TABLE 7. Clinical Evaluation of Confirmed Hypertension

Study or Procedure Purpose Target Population

Evaluation for identifiable causes
    History, including sleep history, family history, risk factors, diet, and habits such as smoking and drinking alcohol; physical examination History and physical examination help focus subsequent evaluation All children with persistent BP ≥95th percentile
    BUN, creatinine, electrolytes, urinalysis, and urine culture R/O renal disease and chronic pyelonephritis All children with persistent BP ≥95th percentile
    CBC R/O anemia, consistent with chronic renal disease All children with persistent BP ≥95th percentile
    Renal U/S R/O renal scar, congenital anomaly, or disparate renal size All children with persistent BP ≥95th percentile
Evaluation for comorbidity
    Fasting lipid panel, fasting glucose Identify hyperlipidemia, identify metabolic abnormalities Overweight patients with BP at 90th–94th percentile; all patients with BP ≥95th percentile; family history of hypertension or CVD; child with chronic renal disease
    Drug screen Identify substances that might cause hypertension History suggestive of possible contribution by substances or drugs.
    Polysomnography Identify sleep disorder in association with hypertension History of loud, frequent snoring
Evaluation for target-organ damage
    Echocardiogram Identify LVH and other indications of cardiac involvement Patients with comorbid risk factors* and BP 90th–94th percentile; all patients with BP ≥95th percentile
    Retinal exam Identify retinal vascular changes Patients with comorbid risk factors and BP 90th–94th percentile; all patients with BP ≥95th percentile
Additional evaluation as indicated
    ABPM Identify white-coat hypertension, abnormal diurnal BP pattern, BP load Patients in whom white-coat hypertension is suspected, and when other information on BP pattern is needed
    Plasma renin determination Identify low renin, suggesting mineralocorticoid-related disease Young children with stage 1 hypertension and any child or adolescent with stage 2 hypertension
Positive family history of severe hypertension
Renovascular imaging Identify renovascular disease Young children with stage 1 hypertension and any child or adolescent with stage 2 hypertension
    Isotopic scintigraphy (renal scan)
    MRA
    Duplex Doppler flow studies
    3-Dimensional CT
    Arteriography: DSA or classic
    Plasma and urine steroid levels Identify steroid-mediated hypertension Young children with stage 1 hypertension and any child or adolescent with stage 2 hypertension
    Plasma and urine catecholamines Identify catecholamine-mediated hypertension Young children with stage 1 hypertension and any child or adolescent with stage 2 hypertension

BUN, blood urea nitrogen; CBC, complete blood count; R/O, rule out; U/S, ultrasound.

* Comorbid risk factors also include diabetes mellitus and kidney disease.