CC BY
14
Nechytailo Yuriy, professor, Head of the Department of Pediatrics Bukovinian State Medical University, Chernivtsi, Ukraine E-mail: [email protected] Pidmurniak Olesya, Ph D., student of the Department of Pediatrics E-mail: [email protected]
AMBULATORY BLOOD PRESSURE MONITORING IN ADOLESCENTS WITH ENDOCRINE PATHOLOGY
Abstract: Arterial hypertension is one of the most important modifiable risk factors for cardiovascular diseases. In recent years, arterial hypertension has shown prevalence increase in children and adolescents. Early and accurate detection of hypertension in childhood is important in preventing it in adulthood. We have examined 59 children in age 12-18 years with endocrine pathology (diabetes, obesity) for elevated blood pressure. Office measurements of blood pressure and ambulatory blood pressure monitoring were done. Ambulatory blood pressure monitoring allows obtaining more accurate detection of subjects at high risk for hypertension.
Keywords: adolescents, diabetes, obesity, arterial hypertension, ambulatory blood pressure monitoring.
According to the World Health Organization cardiovas- sessment of resting anthropometric data, nutrition, physical cular disease is the number one cause of death globally: more activity habits, peculiarities of sleep, family and socioeconom-people die annually from cardiovascular disorders than from ic data etc. The BP measurements were done triple after the
any other cause. In recent years, arterial hypertension (AH) has shown an increase in the prevalence in adults and among adolescents too [7, 10]. The diabetes and endocrine pathology with obesity are two conditions with higher risk ofvarious cardiovascular problems in childhood, especially such as AH [1; 8; 9]. The blood pressure (BP) even in healthy children was reported to increase with a higher body mass index (BMI) [2]. Obese children have an approximately 3-fold higher risk of AH than non-obese children. To establish diagnosis of AH manual measurements of BP is widely used but they have the disadvantage of not checking the BP continuously. Ambulatory blood pressure monitoring (ABPM) allows obtaining more accurate and more physiological results by considering daily changes [6; 7]. ABPM could predict vascular events better than office BP or random BP measurements and could identify the nondipper status, characterized by a decrease in physiological nighttime drop of BP, constituting the first sign of the increase of pressure load on blood vessels [3; 5]. However, standards have not been established, so medical staffs hesitate to use it.
Objective: The aim of this study was to assess blood pressure in adolescents with endocrine pathology on basis of ambulatory blood pressure monitoring.
Materials and methods. In the study 59 children in age 12-18 years from urban and rural areas were examined. They were subdivided into two groups - first with type 1 diabetes (29 persons) and second with other endocrine pathology mostly with overweight (30 persons). The study includes as-
subject had been in a sitting position for at least 5 min. The average of two last measurements assessed. Participants with systolic or diastolic blood pressure above the 95th percentiles by age, sex and height regarded as hypertensives. All persons with elevated BP underwent ABPM. ABPM was performed using a "Ritm-2000" ambulatory blood pressure system (RTO Beta, Ukraine), with a suitably sized cuff. The blood pressure system programmed to measure every 30 min, from 8:00 AM to 10:00 PM and every 60 min, from 10:00 PM to 8:00 AM. Hypertension was regarded when the daytime or nighttime mean systolic or diastolic BP was higher than the 95th percentile of the pediatric norms for ABPM. Circadian rhythm chronotype assessed too with the standard questionnaire for identifying the chronotypes (morningness-eveningness). Statistical analysis conducted with program Statistica (version 5.11, StatSoft Inc.). All p-values were two-tailed and p<0.05 was considered statistically significant.
Results. Diabetes is associated with a higher BP but it is more typical for second type of disease. In our cohort all diabetic patients had first type of disease. Elevated BP by first office measurements registered in 10 children (34.5%) and average systolic blood pressure (SBP) was 130.3 ± 3.07 mm Hg. By ABPM elevated BP was only in 2 subjects (6.9%) and average SBP was 110.8 ± 2.27 mm Hg (fig.1). Office measurements in following days show decrease of SBP that could be signs of subject's psychological adaptation and diminish of "white coat" reaction.
Section 7. Medicine
Figure 1. Comparisons average SBP of morning office measurement and daytime part of ABPM
Obesity is another independent risk factor for AH and more than 60% of adult hypertensive patients have overweight. In our cohort in diabetic patients average BMI was 20.4 ± 1.21 kg/m2 and overweight was registered in 17.2% of patients, in second group average BMI was 27.7 ± 1.22 kg/ m2 with 83.3% overweight persons. Elevated BP in second group by first office measurements was registered in 10 children (33.3%) and average SBP was 119.5 ± 2.86 mm Hg. By ABPM elevated BP was in 20 subjects (66.7%) and average SBP was 126.3 ± 2.65 mm Hg. SBP in this group had correlation with BMI (R =0.51, p < 0.05).
The significant positive correlations of BMI with daytime, nighttime and 24-hour SBP (r = 0.36, r = 0.41, r = 0.40, respectively; p < 0.05) were stronger than the correlations with DBP (r = 0.21, r = 0.24, r = 0.23, respectively; p < 0.05). Nighttime BP also positively correlate with adolescent evening chronotype (r = 0.26,p < 0.05). Our study demonstrated that elevated nighttime SBP is more common in all children and based on ABPM data the risk of ambulatory nighttime systolic hypertension increased significantly with the degree of BMI. Macumber IR et al. [5] also reported that the BMI is associated with the severity of ambulatory hypertension, similar to our findings.
Our study did not show significant differences in numbers of nondippers subjects between both groups. The nondipper status, characterized by physiological decrease of nighttime BP and mostly is the first sign of the of pressure overload on blood vessels, which is leading factor to the vascular damage of the kidneys [2; 4]. Alterations of the normal circadian blood pressure rhythm have been correlated with the progression of diabetic nephropathy [4].
Both types of endocrine pathology diabetes and overweight are conditions with increased cardiovascular risk. Type 1 diabetes patients present in the long-term outcome micro-and macroangiopathy such as nephropathy, retinopathy, and cardiovascular disease, that lead to increased morbidity and premature mortality [1] and elevated systemic blood pressure is a promoter of both the development and the progression of vascular sequelae such as diabetic kidney [4].
Traditionally, the assessment of hypertension in children has relied on office blood BP measurements. However, office BP measurements may be misleading for the diagnosis of hypertension, due to the white coat and masked hypertension phenomena in children, as observed in adults [7; 10]. Also it could be a masked hypertension - a clinical condition in which the office BP is normal but ABPM shows hypertensive values. In our patient, we just obtained both types of data misleading.
Conclusions
ABPM could help to define patients with increased risk for the development of AH, who might benefit from the early introduction of anti-hypertensive treatment. Masked and/or subclinical AH, reduced nightdipping could be diagnosed only via ABPM use. Include ofABPM in follow-up of diabetes and overweight subjects much better in diagnostic of cardiovascular events than that provided by office measurements. ABPM also offers numerous advantages in adolescents, thus providing continuous data about BP during everyday activities and nighttime sleep, which is better correlated with real level of daily BP.
References:
1. Giacchi V., Timpanaro T., Presti D. L., Passanisi S et al. Prehypertension in adolescents with cardiovascular risk: a comparison between type 1 diabetic patients and overweight subjects. BMC Res Notes. 2016; 9: 122. doi: 10.1186/
s13104-016-1839-3.
2. Hvidt K. N., Olsen M. H., Holm J., Ibsen H. Obese children and adolescents have elevated nighttime blood pressure independent of insulin resistance and arterial stiffness. Am J Hypertens. 2014. Nov; 27(11): 1408-1415. doi:10.1093/ ajh/hpu055.
3. Jing L., Nevius C. D., Friday C. M., Suever J. D. et al. Ambulatory systolic blood pressure and obesity are independently associated with left ventricular hypertrophic remodeling in children. J Cardiovasc Magn Reson. 2017; 19: 86. doi: 10.1186/ s12968-017-0401-3.
4. Lee S. H., Kim J. H., Kang M. J., Lee Y. A. Implications of nocturnal hypertension in children and adolescents with type 1 diabetes. Diabetes Care. 2011. Oct; 34(10): 2180-2185. doi: 10.2337/dc11-0830
5. Macumber I. R., Weiss N. S., Halbach S. M., Hanevold C. D., Flynn J. T. The association of pediatric obesity with nocturnal non-dipping on 24-hour ambulatory blood pressure monitoring. Am J Hypertens. 2016 May; 29(5): 647-652. doi: 10.1093/ajh/hpv147.
6. Pellizzari M., Speiser P. W., Carey D. E., Fort P., Kreitzer P. M., Frank G. R. Twenty-four hour ambulatory blood pressure monitoring in adolescents with type 1 diabetes: getting started. J Diabetes Sci Technol. 2008.- Nov; 2(6): 1087-1093. doi: 10.1177/193229680800200617
7. Peterson C. G., Miyashita Y. The use of ambulatory blood pressure monitoring as standard of care in pediatrics. Front Pediatr. 2017; 5: 153. doi: 10.3389/fped.2017.00153
8. Shikha D., Singla M., Walia R., Potter N. et al. Ambulatory blood pressure monitoring in lean, obese and diabetic children and adolescents. Cardiorenal Med. 2015. Jun; 5(3): 183-190. doi: 10.1159/000381629
9. Tekin N., Ersoy B., Coskun S., Tekin G., Polat M. Ambulatory blood pressure parameters in office normotensive obese and non-obese children: relationship with insulin resistance and atherosclerotic markers. Med Princ Pract. 2014. Feb; 23(2): 154-159. doi: 10.1159/000356120
10. Turner J. R., Viera A. J., Shimbo D. Ambulatory blood pressure monitoring in clinical practice: a review. Am J Med. 2015. Jan; 128(1): 14-20. doi: 10.1016/j.amjmed.2014.07.021
