Discrepancies in the diagnosis of hypertension in adolescents according to available office and home high blood pressure criteria

Abstract This study aimed at comparing the prevalence of abnormal blood pressure (BP) phenotypes among 241 adolescents referred for hypertension (15.4 ± 1.4 years, 62% males, 40% obese) according to mostly used or available criteria for hypertension [AAP or ESH criteria for high office BP (OBP); Arsakeion or Goiânia schools’ criteria for high home BP monitoring (HBPM)]. High OBP prevalence was greater when defined by AAP compared with ESH criteria (43.5% vs. 24.5%; p < .001), while high HBPM prevalence was similar between Arsakeion and Goiânia criteria (33.5% and 37.5%; p = .34). Fifty‐five percent of the sample fulfilled at least one criterion for high BP, but only 31% of this subsample accomplished all four criteria. Regardless of the HBPM criteria, AAP thresholds were associated with lower prevalence of normotension and masked hypertension and greater prevalence of white‐coat and sustained hypertension than ESH thresholds. These findings support the need to standardize the definition of hypertension among adolescents.

and greater prevalence of white-coat and sustained hypertension than ESH thresholds.
These findings support the need to standardize the definition of hypertension among adolescents.

K E Y W O R D S
adolescents, home blood pressure, hypertension, office blood pressure INTRODUCTION The diagnosis of hypertension in adolescents relies on office blood pressure (OBP) measures, and thresholds used to identify abnormal values are usually derived from guidelines of the European Society of Hypertension (ESH) and the American Academy of Pediatrics (AAP). 1,2 However, OBP thresholds recommended by these societies markedly differ, due to discrepancies in normative blood pressure (BP) tables and the age at which BP classification is replaced by adult classification. 3 Evaluation of out-of-office BP in adolescents has been encouraged by current guidelines, aiming at unmasking white-coat and masked BP effects and identifying the true hypertension phenotype. 1,4 Growing attention has been devoted to home BP monitoring (HBPM), because of its feasibility, good agreement with ambulatory BP monitoring (ABPM), and relatively low cost. 1,5 However, HBPM use in adolescents is still limited, and the prevalence of white-coat hypertension (WH) and masked hypertension (MH) defined by HBPM, especially when comparing OBP thresholds defined by ESH and AAP, is uncertain. Furthermore, only two cross-sectional studies suggested normalcy values for HBPM in adolescents, 6,7 but whether these normative data have similar ability to detect out-of-office hypertension is unknown. This study aimed at estimating the magnitude of the divergence in hypertension and BP phenotypes prevalence according to mostly used or available criteria to identify adolescents with high OBP and HBPM.

METHODS
We performed a cross-sectional analysis of 241 adolescents with 12-17 years-old from 129 Brazilian centers who were referred for evaluation of hypertension and performed HBPM from December, 2017 to April, 2021 using an online platform (www.telemrpa.com). [8][9][10] The protocol was approved by the Oswaldo Cruz University Hospi-  (Table S1).
The Venn diagram shown in Figure 1 presents the overlap of abnor-  (Table S2), and AAP-OBP thresholds were associated with lower prevalence of normotension and MH and greater prevalence of WH and sustained hypertension (Table 1). Furthermore, the sum of adolescents with WH and MH ranged between 22% and 28% when considering the possible combinations of the studied OBP and HBPM criteria.
Results of additional analysis showed that: (1) the prevalence of abnormal BP by Brazilian-OBP was 43% and its performance to identify hypertension and BP phenotypes was more similar to AAP-OBP than to ESH-OBP (Tables S3 and S4, Figure S1); (2) obese participants had greater prevalence of high OBP and sustained hypertension, and AAP-OBP was associated with higher rates of high OBP and sustained hypertension than ESH-OBP, particularly among obese participants (Tables S5 and S6); and (3) high HBPM prevalence did not change when using the first two home BP readings rather than triplicate measurements on each occasion (Table S7).

DISCUSSION
This study confirmed that the identification of high OBP was greater when using AAP-OBP compared with ESH-OBP, 3  WH and MH are associated with higher prevalence of hypertensive organ-damage in adolescents, and presumably higher cardiovascular risk later in life than normotension. 1,4,14 In our analysis, approximately one fourth of the participants had WH or MH independent of the criteria for abnormal OBP and HBPM. This prevalence is similar to that of adolescents referred to alternative hypertension centers for elevated BP, but greater than that of school samples, which would be more representative of general populations. 5,15 Additionally, In conclusions, we found marked discrepancies in the prevalence of abnormal BP phenotypes when applying the mostly used criteria for high OBP and HBPM in adolescents. These data support the need for standardization of hypertension definition among adolescents.

ACKNOWLEDGMENTS
The study was supported by the Brazilian National Council for Scien-