Evidence Synthesis Number 99 Screening for Hypertension in Children and Adolescents to Prevent Cardiovascular Disease: Systematic Review for the U.S. Preventive Services Task Force Prepared for: Agency for Healthcare Research and Quality U.S. Department of Health and Human Services 540 Gaither Road Rockville, MD 20850 www.ahrq.gov Contract No. HHSA-290-2007-10057-I-EPC3, Task Order No. 3 Prepared by: Oregon Evidence-based Practice Center Oregon Health & Science University Mail Code: BICC 3181 SW Sam Jackson Park Road Portland, OR 97239 www.ohsu.edu/epc Investigators: Matthew Thompson, MD, MPH, DPhil Tracy Dana, MLS Christina Bougatsos, MPH Ian Blazina, MPH Susan Norris, MD, MPH, MSc AHRQ Publication No. 13-05181-EF-1 February 2013 Disclaimer This report is based on research conducted by the Oregon Evidence-based Practice Center (EPC) under contract to the Agency for Healthcare Research and Quality (AHRQ), Rockville, MD (Contract No. 290-02-0024). The investigators involved have declared no conflicts of interest with objectively conducting this research. The findings and conclusions in this document are those of the author(s), who are responsible for its content, and do not necessarily represent the views of AHRQ. No statement in this report should be construed as an official position of AHRQ or of the U.S. Department of Health and Human Services. The information in this report is intended to help clinicians, employers, policymakers, and others make informed decisions about the provision of health care services. This report is intended as a reference and not as a substitute for clinical judgment. The final report may be used, in whole or in part, as the basis for the development of clinical practice guidelines and other quality enhancement tools, or as a basis for reimbursement and coverage policies. AHRQ or U.S. Department of Health and Human Services endorsement of such derivative products may not be stated or implied. Acknowledgements The authors thank and acknowledge AHRQ Medical Officer Iris Mabry-Hernandez, MD, MPH, and U.S. Preventive Services Task Force Leads Kirsten Bibbins-Domingo, PhD, MD, David Grossman, MD, MPH, Bernadette Melnyk, PhD, RN, CPNP/NPP, and Wanda Nicholson, MD, MPH. The authors also thank Matthew Gillman, MD. Suggested Citation Thompson M, Dana T, Bougatsos C, Blazina I, Norris S. Screening for Hypertension in Children and Adolescents to Prevent Cardiovascular Disease: Systematic Review for the U.S. Preventive Services Task Force. Evidence Synthesis No. 99. AHRQ Publication No. 13-05181-EF-1. Rockville, MD: Agency for Healthcare Research and Quality; February 2013. Screening for Hypertension in Children and Adolescents i Oregon Evidence-based Practice Center Structured Abstract Background: Hypertension in children can be associated with adverse health outcomes and may persist into adulthood, where it presents a significant personal and public health burden. Screening asymptomatic children has the potential to detect hypertension at earlier stages, so that interventions can be initiated which, if effective, could reduce the adverse health effects of childhood hypertension in children and adults. Purpose: To assess the effects of screening for hypertension in asymptomatic children and adolescents to prevent cardiovascular disease. Methods: We searched the Cochrane Central Register of Controlled Trials and the Cochrane Database of Systematic Reviews (through July 2012) and MEDLINE (1946–July 9, 2012) and manually reviewed reference lists of included studies. Citations were independently reviewed by two investigators, and data extraction performed by one investigator and checked by a second for accuracy. We included studies of screening for hypertension in asymptomatic children and studies of benefits and harms of treatments for children with hypertension. Diagnostic accuracy studies were included if they used a reference standard and allowed calculation of sensitivity and specificity. We excluded studies focusing on secondary hypertension. Results: No studies evaluated the effect of screening asymptomatic children for hypertension on subsequent health outcomes, including onset of hypertension. Two studies that assessed accuracy of screening tests for elevated blood pressure found moderate sensitivities (0.65 and 0.72) and specificities (0.75 and 0.92) and low positive predictive values (0.37, 0.17). The association between elevated blood pressure or hypertension in childhood and hypertension in adulthood was assessed in 10 studies, with most studies finding a small but significant association. Seven fair- quality studies found drug interventions were effective at lowering blood pressure after 4 weeks, based on the proportion achieving normotensive status and/or mean reductions in blood pressure. One trial of a drug combined with lifestyle modifications found lower mean blood pressures at 30 months, and one trial of increased exercise found lower mean blood pressures at 8 months, whereas other lifestyle trials found no differences. Of 13 studies assessing harms of interventions, only one study found that adverse event rates were significantly lower for those in the intervention group; all other studies found no difference in adverse events. Conclusions: Studies are needed to assess whether screening for hypertension in children and adolescents reduces adverse health outcomes or delays the onset of hypertension. Blood pressure screening may be effective at identifying children with hypertension, though evidence is limited and false-positive rates were high. The presence of hypertension in childhood is associated with hypertension in adults, but with limited evidence available for its association with end-organ damage markers in adults. Drug interventions for hypertension may be effective at lowering blood pressure with few serious side effects; however, studies of longer duration are needed to confirm results from short-term studies. Evidence on the effectiveness of childhood combination drug and lifestyle interventions and lifestyle-only interventions is sparse and mixed, with most studies showing no sustained reduction in blood pressure in childhood. Studies are needed to assess whether treating hypertension in childhood affects subsequent intermediate or clinical outcomes in adulthood. Screening for Hypertension in Children and Adolescents ii Oregon Evidence-based Practice Center Table of Contents Chapter 1. Introduction ..................................................................................................... 1 Purpose and Prior USPSTF Recommendation .................................................................................... 1 Condition Definition ............................................................................................................................ 1 Prevalence and Burden of Disease ....................................................................................................... 2 Etiology and Natural History ............................................................................................................... 2 Rationale for Screening/Screening Strategies ...................................................................................... 3 Interventions/Treatment ....................................................................................................................... 3 Current Clinical Practice ...................................................................................................................... 4 Recommendations of Other Groups..................................................................................................... 5 Chapter 2. Methods ........................................................................................................... 6 Key Questions and Analytic Framework ............................................................................................ 6 Key Questions ................................................................................................................................ 6 Contextual Questions ..................................................................................................................... 6 Search Strategies ................................................................................................................................. 6 Study Selection ................................................................................................................................... 7 Data Abstraction and Quality Rating .................................................................................................. 7 Data Synthesis ..................................................................................................................................... 7 External Review ................................................................................................................................... 8 Chapter 3. Results .............................................................................................................. 9 Key Question 1. Is Screening for Hypertension in Children/Adolescents Effective in Delaying the Onset of or Reducing Adverse Health Outcomes Related to Hypertension? ................................ 9 Key Question 2. What Is the Diagnostic Accuracy of Screening Tests for Elevated Blood Pressure in Children/Adolescents? ...................................................................................................... 9 Summary .......................................................................................................................................