ISSN: 1679-9941 (Print), 2177-5281 (Online)
Official website of the journal Adolescencia e Saude (Adolescence and Health Journal)

Vol. 3 nº 3 - Jul/Sep - 2006

High blood pressure in adolescence: approach and treatment

Systemic arterial hypertension (SAH) is a multifactorial disease characterized by increased systolic (SBP) and/or diastolic (DBP) blood pressure, in which several mechanisms are involved and have relationships that are not yet fully understood, leading to increased cardiac output and peripheral vascular resistance.

To establish the diagnosis of arterial hypertension in children and adolescents, we follow the recommendations of the National High Blood Pressure Education Program Working Group on Hypertension Control in Children and Adolescents(4).

The prevalence of arterial hypertension in the general population is high, with an estimated 15% to 20% of the adult Brazilian population being hypertensive. Although it predominates in adults, the prevalence in children and adolescents is not negligible, especially when considering hypertensive adolescents whose blood pressure levels are in the distribution range with percentiles between 95th and 99th . According to the III Brazilian Consensus on Arterial Hypertension (III CBHA)(6), its prevalence in children and adolescents can vary from 2% to 13%.

It is important to remember that when arterial hypertension is diagnosed and treated early in children and adolescents, cardiac, renal and nervous system complications are prevented, which interfere with quality of life and, in most cases, occur in later age groups, but not only in them.

One of the main risk factors for cardiovascular morbidity and mortality, hypertension entails high social costs, since it accounts for approximately 40% of cases of early retirement and absenteeism from work in our environment. CARDIAC

COMPLICATIONS

  • Coronary diseases: acute myocardial infarction (AMI).
  • Left ventricular hypertrophy: congestive heart failure (CHF), arrhythmias and sudden death. It is worth noting that left ventricular hypertrophy is a predictive factor of the severity of hypertension and is often found in adolescents.

RENAL

  • Nephrosclerosis: chronic renal failure.

CENTRAL NERVOUS SYSTEM

  • Ischemic stroke – most common.
  • Hemorrhagic stroke.

OPHTHALMOLOGICAL CHANGES

  • Characteristic changes of hypertension already observed in adolescents.

CARE FOR HYPERTENSIVE ADOLESCENTS

  • Identify secondary arterial hypertension.
  • Research risk factors.
  • Observe the presence of signs and symptoms of hypertension.

PHYSICAL EXAMINATION

The physical examination should include weight, height, Tanner stage and abdominal circumference measurement. Fat located around the waist indicates greater insulin resistance and, consequently, greater chances of clinical complications and increased blood pressure. Also significant in the clinical examination are pulse tests in the lower limbs, fundoscopy and search for signs that reveal underlying diseases causing secondary arterial hypertension.

LABORATORY INVESTIGATION

Some authors suggest laboratory evaluation protocols in children. For adolescents, we understand that laboratory investigation should be individualized, respecting the history and physical examination of each individual.

The performance of complementary tests aims to find the cause of hypertension and verify the establishment of possible complications caused by it, respecting the peculiarities of each case. In general, the aim is to establish the presence of an underlying chronic disease, highlighting the main causes of hypertension in our environment, such as kidney and heart diseases. Therefore, a complete blood count, erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP), urea, creatinine, electrolytes and urinary sediment should be performed initially.

In the case of obese adolescents, we assess cholesterol, high-density lipoprotein (HDL), low-density lipoprotein (LDL), triglycerides, uric acid, basal insulin and fasting glucose.

The cardiovascular system should be assessed by echocardiogram and, when indicated, the renal arteries should be assessed.

TREATMENT AND MONITORING

Primary arterial hypertension is a multicausal disease, caused by factors intrinsic to the individual and external to him/her. Therefore, its treatment should address all of these possible factors, as well as understanding them in order to then attempt to minimize and/or eliminate them. Therefore, the participation of a multidisciplinary team is necessary.

When dealing with adolescents, this fact becomes even more pressing, since adolescence is characterized by rapid changes in an individual’s life. It is a period of growth, in which illness is a mark of inferiority compared to others. For adolescents, health is one of the tools for success. Thus, monitoring any chronic illness at this stage is fraught with great difficulty. When the illness is asymptomatic, it becomes even more difficult for them to understand that it is necessary to treat it to prevent complications in adulthood.

NON-PHARMACOLOGICAL TREATMENT

Non-pharmacological treatment is recommended for all hypertensive patients and for those who have high normal levels. Below are some examples of how this treatment can be carried out.

  • Individual service

Carried out by doctors, nurses, nutritionists, psychologists, social workers and physical education teachers, according to the adolescent’s needs.

  • Group activities

They must be carried out in a space suitable for the development of educational actions regarding the disease and other issues inherent to adolescent health, and it is also a privileged place for observing each adolescent and their relationship with the disease.

  • Community activities

Carrying out educational work in schools, community centers and churches, aiming at prevention and/or active search for children and adolescents who exhibit risk factors for the development of primary arterial hypertension.

  • Family support

It is essential that the family be informed about all aspects of adolescent hypertension. Family partnership is a determining factor in the success of controlling the disease.

These coordinated actions aim to propose alternatives to the inadequate lifestyle for maintaining the health of adolescents and their families.

DIETARY GUIDANCE

When providing dietary guidance to adolescents with primary arterial hypertension, it is essential to follow three basic principles:

  • weight maintenance;
  • change in eating habits;
  • restriction of intake of foods rich in sodium.

The correlation between weight gain and high blood pressure is aggravated during adolescence. Inappropriate distribution of time, excessive school activities and food prices lead to excessive consumption of quick-to-prepare and low-cost foods, leading to excessive consumption of saturated fats, simple carbohydrates, calories in general and foods with high sodium content.

The following items can be cited as general guidelines for nutritional treatment:

  • provide individualized care;
  • promote nutritional education for the whole family;
  • in case of overweight/obesity, start a low-calorie diet;
  • eliminate foods rich in sodium, keeping salt consumption to less than 6 grams/day (one teaspoon); also avoid salted meats, canned and preserved foods, processed meats (sausage, paio and mortadella), as well as other industrialized products, such as sauces, meat and/or chicken broths, instant foods and soups;
  • restrict the consumption of animal fats, giving preference to vegetable oils (mono and polyunsaturated);
  • avoid sweets, alcoholic beverages and sugar;
  • give preference to natural seasonings (garlic, onion, parsley, mint, coriander, basil, lemon, etc.);
  • use baked, boiled, grilled or sautéed preparations;
  • increase your intake of foods low in sodium and rich in potassium (beans, peas, dark green vegetables, bananas, melons, carrots, beets, dried fruits, tomatoes, potatoes, oranges, etc.);
  • use foods rich in fiber (grains, fruits, whole grains, vegetables and legumes, especially raw) to improve intestinal function and reduce the absorption of carbohydrates.

PHYSICAL ACTIVITY

It is important to guide adolescents to do regular physical exercise. According to Rocchini(5), when weight loss is accompanied by physical activity, the drop in blood pressure is greater. This activity should be individualized, respecting the characteristics of each adolescent and their family. Exercises should be aerobic and performed under specialized supervision.

PHARMACOLOGICAL TREATMENT

Non-pharmacological treatment should always be prioritized and, in most cases, is effective in controlling blood pressure. However, sometimes it is necessary to include antihypertensive medications. In this case, diuretics, beta-blockers, angiotensin-converting enzyme inhibitors (ACEIs), calcium antagonists, angiotensin II receptor blockers (ARB II) and alpha-blockers, among others, are used. Treatment should begin with only one drug at the appropriate dose. If the desired control is not achieved, a second drug is added.

There are no long-term studies on the pharmacological treatment of primary arterial hypertension in children and adolescents. However, some considerations can be established. Among the diuretics, the most commonly used is hydrochlorothiazide, due to its efficacy and low cost. It should not be used in high doses because it leads to an increase in triglycerides, blood glucose, uric acid and their consequences.

Beta-blockers should not be used in asthmatics. In this group of patients, the use of beta-adrenergics and systemic corticosteroids should be discouraged, with preference given to inhaled preparations.

ACE inhibitors, because they have positive effects on myocardial and renal functions and on blood vessels in general, have become the first choice for the treatment of hypertension. However, these inhibitors produce teratogenic effects in the second and third trimesters of pregnancy and should be used with caution in sexually active adolescents.

The professional on the multidisciplinary team, when approaching adolescents, should aim to take care of their immediate health needs. However, prevention of future diseases cannot be excluded from its objectives. Primary arterial hypertension in adolescence falls into this context. Non-pharmacological treatment is effective in the vast majority of cases. A small number of patients will require only one drug, and a very small number will need to use more than one drug. At this stage of life, prevention of degenerative diseases that may affect the individual in adulthood is essential.

Bibliographic References

1. Kaplan N. Clinical hypertension. 6th ed. Baltimore: Williams & Wilkins 1994.

2. Kilcoyne M. Natural history of hypertension in adolescence. Pediatric Clinics of North America 1978;25(1):47-53.

3. National Institutes of Health. National Heart, Lung and Blood Institute: The Sixth Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure. Maryland: US. Department of Health and Human Services/Public Health Service. 1997.

4. National High Blood Pressure Education Program Working Group. Update on the 1987 Task force on high blood pressure in children and adolescents. Pediatrics 1996;98(4):649-658.

5. Rocchini AP. Adolescent obesity and hypertension. Pediatric Clinics of North America 1993;40(1):81-93.

6. III Brazilian Consensus on Arterial Hypertension. Working Group. São Paulo; February, 1998.

1. Assistant Professor of Adolescent Medicine at the School of Medical Sciences, Center for Studies in Adolescent Health, Rio de Janeiro State University (FCM/NESA/UERJ); PhD in Epidemiology.
2. Nutritionist at NESA/UERJ .