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New Hypertension Guidelines: Should They Inform The Way We Care For Pediatric Cardiology Patients?

In reflecting on my time at the 2017 AHA Scientific Sessions, I can summarize my thought process about the new AHA Hypertension Guidelines as a complete 180.  When I first heard about the guidelines, my inner monologue went something like this:

“I don’t need to pay attention to these guidelines – they don’t affect me or my patients.  We already have separate pediatric guidelines.  Wasn’t there a new set of guidelines this year?  Maybe I should look at them a little closer…”

After reviewing the 2017 pediatric hypertension guidelines, I was pleasantly surprised how well they align with the AHA adult guidelines.  Of course, the pediatric guidelines are a little more complicated, since all of our patients have different cutoffs based on age, gender, and height.  And the cutoffs are now lower, due to the exclusion of overweight/obese children in the normative data.  But once our patients become adolescents, the cutoffs are the same as the new AHA adult guidelines.
After hearing that now nearly half of all U.S. adults will meet the diagnostic criteria for hypertension under the new guidelines, I realized: “OMG! Almost all of my patients are going to turn 13 and be hypertensive!”

Of course, as pediatric cardiologists, our patients are at especially high risk of cardiac events in adulthood, and the adult congenital heart disease population continues to grow every day, so we should be even more aware of hypertension as a significant risk factor for these children.  As Bradley Marino, MD (Chair of the Council on Cardiovascular Disease in the Young) stated during the CVDY Council Dinner, in light of current changes in the hypertension guidelines and national trends in increasing rates of obesity and heart disease-related morbidity, our role as pediatricians and cardiologists in prevention is becoming more and more important.

By the end of Scientific Sessions and in the weeks thereafter, I have become more cognizant and appreciative of my role in preventing my own patients from becoming hypertensive.  Of course, my ability to encourage lifestyle changes and long-term nutritional improvements is quite limited in the CVICU, but I am much more appreciative of my colleagues in the outpatient world and those who specialize in preventative pediatric cardiology.  I have also made a few lifestyle changes myself, since I am now uncomfortably close to meeting hypertension criteria.

David Werho Headshot

David K. Werho, MD is an Assistant Clinical Professor at the University of California San Diego and a Pediatric Cardiac Intensivist at Rady Children’s Hospital – San Diego.  His research focuses on pediatric cardiac ICU outcomes as well as interventions and curriculum development in medical education.  He tweets @DWerho and contributes to the Pediatric Cardiac Intensive Care Society Newsletter as editor and contributor.

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A Gateway To Better Health With Bariatric Surgery

This year’s AHA Scientific Sessions has already provided the medical community with a number of excellent studies. The “GATEWAY” trial addresses the role of bariatric surgery and its effect on hypertension.1 Patients with morbid obesity are well known to be at risk for a litany of cardiorespiratory complications such as hypertension, obstructive sleep apnea, atrial fibrillation, among others. For many, dietary and lifestyle changes are insufficient measures to lose weight. The past decade has seen the emergence of bariatric surgery as a valid therapeutic approach. In trained hands and with meticulous follow-up, the results can be life-changing.
 
There already exists published literature regarding the favorable effects on glycemic control and in some cases resolution of type II diabetes in patients followed after Roux-en-Y bypass.2
 
GATEWAY (Gastric Bypass to Treat Obese Patients With Steady Hypertension) was a randomized trial comparing the effects of surgery to standard medical therapy in patients with morbid obesity (defined as BMI 30-39.9 Kg/m2) with the purpose of achieving control of hypertension. The surgery technique employed is known as a Roux-en-Y gastric bypass; these patients also received medical treatment.
 
The primary endpoint was reduction of ≥30% of the total number of antihypertensive medications while maintaining systolic and diastolic blood pressure <140 mm/90 mm Hg, respectively, at 12 months. Although the study did not enroll patients with diabetes mellitus, and was limited to 100 patients, the results are intriguing. In fact, the surgical arm was six times more likely to require less antihypertensives with more than half achieving remission of hypertension using the above target value. Encouragingly, the surgical complication rate was low.

This is encouraging data which also leads to additional questions:

  • Are such results also obtainable with other surgical methods (Laparoscopic adjustable gastric banding; Sleeve gastrectomy;
  • Duodenal switch with biliopancreatic diversion etc)3?
  • Are the antihypertensive effects durable?

Larger studies will further validate these findings.

References:

  1. Schiavon CA et al. Effects of Bariatric Surgery in Obese Patients With Hypertension The GATEWAY Randomized Trial (Gastric Bypass to Treat Obese Patients With Steady Hypertension). http://circ.ahajournals.org/content/early/2017/11/10/CIRCULATIONAHA.117.032130
  2. Schauer PR Burguera B, Ikramuddin S, Cottam D, Gourash W, Hamad G, Eid GM, Mattar S, Ramanathan R, Barinas-Mitchel E, Rao RH, Kuller L, Kelley D. Effect of laparoscopic Roux-en Y gastric bypass on type 2 diabetes mellitus. Ann Surg. 2003 Oct;238(4):467-8
  3. Colquitt JL1, Pickett K, Loveman E, Frampton GK. Surgery for weight loss in adults. Cochrane Database Syst Rev. 2014 Aug 8;(8):CD00364

Christian Perzanowski Headshot

Christian Perzanowski is an electrophysiologist in Tampa, FL. His main interests are ablation techniques for atrial fibrillation and device therapy for congestive heart failure.