Abstract
This study aimed to evaluate the accuracy and performance of modified blood pressure‐to‐height ratio (MBPHR) for identifying high blood pressure (HBP) in a large population of children. This multicentric cross‐sectional study was conducted on a nationally representative sample of 7349 Iranian students aged 7‐12 years living in 30 provinces in Iran. High systolic blood pressure and diastolic blood pressure were defined according to the 2017 American Academy of Pediatrics (AAP) guidelines. The BP‐to height ratio (BPHR) was calculated as BP (mmHg)/height (cm), MBPHR3 as BP (mmHg)/(height (cm) + 3 (13‐age)), and MBPHR7 as BP (mmHg)/(height (cm) + 7 (13‐age). The receiver‐operating characteristic curve analysis was used to evaluate the performance of these three ratios for identification of HBP in children compared to the 2017 AAP guidelines as the gold standard. Mean age of participants was 12.29 ± 3.15 years and 3736 (50.8%) were girls. The prevalence of HBP was 11.9% (11.5% in boys, 12.3% in girls). The area under the curve (AUC) was higher for MSBPHR3/MDBPHR3 (0.97/0.98) than MSBPHR7/MDBPHR7 (0.96/0.97) and SBPHR/DBPHR (0.96/0.95) for identifying high Systolic and diastolic BP. The optimal cut‐off points for MSBPHR3/MDBPH, MSBPHR7/MDBPHR7, and SBPHR/DBPHR were 0.76/0.50, 0.69/0.46, and 0.81/0.52 respectively. Negative predictive value was nearly perfect for three ratios (≥98%). Positive predictive value was higher for MBPHR3 (52.7%) than MBPHR7 (51.0%) and BPHR (39.8%). Overall, MBPHR3 had better performance than MBPHR7 and BPHR for identification of HBP in Iranian children and it may improve early hypertension recognition and control in primary screening.
Keywords: children, hypertension, modified blood pressure‐to‐height ratio, screening method
1. INTRODUCTION
The prevalence of high blood pressure (HBP) in children and adolescents is globally increasing. 1 , 2 HBP through childhood is associated with adult onset hypertension and it is considered to be a major cardiovascular (CVD) risk factor and a leading cause of morbidity and mortality in adults. 3 Therefore, diagnosis and management of HBP in childhood would be important to reduce the risk of CVD in adulthood. In children and adolescents, screening and management of HBP is more complicated than in adults; and this may be due to various factors, which may influence the BP measurements in children based on age, sex, and height. 4
Recently, the American Academy of Pediatrics has updated its recommendations on recognition of HBP in children and adolescents by including new simplified screening tables with BP cut‐offs at the 5th percentile for height for every child under the age of 13 years. 5 However, this approach gives the table more than 99% sensitivity to detect HBP values that may result in an overall increase in prevalence of HBP, particularly in overweight and obese children who are at higher risk of CVD. 6 , 7
Blood pressure‐to‐height rate ratio (BPHR, mmHg/cm) was first suggested by Lu et al 4 to ease the diagnosis of HBP in adolescents. Other research subsequently verified that BPHR was a clear and reliable method for the identification of HBP in children and adolescents. 8 , 9 , 10 , 11 Some studies, however, have indicated that BPHR sensitivity and specificity are lower in children younger than 12 years compared with adolescents. 12
Mourato et al, 11 recently reported that the modified blood pressure‐to‐height ratio (MBPHR7), calculated as BP/(height (cm) + 7 (13‐age) yields better sensitivity and specificity than BPHR for identifying HBP in 5‐12 years Brazilian children. Similarly, Dang et al reported that MBPHR7 generally performed better than BPHR in the discrimination of BP abnormalities in the young Chinese children. 14 , 15
Subsequently, Ma et al 16 reported that a new modified BP to‐height ratio MBPHR3 represented as BP/(height + 3 (13‐age) was superior to MBPHR7 in Chinese children for HBP screening.
More recently, Zhang et al compared the performance of BPHR, MBHR3, and MBHR7 in Chinese and American children aged 6‐12 and reported a better performance of MBHR3 for screening HBP. 17 However, the positive predictive values (PPV) in their study were less than 0.5, comprising a limited use of this simplified index. In addition, for each study, the optimal MBPHRs cut‐offs were different in identifying HBP, indicating that each country should set its own optimal cut‐offs to detect HBP in children and adolescents. 18
These few studies were conducted in western countries and East Asians and no information is available regarding the accuracy and thresholds of modified BP‐to‐height ratios to screen HBP in the Middle Eastern pediatric population. In the present study, we have provided cut‐off points derived from blood pressure to height ratio and compared the performance of three basic blood pressure to height methods (BPHR, MBPHR7, and MBPHR3) for HBP screening and recognition in Iranian children aged 7‐12 years based on nationally representative survey CASPIN V.
2. METHODS
Data were obtained from a national school‐based project, entitled Childhood and Adolescence Surveillance, and Prevention of Adult Non‐communicable Disease (CASPIAN‐V) study. The study was conducted in 2015 on the basis of the World Health Organization‐Global School‐based Student Health Survey (WHO‐GSHS) protocol. Methods used for the survey have been described elsewhere. 19 In brief, the study population consisted of school students aged 7‐18 in urban and rural areas throughout the country that in this study we included students aged 7‐12 years. They were selected using a stratified, multistage sampling approach. Random sampling within each province was undertaken using the proportional to size meth according to the living area (urban or rural) and school levels (elementary and high school). The participants and their parents were given a comprehensive verbal description of the nature and purpose of the study. Written informed consent from parents has been obtained. The Research Ethics Committee of Tehran Isfahan University of Medical Sciences reviewed and approved the study protocols (Trial Registration ISUMS194049).
3. MEASUREMENTS
A group of trained health care professionals including physicians registered the children data and carried out the physical examinations. The height and weight of the students were measured under standard protocols and by using calibrated instruments. Body mass index (BMI) was calculated by dividing weight (kg) to height squared (m2) and then categorized based on the WHO growth charts. 20
The 2017 American Academy of Pediatrics Clinical Practice Guideline foe Screening and Management of High Blood Pressure in Children and Adolescents was used to diagnose high blood pressure (HBP). 5 For consistency and comparisons with standard and simplified blood pressure tables, systolic blood pressure (SBP) and diastolic blood pressure (DBP) were measured in the upper right arm with a standard mercury sphygmomanometer, using a stethoscope placed over the brachial artery pulse on the cubital fossa at heart level and appropriately sized cuff with an inflammable bladder width of at least 40% of the arm circumference at a point midway between the olecranon and the acromion with the child in a sitting position after at least 5 minutes rest. 5 SBP was determined by the onset of the appearance of Korotokoff sounds (K1) and DBP by the disappearance of Korotokoff sounds (K5). Three measurements were recorded at 2‐minute intervals and this averaged measurement was used for the present analysis.
4. DEFINITIONS
HBP was diagnosed as average SBP or DBP greater than or qual to the 95th percentile for age, sex, and height on at least three occasions at 3‐5 minutes intervals according to the 2017 “Clinical Practice Guideline for Screening and Management of High Blood Pressure in Children and Adolescents”. 5 In addition, participants were classified by WHO guidelines as normal weight or overweight (including obesity). Overweight and obesity were defined as a BMI between 85th and 95th and ≥95th percentile, respectively, based on the child's age and sex. 21
SBPHR was computed as SBP/height and DBPHR as DBP/height. 4 MSBPHR7 and NDBPHR were calculated as SBP/(height + 7(13‐age) and DBP/(height + 7 (13‐age) respectively. 13 MSBPHR3 and MDBPR3 were measured as SBP/(height + 3(13‐age) and as DBP/(height + 3(13‐age) respectively. 14 Height is measured in centimetres in all of these ratios.
5. STATISTICAL ANALYSIS
The mean (SD) was used for continuous variables and frequency (percentage) for qualitative variables. High SBP, DBP, and HBP were reported by frequency (percentage).
The difference in continuous and categorical variables were analysed by chi‐squared test and two independent sample t test.
Receiver‐operating characteristics curve (ROC) analysis was used to assess the performance of SBPHR, MSBPHR7, and MSBPHR3 for screening high SBP and the performance of DBPHR, MDBPHR7, and MDBPHR3 for screening high DBP. Optimal cut‐off points of the BPHR and MBPHR for the identification of HBP were selected according to the maximum values of the of Youden's index (sensitivity + specificity‐1). 22 The area under the curve (AUC) and the corresponding 95% confidence interval were determined to evaluate the discriminatory strength of these ratios compared with 2017 AAP guidelines.
An AUC >0.90 is considered as excellent discriminative ability. 23 Also, the sensitivity, specificity, and positive predictive value (PPV) and negative predictive value (NPV) were calculated to assess the performance of BPHR and MBPHR to identify HBP in children. The Kappa coefficients were calculated to assess the consistency of hypertension classifications according to BPHR, MBPHR7, and MBPHR3 compared with the 2017 AAP guidelines. Stratified analysis was performed according to weight status of subjects (Normal weight and obese/overweight. All analyses were performed using SPSS version 20.0. A P‐value less than .05 were considered statistically significant.
6. RESULTS
A total of 7349 children aged 7‐12 years were included in this study. The characteristics of the study participants are presented in Table 1. The prevalence of HBP was 11.9% (95% CI: 11.2%‐12.6%). There was no significant difference in the prevalence of HBP between boys (11.5%; 95% CI: 10.5%‐12.5%) and girls (12.3%; 95% CI: 11.2%‐13.4%) (P = .275). BPHR, MBPHR3, and MBPHR7 did not significantly differ between boys and girls (P > .05) but MBPHR3 showed a significant difference in the sex groups (P < .05).
TABLE 1.
Characteristics of the study population
| Girl | Boy | Total | P‐value | |
|---|---|---|---|---|
| N | 3736 | 3613 | 7349 | |
| SBP (mmHg) | 95.53 ± 12.70 | 95.40 ± 12.77 | 95.47 ± 12.74 | .673 |
| DBP (mmHg) | 61.72 ± 10.15 | 61.66 ± 10.32 | 61.69 ± 10.23 | .802 |
| Weight (kg) | 31.06 ± 10.62 | 31.56 ± 11.42 | 31.31 ± 11.02 | .052 |
| Height (cm) | 134.75 ± 12.51 | 135.33 ± 12.03 | 135.04 ± 12.28 | .042 |
| Waist (cm) | 61.28 ± 9.85 | 62.12 ± 10.39 | 61.69 ± 10.13 | <.001 |
| BMI (kg/m2) | 16.74 ± 3.64 | 16.95 ± 5.06 | 16.84 ± 4.39 | .042 |
| Age (y) | 9.71 ± 1.61 | 9.79 ± 1.59 | 9.75 ± 1.60 | .031 |
| MSBPHR3 | 0.66 ± 0.09 | 0.66 ± 0.09 | 0.66 ± 0.09 | .300 |
| MDBPHR3 | 0.43 ± 0.07 | 0.43 ± 0.07 | 0.43 ± 0.07 | .466 |
| MSBPHR7 | 0.61 ± 0.08 | 0.61 ± 0.09 | 0.61 ± 0.09 | .883 |
| MDBPHR7 | 0.39 ± 0.07 | 0.39 ± 0.07 | 0.39 ± 0.07 | .950 |
| SBPHR | 0.71 ± 0.10 | 0.71 ± 0.10 | 0.71 ± 0.10 | .077 |
| DBPHR | 0.46 ± 0.08 | 0.46 ± 0.08 | 0.46 ± 0.08 | .158 |
| HBP | 461 (12.3%) | 416 (11.5%) | 877 (11.9%) | .275 |
| High SBP | 223 (6.0%) | 164 (4.5%) | 387 (5.3%) | .006 |
| High DBP | 371 (9.9%) | 359 (9.9%) | 730 (9.9%) | .993 |
MSBPHR7 = SBP/(height + 7*(13‐age)); MDBPHR7 = DBP/(height + 7*(13‐age)); MSBPHR3 = SBP/(height + 3*(13‐age)); MDBPHR3 = DBP/(height + 3*(13‐age)).
Abbreviations: BMI, body mass index; DBP, diastolic blood pressure; DBPHR, diastolic blood pressure‐to‐height ratio; HBP, high blood pressure; SBP, systolic blood pressure; SBPHR, systolic blood pressure‐to‐height ratio.
The optimal cut‐off points, sensitivity, specificity, and AUC of the BPHR, MBPHR7, and MBPHR3 for identifying HBP across weight groups and general sample are shown in Table 2. The optimal cut‐off points and performance for BPHR, MBPHR3, and MBPHR7 in detecting HBP among boys and girls in different weight groups are shown in Tables 3 and 4 respectively. ROC illustrating sensitivity and specificity of systolic and diastolic blood pressure to various height screening methods among girls (Figures 1, 2 and 2) and boys (Figures 3, 4 and 4),respectively.
TABLE 2.
The optimal cut‐offs and the performance of BPHR, MBPHR7, and MBPHR3 for identifying hypertension
| Cut‐off | AUC (95% CI) | Sensitivity% (95% CI) | Specificity% (95% CI) | PPV% (95% CI) | NPV% (95% CI) | Kappa | |
|---|---|---|---|---|---|---|---|
| General | |||||||
| BPHR | 0.869 (0.855,0.882) | 92.8 (91.1, 94.5) | 80.9 (80.0, 81.9) | 39.8 (37.6, 41.9) | 98.8 (98.5, 99.1) | 0.47 | |
| SBPHR | 0.81 | 0.959 (0.952, 0.965) | 93.0 (90.5, 95.6) | 87.9 (87.1, 88.6) | 29.9 (27.3, 32.5) | 99.6 (99.4, 99.7) | |
| DBPHR | 0.52 | 0.953 (0.947, 0.959) | 92.1 (90.1, 94.0) | 85.6 (84.8, 86.5) | 41.4 (39.0, 43.8) | 99.0 (98.7, 99.2) | |
| MBPHR3 | 0.907 (0.894,0.919) | 92.6 (90.9, 94.3) | 88.8 (88.0, 89.5) | 52.8 (50.3, 55.3) | 98.9 (98.6, 99.2) | 0.61 | |
| MSBPHR3 | 0.76 | 0.973 (0.967, 0.979) | 94.3 (92.0, 96.6) | 92.2 (91.6, 92.9) | 40.3 (37.1, 43.5) | 99.7 (99.5, 99.8) | |
| MDBPHR3 | 0.5 | 0.975 (0.971, 0.979) | 92.2 (90.2, 94.1) | 92.3 (91.7, 93.0) | 57.0 (54.2, 59.8) | 99.1 (98.8, 99.3) | |
| MBPHR7 | 0.908 (0.895,0.920) | 93.7 (92.1, 95.3) | 87.8 (87.0, 88.6) | 51.0 (48.5, 53.4) | 99.0 (98.8, 99.3) | 0.60 | |
| MSBPHR7 | 0.69 | 0.961 (0.953, 0.969) | 92.8 (90.2, 95.3) | 89.7 (89.0, 90.5) | 33.5 (30.6, 36.3) | 99.6 (99.4, 99.7) | |
| MDBPHR7 | 0.46 | 0.977 (0.973, 0.981) | 92.7 (90.9, 94.6) | 93.1 (92.5, 93.7) | 59.7 (56.8, 62.6) | 99.1 (98.9, 99.4) | |
| Normal weight | |||||||
| BPHR | 0.892 (0.879,0.905) | 96.2 (94.7, 97.7) | 82.2 (81.2, 83.2) | 38.4 (36.0, 40.9) | 99.5 (99.3, 99.7) | 0.47 | |
| SBPHR | 0.82 | 0.972 (0.965, 0.978) | 94.6 (91.8, 97.3) | 90.5 (89.7, 91.3) | 31.6 (28.3, 34.8) | 99.7 (99.6, 99.9) | |
| DBPHR | 0.52 | 0.964 (0.958, 0.970) | 95.6 (93.7, 97.4) | 85.5 (84.6, 86.4) | 38.0 (35.3, 40.7) | 99.5 (99.3, 99.7) | |
| MBPHR3 | 0.923 (0.911,0.935) | 95.9 (94.3, 97.4) | 88.7 (87.8, 89.6) | 49.5 (46.6, 52.4) | 99.5 (99.3, 99.7) | 0.60 | |
| MSBPHR3 | 0.76 | 0.985 (0.980, 0.990) | 97.3 (95.3, 99.3) | 92.7 (92.0, 93.3) | 38.0 (34.3, 41.7) | 99.9 (99.8, 100.0) | |
| MDBPHR3 | 0.5 | 0.984 (0.981, 0.988) | 95.2 (93.3, 97.0) | 92.3 (91.6, 93.0) | 53.4 (50.1, 56.7) | 99.5 (99.3, 99.7) | |
| MBPHR7 | 0.921 (0.909,0.933) | 96.2 (94.7, 97.7) | 88.1 (87.2, 89.0) | 48.3 (45.4, 51.1) | 99.5 (99.3, 99.7) | 0.59 | |
| MSBPHR7 | 0.69 | 0.973 (0.966, 0.979) | 95.0 (92.3, 97.6) | 90.5 (89.7, 91.2) | 31.6 (28.3, 34.8) | 99.7 (99.6, 99.9) | |
| MDBPHR7 | 0.46 | 0.984 (0.981, 0.988) | 95.6 (93.7, 97.4) | 93.2 (92.5, 93.8) | 56.4 (53.1, 59.8) | 99.6 (99.4, 99.7) | |
| OB/OW | |||||||
| BPHR | 0.840 (0.813,0.866) | 93.8 (90.9, 96.6) | 74.2 (71.7, 76.6) | 44.3 (40.3, 48.4) | 98.2 (97.3, 99.0) | 0.47 | |
| SBPHR | 0.79 | 0.926 (0.909, 0.943) | 93.0 (88.5, 97.4) | 82.4 (80.4, 84.4) | 32.8 (28.0, 37.6) | 99.2 (98.7, 99.7) | |
| DBPHR | 0.5 | 0.93 (0.916, 0.944) | 94.8 (92.0, 97.7) | 78.7 (76.5, 81.0) | 44.8 (40.4, 49.2) | 98.8 (98.2, 99.5) | |
| MBPHR3 | 0.884 (0.857,0.910) | 91.2 (87.8, 94.5) | 85.6 (83.6, 87.5) | 58.1 (53.4, 62.8) | 97.8 (96.9, 98.7) | 0.63 | |
| MSBPHR3 | 0.75 | 0.94 (0.922, 0.957) | 89.8 (84.6, 95.1) | 89.2 (87.5, 90.8) | 43.4 (37.4, 49.4) | 99.0 (98.4, 99.5) | |
| MDBPHR3 | 0.48 | 0.953 (0.942, 0.965) | 91.4 (87.8, 95.0) | 88.5 (86.7, 90.2) | 59.2 (54.1, 64.2) | 98.3 (97.5, 99.0) | |
| MBPHR7 | 0.891 (0.866,0.917) | 92.3 (89.1, 95.5) | 86.0 (84.0, 87.9) | 59.1 (54.4, 63.7) | 98.1 (97.2, 98.9) | 0.64 | |
| MSBPHR7 | 0.7 | 0.928 (0.906, 0.950) | 87.5 (81.8, 93.2) | 89.6 (88.0, 91.2) | 43.8 (37.7, 49.8) | 98.7 (98.1, 99.3) | |
| MDBPHR7 | 0.45 | 0.957 (0.946, 0.968) | 92.3 (88.8, 95.7) | 88.5 (86.7, 90.2) | 59.4 (54.3, 64.5) | 98.4 (97.7, 99.2) | |
AUC, area under the curve; CI, confidence interval; SBPHR, systolic blood pressure‐to‐height ratio; DBPHR, diastolic blood pressure‐to‐height ratio; MSBPHR7 = SBP/(height + 7*(13‐age)); MDBPHR7 = DBP/(height + 7*(13‐age)); MSBPHR3 = SBP/(height + 3*(13‐age)); MDBPHR3 = DBP/(height + 3*(13‐age)); PPV, positive predictive value; NPV, negative positive value.
TABLE 3.
The optimal cut‐offs and performance of BPHR, MBPHR7, and MBPHR3 for identifying hypertension in boys
| Cut‐off | AUC(95% CI) | Sensitivity % (95% CI) | Specificity % (95% CI) | PPV % (95% CI) | NPV % (95% CI) | Kappa | |
|---|---|---|---|---|---|---|---|
| General | |||||||
| BPHR | 0.880 (0.861, 0.898) | 93.8 (91.4, 96.1) | 82.2 (80.9, 83.5) | 40.7 (37.6, 43.8) | 99.0 (98.6,99.4) | 0.48 | |
| SBPHR | 0.81 | 0.954 (0.943, 0.966) | 93.3 (89.5, 97.1) | 88.0 (86.9, 89.1) | 27.0 (23.3, 30.6) | 99.6 (99.4,99.9) | |
| DBPHR | 0.52 | 0.958 (0.950, 0.965) | 93.3 (90.7, 95.9) | 86.6 (85.4, 87.8) | 43.5 (40.0, 46.9) | 99.2 (98.8,99.5) | |
| MBPHR3 | 0.912 (0.895, 0.930) | 93.3 (90.9, 95.7) | 89.2 (88.1, 90.3) | 52.9 (49.2, 56.5) | 99.0 (98.7,99.4) | 0.62 | |
| MSBPHR3 | 0.76 | 0.973 (0.962, 0.983) | 93.3 (89.5, 97.1) | 92.8 (91.9, 93.6) | 38.0 (33.2, 42.7) | 99.7 (99.5,99.9) | |
| MDBPHR3 | 0.50 | 0.976 (0.970, 0.981) | 93.3 (90.7, 95.9) | 92.2 (91.3, 93.1) | 56.9 (52.9, 60.9) | 99.2 (98.9,99.5) | |
| MBPHR7 | 0.909 (0.892, 0.925) | 94.5 (92.3, 96.7) | 87.2 (86.1, 88.4) | 49.1 (45.6, 52.5) | 99.2 (98.8,99.5) | 0.58 | |
| MSBPHR7 | 0.69 | 0.965 (0.954, 0.977) | 94.5 (91.0, 98.0) | 89.5 (88.5, 90.6) | 30.0 (26.1, 34.0) | 99.7 (99.5,99.9) | |
| MDBPHR7 | 0.46 | 0.976 (0.971, 0.982) | 93.3 (90.7, 95.9) | 92.5 (91.6, 93.4) | 57.8 (53.7, 61.8) | 99.2 (98.9,99.5) | |
| Normal weight | |||||||
| BPHR | 0.900 (0.886, 0.914) | 98.6 (97.2, 100.0) | 81.4 (79.9, 82.9) | 37.1 (33.6, 40.6) | 99.8 (99.6,100.0) | 0.46 | |
| SBPHR | 0.81 | 0.976 (0.968, 0.983) | 99.0 (97.2, 100.9) | 88.8 (87.6, 90.0) | 25.4 (21.2, 29.6) | 100.0 (99.9,100.0) | |
| DBPHR | 0.51 | 0.971 (0.964, 0.977) | 98.3 (96.7, 100.0) | 85.3 (83.9, 86.6) | 38.2 (34.4, 42.1) | 99.8 (99.6,100.0) | |
| MBPHR3 | 0.933 (0.916, 0.950) | 96.5 (94.3, 98.6) | 90.1 (89.0, 91.3) | 52.1 (47.8, 56.4) | 99.6 (99.3,99.8) | 0.63 | |
| MSBPHR3 | 0.77 | 0.990 (0.984, 0.995) | 98.1 (95.5, 100.7) | 94.5 (93.6, 95.3) | 40.7 (34.7, 46.8) | 99.9 (99.8,100.0) | |
| MDBPHR3 | 0.50 | 0.987 (0.983, 0.991) | 97.1 (95.0, 99.2) | 92.3 (91.2, 93.3) | 53.8 (49.1, 58.5) | 99.7 (99.5,99.9) | |
| MBPHR7 | 0.924 (0.908, 0.941) | 96.8 (94.8, 98.9) | 88.0 (86.7, 89.3) | 47.3 (43.3, 51.4) | 99.6 (99.3,99.9) | 0.58 | |
| MSBPHR7 | 0.69 | 0.979 (0.970, 0.987) | 98.1 (95.5, 100.7) | 90.0 (88.8, 91.1) | 27.4 (22.9, 31.9) | 99.9 (99.8,100.0) | |
| MDBPHR7 | 0.46 | 0.986 (0.982, 0.990) | 96.2 (93.8, 98.7) | 93.6 (92.7, 94.6) | 58.3 (53.5, 63.2) | 99.6 (99.4,99.9) | |
| OB/OW | |||||||
| BPHR | 0.840 (0.800, 0.880) | 91.7 (87.0, 96.4) | 76.4 (73.1, 79.7) | 44.2 (38.3, 50.0) | 97.8 (96.6,99.1) | 0.48 | |
| SBPHR | 0.79 | 0.910 (0.881, 0.938) | 91.5 (84.4, 98.6) | 82.3 (79.5, 85.1) | 29.7 (23.0, 36.3) | 99.2 (98.4,99.9) | |
| DBPHR | 0.50 | 0.931 (0.912, 0.951) | 94.1 (89.8, 98.3) | 79.6 (76.5, 82.7) | 45.1 (38.9, 51.3) | 98.7 (97.7,99.7) | |
| MBPHR3 | 0.870 (0.829, 0.911) | 88.6 (83.2, 94.1) | 85.3 (82.6, 88.1) | 55.2 (48.5, 61.9) | 97.4 (96.0,98.7) | 0.60 | |
| MSBPHR3 | 0.74 | 0.934 (0.906, 0.962) | 91.5 (84.4, 98.6) | 86.1 (83.6, 88.7) | 35.1 (27.5, 42.6) | 99.2 (98.5,99.9) | |
| MDBPHR3 | 0.49 | 0.949 (0.933, 0.965) | 88.1 (82.3, 94.0) | 90.6 (88.4, 92.9) | 62.7 (55.3, 70.0) | 97.7 (96.5,98.9) | |
| MBPHR7 | 0.875 (0.838, 0.912) | 92.4 (87.9, 96.9) | 82.6 (79.6, 85.5) | 51.9 (45.5, 58.3) | 98.2 (97.0,99.3) | 0.57 | |
| MSBPHR7 | 0.70 | 0.934 (0.901, 0.966) | 88.1 (79.9, 96.4) | 89.1 (86.8, 91.3) | 39.7 (31.3, 48.1) | 98.9 (98.1,99.7) | |
| MDBPHR7 | 0.44 | 0.950 (0.934, 0.967) | 93.2 (88.7, 97.8) | 84.7 (82.0, 87.5) | 52.1 (45.4, 58.9) | 98.6 (97.6,99.6) | |
AUC, area under the curve; CI, confidence interval; BPHR, blood pressure‐to‐height ratio; MBPHR, modified blood pressure‐to‐height ratio; SBPHR, systolic blood pressure‐to‐height ratio; DBPHR, diastolic blood pressure‐to‐height ratio; MSBPHR7 = SBP/(height + 7*(13‐age)); MDBPHR7 = DBP/(height + 7*(13‐age)); MSBPHR3 = SBP/(height + 3*(13‐age)); MDBPHR3 = DBP/(height + 3*(13‐age)); PPV, positive predictive value; NPV, negative positive value, OB/OW, obese/overweight.
TABLE 4.
The optimal cut‐offs and performance of BPHR, MBPHR7, and MBPHR3 for identifying hypertension in girls
| Cut‐off | AUC(95% CI) | Sensitivity % (95% CI) | Specificity % (95% CI) | PPV % (95% CI) | NPV % (95% CI) | Kappa | |
|---|---|---|---|---|---|---|---|
| General | |||||||
| BPHR | 0.862 (0.842,0.881) | 92.0 (89.5,94.5) | 80.4 (79.0,81.7) | 39.7 (36.8,42.7) | 98.6 (98.2,99.1) | 0.46 | |
| SBPHR | 0.81 | 0.962 (0.954,0.971) | 92.8 (89.4,96.2) | 88.4 (87.4,89.5) | 33.8 (30.0,37.5) | 99.5 (99.2,99.7) | |
| DBPHR | 0.52 | 0.948 (0.939,0.957) | 90.8 (87.9,93.8) | 84.7 (83.5,86.0) | 39.6 (36.4,42.9) | 98.8 (98.4,99.2) | |
| MBPHR3 | 0.905 (0.887,0.923) | 92.0 (89.5,94.5) | 89.0 (88.0,90.1) | 54.2 (50.7,57.6) | 98.7 (98.3,99.1) | 0.62 | |
| MSBPHR3 | 0.76 | 0.974 (0.966,0.982) | 94.6 (91.7,97.6) | 92.6 (91.8,93.5) | 44.9 (40.4,49.4) | 99.6 (99.4,99.8) | |
| MDBPHR3 | 0.50 | 0.974 (0.968,0.980) | 91.1 (88.2,94.0) | 92.5 (91.6,93.4) | 57.3 (53.3,61.3) | 99.0 (98.6,99.3) | |
| MBPHR7 | 0.903 (0.887,0.920) | 94.4 (92.3,96.5) | 86.3 (85.1,87.5) | 49.2 (45.9,52.5) | 99.1 (98.7,99.4) | 0.58 | |
| MSBPHR7 | 0.69 | 0.958 (0.948,0.968) | 92.8 (89.4,96.2) | 89.0 (87.9,90.0) | 34.8 (31.0,38.6) | 99.5 (99.2,99.7) | |
| MDBPHR7 | 0.45 | 0.978 (0.972,0.983) | 94.9 (92.6,97.1) | 91.5 (90.6,92.4) | 55.2 (51.3,59.0) | 99.4 (99.1,99.7) | |
| Normal weight | |||||||
| BPHR | 0.881 (0.860,0.902) | 92.5 (89.6,95.4) | 83.7 (82.3,85.1) | 40.4 (36.8,43.9) | 98.9 (98.5,99.4) | 0.49 | |
| SBPHR | 0.82 | 0.969 (0.960,0.979) | 92.8 (88.7,96.9) | 90.8 (89.7,91.9) | 35.1 (30.5,39.8) | 99.6 (99.3,99.8) | |
| DBPHR | 0.52 | 0.958 (0.948,0.967) | 91.8 (88.4,95.1) | 87.3 (86.0,88.5) | 40.1 (36.2,44.1) | 99.1 (98.8,99.5) | |
| MBPHR3 | 0.925 (0.907,0.943) | 94.4 (91.9,96.9) | 90.7 (89.6,91.8) | 54.7 (50.6,58.9) | 99.3 (98.9,99.6) | 0.65 | |
| MSBPHR3 | 0.76 | 0.983 (0.975,0.990) | 96.1 (93.0,99.2) | 93.0 (92.1,94.0) | 42.6 (37.4,47.8) | 99.8 (99.6,100.0) | |
| MDBPHR3 | 0.51 | 0.981 (0.976,0.987) | 92.2 (88.9,95.5) | 94.8 (94.0,95.7) | 62.3 (57.4,67.2) | 99.2 (98.9,99.6) | |
| MBPHR7 | 0.909 (0.893,0.925) | 96.9 (95.0,98.8) | 84.9 (83.5,86.2) | 43.4 (39.7,47.0) | 99.6 (99.3,99.8) | 0.53 | |
| MSBPHR7 | 0.67 | 0.969 (0.960,0.978) | 98.7 (96.9,100.5) | 86.0 (84.7,87.3) | 27.5 (23.7,31.2) | 99.9 (99.8,100.0) | |
| MDBPHR7 | 0.46 | 0.983 (0.978,0.988) | 94.5 (91.7,97.3) | 93.3 (92.4,94.3) | 56.8 (52.1,61.6) | 99.5 (99.2,99.7) | |
| OB/OW | |||||||
| BPHR | 0.840 (0.802,0.878) | 93.6 (89.5,97.6) | 74.5 (70.9,78.0) | 46.5 (40.6,52.3) | 98.0 (96.7,99.3) | 0.49 | |
| SBPHR | 0.79 | 0.941 (0.922,0.960) | 92.8 (86.6,98.9) | 84.9 (82.2,87.6) | 39.0 (31.6,46.5) | 99.1 (98.4,99.9) | |
| DBPHR | 0.50 | 0.927 (0.906,0.949) | 95.7 (91.9,99.4) | 78.1 (74.8,81.4) | 44.9 (38.7,51.1) | 99.0 (98.1,99.9) | |
| MBPHR3 | 0.902 (0.867,0.938) | 92.1 (87.7,96.6) | 88.3 (85.7,90.9) | 65.2 (58.5,71.8) | 97.9 (96.7,99.1) | 0.70 | |
| MSBPHR3 | 0.76 | 0.946 (0.924,0.968) | 91.3 (84.7,98.0) | 90.8 (88.6,93.0) | 50.8 (42.0,59.6) | 99.0 (98.2,99.8) | |
| MDBPHR3 | 0.49 | 0.958 (0.942,0.974) | 92.2 (87.3,97.1) | 90.6 (88.3,92.9) | 64.6 (57.3,72.0) | 98.4 (97.4,99.4) | |
| MBPHR7 | 0.901 (0.865,0.936) | 92.1 (87.7,96.6) | 88.0 (85.4,90.6) | 64.5 (57.9,71.1) | 97.9 (96.7,99.1) | 0.69 | |
| MSBPHR7 | 0.70 | 0.923 (0.893,0.953) | 88.4 (80.9,96.0) | 89.0 (86.6,91.4) | 45.5 (37.1,54.0) | 98.7 (97.7,99.6) | |
| MDBPHR7 | 0.45 | 0.965 (0.950,0.980) | 92.2 (87.3,97.1) | 92.0 (89.9,94.2) | 68.4 (61.1,75.7) | 98.4 (97.4,99.5) | |
AUC, area under the curve; CI, confidence interval; BPHR, blood pressure‐to‐height ratio; MBPHR, modified blood pressure‐to‐height ratio; SBPHR, systolic blood pressure‐to‐height ratio; DBPHR, diastolic blood pressure‐to‐height ratio; MSBPHR7 = SBP/(height + 7*(13‐age)); MDBPHR7 = DBP/(height + 7*(13‐age)); MSBPHR3 = SBP/(height + 3*(13‐age)); MDBPHR3 = DBP/(height + 3*(13‐age)); PPV, positive predictive value; NPV, negative positive value; OB/OW, obese/overweight.
FIGURE 1.
Receiving‐operating curves illustrating high sensitivity and specificity to various systolic blood pressure‐height screening methods among girl participants
FIGURE 2.
Receiving‐operating curves illustrating high sensitivity and specificity to various diastolic blood pressure‐height screening methods among girl participants
FIGURE 3.
Receiving‐operating curves illustrating sensitivity and specificity of various systolic blood BP‐height screening methods among boy participants
FIGURE 4.
Receiving‐operating curves illustrating sensitivity and specificity of various diastolic blood BP‐height screening methods among boy participants
Among the general sample, the optimal cut‐off points of SBPHR/DBPHR, MSBPHR7/MDBPHR7, and MSBPHR3/MDBPHR3 were 0.80/0.52, 0.75/0.49, and 0.69/0.46 respectively. AUC was larger than 0.97 for all three ratios which show excellent discriminative ability of these ratios. MSBPHR3/MDBPHR3 had a larger AUC than SBPHR/DBPHR and MSBPHR7/MDBPHR7 for identifying high SBP/DBP in the general sample.
Among the normal weight group, the optimal cut‐off points of SBPHR/DBPHR, MSBPHR7/MDBPHR7, and MSBPHR3/MDBPHR3 were 0.82/0.52, 0.76/0.50, and 0.69/0.50 respectively. AUC was greater than 0.95 for all three ratios. All three indices had a larger AUC compared with the general sample for identifying high SBP/DBP.
Among the overweight/obesity group, the optimal cut‐off points of SBPHR/DBPHR, MSBPHR7/MDBPHR7, and MSBPHR3/MDBPHR3 were 0.79/0.50, 0.75/0.48, and 0.70/0.45 respectively. AUC was smaller than 0.95 for SBPHR and DBPHR ratios. All three indices had a smaller AUC compared with the general sample and normal weight group for identifying high SBP/DBP.
All three ratios had high sensitivity and specificity in children. The NPV of the three ratios was nearly perfect (≥98%). The PPV was higher for MBPHR3 than BPHR in normal‐weight children and general sample (general: 52.7% vs 39.8%, normal weight: 49.1% vs 44.4%). In contrast, the PPV was higher for MBPHR7 than BPHR in OB/OW (59.1% vs 44.3%) (Figure 1). The higher PPV in OB/OW group compared with normal‐weight children and total general partly arises from a higher prevalence of high SBP/DBP (19.7% vs 10.9% in the normal weight group and 11.9% in the general sample).
FIGURE 5.
Positive predictive value of the three simplified methods for identifying hypertension in the general sample, normal weight, and overweight/obesity groups
Kappa agreement coefficient was higher for MBPHR3 than BPHR in the general sample (0.61 vs 0.47) and normal weight children (0.60 vs 0.47), implying more correct classification resulted from MPBPHR3. In overweight/obesity group Kappa agreement coefficients for MBPHR3 and MBPHR7 were 0.63 and 0.64, respectively, and were higher than BPHR (0.47).
The performance of three BP‐height ratios by sex and age are provided in Tables S1 and S2. The results show that the cut‐off points are age‐dependent. The performance of all three ratios was better in girls aged 7‐9 years compared with girls aged 10‐12 years. In boys, performance of three BP‐height ratios was better on older age group. Furthermore, age‐dependent MBPHRs provided better performance compared to nonage‐dependent MBPHRs with higher AUC, Kappa, and PPV coefficients in girls and boys.
7. DISCUSSION
The present study showed that BPHR3 is better at identifying HBP in Iranian children aged 7‐12 compared to BPHR and MBPHR7. The optimal cut‐off points for SBPHR3/DBPHR3 were 0.75/0.49 respectively. AUC for MBPHR3 was >0.97 (sensitivity: 92.6%, specificity: 88.8) in the general sample and higher than for MBPHR7 and BPHR, indicating that MBPHR3 had the highest discriminative ability to identify HBP among the three ratios in young children.
Hansen et al 24 previously showed that, despite the availability of BP charts and computer programs, pediatricians are still not using these items for routine examinations. Factors including accuracy, simplicity, cost, and easy use are important for developing a new diagnostic tool for assessing and monitoring BP in pediatrics. 4 As a simplified tool for HBP screening, Modified BPHRs (MBPHR3 and MBPHR7) have been used as alternative methods for HBP screening by considering different heights and BP growth rates in young children. 13 , 16
Previous studies that compared the efficacies of different BPHR indices on identification of HBP in children have produced discrepant results. 13 , 14 , 15 , 16 , 17 The findings in our study are consistent with the study reported by Zhang et al 17 In their study, the authors compared the efficacy of MBPHR3 and MBPHR7 with BPHR3 in young American and Chinese children and found MBPHR3 had a better predictive performance in identifying HBP compared to BPHR and MBPHR7, but only in American children but not in Chinese children, in whom the MBPHR7 achieved better performance than BPHR and MBPHR3. 17
In a study by Ma et al 14 on hundred Chinese children aged between 7 and 12 years, MBPHR3 showed an acceptable performance compared with MBPHR7 and BPHR.
In the present study, we found better performance for MBPHR7 compared with BPHR that is in line with Dong et al 14 and Mourato et al studies 11 but inconsistent with the study reported by Ma et al 15 It should be noted that found optimal cut‐off points were different in different populations.
The discrepancy between the findings in our study and the study reported by others is likely the results of diversity in the study designs and methodologies used by different investigators. Many factors can influence the efficacy of MBPHRs including patients’ age, body weight, ethnicity, the BP technique, and the child anxiety during the BP measurements. 25 In addition, the diurnal variation of blood pressure may also affect the efficacy of MBPHR indices.
In the present study, the NPV of the three ratios was superior ≥98%, excluding the remote possibility of a false negative HBP detection. However, the PPV was about 50.0% for both MBPHRs and this value was higher than the PPV value for BPHR. Furthermore, the PPV values for all three ratios in our study were higher than those reported previously among Chinese and American children aged between 6 and 12 years. 17 This might be in part due to the higher prevalence of hypertension among Iranian children.
Compared to the 2017 AAP Guideline, the PPV of MBPHR3 of nearly 50% in the present study accounts for a relatively high rate of false positive HBP cases, which would limit its routine use for HBP screening in children, compared with other simple methods such as absolute height‐specific BP cut‐off values. 26 , 27
The low PPV of the MBPHRs makes these tools of limited value for performing screening BP measurements in children, especially when these ratios are used in the general population and among children who are not overweight or obese. As a result, identifying simple screening tools with a good predictive ability to screen HBP in children, along with a reasonably high PPV, should be a matter of further investigation.
It is well‐documented that hypertension is strongly associated with overweight and obesity in children and adolescents. 28 , 29 In the subgroup analysis by weight status based on BMI, among overweight/obese children, PPV for MBPHRs (especially MBPHR7) was higher than in subjects with normal weight, partly due to the higher prevalence of hypertension in obese children. Further studies should focus on whether alternative strategies could enhance the accuracy and/or validity of simplified methods in HBP screening by taking into account the child's body weight.
To date MBPHRs may be recommended on the initial evaluation of HBP and ambulatory BP monitoring because of its low cost and simplicity. If the BP is elevated, the standard tools should recheck the child's BP.
The major strength of this study is that it was based on a large school‐based sample and it is the first study to investigate the accuracy of MBPHR indices in the Eastern Mediterranean region. In this regard, the findings are applicable to Iranian young children and the results can be generalized to other similar populations. Our proposed thresholds are simple for HBP screening in Iranian young children. Our study also has several limitations. First, calculation of BP and height could involve measurement errors, which may bias the results. Second, we did not assess the performance of the three ratios for identifying stage‐2 hypertension, which limits the generalizability of the study. Continued study is required to evaluate the impact of age and sex for screening and recognition of HBP in children.
8. CONCLUSION
Compared with MBPHR7 and BPHR, MBPHR3 performed better HBP screening in children. However the low PPV of nearly 50.0%, which accounts for a high rate of false positive classifications, would limit usefulness of the MBPHR3 index for screening and recognition of HBP in young children. Further study is needed to identify new simple screening tables to detect HBP in the young that might include other variables.
CONFLICT OF INTEREST
Authors acknowledge that the submitted article is original, has not been published previously in whole or part, and is not currently under review elsewhere. Authors further declare that there is no financial support or relationships that may pose conflict of interest regarding the content of this article.
AUTHORS’ CONTRIBUTIONS
All authors substantially contributed to the conception or design of the work, or the acquisition, analysis, or interpretation of data of the study and drafting the article. In addition, Dr Assadi and Dr Kelishadi, as corresponding authors, provided equal contributions for important intellectual content of the work submitted. All authors read and approved the final version of the submitted manuscript for publication and accept the responsibility of the work in ensuring that questions related to the accuracy or integrity of any apart of the work investigated and resolved.
COMPLIANCE WITH ETHICAL STANDARDS
All procedures performed in this study were in accordance with the ethical standards of the appropriate institutional research ethics committee on human experimentation and has been performed in accordance with the ethical standards with ethical standards as laid in the 1964 Declaration of Helsinki Declaration and its later amendments as revised in 2013 and followed the CONSORT 2010 checklist guidelines for reporting the randomized clinical trial.
Supporting information
Table S1
Table S2
ACKNOWLEDGMENTS
We are grateful to patients and their families for making this trial possible. We also thank the nursing staff of participating medical centers for their contributions and administrative support during this study period.
Yazdi M, Assadi F, Daniali SS, et al. Performance of modified blood pressure‐to‐height ratio for diagnosis of hypertension in children: The CASPIAN‐V study. J Clin Hypertens. 2020;22:867–875. 10.1111/jch.13860
REFERENCES
- 1. Fallah Z, Djalalinia S, Qorbani M, Farzadfar F, Kelishadi R. A systematic review of studies on blood pressure in Iranian pediatric population: first report from the Middle East and North Africa. Iran J Pediatr. 2016;26(2):e4496‐e4496. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 2. Kit BK, Kuklina E, Carroll MD, Ostchega Y, Freedman DS, Ogden CL. Prevalence of and trends in dyslipidemia and blood pressure among US children and adolescents, 1999–2012. JAMA Pediatr. 2015;169(3):272‐279. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 3. Gray L, Lee I‐M, Sesso HD, Batty GD. Blood pressure in early adulthood, hypertension in middle age, and future cardiovascular disease mortality: HAHS (Harvard Alumni Health Study). J Am Coll of Cardiol. 2011;58(23):2396‐2403. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 4. Lu Q, Ma C, Yin F, Liu B, Lou D, Liu X. How to simplify the diagnostic criteria of hypertension in adolescents. J Hum Hypertens. 2011;25(3):159‐163. [DOI] [PubMed] [Google Scholar]
- 5. Flynn JT, Kaelber DC, Baker‐Smith CM, et al. Clinical practice guideline for screening and management of high blood pressure in children and adolescents. Pediatrics. 2017;140(3):e20171904. 10.1542/peds.2017-1904 [DOI] [PubMed] [Google Scholar]
- 6. Dionne J. Updated guideline may improve the recognition and diagnosis of hypertension in children and adolescents; review of the 2017 AAP blood pressure clinical guideline. Curr Hypertens Rep. 2017;19(10)84. 10.1007/s11906-017-0780-8 [DOI] [PubMed] [Google Scholar]
- 7. Blanchette E, Flynn JT. Implication of the 2017 clinical practice guidelines for management of hypertension in children and adolescents: a review. Curr Hypertens Rep. 2019;21(5):35. 10.1007/s11906-019-0943-x [DOI] [PMC free article] [PubMed] [Google Scholar]
- 8. Kelishadi R, Heshmat R, Ardalan G, et al. First report on simplified diagnostic criteria for pre‐hypertension and hypertension in a national sample of adolescents from the Middle East and North Africa: the CASPIAN‐III study. J Pediatr. 2014;90(1):85‐91. [DOI] [PubMed] [Google Scholar]
- 9. Xi B, Zhang M, Zhang T, Li S, Steffen LM. Simplification of childhood hypertension definition using blood pressure to height ratio among US youths aged 8–17 years, NHANES 1999–2012. Int J Cardiol. 2015;180:210‐213. [DOI] [PubMed] [Google Scholar]
- 10. Ahmed A, Ali SW, Massodi S, Bhat MA. Blood pressure‐to‐height ratio as a screening tool for hypertension in children. Indian Pediatr. 2016;53:137‐139. [DOI] [PubMed] [Google Scholar]
- 11. Galescu O, George M, Basetty S, et al. Blood pressure over height ratios: simple and accurate method of detecting elevated blood pressure in children. Int J Pediatr. 2012;2012. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 12. Guo X, Zheng L, Li Y, Zhang X, Yu S, Sun Y. Blood pressure to height ratio: a novel method for detecting hypertension in paediatric age groups. Padiatr Child Health. 2013;18(2):65‐69. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 13. Mourato FA, Nadruz W Jr, Moser LR, de Lima Filho JL, Mattos SS. A modified blood pressure to height ratio improves accuracy for hypertension in childhood. Am J Hypertens. 2014;28(3):409‐413. [DOI] [PubMed] [Google Scholar]
- 14. Dong B, Wang Z, Wang HJ, Ma J. Improving hypertension screening in childhood using modified blood pressure to height ratio. J Clin Hypertens. 2016;18(6):557‐564. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 15. Ma C, Lu Q, Yin F. The performance of modified blood pressure‐to‐height ratio as a screening measure for identifying children with hypertension. Clin Exp Hypertens. 2016;38(2):155‐159. [DOI] [PubMed] [Google Scholar]
- 16. Ma C, Lu Q, Wang R, Liu X, Lou D, Yin F. A new modified blood pressure‐to‐height ratio simplifies the screening of hypertension in Han Chinese children. Hypertens Res. 2016;39(12):893‐898. [DOI] [PubMed] [Google Scholar]
- 17. Zhang Y, Ma C, Yang L, Bovet P, Xi B. Performance of modified blood pressure‐to‐height ratio for identifying hypertension in Chinese and American children. J Hum Hypertens. 2018;32(6):408‐414. [DOI] [PubMed] [Google Scholar]
- 18. Yin X, Liu Q, Bovet P, Ma C, Xi B. Performance of blood pressure‐to‐height ratio as a screening tool for elevated blood pressure in pediatric population: a systematic meta‐analysis. J Hum Hypertens. 2016;30(11):697‐702. [DOI] [PubMed] [Google Scholar]
- 19. Motlagh ME, Ziaodini H, Qorbani M, et al. Methodology and early findings of the fifth survey of childhood and adolescence surveillance and prevention of adult noncommunicable disease: the CASPIAN‐V study. Int J Prev Med. 2017;8:4. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 20. Group WMGRS . WHO child growth standards based on length/height, weight and age. Acta Paediatrica. 2006;450:76‐85. [DOI] [PubMed] [Google Scholar]
- 21. Li C, Ford ES, Mokdad AH, Cook S. Recent trends in waist circumference and waist‐height ratio among US children and adolescents. Pediatrics. 2006;118(5):e1390‐e1398. [DOI] [PubMed] [Google Scholar]
- 22. Zou KH, O’Malley AJ, Mauri L. Receiver‐operating characteristic analysis for evaluating diagnostic tests and predictive models. Circulation. 2007;115(5):654‐657. [DOI] [PubMed] [Google Scholar]
- 23. Youngstrom EA. A primer on receiver operating characteristic analysis and diagnostic efficiency statistics for pediatric psychology: we are ready to ROC. J Pediatr Psychol. 2013;39(2):204‐221. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 24. Hansen ML, Gunn PW, Kaelber DC. Underdiagnosis of hypertension in children and adolescents. JAMA. 2007;298(8):874‐879. [DOI] [PubMed] [Google Scholar]
- 25. Badeli H, Assadi F. Strategies to reduce pitfalls in measuring blood pressure. Int J Prev Med. 2014;5(Suppl 1):S17‐S20. [PMC free article] [PubMed] [Google Scholar]
- 26. Chiolero A, Paradis G, Simonetti GD, Bovet P. Absolute height‐specific thresholds to identify elevated blood pressure in children. J Hypertens. 2013;31(6):1170‐1174. [DOI] [PubMed] [Google Scholar]
- 27. Mitchell CK, Theriot JA, Sayat JG, Muchant DG, Franco SM. A simplified table improves the recognition of paediatric hypertension. J Pediatri and child health. 2011;47(1‐2):22‐26. [DOI] [PubMed] [Google Scholar]
- 28. Koebnick C, Black MH, Wu J, et al. High blood pressure in overweight and obese youth: implications for screening. J Clin Hypertens. 2013;15(11):793‐805. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 29. Falkner B, Gidding SS, Ramirez‐Garnica G, Wiltrout SA, West D, Rappaport EB. The relationship of body mass index and blood pressure in primary care pediatric patients. Pediatr. 2006;148(2):195‐200. [DOI] [PubMed] [Google Scholar]
Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Supplementary Materials
Table S1
Table S2