Abstract Body (Do not enter title and authors here): Background: Presence of cardiovascular-kidney-metabolic (CKM) syndrome may help guide hypertension (HTN) management. However, whether initial management of youth with HTN disorders differs by CKM syndrome stage is unknown.

Methods: Inferential cross-sectional analysis of baseline data from 7 sites in the Study of the Epidemiology of Pediatric Hypertension (SUPERHERO), a retrospective Registry of electronic health record data using standardized biomedical informatics scripts validated by manual record review. Inclusion criteria were youth <19 years old who received care from subspecialists for ICD-10 code-defined HTN disorders from 1/1/2016–12/31/2023. Exclusion criteria were ICD-10 code-defined kidney replacement therapy (dialysis or transplantation) or pregnancy. Exposure was CKM syndrome (Stage 0, Stage 1, Stage 2, or Unclassified) defined by ICD-10 codes and recorded blood pressure and BMI. Outcomes were orders for antihypertensive prescriptions (n=5,766) and for echocardiograms and dietitian referrals (n=9,356). We used directed acyclic graph-informed generalized linear models adjusted for acute kidney injury, cancer, growth restriction, lower birth weight, preterm birth, and social risk factors by ICD-10 codes and visit season.

Results: Of 9,356 participants, 85% had CKM syndrome, 16% were prescribed a medication, 33% had an echocardiogram ordered, and 7% had a dietitian referral ordered. Participants with Stage 2 CKM syndrome were 34% more likely to have an echocardiogram ordered vs. Stage 0 (95% CL 1.16–1.55) and 25% more likely vs. Stage 1 (95% CL 1.14–1.38). Those with Stage 2 were 29% more likely to be prescribed medication vs. Stage 0 (95% CL 1.03–1.62) and 62% more likely vs. Stage 1 (95% CL 1.35–1.94). Compared to Stage 0, dietitian referrals were more common in those with Stage 2 CKM syndrome (RR 1.85, 95% CL 1.28–2.68), Stage 1 (RR 1.79, 95% CL 1.21–2.67), and Unclassified (RR 1.91, 95% CL 1.21–3.02).

Discussion: At the first HTN disorder clinic visit, providers were more likely to order echocardiograms, prescribe antihypertensive medication, and refer to dietitians in youth with worse CKM syndrome stage. This supports current guideline recommendations for youth with HTN disorders. Ongoing steps in SUPERHERO are improving the definition of CKM syndrome and outcomes. Future analyses will investigate if presence of CKM syndrome can improve management and health outcomes.