Experts at Cincinnati Children’s partnered with colleagues across the country to develop updated guidelines on ambulatory blood pressure monitoring (ABPM) with new classifications that redefine ambulatory blood pressure in children. The American Heart Association approved the guidelines.

“This will dramatically change the way we classify ambulatory blood pressure and diagnose ambulatory hypertension in children,” says Mark Mitsnefes, MD, MS, Pediatric Nephrologist at Cincinnati Children’s. He and Elaine Urbina, MD, MS, Pediatric Cardiologist and Director of Preventive Cardiology at Cincinnati Children’s, are coauthors of the new guidelines.

Previous classifications for ABPM in children were complex, lacked uniformity and were not backed up by scientific evidence, Mitsnefes says. Their limitations and justification for new ambulatory blood pressure guidelines are outlined in a recent review article, “Pediatric ambulatory blood pressure classification: The case for a change, in Hypertension, 2021; 78(5):1206-1210.

Putting Guidelines into Practice

Teamwork was key to adopting the new classifications, Mitsnefes says.

Problems with the old guidelines included:

• A normal reading above the cutoff for normal adult blood pressure values
• Complexity caused by six categories
• Inclusion of blood pressure load
• Lack of uniformity between Canada, Europe and the United States

“Based on the old rules and categories, some kids would not even be classified,” Mitsnefes says. “There were multiple limitations.”

The dedicated ABPM clinic at Cincinnati Children’s with trained personnel—including medical assistants and nurses—has already adapted the new classification and closely follows its patients and their clinical outcomes under the new guidelines.

“We hope that over the next few years there will be more studies trying to prove or disprove whether this new classification works or not,” Mitsnefes says.

Aligning with Scientific Data

The pediatric healthcare community realized the limitations of existing ABPM classification in children and spent several years studying ways to simplify and strengthen it. Two multicenter studies that researched the association between various blood pressure categories and clinically important outcomes, such as chronic kidney disease progression and left ventricular hypertrophy (LVH),provided key insight.

The two studies—the Chronic Kidney Disease in Children (CKiD) study and the Study of Hypertension in Pediatrics, Adult Hypertension Onset in Youth (SHIP AHOY)—provided the scientific background and data needed to develop new classifications, Mitsnefes says.

“We found that blood pressure load doesn’t contribute to the outcomes, and we also found that the adult criteria work very well for children 13 and older,” Mitsnefes says.

The new ABPM classification:

• Aligns with ABPM classification in Europe by focusing on just four categories
• Does not include blood pressure load as a measurement
• Uses fixed adult criteria to define ambulatory hypertension in children ≥ 13 years of age

The American Heart Association published the new guidelines on May 23, 2022.