Pediatric hypertension as an early manifestation of cardiovascular disease in children

In adults, cardiovascular events associated with arterial hypertension (AH) have a major impact on morbidity and mortality. In light of recent findings, AH in children has been interpreted as early cardiovascular disease (CVD), while exposure to CV risk factors in children proves to be a predictor of subclinical CVD in adults. The American College of Cardiology/American Heart Association has recently updated the classifications for measuring blood pressure (BP) in adults and children. Primary AH in children is generally asymptomatic, and it is associated with a family history of AH, overweight/obesity, and normal morphofunctional characteristics of the urinary system. The younger the child and the higher the BP, the greater the likelihood of secondary AH. The investigation into the etiology of AH begins with a detailed anamnesis, which should include clinical information and details on the use of medication, smoking, and alcohol consumption from the perinatal period to the time of consultation. Modifying risk factors by reducing weight, decreasing alcohol consumption and increasing vegetable intake from childhood to adulthood has been associated with the resolution of AH in the childhood-adulthood transition, and with the reversal of cardiometabolic adverse effects in non-obese adult individuals. Pharmacological therapy should be initiated in cases of symptomatic AH, AH secondary to chronic kidney disease or diabetes mellitus, presence of target organ lesions, stage 2 AH with no modifiable cause and resistant AH unresponsive to lifestyle changes.


Descritores:
Hipertensão; Criança; Anormalidades Cardiovasculares.In adults, cardiovascular events associated with arterial hypertension (AH) have a major impact on morbidity and mortality.In light of recent findings, AH in children has been interpreted as early cardiovascular disease (CVD), while exposure to CV risk factors in children proves to be a predictor of subclinical CVD in adults.The American College of Cardiology/American Heart Association has recently updated the classifications for measuring blood pressure (BP) in adults and children.Primary AH in children is generally asymptomatic, and it is associated with a family history of AH, overweight/obesity, and normal morphofunctional characteristics of the urinary system.The younger the child and the higher the BP, the greater the likelihood of secondary AH.The investigation into the etiology of AH begins with a detailed anamnesis, which should include clinical information and details on the use of medication, smoking, and alcohol consumption from the perinatal period to the time of consultation.Modifying risk factors by reducing weight, decreasing alcohol consumption and increasing vegetable intake from childhood to adulthood has been associated with the resolution of AH in the childhoodadulthood transition, and with the reversal of cardiometabolic adverse effects in non-obese adult individuals.Pharmacological therapy should be initiated in cases of symptomatic AH, AH secondary to chronic kidney disease or diabetes mellitus, presence of target organ lesions, stage 2 AH with no modifiable cause and resistant AH unresponsive to lifestyle changes.

IntRoductIon
The causes of death and disability can be grouped into three broad categories: communicable diseases, maternal, perinatal and nutritional conditions, and non-communicable diseases.Monitoring mortality associated with these three conditions should guide health systems' actions, promoting responses across multiple sectors and strengthening the various levels of health prevention.The result of this integrated action translates into a reduction in preventable deaths and agility in the event of changes in epidemiological circumstances 1 .
The latest World Health Organization (WHO) report, covering the period 2000-2019 1 , indicates that non-communicable diseases have become more prominent, while communicable diseases are declining.Ischemic heart disease emerged as the leading cause of death in the period 2000-2019, accounting for the largest increase in deaths -more than 2 million -in the past two decades 1 .
An estimated 17.9 million people died from cardiovascular disease (CVD) in 2019 1 , representing 32% of all deaths 1 .Of these deaths, 85% were due to ischemic heart disease and stroke.More than threequarters of CVD deaths occur in low-and middleincome countries 1 .
Eight risk factors (alcohol use, tobacco use, high blood pressure, overweight/obesity, hypercholesterolemia, diabetes mellitus, a diet low in fruit and vegetables and high in salt, and a sedentary lifestyle) are responsible for 61% of cardiovascular deaths 2 .The combination of these factors accounts for more than three-quarters of cases of ischemic heart disease, which is the primary cause of death worldwide 2 .Additionally, over 84% of the total global burden of diseases associated with these factors occurs in low-and middle-income countries 2 .Table 1 presents the American Heart Association recommendations for optimal cardiovascular health in adults and children.
The development of arterial hypertension (AH), diabetes mellitus, dyslipidemia, overweight, and obesity is the clinical translation of continuous exposure to CV risk factors 1 .Conversely, there is evidence of a reduction in the risk of CVD following smoking cessation, reduced salt intake in the diet, increased consumption of fruit and vegetables, regular physical activity, and prevention of harmful alcohol consumption 2 .Health policies should promote environments conducive to making healthy choices accessible and available in order to motivate individuals to adopt and maintain healthy behaviors 1 .In Brazil, according to WHO data in 2019, ischemic heart disease is also the leading cause of death in both sexes, as shown in Table 2 3 .
Children may develop hypertension due to primary or secondary causes 4,5 .Risk factors for pediatric primary hypertension are the same as those previously mentioned for adults, including adverse perinatal events, family history of hypertension, minority race/ethnicity, inadequate sleep duration (≤8 hours/ night) and quality, in addition to social determinants such as poverty and multiple adverse childhood experiences 4,5 .The association between maternal cardiovascular health during pregnancy and its effect on offspring cardiovascular health was assessed in a multinational cohort study 6 .By assessing exposure to risk factors known to be associated with CVD, it was confirmed that better maternal cardiovascular health conditions at 28 weeks of pregnancy are associated with improved offspring cardiovascular health indices at ages 10 to 14 years 6 .Data compiled from longitudinal studies mapping cardiovascular risk factors 7 and CVD from childhood to adulthood demonstrate that the diagnosis of AH in childhood, especially with multiple measurements, is associated with the risk of AH in adulthood.Furthermore, exposure to cardiovascular risk factors in childhood is a predictor of subclinical CVD in adults 7 .The child's body mass index, family socioeconomic status, parental risk factors, as well as genetic polymorphisms, are independent predictors of adult obesity, AH and dyslipidemia 8 .Lifestyle habits in childhood starting at the age of 9 (diet, physical activity, smoking), as well as dyslipidemia, obesity, high BP, are associated with subclinical atherosclerosis 9 , carotid intimamedia thickness (C-IMT) and its progression into adulthood 9 .However, modifying risk factors by reducing BMI 8 , decreasing alcohol consumption 8 , and increasing vegetable intake from childhood 8 to adulthood have been associated with the resolution of AH in the childhood-adulthood transition, and with the clinical reversal of adverse cardiometabolic effects in individuals who become non-obese adults [7][8][9][10][11] .A recent study confirms the association between AH in adolescence and cardiovascular events with repercussions on cardiovascular morbidity and mortality in adults.It suggests that elevated BP in children and adolescents should be clinically interpreted as early CVD 12 .
Primary AH in children is usually diagnosed as a clinical examination finding in asymptomatic children with a family history of hypertension, overweight/ obesity, and normal morphofunctional characteristics of the urinary system.The diagnosis of secondary hypertension is based on information from history and clinical examination, with particular emphasis on obstructive sleep apnea, heart disease, endocrinopathies, nephropathies, and renovascular disease.In addition, there is the possibility of AH associated with medication use (decongestants, caffeine, nonsteroidal anti-inflammatory drugs, medications for neurological disorders, corticosteroids, hormonal contraceptives, tricyclic antidepressants, amphetamines) or induced by the use of illicit drugs.Secondary AH should always be considered when hypertension is diagnosed in young children with any instance of hypertensive urgency or emergency, and whenever AH accompanies signs of systemic disease, sexual development disorders, or hydroelectrolytic/acid-base imbalances 13 .defInItIon Blood pressure (BP) in children varies depending on their age, sex and height 14 .In newborns and infants, values may vary more in the first few days of life, particularly in preterm newborns, due to the influence of birth weight and maternal conditions 14 .
Starting in 1977, with a study conducted by the "Task Force on Blood Pressure in Chidren" 15 , the BP measurement in children started to be valued.Subsequent publications in 1987, 1996 and 2004 [16][17][18] strengthened the methodological aspects of BP measurement in children and adolescents, as well as the design of investigation and treatment protocols for pediatric AH.Except for the first two years of life, when the oscillometric methodology shows greater technical feasibility, it is preferable to perform BP measurements using the auscultatory method, while considering the child's sex, age and height percentile [16][17][18] .
In 2017, the American Academy of Pediatrics (AAP) published a new guideline 13 with modifications to the diagnosis and management of AH.It excluded from the database previously used to develop earlier guidelines [16][17][18]  However, efforts are underway to standardize the diagnosis of AH worldwide 19,20 .Table 3 presents the updated definition of normal BP, high BP, stages 1 and 2 of AH in children and adolescents, according to age, sex, and height percentile 13 .

PRevAlence
The prevalence of pediatric AH is approximately 3.5%.It is higher in children with obesity, chronic kidney disease and a history of prematurity 21 .Epidemiological data from the United States show an increased prevalence of AH in African-American boys and adolescents 21 , as well as high BP in 10-15% of the individuals 21,22 .In obese children aged 7 to 12, the prevalence of high BP and AH is 4.7% and 1.9%, respectively 23,24 .In China, from 1995 to 2014, there was an increase in the prevalence of overweight among children aged 7 to 17, rising from 4.3% in 1995 to 18.4% in 2014.Meanwhile, the prevalence of hypertension ranged from 4.4% to 6.4% during this period.Despite significant increases in the prevalence of overweight among Chinese children from 1995 to 2014, the prevalence of AH remained relatively stable.This suggests that other independent factors may play a role in moderating the development of AH in the pediatric population 24 .
In a study conducted in Brazil with 73,399 students aged 12 to 17, the prevalence of high BP ranged from 14.5% to 29.3% in boys aged 15-17, while the prevalence of AH was 9.6% 25 , with 17.8% of the AH prevalence attributable to obesity 25 .
The changes proposed in the 2017 guideline 13 resulted in increased prevalence of high BP and AH, with a greater correlation between high BP and target organ damage 5,26,27 .

bP meAsuRement
The indirect blood pressure measurement method was developed in 1896 by Riva-Rocci 28 , and the auscultatory method in 1905, by Korotkoff 29 .In recent years, technical advancements in BP measurement have greatly improved its accuracy.This measurement has become crucial for the diagnosis and treatment of hypertension 30 .The procedures for measuring blood pressure require careful attention, which is not always observed.This often leads to inadequate assessment of the patient's blood pressure values and, consequently, to misdiagnosis.
In children, BP measurements may vary between visits, and even within the same visit to the doctor.Generally, BP values tend to decrease with repeated measurements 18,31 .
BP shows variations associated with physical and mental activities that, acting on respiratory, diurnal and seasonal variations, generate patterns  of BP behavior with higher levels during the day and a decrease of 15% to 25% in nighttime blood pressure levels 31 .Therefore, in order to confirm AH, the diagnosis depends on multiple blood pressure measurements taken at several medical visits 16 .
The current recommendation from the Clinical Practice Guideline for Screening and Management of High Blood Pressure in Children and Adolescents 13 considers it mandatory to measure BP annually from the age of 3. In the case of obesity, kidney disease, use of medications with an effect on BP, history of coarctation of the aorta or diabetes, it should be measured at every visit.In children under 3 years of age, this measurement should be performed in situations of increased risk of developing hypertension 13 .These include prematurity, neonates with very low birth weight, or small for gestational age, or those who required neonatal intensive care; children with diseases associated with hypertension; malformation of the urinary system, urinary tract infections or use of medications with an effect on BP 13 .It is worth noting the multiplicity of clinical situations routinely faced by pediatricians that require the systematic inclusion of blood pressure measurement in pediatric physical examinations.BP varies with age, with a progressive increase in values during childhood, reaching adult values by adolescence 8 .
The most commonly used technique is casual BP measurement in office, using auscultation with an aneroid sphygmomanometer 32 .It is known that the accuracy of these measurements will influence the diagnosis and therapeutic evaluation 31 .This assessment is subject to errors, such as poor equipment calibration, anxiety or severe crying, noisy surroundings that hinder BP auscultation, and false diagnoses 31 .
In children, BP measurement requires more time available than it does in adults, also requiring a greater variety of cuff sizes 13 .The selection of the cuff should be appropriate to the child /adolescent's arm circumference.The width of the inflatable cuff bladder should encircle 40% of the arm circumference (measured at the midpoint between the olecranon and the acromion) and the bladder length should be 80 to 100% of this measurement 13 .
Regarding the technique used, in children over 3 years old, BP should be measured with the child seated, with the right arm at heart level 16,31 , while those under 3 years old should be assessed in the supine position 13 .Auscultation of Korotkoff phase I and the disappearance of the sounds (Korotkoff phase V) correspond to systolic blood pressure (SBP) and diastolic blood pressure (DBP), respectively.If Korotkoff phase V is heard at 0 mmHg, Korotkoff phase IV (muffling of sound) should be taken as the DBP value 13 .
The prone position can be used to measure BP in lower limbs.In this case, the cuff is placed in the calf region, covering at least 2/3 of the distance between the knee and the ankle.Due to distal pulse amplification, the SBP value at this site shows an increase of 10% to 20% compared to the measurement in the brachial artery 13 .
The 2017 pediatric AH evaluation guideline allows BP screening to be performed using oscillometric techniques, with oscillometric devices validated for the pediatric population 13 .However, these oscillometric devices can be inaccurate, especially in diastolic BP, compared to the auscultatory method 33 .Therefore, if AH is suspected with the oscillometric device, confirmatory measurements should be taken using the auscultatory method 13 .A compilation of normative values for BP in neonatal period is available for neonates aged 15 days and older, with postnatal gestational age ranging from 26 to 44 weeks 34 .The validated oscillometric devices for use in the pediatric age group 30 can be used for non-invasive BP assessment in NB and infants until they are able to cooperate with auscultatory BP measurement.The selection of cuffs for these devices should follow the same rules used for auscultatory BP measurement 13 .The list of validated oscillometric devices for children and adolescents can be found at https://bihsoc.org/bp-monitors/ (BHS); https://www.validatebp.org (US/AMA); https://hypertension.ca/bpdevices (CANADA); https://www.stridebp.org/bp-monitors(STRIDE BP, a joint initiative of ESH, ISH and the World Hypertension League).

bP Assessment by AbPm
Current studies have demonstrated a correlation between high BP values in childhood and adolescence and target organ damage in adulthood 35,36 .
Normative outpatient definitions for ABPM values in the pediatric population are derived from studies in the normal population.Recommendations for the use of ABPM in this population are based on expert opinions rather than evidence from well-designed studies for this purpose 37 .
ABPM is considered a mandatory procedure for confirming the diagnosis of arterial hypertension (AH) in children and adolescents 13 presenting with office measurements at a high BP level for 1 year or more, or at a stage 1 hypertension level over 3 consecutive clinic visits 13 .Additionally, ABPM is recommended for evaluating AH and the occurrence of abnormal circadian BP patterns in children and adolescents with high-risk conditions, such as chronic kidney disease, type 1 and type 2 diabetes mellitus, pre and postoperative coarctation of the aorta, solid organ transplantation, obstructive sleep apnea syndrome, obesity, suspected masked hypertension or white coat hypertension and genetic syndromes associated with AH, such as Williams syndrome, Turner syndrome and neurofibromatosis 13 .In children with chronic kidney disease, BP should be assessed using ABPM at least annually to exclude masked AH, regardless of apparent office BP control 13 .
The equipment used for measuring ABPM could be either oscillometric or auscultatory 13 .The list of validated devices for children and adolescents can be found on the websites of British and Irish Hypertension Society (https://bihsoc.org/bp-monitors),American Medical Association (US Blood Pressure Validated Device Listing: www.validatebp.org),Hypertension Canada (https://hypertension.ca/bpdevices) or STRIDE BP, a joint initiative of the European Society of Hypertension, International Society of Hypertension and World Hypertension League (https://www.stridebp.org/bp-monitors).
In 2017, the new guideline for the diagnosis and management of pediatric AH 13 eased the transition from adolescence to young adulthood by establishing for adolescents ≥13 years of age the same casual BP cutoff point adopted by the adult guideline 38 .
Regarding ABPM, new American guidelines for adults have included the adoption of lower thresholds to define hypertension by ABPM in adults (mean awake BP, 130/80 mmHg, equivalent to casual BP; mean nighttime BP, 110/65 mmHg; and 24-hour mean BP, 125/75 mmHg).However, similar measures had not been taken regarding normative values for pediatric ABPM, which had been subject to controversy in the literature.In a 2014 publication 37 , Flynn et al. used the 95th percentiles of BP as a cutoff point for all pediatric ages.Meanwhile, the European Society of Hypertension (ESH), in 2016 39,40 , recommended adopting the 95th percentile of BP measured by ABPM, until they were lower than the adult cutoff points in force in Europe: awake BP, 135/85 mmHg; nighttime BP, 120/70 mmHg; and 24-hour BP, 130/80 mmHg 39,40 .
Furthermore, recent evidence has shown no additive value of pressure load in risk stratification or prediction of intermediate clinical outcomes (left ventricular hypertrophy) or progression to end-stage renal disease, favoring the elimination of pressure load measurement in pediatric ABPM classification [41][42][43][44] .
The recently published new guidelines for ABPM in children and adolescents 44 respond to these concerns by presenting new data for classifying BP measurements through ABPM.Additionally, besides favoring the transition of care from adolescent to young adult patients, it eliminates the use of the pressure load (Table 4) 44 .When office BP and ABPM BP are both within normal range, the patient should be considered normotensive.When both are abnormal, the patient is diagnosed with ambulatory hypertension.If there is a divergence between the BP measured by the two techniques, the patient has white coat AH or masked hypertension (see Table 4).The diagnosis of pediatric AH is based on the confirmation of BP values ≥95th percentile at three different visits using auscultatory methodology 13 .In many cases, AH in children and adolescents develops asymptomatically but with significant sequelae, such as increased carotid intima-media thickness, reduced arterial distensibility, retinal arteriolar narrowing 45 and left ventricular hypertrophy (LVH), which is present in up to 40% of cases at the time of initial diagnosis 46 , and may be a precursor to arrhythmias and heart failure in adults 44 .
The investigation into the etiology of AH begins with a thorough anamnesis and collection of information from the perinatal period up to the present moment.During investigation, it is essential to inquire history of the need for neonatal or pediatric ICU admission, umbilical vein catheterization, personal history of illness or trauma, and sleep disorders, with particular attention to sleep apnea.Also important to consider the coexistence of systemic diseases, weight loss or gain, use of medications with effects on BP, such as vasoactive drugs, immunosuppressants, and steroids, as well as the use of illicit drugs, and smoking habits 13 .Other diagnoses, such as coarctation of the aorta, central nervous system alterations, and increased intracranial pressure 13 , represent less than 10% of the etiology of AH in children 13,18 .
Physical examination should be comprehensive, including palpation of pulses in all 4 limbs, detection of abdominal murmurs through abdominal auscultation, and skin changes such as neurofibromas or acanthosis nigricans 13 .The presence of hypertensive retinopathy, enlarged heart, heart failure or neurological deficit generally correlates with the chronicity and severity of hypertension 17 .The diagnostic evaluation of hypertension in children and adolescents should be adapted to the clinical picture, family history, BP value and age at presentation 17,47 .Secondary hypertension usually occurs in younger children, with markedly elevated BP values, with 60% to 90% of cases caused by parenchymal or obstructive nephropathy or renal artery stenosis 13 .
Renovascular hypertension (RVH) is a potentially reversible cause of secondary hypertension.It may be caused by partial or total, unilateral or bilateral renal artery stenosis (RAS) or its branches, triggering and maintaining renal ischemia.Evaluation with renal Doppler ultrasound is the recommended noninvasive method for screening this clinical situation, with estimated sensitivity and specificity of 75% and 90%, respectively 48 .Magnetic resonance angiography (MRA) by digital subtraction or BOLD method or spiral CT have equal accuracy and greater sensitivity and specificity when compared to ultrasound 49 .
Endocrine disorders may account for up to 5% of AH cases, through multiple pathophysiological mechanisms, such as mineralocorticoid excess, corticoids or catecholamines; thyroid disease or hyperparathyroidism.Catecholamine-secreting tumors arising from chromaffin cells of the sympatheticadrenal-medullary axis 50 are characterized by the classic triad of headache, hyperhidrosis and palpitations with permanent or paroxysmal AH (50%; hypertensive peaks alternating with moments of normal BP).They could be either pheochromocytomas or paragangliomas (PPGLs), and depending on their underlying germline or somatic mutations, they could be classified into 3 groups that also differ in clinical presentation, biochemical and imaging profile 51 .Group 1 and probably group 3 tumors generally present with more aggressive symptoms and a higher metastatic risk when compared to those in group 2. Tumors from group 1 (located mainly extra-adrenal) have a noradrenergic biochemical phenotype with a tendency towards arterial hypertension, while those from group 2 (primarily located in the adrenal) have an adrenergic biochemical phenotype with intermittent secretion of catecholamines with sporadic symptoms.Plasma free metanephrine (metanephrine and normetanephrine) levels have high sensitivity (97%) and specificity (93%) 50 for diagnosing these tumors; however, they are very expensive 50 .Urinary metanephrine measurement alone or in combination with urinary catecholamines (epinephrine, norepinephrine, and dopamine) has also been used at lower cost, although it is less sensitive.Increased values (>2 times the upper limit of normal) of urinary catecholamines indicate a high diagnostic probability 52 .Urinary catecholamines and vanillylmandelic acid levels are less sensitive for diagnosing PPGLs 53 than urinary metanephrine levels.The location of adrenal tumors can be investigated using computed tomography, with a sensitivity of 89%, or nuclear magnetic resonance imaging (pheochromocytoma shows hyperintense signal in T2-weighted images), with a sensitivity of 98% 54 .Whole-body scintigraphy with 123I-MIBG or 68Ga DOTATE-PET-CT is highly effective in locating pheochromocytoma and paragangliomas, metastatic disease or multiple chromaffin tumors 55 .Characterizing the grouping to which the PPGL belongs, in addition to diagnostic implications, can also guide follow-up and therapeutic choices, facilitating a personalized therapeutic plan according to each patient's specific grouping.
Monogenic AH is a cause of secondary hypertension with a familial inheritance pattern, often caused by a mutation in a single gene.It should be suspected in patients with a family history of early-onset hypertension, hypokalemia, suppressed plasma renin activity or elevated aldosterone-to-renin ratio.Among the multiple etiologies, familial hyperaldosteronism, Liddle's syndrome and congenital adrenal hyperplasia are worth mentioning 56,57 .Genetic diagnosis may lead to appropriate treatment and enable family genetic counseling and early screening in asymptomatic family members 56 .
Primary AH is more common in older children and adolescents and is associated with overweight, obesity or a family history of AH.However, considering the wide range of secondary hypertension etiologies that may affect children or adolescents, the diagnosis of primary AH should be made with caution.In the medical history, detailed information should be provided on birth, growth and development, personal history of kidney, urological, endocrine, cardiac and neurological diseases and lifestyle habits, as well as the use of medication and other substances that may alter BP.Family history of AH, kidney disease, and other cardiovascular risk factors should also be investigated.As part of the physical examination, it is important to calculate body mass index 58 , and look for signs of secondary AH 59 .Diagnostic investigation with more invasive tests should be conducted in children under 6 years of age with signs of secondary AH 13,16 .
Sleep studies, using polysomnography, are indicated for children and adolescents with sleep disorders detected by anamnesis 13 .
Laboratory and imaging tests requested in the investigation of AH aim to define the etiology (primary or secondary), and detect target organ damage (TOD) and cardiovascular risk factors associated with AH (Chart 1) 13 .Target organ assessment should be performed in cases of stages 1 and 2 AH.

tReAtment
In pediatric patients with BP values equal to or greater than the 90th percentile, non-pharmacological guidelines should be followed, focusing on weight reduction, physical exercise and dietary intervention 18,60 .This is because weight reduction in obese children and adolescents has been shown to be important in the treatment of AH and in the cardiovascular prognosis of adults 8,9 .
Regular physical activity, that is, 30 to 60 minutes of moderate physical exercise, daily if possible, has a major impact on reducing weight and blood pressure, with a better effect on systolic blood pressure than on diastolic blood pressure 61,62 .Resistance training, apart from weightlifting, can be performed by hypertensive children, but competitive sports are not recommended for patients with stage 2 hypertension 63 .
In symptomatic AH patients with secondary forms of chronic kidney disease or diabetes mellitus, presence of target organ damage, stage 2 AH and resistant AH not responsive to lifestyle changes 13 , pharmacological therapy should be initiated with an antihypertensive agent at its lowest dose, and gradually increased until BP is reduced below the 90th percentile 13 .In general, children have experienced few adverse events from antihypertensive agents 13,64 , and in the short term the use of all classes of antihypertensive agents seems to be safe 64 .International guidelines recommend as first line treatment the use of angiotensin-converting enzyme inhibitors, angiotensin receptor blockers, long-acting calcium channel blockers or thiazide diuretics.In cases of resistant AH, alpha blockers, beta blockers, centrally acting sympatholytics or potassium-sparing agents can be used 13,64 .The choice of antihypertensive medication should be made in line with the underlying pathophysiology, considering the comorbidities present in each case 65,66 .Strict dietary guidance with reduced salt intake, improved adherence to drug treatment and optimization of antihypertensive drugs should be instituted in all patients with AH, especially those with resistant AH 13 .In the event of non-response to monotherapy for longer than 6 months, referral to a specialist in pediatric AH is considered 67 .

conclusIon
This article highlights the importance of early diagnosis of hypertension and high blood pressure in children and adolescents, emphasizing the peculiarities and difficulties of measuring blood pressure in pediatrics, as well as the importance of secondary hypertension in this age group.AH is a frequently asymptomatic condition, and it tends to progress with structural and/or functional changes in target organs such as the heart, brain, kidneys and vessels.AH is the major modifiable risk factor with an independent, linear, and continuous association for cardiovascular diseases, chronic kidney disease and premature death.The diagnosis and treatment of cardiovascular risk factors in childhood have a significant impact on reducing cardiovascular morbidity and mortality in adults.
tract US with Doppler of renal arteries chARt 1 initiAl investigAtion of children And Adolescents with Ah 13

tAble 1 AmericAn heArt AssociAtion recommendAtions for optimAl cArdiovAsculAr heAlth in Adults And children
the BP data of overweight and obese

tAble 3 updAted
13 definition According to Age group13

tAble 4
45AssificAtion for office And ABpm Bp in pediAtric pAtients45