Blood pressure reference values for Brazilian

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www.jped.com.br

ORIGINAL ARTICLE

Blood pressure reference values for Brazilian

adolescents: data from the Study of Cardiovascular Risk in Adolescents (ERICA Study) ^夽

Thiago Veiga Jardim

^a^,^b^,∗

, Bernard Rosner

^c

, Katia Vergetti Bloch

^d

,

Maria Cristina Caetano Kuschnir

^e

, Moyses Szklo

^f^,^g

, Paulo César Veiga Jardim

^a

aUniversidadeFederaldeGoiás,LigadeHipertensãoArterial,Goiânia,GO,Brazil

bBrigham&Women’sHospital,DivisionofCardiovascularMedicine,Boston,UnitedStates

cChanningLaboratory,DepartmentofBiostatistics,HarvardT.H.ChanSchoolofPublicHealth,Boston,UnitedStates

dUniversidadeFederaldoRiodeJaneiro,InstitutodeEstudosemSaúdeColetiva,RiodeJaneiro,RJ,Brazil

eUniversidadedoEstadodoRiodeJaneiro,FaculdadedeCiênciasMédicas,RiodeJaneiro,RJ,Brazil

fTheJohnsHopkinsUniversity,DepartmentofEpidemiology,Baltimore,UnitedStates

gTheJohnsHopkinsUniversity,DepartmentofMedicine(Cardiology),Baltimore,UnitedStates

Received17May2018;accepted4September2018 Availableonline4December2018

KEYWORDS Pediatric;

Ofﬁcebloodpressure;

Hypertension;

Bloodpressure measure-

ment/monitoring;

Diagnosticmethod

Abstract

Objective: Bloodpressure(BP)referencesforBrazilianadolescentsarelackinginthelitera- ture.ThisstudyaimstoinvestigatethenormalrangeofofﬁceBPinahealthy,non-overweight Brazilianpopulationofadolescents.

Method: The Brazilian Study of Cardiovascular Risks in Adolescents (Portuguese acronym

‘‘ERICA’’)isanationalschool-basedstudythatincludedadolescents(aged12through17years), enrolledinpublicandprivate schools,incitieswithover100,000inhabitants, fromallfive Brazilianmacro-regions.Adolescents’heightandbodymassindex(BMI)wereclassifiedinper- centilesaccordingtoageandgender,andreferencecurvesfromtheWorldHealthOrganization wereadopted.ThreeconsecutiveofficeBPmeasurementsweretakenwithavalidatedoscillo- metricdeviceusingtheappropriatecuffsize.Themeanvaluesofthelasttworeadingswere usedforanalysis.PolynomialregressionmodelsrelatingBP,age,andheightwereapplied.

Results: Among 73,999 adolescents, non-overweightindividuals represented 74.5% (95%CI:

73.3---75.6) of the total, with similar distribution across ages. The majority of the non- overweightsamplewasfrompublicschools84.2%(95%CI:79.9---87.7)andsedentary54.8%(95%

夽 Pleasecitethisarticleas:JardimTV,RosnerB,BlochKV,KuschnirMC,SzkloM,JardimPC.BloodpressurereferencevaluesforBrazilian adolescents:datafromtheStudyofCardiovascularRiskinAdolescents(ERICAStudy).JPediatr(RioJ).2020;96:168---76.

∗Correspondingauthor.

E-mails:[email protected],[email protected](T.V.Jardim).

https://doi.org/10.1016/j.jped.2018.09.003

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CI:53.7---55.8).Adolescentsreportingtheirskincolorasbrown(48.8%[95%CI:47.4---50.1])or white(37.8%[95%CI:36.1---39.5])weremostfrequentlyrepresented.BPincreasedbybothage andheightpercentile.SystolicBPgrowthpatternsweremoremarkedinmaleswhencompared tofemales,alongallheightpercentiles.ThesamepatternwasnotobservedfordiastolicBP.

Conclusions: Bloodpressurereferencesbysex,age,andheightpercentilesforBrazilianado- lescentsareprovided.

4.0/).

PALAVRAS-CHAVE Pediátrico;

Pressãoarterialno consultório;

Hipertensão;

Mensurac¸ão/

monitorizac¸ãoda pressãoarterial;

Métododiagnóstico

Valoresdereferênciaparapressãoarterialemadolescentesbrasileiros:dadosdo EstudodosRiscosCardiovascularesemAdolescentes(EstudoERICA)

Resumo

Objetivo: Referênciasdepressãoarterial(PA)paraadolescentesbrasileirosestãoausentesna literatura.Esteestudotemcomoobjetivoinvestigaravariac¸ãonormaldapressãoarterialno consultórioemumapopulac¸ãobrasileirasaudáveldeadolescentessemsobrepeso.

Método: OEstudodosRiscosCardiovascularesemAdolescentes(ERICA)éumestudobrasileiro, deâmbitonacionaledebaseescolar,queincluiuadolescentes(12a17anos)matriculadosem escolaspúblicaseprivadas,em cidadescommaisde100.000habitantes,de todasascinco macrorregiõesbrasileiras.Aalturaeoíndicedemassacorporal(IMC)dosadolescentesforam classiﬁcadosempercentisdeacordocomaidadeeosexo,sendoadotadasascurvasderefer- ênciadaOrganizac¸ãoMundialdeSaúde.ForamrealizadastrêsmedidasconsecutivasdePAno consultóriocomumdispositivooscilométricovalidado,utilizandoomanguitodetamanhoapro- priado.Osvaloresmédiosdasduasúltimasleiturasforamutilizadosnasanálises.Modelosde regressãopolinomialrelacionandoPA,idadeeestaturaforamaplicados.

Resultados: Entreos73.999adolescentes,osindivíduossemsobrepesorepresentaram74,5%

(IC95%:73,3-75,6)dototal,comdistribuic¸ãosimilarentreasidades.Amaiorpartedaamostra semsobrepesooriginava-sedasescolaspúblicas,com84,2%(IC95%:79,9-87,7),eossedentários 54,8%(IC95%:53,7-55,8).Osadolescentesquerelataramsuacordepelecomoparda(48,8%

[IC95%: 47,4-50,1]) ebranca(37,8%:[IC95%36,1-39,5])foramos maisrepresentados.A PA aumentoutantocomaidade,quantocomopercentildealtura.Ospadrõesdeaumentosistólico daPAforammaisacentuadosnosexomasculinoquandocomparadosaosexofeminino,emtodos ospercentisdealtura.OmesmopadrãonãofoiobservadoparaaPAdiastólica.

Conclusões: Sãofornecidasreferênciasdepressãoarterialporsexo,idadeepercentildealtura paraadolescentesbrasileiros.

0/).

Introduction

Elevated blood pressure (BP) in children and adolescents is a public health concern worldwide,¹ and it is mainly attributabletoaremarkableincreaseinchildhoodobesity over the past three decades.² The rate of hypertension (HTN) diagnosis in this age group is estimated to have doubled in the past two decades.³ HTN in the pediatric population is associated with target organ damage⁴ and moderatelytracksintohighBPinadulthood.⁵

Measuring BP during physical examination in pediatric clinicalpracticewasquiteunusualuntilafewyearsago.⁶ Nowadays, theimportanceof BPmeasurementinchildren andadolescentsisunquestionable,andtheremainingissue iswhethertouseauscultatoryoroscillometricdevices.⁷The availablereferencevaluesfordeﬁningbloodpressure(BP) classes,recommendedinmost guidelines,^7---9 weredeﬁned bythe auscultatorymethod.Notwithstanding, theeaseof

use,theminimizationof observerbiasor digitpreference (whicharethecommonerrorsassociatedwiththeausculta- torymethod),¹⁰andtherecentbanningofmercurydevices intheEuropeanCommunitywillundoubtedlyfavortheuse ofoscillometricdevices.¹¹Fromthatperspective,itiscon- venient to start assembling reference BP data for using oscillometricdevices¹¹inchildrenandadolescents.

Unlike the adult population, there is no childhood hypertensiondefinitionbasedonclinicallydefined,health- risk-related cut-off levels for increased BP. Instead, age-specific, sex-specific,height-specific, and population- baseddistributions of BP (90th and 95th percentiles) are usedtodefinenormalBPthresholds.¹²BPpercentilesshould notbeprovidedasafunctionofweight,becauserelatively highBPwouldbeconsiderednormalmerelybecauseachild is overweight.¹³ The increasing obesity prevalence could resultininappropriatenormsforBPifoverweightchildren areincludedinthenormativedatabase.¹²

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Despitetheglobalgrowinguseofoscillometricdevicesin adolescents,totheauthors’knowledge,therearenoavail- ablestudies assessing pediatric BP references for healthy normal-weightBrazilianadolescentsbasedonoscillometric measurements.Furthermore,noreferencesatall,usingany kindofBPmeasurementdevices,areavailableforBrazilian adolescents.

The present study aims to provide age-, height-, and sex-stratiﬁed systolic and diastolic BP reference values in non-overweight Brazilian adolescents using a validated oscillometric device. Further, the study aims to compare theobtainednormativevalueswithavailableinternational BP percentiles from auscultatory^1,13 and oscillometric^12,14 devices.

Methods

This study is part of the Study of Cardiovascular Risk in Adolescents (Portuguese acronym ‘‘ERICA’’), which is a national,cross-sectional,school-basedstudy,aimedatesti- mating the prevalence of metabolic syndrome and other cardiovascularriskfactorsinadolescentsagedbetween12 and17years.

The sample was divided into 32 strata, comprised of 27 capitals of Brazilian States and five cities with more than100,000inhabitantsfromeach ofthefivegeographic regions of the country. Stratification was done according tothreecategories:schools,year/shiftclasscombinations, andclassrooms.Thus,thesamplewasrepresentativeatthe nationalandregional,levels,andalsoatthelevelofState capitals.

Sample size calculation was based on an expected metabolicsyndromeprevalenceof4%,¹⁵amaximumestima- tionerrorof0.9%,aconﬁdencelevelof95%,andadesign effectof2.97.Thesamplingprocesshasbeenfullydescribed previously.¹⁶

ERICAwasapprovedbythe ResearchEthics Committee (REC)of each participating institution. Adolescents’ were includedinthestudyaftersigningaconsentformand,when requiredbylocaltheREC,afterhavinganinformedconsent formsignedbytheirlegalguardian.

Information about sex, age, type of school (public or private), skin color, smoking, alcohol consumption, and physical activity were obtained from a self-administered questionnaire using a personal digital assistant (PDA) for dataentry.

Adolescentsweregroupedintosixagegroups:≥12and

<13years;≥13and<14years;≥14and<15years;≥15and

<16years;≥16and<17years;≥17and<18years.Skincolor includedfivecategories:white,black,brown, yellow,and indigenous,accordingtotheBrazilianInstituteof Geogra- phyandStatisticsclassification.¹⁷Adolescentswhoreported smokingononeormoredaysinthepast30dayswerecon- sideredsmokers,followingtheCentersforDiseaseControl and Prevention¹⁸ and the Brazilian National Cancer Insti- tute’srecommendations.¹⁹Alcoholconsumptionwasdefined asapositiveanswertothequestionwhethertheadolescents consumedalcohol (atleastoneglassor adose) withinthe past30days.²⁰

Physical activity level was assessed by the Self- Administered Physical Activity Checklist, which has been

previouslyvalidatedfortheBrazilianpopulation.²¹Thelevel was determined by the sum of the product of the time spent in each physical activity and the respective fre- quency.Adolescentswhospentlessthan300minperweek in moderatetovigorousphysical activity wereconsidered inactive.²²

Height was measured using a calibrated portable sta- diometer(Alturexata,MinasGerais,Brazil)withmillimeter resolutionandheightupto213cm.Individualswereinfull standing positionand measurementswere taken in dupli- cateforqualitycontrolpurposes(ifthedifferenceexceeded 0.5cm,heightneeded tobemeasured again).Mean value of the two measures was used in the analysis. Height percentiles were classiﬁed according tothe World Health Organization(WHO)curves.²³

Body weight was measured using an electronic scale (Líder,ModelP200M,SãoPaulo,Brazil),with300kgofcapac- ityand50gprecision.

Waistcircumference(WC)wasmeasuredusinganinelas- tic measuring tape, with 0.1cm resolution and length of 1.5m(Sanny,SãoPaulo,Brazil).Individualswereatupright position,withabdomenrelaxedattheendof gentleexpi- ration.Measurementswereperformed horizontallyathalf distancebetweentheiliaccrestandthelowercostalmar- gin,andweretakeninduplicateforqualitycontrolpurposes (ifthedifferenceexceeded1cm,WChadtobemeasured again).Themeanvalueofthetwomeasureswasusedinthe analysis.

Arm length was measured from the acromion to the olecranonusingthesamemeasuringtapeusedforWCmea- surements.Themidpointonthedorsal(back)surfaceofthe armwasmarkedwithapen.Theparticipantwasaskedto relax thearm alongside the bodyandthe measuringtape wasplaced snugly aroundthe arm at the midpoint mark, keepingthetapehorizontal.Thetapeshouldnotindentthe skin.

Nutritionalstatuswasclassiﬁedaccordingtobodymass index(BMI),namelythebodymass(kg)dividedbythesquare of the body height (m). Reference curves from the WHO wereadopted,²³ usingtheBMI-for-age chart,accordingto sex. The following cut-off points were adopted: Z-score

<−3(verylowweight);Z-score≥−3and<−2(lowweight);

Z-score≥−2 and ≤1 (normal weight); Z-score>1 and ≤2 (overweight);Z-score>2(obesity).

Bloodpressure

Bloodpressuremeasurementswereperformedfollowingthe recommendationsofthe4thReportontheDiagnosis,Evalu- ation,andTreatmentofHighBloodPressureinChildrenand Adolescents, publishedin 2004.²⁴ The oscillometricdevice Omron^®705-IT(OmronHealthcare,Bannockburn,USA),previously validated for use in adolescents,²⁵ was used.The appropriatecuffsizefortheupperrightarmwasindicated accordingtoarmlengthmeasurements.²⁴Threeconsecutive BPmeasuresweretakenforeachindividual,withaninter- valofthreeminutesbetweeneach.Themeanvaluesof2nd and3rdreadingswereusedinthisanalysisinordertoreduce theimpactofreactivityonthebloodpressure(higherﬁrst reading).²⁶

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Statisticalanalyses

Statisticalanalysestookintoaccountthecomplexsampling thatconsidersallvariabilitysourcesoftheERICAsample.¹⁶ Thesamplingweightwascalculatedbytheproductsofthe inverse of the probabilities of inclusion in each selection stage,andcalibratedbyageandsex,consideringtheesti- matednumberofadolescentsenrolledinschoolslocatedin thegeographicstrataincludedinthestudy.

Normallydistributedvariableswereexpressedasmeans and95%conﬁdenceintervals(95%CI)andcategoricalvaria- blesasproportionsand95%CI.

ForBPpercentilesestimationsgirlswereassessedapart fromboys.Systolic anddiastolic BPwere then separately regressedwithage(withuptoapolynomialofterms:age, age²,age³,andage⁴)andheightZ-score(withuptoapolynomialofterms:z,z²,z³,andz⁴):

BP=ˇ0+ˇ1z+ˇ2z²+ˇ3z³+ˇ4z⁴+ˇ5(age−15)

+ˇ6(age−15)²+ˇ7(age−15)³+ˇ8(age−15)⁴+(∗z˛)

where denotes the regression residual standard deviation,and z˛=0, z˛=1.28155, z˛=1.64485, z˛=2.32635 for the50th,90th,95th,and99thpercentiles,respectively.

Regressionresidualstandard deviationwasobtainedby estimating a residual for each observation followed by calculating a weighted residuals sum of squares, where the applied weight was the survey weight. The square root of this weighted sum of squares was the estimated regression residual standard deviation. The results from polynomialregressionmodelsrelatingbloodpressuretoage andheight Z-score amongnon-overweight children in the ERICAdatabaseareshowninTableS1.

The regression equations were then used to estimate theexpectedsystolicand diastolicBP at specific ageand heightpercentiles. Obtainedpolynomial coefficientswere appliedtocomputespecific50th,90th,95th,and99thage andheightBPpercentiles.

ThevariableswereanalyzedbyusingthesoftwareStata 14.0(StataCorp.,CollegeStation,TX,USA)signiﬁcancelevel wassetas5%.

Results

Atotalof73,399adolescentswereincludedinthisanalysis oftheERICAstudy(adescriptionoftheresponserateandthe characteristicsofpeoplewhodidordidnottakepartinthe study wasprovidedelsewhere²⁷).From those,25.5% (95%

CI:24.4---26.6)wereidentiﬁed asbeingoverweight(17.1%

Table1 Distributionofnon-overweightadolescentsbyselectedvariables.

Variable Overall Females Males

Sampledistribution 100 50.0(49.3---50.6) 50.0(49.4---50.7)

Agedistribution

12years 16.4(16.0---16.9) 16.8(16.2---17.4) 16.1(15.5---16.7)

13years 16.8(16.4---17.3) 16.7(16.0---17.4) 16.9(16.4---17.5)

14years 17.7(17.3---18.0) 17.3(16.8---17.7) 18.1(17.5---18.6)

15years 18.0(17.7---18.3) 18.1(17.8---18.5) 17.9(17.4---18.4)

16years 17.0(16.5---17.4) 16.8(16.2---17.4) 17.1(16.6---17.7)

17years 14.1(13.8---14.4) 14.3(13.8---14.8) 13.8(13.3---14.4)

Skincolor

White 37.8(36.2---39.5) 38.2(36.3---40.2) 37.4(35.6---39.2)

Black 8.0(7.4---8.8) 6.5(5.8---7.2) 9.6(8.6---10.7)

Brown 48.8(47.4---50.1) 51.2(49.5---52.9) 46.4(44.7---48.1)

Asian 2.2(1.9---2.5) 2.3(2.0---2.7) 2.1(1.7---2.5)

Indigenous 0.7(0.5---0.8) 0.4(0.3---0.6) 0.9(0.7---1.2)

Notdeclared 2.5(2.2---2.8) 1.4(1.2---1.7) 3.6(3.2---4.1)

Publicschool 84.2(79.9---87.7) 84.1(79.7---87.7) 84.2(79.9---87.8)

Alcoholconsumption 22.2(21.1---23.3) 22.2(20.8---23.7) 22.1(20.5---23.8) Physicallyinactive 54.8(53.7---55.8) 71.6(70.3---73.0) 37.9(36.5---39.4)

Smoking 2.6(2.2---2.9) 2.2(1.8---2.7) 2.9(2.4---3.5)

Height(m) 1.62(1.62---1.63) 1.59(1.59---1.59) 1.66(1.66---1.66)

Weight(kg) 51.1(50.9---51.3) 49.4(49.2---49.6) 52.8(52.5---53.1)

BMI(kg/m²) 19.3(19.2---19.3) 19.5(19.4---19.6) 19.0(19.0---19.1)

WC(cm) 67.4(67.3---67.6) 66.7(66.5---66.8) 68.2(68.0---68.4)

SBP^a(mmHg) 108.6(108.3---109.0) 105.9(105.5---106.4) 111.4(110.9---111.8)

DBP^b(mmHg) 64.9(64.6---65.2) 65.4(65.0---65.8) 64.4(64.1---64.7)

Heartrate(bpm) 81.3(80.8---81.8) 84.2(83.7---84.7) 78.4(77.9---78.9)

Valuesgivenasproportion(95%CI)ormean(95%CI).

BMI,bodymassindex;WC,waistcircumference.

a SBP,meanofsecondandthirdsystolicbloodpressuremeasurements.

b DBP,meanofsecondandthirddiastolicbloodpressuremeasurements.

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[95%CI:16.3---18.0])andobese(8.4%[95%CI:7.9---8.9]),and wereexcludedfromtheconstructionoftheBPpercentiles(a tabledescribingtheoverallERICAsample,non-overweight, andoverweightsamplesisprovidedasanonlinesupplement ---TableS2).

Non-overweightadolescentsrepresented74.5%(95%CI:

73.3---75.6)ofthetotalsample.Agedistributionacrossthe samplevariedfrom14.1%(95%CI:13.8---14.4)amongthose aged 17 years to 18.0% (95% CI: 17.7---18.3) in those 15 yearsold.Themajorityofthenon-overweightsample was frompublic schoolsandwassedentary. Reportedskincol- orsofbrownandwhiteweremostfrequent.Whensexwas assessedseparately, the proportionsof blacks and indigenous werehigher in males,while theproportion of those who reported themselves as brown was higher in female adolescents.Additionally,thepercentageoffemaleadoles- centsphysicallyinactivewashigherthanmales.Theoverall descriptionofthesampleusedtobuildthereferencevalues forofﬁceBP,anditssexstratiﬁcationisreportedinTable1.

BPpercentilesfromnon-overweightadolescentsbyage and height are shown in Tables 2 and 3. BP increased in adolescentswithbothageandheightpercentiles. Systolic BP growth patterns were more marked in males than in

females,alongallheightpercentiles.Thesamepatternwas notobservedfordiastolicBP.

Thecomparisons of ourstudy’s95thBP percentilesfor median height with the available international normative valuesobtainedwithtwoauscultatoryandtwooscillometric devices are presented in Fig. 1. For females, these sys- tolicBPresultswereslightlylowerthanthefourcompared references.FordiastolicBP, theresultswerebetweenthe twootherstudiesconductedusingoscillometricdevicesand lowerthanthetwostudiesusingauscultatorytechniques.

Formales,this study’s systolicBP 95thpercentiles for medianheightswerebetweenthetwohighervalues(using oscillometric devices)andthe twolower ones (usingaus- cultatory devices). For diastolic BP in males, the 95th percentiles for median height pattern wassimilarto that in females (valuesbetween studies conducted with oscil- lometricdevicesandlowerthanstudiesusingauscultatory sphygmomanometers).

Discussion

This study provided sex, age, and height-speciﬁc BP per- centilesusingdatafromalarge,nationallyrepresentative

Table2 OfﬁcebloodpressurevaluesobtainedwithoscillometricdevicesinBrazilianfemaleadolescents.

Systolicbloodpressure(mmHg) Diastolicbloodpressure(mmHg)

Heightpercentile Heightpercentile

Age(years) BPpercentile 5th 10th 25th 50th 75th 90th 95th 5th 10th 25th 50th 75th 90th 95th

12 50th 100 101 102 103 104 105 106 62 62 63 64 64 65 66

90th 112 113 114 115 116 117 118 71 72 72 73 74 75 76

95th 115 116 118 119 120 120 122 74 74 75 76 77 77 78

99th 122 123 124 125 126 127 128 79 80 80 81 82 82 83

13 50th 102 104 105 105 107 108 109 63 63 64 65 65 66 67

90th 114 116 117 117 119 120 121 72 73 73 74 75 76 76

95th 118 119 120 121 122 123 124 75 76 76 77 78 78 79

99th 124 125 126 127 128 129 131 80 81 81 82 83 83 84

14 50th 104 105 106 107 108 109 110 64 65 65 66 67 67 68

90th 116 117 118 119 120 121 122 74 74 75 75 76 77 78

95th 119 120 121 122 123 124 126 76 77 77 78 79 80 80

99th 126 127 128 129 130 131 132 81 82 82 83 84 85 85

15 50th 105 106 107 108 109 110 111 65 66 66 67 68 68 69

90th 117 118 119 120 121 122 123 74 75 76 76 77 78 79

95th 120 121 122 123 124 125 127 77 78 78 79 80 80 81

99th 127 128 129 130 131 132 133 82 83 83 84 85 85 86

16 50th 105 107 107 108 110 111 112 65 66 67 67 68 69 70

90th 117 119 119 120 122 123 124 75 76 76 77 78 78 79

95th 121 122 123 124 125 126 127 78 78 79 79 80 81 82

99th 127 128 129 130 131 132 134 83 83 84 84 85 86 87

17 50th 106 107 108 109 110 111 112 66 66 67 68 68 69 70

90th 118 119 120 121 122 123 124 75 76 76 77 78 79 80

95th 121 122 123 124 125 126 128 78 79 79 80 81 81 82

99th 127 129 130 131 132 133 134 83 84 84 85 86 86 87

BP,bloodpressure.

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Table3 OfﬁcebloodpressurevaluesobtainedwithoscillometricdevicesinBrazilianmaleadolescents.

Systolicbloodpressure(mmHg) Diastolicbloodpressure(mmHg)

Heightpercentile Heightpercentile

Age(years) BPpercentile 5th 10th 25th 50th 75th 90th 95th 5th 10th 25th 50th 75th 90th 95th

12 50th 98 99 101 103 106 107 110 60 60 61 62 63 63 65

90th 111 113 114 117 119 120 123 70 70 71 72 73 73 75

95th 114 116 118 120 122 124 126 73 73 74 75 76 76 77

99th 121 123 125 127 129 131 133 78 79 79 80 81 82 83

13 50th 101 103 105 107 109 111 112 61 61 62 63 64 64 65

90th 114 116 118 120 122 124 125 71 71 72 73 74 74 75

95th 118 120 122 124 126 127 129 73 74 75 76 77 77 78

99th 125 127 129 131 133 134 136 79 80 80 81 82 82 83

14 50th 106 108 110 112 114 115 117 62 63 64 64 65 66 66

90th 119 121 123 125 127 128 130 72 73 74 74 75 76 76

95th 122 125 127 129 131 132 133 75 76 77 77 78 78 79

99th 129 132 134 136 138 139 140 80 81 82 82 83 84 84

15 50th 110 112 114 116 118 119 120 63 64 65 66 67 67 67

90th 123 125 127 129 131 132 133 73 74 75 76 77 77 77

95th 126 129 131 133 134 136 137 76 77 78 79 79 80 80

99th 133 136 138 140 141 143 144 82 82 83 84 85 85 86

16 50th 112 114 116 118 119 121 122 65 65 66 67 67 68 69

90th 125 127 129 131 132 134 136 75 75 76 77 77 78 79

95th 129 131 133 135 136 137 139 77 78 79 80 80 81 82

99th 136 138 140 142 143 144 146 83 84 84 85 86 86 87

17 50th 114 116 118 120 122 123 125 65 66 67 68 68 69 70

90th 127 129 131 133 135 136 138 75 76 77 78 78 79 80

95th 131 133 135 137 138 139 141 78 79 80 80 81 82 83

99th 138 140 142 144 145 146 148 84 84 85 86 86 87 88

BP,bloodpressure.

populationsampleof school-agedadolescentsinBrazil.To the authors’ knowledge, ERICAis theﬁrst Brazilian study providingreferenceBPvaluesforadolescentsusingavali- datedoscillometricdevice.Inadditiontobeingthelargest studydesignedtoconstructBPpercentilesforadolescents conducted heretofore, it used rigorous and standardized methodologyfordatacollection.Becauseofthestrongrela- tionshipbetweenBPandoverweight/obesity,²⁸theinclusion of overweight subjects would have raised the threshold for normal BP and, as a result,obesity-related BP eleva- tions would be more difﬁcult to detect.¹⁴ To avoid this, overweightadolescentswereexcludedfromthereference population. Thesame exclusioncriterion hasbeen consis- tentlyappliedinstudiesassessingBPpercentilesinchildren andadolescents.1,6,12---14,29

Referencevaluesdescribeapopulationsampleexpected toberepresentativewithrespecttotheparameterevalu- ated.Itremainstobeevaluatedtowhatextenttheresults canbeusedforotherracesorcontinents.³⁰Fromthatper- spective, it is important that other countries or at least regionswithsimilarpopulationcharacteristicsproducetheir ownBPpercentiletablesforadolescentsusingoscillometric devices.Untilallthesetablesareavailable,theresultspro- videdinthepresentstudymaybeusedasreferencevalues

consideringthelargesamplesizeandtheethnicheterogene- ityoftheBrazilianpopulation.³¹

Bloodpressurevaluesobtainedwithoscillometricdevices areconsiderablyhigherthanthoseresultingfromtheauscul- tatorytechnique.⁷Thepresentstudyreportedlowersystolic anddiastolicBPpercentiles(withtheexceptionofsystolic BPinmaleadolescents)comparedwiththeBPpercentiles obtained with auscultatorydevices. These results can be explainedbythefactthatinERICAthemeanofsecondand thirdreadingswasusedtocomputeBPpercentiles,whichis onaverage1---2mmHglowerthanthefirstBPreading.³²This methodologyis consistent withthe two studies that used oscillometricdevices^12,14whichwereusedasreferencesfor comparison.Oppositelythestudiesusingauscultatorytech- niquethatwerecomparedtotheseresultsusedeitheronly thefirstreading¹³oramixtureofthefirstandthemeanof thesecond/thirdreadings.¹

NationalHTNguidelinesplayanimportantroleinhelping thehealthcarecommunitytodiagnoseandtreatthedisease.

The Brazilian Guidelines of Arterial Hypertension,⁸ which in2016reached itsseventhedition,is avaluedandoften reviseddocument.BPreferencesusedintheHypertension inChildrenandAdolescentschapteroftheseguidelineswere developed using United States data.²⁴ Since the current

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115 120 125 130 135 140 145

12 13 14 15 16 17

SBP 95th percentile (mmHg)

Erica (oscillometric)

International BP References (auscultatory) Germany BP Percentiles (oscillometric) U.S. BP percentiles (auscultatory) Polish BP Percentiles (oscillometric)

A

70 72 74 76 78 80 82 84 86 88 90

12 13 14 15 16 17

DBP 95th percentile (mmHg)

B

115 120 125 130 135 140 145

12 13 14 15 16 17

SBP 95th percentile (mmHg)

70 72 74 76 78 80 82 84 86 88 90

12 13 14 15 16 17

DBP 95th percentile (mmHg)

International BP References (auscultatory) Germany BP Percentiles Germany BP Percentiles U.S. BP percentiles (auscultatory) Polish BP Percentiles (oscillometric)

C

D

Figure1 Comparisonofthe95thsystolicanddiastolicblood pressurepercentilesatmedianheightbyageinﬁvestudiesfor female(AandB)andmaleadolescents(CandD).

studyis presenting for theﬁrst timereferencevalues for ofﬁcebloodpressureinnormalweightBrazilianadolescents, considerationshouldbegiventousingtheminthefollowing versionsoftheBrazilianhypertensionguidelines.

The accuracy ofa deviceis mandatoryin anyBP mea- surementmethod,³³especiallyconsideringstudiesproviding referencevaluesforchildrenandadolescents.Oscillomet- ricBPmonitorsneedtobetestedinvalidationstudieswith

speciﬁc protocols,andalthougha considerablenumber of these devices are available in the market, most of them were not successfully subjected to validation studies.³⁴ The present study used a device that was validated for adolescents’ systolic and diastolic BP using two different internationalprotocols(AssociationfortheAdvancementof MedicalInstrumentationandEuropeanSocietyofHyperten- sionInternationalProtocol).²⁵

TheEuropeanSocietyofHypertensionguidelinesforthe managementofhighBPinchildrenandadolescents(2016)⁷ proposedthattheBPcut-offsfor16yearsandolderadoles- centsshouldnolongerbebasedonthe95thpercentile,but ontheabsolutecut-offusedforadults(BP≥140/90mmHg).

Alternatively,theClinicalPracticeGuidelinefor Screening andManagementofHighBloodPressureinChildrenandAdo- lescentsfromtheAmericanAcademy ofPediatrics(2017)⁹ proposed as a definition of HTN for adolescents aged 12 and13yearsBPvalues≥95thpercentileor≥130/80mmHg (whicheverislower),andforadolescentsaged>13years,BP values≥130/80mmHg.This differenceisprobablyrelated totheabsenceofdatatoidentifyaspecificlevelof BPin childhoodthat resultsin adverse cardiovascularoutcomes inadulthood.⁹Becausethereisnoclearconsensusinado- lescents’ definitionof HTN, it wasdecided tojust report thereferencevaluesforofficebloodpressureusingoscillo- metricdevicesinnormalweightadolescents,withoutcalling intoquestiontheoverallmeritofthedefinitionofHTN.

Alimitation of this study is that it provides reference valuesforofﬁceBPusingoscillometricdevicesonlyinnon- overweightadolescents(12---17yearsrange)asthesample selectionwasrestrictedtothisagegroup.NormalcyBPref- erences for younger Braziliansare alsorequired andthus studiesincludingthisagegroup(<12years)areneeded.

Althoughsomestudieshavefoundanindependenteffect ofsexualmaturityonBP,^35,36ithasbeenpostulatedthatthe effect of sexual maturity mainly operates through height andbodyfat.³⁷ Thus,evenwiththedebateaboutthepos- sibleroleofsexualmaturationonBP,knowledgeaboutthe exactinﬂuenceofsexhormonesonBPisratherpoor.³⁸Given that,andtheadditionalobjectivetomaketheresultsmore comparablewithother adolescents’BPpercentilestables, theauthorsdidnotstratifyourresultsaccordingtopre-and post-puberty.

The recommendedmethodof BP measurementin chil- drenandadolescentsisstilltheauscultatory.Oscillometric devicesareasuitablealternativeforinitialscreening³⁹and their increasinguse, not only for homeBP measurements but also in clinics, justifies efforts to construct BP refe- rencevaluesbasedontheoscillometrictechniquewiththe useofvalidateddevices.¹²Althoughcountry-specificBPper- centiles for adolescents using oscillometric devices have beenestablishedinsomecountries,12,14,29,40itisimportant that more countriesand regions construct theirown per- centilesusingstandardizedmethodologies.Thus,aglobally unifiedBPreferencefordefiningelevatedBPinchildrenand adolescentsusingoscillometricdevicescan bedeveloped, which will ultimatelyenable international comparisons of pediatricHTNprevalencebetweencountriesandregions.

In conclusion, the references presented here are, to the authorsknowledge,the ﬁrstBrazilian adolescents’BP referencesbyageandheightbasedonmeasurementsper- formedwithavalidatedoscillometricdeviceandfollowing

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an appropriatemethodology for datacollection. The proposed reference values were stratiﬁed by sex, age, and height,andwerenotinﬂuencedbytheprevalenceofover- weightchildreninthereferencepopulation.

Funding

The ERICA study was supported by the Brazilian Min- istry of Health (Science and Technology Department) and the Brazilian Ministry of Science and Technology (Financiadora de Estudos e Projetos/FINEP and Conselho NacionaldePesquisa/CNPq)(grantsFINEP:01090421,CNPq:

565037/2010-2,405009/2012-7and457050/2013-6).

Conﬂicts of interest

Theauthorsdeclarenoconﬂictsofinterest.

Appendix A. Supplementary data

Supplementary data associated with this article can be found, in the online version, at doi:10.1016/j.jped.2018.

09.003.

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Blood pressure reference values for Brazilian

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