Red Bull beverage and high blood pressure in adolescents. Watch out ¡¡¡¡¡.

redThose who has drunk the energy beverage called Red Bull might be aware that its slogan since 1984 when it was first introduced into the Market is “Red Bull gives you wings”, meaning somehow that by consuming it you are freer.

To start with, briefly, I will tell you something that happened to me at my hospital in Cuba. It was a very exhausting day, and the last patient was a 16-aged male teenager who came in along with his parents which seemed to be very concerned for the lack of control of their child´s blood pressure despite the right measurements ordered to him over the past month when the diagnosis was made.

It was a moderate high blood pressure without known cardiovascular risk factors and all the tests indicated so far were within the normal range. The patient and his parents assured me that the non-pharmacological and pharmacological measurements are being carried out in good terms.

After a long chat where I could not find any insights related with this lack of blood pressure control, at last I asked him the following: Continue reading “Red Bull beverage and high blood pressure in adolescents. Watch out ¡¡¡¡¡.”

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.

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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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The uncertain beginnings and the “why” of this blog.

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If you want to see the spanish translation click here.

Back in 1998. I was doing my Residence in General Medicine in Santa Clara. Villa Clara. Cuba, it was noon and I was set out to see my last patient. He was a 10-year-old boy brought to the clinic by his mother. He looked like a bit overweight and reported intermittent headache for more than two days. Upon taking medical history, the only positive complain was a frontal headache lasting about an hour with no other accompanying symptom.

At physical examination, there was nothing relevant, in my opinion, to point out. I must confess that I was somewhat bewildered about the cause of the headache. However, I explained to the mother that this pain could be the result of multiple causes while I was ordering a routine checkup. The patient was prescribed pain killers and I advised the mother that if something new raised to go the nearest health center. At the stage, the patient was ready to leave the office I came up with the idea to measure his blood pressure (BP) and to my surprise, he had 140 mmHg of systolic blood pressure with 95 mmHg of diastolic blood pressure. Undoubtedly, that was the cause of the persistent headache. I said to myself: “this patient is hypertensive and he is only 11 years old, what should I do?” Continue reading “The uncertain beginnings and the “why” of this blog.”

Cardiovascular risk prediction since early stages of life.

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Nowadays, risk prediction is being focused as a key element in identifying risk factors for cardiovascular disease (CVD) since there are conditions such as arterial hypertension (HTN) for which the former statement can be fully justified,
taking into consideration its increasing prevalence in the early stages of life.
It is thus justifiable to give a wake-up call to the medical community to go to the root of the problem (childhood and adolescence) where the genesis of hypertension occurs. A management strategy should then be adopted to prevent the increased chances of developing hypertension in adulthood. This can also apply to other conditions such as familial hyperlipidemia, diabetes and obesity, involving the broad class of CVD.
The benefit will be far less when addressing these risk factors once damage is already established.
What do you think? We are looking forward to your comments. A “rate” always is highly appreciated.

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.

Please rate this post

Los inciertos comienzos y el “porque” de este blog.

Transcurría el año 1998. Me encontraba cursando la Residencia en Medicina General Integral (MGI) en Santa Clara. Villa Clara. Cuba, cuando sobre las 10 de la mañana me traen al consultorio a un adolescente de 11 años, algo pasado de peso, el cual refería dolor de cabeza intermitente desde hacia más de dos días. Cuando interrogo al paciente y a la madre, que lo acompañaba, lo único positivo al interrogatorio era la cefalea “en toda la cabeza”, con una duración de alrededor de una hora sin otro síntoma acompañante. Al examen físico, no había nada significativo, en mi opinión, a señalar. Confieso que me sentí algo desconcertado en cuanto al diagnóstico.

Le explique a la madre, que ese dolor podría ser el resultado de múltiples causas e indiqué los complementarios de rutina. Le receté al paciente medicación analgésica y le orienté que si el dolor continuaba o aparecía algún otro síntoma debía acudir al Policlínico Principal de Urgencia.

Fue cuando el paciente se iba del consultorio, que se me ocurrió medirle la presión arterial (PA) y para mi sorpresa, presentaba 140 mmHg de presión arterial sistólica (PAS) con 95 mmHg de presión arterial diastólica (PAD). Indudablemente, esa era la causa del dolor de cabeza persistente. Me dije a mi mismo: “este paciente esta hipertenso y tiene solo 11 años, ¿qué hago?”.
Debo confesar que la desesperación de la madre cuando le dije las cifras de PA fue visible, y me dijo: “doctor, ¿qué hacemos?, es solo un niño, ¿le puedo dar un captopril con esa edad?”

Siempre he considerado que la sinceridad es un atributo fundamental en el ser humano y el primer mandamiento del Juramento Hipocrático es: “No hacer  daño”; entonces, le dije a la madre “vengo enseguida”, crucé la calle, fui a un teléfono y llamé al cuerpo de guardia del hospital pediátrico y me dijeron que hacer.

En Cuba, en los 90, hablar de HTA en niños y adolescentes era algo totalmente inusual para la comunidad médica, sobre todo para el nivel de Atención Primario de Salud. Durante la carrera en aquel tiempo sabíamos que la HTA en niños y adolescentes podía existir y era sobre todo “una enfermedad de causa renal”, según nos decían muchos profesores de la época, y realmente la percepción del riesgo sobre la entidad por parte de la mayoría de los médicos era prácticamente nula. Del mismo modo, decirle a un padre o madre que su hijo era hipertenso era un asunto muy difícil, ya que la HTA era considerada por la población en general como una enfermedad de los adultos.

Tras casi dos décadas de este hecho, agradezco ser protagonista del relato anterior, el cual me demostró y alertó sobre mi desconocimiento. Gracias a ello, es que comencé a “explorar” el apasionante mundo del riesgo cardiovascular y la HTA desde la edad pediátrica.

No descarto que hechos parecidos a mi relato puedan todavía ocurrir, aunque en la actualidad parece poco probable si tenemos en cuenta la cantidad de libros, monografías, revistas científicas especializadas y eventos que se realizan sobre HTA. Si, no hay dudas que la comunidad médica ha adquirido más conciencia sobre la problemática de la HTA, Sin embargo, la HTA sigue en sostenido incremento desde edades pediátricas, donde se incluye la adolescencia.

¿Por qué? ¿Qué estamos haciendo mal? ¿Qué perspectivas futuras tenemos? Para dar respuesta a estas interrogantes ha nacido este blog, dirigido al médico general  y de otras especialidades, desde la convicción que podemos mejorar lo que hacemos, pero actuando desde lo autóctono y con inteligencia.

El autor.

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