儿童及青少年单纯收缩期高血压发病机制研究进展

单纯收缩期高血压(ISH)是老年人高血压最为常见的类型,其对心血管事件的发生有重要影响。值得注意的是,ISH在儿童及青少年中也很常见。与儿童及青少年ISH发病机制不同,大动脉僵硬度增加是老年人ISH的主要发病机制。多项研究表明,儿童及青少年ISH的主要发病机制为交感神经活动亢进,可表现为:高动力状态、肾素-血管紧张素-醛固酮系统激活等。现从儿童及青少年ISH发病机制的研究进展做一综述。     

青少年高血压

近年来的流行病学调查研究表明高血压发病率呈年轻化趋势,高血压已不再是中老年人的专利,越来越多的青少年也受到高血压的威胁。由于青少年高血压往往无明显症状,因此最近对青少年高血压的认识、诊断和治疗提出了新的要求,本文就青少年高血压的定义、诊断及其病因做一综述。     

单基因遗传性高血压

目前已公认遗传机制是高血压发生的基础之一,对于高血压的遗传模式,现认为有2种,即单基因遗传模式(oligogenic model)) 和多基因遗传模式(polygenic model).其中多基因遗传模式是主要的一种模式,主要见于原发性高血压;而单基因遗传模式主要见于一些继发性高血压,仅在少数高血压患者中存在,但其治疗有特异性,并且大多具有家族性,因此明确诊断,对患者及其家属具有很大意义,临床上应予适当关注.单基因遗传高血压是指由一个基因突变引起的高血压,一般符合孟德尔遗传规律,但表型亦受环境因素的影响.这类高血压一般发病早,多在青少年发病,有家族史,为重度高血压或难治性高血压,常伴有激素和生化水平的异常.对于有家族史的青少年中重度高血压患者,应测定血浆肾素-血管紧张素-醛固酮、血电解质和皮质醇、性激素等激素水平,根据病史、体征和检测结果,确定单基因高血压的类型.     

儿童及青少年高血压的研究概况

随着生活水平的提高和饮食模式的改变,儿童及青少年高血压的发病率有逐渐增加的趋势。高血压的防治重在预防,在儿童及青少年时期识别高血压高危人群有助于早期进行有效干预和治疗,降低成人高血压的发生率。该文从儿童及青少年高血压的流行病学特点、诊断标准、危险因素、靶器官损害等方面的研究进展作一综述。     

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高血压是威胁人类健康的主要疾病之一,已成为全球性问题。尽管近年来儿童及青少年高血压患病率显著上升,其诊断及防治相关工作仍相对滞后。儿童青少年高血压易发展为成人高血压,且易造成多种靶器官损害,严重影响儿童青少年生长发育,必须给予足够重视。儿童青少年高血压常无症状,临床工作中应提高警惕,熟悉常见危险因素,仔细评估病史、体格检查及物理检查结果,制定合理的诊断路径和有效的治疗方案。     

关注儿童青少年中的代谢综合征

在全球糖尿病发病率不断增长的大背景之下,还有一个变化非常值得我们关注,这就是糖尿病发病的低龄化。越来越多的儿童青少年过早背负上肥胖、代谢综合征、糖尿病等健康问题,由于他们将要面临更长的病程,所以更加需要及时有效的干预治疗。为此,美国心脏协会的青少年心血管疾病委员会青少年动脉粥样硬化、高血压和肥胖分会、心血管护理委员会和营养、运动和代谢委员会在2009年共同发表了一份名为"儿童和青少年中代谢综合征的进展与挑战"的科学声明,呼吁人们关注儿童青少年代谢综合征的问题。     

湖北省15~18岁青少年高血压流行病学调查

目的探讨湖北省15~18岁青少年高血压流行病学特点及相关影响因素。方法采用分层多级随机抽样方法,按城乡、性别抽取相应数目的个体。总共1540(男839、女701)人,城市767人,农村773人,在校生1481人。采取现场问卷调查获取人口学特征资料,并进行现场血压、身高、体质量、腰围测量。采用Epidata3.1软件建立数据库,双录入数据,应用统计学软件SPSS 21.0进行统计分析。结果湖北省15~18岁青少年高血压检出率为17.99%(277/1540)。单因素分析显示:农村、高血压家族史、中学文化程度、高盐膳食、低强度运动、睡眠不足、超重和肥胖、腹型肥胖和高血压患病相关(均P0.05),在校生初中生及高中生高血压检出率较大学生高(P0.05);多因素Logistic回归分析显示:农村(OR=1.474,95%CI 1.078~2.015)、超重(OR=2.709,95%CI 1.726~4.251)及肥胖(OR=4.065,95%CI 2.077~7.955)与青少年高血压发病呈正相关,中等强度运动(OR=0.615,95%CI0.435~0.869)、高强度运动(OR=0.498,95%CI0.352~0.705)、睡眠充足(OR=0.619,95%CI0.460~0.834)与青少年高血压发病呈负相关。结论湖北省15~18岁青少年高血压检出率较高,其可能的影响因素有城乡差异、体质量指数、运动强度及睡眠时间。     

《儿童青少年高血压筛查和管理的临床实践指南》主要更新内容

<正>2017年9月,美国儿科学会对2004年《儿童青少年高血压诊断、评估和治疗的第四次报告》进行了更新,并发布了《儿童青少年高血压筛查和管理的临床实践指南》,该指南主要更新内容如下。(1)使用术语"血压升高"代替"高血压前期";(2)基于正常体质量儿童青少年,制定了新的儿童青少年血压数据表格;(3)制定了简化筛查表,用于识别需进一步评估的儿童青少年;     

导读

<正>中国3～17岁儿童性别、年龄别和身高别血压参照标准(范晖等p428)中国3～17岁儿童血压简化标准的研制(范晖等p436)儿童青少年高血压检出率的逐年上升和高血压发病的快速低龄化趋势,给我国成人高血压防治带来了新的挑战。将高血压防治窗口下移至儿童人群,早期识别儿童高危人群,采取有效措施加以防治,是控制高血压发病上升的重要策略。儿童血压受多种因素影响,性别、年龄别和身高别的儿童血压     

家族性高胆固醇血症青少年早发冠心病3例

冠心病随着年龄增加罹患风险增加,过去常被认为是老年性疾病,近年来,随着生活条件的提高和生活方式的改变,发病年龄有年轻化趋势,但多数病人均伴有肥胖、高血压、吸烟、糖尿病或家族史等危险因素。无上述因素的青少年发病仍属少见,家族     

Obesity hypertension in adolescents: epidemiology, evaluation, and management

The prevalence of hypertension among all adolescents is approximately 3.5%, with somewhat higher rates of prehypertension. Obesity affects approximately 20% of adolescents in the United States, and the prevalence of hypertension is much higher among obese adolescents compared with nonobese adolescents. As in other populations, the evaluation of elevated blood pressure in obese adolescents should begin with a confirmation of the blood pressure elevation, followed by a focused diagnostic work-up to detect possible secondary causes of hypertension. Primary therapy for obesity-related hypertension in adolescents begins with weight loss, and may include antihypertensive medications if target-organ damage or other indications for drug therapy are present. The emphasis of management should be reduction of future cardiovascular risk.     

Ambulatory blood pressure monitoring and target organ damage in pediatrics

The prevalence of hypertension in children and adolescents is rising in association with the increasing rate of childhood obesity, and it is associated with early target organ damage. Published guidelines on high blood pressure in children and adolescents, focused on the early and accurate diagnosis of hypertension, resulted in improved ability to identify children with hypertension. Although auscultation using a mercury sphygmomanometer remains the method of choice for evaluation of hypertension in children, accumulating evidence suggests that ambulatory blood pressure monitoring is a more accurate method for diagnosis, and it is more closely associated with target organ damage. In addition, ambulatory blood pressure monitoring is a valuable tool in the assessment of white-coat hypertension, and masked hypertension in children and adolescents. Masked hypertension in children and adolescents is associated with a similar risk of target organ damage as in established hypertension.     

Association between hypertension in adolescents and the health risk factors of their parents: an epidemiological family study

Hypertension in adolescence may be a predictor of cardiovascular problems in adulthood. Therefore, verification of the factors associated with this condition in adolescence is important. The aim of this study was to analyze the relationship between hypertension in adolescents with hypertension and the sociodemographic characteristics and lifestyle of their parents. This study was conducted on 1231 adolescents, 1202 mothers, and 871 fathers. The blood pressure of the adolescents was measured with an oscillometric device. Details of parental hypertension, sociodemographic characteristics, and lifestyle were obtained by self-report. The prevalence of hypertension was higher among adolescents with older fathers and older mothers, with both parents reporting hypertension and with mothers who were overweight. In multivariable analysis, adolescents with older mothers (OR = 2.36; 95% confidence interval [CI] = 1.12–4.98), hypertensive mothers (OR = 2.22 [95% CI = 1.26–3.89]), and hypertensive fathers (OR = 1.70 [95% CI = 1.03–2.81]) were more likely to have hypertension. In the analysis that considered clusters of health risk factors, higher risks of hypertension were observed in adolescents whose mothers had four or more aggregated risk factors (OR = 2.53 [95% CI = 1.11–5.74]). In conclusion, there was a relationship between hypertension in adolescents and hypertension in their parents. However, an association between hypertension in adolescents and parental age and clusters of health risk factors was only observed for their mothers.     

Significance of heritability in primary and secondary pediatric hypertension

BACKGROUND: Patient weight and family history are significant risk factors for the development of hypertension in children. Multiple genetic factors have been identified in primary (essential) hypertension in adults; however, the delineation of genetic factors in the separate populations of children with primary or secondary hypertension are not well understood. Heritability is the proportion of observed variation in a particular trait that can be attributed to an inherited genetic factor in contrast to environmental factors. In the consideration of hypertension, heritability can be assessed in terms of an underlying continuous gradient of the liability for developing hypertension. With this assumption it is possible to compute heritability using hypertension incidence among relatives and described by Falconer. Heritability values range from 0 (no genetic contribution) to 1 (complete genetic contribution). The aim of this study was to determine the genetic contribution to primary and secondary hypertension in a pediatric population through heritability analysis. METHODS: This was a retrospective case-control analysis of medical records of children (n=276) followed in the Pediatric Nephrology Clinic over a 4-year period from 1999 to 2002. There were 192 children and adolescents with primary hypertension (124 male, 68 female, age 0 to 21 years) and 84 children and adolescents with secondary hypertension (46 male, 38 female, age 0 to 21 years). Each hypertensive group served as the control for the other. Estimates of heritability were made using Falconer's method 2. The model assumes independence between the environment and genetic factors and that the joint distribution of liabilities between parent and child are normally distributed. Problems can arise from computing heritability due to dominance within loci, correlations between nongenetic familial effects, or the presence of a major gene. RESULTS: Of the children and adolescents with primary hypertension, 49% had parents with primary hypertension; and of the children and adolescents with secondary hypertension, 24% had parents with primary hypertension. Of the children and adolescents with primary hypertension, 10% had parents with secondary hypertension; and of the children and adolescents with secondary hypertension, 46% had parents with secondary hypertension. The estimated heritability for primary hypertension was 0.84 (SE=0.21). The estimated heritability for secondary hypertension was 1.14 (SE=0.21). As the value was >1, this indicates that the fit of the liability model is poor and that a few genes, or even one major gene, were significantly involved in the causes of secondary hypertension in the children and adolescents studied. CONCLUSIONS: The results suggest that primary and secondary hypertension do not share the same type of genetic profile. Primary hypertension in children and adolescents is likely due to a large number of additive contributions of genes, although a highly correlated environmental component can not be excluded. The continuous liability model is inappropriate for secondary hypertension because the estimate was substantially greater than one. This study supports the model that secondary hypertension in children and adolescents may be related to just a few genes.     

Hypertension in adolescents: The role of obesity and family history

We evaluated the combined effect of obesity and family history (FH) on the risk of hypertension in adolescents. We studied 1288 school‐aged adolescents aged 16.0 ± 0.5 years (49.0% males) attending the medical examination for enrollment in the city of Nanning, China. Their blood pressure, weight, and height were measured. A questionnaire was administered to both adolescents and their parents to obtain information on the participants’ medical history. Multiple logistic regression analysis, according to bodyweight categories and adjusted for age, gender, and body mass index (BMI), was done to determine the association of FH with hypertension. Hypertension was found in 14.1% of adolescents. The prevalence of hypertension was significantly higher in adolescents with obesity and positive FH than their normal weight and negative FH counterparts. For adolescents with normal weight and waist circumstance (WC), those with a positive FH in parents compared to those without had an significantly increased risk for hypertension (odds ratio [OR], 2.15; 95% confidence interval [CI] 1.28–3.61, and 1.96; 95% CI 1.16–3.32, respectively). These findings were adjusted for age, gender, and BMI. Our study showed that routine screening for pediatric hypertension should be performed in adolescents who are overweight and obese. Furthermore, parental FH of hypertension played an important role in predicting the hypertension phenotype among adolescents with normal weight.     

Hypertension in children and adolescents: An approach to management of complex hyper tension in pediatric patients

Although primary (essential) hypertension is detectable in childhood, secondary causes of hypertension must be considered in evaluating and managing hypertension in children and adolescents. Very young children and children with severe hypertension may have an underlying cause of the hypertension. Interventions to control elevated blood pressure (BP) are clinically important for all children with high BP. Nonpharmacologic approaches are recommended for all asymptomatic children with hypertension and prehypertension. Some children and adolescents will require pharmacologic therapy to control BP and to optimize organ protection. Recent advancements in pediatric clinical trials of antihypertensive agents have provided data on BP-lowering effects and safety in children. Little has been published on the choice and use of various classes of antihypertensive drugs for management of secondary hypertension in children and adolescents. This review focuses on the clinical management of specific types of secondary hypertension in pediatric patients.     

Usefulness of ambulatory blood pressure monitoring in diagnosis of arterial hypertension in children and adolescents

BACKGROUND: Arterial hypertension in children and adolescents is an important medical problem with a prevalence rising over the last ten years from 1 to 4.5%. AIM: To assess the usefulness of ambulatory blood pressure monitoring (ABPM) in diagnosis of arterial hypertension in children and adolescents. METHODS: Two hundred and twelve children with elevated blood pressure (BP) and 81 healthy controls participated in this study. In all children from the study and control groups standard BP measurement and ABPM were performed. RESULTS: With the use of standard BP measurement, 168 (79.2%) children were diagnosed as hypertensive and the remaining 44 (20.8%) as prehypertensive. When the ABPM was used, arterial hypertension was diagnosed in 143 (67.4%) cases and white coat hypertension in the remaining 69 (32.6%) subjects. In 7 (8.7%) control children elevated BP in ABPM was detected, and masked hypertension were diagnosed. CONCLUSIONS: 1. Ambulatory blood pressure monitoring is a useful tool in diagnosis of arterial hypertension in children and adolescents. 2. Systolic hypertension is a major form of hypertension in childhood. 3. Ambulatory blood pressure monitoring is helpful to identify patients with white coat hypertension. 4. Further studies are necessary to establish uniform indications, standards and rules for interpretation of ABPM in children and adolescents.     

Diagnosis and Treatment of Hypertension in Children

Hypertension is a global problem, affecting both developed and developing nations. In children and adolescents, hypertension has gained ground in cardiovascular medicine, thanks to the progress made in several areas of pathophysiologic and clinical research. Childhood hypertension is often asymptomatic and is easily missed, even by health professionals. Target organ damage is detectable in children and adolescents. Management of hypertension includes lifestyle changes and pharmacologic treatment. In the case of secondary hypertension, pharmacologic treatment usually is required. In essential hypertension, assessment of early organ damage provides a useful tool for treatment decisions.     

Cardiovascular response to mental stress in normal adolescents with hypertensive parents. Hemodynamics and mental stress in adolescents

The hemodynamic response to mental stress (mental arithmetic) was studied in adolscents with varying risk factors for essential hypertension (EH), One group (genetic) consisted of normotensive well adolescents who had at least one parentnt with EH. Another group (labile) consisted of adolescents with labile hypertension each of whom also had at least one pare with EH. The control population consisted of normotensive adolescents with a negative family history of EH. Subjects with labile hypertension demonstrated a sustained increase in systolic and diastolic pressure and heart rate during stress. This response was significantly different than the control population (P less than THE CONTROL POPULATION (P LESS THAN 0.001). The stress response of the normotensive genetic population was qualitatively similar to the group with labile hypertension and significantly different than the controls in diastolic pressure and heart rate (p less than 0.001, less than 0.02). Post-stress plasma catecholamines were higher in the labile hypertensive and genetic groups than in the control group. These findings demonstrate increased central nervous system mediated adrenergic activity and cardiovascular response in labile hypertension and also in some normotensive subjects with a genetic risk for hypertension.     

有高血压家族史血压正常的青少年心血管危险因素分析

目的探讨高血压家族史对血压正常青少年心血管危险因素的影响。方法通过分层整群随机抽样,共抽取13～18岁青少年3874人,血压正常青少年3724例,分为高血压家族史阳性组(FH~+)(n=1145)和高血压家族史阴性组(FH~-)(n=2579)。测量身高、体质量、腰围、臀围、血压、空腹血糖(FPG)、血三酰甘油(TG)、胆固醇(TC)、高密度脂蛋白胆固醇(HDL-C)及低密度脂蛋白胆固醇(LDL-C)水平。结果 1)FH~+组体质量指数(BMI)、腰围、腰臀比(WHR)、FPG、TC 和 LDL-C 均高于 FH 组(P<0.05)。2)FH~+组超重肥胖、高 FPG 检出率高于 FH~-组(P<0.05),两组间高 TG、低 HDL-C 检出率差异无统计学意义(P>0.05)。3)校正年龄和性别后,lo-gistic 多因素回归分析显示:FH~+青少年具有2项以上心血管危险因素的危险性是 FH~-青少年的1.7倍(95%CI:1.2～2.2),FH~+组男性青少年具有2项以上心血管危险因素的危险性是女性青少年的3.0倍(95%CI:1.8～5.0)。结论原发性高血压患者的一级亲属青少年已存在心血管危险因素增...