Key result
ACE inhibitors (lisinopril, enalapril) and ARBs (losartan) were superior to placebo in reducing systolic and diastolic blood pressure in pediatric patients with hypertension.
Why the study?
A lack of head-to-head pharmacological trials has prevented recommending one class of anti-hypertensive medications over others in pediatric hypertension.
Do anti-hypertensive medications, specifically ACE inhibitors and ARBs, reduce systolic and diastolic blood pressure compared to placebo in pediatric patients with arterial hypertension?
Meta-Analysis (n=2,378)
Do anti-hypertensive medications, specifically ACE inhibitors and ARBs, reduce systolic and diastolic blood pressure compared to placebo in pediatric patients with arterial hypertension?
ACE inhibitors (lisinopril, enalapril) and ARBs (losartan) are effective in reducing blood pressure in pediatric hypertension and may represent the best pharmacological choices.
No class can be prioritized in children; leaves open optimal selection pending head-to-head trials.
Objective: Pediatric arterial hypertension is not uncommon (prevalence between 2.2% and 13%) and it is associated with target organ damage and increased cardiovascular mortality. Pharmacological treatment is indicated in all patients with symptomatic hypertension, target organ damage, secondary hypertension, diabetes or hypertension unresponsive to lifestyle modifications. The lack of head-to-head pharmacological trials does not allow to recommend one class of anti-hypertensive medications over the others. The aim of our study was to evaluate the effectiveness of different anti-hypertensive medications in the pediatric population, combining the data from available randomized placebo-controlled clinical trials (RCTs), through a network meta-analysis (NMA) and meta-regression (NMR) approach. Design and method: We searched MEDLINE and Cochrane Library for RCTs on treatment of pediatric hypertension, enrolling >/= 50 patients and with a follow-up >/= 4 weeks. The reduction of systolic (SBP) and diastolic blood pressure (DBP) after treatment were the co-primary endpoints. Results: From a total of 554 potentially relevant studies, 13 RCTs, including 2,378 pediatric patients with a median age of 12 years, were included in the analysis. After a median follow-up of 35 days, lisinopril and enalapril were superior to placebo in reducing SBP and DBP whereas, only for DBP, losartan was superior to placebo and the two angiotensin converting enzyme inhibitors (ACE-Is) were superior to eplerenone. Consistenly, in the NMA by pharmacological classes of drugs, ACE-Is and angiotensin receptor blockers (ARBs) were associated with a greater SBP and DBP reduction compared to placebo, likewise the mineralocorticoid receptor antagonist was inferior to ACE-Is in DBP reduction. Through NMR, the analysis was adjusted for age, gender, baseline blood pressure and weight: only the latter significantly affected DBP reduction. Losartan, lisinopril and enalapril confirmed their superiority versus placebo, regardless of the considered confounding factors. Conclusions: We demonstrated that ACE-Is (in particular lisinopril and enalapril) and ARBs (in particular losartan) could represent the best choice as anti-hypertensive treatment for pediatric hypertension.
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Burrello et al. (2019) conducted a meta-analysis in pediatric hypertension (n=2,378). Anti-hypertensive medications (ACE-Is and ARBs) vs. Placebo was evaluated on Reduction of systolic (SBP) and diastolic blood pressure (DBP). ACE inhibitors (lisinopril, enalapril) and ARBs (losartan) were superior to placebo in reducing systolic and diastolic blood pressure in pediatric patients with hypertension.
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