What is it about?
This audit aimed to describe the BP profile of a sample of otherwise healthy CYP on medications for ADHD attending routine clinical reviews, and to compare the proportions meeting cut-off for HT or PreHT/‘Elevated BP’ (EBP) based on British vs AAP/ESH reference definitions. Between March 2019 and March 2020, 67 CYP who attended routine clinician-led appointments for ADHD medication review had their BP and Pulse measured with electronic sphygmomanometers. The equipment was regularly calibrated and clinicians followed standard procedures for checking BP and Pulse.
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Why is it important?
Stimulant medications (Methylphenidate and Dexamfetamine/Lisdexamfetamine) and Atomoxetine are associated with small but statistically significant increases in Blood Pressure (BP) and Pulse. Intuniv is an alpha 2a agonist, which can be associated with low BP and bradycardia. Thus, guidelines recommend regular monitoring of BP and Pulse and plotting the figures on reference centile charts. However, confusion can arise about which reference centiles to use due to differences in the cut-offs applied in different regions of the world. Both the American Academy of Pediatrics (AAP) and European Society of Hypertension (ESH) define hypertension (HT) in CYP as BP ≥95th percentile for gender, age and height on three or more separate occasions, while pre-hypertension (PreHT) (now redefined as elevated BP) is BP ≥90th percentile but less 95th percentile. However, the British reference for CYP between 4 and 23 years defined HT as BP above the 98th percentile for age, and ‘high-normal BP’ (PreHT) between the 91st and 98th percentile.
Perspectives
The proportions of CYP classified by the British or AAP/ESH reference as having HT or PreHT were different albeit with small margins. However these small differences in proportion could have population-level implications if mapped onto the full cohort of CYP with ADHD attending similar medication reviews in the UK. Also, the differences could lead to frontline clinicians using different thresholds for triggering remedial actions in CYP with suspected HT such as medication dose reduction or paediatric cardiology referral. Therefore, we recommend further review of these different reference points to avoid confusion among front-line clinicians. One potential reason for the differences is that the British reference does not consider the CYP’s height. Perhaps, including height in the algorithm that determines all BP reference centiles for CYP would provide closer results.
Dr Michael O Ogundele
Mid Cheshire Hospitals NHS Foundation Trust Postgraduate Medical Centre
Read the Original
This page is a summary of: 314 Disparity between different reference values for hypertension among children and adolescents treated for ADHD: experience from a North West England CCH clinic, April 2021, BMJ,
DOI: 10.1136/bmjpo-2021-rcpch.173.
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