Andersons pediatric cardiology 1612

Assessing Comorbidities ■ Random urine microalbuminuria ■ Uric acid ■ Lipid profile (cholesterol: total, LDL, HDL, triglycerides) ■ Fasting glucose and hemoglobin A1c ■ Funduscopy Further Investigations as Indicated ■ Glomerulonephritis screen (e.g., C3, C4, ANA, ANCA) ■ 24-h urine collection for sodium ■ Peripheral plasma renin and plasma aldosterone ■ Plasma cortisol ■ Technetium 99 dimercaptosuccinic acid scan ■ Urine and plasma catecholamines or metanephrines ■ Renal color Doppler ultrasonography ■ Urinary steroid profile ■ Sleep study ■ Magnetic resonance angiography of abdominal aorta ■ Computed tomographic angiography ■ Metaiodobenzylguanidine scanning ■ Digital subtraction angiography of abdominal aorta and renal vessels ■ Selective renal vein renin measurement ■ Genetic studies ANA, Antinuclear antibody; ANCA, Antineutrophilic cytoplasmic antibody; HDL, high-density lipoprotein; LDL, low-density lipoprotein From Singh C, Jones H, Copeman H, Sinha MD Fifteen-minute consultation: the child with systemic arterial hypertension Arch Dis Child Educ Pract Ed 2017;102(1):2–7 Renal disease, or renal arterial stenosis, is the most common cause of secondary hypertension in childhood, and this will usually be apparent as the cause after initial routine investigations Routine investigations, and those designed to establish the severity of the hypertension, will include a full blood count, plasma urea, electrolytes, creatinine, and uric acid A hypokalemic alkalosis suggests excess activity of aldosterone, either from a mineralocorticoid syndrome or secondary to hyper-reninism Further blood tests may include measurements of renin, aldosterone, and catecholamines in the plasma, but the use of antihypertensive drugs prior to investigation frequently invalidates these assays The urine should be examined for blood, protein, cells, and casts as markers of renal disease, and should be cultured if urinalysis is abnormal Unless the cause is obvious, measurements are usually made of vanillylmandelic acid in the urine to exclude either a pheochromocytome or hypertension caused by neuroblastoma As will be discussed, renal arteriography and other specific investigations may be required As already indicated, the control of the hypertension with drugs may invalidate the determination of renin, aldosterone, and catecholamines in the plasma, as well as the latter agents in the urine,226,227 so that samples of blood and urine for these investigations, whenever possible, should always be taken prior to initiation of therapy Screening Controversy still exists as to whether normal children should be screened for hypertension Both the European Society of Hypertension and AAP guidelines recommend the measurement of blood pressure in all children older than 3 years when seen by a health professional.36,37 For children younger than 3 years, measurement of blood pressure has been recommended in specific groups.36,37 Due to some of the inherent problems with measurement of blood pressure discussed previously, the usefulness of routine measurement in children has been debated.228,229 Despite the lack of evidence, as suggested by some commentaries,228 it has been argued that because a growing body of evidence indicates that elevated blood pressure early in life has detrimental lifelong cardiovascular effects, there are potential benefits of hypertension screening and prevention starting in childhood from a public health perspective.230 For mild hypertension, the dilemma is considerable because a large number of such children would be identified by a screening program It has been argued that to label an apparently well child as hypertensive could cause great harm On the other hand, to leave hypertensive children undiagnosed, to become hypertensive adults, is not desirable The issues with severe hypertension are clearer Early diagnosis allows effective treatment, prevents complications, and improves life expectancy The child with severe hypertension should be investigated immediately The child with mild hypertension should be followed up Ambulatory monitoring will help establish whether such children discovered during visits to the clinic have mild but sustained hypertension at home or at school, or if they have WCH Hypertension in Infants Hypertension in the term or preterm infant may be seen in up to 2% infants.231 The diagnosis of hypertension in infancy requires knowledge of the normal limits for blood pressure An increasing amount of data are available, providing values for premature and term neonates, and in infants in the first year of life.232–239 A simple guide is that repeated measurements of systolic pressure above 90 mm Hg in neonates at term, and above 80 mm Hg in preterm neonates, are indicative of hypertension.240 Systemic hypertension in the newborn that is not related to aortic coarctation appears to be increasing Thromboembolic occlusions of the renal vasculature are commonly related to indwelling umbilical arterial and venous catheters, with 80% of cases of renal arterial thrombosis reported in one series associated with indwelling umbilical arterial catheters.231,241 Aortic thrombosis has been demonstrated in up to one-third of neonates with indwelling catheters.242 It is important to check that the tip of the catheter is left below the level of the renal artery, which is between the ninth thoracic and first lumbar vertebrae, and immediately to withdraw it below this level if it is found to be incorrectly positioned The diagnosis of renal vascular involvement may be made by ultrasonic investigation, although computerized tomography or magnetic resonance angiography may give clearer imaging In some patients, an aortogram and selective renal arteriography may be necessary Direct dissolution of clotting with recombinant human tissue plasminogen activators can also be achieved using the catheter used for the diagnostic study Infants who suffer an intravascular thrombosis should be screened for inherited thrombophilic disorders.243 A relatively common cause of neonatal hypertension is bronchopulmonary dysplasia.244 Other rarer causes of neonatal hypertension include congenital