Importance of ambulatory blood pressure monitoring in the diagnosis and prognosis of pediatric hypertension | Revista Portuguesa de Cardiologia (English edition)

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The prevalence of hypertension at pediatric age is increasing,<a class="elsevierStyleCrossRefs" href="#bib0125">1–4</a> particularly in developed countries,<a class="elsevierStyleCrossRef" href="#bib0145">5</a> with recent data showing prevalences around 4% and that of prehypertension reaching 10%.<a class="elsevierStyleCrossRef" href="#bib0130">2</a> In Portugal, a study by Maldonado et al.<a class="elsevierStyleCrossRef" href="#bib0150">6</a> analyzing 5381 children found that 12.8% were hypertensive.<a class="elsevierStyleCrossRef" href="#bib0150">6</a>Increasing obesity has led to changes in blood pressure (BP) patterns, including elevated BP levels in children and adolescents.<a class="elsevierStyleCrossRefs" href="#bib0125">1,5</a> Sustained adiposity and hence higher BP in childhood will tend to increase the prevalence of hypertension and its complications in adulthood.<a class="elsevierStyleCrossRefs" href="#bib0135">3,7–9</a> Obesity is the cardiovascular risk factor with the strongest relationship with BP, and higher body mass index is associated with progression from prehypertension to hypertension.<a class="elsevierStyleCrossRef" href="#bib0170">10</a> However, the dominant etiology of hypertension in this age-group is renal and/or cardiovascular pathology.<a class="elsevierStyleCrossRef" href="#bib0155">7</a>Definition of hypertensionThe definition of hypertension in children has undergone significant changes in recent decades.<a class="elsevierStyleCrossRef" href="#bib0160">8</a> The European Society of Hypertension (ESH) guidelines, published in 2016,<a class="elsevierStyleCrossRef" href="#bib0140">4</a> classified resting BP values for children aged 0-15 years (<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>) based on percentiles, while for those aged 16 or older the consensus was that the definitions used should be based on the absolute cut-offs used for adults.<elsevierMultimedia ident="tbl0005"></elsevierMultimedia>Hypertension in children is generally defined as systolic blood pressure (SBP) and/or diastolic blood pressure (DBP) at or above the 95th percentile on three or more separate occasions.<a class="elsevierStyleCrossRefs" href="#bib0130">2–4,11</a>The ESH guidelines<a class="elsevierStyleCrossRef" href="#bib0140">4</a> also stress the importance of isolated systolic hypertension (ISH), the clinical significance of which in youth is still debated. ISH is the most prevalent form of elevated BP in adults aged over 50 years and its causes are multifactorial.Neonatal hypertension has been defined as SBP at or above the 95th percentile for gender, gestational age and postnatal age. Its incidence is low (0.2-3%) and a history of umbilical catheterization is an important risk factor.<a class="elsevierStyleCrossRef" href="#bib0180">12</a> The importance of intrauterine and early life events in the development of cardiometabolic disease in adult life has been underlined.<a class="elsevierStyleCrossRef" href="#bib0140">4</a> The time immediately before and after birth is a sensitive period in which multiple interactions between hemodynamic and metabolic parameters may contribute to risk of cardiometabolic disease.<a class="elsevierStyleCrossRef" href="#bib0140">4</a> Target organ damage (TOD) has been reported in persistent neonatal hypertension.<a class="elsevierStyleCrossRef" href="#bib0185">13</a>Birth weight affects ambulatory BP, with various studies showing an inverse relationship with daytime SBP.<a class="elsevierStyleCrossRefs" href="#bib0125">1,2</a> Premature infants born with intrauterine growth restriction have higher nocturnal BP in childhood and adolescence.<a class="elsevierStyleCrossRefs" href="#bib0130">2,10</a> BP monitoring is advisable from an early age in such high-risk cases,<a class="elsevierStyleCrossRef" href="#bib0185">13</a> while regular BP measurement is recommended for all children from the age of three years.Methods of blood pressure measurement in childrenOffice measurement, home readings or ambulatory monitoring?Office BP measurement is the first step in identifying children with suspected hypertension.<a class="elsevierStyleCrossRef" href="#bib0130">2</a> However, BP values are subject to dynamic variations due to interactions among neurohormonal, behavioral and environmental factors.<a class="elsevierStyleCrossRef" href="#bib0165">9</a> BP is around 10% higher during waking hours than during sleep. An office BP measurement thus merely reflects a single point of a circadian variable.<a class="elsevierStyleCrossRefs" href="#bib0155">7,14</a> BP measurement under normal day-to-day conditions gives a more reliable figure than one obtained in the artificial environment of the physician's office.<a class="elsevierStyleCrossRef" href="#bib0195">15</a>Home (‘self-measured’) BP assessment is widely used in adults. However, it has two serious limitations in children: the lack of home devices that have been validated in the pediatric age-group, and the lack of accepted normative data for home BP levels in children.<a class="elsevierStyleCrossRef" href="#bib0130">2</a>Ambulatory blood pressure monitoring (ABPM) is well established for the assessment and treatment of hypertension in adults (including the elderly and pregnant women<a class="elsevierStyleCrossRef" href="#bib0205">17</a>) but has only relatively recently been used in children,<a class="elsevierStyleCrossRefs" href="#bib0130">2,16</a> the first reports dating to the 1990s.<a class="elsevierStyleCrossRef" href="#bib0210">18</a> It is now the method of choice for diagnosis and therapeutic monitoring in pediatric age-groups,<a class="elsevierStyleCrossRefs" href="#bib0135">3,8,9,14,17,18</a> especially in children at high cardiovascular risk.<a class="elsevierStyleCrossRef" href="#bib0215">19</a> The first consensus document on application and interpretation of ABPM in children and adolescents was published in 2008<a class="elsevierStyleCrossRef" href="#bib0125">1</a> and updated in 2014.<a class="elsevierStyleCrossRef" href="#bib0170">10</a>Although home BP measurement is more reliable and consistent than office measurements,<a class="elsevierStyleCrossRefs" href="#bib0135">3,14</a> its diagnostic sensitivity is only 81% and it is thus not recommended as an alternative to ABPM.<a class="elsevierStyleCrossRefs" href="#bib0125">1,9,20</a>Methodology of ambulatory blood pressure monitoring in childrenEquipmentMany of the recommendations for ABPM in adults are also applicable in children, but there are substantial differences.The equipment should be light and sturdy, and able to tolerate some subject movement without giving excessive error readings.<a class="elsevierStyleCrossRefs" href="#bib0125">1,17</a> Pediatric patients and their parents need to understand how the apparatus functions and be aware of the importance of keeping the arm still during BP readings.<a class="elsevierStyleCrossRef" href="#bib0125">1</a>Selection of the cuff is key to obtaining accurate BP readings. The width of the cuff should be 40%, and its length should be 80%, of the mid-arm circumference,<a class="elsevierStyleCrossRefs" href="#bib0125">1,3,17</a> measured at a point midway between the acromion and the olecranon. The cuff should be applied to the non-dominant arm to avoid interference with school work, unless contraindicated (for example due to an arteriovenous fistula).<a class="elsevierStyleCrossRefs" href="#bib0125">1,10</a> If there is a significant BP discrepancy between the arms, the monitor should be placed on the arm with the higher BP.There are two techniques for measuring BP: oscillometric and auscultatory.<a class="elsevierStyleCrossRef" href="#bib0125">1</a> Despite the known limitations of oscillometry, this is the technique used in most centers, as well as in the development of reference tables.<a class="elsevierStyleCrossRefs" href="#bib0125">1,3,17</a> Its main advantages are ease of use and fewer erroneous readings.AgeAlthough some trials have successfully included younger children, routine use of ABPM is limited to those aged five years or more.<a class="elsevierStyleCrossRef" href="#bib0125">1</a>The proportion of successful measurements increases from 87.5% at younger ages to 92.7% in older children, due to the fact that older children and adolescents are more likely to cooperate in performing the measurement correctly.<a class="elsevierStyleCrossRef" href="#bib0210">18</a>Frequency of assessmentThe software controlling the ABPM monitor can be programmed to record every 15-20 min throughout the 24 hours, adjustable from every 15 to 20 min during waking hours and from every 20 to 30 min during sleep.<a class="elsevierStyleCrossRef" href="#bib0170">10</a> The most common protocol is every 20 min during the day and every 30 min at night.<a class="elsevierStyleCrossRef" href="#bib0125">1</a>The best way to identify periods of wakefulness and sleep is by the patient recording times of waking and sleeping in a diary.<a class="elsevierStyleCrossRef" href="#bib0160">8</a>Most authors consider that a minimum of one or two readings per hour are required to consider an ABPM study to be interpretable.<a class="elsevierStyleCrossRefs" href="#bib0125">1,9,10</a> A sufficient number of valid BP recordings would be at least 40 to 50 readings for a full 24-hour report and 65-75% of all possible BP readings for a partial day report (depending on the protocol used).<a class="elsevierStyleCrossRef" href="#bib0125">1</a> Periods of over two hours without a valid reading compromise the quality of the exam.<a class="elsevierStyleCrossRef" href="#bib0170">10</a>Physical activityAn important concern in interpreting ABPM data in pediatric patients is how to divide the recording into sleep and wake times. This is usually done through the times of sleeping and waking recorded in the patient diary.<a class="elsevierStyleCrossRef" href="#bib0125">1</a>When accounting for levels of physical activity, most hypertension specialists recommend that children undergoing ABPM should continue their normal activities but refrain from contact sports and vigorous exercise.<a class="elsevierStyleCrossRef" href="#bib0125">1</a> ABPM is also incompatible with water sports.<a class="elsevierStyleCrossRef" href="#bib0155">7</a> Children should be told to stop moving and talking when the cuff inflates and to keep the arm still with the cuff at heart level.<a class="elsevierStyleCrossRef" href="#bib0225">21</a>DiaryChildren and their parents should be instructed to maintain a diary in which they record sleeping and waking times, naps, activities that may influence BP measurements, including stressful situations or exercise, and timing of anti-hypertensive medications.<a class="elsevierStyleCrossRefs" href="#bib0125">1,10</a>Symptoms such as dizziness should also be recorded, because up to 91% of children with a history of syncope demonstrate postural hypotension on ABPM.<a class="elsevierStyleCrossRef" href="#bib0170">10</a>Interpretation of ambulatory blood pressure monitoringValues that fall outside of the following range should be discarded<a class="elsevierStyleCrossRefs" href="#bib0170">10,17</a>:<ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005">•SBP 60-220 mmHg</li><li class="elsevierStyleListItem" id="lsti0010">•DBP 35-120 mmHg</li><li class="elsevierStyleListItem" id="lsti0015">•Heart rate 40-180 bpm</li><li class="elsevierStyleListItem" id="lsti0020">•Pulse pressure 40-120 mmHg.</li></ul>Mean arterial pressureMost ABPM devices calculate the 24-hour value of mean arterial pressure (MAP), the mean of SBP and DBP, and, on the basis of diary entries for sleeping and waking times, daytime and nocturnal MAP.<a class="elsevierStyleCrossRefs" href="#bib0125">1,10</a> These values can then be compared with reference values in order to interpret the exam.<a class="elsevierStyleCrossRef" href="#bib0125">1</a> It is preferred to use the tables for height, except in children less than 120 cm tall, in whom it may be necessary to use the tables by age.<a class="elsevierStyleCrossRef" href="#bib0165">9</a>Reference values are provided by the German Working Group on Pediatric Hypertension, published in 2002. However, this data set has several limitations: it includes only central European white children and relatively few shorter children (<140 cm in height), and shows a striking lack of variability in ambulatory DBP values. Thus, many authors consider that these normative values may not be representative of the normal ambulatory DBP in all pediatric patients.<a class="elsevierStyleCrossRef" href="#bib0170">10</a>It should be noted that BP values obtained from ABPM should not be interpreted with reference to values from single measurements,<a class="elsevierStyleCrossRefs" href="#bib0125">1,9</a> since ABPM values tend to be higher than the latter.<a class="elsevierStyleCrossRefs" href="#bib0165">9,10</a>Blood pressure loadBP load is defined as the percentage of valid measurements above the 95th percentile for age, gender and height.<a class="elsevierStyleCrossRefs" href="#bib0125">1,8,17</a> Like MAP, it can calculated for the entire 24-hour period or for daytime and nocturnal periods separately.<a class="elsevierStyleCrossRef" href="#bib0125">1</a>BP loads in excess of 25-30% are considered pathological<a class="elsevierStyleCrossRefs" href="#bib0125">1,2</a> and those in excess of 50% have been demonstrated to be predictive of left ventricular hypertrophy (LVH).<a class="elsevierStyleCrossRefs" href="#bib0160">8,17</a>A combination of MAP and BP load is used to categorize ABPM results as normal or abnormal (<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>).<a class="elsevierStyleCrossRefs" href="#bib0125">1,8,10</a><elsevierMultimedia ident="tbl0010"></elsevierMultimedia>Nocturnal dippingDipping refers to the physiological decline in BP during sleep, normally of ≥10% in mean SBP and DBP.<a class="elsevierStyleCrossRefs" href="#bib0125">1,8,9,16,17</a>ABPM is the only method that can measure nocturnal BP, which cannot be estimated by single measurements either at home or in a clinical setting.<a class="elsevierStyleCrossRef" href="#bib0240">24</a>A fall of less than 10% (non-dipper pattern) correlates with a higher likelihood of TOD and worse cardiovascular prognosis.<a class="elsevierStyleCrossRefs" href="#bib0155">7,9,16,22</a> This pattern is also seen in cases of sustained adrenergic stimulation, such as those resulting from disorders of the adrenal glands.Blood pressure variabilityABPM is also useful in the assessment of BP variability, which has prognostic value. The activity of BP regulatory systems is needed to meet the changing physical and psychological demands of a normal day.<a class="elsevierStyleCrossRef" href="#bib0125">1</a> Increased BP variability has been demonstrated in obese children and is most likely related to increased sympathetic nervous system activation. In adults, greater BP variability has been correlated with the development of hypertensive LVH.<a class="elsevierStyleCrossRef" href="#bib0125">1</a>Indications for ambulatory blood pressure monitoringThe main indication for ABPM is to confirm the diagnosis of hypertension, whether true hypertension, white coat hypertension (WCH) or masked hypertension (MH).<a class="elsevierStyleCrossRef" href="#bib0200">16</a>The recommendations for ABPM are listed in <a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a>.<a class="elsevierStyleCrossRefs" href="#bib0135">3,4</a><elsevierMultimedia ident="tbl0015"></elsevierMultimedia>White coat hypertensionOne of the most important indications for ABPM is to exclude WCH.<a class="elsevierStyleCrossRefs" href="#bib0125">1,7,9</a>WCH is defined as BP levels that are the 95th percentile or higher when measured in the physician's office or clinic but are completely normal (average BP <90th percentile) outside of a clinical setting.<a class="elsevierStyleCrossRef" href="#bib0125">1</a> It is a transient, stress-induced elevation of BP associated with the medical examination,<a class="elsevierStyleCrossRef" href="#bib0130">2</a> and is especially pronounced in younger patients, especially those aged under 12 years, and in obese patients.<a class="elsevierStyleCrossRef" href="#bib0130">2</a> Its incidence ranges between 22% and 40%, depending on the series,<a class="elsevierStyleCrossRefs" href="#bib0125">1,2,4,17</a> similar values to those seen in adults.<a class="elsevierStyleCrossRef" href="#bib0210">18</a>The likelihood of WCH decreases as office BP increases; children with office BP >10% above the 95th percentile are more likely to be true hypertensives.<a class="elsevierStyleCrossRef" href="#bib0125">1</a>WCH may not be entirely benign.<a class="elsevierStyleCrossRef" href="#bib0130">2</a> In adults with normal ABPM, BP variability increases with increasing BP and is associated with TOD (cardiovascular system, kidneys, central nervous system and retina<a class="elsevierStyleCrossRef" href="#bib0135">3</a>).<a class="elsevierStyleCrossRef" href="#bib0170">10</a>Several studies have shown that although left ventricular mass in children with WCH is within normal ranges, it is greater than in control groups, which means that these children should be closely monitored. Other forms of TOD, such as endothelial dysfunction and increased carotid intima-media thickness, are also associated with higher ABPM levels.<a class="elsevierStyleCrossRef" href="#bib0125">1</a> In fact, WCH may represent an intermediate stage between normotension and hypertension,<a class="elsevierStyleCrossRef" href="#bib0170">10</a> and some studies suggest that these children should be treated as having prehypertension.<a class="elsevierStyleCrossRef" href="#bib0200">16</a>Masked hypertensionABPM may also identify MH, defined as a normal office BP but elevated ambulatory levels.<a class="elsevierStyleCrossRefs" href="#bib0125">1,2,21</a> This condition, the etiology of which is poorly understood,<a class="elsevierStyleCrossRef" href="#bib0240">24</a> in children is associated with progression to sustained hypertension and LVH,<a class="elsevierStyleCrossRef" href="#bib0200">16</a> in a similar way to children with hypertension confirmed by ambulatory BP measurements.<a class="elsevierStyleCrossRef" href="#bib0240">24</a>MH may be suspected when there are previous reports of elevated clinical BP from other providers such as primary health care, or if the presence of LVH is inconsistent with the office BP.<a class="elsevierStyleCrossRefs" href="#bib0125">1,2,10</a>An excessive BP response to exercise testing, which has been observed in children with WCH, may also be a manifestation of MH, and in such cases ABPM is recommended. Longitudinal studies have shown that SBP during exercise is positively associated with future resting SBP, independently of resting SBP and other cardiovascular risk factors.<a class="elsevierStyleCrossRef" href="#bib0140">4</a>The prevalence of MH has not been clearly determined, ranging from 5.7% to 15% in different studies.<a class="elsevierStyleCrossRefs" href="#bib0125">1,3,4,9,10,16</a> It is more common in obese children,<a class="elsevierStyleCrossRef" href="#bib0230">22</a> especially if they display a non-dipper pattern.<a class="elsevierStyleCrossRef" href="#bib0170">10</a> It is also found in other conditions including diabetes, cardiomyopathy, hyperthyroidism,<a class="elsevierStyleCrossRefs" href="#bib0155">7,16</a> and obstructive sleep apnea.<a class="elsevierStyleCrossRef" href="#bib0165">9</a>Children with isolated nocturnal hypertension should be considered to have MH and the same significance should be attributed as to daytime hypertension. Its incidence is higher in children who have been transplanted (38%) and those with chronic kidney disease; renal transplantation appears to be a major risk factor for MH.<a class="elsevierStyleCrossRefs" href="#bib0165">9,22</a> Other factors include a high-salt diet and a sedentary lifestyle.<a class="elsevierStyleCrossRef" href="#bib0230">22</a>PrehypertensionPrehypertension is defined as office BP ≥90th percentile or >120/80 mmHg<a class="elsevierStyleCrossRef" href="#bib0175">11</a> and mean ambulatory BP <95th percentile with elevated BP loads.<a class="elsevierStyleCrossRef" href="#bib0170">10</a> It is recognized as a condition that requires assessment and follow-up, due to the risk of progression to sustained hypertension.<a class="elsevierStyleCrossRef" href="#bib0170">10</a>Patients with prehypertension demonstrate abnormalities on ABPM intermediate between normotensive and truly hypertensive people.<a class="elsevierStyleCrossRef" href="#bib0170">10</a> ABPM can be very helpful in stratifying risk for TOD, because even with normal mean BP, increased BP variability is associated with TOD in adults.<a class="elsevierStyleCrossRef" href="#bib0125">1</a>Adolescents with prehypertension already have higher LVM values, lower glomerular filtration rate, and increased urine protein excretion, as well as greater carotid intima-media thickness, than normotensive control subjects.<a class="elsevierStyleCrossRef" href="#bib0170">10</a>Assessment of risk for target organ damageLVH, thickening and stiffening of large arteries and urinary albumin excretion are the most easily assessed markers of TOD.<a class="elsevierStyleCrossRef" href="#bib0135">3</a> LVH remains to date the most thoroughly documented form of TOD caused by hypertension in children and adolescents.<a class="elsevierStyleCrossRef" href="#bib0135">3</a> The prevalence of LVH in children with hypertension is 8-41%, depending on the criteria used to define both hypertension and LVH; studies that use age-specific reference intervals show higher prevalences.<a class="elsevierStyleCrossRefs" href="#bib0140">4,23</a>Renal damage is rarely seen in children with essential hypertension, but these patients have higher albuminuria levels. The severity of albuminuria correlates with LVH.<a class="elsevierStyleCrossRef" href="#bib0140">4</a>In adults, ABPM, particularly nocturnal SBP and BP load,<a class="elsevierStyleCrossRef" href="#bib0125">1</a> is a better marker of TOD,<a class="elsevierStyleCrossRef" href="#bib0220">20</a> especially with LVH, than office BP readings. It also correlates better with renal damage as indicated by albuminuria. The albumin/creatinine ratio is strongly related to variability of DBP.<a class="elsevierStyleCrossRef" href="#bib0125">1</a>Higher SBP values at the age of 12 years are associated with carotid intima-media thickening in adulthood, which in turn is correlated with higher risk for developing atherosclerosis at older ages.<a class="elsevierStyleCrossRefs" href="#bib0135">3,4</a> Changes in vascular function are also more common in children with higher BP levels.<a class="elsevierStyleCrossRefs" href="#bib0135">3,10</a>Assessment of secondary hypertensionSecondary hypertension is more common in children than in adults.<a class="elsevierStyleCrossRef" href="#bib0135">3</a> Hypertension detected in very young children, or in children with systemic conditions and a diagnosis of stage 2 hypertension, is suggestive of secondary hypertension.<a class="elsevierStyleCrossRef" href="#bib0125">1</a> The likelihood of identifying a secondary cause of hypertension is inversely related to the age of the child and directly related to the degree of BP elevation.<a class="elsevierStyleCrossRef" href="#bib0135">3</a>ABPM may be useful in differentiating primary from secondary hypertension, since children with secondary hypertension manifest greater nocturnal SBP loads and greater daytime and nocturnal DBP loads, as well as decreased nocturnal dipping.<a class="elsevierStyleCrossRefs" href="#bib0125">1,16</a>Assessment of efficacy of antihypertensive therapyABPM is useful for assessing response to antihypertensive therapy and to identify those with uncontrolled hypertension, especially in patients with isolated nocturnal hypertension<a class="elsevierStyleCrossRef" href="#bib0200">16</a> or secondary hypertension,<a class="elsevierStyleCrossRef" href="#bib0170">10</a> in cases of apparently drug-resistant hypertension, or when the symptoms of hypertension are suspected of being secondary to medication.<a class="elsevierStyleCrossRefs" href="#bib0125">1,14,16</a>ABPM is also valuable in the identification of periods of hypertension when medication is ineffective, in order to optimize the timing of medication with respect to circadian BP patterns.<a class="elsevierStyleCrossRef" href="#bib0200">16</a>Characterization of blood pressure profile in children with chronic disease that could lead to hypertensionHypertension is common in children and adolescents with chronic renal disease. It has a very high prevalence in children undergoing dialysis, in whom 40% of mortality is due to cardiovascular causes.<a class="elsevierStyleCrossRef" href="#bib0220">20</a>Non-dipping in patients undergoing dialysis may be an independent predictor of poor cardiovascular outcomes.<a class="elsevierStyleCrossRef" href="#bib0220">20</a>Since the reference values were obtained in healthy children, there are doubts concerning their applicability in children with chronic conditions such as renal disease, as well as concerning determination of the ideal BP values for children at risk for hypertension.<a class="elsevierStyleCrossRef" href="#bib0155">7</a>Some authors argue that in children with chronic renal disease, BP should be maintained below the 50th percentile for age and gender. Hypertension is a determining factor for progression to renal failure, and so prompt treatment is protective and can avoid the need for renal replacement therapy (dialysis or transplantation), improving survival and quality of life.<a class="elsevierStyleCrossRef" href="#bib0155">7</a>Isolated nocturnal hypertension is common in children undergoing solid organ transplantation (22-41% of cases) and various studies have shown that it is the most frequent type of hypertension in these patients.<a class="elsevierStyleCrossRef" href="#bib0230">22</a> Its etiology is multifactorial, the main causes being steroid therapy, sodium retention, chronic rejection, and stenosis of the transplanted renal artery.<a class="elsevierStyleCrossRef" href="#bib0230">22</a>Cardiovascular risk factorsTotal adiposity and insulin resistance have been correlated with a high prevalence of the nondipping phenomenon, as has higher salt intake.<a class="elsevierStyleCrossRef" href="#bib0125">1</a>Abnormally elevated daytime and nocturnal BP levels, and diminished dipping, have been demonstrated in children with type 2 diabetes. These changes may be related to subclinical vascular damage<a class="elsevierStyleCrossRef" href="#bib0155">7</a> and renal disease and may be an early marker for renal deterioration.<a class="elsevierStyleCrossRefs" href="#bib0125">1,22</a>In unilateral multicystic dysplastic kidney, ABPM is of particular value for the early detection of elevated BP, in view of the risk of secondary damage to the contralateral kidney.<a class="elsevierStyleCrossRef" href="#bib0155">7</a>Daytime BP variability is increased and a non-dipper pattern is observed at night in 68.7% of children with obstructive sleep apnea.<a class="elsevierStyleCrossRefs" href="#bib0125">1,16,21</a>Higher MAP levels are seen on ABPM in sedentary children, those subjected to psychosocial stress and those medicated with stimulants, such as in attention deficit hyperactivity disorder.<a class="elsevierStyleCrossRef" href="#bib0125">1</a>ContraindicationsThe contraindications for ABPM are<a class="elsevierStyleCrossRefs" href="#bib0125">1,17</a>:<ul class="elsevierStyleList" id="lis0010"><li class="elsevierStyleListItem" id="lsti0025">•Coagulation disorders</li><li class="elsevierStyleListItem" id="lsti0030">•Cardiac rhythm disorders (e.g. atrial fibrillation)</li><li class="elsevierStyleListItem" id="lsti0035">•Known allergies to elements of the monitoring device.</li></ul>Although serious adverse events such as venous thrombosis have not been reported in children, mild sleep disturbances,<a class="elsevierStyleCrossRef" href="#bib0125">1</a> petechiae and ecchymosis<a class="elsevierStyleCrossRef" href="#bib0205">17</a> have been documented.ConclusionsThe prevalence of hypertension in children and adolescents is rising worldwide, largely due to increased adiposity. Timely diagnosis of hypertension in children can potentially reduce the risk of future cardiovascular disease.<a class="elsevierStyleCrossRef" href="#bib0145">5</a>ABPM enables the diagnosis and classification of hypertension, provides cardiovascular prognostic information<a class="elsevierStyleCrossRef" href="#bib0220">20</a> and identifies patients with WCH or MH, which are intermediate phenotypes of hypertension.<a class="elsevierStyleCrossRef" href="#bib0240">24</a>Conflicts of interestThe authors have no conflicts of interest to declare." "textoCompletoSecciones" => array:1 [ "secciones" => array:10 [ 0 => array:3 [ "identificador" => "xres1270135" "titulo" => "Abstract" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0005" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec1175480" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres1270134" "titulo" => "Resumo" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0010" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec1175479" "titulo" => "Palavras-chave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:2 [ "identificador" => "sec0010" "titulo" => "Definition of hypertension" ] 6 => array:3 [ "identificador" => "sec0015" "titulo" => "Methods of blood pressure measurement in children" "secciones" => array:5 [ 0 => array:2 [ "identificador" => "sec0020" "titulo" => "Office measurement, home readings or ambulatory monitoring?" ] 1 => array:3 [ "identificador" => "sec0025" "titulo" => "Methodology of ambulatory blood pressure monitoring in children" "secciones" => array:5 [ 0 => array:2 [ "identificador" => "sec0030" "titulo" => "Equipment" ] 1 => array:2 [ "identificador" => "sec0035" "titulo" => "Age" ] 2 => array:2 [ "identificador" => "sec0040" "titulo" => "Frequency of assessment" ] 3 => array:2 [ "identificador" => "sec0045" "titulo" => "Physical activity" ] 4 => array:2 [ "identificador" => "sec0050" "titulo" => "Diary" ] ] ] 2 => array:3 [ "identificador" => "sec0055" "titulo" => "Interpretation of ambulatory blood pressure monitoring" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "sec0060" "titulo" => "Mean arterial pressure" ] 1 => array:2 [ "identificador" => "sec0065" "titulo" => "Blood pressure load" ] 2 => array:2 [ "identificador" => "sec0070" "titulo" => "Nocturnal dipping" ] 3 => array:2 [ "identificador" => "sec0075" "titulo" => "Blood pressure variability" ] ] ] 3 => array:3 [ "identificador" => "sec0080" "titulo" => "Indications for ambulatory blood pressure monitoring" "secciones" => array:8 [ 0 => array:2 [ "identificador" => "sec0100" "titulo" => "White coat hypertension" ] 1 => array:2 [ "identificador" => "sec0105" "titulo" => "Masked hypertension" ] 2 => array:2 [ "identificador" => "sec0110" "titulo" => "Prehypertension" ] 3 => array:2 [ "identificador" => "sec0115" "titulo" => "Assessment of risk for target organ damage" ] 4 => array:2 [ "identificador" => "sec0120" "titulo" => "Assessment of secondary hypertension" ] 5 => array:2 [ "identificador" => "sec0125" "titulo" => "Assessment of efficacy of antihypertensive therapy" ] 6 => array:2 [ "identificador" => "sec0130" "titulo" => "Characterization of blood pressure profile in children with chronic disease that could lead to hypertension" ] 7 => array:2 [ "identificador" => "sec0135" "titulo" => "Cardiovascular risk factors" ] ] ] 4 => array:2 [ "identificador" => "sec0085" "titulo" => "Contraindications" ] ] ] 7 => array:2 [ "identificador" => "sec0090" "titulo" => "Conclusions" ] 8 => array:2 [ "identificador" => "sec0095" "titulo" => "Conflicts of interest" ] 9 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec1175480" "palabras" => array:6 [ 0 => "Pediatric age" 1 => "High blood pressure" 2 => "Ambulatory blood pressure monitoring" 3 => "White coat hypertension" 4 => "Masked hypertension" 5 => "Target organ damage" ] ] ] "pt" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palavras-chave" "identificador" => "xpalclavsec1175479" "palabras" => array:6 [ 0 => "Idade pediátrica" 1 => "Hipertensão arterial" 2 => "Monitorização ambulatória de pressão arterial" 3 => "Hipertensão da bata branca" 4 => "Hipertensão mascarada" 5 => "Lesão de órgão alvo" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:2 [ "titulo" => "Abstract" "resumen" => "The prevalence of high blood pressure (BP) at pediatric age has increased progressively, one of the causes of which is obesity. However, the dominant etiology in this age group is renal and/or cardiovascular pathology. Ambulatory blood pressure monitoring (ABPM) is the method of choice for the diagnosis of hypertension, especially in children at high cardiovascular risk. Its use is limited to children from five years of age. Choosing appropriate cuff size is key to obtaining correct blood pressure.The main indication for ABPM is to confirm the diagnosis of hypertension. It also allows the diagnosis of white coat hypertension (which may represent an intermediate stage between the normotensive phase and hypertension), or masked hypertension, associated with progression to sustained hypertension and left ventricular hypertrophy (LVH). Children with isolated nocturnal hypertension should be considered as having masked hypertension.BP load is defined as the percentage of valid measurements above the 95th percentile for age, gender, and height. Values above 25-30% are pathological and those above 50% are predictive of LVH. ABPM correlates with target organ damage, particularly LVH and renal damage. It is useful in the differentiation of secondary hypertension, since these children show higher BP load and less nocturnal dipping, and confirmation of response to therapy. Thus ABPM allows the diagnosis and classification of hypertension, provides cardiovascular prognostic information and identifies patients with intermediate phenotypes of hypertension." ] "pt" => array:2 [ "titulo" => "Resumo" "resumen" => "Em idade pediátrica a prevalência da hipertensão arterial (HTA) tem aumentado progressivamente, sendo a obesidade uma das responsáveis. Apesar disso, a etiologia dominante nesta faixa etária é a patologia renal e/ou a cardiovascular. A monitorização ambulatória de pressão arterial (MAPA) é o método de eleição para o diagnóstico de HTA, especialmente em crianças com risco cardiovascular elevado. O seu uso está limitado a crianças a partir dos cinco anos. A seleção do tamanho da braçadeira é o ponto chave na obtenção de leituras corretas da tensão arterial (TA).O MAPA tem como principal indicação a confirmação do diagnóstico de HTA. Também permite diagnosticar hipertensão da bata branca (que pode representar um estádio intermédio entre a fase normotensa e a hipertensão), ou hipertensão mascarada, associada a progressão para hipertensão mantida e HVE. As crianças com HTA noturna isolada devem ser consideradas como portadoras de hipertensão mascarada. A carga tensional é definida como a percentagem de medições válidas acima do p95 para a idade, sexo e estatura, sendo que valores superiores a 25-30% são patológicos e superiores a 50% são preditivos de hipertrofia ventricular esquerda (HVE). O MAPA correlaciona-se com lesão de órgão alvo, nomeadamente com a HVE e a lesão renal. É útil na diferenciação da hipertensão secundária, já que estas crianças manifestam maiores cargas tensionais e menor dipping nocturno, e na confirmação da resposta à terapêutica.Assim, o MAPA permite o diagnóstico e a classificação da HTA, fornece informação prognóstica cardiovascular e identifica doentes com fenótipos intermédios de HTA." ] ] "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "Please cite this article as: Andrade H, Pires A, Noronha N, Amaral ME, Lopes L, Martins P, et al. Importância da monitorização ambulatória da pressão arterial no diagnóstico e prognóstico da hipertensão arterial em idade pediátrica. Rev Port Cardiol. 2018;37:783–789." ] ] "multimedia" => array:3 [ 0 => array:8 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at1" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:2 [ "leyenda" => "p90: 90th percentile; p95: 95th percentile; p99: 99th percentile; DBP: diastolic blood pressure; ISH: isolated systolic hypertension; SBP: systolic blood pressure." "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">0-15 years \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">16 years and older \t\t\t\t\t\t\n \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Normal \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><130/85 mmHg \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">High-normal \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">≥p90 to \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">130-139/85-89 mmHg \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Hypertension \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">≥p95 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">≥140/90 mmHg \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Stage 1 hypertension \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">p95 to p99 plus 5 mmHg \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">140-159/90-99 mmHg \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Stage 2 hypertension \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">>p99 plus 5 mmHg \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">160-179/100-109 mmHg \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">ISH \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">SBP ≥p95 and DBP \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">≥140/<90 mmHg \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab2172781.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Classification of hypertension in children and adolescents." ] ] 1 => array:8 [ "identificador" => "tbl0010" "etiqueta" => "Table 2" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at2" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:2 [ "leyenda" => "p90: 90th percentile; p95: 95th percentile; p99: 99th percentile; BP: blood pressure; MAP: mean arterial pressure; MH: masked hypertension; WCH: white coat hypertension." "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Office BP \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Ambulatory MAP \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">BP load (%) \t\t\t\t\t\t\n \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Normal \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">≤p90 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><25 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">WCH \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">≥p95 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><25 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Prehypertension \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">≥p90 or >120/80 mmHg \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">≥25 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">MH \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">>p95 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">≥25 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Stage 1 hypertension \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">>p95 to \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">25-50 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Stage 2 hypertension \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">≥p99 plus 5 mmHg \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">≥P95 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">25-50 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Stage 3 hypertension \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">≥p99 plus 5 mmHg \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">≥p95 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">>50 \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab2172779.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Interpretation of ambulatory blood pressure monitoring results and classification of hypertension." ] ] 2 => array:8 [ "identificador" => "tbl0015" "etiqueta" => "Table 3" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at3" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:2 [ "leyenda" => "BP: blood pressure; TOD: target organ damage." "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">During the process of diagnosis \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">To confirm hypertension before starting antihypertensive drug treatmentTOD and normal office BPType 1 and 2 diabetesChronic kidney diseaseRenal, liver or heart transplantSevere obesityHypertensive response during exercise testing \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">During antihypertensive drug treatment \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Evaluation of refractory hypertensionAssessment of BP control in children with TODSymptoms of hypotension \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Other clinical conditions \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Autonomic dysfunctionSuspicion of catecholamine-secreting tumors \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab2172780.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Recommendations for ambulatory blood pressure monitoring." ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0015" "bibliografiaReferencia" => array:24 [ 0 => array:3 [ "identificador" => "bib0125" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Ambulatory blood pressure monitoring in children and adolescents: recommendations for standard assessment. A scientific statement from the American Heart Association, Atherosclerosis Hypertension, and Obesity in Youth Committee of the Council on Cardiovascular Disease in the Young and the Council for High Blood Pressure Research" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:3 [ 0 => "E. Urbina" 1 => "B. Alpert" 2 => "J. Flynn" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1161/HYPERTENSIONAHA.108.190329" "Revista" => array:6 [ "tituloSerie" => "Hypertension" "fecha" => "2008" "volumen" => "52" "paginaInicial" => "433" "paginaFinal" => "451" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/18678786" "web" => "Medline" ] ] ] ] ] ] ] ] 1 => array:3 [ "identificador" => "bib0130" "etiqueta" => "2" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Pediatric ambulatory blood pressure monitoring: indications and interpretations" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "J. Flynn" 1 => "E. Urbina" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:5 [ "tituloSerie" => "J Clin Hypertens" "fecha" => "2012" "volumen" => "14" "paginaInicial" => "372" "paginaFinal" => "382" ] ] ] ] ] ] 2 => array:3 [ "identificador" => "bib0135" "etiqueta" => "3" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Management of high blood pressure in children and adolescents: recommendations of the European Society of Hypertension" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:3 [ 0 => "E. Lurbe" 1 => "R. Cifkova" 2 => "J.K. 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Importance of ambulatory blood pressure monitoring in the diagnosis and prognosis of pediatric hypertension

Importância da monitorização ambulatória da pressão arterial no diagnóstico e prognóstico da hipertensão arterial em idade pediátrica

Helena Andrade

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helenaandradecarvalho@gmail.com

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, António Pires, Natália Noronha, Maria Emanuel Amaral, Lisete Lopes, Paula Martins, António Marinho da Silva, Eduardo Castela

Serviço de Cardiologia Pediátrica, Hospital Pediátrico de Coimbra, Centro Hospitalar e Universitário de Coimbra, Coimbra, Portugal

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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">One in four adults worldwide is hypertensive&#46; The prevalence of hypertension at pediatric age is increasing&#44;<a class="elsevierStyleCrossRefs" href="#bib0125"><span class="elsevierStyleSup">1&#8211;4</span></a> particularly in developed countries&#44;<a class="elsevierStyleCrossRef" href="#bib0145"><span class="elsevierStyleSup">5</span></a> with recent data showing prevalences around 4&#37; and that of prehypertension reaching 10&#37;&#46;<a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">2</span></a> In Portugal&#44; a study by Maldonado et al&#46;<a class="elsevierStyleCrossRef" href="#bib0150"><span class="elsevierStyleSup">6</span></a> analyzing 5381 children found that 12&#46;8&#37; were hypertensive&#46;<a class="elsevierStyleCrossRef" href="#bib0150"><span class="elsevierStyleSup">6</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">Increasing obesity has led to changes in blood pressure &#40;BP&#41; patterns&#44; including elevated BP levels in children and adolescents&#46;<a class="elsevierStyleCrossRefs" href="#bib0125"><span class="elsevierStyleSup">1&#44;5</span></a> Sustained adiposity and hence higher BP in childhood will tend to increase the prevalence of hypertension and its complications in adulthood&#46;<a class="elsevierStyleCrossRefs" href="#bib0135"><span class="elsevierStyleSup">3&#44;7&#8211;9</span></a> Obesity is the cardiovascular risk factor with the strongest relationship with BP&#44; and higher body mass index is associated with progression from prehypertension to hypertension&#46;<a class="elsevierStyleCrossRef" href="#bib0170"><span class="elsevierStyleSup">10</span></a> However&#44; the dominant etiology of hypertension in this age-group is renal and&#47;or cardiovascular pathology&#46;<a class="elsevierStyleCrossRef" href="#bib0155"><span class="elsevierStyleSup">7</span></a></p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Definition of hypertension</span><p id="par0015" class="elsevierStylePara elsevierViewall">The definition of hypertension in children has undergone significant changes in recent decades&#46;<a class="elsevierStyleCrossRef" href="#bib0160"><span class="elsevierStyleSup">8</span></a> The European Society of Hypertension &#40;ESH&#41; guidelines&#44; published in 2016&#44;<a class="elsevierStyleCrossRef" href="#bib0140"><span class="elsevierStyleSup">4</span></a> classified resting BP values for children aged 0-15 years &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#41; based on percentiles&#44; while for those aged 16 or older the consensus was that the definitions used should be based on the absolute cut-offs used for adults&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0020" class="elsevierStylePara elsevierViewall">Hypertension in children is generally defined as systolic blood pressure &#40;SBP&#41; and&#47;or diastolic blood pressure &#40;DBP&#41; at or above the 95th percentile on three or more separate occasions&#46;<a class="elsevierStyleCrossRefs" href="#bib0130"><span class="elsevierStyleSup">2&#8211;4&#44;11</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">The ESH guidelines<a class="elsevierStyleCrossRef" href="#bib0140"><span class="elsevierStyleSup">4</span></a> also stress the importance of isolated systolic hypertension &#40;ISH&#41;&#44; the clinical significance of which in youth is still debated&#46; ISH is the most prevalent form of elevated BP in adults aged over 50 years and its causes are multifactorial&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">Neonatal hypertension has been defined as SBP at or above the 95th percentile for gender&#44; gestational age and postnatal age&#46; Its incidence is low &#40;0&#46;2-3&#37;&#41; and a history of umbilical catheterization is an important risk factor&#46;<a class="elsevierStyleCrossRef" href="#bib0180"><span class="elsevierStyleSup">12</span></a> The importance of intrauterine and early life events in the development of cardiometabolic disease in adult life has been underlined&#46;<a class="elsevierStyleCrossRef" href="#bib0140"><span class="elsevierStyleSup">4</span></a> The time immediately before and after birth is a sensitive period in which multiple interactions between hemodynamic and metabolic parameters may contribute to risk of cardiometabolic disease&#46;<a class="elsevierStyleCrossRef" href="#bib0140"><span class="elsevierStyleSup">4</span></a> Target organ damage &#40;TOD&#41; has been reported in persistent neonatal hypertension&#46;<a class="elsevierStyleCrossRef" href="#bib0185"><span class="elsevierStyleSup">13</span></a></p><p id="par0035" class="elsevierStylePara elsevierViewall">Birth weight affects ambulatory BP&#44; with various studies showing an inverse relationship with daytime SBP&#46;<a class="elsevierStyleCrossRefs" href="#bib0125"><span class="elsevierStyleSup">1&#44;2</span></a> Premature infants born with intrauterine growth restriction have higher nocturnal BP in childhood and adolescence&#46;<a class="elsevierStyleCrossRefs" href="#bib0130"><span class="elsevierStyleSup">2&#44;10</span></a> BP monitoring is advisable from an early age in such high-risk cases&#44;<a class="elsevierStyleCrossRef" href="#bib0185"><span class="elsevierStyleSup">13</span></a> while regular BP measurement is recommended for all children from the age of three years&#46;</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Methods of blood pressure measurement in children</span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Office measurement&#44; home readings or ambulatory monitoring&#63;</span><p id="par0040" class="elsevierStylePara elsevierViewall">Office BP measurement is the first step in identifying children with suspected hypertension&#46;<a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">2</span></a> However&#44; BP values are subject to dynamic variations due to interactions among neurohormonal&#44; behavioral and environmental factors&#46;<a class="elsevierStyleCrossRef" href="#bib0165"><span class="elsevierStyleSup">9</span></a> BP is around 10&#37; higher during waking hours than during sleep&#46; An office BP measurement thus merely reflects a single point of a circadian variable&#46;<a class="elsevierStyleCrossRefs" href="#bib0155"><span class="elsevierStyleSup">7&#44;14</span></a> BP measurement under normal day-to-day conditions gives a more reliable figure than one obtained in the artificial environment of the physician&#39;s office&#46;<a class="elsevierStyleCrossRef" href="#bib0195"><span class="elsevierStyleSup">15</span></a></p><p id="par0045" class="elsevierStylePara elsevierViewall">Home &#40;&#8216;self-measured&#8217;&#41; BP assessment is widely used in adults&#46; However&#44; it has two serious limitations in children&#58; the lack of home devices that have been validated in the pediatric age-group&#44; and the lack of accepted normative data for home BP levels in children&#46;<a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">2</span></a></p><p id="par0050" class="elsevierStylePara elsevierViewall">Ambulatory blood pressure monitoring &#40;ABPM&#41; is well established for the assessment and treatment of hypertension in adults &#40;including the elderly and pregnant women<a class="elsevierStyleCrossRef" href="#bib0205"><span class="elsevierStyleSup">17</span></a>&#41; but has only relatively recently been used in children&#44;<a class="elsevierStyleCrossRefs" href="#bib0130"><span class="elsevierStyleSup">2&#44;16</span></a> the first reports dating to the 1990s&#46;<a class="elsevierStyleCrossRef" href="#bib0210"><span class="elsevierStyleSup">18</span></a> It is now the method of choice for diagnosis and therapeutic monitoring in pediatric age-groups&#44;<a class="elsevierStyleCrossRefs" href="#bib0135"><span class="elsevierStyleSup">3&#44;8&#44;9&#44;14&#44;17&#44;18</span></a> especially in children at high cardiovascular risk&#46;<a class="elsevierStyleCrossRef" href="#bib0215"><span class="elsevierStyleSup">19</span></a> The first consensus document on application and interpretation of ABPM in children and adolescents was published in 2008<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">1</span></a> and updated in 2014&#46;<a class="elsevierStyleCrossRef" href="#bib0170"><span class="elsevierStyleSup">10</span></a></p><p id="par0055" class="elsevierStylePara elsevierViewall">Although home BP measurement is more reliable and consistent than office measurements&#44;<a class="elsevierStyleCrossRefs" href="#bib0135"><span class="elsevierStyleSup">3&#44;14</span></a> its diagnostic sensitivity is only 81&#37; and it is thus not recommended as an alternative to ABPM&#46;<a class="elsevierStyleCrossRefs" href="#bib0125"><span class="elsevierStyleSup">1&#44;9&#44;20</span></a></p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Methodology of ambulatory blood pressure monitoring in children</span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Equipment</span><p id="par0060" class="elsevierStylePara elsevierViewall">Many of the recommendations for ABPM in adults are also applicable in children&#44; but there are substantial differences&#46;</p><p id="par0065" class="elsevierStylePara elsevierViewall">The equipment should be light and sturdy&#44; and able to tolerate some subject movement without giving excessive error readings&#46;<a class="elsevierStyleCrossRefs" href="#bib0125"><span class="elsevierStyleSup">1&#44;17</span></a> Pediatric patients and their parents need to understand how the apparatus functions and be aware of the importance of keeping the arm still during BP readings&#46;<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">1</span></a></p><p id="par0070" class="elsevierStylePara elsevierViewall">Selection of the cuff is key to obtaining accurate BP readings&#46; The width of the cuff should be 40&#37;&#44; and its length should be 80&#37;&#44; of the mid-arm circumference&#44;<a class="elsevierStyleCrossRefs" href="#bib0125"><span class="elsevierStyleSup">1&#44;3&#44;17</span></a> measured at a point midway between the acromion and the olecranon&#46; The cuff should be applied to the non-dominant arm to avoid interference with school work&#44; unless contraindicated &#40;for example due to an arteriovenous fistula&#41;&#46;<a class="elsevierStyleCrossRefs" href="#bib0125"><span class="elsevierStyleSup">1&#44;10</span></a> If there is a significant BP discrepancy between the arms&#44; the monitor should be placed on the arm with the higher BP&#46;</p><p id="par0075" class="elsevierStylePara elsevierViewall">There are two techniques for measuring BP&#58; oscillometric and auscultatory&#46;<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">1</span></a> Despite the known limitations of oscillometry&#44; this is the technique used in most centers&#44; as well as in the development of reference tables&#46;<a class="elsevierStyleCrossRefs" href="#bib0125"><span class="elsevierStyleSup">1&#44;3&#44;17</span></a> Its main advantages are ease of use and fewer erroneous readings&#46;</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Age</span><p id="par0080" class="elsevierStylePara elsevierViewall">Although some trials have successfully included younger children&#44; routine use of ABPM is limited to those aged five years or more&#46;<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">1</span></a></p><p id="par0085" class="elsevierStylePara elsevierViewall">The proportion of successful measurements increases from 87&#46;5&#37; at younger ages to 92&#46;7&#37; in older children&#44; due to the fact that older children and adolescents are more likely to cooperate in performing the measurement correctly&#46;<a class="elsevierStyleCrossRef" href="#bib0210"><span class="elsevierStyleSup">18</span></a></p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0060">Frequency of assessment</span><p id="par0090" class="elsevierStylePara elsevierViewall">The software controlling the ABPM monitor can be programmed to record every 15-20 min throughout the 24 hours&#44; adjustable from every 15 to 20 min during waking hours and from every 20 to 30 min during sleep&#46;<a class="elsevierStyleCrossRef" href="#bib0170"><span class="elsevierStyleSup">10</span></a> The most common protocol is every 20 min during the day and every 30 min at night&#46;<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">1</span></a></p><p id="par0095" class="elsevierStylePara elsevierViewall">The best way to identify periods of wakefulness and sleep is by the patient recording times of waking and sleeping in a diary&#46;<a class="elsevierStyleCrossRef" href="#bib0160"><span class="elsevierStyleSup">8</span></a></p><p id="par0100" class="elsevierStylePara elsevierViewall">Most authors consider that a minimum of one or two readings per hour are required to consider an ABPM study to be interpretable&#46;<a class="elsevierStyleCrossRefs" href="#bib0125"><span class="elsevierStyleSup">1&#44;9&#44;10</span></a> A sufficient number of valid BP recordings would be at least 40 to 50 readings for a full 24-hour report and 65-75&#37; of all possible BP readings for a partial day report &#40;depending on the protocol used&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">1</span></a> Periods of over two hours without a valid reading compromise the quality of the exam&#46;<a class="elsevierStyleCrossRef" href="#bib0170"><span class="elsevierStyleSup">10</span></a></p></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Physical activity</span><p id="par0105" class="elsevierStylePara elsevierViewall">An important concern in interpreting ABPM data in pediatric patients is how to divide the recording into sleep and wake times&#46; This is usually done through the times of sleeping and waking recorded in the patient diary&#46;<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">1</span></a></p><p id="par0110" class="elsevierStylePara elsevierViewall">When accounting for levels of physical activity&#44; most hypertension specialists recommend that children undergoing ABPM should continue their normal activities but refrain from contact sports and vigorous exercise&#46;<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">1</span></a> ABPM is also incompatible with water sports&#46;<a class="elsevierStyleCrossRef" href="#bib0155"><span class="elsevierStyleSup">7</span></a> Children should be told to stop moving and talking when the cuff inflates and to keep the arm still with the cuff at heart level&#46;<a class="elsevierStyleCrossRef" href="#bib0225"><span class="elsevierStyleSup">21</span></a></p></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Diary</span><p id="par0115" class="elsevierStylePara elsevierViewall">Children and their parents should be instructed to maintain a diary in which they record sleeping and waking times&#44; naps&#44; activities that may influence BP measurements&#44; including stressful situations or exercise&#44; and timing of anti-hypertensive medications&#46;<a class="elsevierStyleCrossRefs" href="#bib0125"><span class="elsevierStyleSup">1&#44;10</span></a></p><p id="par0120" class="elsevierStylePara elsevierViewall">Symptoms such as dizziness should also be recorded&#44; because up to 91&#37; of children with a history of syncope demonstrate postural hypotension on ABPM&#46;<a class="elsevierStyleCrossRef" href="#bib0170"><span class="elsevierStyleSup">10</span></a></p></span></span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Interpretation of ambulatory blood pressure monitoring</span><p id="par0125" class="elsevierStylePara elsevierViewall">Values that fall outside of the following range should be discarded<a class="elsevierStyleCrossRefs" href="#bib0170"><span class="elsevierStyleSup">10&#44;17</span></a>&#58;<ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005"><span class="elsevierStyleLabel">&#8226;</span><p id="par0130" class="elsevierStylePara elsevierViewall">SBP 60-220 mmHg</p></li><li class="elsevierStyleListItem" id="lsti0010"><span class="elsevierStyleLabel">&#8226;</span><p id="par0135" class="elsevierStylePara elsevierViewall">DBP 35-120 mmHg</p></li><li class="elsevierStyleListItem" id="lsti0015"><span class="elsevierStyleLabel">&#8226;</span><p id="par0140" class="elsevierStylePara elsevierViewall">Heart rate 40-180 bpm</p></li><li class="elsevierStyleListItem" id="lsti0020"><span class="elsevierStyleLabel">&#8226;</span><p id="par0145" class="elsevierStylePara elsevierViewall">Pulse pressure 40-120 mmHg&#46;</p></li></ul></p><span id="sec0060" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Mean arterial pressure</span><p id="par0150" class="elsevierStylePara elsevierViewall">Most ABPM devices calculate the 24-hour value of mean arterial pressure &#40;MAP&#41;&#44; the mean of SBP and DBP&#44; and&#44; on the basis of diary entries for sleeping and waking times&#44; daytime and nocturnal MAP&#46;<a class="elsevierStyleCrossRefs" href="#bib0125"><span class="elsevierStyleSup">1&#44;10</span></a> These values can then be compared with reference values in order to interpret the exam&#46;<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">1</span></a> It is preferred to use the tables for height&#44; except in children less than 120 cm tall&#44; in whom it may be necessary to use the tables by age&#46;<a class="elsevierStyleCrossRef" href="#bib0165"><span class="elsevierStyleSup">9</span></a></p><p id="par0155" class="elsevierStylePara elsevierViewall">Reference values are provided by the German Working Group on Pediatric Hypertension&#44; published in 2002&#46; However&#44; this data set has several limitations&#58; it includes only central European white children and relatively few shorter children &#40;&#60;140 cm in height&#41;&#44; and shows a striking lack of variability in ambulatory DBP values&#46; Thus&#44; many authors consider that these normative values may not be representative of the normal ambulatory DBP in all pediatric patients&#46;<a class="elsevierStyleCrossRef" href="#bib0170"><span class="elsevierStyleSup">10</span></a></p><p id="par0160" class="elsevierStylePara elsevierViewall">It should be noted that BP values obtained from ABPM should not be interpreted with reference to values from single measurements&#44;<a class="elsevierStyleCrossRefs" href="#bib0125"><span class="elsevierStyleSup">1&#44;9</span></a> since ABPM values tend to be higher than the latter&#46;<a class="elsevierStyleCrossRefs" href="#bib0165"><span class="elsevierStyleSup">9&#44;10</span></a></p></span><span id="sec0065" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Blood pressure load</span><p id="par0165" class="elsevierStylePara elsevierViewall">BP load is defined as the percentage of valid measurements above the 95th percentile for age&#44; gender and height&#46;<a class="elsevierStyleCrossRefs" href="#bib0125"><span class="elsevierStyleSup">1&#44;8&#44;17</span></a> Like MAP&#44; it can calculated for the entire 24-hour period or for daytime and nocturnal periods separately&#46;<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">1</span></a></p><p id="par0170" class="elsevierStylePara elsevierViewall">BP loads in excess of 25-30&#37; are considered pathological<a class="elsevierStyleCrossRefs" href="#bib0125"><span class="elsevierStyleSup">1&#44;2</span></a> and those in excess of 50&#37; have been demonstrated to be predictive of left ventricular hypertrophy &#40;LVH&#41;&#46;<a class="elsevierStyleCrossRefs" href="#bib0160"><span class="elsevierStyleSup">8&#44;17</span></a></p><p id="par0175" class="elsevierStylePara elsevierViewall">A combination of MAP and BP load is used to categorize ABPM results as normal or abnormal &#40;<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>&#41;&#46;<a class="elsevierStyleCrossRefs" href="#bib0125"><span class="elsevierStyleSup">1&#44;8&#44;10</span></a></p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia></span><span id="sec0070" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Nocturnal dipping</span><p id="par0180" class="elsevierStylePara elsevierViewall">Dipping refers to the physiological decline in BP during sleep&#44; normally of &#8805;10&#37; in mean SBP and DBP&#46;<a class="elsevierStyleCrossRefs" href="#bib0125"><span class="elsevierStyleSup">1&#44;8&#44;9&#44;16&#44;17</span></a></p><p id="par0185" class="elsevierStylePara elsevierViewall">ABPM is the only method that can measure nocturnal BP&#44; which cannot be estimated by single measurements either at home or in a clinical setting&#46;<a class="elsevierStyleCrossRef" href="#bib0240"><span class="elsevierStyleSup">24</span></a></p><p id="par0190" class="elsevierStylePara elsevierViewall">A fall of less than 10&#37; &#40;non-dipper pattern&#41; correlates with a higher likelihood of TOD and worse cardiovascular prognosis&#46;<a class="elsevierStyleCrossRefs" href="#bib0155"><span class="elsevierStyleSup">7&#44;9&#44;16&#44;22</span></a> This pattern is also seen in cases of sustained adrenergic stimulation&#44; such as those resulting from disorders of the adrenal glands&#46;</p></span><span id="sec0075" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Blood pressure variability</span><p id="par0195" class="elsevierStylePara elsevierViewall">ABPM is also useful in the assessment of BP variability&#44; which has prognostic value&#46; The activity of BP regulatory systems is needed to meet the changing physical and psychological demands of a normal day&#46;<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">1</span></a> Increased BP variability has been demonstrated in obese children and is most likely related to increased sympathetic nervous system activation&#46; In adults&#44; greater BP variability has been correlated with the development of hypertensive LVH&#46;<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">1</span></a></p></span></span><span id="sec0080" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">Indications for ambulatory blood pressure monitoring</span><p id="par0200" class="elsevierStylePara elsevierViewall">The main indication for ABPM is to confirm the diagnosis of hypertension&#44; whether true hypertension&#44; white coat hypertension &#40;WCH&#41; or masked hypertension &#40;MH&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0200"><span class="elsevierStyleSup">16</span></a></p><p id="par0205" class="elsevierStylePara elsevierViewall">The recommendations for ABPM are listed in <a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a>&#46;<a class="elsevierStyleCrossRefs" href="#bib0135"><span class="elsevierStyleSup">3&#44;4</span></a></p><elsevierMultimedia ident="tbl0015"></elsevierMultimedia><span id="sec0100" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0105">White coat hypertension</span><p id="par0215" class="elsevierStylePara elsevierViewall">One of the most important indications for ABPM is to exclude WCH&#46;<a class="elsevierStyleCrossRefs" href="#bib0125"><span class="elsevierStyleSup">1&#44;7&#44;9</span></a></p><p id="par0220" class="elsevierStylePara elsevierViewall">WCH is defined as BP levels that are the 95th percentile or higher when measured in the physician&#39;s office or clinic but are completely normal &#40;average BP &#60;90th percentile&#41; outside of a clinical setting&#46;<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">1</span></a> It is a transient&#44; stress-induced elevation of BP associated with the medical examination&#44;<a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">2</span></a> and is especially pronounced in younger patients&#44; especially those aged under 12 years&#44; and in obese patients&#46;<a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">2</span></a> Its incidence ranges between 22&#37; and 40&#37;&#44; depending on the series&#44;<a class="elsevierStyleCrossRefs" href="#bib0125"><span class="elsevierStyleSup">1&#44;2&#44;4&#44;17</span></a> similar values to those seen in adults&#46;<a class="elsevierStyleCrossRef" href="#bib0210"><span class="elsevierStyleSup">18</span></a></p><p id="par0225" class="elsevierStylePara elsevierViewall">The likelihood of WCH decreases as office BP increases&#59; children with office BP &#62;10&#37; above the 95th percentile are more likely to be true hypertensives&#46;<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">1</span></a></p><p id="par0230" class="elsevierStylePara elsevierViewall">WCH may not be entirely benign&#46;<a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">2</span></a> In adults with normal ABPM&#44; BP variability increases with increasing BP and is associated with TOD &#40;cardiovascular system&#44; kidneys&#44; central nervous system and retina<a class="elsevierStyleCrossRef" href="#bib0135"><span class="elsevierStyleSup">3</span></a>&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0170"><span class="elsevierStyleSup">10</span></a></p><p id="par0235" class="elsevierStylePara elsevierViewall">Several studies have shown that although left ventricular mass in children with WCH is within normal ranges&#44; it is greater than in control groups&#44; which means that these children should be closely monitored&#46; Other forms of TOD&#44; such as endothelial dysfunction and increased carotid intima-media thickness&#44; are also associated with higher ABPM levels&#46;<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">1</span></a> In fact&#44; WCH may represent an intermediate stage between normotension and hypertension&#44;<a class="elsevierStyleCrossRef" href="#bib0170"><span class="elsevierStyleSup">10</span></a> and some studies suggest that these children should be treated as having prehypertension&#46;<a class="elsevierStyleCrossRef" href="#bib0200"><span class="elsevierStyleSup">16</span></a></p></span><span id="sec0105" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0110">Masked hypertension</span><p id="par0245" class="elsevierStylePara elsevierViewall">ABPM may also identify MH&#44; defined as a normal office BP but elevated ambulatory levels&#46;<a class="elsevierStyleCrossRefs" href="#bib0125"><span class="elsevierStyleSup">1&#44;2&#44;21</span></a> This condition&#44; the etiology of which is poorly understood&#44;<a class="elsevierStyleCrossRef" href="#bib0240"><span class="elsevierStyleSup">24</span></a> in children is associated with progression to sustained hypertension and LVH&#44;<a class="elsevierStyleCrossRef" href="#bib0200"><span class="elsevierStyleSup">16</span></a> in a similar way to children with hypertension confirmed by ambulatory BP measurements&#46;<a class="elsevierStyleCrossRef" href="#bib0240"><span class="elsevierStyleSup">24</span></a></p><p id="par0250" class="elsevierStylePara elsevierViewall">MH may be suspected when there are previous reports of elevated clinical BP from other providers such as primary health care&#44; or if the presence of LVH is inconsistent with the office BP&#46;<a class="elsevierStyleCrossRefs" href="#bib0125"><span class="elsevierStyleSup">1&#44;2&#44;10</span></a></p><p id="par0255" class="elsevierStylePara elsevierViewall">An excessive BP response to exercise testing&#44; which has been observed in children with WCH&#44; may also be a manifestation of MH&#44; and in such cases ABPM is recommended&#46; Longitudinal studies have shown that SBP during exercise is positively associated with future resting SBP&#44; independently of resting SBP and other cardiovascular risk factors&#46;<a class="elsevierStyleCrossRef" href="#bib0140"><span class="elsevierStyleSup">4</span></a></p><p id="par0260" class="elsevierStylePara elsevierViewall">The prevalence of MH has not been clearly determined&#44; ranging from 5&#46;7&#37; to 15&#37; in different studies&#46;<a class="elsevierStyleCrossRefs" href="#bib0125"><span class="elsevierStyleSup">1&#44;3&#44;4&#44;9&#44;10&#44;16</span></a> It is more common in obese children&#44;<a class="elsevierStyleCrossRef" href="#bib0230"><span class="elsevierStyleSup">22</span></a> especially if they display a non-dipper pattern&#46;<a class="elsevierStyleCrossRef" href="#bib0170"><span class="elsevierStyleSup">10</span></a> It is also found in other conditions including diabetes&#44; cardiomyopathy&#44; hyperthyroidism&#44;<a class="elsevierStyleCrossRefs" href="#bib0155"><span class="elsevierStyleSup">7&#44;16</span></a> and obstructive sleep apnea&#46;<a class="elsevierStyleCrossRef" href="#bib0165"><span class="elsevierStyleSup">9</span></a></p><p id="par0265" class="elsevierStylePara elsevierViewall">Children with isolated nocturnal hypertension should be considered to have MH and the same significance should be attributed as to daytime hypertension&#46; Its incidence is higher in children who have been transplanted &#40;38&#37;&#41; and those with chronic kidney disease&#59; renal transplantation appears to be a major risk factor for MH&#46;<a class="elsevierStyleCrossRefs" href="#bib0165"><span class="elsevierStyleSup">9&#44;22</span></a> Other factors include a high-salt diet and a sedentary lifestyle&#46;<a class="elsevierStyleCrossRef" href="#bib0230"><span class="elsevierStyleSup">22</span></a></p></span><span id="sec0110" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0115">Prehypertension</span><p id="par0275" class="elsevierStylePara elsevierViewall">Prehypertension is defined as office BP &#8805;90th percentile or &#62;120&#47;80 mmHg<a class="elsevierStyleCrossRef" href="#bib0175"><span class="elsevierStyleSup">11</span></a> and mean ambulatory BP &#60;95th percentile with elevated BP loads&#46;<a class="elsevierStyleCrossRef" href="#bib0170"><span class="elsevierStyleSup">10</span></a> It is recognized as a condition that requires assessment and follow-up&#44; due to the risk of progression to sustained hypertension&#46;<a class="elsevierStyleCrossRef" href="#bib0170"><span class="elsevierStyleSup">10</span></a></p><p id="par0280" class="elsevierStylePara elsevierViewall">Patients with prehypertension demonstrate abnormalities on ABPM intermediate between normotensive and truly hypertensive people&#46;<a class="elsevierStyleCrossRef" href="#bib0170"><span class="elsevierStyleSup">10</span></a> ABPM can be very helpful in stratifying risk for TOD&#44; because even with normal mean BP&#44; increased BP variability is associated with TOD in adults&#46;<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">1</span></a></p><p id="par0285" class="elsevierStylePara elsevierViewall">Adolescents with prehypertension already have higher LVM values&#44; lower glomerular filtration rate&#44; and increased urine protein excretion&#44; as well as greater carotid intima-media thickness&#44; than normotensive control subjects&#46;<a class="elsevierStyleCrossRef" href="#bib0170"><span class="elsevierStyleSup">10</span></a></p></span><span id="sec0115" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0120">Assessment of risk for target organ damage</span><p id="par0295" class="elsevierStylePara elsevierViewall">LVH&#44; thickening and stiffening of large arteries and urinary albumin excretion are the most easily assessed markers of TOD&#46;<a class="elsevierStyleCrossRef" href="#bib0135"><span class="elsevierStyleSup">3</span></a> LVH remains to date the most thoroughly documented form of TOD caused by hypertension in children and adolescents&#46;<a class="elsevierStyleCrossRef" href="#bib0135"><span class="elsevierStyleSup">3</span></a> The prevalence of LVH in children with hypertension is 8-41&#37;&#44; depending on the criteria used to define both hypertension and LVH&#59; studies that use age-specific reference intervals show higher prevalences&#46;<a class="elsevierStyleCrossRefs" href="#bib0140"><span class="elsevierStyleSup">4&#44;23</span></a></p><p id="par0300" class="elsevierStylePara elsevierViewall">Renal damage is rarely seen in children with essential hypertension&#44; but these patients have higher albuminuria levels&#46; The severity of albuminuria correlates with LVH&#46;<a class="elsevierStyleCrossRef" href="#bib0140"><span class="elsevierStyleSup">4</span></a></p><p id="par0305" class="elsevierStylePara elsevierViewall">In adults&#44; ABPM&#44; particularly nocturnal SBP and BP load&#44;<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">1</span></a> is a better marker of TOD&#44;<a class="elsevierStyleCrossRef" href="#bib0220"><span class="elsevierStyleSup">20</span></a> especially with LVH&#44; than office BP readings&#46; It also correlates better with renal damage as indicated by albuminuria&#46; The albumin&#47;creatinine ratio is strongly related to variability of DBP&#46;<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">1</span></a></p><p id="par0310" class="elsevierStylePara elsevierViewall">Higher SBP values at the age of 12 years are associated with carotid intima-media thickening in adulthood&#44; which in turn is correlated with higher risk for developing atherosclerosis at older ages&#46;<a class="elsevierStyleCrossRefs" href="#bib0135"><span class="elsevierStyleSup">3&#44;4</span></a> Changes in vascular function are also more common in children with higher BP levels&#46;<a class="elsevierStyleCrossRefs" href="#bib0135"><span class="elsevierStyleSup">3&#44;10</span></a></p></span><span id="sec0120" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0125">Assessment of secondary hypertension</span><p id="par0320" class="elsevierStylePara elsevierViewall">Secondary hypertension is more common in children than in adults&#46;<a class="elsevierStyleCrossRef" href="#bib0135"><span class="elsevierStyleSup">3</span></a> Hypertension detected in very young children&#44; or in children with systemic conditions and a diagnosis of stage 2 hypertension&#44; is suggestive of secondary hypertension&#46;<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">1</span></a> The likelihood of identifying a secondary cause of hypertension is inversely related to the age of the child and directly related to the degree of BP elevation&#46;<a class="elsevierStyleCrossRef" href="#bib0135"><span class="elsevierStyleSup">3</span></a></p><p id="par0325" class="elsevierStylePara elsevierViewall">ABPM may be useful in differentiating primary from secondary hypertension&#44; since children with secondary hypertension manifest greater nocturnal SBP loads and greater daytime and nocturnal DBP loads&#44; as well as decreased nocturnal dipping&#46;<a class="elsevierStyleCrossRefs" href="#bib0125"><span class="elsevierStyleSup">1&#44;16</span></a></p></span><span id="sec0125" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0130">Assessment of efficacy of antihypertensive therapy</span><p id="par0335" class="elsevierStylePara elsevierViewall">ABPM is useful for assessing response to antihypertensive therapy and to identify those with uncontrolled hypertension&#44; especially in patients with isolated nocturnal hypertension<a class="elsevierStyleCrossRef" href="#bib0200"><span class="elsevierStyleSup">16</span></a> or secondary hypertension&#44;<a class="elsevierStyleCrossRef" href="#bib0170"><span class="elsevierStyleSup">10</span></a> in cases of apparently drug-resistant hypertension&#44; or when the symptoms of hypertension are suspected of being secondary to medication&#46;<a class="elsevierStyleCrossRefs" href="#bib0125"><span class="elsevierStyleSup">1&#44;14&#44;16</span></a></p><p id="par0340" class="elsevierStylePara elsevierViewall">ABPM is also valuable in the identification of periods of hypertension when medication is ineffective&#44; in order to optimize the timing of medication with respect to circadian BP patterns&#46;<a class="elsevierStyleCrossRef" href="#bib0200"><span class="elsevierStyleSup">16</span></a></p></span><span id="sec0130" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0135">Characterization of blood pressure profile in children with chronic disease that could lead to hypertension</span><p id="par0350" class="elsevierStylePara elsevierViewall">Hypertension is common in children and adolescents with chronic renal disease&#46; It has a very high prevalence in children undergoing dialysis&#44; in whom 40&#37; of mortality is due to cardiovascular causes&#46;<a class="elsevierStyleCrossRef" href="#bib0220"><span class="elsevierStyleSup">20</span></a></p><p id="par0355" class="elsevierStylePara elsevierViewall">Non-dipping in patients undergoing dialysis may be an independent predictor of poor cardiovascular outcomes&#46;<a class="elsevierStyleCrossRef" href="#bib0220"><span class="elsevierStyleSup">20</span></a></p><p id="par0360" class="elsevierStylePara elsevierViewall">Since the reference values were obtained in healthy children&#44; there are doubts concerning their applicability in children with chronic conditions such as renal disease&#44; as well as concerning determination of the ideal BP values for children at risk for hypertension&#46;<a class="elsevierStyleCrossRef" href="#bib0155"><span class="elsevierStyleSup">7</span></a></p><p id="par0365" class="elsevierStylePara elsevierViewall">Some authors argue that in children with chronic renal disease&#44; BP should be maintained below the 50th percentile for age and gender&#46; Hypertension is a determining factor for progression to renal failure&#44; and so prompt treatment is protective and can avoid the need for renal replacement therapy &#40;dialysis or transplantation&#41;&#44; improving survival and quality of life&#46;<a class="elsevierStyleCrossRef" href="#bib0155"><span class="elsevierStyleSup">7</span></a></p><p id="par0370" class="elsevierStylePara elsevierViewall">Isolated nocturnal hypertension is common in children undergoing solid organ transplantation &#40;22-41&#37; of cases&#41; and various studies have shown that it is the most frequent type of hypertension in these patients&#46;<a class="elsevierStyleCrossRef" href="#bib0230"><span class="elsevierStyleSup">22</span></a> Its etiology is multifactorial&#44; the main causes being steroid therapy&#44; sodium retention&#44; chronic rejection&#44; and stenosis of the transplanted renal artery&#46;<a class="elsevierStyleCrossRef" href="#bib0230"><span class="elsevierStyleSup">22</span></a></p></span><span id="sec0135" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0140">Cardiovascular risk factors</span><p id="par0380" class="elsevierStylePara elsevierViewall">Total adiposity and insulin resistance have been correlated with a high prevalence of the nondipping phenomenon&#44; as has higher salt intake&#46;<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">1</span></a></p><p id="par0385" class="elsevierStylePara elsevierViewall">Abnormally elevated daytime and nocturnal BP levels&#44; and diminished dipping&#44; have been demonstrated in children with type 2 diabetes&#46; These changes may be related to subclinical vascular damage<a class="elsevierStyleCrossRef" href="#bib0155"><span class="elsevierStyleSup">7</span></a> and renal disease and may be an early marker for renal deterioration&#46;<a class="elsevierStyleCrossRefs" href="#bib0125"><span class="elsevierStyleSup">1&#44;22</span></a></p><p id="par0390" class="elsevierStylePara elsevierViewall">In unilateral multicystic dysplastic kidney&#44; ABPM is of particular value for the early detection of elevated BP&#44; in view of the risk of secondary damage to the contralateral kidney&#46;<a class="elsevierStyleCrossRef" href="#bib0155"><span class="elsevierStyleSup">7</span></a></p><p id="par0395" class="elsevierStylePara elsevierViewall">Daytime BP variability is increased and a non-dipper pattern is observed at night in 68&#46;7&#37; of children with obstructive sleep apnea&#46;<a class="elsevierStyleCrossRefs" href="#bib0125"><span class="elsevierStyleSup">1&#44;16&#44;21</span></a></p><p id="par0400" class="elsevierStylePara elsevierViewall">Higher MAP levels are seen on ABPM in sedentary children&#44; those subjected to psychosocial stress and those medicated with stimulants&#44; such as in attention deficit hyperactivity disorder&#46;<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">1</span></a></p></span></span><span id="sec0085" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0145">Contraindications</span><p id="par0405" class="elsevierStylePara elsevierViewall">The contraindications for ABPM are<a class="elsevierStyleCrossRefs" href="#bib0125"><span class="elsevierStyleSup">1&#44;17</span></a>&#58;<ul class="elsevierStyleList" id="lis0010"><li class="elsevierStyleListItem" id="lsti0025"><span class="elsevierStyleLabel">&#8226;</span><p id="par0410" class="elsevierStylePara elsevierViewall">Coagulation disorders</p></li><li class="elsevierStyleListItem" id="lsti0030"><span class="elsevierStyleLabel">&#8226;</span><p id="par0415" class="elsevierStylePara elsevierViewall">Cardiac rhythm disorders &#40;e&#46;g&#46; atrial fibrillation&#41;</p></li><li class="elsevierStyleListItem" id="lsti0035"><span class="elsevierStyleLabel">&#8226;</span><p id="par0420" class="elsevierStylePara elsevierViewall">Known allergies to elements of the monitoring device&#46;</p></li></ul></p><p id="par0425" class="elsevierStylePara elsevierViewall">Although serious adverse events such as venous thrombosis have not been reported in children&#44; mild sleep disturbances&#44;<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">1</span></a> petechiae and ecchymosis<a class="elsevierStyleCrossRef" href="#bib0205"><span class="elsevierStyleSup">17</span></a> have been documented&#46;</p></span></span><span id="sec0090" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0150">Conclusions</span><p id="par0430" class="elsevierStylePara elsevierViewall">The prevalence of hypertension in children and adolescents is rising worldwide&#44; largely due to increased adiposity&#46; Timely diagnosis of hypertension in children can potentially reduce the risk of future cardiovascular disease&#46;<a class="elsevierStyleCrossRef" href="#bib0145"><span class="elsevierStyleSup">5</span></a></p><p id="par0435" class="elsevierStylePara elsevierViewall">ABPM enables the diagnosis and classification of hypertension&#44; provides cardiovascular prognostic information<a class="elsevierStyleCrossRef" href="#bib0220"><span class="elsevierStyleSup">20</span></a> and identifies patients with WCH or MH&#44; which are intermediate phenotypes of hypertension&#46;<a class="elsevierStyleCrossRef" href="#bib0240"><span class="elsevierStyleSup">24</span></a></p></span><span id="sec0095" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0155">Conflicts of interest</span><p id="par0440" class="elsevierStylePara elsevierViewall">The authors have no conflicts of interest to declare&#46;</p></span></span>"
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              "titulo" => "Methodology of ambulatory blood pressure monitoring in children"
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                  "titulo" => "Nocturnal dipping"
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              "titulo" => "Indications for ambulatory blood pressure monitoring"
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                  "identificador" => "sec0100"
                  "titulo" => "White coat hypertension"
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                  "titulo" => "Masked hypertension"
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                  "titulo" => "Assessment of risk for target organ damage"
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                  "titulo" => "Assessment of secondary hypertension"
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                  "titulo" => "Characterization of blood pressure profile in children with chronic disease that could lead to hypertension"
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          "clase" => "keyword"
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          "identificador" => "xpalclavsec1175480"
          "palabras" => array:6 [
            0 => "Pediatric age"
            1 => "High blood pressure"
            2 => "Ambulatory blood pressure monitoring"
            3 => "White coat hypertension"
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          "palabras" => array:6 [
            0 => "Idade pedi&#225;trica"
            1 => "Hipertens&#227;o arterial"
            2 => "Monitoriza&#231;&#227;o ambulat&#243;ria de press&#227;o arterial"
            3 => "Hipertens&#227;o da bata branca"
            4 => "Hipertens&#227;o mascarada"
            5 => "Les&#227;o de &#243;rg&#227;o alvo"
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        "titulo" => "Abstract"
        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">The prevalence of high blood pressure &#40;BP&#41; at pediatric age has increased progressively&#44; one of the causes of which is obesity&#46; However&#44; the dominant etiology in this age group is renal and&#47;or cardiovascular pathology&#46; Ambulatory blood pressure monitoring &#40;ABPM&#41; is the method of choice for the diagnosis of hypertension&#44; especially in children at high cardiovascular risk&#46; Its use is limited to children from five years of age&#46; Choosing appropriate cuff size is key to obtaining correct blood pressure&#46;</p><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">The main indication for ABPM is to confirm the diagnosis of hypertension&#46; It also allows the diagnosis of white coat hypertension &#40;which may represent an intermediate stage between the normotensive phase and hypertension&#41;&#44; or masked hypertension&#44; associated with progression to sustained hypertension and left ventricular hypertrophy &#40;LVH&#41;&#46; Children with isolated nocturnal hypertension should be considered as having masked hypertension&#46;</p><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">BP load is defined as the percentage of valid measurements above the 95th percentile for age&#44; gender&#44; and height&#46; Values above 25-30&#37; are pathological and those above 50&#37; are predictive of LVH&#46; ABPM correlates with target organ damage&#44; particularly LVH and renal damage&#46; It is useful in the differentiation of secondary hypertension&#44; since these children show higher BP load and less nocturnal dipping&#44; and confirmation of response to therapy&#46; Thus ABPM allows the diagnosis and classification of hypertension&#44; provides cardiovascular prognostic information and identifies patients with intermediate phenotypes of hypertension&#46;</p></span>"
      ]
      "pt" => array:2 [
        "titulo" => "Resumo"
        "resumen" => "<span id="abst0010" class="elsevierStyleSection elsevierViewall"><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Em idade pedi&#225;trica a preval&#234;ncia da hipertens&#227;o arterial &#40;HTA&#41; tem aumentado progressivamente&#44; sendo a obesidade uma das respons&#225;veis&#46; Apesar disso&#44; a etiologia dominante nesta faixa et&#225;ria &#233; a patologia renal e&#47;ou a cardiovascular&#46; A monitoriza&#231;&#227;o ambulat&#243;ria de press&#227;o arterial &#40;MAPA&#41; &#233; o m&#233;todo de elei&#231;&#227;o para o diagn&#243;stico de HTA&#44; especialmente em crian&#231;as com risco cardiovascular elevado&#46; O seu uso est&#225; limitado a crian&#231;as a partir dos cinco anos&#46; A sele&#231;&#227;o do tamanho da bra&#231;adeira &#233; o ponto chave na obten&#231;&#227;o de leituras corretas da tens&#227;o arterial &#40;TA&#41;&#46;</p><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">O MAPA tem como principal indica&#231;&#227;o a confirma&#231;&#227;o do diagn&#243;stico de HTA&#46; Tamb&#233;m permite diagnosticar hipertens&#227;o da bata branca &#40;que pode representar um est&#225;dio interm&#233;dio entre a fase normotensa e a hipertens&#227;o&#41;&#44; ou hipertens&#227;o mascarada&#44; associada a progress&#227;o para hipertens&#227;o mantida e HVE&#46; As crian&#231;as com HTA noturna isolada devem ser consideradas como portadoras de hipertens&#227;o mascarada&#46; A carga tensional &#233; definida como a percentagem de medi&#231;&#245;es v&#225;lidas acima do p95 para a idade&#44; sexo e estatura&#44; sendo que valores superiores a 25-30&#37; s&#227;o patol&#243;gicos e superiores a 50&#37; s&#227;o preditivos de hipertrofia ventricular esquerda &#40;HVE&#41;&#46; O MAPA correlaciona-se com les&#227;o de &#243;rg&#227;o alvo&#44; nomeadamente com a HVE e a les&#227;o renal&#46; &#201; &#250;til na diferencia&#231;&#227;o da hipertens&#227;o secund&#225;ria&#44; j&#225; que estas crian&#231;as manifestam maiores cargas tensionais e menor <span class="elsevierStyleItalic">dipping</span> nocturno&#44; e na confirma&#231;&#227;o da resposta &#224; terap&#234;utica&#46;</p><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Assim&#44; o MAPA permite o diagn&#243;stico e a classifica&#231;&#227;o da HTA&#44; fornece informa&#231;&#227;o progn&#243;stica cardiovascular e identifica doentes com fen&#243;tipos interm&#233;dios de HTA&#46;</p></span>"
      ]
    ]
    "NotaPie" => array:1 [
      0 => array:2 [
        "etiqueta" => "&#9734;"
        "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as&#58; Andrade H&#44; Pires A&#44; Noronha N&#44; Amaral ME&#44; Lopes L&#44; Martins P&#44; et al&#46; Import&#226;ncia da monitoriza&#231;&#227;o ambulat&#243;ria da press&#227;o arterial no diagn&#243;stico e progn&#243;stico da hipertens&#227;o arterial em idade pedi&#225;trica&#46; Rev Port Cardiol&#46; 2018&#59;37&#58;783&#8211;789&#46;</p>"
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          "leyenda" => "<p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">p90&#58; 90th percentile&#59; p95&#58; 95th percentile&#59; p99&#58; 99th percentile&#59; DBP&#58; diastolic blood pressure&#59; ISH&#58; isolated systolic hypertension&#59; SBP&#58; systolic blood pressure&#46;</p>"
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                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">0-15 years&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">16 years and older&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Normal&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#60;130&#47;85 mmHg&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">High-normal&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#8805;p90 to&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">130-139&#47;85-89 mmHg&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Hypertension&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#8805;p95&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#8805;140&#47;90 mmHg&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Stage 1 hypertension&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">p95 to p99 plus 5 mmHg&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">140-159&#47;90-99 mmHg&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Stage 2 hypertension&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#62;p99 plus 5 mmHg&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">160-179&#47;100-109 mmHg&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">ISH&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">SBP &#8805;p95 and DBP&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#8805;140&#47;&#60;90 mmHg&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
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          "leyenda" => "<p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">p90&#58; 90th percentile&#59; p95&#58; 95th percentile&#59; p99&#58; 99th percentile&#59; BP&#58; blood pressure&#59; MAP&#58; mean arterial pressure&#59; MH&#58; masked hypertension&#59; WCH&#58; white coat hypertension&#46;</p>"
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">Normal&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">&#60;25&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">&#8805;p95&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">&#60;25&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t">Prehypertension&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">&#8805;p90 or &#62;120&#47;80 mmHg&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">&#8805;25&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t">MH&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#62;p95&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">&#8805;25&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t\ttop\n
                  \t\t\t\t">Stage 1 hypertension&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#62;p95 to&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">25-50&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t">Stage 2 hypertension&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">&#8805;p99 plus 5 mmHg&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">&#8805;P95&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">25-50&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
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                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t">Stage 3 hypertension&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">&#8805;p99 plus 5 mmHg&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">&#8805;p95&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#62;50&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Evaluation of refractory hypertension<span class="elsevierStyleHsp" style=""></span>Assessment of BP control in children with TOD<span class="elsevierStyleHsp" style=""></span>Symptoms of hypotension&nbsp;\t\t\t\t\t\t\n
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                    0 => array:2 [
                      "titulo" => "Ambulatory blood pressure monitoring in children and adolescents&#58; recommendations for standard assessment&#46; A scientific statement from the American Heart Association&#44; Atherosclerosis Hypertension&#44; and Obesity in Youth Committee of the Council on Cardiovascular Disease in the Young and the Council for High Blood Pressure Research"
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                      "doi" => "10.1161/HYPERTENSIONAHA.108.190329"
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                        "tituloSerie" => "Hypertension"
                        "fecha" => "2008"
                        "volumen" => "52"
                        "paginaInicial" => "433"
                        "paginaFinal" => "451"
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              "etiqueta" => "2"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Pediatric ambulatory blood pressure monitoring&#58; indications and interpretations"
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                        0 => array:2 [
                          "etal" => false
                          "autores" => array:2 [
                            0 => "J&#46; Flynn"
                            1 => "E&#46; Urbina"
                          ]
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                    0 => array:1 [
                      "Revista" => array:5 [
                        "tituloSerie" => "J Clin Hypertens"
                        "fecha" => "2012"
                        "volumen" => "14"
                        "paginaInicial" => "372"
                        "paginaFinal" => "382"
                      ]
                    ]
                  ]
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              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Management of high blood pressure in children and adolescents&#58; recommendations of the European Society of Hypertension"
                      "autores" => array:1 [
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                          "etal" => true
                          "autores" => array:3 [
                            0 => "E&#46; Lurbe"
                            1 => "R&#46; Cifkova"
                            2 => "J&#46;K&#46; Cruickshank"
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                        ]
                      ]
                    ]
                  ]
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                    0 => array:2 [
                      "doi" => "10.1097/HJH.0b013e32832f4f6b"
                      "Revista" => array:6 [
                        "tituloSerie" => "J Hypertens"
                        "fecha" => "2009"
                        "volumen" => "27"
                        "paginaInicial" => "1719"
                        "paginaFinal" => "1742"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/19625970"
                            "web" => "Medline"
                          ]
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              "etiqueta" => "4"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "2016 European Society of Hypertension guidelines for the management of high blood pressure in children and adolescents"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:3 [
                            0 => "E&#46; Lurbe"
                            1 => "E&#46; Rosei-Agabiti"
                            2 => "J&#46; Cruickshank"
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                    0 => array:2 [
                      "doi" => "10.1097/HJH.0000000000001039"
                      "Revista" => array:6 [
                        "tituloSerie" => "J Hypertens"
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                        "volumen" => "34"
                        "paginaInicial" => "1887"
                        "paginaFinal" => "1920"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/27467768"
                            "web" => "Medline"
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              "referencia" => array:1 [
                0 => array:2 [
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                    0 => array:2 [
                      "titulo" => "Screening for hypertension in children and adolescents to prevent cardiovascular disease"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:3 [
                            0 => "M&#46; Thompson"
                            1 => "T&#46; Dana"
                            2 => "C&#46; Bougatsos"
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                    ]
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                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1542/peds.2012-3523"
                      "Revista" => array:6 [
                        "tituloSerie" => "Pediatrics"
                        "fecha" => "2013"
                        "volumen" => "131"
                        "paginaInicial" => "490"
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  "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2174204918303064?idApp=UINPBA00004E"
]

Article information

ISSN: 21742049
Original language: English

DOI:10.1016/j.repce.2018.08.005

The statistics are updated each day

Year/Month	Html	Pdf	Total

2024 November	10	5	15
2024 October	63	34	97
2024 September	89	32	121
2024 August	82	24	106
2024 July	88	35	123
2024 June	93	19	112
2024 May	69	29	98
2024 April	69	27	96
2024 March	48	19	67
2024 February	50	30	80
2024 January	40	31	71
2023 December	44	30	74
2023 November	54	31	85
2023 October	57	14	71
2023 September	43	26	69
2023 August	54	17	71
2023 July	67	9	76
2023 June	74	14	88
2023 May	82	28	110
2023 April	58	7	65
2023 March	91	23	114
2023 February	68	19	87
2023 January	40	15	55
2022 December	66	21	87
2022 November	60	42	102
2022 October	56	23	79
2022 September	54	37	91
2022 August	52	34	86
2022 July	54	45	99
2022 June	60	28	88
2022 May	46	41	87
2022 April	50	50	100
2022 March	41	42	83
2022 February	58	32	90
2022 January	87	25	112
2021 December	85	44	129
2021 November	76	39	115
2021 October	145	45	190
2021 September	87	24	111
2021 August	88	34	122
2021 July	76	21	97
2021 June	55	28	83
2021 May	51	33	84
2021 April	157	56	213
2021 March	95	35	130
2021 February	98	24	122
2021 January	72	15	87
2020 December	63	18	81
2020 November	66	37	103
2020 October	50	13	63
2020 September	58	17	75
2020 August	57	15	72
2020 July	53	19	72
2020 June	58	10	68
2020 May	66	9	75
2020 April	86	26	112
2020 March	103	21	124
2020 February	244	35	279
2020 January	69	8	77
2019 December	62	5	67
2019 November	48	14	62
2019 October	62	16	78
2019 September	153	15	168
2019 August	51	20	71
2019 July	56	12	68
2019 June	52	32	84
2019 May	59	18	77
2019 April	46	19	65
2019 March	20	17	37
2019 February	22	18	40
2019 January	10	9	19
2018 December	9	13	22
2018 November	24	25	49
2018 October	53	30	83
2018 September	6	7	13

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