ABC | Volume 113, Nº4, October 2019

Updated Updated Cardiovascular Prevention Guideline of the Brazilian Society Of Cardiology – 2019 Arq Bras Cardiol. 2019; 113(4):787-891 surgery has only been used in severely obese adolescents when dietary and physical activity strategies are not effective in weight control. 580,581 ( Recommendation Level IIa, level of evidence B). 11.6. Systemic Arterial Hypertension in Childhood and Adolescence BP screening data in childhood and adolescence show a prevalence of SAH of up to 8.2%, 582,583 which decreases to approximately 3.5% when measurements are repeated at clinical follow-up. Prehypertension is observed in approximately 2.2 to 3.5% of the population; in overweight and obese adolescents, it can reach 24.8%. It is also associated with sleep disorders (3.6 to 14%), chronic kidney disease (up to 50%), diabetes mellitus (9.5%); aorta narrowing (17 to 77%), endocrine alterations (0.05 to 6%) and prematurity 7.3%. 584 Although hypertension in children is more often due to a secondary cause, with a defined etiology, there has been an increase in the diagnoses of primary hypertension, especially in older children and adolescents, when other risk factors are associated, such as overweight and obesity. Blood pressure measurement is considered mandatory from the age of three, on an annual basis, or before this age when the child has a neonatal history, history of prematurity, history of aortic narrowing, kidney disease, diabetes mellitus or is using medication that can increase blood pressure. SAH is defined by the blood pressure percentile in relation to age, sex and height. The tables with gender, age and height percentiles (https://pediatrics. aappublications.org/content/pediatrics/140/3/e2017 ) have been redefined in the American Clinical Practice Guideline for Screening and Management of High Blood Pressure in Children and Adolescents, facilitating the adoption of a single table containing the three parameters used and the assigned percentile. As we do not have specific tables for the Brazilian population, this criterion is used for our population. The first blood pressure measurement can be performed by the oscillometric method on the right arm using an appropriate cuff. If the result of this measurement is greater than or equal to the 90th percentile, another measurement must be taken; If the mean of these two measurements is still ≥ 90 th percentile, two measurements by auscultatory method should be performed. Table 11.1 shows blood pressure levels in normal and hypertensive children and adolescents. (Recommendation Level I; level of evidence B). In children and adolescents > 13 years of age, blood pressure is considered normal when: < 120/80 mmHg; Chart 11.1 – Causes of secondary obesity in childhood and adolescence Cause Type Examples Medicines Psychoactive drugs (olanzapine, risperidone), antiepileptic drugs, corticosteroids Endocrine Diseases Cortisol excess, hypothyroidism, growth hormone deficiency, pseudohypoparathyroidism, hypothalamic obesity Genetic syndromes Prader-Willi, Bardet-Biedl, melanocortin or leptin receptor mutation Programming Epigenetic changes in vulnerable phases of pregnancy and childhood Other Intestinal microbiome, individual response to viruses and toxins elevated when between 120/< 80 and 129/< 80 mmHg, HAS stage 1 when between 130/80 and 139/89 mmHg and stage 2 when ≥ 140/90 mmHg. (Recommendation Level I; level of evidence B). When BP remains persistently at or above the 90th percentile, measured 6 and 12 months after initial diagnosis, the initial assessment should attempt to identify the etiology, if any, based on information on sleep habits, family history, and risk factors, diet, smoking and alcohol intake. It is important that BP is measured in both upper limbs and one lower limb. The initial complementary exams should include: blood count, urea dosage, creatinine, sodium, potassium, calcium, uric acid, lipid profile, urine summary, renal ultrasound when < 6 years of age or with impaired renal function. For children with a BMI percentile greater than the 95th percentile, glycosylated hemoglobin, liver enzymes, blood glucose and fasting lipid profile should also be ordered. 584,585 (Recommendation Level IIa; level of evidence C). When BP indicates stage 1 or 2 hypertension in asymptomatic children, it should be confirmed by three measurements and ABPM. Non-pharmacological measures should be initiated and, only if necessary, drug treatment should be started. If the child is symptomatic or the BP is 30 mm Hg above the 95th percentile or > 180 x 120 mmHg in adolescents, the patient should be referred to an emergency room service. 584.585 (Recommendation level IIa; Level of Evidence B). ABPM is indicated in children above 5 years of age when the diagnosis of elevated BP continues after one year from the initial diagnosis or after three measurements in patients with stage 1 hypertension, it is very important to investigate Table 11.1 – Blood pressure classification in children and adolescents 563 Up to 13 years old Systolic or diastolic blood pressure percentile Normal (1-13 years old) < 90 High blood pressure ≥ 90 to <95 or PA 120 x 80 mmHg at < 95 (whichever is lower) SAH stage 1 ≥ 95 to < 95 + 12 mmHg or 130 x 80 mmHg to 139 x 89 mmHg (whichever is lower) SAH stage 2 ≥ 95 + 12 mmHg or ≥ 140 x 90 mmHg (whichever is lower) 856