Isolated nocturnal hypertension is associated with increased left ventricular mass index in children.

BACKGROUND: Isolated nocturnal hypertension (INH) is associated with increased prevalence of left ventricular hypertrophy (LVH) and cardiovascular morbidity and mortality in adult patients. Unlike in adults, data illustrating the possible association between INH and cardiac target organ damage is lacking in children. This study aimed to investigate whether INH is associated with increased left ventricular mass index (LVMI) and LVH in children. METHODS: Retrospective data from all untreated children with confirmed ambulatory hypertension (HT) in our center was reviewed. Ambulatory blood pressure monitoring (ABPM) and echocardiography were performed concurrently. Ambulatory normotensive children served as controls. LVH was defined as LVMI ≥ 95th percentile. RESULTS: There were 102 ABPM studies; of these, 79 children had renal HT, and 23 had primary HT. Median age of children was 13.2 years (3.8-18.9). Nineteen children had INH, 9 children had isolated daytime HT, 54 had daytime and nighttime HT, and 20 were normotensive. The LVMI adjusted for age (patient's LVMI/95th percentile of the LVMI) was significantly higher in children with INH than in normotensive children (0.83 ± 0.03 vs. 0.74 ± 0.03, p = 0.03). Left ventricular hypertrophy was present in 11% of children with INH; this was not significantly higher than in normotensive children (0%, p = 0.23). CONCLUSIONS: This study investigated the association between INH and cardiac structure in children with primary and renal HT and showed children with INH had higher LVMI adjusted for age than normotensive children and children with INH had similar LVMI adjusted for age to children with isolated daytime HT.

Nocturnal blood pressure non-dipping is not associated with increased left ventricular mass index in hypertensive children without end-stage renal failure.

UNLABELLED: The aim of our study was to investigate whether nocturnal blood pressure (BP) dip is associated with increased left ventricular mass index and hypertrophy in children with hypertension (HT). We retrospectively reviewed data from all children with confirmed ambulatory HT in our center and performed ambulatory blood pressure monitoring (ABPM) and echocardiography at the same time. Left ventricular hypertrophy (LVH) was defined as left ventricular mass index (LVMI) ≥95th centile. Non-dipping phenomenon was defined as nocturnal BP dip <10 %. A total of 114 ABPM studies were included, the median age of children was 15.3 years (3.8-18.9), 80 children had renoparenchymal HT without end-stage renal failure, 34 had primary HT, and 27 studies were done on untreated children and 87 on treated children. Non-dipping phenomenon was present in 63 (55 %) studies (non-dippers). The LVMI adjusted for age was not significantly different between non-dippers and dippers (0.87 ± 0.03 vs. 0.81 ± 0.02, p = 0.13). Left ventricular hypertrophy was not significantly higher in non-dippers than in dippers (20 vs. 9 %, p = 0.12). CONCLUSION: Hypertensive children without end-stage renal failure with non-dipping phenomenon do not have increased prevalence of LVH or higher LVMI adjusted for age than hypertensive children with preserved nocturnal BP dip. WHAT IS KNOWN: • Adult and pediatric hypertensive patients with end-stage renal failure have often nocturnal blood pressure non-dipping phenomenon. • Non-dipping phenomenon is in patients with end-stage renal failure associated with increased prevalence of left ventricular hypertrophy. What is New: • Pediatric hypertensive patients without end-stage renal failure with blood pressure non-dipping phenomenon do not have increased prevalence of left ventricular hypertrophy.

Experience with the surgical treatment of atrioventricular septal defect with left ventricular outflow tract obstruction.

OBJECTIVES: We sought to determine the prevalence, morphology, surgical methods and results of surgery for left ventricular outflow tract obstruction (LVOTO) associated with atrioventricular septal defect (AVSD). METHODS: Correction of AVSD was performed in 615 patients. Twenty-three (3.7%) patients with LVOTO were identified. Sixteen (70%) of them had partial and 7 (30%) had complete AVSD. Surgery for AVSD was performed at a median of 0.6 years (mean 2.1 ± 3.0 years), and surgery for LVOTO at a median of 3.4 years (mean 4.7 ± 3.5 years). The point and period prevalence of LVOTO in AVSD were determined. Detailed morphological study, individualized repair of AVSD with LVOTO and long-term follow-up were performed. Early and long-term results were analysed. RESULTS: The point prevalence of LVOTO at the time of AVSD repair was 1.3%. The period prevalence of LVOTO was 3.7% in course of 8.3 ± 6.0 (0-18.4) years and 191.4 patient-years following AVSD repair. Causes of LVOTO were fibromuscular membrane (n = 17), septal hypertrophy (n = 17), abnormal atrioventricular (AV) valve (n = 9), muscular bands (n = 3), fibrous strands (n = 4) and stenotic aortic valve (n = 2). Usually, a combination of several obstructive lesions was present. LVOTO was present at the time of AVSD repair in 8 patients (35%) and developed after repair in 15 (65%) patients. Membrane excision (n = 17), myectomy (n = 17), excision of abnormal AV valvar tissue (n = 8), excision of muscular bands and fibrous strands (n = 6), AV valve replacement (n = 2) and aortic valvotomy (n = 2) were required. There was 1 (4%) early and 1 (4%) late death. Six (29%) survivors required reoperation for recurrence of LVOTO at an average interval of 6.3 ± 3.2 years after surgery. The actuarial survival at 1 and 10 years was 96 and 88%, respectively. The actuarial freedom from reoperation for LVOTO was 80, 40 and 20% at 6, 10 and 15 years after surgery, respectively. Eighteen (78%) patients remain in good condition at mean 6.0 ± 5.5 years after surgery. CONCLUSIONS: The point prevalence of LVOTO at the time of AVSD repair was 1.3%, and period prevalence 3.7%. Fibromuscular membrane, septal hypertrophy and valvar attachments represent the most common causes of LVOTO. Usually, more structures are involved. The repair must be individualized. The presence of LVOTO increases the need for reoperation.

Long-term control of ambulatory hypertension in children: improving with time but still not achieving new blood pressure goals.

BACKGROUND: Short-term therapy can decrease blood pressure (BP) to less than the 95th percentile in only about 50% of children. The aim of our study was to investigate the long-term control of hypertension (HT) in children using ambulatory BP monitoring (ABPM). METHODS: We analyzed data from all children who started ramipril monotherapy in our center. Controlled HT was defined according to the most current guidelines as systolic and diastolic BP at daytime and nighttime <90th percentile in primary HT and <75th percentile in renoparenchymal HT. RESULTS: Thirty-eight children who were on therapy ≥1 year were included. Thirty-two children had renoparenchymal, and 6 had primary HT. The median age at the beginning of therapy was 13.6 years (range = 4.1-18.0 years), and the median time of antihypertensive therapy was 2.6 years (range = 1.0-11.8 years). Thirty-four percent of children received combination therapy; the median number of antihypertensive drugs was 1.5 drugs/patient (range = 1-4). Sixty-eight percent of children had BP <95th percentile, but only 34% of the children had controlled HT. Children with uncontrolled HT had a tendency to have a higher daytime diastolic BP index before the start of therapy than children with controlled HT (0.99±0.11 vs. 0.94±0.11; P = 0.09). There was a significant decrease in prevalence of nondipping (from 47% to 16%; P = 0.006) with therapy. CONCLUSIONS: This first pediatric study focusing on long-term control of HT using ABPM showed that long-term control of HT is better than short-term control, but still only one-third of children achieve the new BP goals. The low control of HT might be improved by more intensive therapy.

Control of hypertension in treated children and its association with target organ damage.

BACKGROUND: The aim of our study was to investigate the control of hypertension (HT) in treated children using ambulatory blood pressure (BP) monitoring (ABPM). METHODS: We retrospectively reviewed all ABPM studies in our center. Controlled HT was defined as systolic and diastolic BP index (patients' BP divided by the 95th percentile) at daytime and nighttime <1.0 or alternatively as BP load (percentage of BP readings above the 95th percentile) <25% in children on antihypertensive therapy. RESULTS: A total of 195 ABPM studies were included. The mean age was 13.6 ± 4.0 years. One hundred and thirty two children had renoparenchymal HT, 10 renovascular (RVH), 10 endocrine, 4 cardiovascular, 29 primary (PH) and 5 children other forms of HT. 53% of all children had controlled HT. There was no difference in the prevalence of controlled HT between primary and secondary HT (52% and 53%) using the BP index criterion. Children with renoparenchymal HT had significantly better control of HT than children with RVH (58% vs. 20% P = 0.02). The use of angiotensin-converting enzyme inhibitors (ACEI) monotherapy was significantly more effective in controlling HT than the use of calcium-channel blockers (CCB, P = 0.02). The prevalence of left ventricular hypertrophy in children with uncontrolled HT (assessed in 58 patients) was significantly higher than in children with controlled HT (46% vs. 13%, P < 0.01). CONCLUSIONS: This is the first pediatric study, to our knowledge, on BP control in hypertensive children using ABPM. It indicates that control of HT is inadequate in ~50% of treated children. Inadequate control of HT is associated with target organ damage in this population.

Long-term (up to 20 years) results of percutaneous balloon angioplasty of recurrent aortic coarctation without use of stents.

AIMS: To assess the efficacy, safety, and long-term results of the balloon angioplasty of recoarctation. METHODS AND RESULTS: The angioplasty was performed in 99 consecutive patients aged 36 days to 32.6 years (median 268 days). Recoarctation to descending aorta diameter ratio increased from 0.44 (0.35/0.50) to 0.66 (0.57/0.77), P < 0.001. Systolic gradient was reduced from 34.0 (26.0/44.75) to 15.0 (8.25/27.0) mmHg, P < 0.001. In seven patients (7.1%) the procedure was ineffective. One patient (1%) with heart failure died within 24 h after a successful angioplasty and in another (1%) an intimal abruption necessitated surgical revision. The follow-up ranged up to 20.7 years (median 8.1 years). Actuarial probability of survival 20.7 years after the procedure was 0.91, and of reintervention-free survival was 0.44. Older age at the angioplasty was associated with a higher incidence of reinterventions (hazard ratio 1.057; 95% confidence interval 1.012-1.103; P = 0.010). The type of surgery and the recoarctation anatomy did not influence the outcome. In 69 patients aneurysm formation was studied by high-sensitive methods with only one positive finding per 462 patient-years. CONCLUSION: Angioplasty is safe and effective regardless of the type of surgery used and the recoarctation anatomy. Older age at the angioplasty is associated with a higher incidence of reinterventions.

Regression of left-ventricular hypertrophy in children and adolescents with hypertension during ramipril monotherapy.

BACKGROUND: Left-ventricular hypertrophy (LVH) is a risk factor for cardiovascular morbidity. Antihypertensive treatment with angiotensin-converting enzyme inhibitors (ACEI) is able to induce the regression of LVH in adults. However, there has been no study of the ability of ACEI to induce the regression of LVH in children. Our aim was to investigate the effect of ramipril on left-ventricular mass and blood pressure (BP) in hypertensive children. METHODS: Twenty-one children (median age, 15 years) with renal (76%) or primary (24%) hypertension were prospectively treated with ramipril monotherapy for 6 months. Blood pressure was evaluated using ambulatory BP monitoring, with hypertension defined as mean BP >or=95th percentile. Left-ventricular hypertrophy was defined either as left-ventricular mass index (LVMI) >38.6 g/m(2.7) (pediatric definition) or as LVMI >51.0 g/m(2.7) (adult definition). RESULTS: Nineteen children completed the study. The median LVMI decreased from 36.8 g/m(2.7) (range, 18.9 to 55.8 g/m(2.7)) to 32.6 g/m(2.7) (range, 19.0 to 52.1 g/m(2.7); P < .05) after 6 months. The prevalence of LVH decreased from 42% to 11% using the pediatric definition (P < .05) and did not change using the adult definition (ie, it remained at 5%). The median ambulatory BP decreased by 11, 7, 8, and 7 mm Hg for daytime systolic, daytime diastolic, nighttime systolic, and nighttime diastolic BP (P < .05), respectively. A positive correlation was found between LVMI and nighttime systolic BP at the start of the study (r = 0.46, P < .05). CONCLUSIONS: Ramipril is an effective drug in children with hypertension, for its ability to reduce not only BP but also left-ventricular mass and induce regression of LVH.

Improved control of hypertension in children after renal transplantation: results of a two-yr interventional trial.

Hypertension is a frequent complication in children after renal transplantation and the control of post-transplant hypertension is unsatisfactorily low. The aim of this prospective interventional study was to improve the control of hypertension in children after renal transplantation. Thirty-six children fulfilled the inclusion criteria (> or =6 months after transplantation and no acute rejection in the last three months). BP was measured using ABPM. Hypertension was defined as mean ambulatory BP > or =95th-centile for healthy children and/or using antihypertensive drugs. The study intervention consisted of using intensified antihypertensive drug therapy - in children with uncontrolled hypertension (i.e., mean ambulatory BP was > or =95th centile in treated children), antihypertensive therapy was intensified by adding new antihypertensive drugs to reach goal BP <95th centile. ABPM was repeated after 12 and 24 months. Daytime BP did not change significantly after 12 or 24 months. Night-time BP decreased from 1.57 +/- 1.33 to 0.88 +/- 0.84 SDS for systolic and from 1.10 +/- 1.51 to 0.35 +/- 1.18 SDS for diastolic BP after 24 months (p < 0.05). The number of antihypertensive drugs increased from 2.1 +/- 0.9 to 2.7 +/- 0.8 drugs per patient (p < 0.05), this was especially seen with the use of ACE-inhibitors (increase from 19% to 40% of children, p < 0.05). In conclusion, this interventional trial demonstrated that, in children after renal transplantation, the control of hypertension, especially at night-time, can be improved by increasing the number of antihypertensive drugs, especially ACE-inhibitors.

Control of hypertension in children after renal transplantation.

The aim of this cross-sectional single-center study was to investigate the efficacy of hypertension control in children who underwent transplantation using ambulatory blood pressure (BP) monitoring, and to determine the risk factors associated with poor control of hypertension. Thirty-six children fulfilled the inclusion criteria. The mean age was 13.9+/-4.4 yr; the mean time after renal transplantation was 2.7+/-2.4 yr (0.5-10.1). Hypertension was defined as a mean ambulatory BP > or =95th centile for healthy children and/or requiring antihypertensive drugs. Hypertension was regarded as controlled if the mean ambulatory BP was <95th centile in children already on antihypertensive drugs, or uncontrolled if the mean ambulatory BP was > or =95th centile in treated children. Hypertension was present in 89% of children. Seventeen children (47%) had controlled hypertension, and 14 (39%) had uncontrolled hypertension. One child (3%) had untreated hypertension, and only four children (11%) showed normal BP without antihypertensive drugs. The efficacy of hypertensive control was 55% (17 of 31 children on antihypertensive drugs had a BP<95th centile), i.e. 45% of treated children still had hypertension. Children with uncontrolled hypertension had significantly higher cyclosporine doses (6.1 vs. 4.3 mg/kg/day, p=0.01) and tacrolimus levels (9.2 vs. 6.1 microg/L, p<0.05), and there was a tendency toward use of lower number of antihypertensive drugs (2.0 vs. 1.5 drugs/patient, p=0.06) and lower use of angiotensin-converting enzyme (ACE) inhibitors (7 vs. 35%, p=0.09) and diuretics (29 vs. 59%, p=0.14) than in children with controlled hypertension. In conclusion, nearly 90% of our children after renal transplantation are hypertensive and the control of hypertension is unsatisfactorily low. The control of hypertension could be improved by increasing the number of prescribed antihypertensive drugs, especially ACE inhibitors, and diuretics, or by using higher doses of currently used antihypertensives.