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Nomograms to identify elevated blood pressure values and left ventricular hypertrophy in a paediatric population

American Academy of Pediatrics Clinical Practice vs. Fourth Report/European Society of Hypertension Guidelines

Antolini, Lauraa; Giussani, Marcob; Orlando, Antoninaa; Nava, Elisaa; Valsecchi, Maria G.a; Parati, Gianfrancoa,c; Genovesi, Simonettaa,c

doi: 10.1097/HJH.0000000000002069

Objective and methods: The study aimed at evaluating, in a large sample of Italian children, the reclassification of blood pressure categories with the new U.S. nomograms, obtained in a population of normal-weight children (American Academy of Pediatrics Clinical Practice Guidelines, AAP-CPG), compared with the Fourth Report/European Society of Hypertension (ESH) nomograms. The performance of the two classifications in identifying the presence of left ventricular hypertrophy was also assessed.

Results: In 951 individuals referred to a Pediatric Center for Cardiovascular Risk Prevention, a 12% increase in the prevalence of children with blood pressure at least 90th percentile was observed by using the new nomograms. In the subsample of children aged at least 13 years, the application of the blood pressure fixed cutoff values of 120/<80 mmHg (for ‘elevated’ blood pressure) and of 130/80 mmHg (for hypertension) led to a change in the blood pressure category (worse or better) in about 30% of cases as compared with the AAP-CPG classification based on percentiles. Regarding the identification of individuals with left ventricular hypertrophy, the AAP-CPG classification led to an increase in the true positive fraction (sensitivity) of 5.5%, and to an increment of the false-positive fraction (1 – specificity) of 5.8%. The logistic regression model, adjusted for possible confounding factors, and the ROC curves obtained from the linear predictor of the model showed an identical performance of the Fourth Report/ESH and the AAP-CPG classifications.

Conclusion: In our paediatric population, the AAP-CPG classification slightly increased the prevalence of elevated blood pressure values compared with the Fourth Report/ESH classification. Moreover, the application of more ‘physiological’ nomograms, based on a population of normal-weight children, did not yield any advantage in identifying individuals with early cardiac organ damage.

aSchool of Medicine and Surgery, University Milano – Bicocca

bFamily Pediatrician, Agenzia Tutela della Salute, Milano

cDepartment of Cardiovascular, Neural, and Metabolic Sciences, S. Luca Hospital, IRCCS, Istituto Auxologico Italiano, Milan, Italy

Correspondence to Simonetta Genovesi, MD, Dipartimento di Medicina e Chirurgia, Università degli Studi di Milano Bicocca, Via Cadore 48, 20900 Monza (MB), Italy. Tel: +39 0392332376; fax: +39 0392332426; e-mail:

Abbreviations: AAP-CPG, American Academy of Pediatrics Clinical Practice Guidelines; BP, blood pressure; CDC, Center for Disease Control and Prevention; ESH, European Society of Hypertension; FPF, false-positive fraction; IVSd, interventricular septum thickness at end diastole; LAd, left atrial end-diastolic diameter; LVEDd, left ventricular end-diastolic diameter; LVH, left ventricular hypertrophy; LVM, left ventricular mass; LVMI, left ventricular mass indexed; LVPWd, left ventricular posterior wall thickness at end diastole; TPF, true positive fraction

Received 4 December, 2018

Revised 17 January, 2019

Accepted 21 January, 2019

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