Nadciśnienie tętnicze u dzieci – Patofizjologia i mechanizm

Nadciśnienie tętnicze u dzieci
Patofizjologia i mechanizm

Nadciśnienie tętnicze u dzieci i młodzieży stanowi istotny problem kliniczny, z częstością występowania nadciśnienia pierwotnego od 2% do 4%, a podwyższonego ciśnienia nawet do 16%. Patogeneza nadciśnienia pierwotnego jest wieloczynnikowa i obejmuje zaburzenia równowagi między pojemnością minutową serca a oporem naczyniowym, z udziałem układu współczulnego, hormonalnego (m.in. układ renina-angiotensyna-aldosteron) oraz czynników metabolicznych i immunologicznych. Otyłość trzewna, hiperinsulinemia oraz zwiększona aktywność układu współczulnego odgrywają kluczową rolę w rozwoju i utrzymywaniu nadciśnienia u dzieci, co potwierdzają obserwacje kliniczne dotyczące fenotypu hemodynamicznego z izolowanym nadciśnieniem skurczowym i podwyższoną częstością akcji serca. Wczesne wykrycie i interwencja są kluczowe, gdyż nadciśnienie w dzieciństwie predysponuje do utrwalenia choroby i powikłań sercowo-naczyniowych w wieku dorosłym.

Nadciśnienie tętnicze u dzieci – Patofizjologia, mechanizm

Model patofizjologiczny nadciśnienia pierwotnego
Podstawowe mechanizmy regulacji ciśnienia tętniczego
Dwie główne teorie patogenezy nadciśnienia pierwotnego
Rola układu współczulnego
Otyłość jako kluczowy czynnik patogenetyczny
Czynniki naczyniowe i metaboliczne

Nadciśnienie pierwotne i wtórne u dzieci

Nadciśnienie pierwotne
Nadciśnienie wtórne

Specyficzne mechanizmy patofizjologiczne u dzieci

Wpływ czynników rozwojowych i okołoporodowych
Fenotyp kliniczny i laboratoryjny
Związek z zespołem metabolicznym
Zmiany strukturalne i funkcjonalne naczyniowe i sercowe

Różnice w patofizjologii między dziećmi a dorosłymi

Znaczenie wczesnej identyfikacji i interwencji
Kolejne rozdziały

Nadciśnienie tętnicze u dzieci – Patofizjologia, mechanizm

Nadciśnienie tętnicze, mimo że kojarzone głównie z osobami dorosłymi, jest istotnym problemem zdrowotnym również u dzieci i młodzieży. Badania pokazują, że częstość występowania nadciśnienia tętniczego wśród dzieci wynosi od 2% do 4%, a częstość występowania podwyższonego ciśnienia krwi (wcześniej określanego jako stan przednadciśnieniowy) sięga nawet 16%.¹ Warto podkreślić, że nadciśnienie tętnicze w wieku dziecięcym może prowadzić do utrzymywania się choroby w wieku dorosłym oraz przyczyniać się do wcześniejszego wystąpienia powikłań sercowo-naczyniowych.²³

Model patofizjologiczny nadciśnienia pierwotnego

Postęp w badaniach nad fizjologią układu sercowo-naczyniowego pozwolił na lepsze zrozumienie patogenezy zarówno wtórnych form nadciśnienia, jak i nadciśnienia pierwotnego u dzieci. Wieloczynnikowy model patogenezy nadciśnienia pierwotnego, opracowany przez Irvinga Page’a w latach 40. XX wieku, znany jako „mozaika Page’a”, obejmuje większość zjawisk patofizjologicznych obserwowanych w nadciśnieniu pierwotnym.⁴⁵ Chociaż większość badań klinicznych potwierdzających wieloczynnikową patogenezę nadciśnienia pierwotnego dotyczy dorosłych, warto podkreślić, że nadciśnienie rozwija się w dzieciństwie, a nawet jest programowane w okresie okołoporodowym.⁶

Podstawowe mechanizmy regulacji ciśnienia tętniczego

Ciśnienie tętnicze jest determinowane przez równowagę między pojemnością minutową serca a oporem naczyniowym. Wzrost któregokolwiek z tych parametrów, przy braku kompensacyjnego spadku drugiego, prowadzi do wzrostu średniego ciśnienia tętniczego, które stanowi siłę napędową przepływu krwi.⁷

Na pojemność minutową serca wpływają:⁸

Baroreceptory
Objętość pozakomórkowa
Efektywna objętość krążąca – przedsionkowe hormony natriuretyczne, mineralokortykosteroidy, angiotensyna
Układ współczulny

Na opór naczyniowy wpływają:⁹

Czynniki presyjne – angiotensyna II, wapń (wewnątrzkomórkowy), katecholaminy, układ współczulny, wazopresyna
Czynniki depresyjne – przedsionkowe hormony natriuretyczne, śródbłonkowe czynniki relaksacyjne, kininy, prostaglandyna E2, prostaglandyna I2

Zmiany w homeostazie elektrolitów, szczególnie zmiany w stężeniu sodu, wapnia i potasu, wpływają na niektóre z tych czynników. W warunkach prawidłowych ilość sodu wydalana z moczem odpowiada ilości spożywanej, co zapewnia względną stałość objętości pozakomórkowej. Zatrzymanie sodu prowadzi do zwiększenia objętości pozakomórkowej, co wiąże się z podwyższeniem ciśnienia tętniczego.¹⁰

Dwie główne teorie patogenezy nadciśnienia pierwotnego

W ciągu ostatnich dekad rozwinęły się dwie główne teorie dotyczące patogenezy nadciśnienia pierwotnego:¹¹¹²

Teoria Guytona – skupia się na czynniku objętościowym i wydalniczej funkcji nerek
Teoria Folkowa – wskazuje, że strukturalna przebudowa naczyń oporowych jest przyczyną utrzymującego się nadciśnienia

W rzeczywistości oba mechanizmy – objętościowy i oporowy – działają wspólnie, a istnieją liczne dowody na ścisły związek między wrażliwością na sól a zwiększonym całkowitym oporem obwodowym.¹³

Rola układu współczulnego

Rola zarówno układu współczulnego, jak i części przywspółczulnej autonomicznego układu nerwowego jest postrzegana zarówno jako fizjologiczny mechanizm szybkiej kontroli wahań ciśnienia tętniczego, jak i istotny system w długoterminowej kontroli ciśnienia tętniczego, odgrywający znaczącą rolę w rozwoju i utrzymywaniu nadciśnienia pierwotnego.¹⁴¹⁵

Ponieważ jedną z głównych cech fenotypowych dziecka/nastolatka z nadciśnieniem jest otyłość trzewna i zaburzony skład ciała, większa aktywność układu współczulnego u osób z otyłością może być ważnym czynnikiem patofizjologicznym w powstawaniu i utrzymywaniu nadciśnienia pierwotnego w dzieciństwie.¹⁶ Badania kliniczne wykazały, że typowy fenotyp hemodynamiczny nadciśnienia w dzieciństwie to izolowane nadciśnienie skurczowe i podwyższona częstość akcji serca, które dominuje zarówno wśród otyłych, jak i nieotyłych nastolatków z nadciśnieniem.¹⁷

Otyłość jako kluczowy czynnik patogenetyczny

Nadwaga i otyłość wpływają na ciśnienie tętnicze na wiele sposobów, a adipozytoza i przyrost masy ciała są istotnymi czynnikami przyczyniającymi się do rozwoju nadciśnienia pierwotnego. Rozwój nadciśnienia w otyłości jest uwarunkowany kilkoma czynnikami, w tym zwiększoną aktywnością układu współczulnego, aktywacją aldosteron/” title=”układ renina-angiotensyna-aldosteron” class=”to-tag” data-termid=”18104″>układu renina-angiotensyna-aldosteron oraz uciskiem nerek spowodowanym nagromadzeniem tkanki tłuszczowej, co prowadzi do zwiększonej reabsorpcji sodu w nerkach i zaburzenia diurezy ciśnieniowej.¹⁸

Zwiększona aktywność układu współczulnego odgrywa istotną rolę jako mechanizm nadciśnienia w otyłości. W badaniu wykazującym, że sam przyrost masy ciała zwiększa aktywność układu współczulnego, 12 zdrowych mężczyzn zwiększyło masę ciała o 5 kg poprzez przejadanie się, a porównując stan przed i po, wykazano znaczący wzrost całkowitej tkanki tłuszczowej i tłuszczu brzusznego oraz istotny wzrost aktywności układu współczulnego w mięśniach i skurczowego ciśnienia tętniczego, sugerując związek między otyłością a nadciśnieniem.¹⁹

Mimo rozszerzenia objętości i zatrzymania sodu związanych z otyłością, nie występuje u tych osób prawidłowa odpowiedź supresyjna układu renina-angiotensyna-aldosteron. Powiązane czynniki, takie jak aktywność reninowa osocza, angiotensynogen, enzym konwertujący angiotensynę (ACE) i aldosteron, są podwyższone w porównaniu z osobami o prawidłowej masie ciała.²⁰

W otyłości trzewna, zaotrzewnowa i nerkowa tkanka tłuszczowa powoduje ucisk nerek i zmiany strukturalne w tkance nerkowej. Fizyczny ucisk przez tłuszcz w nerkach i wokół nich upośledza diurezę ciśnieniową i zwiększa reabsorpcję sodu w kanalikach nerkowych, powodując zatrzymanie sodu i podwyższenie ciśnienia tętniczego.²¹

Czynniki naczyniowe i metaboliczne

Jednym z węzłów mozaiki Page’a są czynniki naczyniowe, co oznacza zaburzoną strukturę i funkcję zarówno dużych, jak i małych tętnic oporowych.²² Kolejnym węzłem w mozaice Page’a jest czynnik metaboliczny związany z nadciśnieniem tętniczym.²³

Zaburzenia immunologiczne nie były początkowo uwzględnione w oryginalnej mozaice Page’a. Jednak wyniki badań eksperymentalnych od lat 60. XX wieku i obserwacje kliniczne wskazywały na układ immunologiczny jako kolejny węzeł w zmodyfikowanej mozaice Page’a.²⁴ Pediatryczne badania kliniczne opublikowane w ciągu ostatnich 2 dekad udokumentowały, że w porównaniu z rówieśnikami z prawidłowym ciśnieniem, dzieci z nadciśnieniem pierwotnym już w momencie diagnozy wykazywały znaczącą aktywację wrodzonej odporności ze zwiększonym stężeniem w surowicy nie tylko hsCRP, ale także chemokin, co wskazuje na aktywację śródbłonka.²⁵

Nadciśnienie pierwotne i wtórne u dzieci

Nadciśnienie tętnicze u dzieci może być pierwotne (bez znanej przyczyny, diagnoza z wykluczenia) lub wtórne (spowodowane innym zaburzeniem, np. chorobą nerek). Po ukończeniu 6 lat dominującą etiologią jest nadciśnienie pierwotne, co jest jeszcze bardziej widoczne u nastolatków i młodych dorosłych. Przed ukończeniem 6 lat częściej występuje nadciśnienie wtórne.²⁶

Nadciśnienie pierwotne

Nadciśnienie pierwotne występuje samoistnie, bez identyfikowalnej przyczyny. Ten typ nadciśnienia występuje częściej u dzieci w wieku 6 lat i starszych.²⁷ Istotne czynniki ryzyka nadciśnienia pierwotnego obejmują historię rodzinną i rosnący wskaźnik masy ciała (BMI).²⁸ Niektóre zaburzenia snu i rasa czarna mogą być potencjalnymi czynnikami ryzyka nadciśnienia pierwotnego. Nadciśnienie pierwotne często jest powiązane z innymi czynnikami ryzyka, które składają się na zespół metaboliczny i mogą prowadzić do chorób sercowo-naczyniowych.²⁹

Dla większości dorosłych nie ma identyfikowalnej przyczyny wysokiego ciśnienia krwi. Ten typ nadciśnienia, nazywany nadciśnieniem pierwotnym lub samoistnym, ma tendencję do powolnego rozwoju przez wiele lat. Odkładanie się blaszek miażdżycowych w tętnicach, zwane miażdżycą, zwiększa ryzyko wysokiego ciśnienia krwi.³⁰

Nadciśnienie wtórne

Nadciśnienie wtórne ma identyfikowalną przyczynę; nadciśnienie może być odwracalne, jeśli przyczyna zostanie wyeliminowana. Najczęstszymi przyczynami nadciśnienia wtórnego u dzieci są choroby miąższu nerek (np. kłębuszkowe zapalenie nerek, odmiedniczkowe zapalenie nerek, nefropatia refluksowa) lub wrodzone anomalie nerek i dróg moczowych (np. uropatia zaporowa, wielotorbielowatość nerek, nerki dysplastyczne).³¹

Ten rodzaj nadciśnienia jest spowodowany innym schorzeniem. Jest częstszy u małych dzieci. Inne przyczyny wysokiego ciśnienia krwi obejmują: przewlekłą chorobę nerek, wielotorbielowatość nerek, problemy z sercem, takie jak ciężkie zwężenie (koarktacja) aorty, zaburzenia nadnerczy, nadczynność tarczycy, zwężenie tętnicy nerkowej oraz zaburzenia snu, szczególnie obturacyjny bezdech senny.³²

Nadciśnienie wtórne jest częstsze u dzieci niż u dorosłych. Choroba nerek jest najczęstszą przyczyną nadciśnienia wtórnego u dzieci. Inne przyczyny obejmują choroby endokrynologiczne (np. guz chromochłonny, nadczynność tarczycy) i leki (np. doustne środki antykoncepcyjne, sympatykomimetyki, niektóre preparaty dostępne bez recepty, suplementy diety).³³

Specyficzne mechanizmy patofizjologiczne u dzieci

Wpływ czynników rozwojowych i okołoporodowych

Chociaż nadciśnienie u osób urodzonych przedwcześnie lub z niską masą urodzeniową (SGA) wydaje się być odrębną formą choroby nadciśnieniowej, zaburzenia związane z wcześniactwem i SGA są przykładem nagromadzenia wszystkich wcześniej opisanych zjawisk patofizjologicznych w nadciśnieniu pierwotnym, takich jak wrażliwość na sól, insulinooporność i zespół metaboliczny, otyłość trzewna, większy napęd adrenergiczny, dysbioza jelitowa i aktywacja układu immunologicznego.³⁴

Urazy, takie jak niedotlenienie okołoporodowe, mogą uszkadzać naczynia krwionośne i serce, powodując zmiany strukturalne i funkcjonalne, a w konsekwencji zwiększając ryzyko nadciśnienia.³⁵ Dzieci z obniżonym szacunkowym współczynnikiem filtracji kłębuszkowej miały dwukrotnie większe szanse na podwyższone ciśnienie krwi niż dzieci z normalnym współczynnikiem filtracji kłębuszkowej.³⁶

Fenotyp kliniczny i laboratoryjny

Wykazano, że fenotyp kliniczno-laboratoryjny dzieci i młodzieży z nadciśnieniem pierwotnym stanowi zestaw patofizjologicznie powiązanych zaburzeń i odpowiada głównym węzłom patofizjologicznym mozaiki Page’a.³⁷

Nadciśnienie tętnicze rozwija się stopniowo. W zwiększaniu ciśnienia tętniczego na różnych etapach rozwoju biologicznego biorą udział różne mechanizmy. Wraz z wiekiem i utrzymywaniem się pierwotnych zaburzeń, zmiany takie jak zaburzony skład ciała, adaptacyjne zmiany naczyniowe, uszkodzenie mikrokrążenia i aktywacja immunologiczna stopniowo generują nowe, nieodwracalne uszkodzenia tętnic ze zwiększoną sztywnością, prowadzące do utrwalenia nadciśnienia.³⁸

Związek z zespołem metabolicznym

U dziecka z otyłością hiperinsulinemia może podwyższać ciśnienie tętnicze poprzez zwiększenie reabsorpcji sodu i napięcia współczulnego.³⁹ Nadciśnienie pierwotne często jest powiązane z innymi czynnikami ryzyka, które składają się na zespół metaboliczny i mogą prowadzić do chorób sercowo-naczyniowych.⁴⁰

Otyłość jest najważniejszym czynnikiem ryzyka nadciśnienia u dzieci i młodzieży. Innymi czynnikami ryzyka, które przyczyniają się do rozwoju nadciśnienia, są płeć męska, rodzinna historia nadciśnienia, czynniki wczesnego życia, takie jak masa urodzeniowa czy wiek ciążowy, dieta wysokosodowa, brak diety typu DASH, dłuższy czas spędzany w pozycji siedzącej i potencjalnie inne czynniki dietetyczne.⁴¹

Zmiany strukturalne i funkcjonalne naczyniowe i sercowe

Nadciśnienie powoduje zmiany w strukturze naczyń krwionośnych i serca. Ponieważ nadciśnienie u dzieci było historycznie niedostatecznie badane, nie ma wielu danych na temat dokładnego znaczenia tych zmian. Wiemy jednak, że u dorosłych nadciśnienie zwiększa ryzyko powikłań dotyczących serca, naczyń krwionośnych i nerek. Istnieją również przekonujące dowody, że niektóre z tych zmian są obserwowane u dzieci z wysokim ciśnieniem krwi.⁴²

Przerost lewej komory (LVH) jest najbardziej wyraźnym klinicznym dowodem uszkodzenia narządów docelowych w nadciśnieniu dziecięcym. Dane pokazują, że LVH można obserwować nawet u 41% pacjentów z nadciśnieniem dziecięcym. Pacjenci z ciężkimi przypadkami nadciśnienia dziecięcego są również narażeni na zwiększone ryzyko rozwoju encefalopatii nadciśnieniowej, drgawek, udarów mózgu i zastoinowej niewydolności serca.⁴³

Różnice w patofizjologii między dziećmi a dorosłymi

Chociaż podstawowe mechanizmy patofizjologiczne nadciśnienia są podobne u dzieci i dorosłych, istnieją pewne istotne różnice, które wpływają na diagnozę, leczenie i rokowanie.⁴⁴

Powikłania ostrego nadciśnienia u dzieci są stosunkowo rzadkie i zwykle związane z nagłymi przypadkami nadciśnieniowymi, w których występuje dysfunkcja lub uszkodzenie narządów docelowych. Przewlekłe powikłania nadciśnienia u dzieci są rzadkie, a jeśli występują, to zwykle nie pojawiają się do późnej adolescencji lub wczesnej dorosłości. Powikłania przewlekłego nadciśnienia u dorosłych, w tym choroba wieńcowa, niewydolność serca, udar niedokrwienny, choroba naczyń obwodowych i nadciśnieniowa schyłkowa niewydolność nerek, rzadko, jeśli w ogóle, występują u dzieci. Jednakże prekursory tych powikłań, w tym niekorzystne zmiany w grubości kompleksu błony wewnętrznej i środkowej tętnicy szyjnej (cIMT), prędkości fali tętna, przeroście lewej komory (LVH) i funkcjach poznawczych, mogą być identyfikowane u dzieci z nadciśnieniem.⁴⁵

Ciśnienie tętnicze ma własny rytm dobowy (cykl sen/czuwanie). Istnieje normalna zmienność. Oceniamy zmiany ciśnienia tętniczego w ciągu dnia i nocy.⁴⁶

Znaczenie wczesnej identyfikacji i interwencji

Na podstawie obserwacji wczesne wykrywanie nadciśnienia i interwencja u dzieci są potencjalnie korzystne w zapobieganiu długoterminowym powikłaniom nadciśnienia.⁴⁷ Amerykańskie Towarzystwo Kardiologiczne zaleca, aby wszystkie dzieci były badane pod kątem wysokiego ciśnienia krwi raz w roku, ponieważ wczesne wykrycie schorzenia i leczenie poprawi zdrowie dziecka i zmniejszy lub zapobiegnie szkodliwym skutkom tego stanu.⁴⁸

Dzieci z prawidłowym ciśnieniem tętniczym mogą wykazywać wczesne oznaki dysfunkcji śródbłonka. W nadciśnieniu pierwszego stopnia (ciśnienie tętnicze 130-139) interwencja środowiskowa jest najbardziej skutecznym sposobem obniżenia ciśnienia tętniczego bez leków.⁴⁹

Nasze badanie sugeruje potrzebę rutynowego pomiaru ciśnienia tętniczego u dzieci po niedotlenieniu okołoporodowym. Jest to ważne dla wczesnej identyfikacji i terminowego leczenia dzieci z podwyższonym ciśnieniem tętniczym. Zachęcamy do rutynowego sprawdzania podwyższonego ciśnienia tętniczego w populacji pediatrycznej, szczególnie u osób ze znanymi czynnikami ryzyka.⁵⁰

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Materiały źródłowe

#1 Hypertension in Children – Pediatrics – Merck Manual Professional Edition
https://www.merckmanuals.com/professional/pediatrics/hypertension-in-children/hypertension-in-children
Hypertension is sustained elevation of resting systolic blood pressure, diastolic blood pressure, or both. Hypertension with no known cause (primary) is most common, as with adults. Hypertension with an identified cause (secondary hypertension) is relatively uncommon in children, although it occurs more frequently in younger children (< 6 years). [...] It has become clear over time that hypertension in adults is affected by both intrauterine and neonatal conditions and often begins in childhood. Also, sequelae of hypertension in adulthood occur earlier in patients who were hypertensive as children. Additionally, there is evidence that hypertension in childhood and adolescence is directly associated with increased risk of cardiovascular disease in adulthood. [...] In the United States, the prevalence of hypertension in children ranges between 2 and 4% with elevated blood pressure (previously called prehypertension) noted in 16%. Worldwide, prevalence is less clear because of regional differences in definitions, reference data, and methodology but is estimated at about 4%. In addition, the prevalence appears to be increasing, likely due to the increased incidence of overweight and obesity in children; obesity is now four times as common among adolescents as it was 60 years ago. Obese adolescents are more likely than their peers to have hypertension.
#2 Hypertension in Children – Pediatrics – Merck Manual Professional Edition
https://www.merckmanuals.com/professional/pediatrics/hypertension-in-children/hypertension-in-children
Hypertension is sustained elevation of resting systolic blood pressure, diastolic blood pressure, or both. Hypertension with no known cause (primary) is most common, as with adults. Hypertension with an identified cause (secondary hypertension) is relatively uncommon in children, although it occurs more frequently in younger children (< 6 years). [...] It has become clear over time that hypertension in adults is affected by both intrauterine and neonatal conditions and often begins in childhood. Also, sequelae of hypertension in adulthood occur earlier in patients who were hypertensive as children. Additionally, there is evidence that hypertension in childhood and adolescence is directly associated with increased risk of cardiovascular disease in adulthood. [...] In the United States, the prevalence of hypertension in children ranges between 2 and 4% with elevated blood pressure (previously called prehypertension) noted in 16%. Worldwide, prevalence is less clear because of regional differences in definitions, reference data, and methodology but is estimated at about 4%. In addition, the prevalence appears to be increasing, likely due to the increased incidence of overweight and obesity in children; obesity is now four times as common among adolescents as it was 60 years ago. Obese adolescents are more likely than their peers to have hypertension.
#3 Hypertension in Children and Adolescents | AAFP
https://www.aafp.org/pubs/afp/issues/2006/0501/p1558.html
There is evidence that childhood hypertension can lead to adult hypertension. […] Hypertension is a known risk factor for coronary artery disease (CAD) in adults, and the presence of childhood hypertension may contribute to the early development of CAD. […] Reports show that early development of atherosclerosis does exist in children and young adults and may be associated with childhood hypertension. […] Left ventricular hypertrophy (LVH) is the most prominent clinical evidence of end-organ damage in childhood hypertension. […] Data show that LVH can be seen in as many as 41 percent of patients with childhood hypertension. […] Patients with severe cases of childhood hypertension are also at increased risk of developing hypertensive encephalopathy, seizures, cerebrovascular accidents, and congestive heart failure.
#4 Pathophysiology of primary hypertension in children and adolescents
https://pmc.ncbi.nlm.nih.gov/articles/PMC11026201/
The progress in research on the physiology of the cardiovascular system made in the last 100 years allowed for the development of the pathogenesis not only of secondary forms of hypertension but also of primary hypertension. […] The multifactorial model of primary hypertension pathogenesis developed by Irving Page in the 1940s, called Page’s mosaic, covers most of the pathophysiological phenomena observed in essential hypertension. […] Most of the clinical studies confirming the validity of the multifactorial pathogenesis of primary hypertension concern adults. However, hypertension develops in childhood and is even perinatally programmed. […] This article presents data from pediatric clinical trials describing the most important pathophysiological processes associated with the development of essential hypertension in children and adolescents.
#5 Pathophysiology of primary hypertension in children and adolescents – UniversitÃ© Marie et Louis Pasteur – SUPMICROTECH-ENSMM
http://ariane.univ-fcomte.fr/discovery/fulldisplay/cdi_unpaywall_primary_10_1007_s00467_023_06142_2/33UFC_INST:33UFC_INST
The progress in research on the physiology of the cardiovascular system made in the last 100 years allowed for the development of the pathogenesis not only of secondary forms of hypertension but also of primary hypertension. The main determinants of blood pressure are described by the relationship between stroke volume, heart rate, peripheral resistance, and arterial stiffness. The theories developed by Guyton and Folkow describe the importance of the volume factor and total peripheral resistance. However, none of them fully presents the pathogenesis of essential hypertension. The multifactorial model of primary hypertension pathogenesis developed by Irving Page in the 1940s, called Page’s mosaic, covers most of the pathophysiological phenomena observed in essential hypertension. The most important pathophysiological phenomena included in Page’s mosaic form a network of interconnected ânodesâ. New discoveries both from experimental and clinical studies made in recent decades have allowed the original Page mosaic to be modified and the addition of new pathophysiological nodes. Most of the clinical studies confirming the validity of the multifactorial pathogenesis of primary hypertension concern adults. However, hypertension develops in childhood and is even perinatally programmed. Therefore, the next nodes in Pageâs mosaic should be age and perinatal factors. This article presents data from pediatric clinical trials describing the most important pathophysiological processes associated with the development of essential hypertension in children and adolescents.
#6 Pathophysiology of primary hypertension in children and adolescents
https://pmc.ncbi.nlm.nih.gov/articles/PMC11026201/
The progress in research on the physiology of the cardiovascular system made in the last 100 years allowed for the development of the pathogenesis not only of secondary forms of hypertension but also of primary hypertension. […] The multifactorial model of primary hypertension pathogenesis developed by Irving Page in the 1940s, called Page’s mosaic, covers most of the pathophysiological phenomena observed in essential hypertension. […] Most of the clinical studies confirming the validity of the multifactorial pathogenesis of primary hypertension concern adults. However, hypertension develops in childhood and is even perinatally programmed. […] This article presents data from pediatric clinical trials describing the most important pathophysiological processes associated with the development of essential hypertension in children and adolescents.
#7 Pediatric Hypertension: Background, Pathophysiology, Etiology
https://emedicine.medscape.com/article/889877-overview
Blood pressure (BP) is determined by the balance between cardiac output and vascular resistance. A rise in either of these variables, in the absence of a compensatory decrease in the other, increases mean BP, which is the driving pressure. […] Factors that affect cardiac output include the following: Baroreceptors, Extracellular volume, Effective circulating volume – Atrial natriuretic hormones, mineralocorticoids, angiotensin, Sympathetic nervous syndrome. […] Factors that affect vascular resistance include the following: Pressors – Angiotensin II, calcium (intracellular), catecholamines, sympathetic nervous system, vasopressin, Depressors – Atrial natriuretic hormones, endothelial relaxing factors, kinins, prostaglandin E2, prostaglandin I2. […] Changes in electrolyte homeostasis, particularly changes in sodium, calcium, and potassium concentrations, affect some of these factors.
#8 Pediatric Hypertension: Background, Pathophysiology, Etiology
https://emedicine.medscape.com/article/889877-overview
Blood pressure (BP) is determined by the balance between cardiac output and vascular resistance. A rise in either of these variables, in the absence of a compensatory decrease in the other, increases mean BP, which is the driving pressure. […] Factors that affect cardiac output include the following: Baroreceptors, Extracellular volume, Effective circulating volume – Atrial natriuretic hormones, mineralocorticoids, angiotensin, Sympathetic nervous syndrome. […] Factors that affect vascular resistance include the following: Pressors – Angiotensin II, calcium (intracellular), catecholamines, sympathetic nervous system, vasopressin, Depressors – Atrial natriuretic hormones, endothelial relaxing factors, kinins, prostaglandin E2, prostaglandin I2. […] Changes in electrolyte homeostasis, particularly changes in sodium, calcium, and potassium concentrations, affect some of these factors.
#9 Pediatric Hypertension: Background, Pathophysiology, Etiology
https://emedicine.medscape.com/article/889877-overview
Blood pressure (BP) is determined by the balance between cardiac output and vascular resistance. A rise in either of these variables, in the absence of a compensatory decrease in the other, increases mean BP, which is the driving pressure. […] Factors that affect cardiac output include the following: Baroreceptors, Extracellular volume, Effective circulating volume – Atrial natriuretic hormones, mineralocorticoids, angiotensin, Sympathetic nervous syndrome. […] Factors that affect vascular resistance include the following: Pressors – Angiotensin II, calcium (intracellular), catecholamines, sympathetic nervous system, vasopressin, Depressors – Atrial natriuretic hormones, endothelial relaxing factors, kinins, prostaglandin E2, prostaglandin I2. […] Changes in electrolyte homeostasis, particularly changes in sodium, calcium, and potassium concentrations, affect some of these factors.
#10 Pediatric Hypertension: Background, Pathophysiology, Etiology
https://emedicine.medscape.com/article/889877-overview
Under normal conditions, the amount of sodium excreted in the urine matches the amount ingested, resulting in near constancy of extracellular volume. Retention of sodium results in increased extracellular volume, which is associated with an elevation of BP. […] A rise in the intracellular calcium concentration, due to changes in plasma calcium concentration, increases vascular contractility. In addition, calcium stimulates release of renin, synthesis of epinephrine, and sympathetic nervous system activity. Increased potassium intake suppresses production and release of renin and induces natriuresis, decreasing BP. […] The complexity of the system explains the difficulties often encountered in identifying the mechanism that accounts for hypertension in a particular patient. These difficulties are the main reason why treatment is often designed to affect regulatory factors rather than the cause of the disease. […] In a child who is obese, hyperinsulinemia may elevate BP by increasing sodium reabsorption and sympathetic tone.
#11 Pathophysiology of primary hypertension in children and adolescents
https://pmc.ncbi.nlm.nih.gov/articles/PMC11026201/
It has been shown that the clinical-laboratory phenotype of children and adolescents with PH represents a set of pathophysiologically related disorders and corresponds to the main pathophysiological nodes of Pages mosaic. […] The problem of what is more important volume or resistance has been debated as early as 100 years ago by giants of physiology and cardiology. […] In the next few decades, two main theories on pathogenesis of PH were developed. One, described by Arthur Guyton, focused on the volume factor and kidney excretory function. […] The second hypothesis presented by Folkow states that a structural remodeling of resistance vessels is a cause of sustained hypertension. […] In fact, both volumetric and resistance mechanisms work together, and there is ample evidence of a close relationship between SS and increased TPR.
#12
https://link.springer.com/article/10.1007/s00467-023-06142-2
It has been shown that the clinical-laboratory phenotype of children and adolescents with PH represents a set of pathophysiologically related disorders and corresponds to the main pathophysiological nodes of Pages mosaic. […] The problem of what is more important volume or resistance has been debated as early as 100 years ago by giants of physiology and cardiology. […] In the next few decades, two main theories on pathogenesis of PH were developed. One, described by Arthur Guyton, focused on the volume factor and kidney excretory function. […] The second hypothesis presented by Folkow states that a structural remodeling of resistance vessels is a cause of sustained hypertension. […] In fact, both volumetric and resistance mechanisms work together, and there is ample evidence of a close relationship between SS and increased TPR.
#13 Pathophysiology of primary hypertension in children and adolescents
https://pmc.ncbi.nlm.nih.gov/articles/PMC11026201/
It has been shown that the clinical-laboratory phenotype of children and adolescents with PH represents a set of pathophysiologically related disorders and corresponds to the main pathophysiological nodes of Pages mosaic. […] The problem of what is more important volume or resistance has been debated as early as 100 years ago by giants of physiology and cardiology. […] In the next few decades, two main theories on pathogenesis of PH were developed. One, described by Arthur Guyton, focused on the volume factor and kidney excretory function. […] The second hypothesis presented by Folkow states that a structural remodeling of resistance vessels is a cause of sustained hypertension. […] In fact, both volumetric and resistance mechanisms work together, and there is ample evidence of a close relationship between SS and increased TPR.
#14 Pathophysiology of primary hypertension in children and adolescents
https://pmc.ncbi.nlm.nih.gov/articles/PMC11026201/
The definitions of SS and SR have changed over time. […] The role of both SNS and the parasympathetic part of ANS is viewed both as a physiological mechanism of fast control of BP fluctuations and as an important system in long-term BP control, playing a significant role in the development and maintenance of PH. […] Since one of the main phenotypic features of the hypertensive child/adolescent is visceral obesity and disturbed body composition, greater SNS activity in adipose subjects may be an important pathophysiological factor in the generation and maintenance of PH in childhood. […] More detailed analyses indicate that it is not obesity but rather disturbed body composition with visceral adipose tissue distribution and male sex that are important in generating SNS activity. […] Clinical studies showed that typical the hemodynamic phenotype of childhood hypertension is isolated systolic hypertension and elevated HR, which dominates both among obese and non-obese hypertensive adolescents.
#15
https://link.springer.com/article/10.1007/s00467-023-06142-2
The definitions of SS and SR have changed over time. […] The role of both SNS and the parasympathetic part of ANS is viewed both as a physiological mechanism of fast control of BP fluctuations and as an important system in long-term BP control, playing a significant role in the development and maintenance of PH. […] Since one of the main phenotypic features of the hypertensive child/adolescent is visceral obesity and disturbed body composition, greater SNS activity in adipose subjects may be an important pathophysiological factor in the generation and maintenance of PH in childhood. […] More detailed analyses indicate that it is not obesity but rather disturbed body composition with visceral adipose tissue distribution and male sex that are important in generating SNS activity. […] Clinical studies showed that typical the hemodynamic phenotype of childhood hypertension is isolated systolic hypertension and elevated HR, which dominates both among obese and non-obese hypertensive adolescents.
#16 Pathophysiology of primary hypertension in children and adolescents
https://pmc.ncbi.nlm.nih.gov/articles/PMC11026201/
The definitions of SS and SR have changed over time. […] The role of both SNS and the parasympathetic part of ANS is viewed both as a physiological mechanism of fast control of BP fluctuations and as an important system in long-term BP control, playing a significant role in the development and maintenance of PH. […] Since one of the main phenotypic features of the hypertensive child/adolescent is visceral obesity and disturbed body composition, greater SNS activity in adipose subjects may be an important pathophysiological factor in the generation and maintenance of PH in childhood. […] More detailed analyses indicate that it is not obesity but rather disturbed body composition with visceral adipose tissue distribution and male sex that are important in generating SNS activity. […] Clinical studies showed that typical the hemodynamic phenotype of childhood hypertension is isolated systolic hypertension and elevated HR, which dominates both among obese and non-obese hypertensive adolescents.
#17 Pathophysiology of primary hypertension in children and adolescents
https://pmc.ncbi.nlm.nih.gov/articles/PMC11026201/
The definitions of SS and SR have changed over time. […] The role of both SNS and the parasympathetic part of ANS is viewed both as a physiological mechanism of fast control of BP fluctuations and as an important system in long-term BP control, playing a significant role in the development and maintenance of PH. […] Since one of the main phenotypic features of the hypertensive child/adolescent is visceral obesity and disturbed body composition, greater SNS activity in adipose subjects may be an important pathophysiological factor in the generation and maintenance of PH in childhood. […] More detailed analyses indicate that it is not obesity but rather disturbed body composition with visceral adipose tissue distribution and male sex that are important in generating SNS activity. […] Clinical studies showed that typical the hemodynamic phenotype of childhood hypertension is isolated systolic hypertension and elevated HR, which dominates both among obese and non-obese hypertensive adolescents.
#18 Obesity and hypertension in children and adolescents | Clinical Hypertension | Full Text
https://clinicalhypertension.biomedcentral.com/articles/10.1186/s40885-024-00278-5
Overweight and obesity affect BP in many ways, and adiposity and weight gain are essential contributors to primary hypertension. The development of hypertension in obesity is influenced by several factors, including increased sympathetic nervous system (SNS) activity, activation of the renin-angiotensin-aldosterone system (RAAS), and compression of the kidneys due to fat accumulation, resulting in increased renal sodium reabsorption and impaired pressure natriuresis. […] Increased SNS is thought to play an essential role as a mechanism for hypertension in obesity. In a study showing that weight gain itself increases SNS, 12 healthy men were made to gain 5 kg of weight by overeating, and when comparing before and after, there was a significant increase in total fat and abdominal fat and a substantial increase in muscle SNS and SBP, suggesting a relationship between obesity and hypertension.
#19 Obesity and hypertension in children and adolescents | Clinical Hypertension | Full Text
https://clinicalhypertension.biomedcentral.com/articles/10.1186/s40885-024-00278-5
Overweight and obesity affect BP in many ways, and adiposity and weight gain are essential contributors to primary hypertension. The development of hypertension in obesity is influenced by several factors, including increased sympathetic nervous system (SNS) activity, activation of the renin-angiotensin-aldosterone system (RAAS), and compression of the kidneys due to fat accumulation, resulting in increased renal sodium reabsorption and impaired pressure natriuresis. […] Increased SNS is thought to play an essential role as a mechanism for hypertension in obesity. In a study showing that weight gain itself increases SNS, 12 healthy men were made to gain 5 kg of weight by overeating, and when comparing before and after, there was a significant increase in total fat and abdominal fat and a substantial increase in muscle SNS and SBP, suggesting a relationship between obesity and hypertension.
#20 Obesity and hypertension in children and adolescents | Clinical Hypertension | Full Text
https://clinicalhypertension.biomedcentral.com/articles/10.1186/s40885-024-00278-5
Despite the volume expansion and sodium retention associated with obesity, they do not have a normal RAAS suppressive response. Related factors, such as plasma renin activity, angiotensinogen, angiotensin-converting enzyme (ACE), and aldosterone, are elevated compared to normal subjects. […] In obesity, visceral, retroperitoneal, and renal sinus fat cause renal compression and structural changes in kidney tissue. Physical compression by fat in and around the kidneys impairs pressure natriuresis and increases renal tubular sodium reabsorption, resulting in sodium retention and increased BP. […] Obesity is the most critical risk factor for hypertension in children and adolescents. Risk factors other than obesity that are known to contribute to the development of hypertension include male sex, a family history of hypertension, early life factors such as birth weight or gestational age, a high-sodium diet, the absence of a Dietary Approaches to Stop Hypertension (DASH)-type diet, larger amounts of sedentary time, and possibly other dietary factors. […] Treatment in obese children is a combination of treatment for obesity and hypertension. Treatment involves lifestyle changes, with weight loss being crucial to lowering BP.
#21 Obesity and hypertension in children and adolescents | Clinical Hypertension | Full Text
https://clinicalhypertension.biomedcentral.com/articles/10.1186/s40885-024-00278-5
Despite the volume expansion and sodium retention associated with obesity, they do not have a normal RAAS suppressive response. Related factors, such as plasma renin activity, angiotensinogen, angiotensin-converting enzyme (ACE), and aldosterone, are elevated compared to normal subjects. […] In obesity, visceral, retroperitoneal, and renal sinus fat cause renal compression and structural changes in kidney tissue. Physical compression by fat in and around the kidneys impairs pressure natriuresis and increases renal tubular sodium reabsorption, resulting in sodium retention and increased BP. […] Obesity is the most critical risk factor for hypertension in children and adolescents. Risk factors other than obesity that are known to contribute to the development of hypertension include male sex, a family history of hypertension, early life factors such as birth weight or gestational age, a high-sodium diet, the absence of a Dietary Approaches to Stop Hypertension (DASH)-type diet, larger amounts of sedentary time, and possibly other dietary factors. […] Treatment in obese children is a combination of treatment for obesity and hypertension. Treatment involves lifestyle changes, with weight loss being crucial to lowering BP.
#22 Pathophysiology of primary hypertension in children and adolescents
https://pmc.ncbi.nlm.nih.gov/articles/PMC11026201/
One of the nodes of Pages mosaic are vascular factors, which means disturbed structure and function of both large and small resistive arteries. […] The next node in Pages mosaic is the metabolic factor associated with arterial hypertension. […] Immune disorders were not included in Pages original mosaic. However, the results of experimental studies since the 1960s and clinical observations pointed to the immune system as another node in Pages modified mosaic. […] Pediatric studies mainly focus on obese children with obesity, type 2 diabetes, and chronic kidney disease. […] Although hypertension in subjects born preterm or as SGA appears to be a separate form of hypertensive disease, prematurity and SGA-associated disorders exemplify the accumulation of all previously described pathophysiological phenomena in PH, such as SS, insulin resistance and MS, visceral obesity, greater adrenergic drive, intestinal dysbiosis, and activation of the immune system.
#23 Pathophysiology of primary hypertension in children and adolescents
https://pmc.ncbi.nlm.nih.gov/articles/PMC11026201/
One of the nodes of Pages mosaic are vascular factors, which means disturbed structure and function of both large and small resistive arteries. […] The next node in Pages mosaic is the metabolic factor associated with arterial hypertension. […] Immune disorders were not included in Pages original mosaic. However, the results of experimental studies since the 1960s and clinical observations pointed to the immune system as another node in Pages modified mosaic. […] Pediatric studies mainly focus on obese children with obesity, type 2 diabetes, and chronic kidney disease. […] Although hypertension in subjects born preterm or as SGA appears to be a separate form of hypertensive disease, prematurity and SGA-associated disorders exemplify the accumulation of all previously described pathophysiological phenomena in PH, such as SS, insulin resistance and MS, visceral obesity, greater adrenergic drive, intestinal dysbiosis, and activation of the immune system.
#24 Pathophysiology of primary hypertension in children and adolescents
https://pmc.ncbi.nlm.nih.gov/articles/PMC11026201/
One of the nodes of Pages mosaic are vascular factors, which means disturbed structure and function of both large and small resistive arteries. […] The next node in Pages mosaic is the metabolic factor associated with arterial hypertension. […] Immune disorders were not included in Pages original mosaic. However, the results of experimental studies since the 1960s and clinical observations pointed to the immune system as another node in Pages modified mosaic. […] Pediatric studies mainly focus on obese children with obesity, type 2 diabetes, and chronic kidney disease. […] Although hypertension in subjects born preterm or as SGA appears to be a separate form of hypertensive disease, prematurity and SGA-associated disorders exemplify the accumulation of all previously described pathophysiological phenomena in PH, such as SS, insulin resistance and MS, visceral obesity, greater adrenergic drive, intestinal dysbiosis, and activation of the immune system.
#25
https://link.springer.com/article/10.1007/s00467-023-06142-2
One of the nodes of Pages mosaic are vascular factors, which means disturbed structure and function of both large and small resistive arteries. […] The next node in Pages mosaic is the metabolic factor associated with arterial hypertension. […] Immune disorders were not included in Pages original mosaic. However, the results of experimental studies since the 1960s and clinical observations pointed to the immune system as another node in Pages modified mosaic. […] Pediatric clinical studies published in the last 2 decades documented that compared to their normotensive peers, children with PH already at diagnosis showed significant activation of innate immunity with increased serum concentrations of not only hsCRP but also chemokines, which indicates endothelial activation. […] Although hypertension in subjects born preterm or as SGA appears to be a separate form of hypertensive disease, prematurity and SGA-associated disorders exemplify the accumulation of all previously described pathophysiological phenomena in PH, such as SS, insulin resistance and MS, visceral obesity, greater adrenergic drive, intestinal dysbiosis, and activation of the immune system. […] Pages mosaic, presented for the first time almost 70 years ago, is still, after modifications related to obtaining new research results, a model describing the multifactorial nature of PH.
#26 Hypertension in Children – Pediatrics – Merck Manual Professional Edition
https://www.merckmanuals.com/professional/pediatrics/hypertension-in-children/hypertension-in-children
Hypertension may be primary (no known cause, a diagnosis of exclusion) or secondary (caused by another disorder, eg, kidney disease). After age 6 years, primary hypertension is the dominant etiology, and this is even more true for adolescents and young adults. Before age 6, secondary hypertension is more common. […] Secondary hypertension has an identifiable cause; the hypertension may be reversible if the cause is resolved. The most common causes of secondary hypertension in children are renal parenchymal disease (eg, glomerulonephritis, pyelonephritis, reflux nephropathy) or congenital anomalies of the kidneys and urinary tract (eg, obstructive uropathy, polycystic kidney disease, dysplastic kidneys). […] As in adults, blood pressure is determined by the balance between cardiac output (affected by myocardial contractility, heart rate, and vascular volume) and vascular resistance (affected by vascular tone, structure, and function). The renin-angiotensin-aldosterone system, sympathetic nervous system, sodium transport, and other factors play a role.
#27 High blood pressure in children – Symptoms & causes – Mayo Clinic
https://www.mayoclinic.org/diseases-conditions/high-blood-pressure-in-children/symptoms-causes/syc-20373440
High blood pressure (hypertension) in children is blood pressure that is at or above the 95th percentile for children who are the same sex, age and height as your child. […] The younger a child is, the more likely it is that the high blood pressure is caused by a specific and identifiable medical condition. Older children can develop high blood pressure for the same reasons adults do excess weight, poor nutrition and lack of exercise. […] High blood pressure in younger children is often related to other health conditions, such as heart defects, kidney disease, genetic conditions or hormonal disorders. Older children especially those who are overweight are more likely to have primary hypertension. This type of high blood pressure occurs on its own, without an underlying condition. […] Primary hypertension occurs on its own, without an identifiable cause. This type of high blood pressure occurs more often in children age 6 and older.
#28 Hypertension in Children and Adolescents | AAFP
https://www.aafp.org/pubs/afp/issues/2006/0501/p1558.html
Based on these observations, early detection of and intervention in children with hypertension are potentially beneficial in preventing long-term complications of hypertension. […] Most childhood hypertension, particularly in preadolescents, is secondary to an underlying disorder. […] Renal parenchymal disease is the most common (60 to 70 percent) cause of hypertension. […] Adolescents usually have primary or essential hypertension, making up 85 to 95 percent of cases. […] Essential hypertension rarely is found in children younger than 10 years and is a diagnosis of exclusion. […] Significant risk factors for essential hypertension include family history and increasing BMI. […] Some sleep disorders and black race can be potential risk factors for essential hypertension. […] Essential hypertension often is linked to other risk factors that make up metabolic syndrome and can lead to cardiovascular disease.
#29 Hypertension in Children and Adolescents | AAFP
https://www.aafp.org/pubs/afp/issues/2006/0501/p1558.html
Based on these observations, early detection of and intervention in children with hypertension are potentially beneficial in preventing long-term complications of hypertension. […] Most childhood hypertension, particularly in preadolescents, is secondary to an underlying disorder. […] Renal parenchymal disease is the most common (60 to 70 percent) cause of hypertension. […] Adolescents usually have primary or essential hypertension, making up 85 to 95 percent of cases. […] Essential hypertension rarely is found in children younger than 10 years and is a diagnosis of exclusion. […] Significant risk factors for essential hypertension include family history and increasing BMI. […] Some sleep disorders and black race can be potential risk factors for essential hypertension. […] Essential hypertension often is linked to other risk factors that make up metabolic syndrome and can lead to cardiovascular disease.
#30 High blood pressure (hypertension) – Symptoms & causes – Mayo Clinic
https://www.mayoclinic.org/diseases-conditions/high-blood-pressure/symptoms-causes/syc-20373410
High blood pressure is most common in adults. But kids can have high blood pressure too. High blood pressure in children may be caused by problems with the kidneys or heart. But for a growing number of kids, high blood pressure is due to lifestyle habits such as an unhealthy diet and lack of exercise. […] Blood pressure is determined by two things: the amount of blood the heart pumps and how hard it is for the blood to move through the arteries. The more blood the heart pumps and the narrower the arteries, the higher the blood pressure. […] For most adults, there’s no identifiable cause of high blood pressure. This type of high blood pressure is called primary hypertension or essential hypertension. It tends to develop gradually over many years. Plaque buildup in the arteries, called atherosclerosis, increases the risk of high blood pressure.
#31 Hypertension in Children – Pediatrics – Merck Manual Professional Edition
https://www.merckmanuals.com/professional/pediatrics/hypertension-in-children/hypertension-in-children
Hypertension may be primary (no known cause, a diagnosis of exclusion) or secondary (caused by another disorder, eg, kidney disease). After age 6 years, primary hypertension is the dominant etiology, and this is even more true for adolescents and young adults. Before age 6, secondary hypertension is more common. […] Secondary hypertension has an identifiable cause; the hypertension may be reversible if the cause is resolved. The most common causes of secondary hypertension in children are renal parenchymal disease (eg, glomerulonephritis, pyelonephritis, reflux nephropathy) or congenital anomalies of the kidneys and urinary tract (eg, obstructive uropathy, polycystic kidney disease, dysplastic kidneys). […] As in adults, blood pressure is determined by the balance between cardiac output (affected by myocardial contractility, heart rate, and vascular volume) and vascular resistance (affected by vascular tone, structure, and function). The renin-angiotensin-aldosterone system, sympathetic nervous system, sodium transport, and other factors play a role.
#32 High blood pressure in children – Symptoms & causes – Mayo Clinic
https://www.mayoclinic.org/diseases-conditions/high-blood-pressure-in-children/symptoms-causes/syc-20373440
Secondary hypertension is caused by another condition. It’s more common in young children. Other causes of high blood pressure include: Chronic kidney disease, Polycystic kidney disease, Heart problems, such as severe narrowing (coarctation) of the aorta, Adrenal disorders, Overactive thyroid (hyperthyroidism), Narrowing of the artery to the kidney (renal artery stenosis), Sleep disorders, especially obstructive sleep apnea. […] Children who have high blood pressure are likely to continue to have high blood pressure as adults unless they begin treatment. […] High blood pressure can be prevented in children by making the same lifestyle changes that can help treat it controlling your child’s weight, providing a healthy diet low in salt (sodium) and encouraging your child to exercise.
#33 Hypertension in Children and Adolescents | AAFP
https://www.aafp.org/pubs/afp/issues/2006/0501/p1558.html
Secondary hypertension is more common in children than in adults. […] Renal disease is the most common cause of secondary hypertension in children. […] Other causes include endocrine disease (e.g., pheochromocytoma, hyperthyroidism) and pharmaceuticals (e.g., oral contraceptives, sympathomimetics, some over-the-counter preparations, dietary supplements). […] Once hypertension has been confirmed, an extensive history and careful physical examination should be conducted to identify underlying causes of the elevated blood pressure and to detect any end-organ damage. […] The NHBPEP has developed an algorithm to help the physician navigate the diagnostic and management choices in childhood hypertension. […] Nonpharmacologic and pharmacologic treatments are recommended based on the age of the child, the stage of hypertension, and response to treatment.
#34 Pathophysiology of primary hypertension in children and adolescents
https://pmc.ncbi.nlm.nih.gov/articles/PMC11026201/
One of the nodes of Pages mosaic are vascular factors, which means disturbed structure and function of both large and small resistive arteries. […] The next node in Pages mosaic is the metabolic factor associated with arterial hypertension. […] Immune disorders were not included in Pages original mosaic. However, the results of experimental studies since the 1960s and clinical observations pointed to the immune system as another node in Pages modified mosaic. […] Pediatric studies mainly focus on obese children with obesity, type 2 diabetes, and chronic kidney disease. […] Although hypertension in subjects born preterm or as SGA appears to be a separate form of hypertensive disease, prematurity and SGA-associated disorders exemplify the accumulation of all previously described pathophysiological phenomena in PH, such as SS, insulin resistance and MS, visceral obesity, greater adrenergic drive, intestinal dysbiosis, and activation of the immune system.
#35 Elevated blood pressure among children born to women with obstructed labour in Eastern Uganda: a cohort study | Clinical Hypertension | Full Text
https://clinicalhypertension.biomedcentral.com/articles/10.1186/s40885-023-00261-6
Globally, high systolic blood pressure accounts for 10.8 million deaths annually. […] The onset of hypertension occurs earlier in sub-Saharan Africa compared to high-income countries. […] Thirdly, insults such as birth asphyxia that occur in the perinatal period could be partly responsible for this disparity. Birth asphyxia is thought to injure the blood vessels and the heart by causing structural and functional changes and consequently increasing the risk for hypertension. […] Our findings show a high incidence of elevated blood pressure among children. […] Our study found a high incidence of elevated blood pressure. […] Participants aged three years and above had twice the odds of elevated blood pressure as those aged less than three years. […] The female participants had twice the odds of elevated blood pressure as their male counterparts.
#36 Elevated blood pressure among children born to women with obstructed labour in Eastern Uganda: a cohort study | Clinical Hypertension | Full Text
https://clinicalhypertension.biomedcentral.com/articles/10.1186/s40885-023-00261-6
Children with reduced estimated glomerular filtration rate had twice the odds of elevated blood pressure as those with normal estimated glomerular filtration rate. […] Our study suggests the need to routinely measure blood pressure for children following birth asphyxia. This is important for early identification and timely management of children with elevated blood pressure. […] We encourage routine checking for elevated blood pressure in the pediatric population particularly those with known risk factors.
#37 Pathophysiology of primary hypertension in children and adolescents
https://pmc.ncbi.nlm.nih.gov/articles/PMC11026201/
It has been shown that the clinical-laboratory phenotype of children and adolescents with PH represents a set of pathophysiologically related disorders and corresponds to the main pathophysiological nodes of Pages mosaic. […] The problem of what is more important volume or resistance has been debated as early as 100 years ago by giants of physiology and cardiology. […] In the next few decades, two main theories on pathogenesis of PH were developed. One, described by Arthur Guyton, focused on the volume factor and kidney excretory function. […] The second hypothesis presented by Folkow states that a structural remodeling of resistance vessels is a cause of sustained hypertension. […] In fact, both volumetric and resistance mechanisms work together, and there is ample evidence of a close relationship between SS and increased TPR.
#38 Pathophysiology of primary hypertension in children and adolescents – PubMed
https://pubmed.ncbi.nlm.nih.gov/37700113/
The progress in research on the physiology of the cardiovascular system made in the last 100 years allowed for the development of the pathogenesis not only of secondary forms of hypertension but also of primary hypertension. […] Most of the clinical studies confirming the validity of the multifactorial pathogenesis of primary hypertension concern adults. However, hypertension develops in childhood and is even perinatally programmed. Therefore, the next nodes in Page’s mosaic should be age and perinatal factors. This article presents data from pediatric clinical trials describing the most important pathophysiological processes associated with the development of essential hypertension in children and adolescents. […] Arterial hypertension develops gradually. Different mechanisms are involved in the increase in blood pressure at different stages of biological development. With age and the persistence of the original disorders, changes such as disturbed body composition, adaptive vascular changes, damage to the microcirculation, and immune activation gradually generate new, irreversible arterial injury with increased stiffness resulting in the perpetuation of hypertension.
#39 Pediatric Hypertension: Background, Pathophysiology, Etiology
https://emedicine.medscape.com/article/889877-overview
Under normal conditions, the amount of sodium excreted in the urine matches the amount ingested, resulting in near constancy of extracellular volume. Retention of sodium results in increased extracellular volume, which is associated with an elevation of BP. […] A rise in the intracellular calcium concentration, due to changes in plasma calcium concentration, increases vascular contractility. In addition, calcium stimulates release of renin, synthesis of epinephrine, and sympathetic nervous system activity. Increased potassium intake suppresses production and release of renin and induces natriuresis, decreasing BP. […] The complexity of the system explains the difficulties often encountered in identifying the mechanism that accounts for hypertension in a particular patient. These difficulties are the main reason why treatment is often designed to affect regulatory factors rather than the cause of the disease. […] In a child who is obese, hyperinsulinemia may elevate BP by increasing sodium reabsorption and sympathetic tone.
#40 Hypertension in Children and Adolescents | AAFP
https://www.aafp.org/pubs/afp/issues/2006/0501/p1558.html
Based on these observations, early detection of and intervention in children with hypertension are potentially beneficial in preventing long-term complications of hypertension. […] Most childhood hypertension, particularly in preadolescents, is secondary to an underlying disorder. […] Renal parenchymal disease is the most common (60 to 70 percent) cause of hypertension. […] Adolescents usually have primary or essential hypertension, making up 85 to 95 percent of cases. […] Essential hypertension rarely is found in children younger than 10 years and is a diagnosis of exclusion. […] Significant risk factors for essential hypertension include family history and increasing BMI. […] Some sleep disorders and black race can be potential risk factors for essential hypertension. […] Essential hypertension often is linked to other risk factors that make up metabolic syndrome and can lead to cardiovascular disease.
#41 Obesity and hypertension in children and adolescents | Clinical Hypertension | Full Text
https://clinicalhypertension.biomedcentral.com/articles/10.1186/s40885-024-00278-5
Despite the volume expansion and sodium retention associated with obesity, they do not have a normal RAAS suppressive response. Related factors, such as plasma renin activity, angiotensinogen, angiotensin-converting enzyme (ACE), and aldosterone, are elevated compared to normal subjects. […] In obesity, visceral, retroperitoneal, and renal sinus fat cause renal compression and structural changes in kidney tissue. Physical compression by fat in and around the kidneys impairs pressure natriuresis and increases renal tubular sodium reabsorption, resulting in sodium retention and increased BP. […] Obesity is the most critical risk factor for hypertension in children and adolescents. Risk factors other than obesity that are known to contribute to the development of hypertension include male sex, a family history of hypertension, early life factors such as birth weight or gestational age, a high-sodium diet, the absence of a Dietary Approaches to Stop Hypertension (DASH)-type diet, larger amounts of sedentary time, and possibly other dietary factors. […] Treatment in obese children is a combination of treatment for obesity and hypertension. Treatment involves lifestyle changes, with weight loss being crucial to lowering BP.
#42 Hypertension | Boston Children’s Hospital
https://www.childrenshospital.org/conditions/hypertension
If left untreated, hypertension can persist into adulthood. […] The rise in the number of children with primary hypertension in the United States is thought to correlate with the rise of obesity. […] Hypertension causes changes in the structures of the blood vessels and heart. […] Since hypertension in children has historically been understudied, there isnât a lot of data about exactly what these changes mean. […] But we do know that in adults, hypertension increases the chance of complications in the heart, blood vessels, and kidneys. […] Thereâs also compelling evidence that some of these changes are seen in children with high blood pressure. […] Hypertension in infants with hypertension almost always has a secondary cause. […] Among kids with hypertension, especially those who are very young, secondary hypertension is more common than primary hypertension. […] But among children who are older than 6 to 8 years old, the ratio of primary to secondary hypertension is approaching 50/50.
#43 Hypertension in Children and Adolescents | AAFP
https://www.aafp.org/pubs/afp/issues/2006/0501/p1558.html
There is evidence that childhood hypertension can lead to adult hypertension. […] Hypertension is a known risk factor for coronary artery disease (CAD) in adults, and the presence of childhood hypertension may contribute to the early development of CAD. […] Reports show that early development of atherosclerosis does exist in children and young adults and may be associated with childhood hypertension. […] Left ventricular hypertrophy (LVH) is the most prominent clinical evidence of end-organ damage in childhood hypertension. […] Data show that LVH can be seen in as many as 41 percent of patients with childhood hypertension. […] Patients with severe cases of childhood hypertension are also at increased risk of developing hypertensive encephalopathy, seizures, cerebrovascular accidents, and congestive heart failure.
#44 Hypertension in Children – Pediatrics – Merck Manual Professional Edition
https://www.merckmanuals.com/professional/pediatrics/hypertension-in-children/hypertension-in-children
Hypertension is sustained elevation of resting systolic blood pressure, diastolic blood pressure, or both. Hypertension with no known cause (primary) is most common, as with adults. Hypertension with an identified cause (secondary hypertension) is relatively uncommon in children, although it occurs more frequently in younger children (< 6 years). [...] It has become clear over time that hypertension in adults is affected by both intrauterine and neonatal conditions and often begins in childhood. Also, sequelae of hypertension in adulthood occur earlier in patients who were hypertensive as children. Additionally, there is evidence that hypertension in childhood and adolescence is directly associated with increased risk of cardiovascular disease in adulthood. [...] In the United States, the prevalence of hypertension in children ranges between 2 and 4% with elevated blood pressure (previously called prehypertension) noted in 16%. Worldwide, prevalence is less clear because of regional differences in definitions, reference data, and methodology but is estimated at about 4%. In addition, the prevalence appears to be increasing, likely due to the increased incidence of overweight and obesity in children; obesity is now four times as common among adolescents as it was 60 years ago. Obese adolescents are more likely than their peers to have hypertension.
#45 Hypertension in Children – Pediatrics – Merck Manual Professional Edition
https://www.merckmanuals.com/professional/pediatrics/hypertension-in-children/hypertension-in-children
Complications of pediatric hypertension can be acute or chronic. Acute complications of hypertension in children are relatively uncommon and are usually related to hypertensive emergencies, in which target organ dysfunction or damage is present. […] Chronic complications of hypertension in children are rare and when present typically do not occur until late adolescence or early adulthood. The complications of chronic hypertension in adults, including coronary artery disease, heart failure, ischemic stroke, peripheral vascular disease, and hypertensive end-stage renal disease, rarely, if ever, occur in children. However, precursors to these complications, including adverse changes in carotid intima-media thickness (cIMT), pulse wave velocity, left ventricular hypertrophy (LVH), and neurocognition, may be identified in children with hypertension.
#46 Can Children Have High Blood Pressure? – UHealth Collective
https://news.umiamihealth.org/en/can-children-have-high-blood-pressure/
Blood pressure has its own circadian rhythm (sleep/wake cycle). Thereâs a normal variability. We evaluate blood pressure changes during the day and night. […] When life on earth transitioned from water to land, it needed something to control blood volume on dry land. The hormone aldosterone, which has a huge effect on regulating water, salt, and potassium, first appeared millions of years ago in the lungfish, a fish with lungs. […] The way we respond to the environment, especially the management of blood volume, is part of our genetic makeup. In many hypertensive patients, aldosterone plays an important role in environmental adaptation and blood pressure regulation. […] Kids with normal blood pressure can have early signs of endothelial dysfunction. […] In stage one hypertension (blood pressure of 130-139), environmental intervention is the most effective way to lower blood pressure without medication. […] Rather than treating the end results of hypertension, Dr. Delgado-Lelievre believes that early identification and intervention, even in children as young as 12, is the key to turning the tide on Americaâs number one killer.
#47 Hypertension in Children and Adolescents | AAFP
https://www.aafp.org/pubs/afp/issues/2006/0501/p1558.html
Based on these observations, early detection of and intervention in children with hypertension are potentially beneficial in preventing long-term complications of hypertension. […] Most childhood hypertension, particularly in preadolescents, is secondary to an underlying disorder. […] Renal parenchymal disease is the most common (60 to 70 percent) cause of hypertension. […] Adolescents usually have primary or essential hypertension, making up 85 to 95 percent of cases. […] Essential hypertension rarely is found in children younger than 10 years and is a diagnosis of exclusion. […] Significant risk factors for essential hypertension include family history and increasing BMI. […] Some sleep disorders and black race can be potential risk factors for essential hypertension. […] Essential hypertension often is linked to other risk factors that make up metabolic syndrome and can lead to cardiovascular disease.
#48 Azthena logo with the word Azthena
https://www.news-medical.net/health/High-Blood-Pressure-in-Children.aspx
Although people usually assume that only middle-aged or elderly people develop high blood pressure (hypertension), it is also possible for the condition to arise in teenagers, children and even babies. […] The American Heart Association advises that all children should be checked for high blood pressure on a yearly basis, as detecting the condition and treating it early will improve the child’s health and reduce or prevent the harmful effects of the condition. […] Hypertension in children is usually caused by another underlying health condition such as heart disease or kidney disease. It is therefore referred to as secondary hypertension and once the medical condition is resolved, the blood pressure typically returns to normal. […] In some cases, a doctor cannot determine what is causing the hypertension, in which case the condition is referred to as primary or essential hypertension.
#49 Can Children Have High Blood Pressure? – UHealth Collective
https://news.umiamihealth.org/en/can-children-have-high-blood-pressure/
Blood pressure has its own circadian rhythm (sleep/wake cycle). Thereâs a normal variability. We evaluate blood pressure changes during the day and night. […] When life on earth transitioned from water to land, it needed something to control blood volume on dry land. The hormone aldosterone, which has a huge effect on regulating water, salt, and potassium, first appeared millions of years ago in the lungfish, a fish with lungs. […] The way we respond to the environment, especially the management of blood volume, is part of our genetic makeup. In many hypertensive patients, aldosterone plays an important role in environmental adaptation and blood pressure regulation. […] Kids with normal blood pressure can have early signs of endothelial dysfunction. […] In stage one hypertension (blood pressure of 130-139), environmental intervention is the most effective way to lower blood pressure without medication. […] Rather than treating the end results of hypertension, Dr. Delgado-Lelievre believes that early identification and intervention, even in children as young as 12, is the key to turning the tide on Americaâs number one killer.
#50 Elevated blood pressure among children born to women with obstructed labour in Eastern Uganda: a cohort study | Clinical Hypertension | Full Text
https://clinicalhypertension.biomedcentral.com/articles/10.1186/s40885-023-00261-6
Children with reduced estimated glomerular filtration rate had twice the odds of elevated blood pressure as those with normal estimated glomerular filtration rate. […] Our study suggests the need to routinely measure blood pressure for children following birth asphyxia. This is important for early identification and timely management of children with elevated blood pressure. […] We encourage routine checking for elevated blood pressure in the pediatric population particularly those with known risk factors.