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Assessment of cardiovascular disease risk factors in Korean children: impact of various pediatric hypertension guidelines and application of the Korean blood pressure reference

BMC Pediatrics volume 25, Article number: 364 (2025) Cite this article

Abstract

Background

The global rise in pediatric hypertension (HTN) is a significant concern as it serves as a precursor to cardiovascular disease (CVD). To address this, we performed a comparative analysis of two guidelines for pediatric HTN: the 2017 American Academy of Pediatrics (AAP) and the 2016 European Society for Hypertension (ESH), applying the Korean blood pressure (BP) reference specifically to the Korean pediatric population.

Methods

Data from 2,060 children and adolescents aged 10–18 years from the Korean National Health and Nutrition Examination Survey (2016–2018) were analyzed. BP was classified according to the AAP, the ESH, and the Korea Regional BP Classification (KRC). High BP was defined as BP exceeding the normotensive range.

Results

The prevalence of high BP in Korean youth was significantly higher according to the AAP group than that in the ESH group (19.5% vs. 10.6%, P < 0.0001). Variations in prevalence were noted based on age, sex, and obesity. No significant differences were observed between the AAP and KRC groups in terms of high BP prevalence. The application of the AAP and KRC provided a more comprehensive reflection of CVD risk factors, including obesity and metabolic profiles, compared to the ESH. The KRC showed a tendency to classify more non-obese individuals as having elevated BP, although this difference was not statistically significant.

Conclusions

In comparing the AAP, ESH, and KRC criteria in the Korean pediatric population, the KRC demonstrated a tendency to identify individuals with CVD risk factors as having high BP. This finding suggests that using the KRC as the criterion for high BP may facilitate earlier intervention in the management of CVD risk.

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Background

The increasing prevalence of elevated blood pressure (BP) among youth is becoming a major public health concern worldwide [1,2,3]. High BP during childhood can lead to early structural or functional changes in vital organs, known as target organ damage (TOD), which may have long-term cardiovascular (CV) implications [4,5,6,7,8]. The clinical assessment of TOD involves markers such as left ventricular hypertrophy (LVH) and microalbuminuria [7, 8]. Uncontrolled BP elevation increases the prevalence of TOD, whereas well-controlled BP can mitigate these risks [9].

While evidence links subclinical TOD in adulthood to clinical CV disease (CVD), the direct association between childhood exposure to CVD risk factors and later-life CVD remains unclear [10,11,12,13]. An ongoing study is currently evaluating childhood BP levels, aiming to predict future CVD morbidity and mortality [14]. Similarly, we assessed the consequences of childhood exposure to CVD risk factors based on relevant studies. Some studies have found that addressing high blood pressure in early childhood improves cardiovascular disease risk and outcomes both in childhood and adulthood [15,16,17,18,19]. These studies show that childhood exposure to CVD risk factors, such as high BP, increases the risk of adult CVD [20]. High BP in childhood is associated with adulthood hypertension (HTN), CVD risk factors, and metabolic syndrome (MS), all of which are modifiable risk factors for CVD and mortality in adults [21, 22]. Therefore, defining BP elevation in youth is critical for preventing CVD in adults.

Traditionally, the diagnosis of elevated BP in the pediatric population is based on statistical definitions using the distribution of normotensive BPs, measured by the auscultatory method, according to sex, age, and height in healthy children. We investigated the differences between the American Academy of Pediatrics (AAP) and European Society for Hypertension (ESH) guidelines for diagnosing BP elevation in Korean pediatric populations [23, 24]. These guidelines differ in several ways. The AAP introduced a normotensive BP reference table that excluded data from overweight and obese children to prevent bias from obesity in BP measurements. They also applied static cutoff values from the adult guidelines at a younger age than the ESH. In response to the AAP, Kim et al. [25] developed a normal-weight BP reference table for Korean youth. However, no BP classification criteria have been proposed specifically for Korean pediatric populations.

In this study, we adapted the AAP BP classification criteria by incorporating a normal-weight Korean BP reference table and creating the Korea Regional BP Classification (KRC). Our aim was to evaluate the prevalence of BP elevation in Korean children using various classification criteria and to investigate the variations in CV risk factor distribution based on these criteria.

Methods

Study population

The data for this study were derived from the Korean National Health and Nutritional Examination Survey (KNHANES) conducted by the Korea Disease Control and Prevention Agency (KDCA) from 2016 to 2018. The KNHANES used a multistage clustered probability design to select its target population, and sample weights were assigned to participants to ensure the sample accurately represented the broader Korean population. The detailed survey design and data resource profiles are described elsewhere [26]. We included children aged 10–18 years, excluding those without available height or BP values. Ultimately, the analysis focused on 2,060 children from the KNHANES dataset to investigate the prevalence of elevated BP (Supplementary Fig. 1). The KNHANES protocol was approved by the Institutional Review Board of the KDCA. Written informed consent was obtained from all participants and/or their legal guardians. The present study was approved by the Institutional Review Board (IRB) of Samsung Medical Center (IRB number 21-10-074).

Clinical and laboratory measurements

In the KNHANES, skilled medical personnel conducted anthropometric measurements of participants, including body weight, height, and waist circumference. Age- and sex-specific z-scores for weight, height, and body mass index (BMI) were computed using Lambda Mu Sigma tables from the KDCA [27]. These z-scores were then converted into age- and sex-specific percentiles. Overweight and obesity were defined as a BMI within the 85–94th percentile and ≥ 95th percentile, respectively, based on the KDCA criteria.

BP was measured using a mercury sphygmomanometer. Three systolic BP and diastolic BP (DBP) readings were recorded, and final values were obtained by averaging the second and third measurements. The DBP was measured based on the fifth Korotkoff sound. BP classification was performed according to the AAP [23] and ESH [24] guidelines, using normotensive reference tables from each guideline (Supplementary Table 1). The KRC, which employs the AAP BP classification using the normotensive reference table from normal-weight Korean youth extracted from Kim et al. [25], was also employed. High BP was defined as BP greater than the normotensive BP. BP was additionally analyzed according to three age groups: <13, 13–16, and ≥ 16 years.

Anthropometric and laboratory data were analyzed to assess CV risk factors. Abnormal cutoff points for total cholesterol (TC), high-density lipoprotein (HDL), low-density lipoprotein (LDL), triglycerides (TG), fasting blood glucose, and hemoglobin A1c were defined based on the guidelines of the National Institutes of Health and the American Diabetes Association [28]. MS was defined based on the International Diabetes Federation criteria, which incorporates central obesity and two or more risk factors [29]. Central obesity was determined using Korean waist reference data [30].

CV risk factor profile differences between guidelines

To assess the differences in CV risk factors among children with high BP according to different BP classifications, a comparative analysis was conducted. A subset of 1,799 pediatric participants with complete CV risk factor data was used for this assessment. We compared normotensive individuals to those with high BP according to each criterion. Individuals initially classified as normotensive based on one criteria but reclassified as having high BP under a different criteria were designated as “upwardly reclassified” or “upwardly high.” Those who remained normotensive under both criteria were categorized as “consistently normotensive.” These two groups—“upwardly reclassified/high” and “consistently normotensive”—were then compared in the analysis. The groups classified as upwardly reclassified/high were compared with age-, sex-, and height-matched consistently normotensive individuals (Supplementary Tables 2–4).

Statistical analyses

Weighted values were used for the demographic and clinical characteristics of the study population, as recommended by the KNHANES. Continuous variables were presented as weighted mean and standard error, whereas categorical variables were expressed as weighted percentages with a 95% confidence interval.

The prevalence of high BP according to various BP classifications was compared using the weighted McNemar’s test of symmetry. When comparing upwardly reclassified/high individuals with consistently normotensive individuals, a propensity score analysis was used to match age, sex, and height (percentile) to minimize their potential influence on BP values. Unweighted paired analyses were used for the comparisons. Continuous variables were presented as mean and standard deviation, with differences being assessed through the paired t-test or Wilcoxon signed-rank test based on normal distribution confirmation. Categorical values were expressed as percentages, with comparisons among groups being performed by using McNemar’s test.

Statistical analyses were performed using SAS version 9.4 (SAS Institute, Cary, NC, USA), with P-values < 0.05 considered statistically significant.

Results

Characteristics of the study participants

This study examined 2,060 participants aged 10–18 years. Participants had a mean age of 14.3 years, with 52.1% being male (47.9%, female). Overweight and obesity rates were 9.9% and 12.5%, respectively, and central obesity was present in 10%. The prevalence of MS was 4.2%. Additional demographic and clinical characteristics of the patients are shown in Table 1.

Table 1 Demographic and clinical characteristic of study population, weighted
Full size table

Prevalence of BP elevation

The prevalence rates of elevated BP/high normal, stage 1 HTN, and stage 2 HTN were 9.4%, 9.3%, and 0.8%, respectively, using the AAP; 6.3%, 3.9%, and 0.4%, respectively, using the ESH; and 9.3%, 9.4%, and 0.8%, respectively, using the KRC (Fig. 1A) (Supplementary Tables 5–7). High BP, as classified by the AAP and KRC, was more prevalent in boys (Fig. 1B). Overweight and obese participants exhibited a higher prevalence of high BP across all criteria compared to participants with normal weight (Fig. 1C).

When data were analyzed according to the three age groups, stage 1 HTN was more prevalent in the < 13-year-old and 13–16-year-old groups according to both the AAP and KRC compared to the ESH. In the ≥ 16-year-old group, all BP stages were more prevalent according to the AAP and KRC groups than the ESH group (Fig. 2). No differences in prevalence were observed between the AAP and KRC groups.

CV risk factor distribution differences

AAP vs. ESH

The AAP reclassified 156 children as having high BP (AAP upwardly reclassified), whereas the ESH reclassified only 11 children (ESH upwardly reclassified). Compared to their matched normotensive counterparts, the AAP upwardly reclassified group showed significant differences in adiposity and metabolic profiles(higher weight z-score, higher BMI z-score, higher waist circumference, higher TC, higher LDL, more central obesity and MS), while the ESH upwardly reclassified group only had lower HDL levels (Table 2).

Table 2 AAP upwardly reclassified and ESH upwardly reclassified vs. age-, sex-, and height-matched consistently normotensive participants, unweighted
Full size table

AAP vs. KRC

A total of 16 children were reclassified as having high BP by the AAP (AAP upwardly high), while 11 were reclassified by the KRC (KRC upwardly high). No significant differences were observed between the upwardly high group and their normotensive counterparts. Although not statistically significant, the KRC demonstrated a tendency to classify more non-obese children (lower weight z-scores, lower BMI z-scores, and lower waist circumferences) as having high BP compared to the AAP (Table 3).

Table 3 AAP upwardly high and KRC upwardly high vs. age-, sex-, and height-matched consistently normotensive participants, unweighted
Full size table

ESH vs. KRC

Eleven children were upwardly reclassified as having high BP by the ESH (ESH upwardly high), whereas the KRC reclassified 151 (KRC upwardly reclassified). Compared to their matched normotensive counterparts, ESH upwardly high children showed significant differences in HDL levels, whereas KRC upwardly reclassified children exhibited differences in adiposity and metabolic profiles (higher weight z-score, higher BMI z-score, higher waist circumference, higher triglycerides, higher LDL, more central obesity and MS) (Table 4).

Table 4 ESH upwardly high and KRC upwardly high vs. age-, sex-, and height-matched consistently normotensive participants, unweighted
Full size table

Discussion

Recently, the prevalence of HTN in Korean children has increased [31]. We sought to compare the clinical characteristics across different BP categories, aiming to propose uniform and practically applicable classification criteria tailored for Koreans. Notable differences include the AAP’s utilization of a lower BP reference value, excluding obese children, and applying a static cutoff BP value at a younger age (13 years) than the ESH (16 years), with lower static cutoff values [23, 24].

Previous studies have consistently shown a higher prevalence of high BP using the AAP compared to the ESH [32,33,34,35,36,37], which is consistent with our findings. There was concern regarding a potential underdiagnosis of HTN in the AAP for youths older than 13 years, as a static cutoff BP value derived from adulthood HTN definitions was applied. Our findings support the applicability of the AAP in Korean teenagers (13–15 years); only stage 1 HTN increased, with no significant decrease. Similar trends were observed in Chinese [38] and Spanish [33] studies, suggesting that the AAP could simplify diagnostic criteria and enhance real-world HTN detection. Because BP can be influenced by race, ethnicity, and obesity, several countries have established local BP references [39,40,41,42]. Conversely, international BP reference values are derived from nationally representative cross-sectional surveys [43]. Studies comparing local and international references, as well as the inclusion or exclusion of overweight or obese children’s BP data, have revealed significant discrepancies in high BP prevalence across different reference Tables [44,45,46,47,48,49]. A study conducted by Fan et al. [48] in China applied a local reference table, the AAP, the fourth report (a previous version of the BP guidelines before the AAP 2017), and international BP reference tables to a longitudinally followed cohort. This study found that high BP, as defined by the AAP and local BP references, effectively predicted subclinical CVD in adulthood [48]. From this perspective, we applied a normal-weight Korean BP reference to the AAP BP classification (KRC) to evaluate the impact of using local BP references.

We focused on the characteristics of children reclassified from normotensive to high BP groups using various criteria. Prior research has explored the clinical differences in defining high BP using the AAP and ESH, leading to controversies regarding their ability to detect CVD risks. A study by Di Bonito et al. [34] showed that despite no prevalence difference in LVH and relative wall thickness between individuals with high BP defined by the AAP and ESH, the AAP identified more abnormal left ventricular geometries among Italian overweight or obese children. Another study by Di Bonito et al. [37] found that Italian overweight or obese children reclassified as having high BP by the AAP but normotensive by the ESH had a higher BMI, poorer metabolic profiles, and higher left ventricular mass index than consistently normotensive children.

Additionally, Kim et al. [50] reported a difference in the prevalence of BP according to the AAP and ESH in Korean youth, with a higher prevalence of high BP found using the AAP than in patients with the ESH. Those newly diagnosed with high BP by the AAP were more obese and had more severe cardiometabolic risk factors than normotensive subjects. Conversely, a study by Antolini et al. [32] reported that although the AAP increased the prevalence of high BP relative to the ESH, it did not enhance the identification of early cardiac organ damage when weight was adjusted in the analyses. Some studies compared the AAP with the fourth report. Sharma et al. [51] and Yang et al. [52] analyzed the clinical characteristics of children newly diagnosed with high BP or upwardly reclassified with a higher stage BP by the AAP, comparing them with age-, sex-, and height-matched normotensive children according to both guidelines. The upwardly reclassified children displayed adverse lipid profiles and a cluster of CV risk factors compared with matched normotensive children. These findings align with our study’s comparison of the AAP and ESH criteria. This alignment may be influenced by the BP reference table used by the ESH, which is derived from the Fourth Report [24].

Children newly classified as having high BP using the KRC were primarily reclassified based on their DBP. Additionally, there was a tendency for non-obese children to be reclassified into the high-BP group when using the KRC. Increased DBP in non-obese children has been associated with insulin resistance in young adults and metabolic disorders [53]. This suggests the importance of using local reference BP tables. A comparison between KRC and ESH revealed similar patterns in the prevalence of CVD risks to the AAP and ESH comparisons. This suggests that high BP identified using the AAP and KRC criteria detects more children with CVD risk factors compared to the ESH. However, this may lead to overdiagnosis of high BP, despite increasing sensitivity for detecting CVD risk factors.

Both the AAP and ESH guidelines recommend lifestyle modifications for the initial management of high BP in children [23, 24]. We suggest that the KRC are more effective in identifying individuals at risk of CVD, contributing to the overall awareness and management of CV health in the pediatric population in Korea.

Our study had several strengths. First, we used national survey data from the KNHANES, which provides a fully representative sample of the Korean pediatric population. The use of comprehensive data strengthens the validity and applicability of the study to a broader population. Second, this study is the first to compare different BP guidelines and the impact of applying normal-weight Korean BP references in Korean youth, with the aim of determining the most reliable BP classification criteria for risk control. However, this study had certain limitations. First, the number of children reclassified according to each guideline was relatively small, potentially affecting the statistical power and generalizability of the findings. Second, the reliance on cross-sectional data from the KNHANES, which includes only one BP measurement, therefore the true prevalence of hypertension cannot be fully determined by the current study design. Third, the retrospective cross-sectional nature of this study prevents assessment of the impact of high BP, including potential TOD.

In conclusion, the KRC effectively identified Korean youth with a higher prevalence of CVD risk factors, categorizing them as having a high BP. Contrary to concerns about underdiagnosis, applying a static HTN definition starting at the age of 13 years in Korean youths did not result in an underdiagnosis of high BP. Using the KRC as a uniform and simplified set of BP criteria can reduce the likelihood of diagnosis failure and enhance early CVD risk control. Further research is warranted to investigate the longitudinal impact of the KRC use on the actual CVD outcomes in adulthood in the Korean pediatric population.

Fig. 1
figure 1

Prevalence of BP elevation in Korean children according to (A) each guideline, (B) sex, (C) obesity, weighted. AAP American Academy of Pediatrics, BP blood pressure, ESH European Society for Hypertension, HTN hypertension, KRC Korea Regional Blood Pressure Classification

Full size image
Fig. 2
figure 2

Difference in prevalence of high BP according to age group as classified by (A) AAP versus ESH and (B) ESH versus KRC. All weighted. AAP American Academy of Pediatrics, BP blood pressure, ESH European Society for Hypertension, HTN hypertension, KRC Korea Regional Blood Pressure Classification

Full size image

Data availability

The datasets utilized in this study are available from the Korea Disease Control and Prevention Agency (KDCA) database (https://knhanes.kdca.go.kr/knhanes/rawDataDwnld/rawDataDwnld.do; accessed April 17, 2025). Registered users, including international researchers, can access and download the raw data upon membership approval.

Abbreviations

AAP:

American Academy of Pediatrics

BMI:

Body mass index

BP:

Blood Pressure

CV:

Cardiovascular

CVD:

Cardiovascular Disease

DBP:

Diastolic Blood Pressure

ESH:

European Society for Hypertension

HDL:

High-density Lipoprotein

HTN:

Hypertension

KDCA:

Korea Disease Control and Prevention Agency

KNHANES:

Korean National Health and Nutritional Examination Survey

KRC:

Korea Regional BP Classification

LDL:

Low-density lipoprotein

LVH:

Left Ventricular Hypertrophy

MS:

Metabolic Syndrome

TC:

Total cholesterol

TG:

Triglycerides

TOD:

Target Organ Damage

References

  1. Song P, Zhang Y, Yu J, Zha M, Zhu Y, Rahimi K, et al. Global prevalence of hypertension in children: A systematic review and Meta-analysis. JAMA Pediatr. 2019;173(12):1154–63. https://doiorg.publicaciones.saludcastillayleon.es/10.1001/jamapediatrics.2019.3310.

    Article  PubMed  PubMed Central  Google Scholar 

  2. Xi B, Bovet P, Hong YM, Zong X, Chiolero A, Kim HS, et al. Recent blood pressure trends in adolescents from China, Korea, Seychelles and the united States of America, 1997–2012. J Hypertens. 2016;34(10):1948–58. https://doiorg.publicaciones.saludcastillayleon.es/10.1097/hjh.0000000000001058.

    Article  PubMed  CAS  Google Scholar 

  3. Hardy ST, Urbina EM. Blood pressure in childhood and adolescence. Am J Hypertens. 2021;34(3):242–9. https://doiorg.publicaciones.saludcastillayleon.es/10.1093/ajh/hpab004.

    Article  PubMed  PubMed Central  Google Scholar 

  4. Khoury M, Urbina EM. Cardiac and vascular target organ damage in pediatric hypertension. Front Pediatr. 2018;6:148. https://doiorg.publicaciones.saludcastillayleon.es/10.3389/fped.2018.00148.

    Article  PubMed  PubMed Central  Google Scholar 

  5. Daniels SR, Loggie JM, Khoury P, Kimball TR. Left ventricular geometry and severe left ventricular hypertrophy in children and adolescents with essential hypertension. Circulation. 1998;97(19):1907–11. https://doiorg.publicaciones.saludcastillayleon.es/10.1161/01.cir.97.19.1907.

    Article  PubMed  CAS  Google Scholar 

  6. Köchli S, Endes K, Steiner R, Engler L, Infanger D, Schmidt-Trucksäss A, et al. Obesity, high blood pressure, and physical activity determine vascular phenotype in young children. Hypertension. 2019;73(1):153–61. https://doiorg.publicaciones.saludcastillayleon.es/10.1161/hypertensionaha.118.11872.

    Article  PubMed  Google Scholar 

  7. Urbina EM, Khoury PR, McCoy C, Daniels SR, Kimball TR, Dolan LM. Cardiac and vascular consequences of pre-hypertension in youth. J Clin Hypertens (Greenwich). 2011;13(5):332–42. https://doiorg.publicaciones.saludcastillayleon.es/10.1111/j.1751-7176.2011.00471.x.

    Article  PubMed  Google Scholar 

  8. Tracy RE, Newman WP 3rd, Wattigney WA, Srinivasan SR, Strong JP, Berenson GS. Histologic features of atherosclerosis and hypertension from autopsies of young individuals in a defined geographic population: the Bogalusa heart study. Atherosclerosis. 1995;116(2):163–79. https://doiorg.publicaciones.saludcastillayleon.es/10.1016/0021-9150(95)05525-2.

    Article  PubMed  CAS  Google Scholar 

  9. Seeman T, Dostálek L, Gilík J. Control of hypertension in treated children and its association with target organ damage. Am J Hypertens. 2012;25(3):389–95. https://doiorg.publicaciones.saludcastillayleon.es/10.1038/ajh.2011.218.

    Article  PubMed  CAS  Google Scholar 

  10. Messerli FH, Williams B, Ritz E. Essential hypertension. Lancet. 2007;370(9587):591–603. https://doiorg.publicaciones.saludcastillayleon.es/10.1016/s0140-6736(07)61299-9.

    Article  PubMed  CAS  Google Scholar 

  11. Mitchell GF, Hwang SJ, Vasan RS, Larson MG, Pencina MJ, Hamburg NM, et al. Arterial stiffness and cardiovascular events: the Framingham heart study. Circulation. 2010;121(4):505–11. https://doiorg.publicaciones.saludcastillayleon.es/10.1161/circulationaha.109.886655.

    Article  PubMed  PubMed Central  Google Scholar 

  12. de Simone G, Devereux RB, Daniels SR, Koren MJ, Meyer RA, Laragh JH. Effect of growth on variability of left ventricular mass: assessment of allometric signals in adults and children and their capacity to predict cardiovascular risk. J Am Coll Cardiol. 1995;25(5):1056–62. https://doiorg.publicaciones.saludcastillayleon.es/10.1016/0735-1097(94)00540-7.

    Article  PubMed  Google Scholar 

  13. Salonen JT, Salonen R. Ultrasonographically assessed carotid morphology and the risk of coronary heart disease. Arterioscler Thromb. 1991;11(5):1245–9. https://doiorg.publicaciones.saludcastillayleon.es/10.1161/01.atv.11.5.1245.

    Article  PubMed  CAS  Google Scholar 

  14. Mendizábal B, Urbina EM, Becker R, Daniels SR, Falkner BE, Hamdani G, et al. SHIP-AHOY (Study of high blood pressure in pediatrics: adult hypertension onset in Youth). Hypertension. 2018;72(3):625–31. https://doiorg.publicaciones.saludcastillayleon.es/10.1161/hypertensionaha.118.11434.

    Article  PubMed  Google Scholar 

  15. Olsen MH, Angell SY, Asma S, Boutouyrie P, Burger D, Chirinos JA, et al. A call to action and a lifecourse strategy to address the global burden of Raised blood pressure on current and future generations: the lancet commission on hypertension. Lancet. 2016;388(10060):2665–712. https://doiorg.publicaciones.saludcastillayleon.es/10.1016/s0140-6736(16)31134-5.

    Article  PubMed  Google Scholar 

  16. Kelly RK, Thomson R, Smith KJ, Dwyer T, Venn A, Magnussen CG. Factors affecting tracking of blood pressure from childhood to adulthood: the childhood determinants of adult health study. J Pediatr. 2015;167(6):1422–8..e2.

    Article  PubMed  Google Scholar 

  17. Lona G, Hauser C, Köchli S, Infanger D, Endes K, Faude O, et al. Blood pressure increase and microvascular dysfunction accelerate arterial stiffening in children: modulation by physical activity. Front Physiol. 2020;11:613003. https://doiorg.publicaciones.saludcastillayleon.es/10.3389/fphys.2020.613003.

    Article  PubMed  PubMed Central  Google Scholar 

  18. Wright JT Jr., Williamson JD, Whelton PK, Snyder JK, Sink KM, Rocco MV, et al. A randomized trial of intensive versus standard Blood-Pressure control. N Engl J Med. 2015;373(22):2103–16. https://doiorg.publicaciones.saludcastillayleon.es/10.1056/NEJMoa1511939.

    Article  PubMed  CAS  Google Scholar 

  19. Sinaiko AR, Jacobs DR Jr., Woo JG, Bazzano L, Burns T, Hu T, et al. The international childhood cardiovascular cohort (i3C) consortium outcomes study of childhood cardiovascular risk factors and adult cardiovascular morbidity and mortality: design and recruitment. Contemp Clin Trials. 2018;69:55–64. https://doiorg.publicaciones.saludcastillayleon.es/10.1016/j.cct.2018.04.009.

    Article  PubMed  PubMed Central  Google Scholar 

  20. Pool LR, Aguayo L, Brzezinski M, Perak AM, Davis MM, Greenland P, et al. Childhood risk factors and adulthood cardiovascular disease: A systematic review. J Pediatr. 2021;232. https://doiorg.publicaciones.saludcastillayleon.es/10.1016/j.jpeds.2021.01.053.:118– 26.e23.

  21. Chen X, Wang Y. Tracking of blood pressure from childhood to adulthood: a systematic review and meta-regression analysis. Circulation. 2008;117(25):3171–80. https://doiorg.publicaciones.saludcastillayleon.es/10.1161/circulationaha.107.730366.

    Article  PubMed  PubMed Central  Google Scholar 

  22. Sun SS, Grave GD, Siervogel RM, Pickoff AA, Arslanian SS, Daniels SR. Systolic blood pressure in childhood predicts hypertension and metabolic syndrome later in life. Pediatrics. 2007;119(2):237–46. https://doiorg.publicaciones.saludcastillayleon.es/10.1542/peds.2006-2543.

    Article  PubMed  Google Scholar 

  23. Flynn JT, Kaelber DC, Baker-Smith CM, Blowey D, Carroll AE, Daniels SR, et al. Clinical practice guideline for screening and management of high blood pressure in children and adolescents. Pediatrics. 2017;140(3):e20171904. https://doiorg.publicaciones.saludcastillayleon.es/10.1542/peds.2017-1904.

    Article  PubMed  Google Scholar 

  24. Lurbe E, Agabiti-Rosei E, Cruickshank JK, Dominiczak A, Erdine S, Hirth A, et al. 2016 European society of hypertension guidelines for the management of high blood pressure in children and adolescents. J Hypertens. 2016;34(10):1887–920. https://doiorg.publicaciones.saludcastillayleon.es/10.1097/hjh.0000000000001039.

    Article  PubMed  CAS  Google Scholar 

  25. Kim SH, Park Y, Song YH, An HS, Shin JI, Oh JH, et al. Korean Circ J. 2019;49(12):1167–80. https://doiorg.publicaciones.saludcastillayleon.es/10.4070/kcj.2019.0075. Blood Pressure Reference Values for Normal Weight Korean Children and Adolescents: Data from The Korea National Health and Nutrition Examination Survey 1998–2016: The Korean Working Group of Pediatric Hypertension.

  26. Kweon S, Kim Y, Jang MJ, Kim Y, Kim K, Choi S, et al. Data resource profile: the Korea National health and nutrition examination survey (KNHANES). Int J Epidemiol. 2014;43(1):69–77. https://doiorg.publicaciones.saludcastillayleon.es/10.1093/ije/dyt228.

    Article  PubMed  PubMed Central  Google Scholar 

  27. Kim JH, Yun S, Hwang SS, Shim JO, Chae HW, Lee YJ, et al. The 2017 Korean National growth charts for children and adolescents: development, improvement, and prospects. Korean J Pediatr. 2018;61(5):135–49. https://doiorg.publicaciones.saludcastillayleon.es/10.3345/kjp.2018.61.5.135.

    Article  PubMed  PubMed Central  Google Scholar 

  28. Expert Panel on Integrated Guidelines for Cardiovascular Health and Risk Reduction in Children and Adolescents. Expert panel on integrated guidelines for cardiovascular health and risk reduction in children and adolescents: summary report. Pediatrics. 2011;128(Suppl 5):S213–56. https://doiorg.publicaciones.saludcastillayleon.es/10.1542/peds.2009-2107C.

    Article  PubMed Central  Google Scholar 

  29. Zimmet P, Alberti KG, Kaufman F, Tajima N, Silink M, Arslanian S, et al. The metabolic syndrome in children and adolescents - an IDF consensus report. Pediatr Diabetes. 2007;8(5):299–306. https://doiorg.publicaciones.saludcastillayleon.es/10.1111/j.1399-5448.2007.00271.x.

    Article  PubMed  Google Scholar 

  30. Moon JS, Lee SY, Nam CM, Choi JM, Choe BK, Seo JW, et al. 2007 Korean National growth charts: review of developmental process and an outlook. Korean J Pediatr. 2008;51(1):1–25.

    Article  Google Scholar 

  31. Cho H, Kim JH. Secular trends in hypertension and elevated blood pressure among Korean children and adolescents in the Korea National health and nutrition examination survey 2007–2015. J Clin Hypertens (Greenwich). 2020;22(4):590–7. https://doiorg.publicaciones.saludcastillayleon.es/10.1111/jch.13842.

    Article  PubMed  Google Scholar 

  32. Antolini L, Giussani M, Orlando A, Nava E, Valsecchi MG, Parati G, et al. Nomograms to identify elevated blood pressure values and left ventricular hypertrophy in a paediatric population: American academy of pediatrics clinical practice vs. Fourth report/european society of hypertension guidelines. J Hypertens. 2019;37(6):1213–22. https://doiorg.publicaciones.saludcastillayleon.es/10.1097/hjh.0000000000002069.

    Article  PubMed  CAS  Google Scholar 

  33. Lurbe E, Torró I, Álvarez J, Aguilar F, Mancia G, Redon J, et al. Impact of ESH and AAP hypertension guidelines for children and adolescents on office and ambulatory blood pressure-based classifications. J Hypertens. 2019;37(12):2414–21. https://doiorg.publicaciones.saludcastillayleon.es/10.1097/hjh.0000000000002229.

    Article  PubMed  CAS  Google Scholar 

  34. Di Bonito P, Valerio G, Pacifico L, Chiesa C, Invitti C, Morandi A, et al. Impact of the 2017 blood pressure guidelines by the American academy of pediatrics in overweight/obese youth. J Hypertens. 2019;37(4):732–8. https://doiorg.publicaciones.saludcastillayleon.es/10.1097/hjh.0000000000001954.

    Article  PubMed  Google Scholar 

  35. Fan H, Zhang X. Difference in hypertension prevalence applying three childhood hypertension management guidelines in a National cohort study. J Hum Hypertens. 2021;35(11):1038–45. https://doiorg.publicaciones.saludcastillayleon.es/10.1038/s41371-020-00447-7.

    Article  PubMed  Google Scholar 

  36. Goulas I, Farmakis I, Doundoulakis I, Antza C, Kollios K, Economou M, et al. Comparison of the 2017 American academy of pediatrics with the fourth report and the 2016 European society of hypertension guidelines for the diagnosis of hypertension and the detection of left ventricular hypertrophy in children and adolescents: a systematic review and meta-analysis. J Hypertens. 2022;40(2):197–204. https://doiorg.publicaciones.saludcastillayleon.es/10.1097/HJH.0000000000003005.

    Article  PubMed  CAS  Google Scholar 

  37. Bonito PD, Licenziati MR, Baroni MG, Maffeis C, Morandi A, Manco M, et al. The American academy of pediatrics hypertension guidelines identify obese youth at high cardiovascular risk among individuals non-hypertensive by the European society of hypertension guidelines. Eur J Prev Cardiol. 2020;27(1):8–15. https://doiorg.publicaciones.saludcastillayleon.es/10.1177/2047487319868326.

    Article  PubMed  Google Scholar 

  38. Liu Q, Hou Y, Yang L, Zhao M, Li S, Xi B. Diagnostic effect of the single BP Cut-Offs for identifying elevated BP and hypertension in adolescents aged 13–17 years. Pediatr Cardiol. 2019;40(4):738–43. https://doiorg.publicaciones.saludcastillayleon.es/10.1007/s00246-019-02058-7.

    Article  PubMed  CAS  Google Scholar 

  39. Neuhauser HK, Thamm M, Ellert U, Hense HW, Rosario AS. Blood pressure percentiles by age and height from nonoverweight children and adolescents in Germany. Pediatrics. 2011;127(4):e978–88. https://doiorg.publicaciones.saludcastillayleon.es/10.1542/peds.2010-1290.

    Article  PubMed  Google Scholar 

  40. Kułaga Z, Litwin M, Grajda A, Kułaga K, Gurzkowska B, Góźdź M, et al. Oscillometric blood pressure percentiles for Polish normal-weight school-aged children and adolescents. J Hypertens. 2012;30(10):1942–54. https://doiorg.publicaciones.saludcastillayleon.es/10.1097/HJH.0b013e328356abad.

    Article  PubMed  CAS  Google Scholar 

  41. Tümer N, Yalçinkaya F, Ince E, Ekim M, Köse K, Cakar N, et al. Blood pressure nomograms for children and adolescents in Turkey. Pediatr Nephrol. 1999;13(5):438–43. https://doiorg.publicaciones.saludcastillayleon.es/10.1007/s004670050636.

    Article  PubMed  Google Scholar 

  42. İsmail Ö, Sebahat T, Yunus Y, Fatih Y. Blood pressure percentiles for school children. Dicle Med J. 2016;43(2):193–8. https://doiorg.publicaciones.saludcastillayleon.es/10.5798/diclemedj.0921.2016.02.0666.

    Article  Google Scholar 

  43. Xi B, Zong X, Kelishadi R, Hong YM, Khadilkar A, Steffen LM, et al. Establishing international blood pressure references among nonoverweight children and adolescents aged 6 to 17 years. Circulation. 2016;133(4):398–408. https://doiorg.publicaciones.saludcastillayleon.es/10.1161/circulationaha.115.017936.

    Article  PubMed  Google Scholar 

  44. Zhang M, Zhang HT, Zha RS, Gui GP, Han D, Hu J, et al. Comparison of China reference with different National and international references: the prevalence of high blood pressure in 695,302 children and adolescents in a metropolis of Yangtze river delta, China. Int J Hypertens. 2021;2021:3976609. https://doiorg.publicaciones.saludcastillayleon.es/10.1155/2021/3976609.

    Article  PubMed  PubMed Central  Google Scholar 

  45. Ye X, Yi Q, Shao J, Zhang Y, Zha M, Yang Q, et al. Trends in prevalence of hypertension and hypertension phenotypes among Chinese children and adolescents over two decades (1991–2015). Front Cardiovasc Med. 2021;8:627741. https://doiorg.publicaciones.saludcastillayleon.es/10.3389/fcvm.2021.627741.

    Article  PubMed  PubMed Central  Google Scholar 

  46. Agirbasli M, Dilek HF, Tatlisu MA, Ankarali H. Reliability of normative tables in assessing elevated blood pressure in children. J Hum Hypertens. 2020;34(3):241–7. https://doiorg.publicaciones.saludcastillayleon.es/10.1038/s41371-019-0290-z.

    Article  PubMed  CAS  Google Scholar 

  47. Li S, Chen W. Identifying elevated blood pressure and hypertension in children and adolescents. J Clin Hypertens (Greenwich). 2018;20(3):515–7. https://doiorg.publicaciones.saludcastillayleon.es/10.1111/jch.13222.

    Article  PubMed  Google Scholar 

  48. Fan H, Hou D, Liu J, Yan Y, Mi J. Performance of 4 definitions of childhood elevated blood pressure in predicting subclinical cardiovascular outcomes in adulthood. J Clin Hypertens (Greenwich). 2018;20(3):508–14. https://doiorg.publicaciones.saludcastillayleon.es/10.1111/jch.13201.

    Article  PubMed  Google Scholar 

  49. Flechtner-Mors M, Neuhauser H, Reinehr T, Roost HP, Wiegand S, Siegfried W, et al. Blood pressure in 57,915 pediatric patients who are overweight or obese based on five reference systems. Am J Cardiol. 2015;115(11):1587–94. https://doiorg.publicaciones.saludcastillayleon.es/10.1016/j.amjcard.2015.02.063.

    Article  PubMed  Google Scholar 

  50. Kim JY, Cho H, Kim JH. Difference in the prevalence of elevated blood pressure and hypertension by references in Korean children and adolescents. Front Med (Lausanne). 2022;9:793771. https://doiorg.publicaciones.saludcastillayleon.es/10.3389/fmed.2022.793771.

    Article  PubMed  Google Scholar 

  51. Sharma AK, Metzger DL, Rodd CJ. Prevalence and severity of high blood pressure among children based on the 2017 American academy of pediatrics guidelines. JAMA Pediatr. 2018;172(6):557–65. https://doiorg.publicaciones.saludcastillayleon.es/10.1001/jamapediatrics.2018.0223.

    Article  PubMed  PubMed Central  Google Scholar 

  52. Yang L, Kelishadi R, Hong YM, Khadilkar A, Nawarycz T, Krzywińska-Wiewiorowska M, et al. Impact of the 2017 American academy of pediatrics guideline on hypertension prevalence compared with the fourth report in an international cohort. Hypertension. 2019;74(6):1343–8. https://doiorg.publicaciones.saludcastillayleon.es/10.1161/hypertensionaha.119.13807.

    Article  PubMed  CAS  Google Scholar 

  53. Nitescu M, Streinu-Cercel A, Tusaliu M, Pitigoi D, Otelea M. Correlation between the waist circumference, diastolic blood pressure and insulin resistance in Non-Obese young adults. Acta Endocrinol (Buchar). 2016;12(4):493–9. https://doiorg.publicaciones.saludcastillayleon.es/10.4183/aeb.2016.493.

    Article  PubMed  CAS  Google Scholar 

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Acknowledgements

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Authors and Affiliations

  1. Department of Pediatrics, Samsung Medical Center, Sungkyunkwan University School of Medicine, 81 Irwon-ro, Gangnam-gu, Seoul, 06351, South Korea

    Jeong Yeon Kim & Heeyeon Cho

  2. Graduate School of Urban Public Health, University of Seoul, 163 Seoulsiripdae-ro, Dongdaemun-gu, Seoul, 02504, South Korea

    Sangshin Park

  3. Department of Pathology and Laboratory Medicine, Alpert Medical School, Brown University, 02903, RI, Providence, USA

    Sangshin Park

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JYK wrote the first draft. SP and HC contributed to conception and design of the study. All authors reviewed the manuscrip.

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Correspondence to Sangshin Park or Heeyeon Cho.

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The present study was approved by the Institutional Review Board (IRB) of Samsung Medical Center (IRB number 21-10-074). The informed consent was waived by IRB of Samsung Medical Center. All the data were obtained in accordance with the ethical principles for medical research involving human subjects established in the Declaration of Helsinki 1975 (revised in 2000).

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Kim, J.Y., Park, S. & Cho, H. Assessment of cardiovascular disease risk factors in Korean children: impact of various pediatric hypertension guidelines and application of the Korean blood pressure reference. BMC Pediatr 25, 364 (2025). https://doiorg.publicaciones.saludcastillayleon.es/10.1186/s12887-025-05713-6

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Keywords

BMC Pediatrics

ISSN: 1471-2431

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