Pediatric hypertension

Hypertension, a leading cause of cardiovascular morbidity and mortality in adults, often begins in childhood, and children with hypertension are very likely to become adults with hypertension. Despite the absence of clear links between childhood hypertension and adult cardiovascular disease, it seems logical to suppose that the treatment of childhood hypertension would reduce cardiovascular risk in adulthood. There is evidence to show that pharmacologic treatment can lower blood pressure in children and adolescents with elevated blood pressure. However, except in the treatment of severe hypertension, no clear evidence demonstrates that treating hypertension in children and adolescents offers long-term benefit. Moreover, few antihypertension drugs have been systematically tested in children; thus little is known about the pharmacokinetics, the efficacy, or the safety of these agents in children, and the use of these agents for pediatric hypertension is largely an uncontrolled experiment. Developing a rational approach to treating pediatric hypertension requires more data than are currently available. To gather the evidence needed to place a therapeutic strategy on an objective foundation, short-term trials of representative agents from all classes of antihypertension compounds should be performed in children and adolescents. These trials would allow researchers to determine the pharmacokinetics, pharmacodynamics, and efficacy of these therapies with respect to lowering blood pressure. However, studying the effects of these medications on the short-term lowering of blood pressure would not be sufficient. Once dosing information is available from initial trials, intermediate-term studies should be designe; with use of the intermediate end points listed above (or others), these trials should seek to answer whether treating hypertension in childhood or adolescence is likely to produce clinical benefit in addition to simply lowering blood pressure. Finally, clinical trialists should design long-term studies that follow up cohorts of patients randomized in childhood so that the influence of early intervention on the risk for cardiovascular disease in adulthood can be assessed. The surrogate end points used in both the intermediate and long-term trials could be evaluated to determine which, if any, would be useful in subsequent trials of new agents or treatment strategies for pediatric hypertension.