eMedicine Specialties > Pediatrics: Cardiac Disease and Critical Care Medicine > Cardiology

Hypertension: Differential Diagnoses & Workup

Author: Edwin Rodriguez-Cruz, MD, Assistant Professor, Department of Pediatrics, San Juan Bautista Medical School and Medical Center; Consulting Interventional/Clinical Pediatric Cardiologist, Department of Pediatrics, Hospital El Maestro and San Juan Bautista Medical Center; Consulting Interventional/Clinical Pediatric Cardiologist, Department of Cardiology, Cardiovascular Center of Puerto Rico and the Caribbean and Veterans Affairs Hospital and Medical Center of Puerto Rico
Coauthor(s): Leigh M Ettinger, MD, MS, Clinical Assistant Professor, Division of Pediatric Nephrology, The Joseph M Sanzari Children's Hospital, Hackensack University Medical Center; Adrian Spitzer, MD, Professor, Department of Pediatrics, Albert Einstein College of Medicine; Director of NIH Training Program, Children's Hospital at Montefiore Medical Center
Contributor Information and Disclosures

Updated: Nov 16, 2009

Differential Diagnoses

Other Problems to Be Considered

Pheochromocytoma

Workup

Laboratory Studies

  • In patients with hypertension, proceed from simple tests that can be performed in an ambulatory setting to complex noninvasive tests and finally to invasive tests.
  • Findings from the patient's history and physical examination dictate the appropriate order of tests.
    • On urine dipstick testing, a positive result for blood and/or protein indicates renal disease.
    • Urine cultures are used to evaluate the patient for chronic pyelonephritis.
    • The CBC count may indicate anemia due to chronic renal disease.
    • Blood chemistry may be helpful. An increased serum creatinine concentration indicates renal disease. Hypokalemia suggests hyperaldosteronism.
    • Blood hormone levels may be measured. High plasma renin activity indicates renal vascular hypertension, including coarctation of the aorta, whereas low activity indicates glucocorticoid remediable aldosteronism, Liddle syndrome, or apparent mineralocorticoid excess. A high plasma aldosterone concentration is diagnostic of hyperaldosteronism. High values of catecholamine (epinephrine, norepinephrine, dopamine) are diagnostic of pheochromocytoma or neuroblastoma.
    • High urinary excretion of catecholamines and catecholamine metabolites (metanephrine) indicates pheochromocytoma or neuroblastoma.
    • Fasting lipid panels and oral (PO) glucose-tolerance tests are performed to evaluate metabolic syndrome in obese children.
    • Drug screening is performed to identify substances that might cause hypertension.
    • Urine sodium levels reflect dietary sodium intake and may be used as a marker to follow up a patient after dietary changes are attempted.

Imaging Studies

  • Echocardiography
    • Left ventricular hypertrophy results from chronic hypertension. This finding confirms the chronicity of the hypertension and is an absolute indication for starting or intensifying treatment.
    • Left ventricular hypertrophy is symmetric, consisting of equivalent increases in thickness of both the left ventricular portion of the ventricular septum and the left ventricular posterior wall.
    • Also assess left ventricular function.
    • Echocardiography is essential in the evaluation of suspected aortic coarctation. Precise anatomic detail of the aortic arch and its branches must be obtained.
  • Abdominal ultrasonography
    • This test may reveal tumors or structural anomalies of the kidneys or renal vasculature.
    • Renal scarring suggests excessive renin release.
    • Asymmetry in renal size suggests renal dysplasia or renal artery stenosis.
    • Renal or extrarenal masses suggest a Wilms tumor or neuroblastoma, respectively.
  • Radionuclide imaging (without or with captopril): Asymmetry suggests renal artery stenosis.
  • Doppler studies: Asymmetry in renal artery blood flow suggests renal artery stenosis.
  • Digital subtraction arteriography: Asymmetry between the 2 renal arteries indicates renal artery stenosis.
  • Angiography
    • This test may reveal differences in the structure (diameter) of the renal vessels.
    • Sampling of blood from renal arteries, renal veins, and aorta may reveal differences in renin secretion between the kidneys.
    • A renin activity ratio of 3:1 between the kidneys is considered diagnostic of renal vascular hypertension.
  • Other tests
    • Cardiac catheterization is not necessary in the evaluation of aortic coarctation.
    • CT and MRI with angiography can provide further anatomic definition of an aortic coarctation, but neither study is necessary for diagnosis.

Other Tests

  • Monitoring of blood pressure (BP) on a 24-hour basis may help in diagnosing white-coat hypertension and provides information about the risk of target end-organ damage.
    • White-coat hypertension is common because most children are uncomfortable at the physicians' office because of invasive examinations, vaccinations, blood draws, and other factors.
    • Use of the 24-hour monitor should be considered first in most uncomplicated cases of pediatric stage I hypertension.
  • Polysomnography helps in identifying sleep disorders associated with hypertension. This test should be considered in obese children with a history of snoring, daytime sleepiness, or any sleep difficulties.
  • Retinal examination may reveal retinal vascular changes.

More on Hypertension

Overview: Hypertension
Differential Diagnoses & Workup: Hypertension
Treatment & Medication: Hypertension
Follow-up: Hypertension
Multimedia: Hypertension
References
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References

  1. [Guideline] Task Force. Report of the Second Task Force on Blood Pressure Control in Children--1987. Task Force on Blood Pressure Control in Children. National Heart, Lung, and Blood Institute, Bethesda, Maryland. Pediatrics. Jan 1987;79(1):1-25. [Medline].

  2. [Guideline] Task Force. Update on the 1987 Task Force Report on High Blood Pressure in Children and Adolescents: a working group report from the National High Blood Pressure Education Program. National High Blood Pressure Education Program Working Group on Hypertension Control. Pediatrics. Oct 1996;98(4 Pt 1):649-58. [Medline].

  3. [Guideline] NHLBI. National High Blood Pressure Education Program Working Group on High Blood Pressure in Children and Adolescents. The fourth report on the diagnosis, evaluation, and treatment of high blood pressure in children and adolescents. Pediatrics. Aug 2004;114(2 Suppl 4th Report):555-76. [Medline]. [Full Text].

  4. Gruskin AB. Factors affecting blood pressure. In: Drukker A, Gruskin AB, eds. Pediatric Nephrology: Pediatric and Adolescent Medicine. 3rd ed. Basel, Switzerland: Karger; 1995:1097.

  5. Hanevold C, Waller J, Daniels S, Portman R, Sorof J. The effects of obesity, gender, and ethnic group on left ventricular hypertrophy and geometry in hypertensive children: a collaborative study of the International Pediatric Hypertension Association. Pediatrics. Feb 2004;113(2):328-33. [Medline].

  6. [Guideline] University of Michigan Health System. Essential hypertension. Ann Arbor (MI): University of Michigan Health System; 2009 Feb. [Full Text].

  7. Bartosh SM, Aronson AJ. Childhood hypertension. An update on etiology, diagnosis, and treatment. Pediatr Clin North Am. Apr 1999;46(2):235-52. [Medline].

  8. Falkner B, Gidding SS, Portman R, Rosner B. Blood pressure variability and classification of prehypertension and hypertension in adolescence. Pediatrics. Aug 2008;122(2):238-42. [Medline].

  9. Gerber LM, Stern PM. Relationship of body size and body mass to blood pressure: sex-specific and developmental influences. Hum Biol. Aug 1999;71(4):505-28. [Medline].

  10. Hindmarsh PC, Brook CG. Evidence for an association between birth weight and blood pressure. Acta Paediatr Suppl. Feb 1999;88(428):66-9. [Medline].

  11. Lauer RM, Connor WE, Leaverton PE, Reiter MA, Clarke WR. Coronary heart disease risk factors in school children: the Muscatine study. J Pediatr. May 1975;86(5):697-706. [Medline].

  12. Moore VM, Cockington RA, Ryan P, Robinson JS. The relationship between birth weight and blood pressure amplifies from childhood to adulthood. J Hypertens. Jul 1999;17(7):883-8. [Medline].

  13. Simsolo RB, Romo MM, Rabinovich L, et al. Family history of essential hypertension versus obesity as risk factors for hypertension in adolescents. Am J Hypertens. Mar 1999;12(3):260-3. [Medline].

  14. Sorof JM, Lai D, Turner J, Poffenbarger T, Portman RJ. Overweight, ethnicity, and the prevalence of hypertension in school-aged children. Pediatrics. Mar 2004;113(3 Pt 1):475-82. [Medline].

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Further Reading

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Keywords

hypertension, pediatric hypertension, infantile hypertension, adolescent hypertension, prehypertension, high blood pressure, high BP, elevated BP, hypertensive, prehypertensive, white-coat hypertension, treatment, diagnosis

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Contributor Information and Disclosures

Author

Edwin Rodriguez-Cruz, MD, Assistant Professor, Department of Pediatrics, San Juan Bautista Medical School and Medical Center; Consulting Interventional/Clinical Pediatric Cardiologist, Department of Pediatrics, Hospital El Maestro and San Juan Bautista Medical Center; Consulting Interventional/Clinical Pediatric Cardiologist, Department of Cardiology, Cardiovascular Center of Puerto Rico and the Caribbean and Veterans Affairs Hospital and Medical Center of Puerto Rico
Edwin Rodriguez-Cruz, MD is a member of the following medical societies: American College of Cardiology, American College of Physicians-American Society of Internal Medicine, American Heart Association, American Medical Association, American Society of Echocardiography, Puerto Rico Medical Association, Society of Cardiac Angiography and Interventions, and Society of Pediatric Echocardiography
Disclosure: Nothing to disclose.

Coauthor(s)

Leigh M Ettinger, MD, MS, Clinical Assistant Professor, Division of Pediatric Nephrology, The Joseph M Sanzari Children's Hospital, Hackensack University Medical Center
Disclosure: Nothing to disclose.

Adrian Spitzer, MD, Professor, Department of Pediatrics, Albert Einstein College of Medicine; Director of NIH Training Program, Children's Hospital at Montefiore Medical Center
Adrian Spitzer, MD is a member of the following medical societies: American Academy of Pediatrics, American Federation for Medical Research, American Pediatric Society, American Society of Nephrology, American Society of Pediatric Nephrology, International Society of Nephrology, and Society for Pediatric Research
Disclosure: Nothing to disclose.

Medical Editor

Ira H Gessner, MD, Professor Emeritus, Pediatric Cardiology
Ira H Gessner, MD is a member of the following medical societies: American Academy of Pediatrics, American College of Cardiology, American Heart Association, American Pediatric Society, and Society for Pediatric Research
Disclosure: Nothing to disclose.

Pharmacy Editor

Mary L Windle, PharmD, Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy, Pharmacy Editor, eMedicine
Disclosure: Pfizer Inc Stock Investment from financial planner; Avanir Pharma Stock Investment from financial planner ; WebMD Salary and stock Employment and investment from financial planner

Managing Editor

John W Moore, MD, MPH, Professor of Clinical Pediatrics, Section of Pediatric Cardiology, Department of Pediatrics, University of California San Diego School of Medicine; Director of Cardiology, Rady Children's Hospital
John W Moore, MD, MPH is a member of the following medical societies: American Academy of Pediatrics, American College of Cardiology, and Society for Cardiac Angiography and Interventions
Disclosure: Nothing to disclose.

CME Editor

Gilbert Z Herzberg, MD, Assistant Professor, Department of Pediatrics, Section of Pediatric Cardiology, New York Medical College; Consulting Staff, Department of Pediatrics, Sound Shore Medical Center
Gilbert Z Herzberg, MD is a member of the following medical societies: American Academy of Pediatrics
Disclosure: Nothing to disclose.

Chief Editor

Steven R Neish, MD, SM, Director of Pediatric Cardiology Fellowship Program, Associate Professor, Department of Pediatrics, Baylor College of Medicine
Steven R Neish, MD, SM is a member of the following medical societies: American Academy of Pediatrics, American College of Cardiology, and American Heart Association
Disclosure: Nothing to disclose.

 
 
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