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 Chart 11.2 – Antihypertensive drugs most frequently used in the treatment of hypertension in children and adolescents in Brazil Medicine Dose Captopril 0,5-6 mg/kg/day Enalapril 0,08-0,6 mg/kg/day Losartan (> 6 years old) 0,7-1,4 mg/kg/day (max 100 mg/day) Amlodipine (1-5 years old) (> 6 years old) 0,1-0,6 mg/kg/dia (max 5 mg/day) 2,5-10 mg/day Hydrochlorothiazide 1-2 mg/kg/day (max 37,5 mg/day) white coat and masked hypertension as well as for diagnosis in obese patients. Additional tests are needed when there is a suspected disease with elevated BP, these include: polysomnography, renin dosage or plasma renin activity; renal scintigraphy with captopril administration; dosage of plasma and urinary catecholamines; dosage of steroids in plasma and urine; nuclear magnetic resonance; digital angiography and renal arteriography. Echocardiography should be performed when drug treatment is indicated for target organ injury evaluation. 586 (Recommendation level IIa; Level of Evidence B). The drug treatment for hypertension in childhood and adolescence is similar to that of adults. Due to the ease of supply in SUS in Brazil, the most used drugs among these groups are described in Chart 11.2. Treatment should be initiated on its own with one of the above drugs and when necessary a second drug, with hydrochlorothiazide bring the prefered choice. 586 (Recommendation Level I; Level of Evidence B). 11.7. Dyslipidemia in Childhood and Adolescence Dyslipidemia is known to be one of the CV risk factors with the greatest impact on accelerating the progression of atherosclerosis. Considering all lipid fractions, the prevalence of dyslipidemia in childhood and adolescence has remained between 30-40%. 587 According to the ERICA study, which evaluated 38,000 adolescents in Brazil, the prevalence of dyslipidemia in this group was as follows: 46% had HDL-cholesterol concentrations below 45 mg/ dL, 20.1% had total cholesterol concentrations greater than 170 mg/dL, 7.8% had triglyceride concentrations greater than 130 mg/dL, and 3.5% LDL-cholesterol concentrations greater than 130 mg/dL. 588 11.7.1. Causes The causes of primary or secondary dyslipidemia are similar in adults and children. It is worth mentioning some specificities in childhood, such as the higher prevalence of more severe primary types that do not allow survival until adulthood if not treated intensively and early, such as familial hypercholesterolaemia (heterozygous or homozygous), and lipoprotein lipase deficiency (monogenic hypertriglyceridemia). Among the secondary causes, ketogenic diet, used in refractory epilepsy, has been identified more frequently, in addition to obesity, physical inactivity and inadequate diet, considered at epidemic levels in the country. 589 11.7.2. Normal Values The lipid profile should be measured between 9 and 11 years of age. At the population level, fasting-free dosing can be of great value, due to its practicality and cost, especially in these cases measuring HDL and non-HDL levels. In younger children, it should be done in children 2 years and older when there is an early family history of atherosclerosis, any CV risk factor or habits (Table 11.2) or clinical signs compatible with monogenic severe primary dyslipidemia. Normal values are described in Table 11.3. 590,591 11.7.3. Treatment The treatment is initially based on intensive lifestyle modification for at least 6 months, with weight control, diet and physical activity, as already described. 7 The goal of LDL-cholesterol for drug use varies according to the risk profile of the child or adolescent following unsuccessful lifestyle changes (Table 11.4). The drug arsenal is similar to that of adults by age group as described in Table 11.5. 7,592 There is no robust evidence on the use of medications in cases of hypertriglyceridemia. However, those of the fibrate class can be used in children older than 12 years, similarly to adults, when triglyceride levels reach concentrations of 700 mg/dL or persistently above 500 mg/dL even with all conventional control measures. 593 Table 11.6 shows the recommendations for approaching children and adolescents. Table 11.2 – Cardiovascular diseases and risk factors, according to risk intensity, in children and adolescents Type and intensity of injuries Health problems High risk diseases Diabetes mellitus, renal failure, heart or kidney transplantation, Kawasaki disease with aneurysm Moderate risk diseases Chronic inflammatory diseases, HIV infection, Early coronary insufficiency in the family High risk factors Blood pressure above the 99th percentile medicated, smoking, body mass index above the 97th percentile Moderate risk factors Hypertension without indication for drug treatment, obesity between 95 and 97 percentile, HDL < 40 mg/dL 857