Hidden hypertension and early cardiac alterations: insights from ambulatory blood pressure monitoring in children and adolescents

Abstract

Hypertension is increasingly recognized as a significant health concern among children and adolescents, often associated with obesity and lifestyle choices. Early-onset hypertension can elevate the risk of cardiovascular diseases in adulthood, making early detection crucial. As it is often asymptomatic, routine screening is essential. Schools serve an effective environment for identifying at-risk students. Accurate diagnosis requires standardized protocols because blood pressure (BP) can vary based on age, sex, and height. Addressing pediatric hypertension is key to reducing long-term cardiovascular morbidity and mortality. The study included 354 students: 234 primary grade 3 students (8–9 years) and 120 secondary grade 9 students (~ 15 years). Assessments included medical history, physical examination (weight, height, BMI, and BP). BP was measured using standardized methods and classified by established percentiles. Ambulatory Blood Pressure Monitoring (ABPM) was performed for students with elevated BP to analyze 24-hour readings, dipping status, and pulse pressure, and to classify hypertension. Echocardiography was performed on all students with elevated BP. Significant differences were observed in BMI and hypertension prevalence between Grade 3 and Grade 9. In Grade 3, 45.7% were underweight, 31.9% had normal BMI, and 22% were overweight or obese; in Grade 9, 81.5% were overweight or obese. Clinic-based hypertension was higher in Grade 3 (15.4%) compared to Grade 9 (12.5%), sustained hypertension was confirmed by ABPM to rule out white-coat hypertension, results correlated with BMI Z scores and lifestyle. Despite being asymptomatic, cardiac changes were observed: the mean interventricular septal thickness (IVSd) was 0.75 cm in Grade 3 versus 1.07 cm in Grade 9. ABPM is crucial for accurate diagnosis of hypertension in schoolchildren and adolescents, clarifying the relationship between obesity, lifestyle, and elevated BP. The study underscores that early cardiac remodeling was already present in asymptomatic children, emphasizing the need for early interventions, including weight management and lifestyle modifications, to reduce hypertension and future cardiovascular risk. This study delivers one of the first comprehensive community-based assessments of pediatric blood pressure in our region, revealing a high burden of hidden hypertension and early cardiovascular alterations, and underscoring the urgent need for routine screening as obesity-related health risks continue to rise among children and adolescents.