (3) and can trouble even more the things to decipher a definition of LVH for prehypertensive patients since the long-established studies that have reported the different formulas to define LVH in children and adolescents have been conducted on hypertensive individuals (2)

Unquestionably, the search for a definition of LVH in the context we are commenting here is complex with multiple answer and a solution far to be beheld to date; even though, the future might unfold some results especially with the American Heart Association’s SHIP-AHOY study, intended to evaluate blood pressure thresholds, ambulatory blood pressure, and metabolic phenotype that predicts hypertensive target organ damage. In addition, it is planned an update of the Fourth Report that would help with the necessary consensus on LVH (3)

In the meantime, according to our opinion, the appraisal of HTN induced LVH must get ahead of the simple quantification of left ventricular mass by focusing on the early diastolic alterations as regional mitral Ea, Aa and the E/Ea ratio by Tissue doppler imaging that precede the onset of LVH since this hypertrophy can be observed with the use of steroid, obesity, athletes, growth hormone use, etc., therefore can be reversible (4)

Those topics are not mentioned in Woroniecki and colleagues’ article (1) and might be key to increase consistency to the assessment of the HTN related cardiac organ damage in children and adolescents.

In the PESESCAD-HTA study we found diastolic abnormalities even in prehypertensive adolescents without LVH which makes it clear the relevance of targeting diastolic alterations on individuals prone to be hypertensive likely in the short term (5)

In short, the issue of LVH in pediatric populations remains challenging. The solution will lie on in undertaking large multinational studies in an attempt to find out a more reliable and matching approach to determine the cardiac organ damage that HTN entails in children and adolescents.

References

1- Woroniecki, Robert P, Andrew Kahnauth, Laurie E Panesar, and Katarina Supe-Markovina Left Ventricular Hypertrophy in Pediatric Hypertension: A Mini Review. Front. Pediatr (2017) 5:101.doi:10.3389/fped.2017.00101

2- Lurbe E, Agabiti-Rosei E, Cruickshank J, Dominiczak A, Erdine S, Hirth A, et al. 2016 European Society of Hypertension guidelines for the management of high blood pressure in children and adolescents. J Am Soc Hypert (2016); vol: 34 (10) pp: 1887-1920.

3- Sethna CB, Leisman DE. Left Ventricular Hypertrophy in Children with Hypertension: in Search of a Definition. Curr Hypertens Rep (2016) Aug;18(8):65. doi: 10.1007/s11906-016-0672-3.

4- Agu NC, McNiece Redwine K, Bell C, Garcia KM, Martin DS, Poffenbarger TS, et al. Detection of early diastolic alterations by tissue Doppler imaging in untreated childhood-onset essential hypertension. J Am Soc Hypertens (2014);8(5):303–11. Available from: http://www.ncbi.nlm.nih.gov/pubmed/24685005.

5- Perez Fernandez GA, Grau Avalo R. Hypertensive heart disease in adolescence. preliminary results of the PESESCAD-HTA study. Hipertens y Riesgo Vasc (2012) ;29(3):75–85.

Thanks.

Note. This editorial has been written by Dr. Guillermo Alberto Perez Fernandez, author of this blog, and reflects his personal opinion about the topic.

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