Original article

Differences Between the Fourth and Fifth

Korotkoff Phases Among Children and
Adolescents
David S. Freedman,1 Jennifer L. Foltz,1 and Gerald S. Berenson2
background
The relative importance of the fourth (K4) and fifth (K5)
Korotkoff phases as the indicator of diastolic blood
pressure (DBP) levels among children remains uncertain.
methods
In a sample of 11,525 youth aged 517, we examined
interexaminer dif-ferences in these 2 phases and the
relation of theses 2 phases to adult blood pressure levels
and hypertension. The longitudinal analyses were
conducted among 2,156 children who were re-examined
after age 25 years.
results
Mean (SD) levels of DBP were 62 (9) mm Hg (K4) and
49 (13) mm Hg (K5). K4 showed less interobserver
variability than did K5, and 7% of the children had at least
1 (of 6) K5 value of 0 mm Hg. Longitudinal analyses
indicated that K4 was more strongly associated with adult
blood pressure levels and hypertension. In correlational
analyses of

Although the onset of the fifth Korotkoff phase

(K5, beginning of silence) is widely used
among adults as the indicator of diastolic blood
pressure (DBP), it is unclear whether K5 or the
fourth Korotkoff phase (K4, muffling of sounds)
should be used for children and adolescents.
1
The most recent (2004) recommendation is to
use K5 for all children and adolescents, but a
2008 meta-analysis found that adult DBP levels
show a slightly stronger cor-relation
with
2
childhood levels of K4 than K5. Neither K4 nor
K5 correlates strongly
with
the
intra-arterial
35
DBP of children.
The recommendations for the assessment of
DBP among children in the United States have
changed considerably over time. In 1977, the
National Heart, Lung, and Blood Institute Task
Force Report on Blood Pressure Control in
Children recommended that
K4 be used for all
6
children and adolescents, whereas the 1987
recommendation was to use 7K4 only for
children
aged
<13
years.
It
was
acknowledged that in some

subjects who were not using antihypertensive medications

in adult-hood (n = 1,848), K4 was more strongly associated
with the adult DBP level than was K5 (r = 0.22 vs. 0.17; P
< 0.01). Analyses of adult hypertension (based on high
blood pressure levels or use of antihy-pertensive
medications) indicated that the screening performance of
childhood levels of K4 was similar to that of systolic blood
pressure and was higher than that of K5, with areas under
the receiver operator characteristic curves of 0.63 (systolic
blood pressure), 0.63 (K4), and 0.57 (K5).
conclusions
As compared with K5 levels among children, K4 shows less
interobserver variability and is more strongly associated with
adult hypertension.

Keywords: blood pressure; children; diastolic blood

pressure; hyperten-sion; Korotkoff phases; longitudinal;
systolic blood pressure.
doi:10.1093/ajh/hpu064

children, the K4 and K5 phases may occur

together and that sounds
can sometimes be
7
heard8 even at 01mm Hg. Subsequent reports in
1996 and 2004 recommended that K5 be used
as the indicator of DBP for all children and
adolescents. Formulas have also been given for
lev-els of systolic blood pressure (SBP) and K5,
but not K4, that can be used to standardize a
childs 1blood pressure level for sex, age, and
height.

There is, however, little longitudinal data

available to determine whether the K4 or K5
level, measured by the same observer, is9more
strongly related to adult hyper-tension. The
purpose of these analyses is to describe, in a
large population-based study, the distribution
of
K4 K5 differences and the relation of these 2
phases to adult hypertension. We use data
from 26,356 exami-nations of youth aged 517
years obtained from 11,525 children in the
Bogalusa Heart Study. Of the 2,156 chil-dren
who were re-examined after age 25 years, 401
were hypertensive.

Correspondence: David S. Freedman (dxf1@cdc.gov).

Initially submitted December 23, 2013; date of first
revision March 3, 2014; accepted for publication March 3,
2014; online publication April 17, 2014.

Division of Nutrition, Physical Activity and Obesity,

Centers for Disease Control and Prevention, Atlanta,
Georgia; 2Tulane Center for Cardiovascular Health,
Tulane University School of Public Health and Tropical
Medicine, New Orleans, Louisiana.
Published by Oxford University Press on behalf of
American Journal of Hypertension Ltd 2014. This work is
written by (a) US Government employees(s) and is in the
public domain in the US.

American Journal of Hypertension 27(12) December 2014

1495

Freedman et
al.
ME
TH
OD
S
St
ud
y
po
pul
ati
on

T
he
Bo
gal
us
a
He
art
St
ud
y
foc
us
es
on
the
nat
ur
al
his
tor
y
of
car
dio
va
sc
ula
r
dis
ea
se
an
d
its
ris
k
fac
tor
s
in
a
bir
aci
al
co
m
mu
nit
y
(1/
3
bla
ck)
in
Wa
shi
ng
ton
Par
ish
,
Lo
uis
ian
1
a.
0
Se
ve
n
cro
ssse
cti
on
al
stu

die
s
of
sc
ho
olc
hil
dre
n
we
re
co
ndu
cte
d
bet
we
en
19
73

19
74
an
d
19
92

19
94.
Inf
or
me
d
co
nse
nt
wa
s
obt
ain
ed
fro
m
all
pa
rtic
ipa
nts
,
an
d
stu
dy
pro
toc
ols
we
re
ap
pro
ve
d
by
ins
tit
uti
on
al
rev
ie
w
bo
ard
s.
E
ac
h
of
the
se
stu
die
s
ex
am
ine
d
ap
pro
xi
ma
tel
y

3,5
00
chi
ldre
n
an
d
ad
ole
sce
nts
.
Of
the
26,
51
8
ex
am
ina
tio
ns
co
nd
uct
ed
am
on
g
yo
uth
ag
ed
5
17
ye
ars
,
we
exc
lud
ed
13
7
ex
am
ina
tio
ns
wit
h
mi
ssi
ng
blo
od
pre
ssu
re
inf
or
ma
tio
n
an
d
56
ex
am
ina
tio
ns
be
ca
us
e
hei
ght
wa
s
mi
ssi
ng
or
rac
e
wa
s

rep
ort
ed
as
oth
er
tha
n
whi
te
or
bla
ck.
Thi
s
res
ult
ed
in
26,
35
6
ex
am
ina
tio
ns
co
nd
uct
ed
am
on
g
11,
52
5
chil
dre
n;
ap
pro
xi
ma
tel
y
60
%
of
the
chil
dre
n
par
tici
pat
ed
in
>1
ex
am
ina
tio
n.

T
o
foll
ow
the
se
chi
ldr
en
as
the
y
ag
ed,
ad
ult
s
we
re
ex
am
ine
d
in
stu
die
s

co
nd
uct
ed
fro
m
19
77
thr
ou
gh
20
10,
11
an
d
ou
r
lon
git
udi
nal
an
aly
se
s
are
res
tric
ted
to
su
bje
cts
wh
o
we
re
re
-ex
am
ine
d
aft
er
ag
e
25
ye
ars
.
Of
the
5,5
04
ex
am
inat
ion
s
co
nd
uct
ed
am
on
g
the
se
ad
ult
s,
we
ex
clu
de
d
78
ex
am
ina
tio
ns
wit
h
mi
ssi
ng
blo
od
pre
ss
ure
dat
a
or

am
on
g
wo
me
n
wh
o
we
re
pre
gn
ant
.
Th
es
e
ex
clu
sio
ns
res
ult
ed
in
a
gro
up
of
2,1
56
ad
ult
s
ag
ed
25

51
ye
ars
,
an
d
we
us
ed
dat
a
fro
m
onl
y
the
ir
fin
al
ex
am
ina
tio
n.
Of
the
se
ad
ult
s,
40
1
we
re
co
nsi
der
ed
to
ha
ve
hy
pe
rte
nsi
on
ba
se
d
on
eit
he
r
rep
ort
ed
us
e
of

ant
ihy
pe
rte
nsi
ve
me
dic
ati
on,
SB
P
1
40
m
m
Hg
,
or
DB
P
9
0
m
m
Hg
.
Ex
am
ina
tio
n
me
th
od
s

T
he
sta
nd
ard
ize
d
ex
am
ina
tio
n
pro
ce
dur
es
us
ed
in
the
Bo
gal
us
a
He
art
Stu
dy
ha
ve
be
en
de
scr
ibe
1
d.
0
Bo
dy
ma
ss
ind
ex
(B
MI)
wa
s
cal
cul
ate
d
as
kil
ogr
am
s
per
me
ter
sq
uar
ed,
an
d
ob

esi
ty
am
on
g
tho
se
ag
ed
5
17
ye
ars
wa
s
de
fin
ed
as
a
BM
Iforag
e
9
5th
per
ce
ntil
e
of
the
Ce
nte
rs
for
Dis
ea
se
Co
ntr
ol
an
d
Pre
ve
nti
on
gro
wt
h
ch
art
12
s
or
a
BM
I
3
0
kg/
2
m
.
Ad
ult
ob
esi
ty
is
ba
se
d
on
a
BM
I
3
0
kg/
2
m
.
B
loo
d
pre
ssu
re
ob
ser
ver
s,
wh
o
we
re
mo
nit
ore
d
thr
ou
ghout
the
ex
am
ina
tio
ns,
rec
ord
ed

the
on
set
of
the
firs
t,
fou
rth
(m
uffl
ing
of
so
un
ds)
,
an
d
fift
h
(be
gin
nin
g
of
sile
nc
e)
Kor
otk
off
ph
as
es.
Ob
ser
ver
trai
nin
g,
inc
lud
ing
au
dio
me
tric
tes
ts
an
d
the
us
e
of
do
ubl
e
ste
tho
sco
pe
s
wit
h 2
me
rcu
ry
col
um
ns,
wa
s
em
ph
asi
ze
d
thr
ou
gh
out
the
stu
dy
per
iod
13,
.14

e
of
the
em
otio
nal
sta
te
of
the
chil
1
d.
5

Att
em
pts
we
re
ma
de
to
mi
ni
mi
ze
the
inf
ue
nc

R
igh
t
ar
m
sitt
ing
lev
els
of
SB
P,
K4,
an
d

Cu
ff
siz
es
we
re
sel
ect
ed
acc
ord
ing
to
a
pro
toc
ol
ba
se
d
on
the
cir
cu
mf
ere
nc
e
an
d
len
gth
of
the
up
per
ar
m,
usi
ng
a
bla
dd
er
wid
th
as
lar
ge
as
po
ssi
ble
whi
le
lea
vin
g
roo
m
for
the
ste
tho
sco
pe
at
the
elb
ow
ski
n
cre
as1
e.
5,16

K5
we
re
ea
ch
me
as
ure
d 3
tim
es
by
2
ob
ser
ver
s
usi
ng
a
me
rcu
ry
sp
hy
gmo
ma
no
me
ter.
10,1
3

As
ha
s
be
en
do
ne
in
pre
vio
us
an
aly
ses
of
dat
a
fro
m
the
Bo
gal
us
a
He
art
Stu
dy,
10,1
3,15
,17,
18

we
us
ed
the
me
an
of
the
6
rec
ord
ed
me
as
ure
me
nts
for
SB
P,
K4,
an
d
K5.
Th
ere
we
re
1,9
62
(7.
4%
)

chil
dre
n
wh
o
ha
d
at
lea
st
1
(of
6)
K5
val
ue
s
rec
ord
ed
as
0
m
m
Hg,
an
d
mo
st
an
aly
ses
tre
at
the
se
0
val
ue
s
no
diff
ere
ntl
y
tha
n
an
y
oth
er
wh
en
cal
cul
ati
ng
the

me
an
K5
val
ue.
On
ly
34
(0.
1%
)
chi
ldr
en
ha
d
all
6
K5
me
asure
me
nts
rec
ord
ed
as
0
m
m
Hg
.
T
he
lon
git
udi
nal
an
aly
se
s,
wh
ich
co
ntr
ast
ed
the
rel
atio
n
of
chi
ldh
oo
d
lev
els
of
K4
an
d
K5
to
ad
ult
blo
od
pre
ssur
e
lev
els
an
d
hy
pe
rte
nsi
on,
als
o
co
mp
are
ou
r
me
tho
d
for

cal
cul
ati
ng
me
an
K5,
wh
ich
tre
ate
d
the
0
m
m
Hg
val
ue
s
no
diff
ere
ntl
y
tha
n
an
y
oth
er
rec
ord
ed
val
ue,
wit
h3
oth
er
me
tho
ds.
In
ad
diti
on
to
usi
ng
all
rec
ord
ed
val
ue
s
of
K5,
we
als
o
cal
cul
ate
d
the
me
an
K5
aft
er
(i)
ex
clu
din
g
the
0
m
m
Hg
val
ue
s,
(ii)
rep
lac
ing
the
K5
val
ue
of
0
m
m

Hg
wit
h
the
cor
res
po
ndi
ng
K4
val
ue,
an
d
(iii)
rep
lac
ing
the
K5
rea
ding
s
<2
0
m
m
Hg
wit
h
the
cor
res
po
ndi
ng
K4
val
ue.
Giv
en
3
rec
ord
ed
K5
val
ue
s
of
0,
15,
an
d
55
m
m
Hg
,
for
ex
am
ple
,
the
cal
cul
ate
d
me
an
K5
un
de
r in
me
tho
d2
wo
uld
be
(1s
t
K4
+
15
+
55
) /
3
rat
he
r
tha
n
23.

3
((0
+
15
+
55
)/3
)
m
m
Hg
.
T
he
Fo
urt
h
Re
po
rt
on
the
Di
ag
no
sis,
Ev
alu
ati
on,
an
d
Tre
at
me
nt
of
Hi
gh
Blo
od
Pre
ss
ure
in
Chi
ldr
en
an
d
Ad
ole
sc
ent
1
s
rec
om
me
nd
s
tha
t
K4
sh
oul
d
be
us
ed
as
the
DB
P if
the
K5
val
ue
re
ma
ins
v
ery
lo
w
aft
er
red
uci
ng
pre
ss
ure
on
the
ste
tho
sc

op
e
he
ad.
T
o
inc
rea
se
s
the
co
mp
ara
bili
ty
of
ou
r
lon
git
udi
nal
res
ult
s
wit
h
tho
se
of
oth
er
stu
die
s,
the
lon
git
udi
nal
an
aly
se
s
are
ba
se
d
on
the
3
me
as
ure
me
nts
fro
m
the
firs
t
ob
ser
ver
(ra
the
r
tha
n
the
6
me
as
ure
me
nts
fro
m
2
ob
ser
ver
s).
Ad
ult

DB
P
is
ba
se
d
on
K5.
St
ati
sti
cal
an
aly
se
s

A
nal
yse
s
we
re
per
for
me
d
wit
h1
R.
9
We
ex
am
ine
d
the
dis
trib
uti
on
s
of
the
K4

K5
diff
ere
nc
e
an
d
the
ir
rel
ati
on
to
the
diff
ere
nc
es
bet
we
en
the
2
ex
am
ine
rs.
Lo
ngi
tud
ina
l
an
aly
ses
, in
the
co
hor
t of
2,1
56
chil
dre
n
wh
o
we
re
reex
am

ine
d
aft
er
ag
e
25
ye
ars
,
ex
am
ine
d
wh
eth
er
lev
els
of
K4
an
d
K5
we
re
cor
rel
ate
d
si
mil
arl
y
wit
h
ad
ult
DB
P
lev
els
(H
0:
rK4
vs.
adul
t
DBP

=
rK5

vs.
adul
t
DBP

)
am
on
g
su
bje
cts
wh
o
we
re
not
usi
ng
ant
ihy
per
ten
siv
e
me
dic
ati
on
s
in
ad
ult
ho
od.
Th
e
sta
tist
i-

cal
sig
nifi
ca
nc
e
of
the
diff
ere
nc
es
bet
we
en
cor
rel
ati

on
wa
s
ass
es
se
d
usi
ng
the
pai
red
.r
fun
cti
on.
20
To
ac
co
un
t
for
differ
en
ce
s
in
chi
ldh
oo
d
lev
els
of
blo
od
pre
ss
ure
by
se
x,
ag
e,
an
d
hei
gh
t,
blo
od
pre
ss
ure
lev
els
in
the
lon
git
udi
nal
an
aly
se
s
we
re
co
nv
ert
ed
int
o z
sc
ore
s
usi
ng
for
mu
las
fro
m
the
Fo
urt
h
Re
po1
rt.
We
als
o
ass
es
se
d
the
pot
ent
ial
im
pa
ct

of
ob
esi
ty
on
the
ob
ser
ve
d
as
so
cia
tio
ns
by
usi
ng
the
res
idu
als
of
var
iou
s
reg
res
sio
n
mo
del
s
tha
t
pre
dic
ted
lev
els
of
SB
P,
K4,
an
d
K5
fro
m
se
x,
ag
e,
hei
gh
t,
an
d
BM
I.
T
he
abi
lity
of
chi
ldh
oo
d
lev
els
of
SB
P,
K4,
an
d
K5
to
ide
ntif
y
ad
ult
hy
per
ten
sio
n
(ba
se
d
on
us
e
of
ant
ihy
per
ten

siv
e
me
dic
ati
on
s,
SB
P
1
40
m
m
Hg,
or
DB
P
9
0
m
m
Hg
)
wa
s
ex
am
ine
d
in
2
2
tab
les
;
30
8
of
the
40
1
ad
ult
s
wit
h
hy
per
ten
sio
n
rep
ort
ed
tak
ing
ant
ihy
per
ten
siv
e
me
dic
ati
on
s.
Be
ca
us
e
onl
y
15
(0.
7%
)
chil
dre
n
in
the
se
an
aly
ses
ha
d a
me
an
K4
tha

t
wa
s
9
5th
per
ce
ntil
e
giv
en
in
the
Fo
urt
h
Re
por
1
t
an
d
no
chi
ld
ha
d a
me
an
K5
ab
ov
e
thi
s
cut
poi
nt,
we
sel
ect
ed
var
iou
s
chi
ldh
oo
d
cut
poi
nts
tha
t
res
ult
ed
in
fair
ly
si
mil
ar
pre
val
en
ces
of
hig
h
chi
ldh
oo
d
lev
els
an
d
ad

ult
hy
per
ten
sio
n
(18
.6
%).
Chi
ldh
oo
d
blo
od
pre
ssu
re
lev
els
in
Bo
gal
us
a,
whi
ch
are
ba
se
d
on
6
me
as
ure
me
nts
,
are
ge
ner
all
y
low
er
tha
n
in
oth
er
rep
ort
3
s,
but
ma
ny
oth
er
stu
dies
obt
ain
onl
y 1
blo
od
pre
ssu
re
me
as
ure
me
nt.
21

1496
American
Journal of
Hypertensio
n 27(12)
December
2014

Differences between the 4th and 5th

Phases

We
also
examined the
screening
performance
of SBP, K4,
and K5 over
all
possible
cut points by
comparing
the
area
under
the
receiver
operator
characteristic
curves
22
(AUC).
These curves
account
for
the trade-offs
between
sensitiv-ity
and
specificity
across
cut
points,
and
AUC can be
inter-preted
as
the
probability
that
the
childhood
blood
pressure of a
randomly
chosen
hypertensive
adult
was
higher
than
the childhood
level
of
a
nonhypertens
ive
adult.
Differences
between
AUCs
were
assessed
using
the
pROC
23
package
or
by
bootstrapping
the
logistic
regression C24
statistic.
RESULTS

Table
1
shows mean
levels
of
various
characteristi
cs
among
children and
adults.
The
mean (SD)
age of the
examined
children was
11.2
(3)
years (range
= 5.0 17.9
years), and
the
prevalence
of
obesity
was
9%.
Although
mean levels
of
blood
pressure did
not
differ
greatly
between
boys
and
girls,
given
the
large
number
of

examinations
(n = 26,356),
most of the
observed differences
were
statistically
significant.
Boys
had
slightly
higher levels
of SBP, but
girls
had
slightly
higher levels
of both K4
and K5. K4
K5
differences
varied from 0
to 76 mm Hg
(mean
=
13.4 7 mm
Hg). A K5
value of 0
mm Hg was
recorded for
1 of the 6
measuremen
ts at 1,962
(7.4%)
examinations
and
was
more
likely
to
occur
among boys
and younger
children. The
mean age at
examination
in adulthood
was 36.5 7
years.

The
correlation
between
levels of K4
and K5 was
0.84.
Approximatel
y 14% of the
children had
a K4 K5
differ-ence
20 mm Hg,
and
2.5%
(the 97.5th
percentile)
had
a
difference
33 mm Hg
(Figure
1).
The mean K4

K5
difference was
approximatel
y 2 mm Hg
higher
among youth
aged
59
years
than
among youth
aged 1417
years
and
was 1.5 mm
higher
among boys
than among
girls.

The mean
interobserver
differences
were 7 6
(K4) and 10
9 (K5) mm
Hg, and both
interobserver
differ-ences
were
larger
among
younger
children than
among older
children.
In
addition, the
K4

K5
difference
was
correlated with
the
interobserver
difference for
K5 (r = 0.42)
but not with
the
interobserver
difference for
K4 (r = 0.08).
As shown in
Table 2, as
the K4 K5
difference
varied
from
<10 mm Hg
to 40 mm
Hg
(2nd
column
of

values),
mean levels
of K4 and the
interobserver
difference for
K4 did not
substan-tially
change.
In
contrast, the
K5
interobserver
difference
var-ied
by
approximatel
y 15 mm Hg
across
categories of
K4 K5 and
the
percentage of
children with
at least 1 K5
value of 0
mm Hg (final
column)
varied
from
0.1%
to
approximatel
y 97%.
The relation
of childhood
levels of K4
and K5 to
adult (age
25
years)
levels of DBP
and SBP are
shown
in
Table 3 for
the
1,848
subjects who
were
not
taking
antihypertens
ive
medications
at follow-up.
As compared
with
childhood levels
of
K5,
levels of K4
were
more
strongly
associated
with
adult
DBP (r = 0.22
vs. 0.17; P <
0.001
for
difference).
The K4 vs. K5
difference
varied
somewhat
across
categories of
the examined
characteristic
s, but in no
case
was
adult DBP

Table 1. Mean levels of various

characteristics among children and adults

Characteristic

No. of examinationsa
Age, y

% Black
Year of examination
BMI, kg/m2
Obeseb
SBP, mm Hg
SBP z score
K4, mm Hg
K4 z score
K5, mm Hg
K5 z score
K4 K5 difference, mm Hg
At least one K5 of 0 mm Hgc
With the exception of the sample size,
values are mean SD or percentages.
Abbreviations: BMI, body mass index; K4,
fourth Korotoff phase; K5, fifth Korotoff
phase; SBP, systolic blood pressure.
a
Childhood estimates are based on levels
recorded from the 26,356 examinations
(representing data from 11,525 subjects).
Adult estimates are based on 2,156
examinations; each adult was examined only
once.
b
Based on a BMI 95th
percentile of the Centers for
Disease Control and
Prevention reference
population or a BMI 30
kg/m2. cTwo observers each
recorded 3 measurements
for each child.
*P < 0.01 for sex difference among
children or adults. Analyses of sex
differences among children accounted for
the within-child clustering of levels of BMI
and blood pressure using the HuberWhite

method23 and multilevel models.37

American Journal of Hypertension

27(12) December 2014
1497

Freedman et al.

Figure 1. Percentile plots of the fourth Korotoff phase (K4) and fifth Korotkoff phase (K5) difference by sex and age group.
Each bar includes the mid-dle 95% (2.5th percentile to 97.5th percentile) of the distribution, and the horizontal lines
represent various percentiles. The dark triangle represents the mean difference. Boys are on the left; girls are on the right.
Table 2. Relation of fourth Korotoff phase and fifth Korotoff phase difference to mean blood pressure levels and to interobserver a differences
among children

K4 K5,
Sex

Overall
Boys

mm Hg

09
1019
2029
3039
40

Girls

09
1019
2029
3039
40

a
Each of the 2 observers recorded 3 measurements for both the fourth Korotoff phase (K4) and the fifth Korotoff phase (K5). Mean values
of K4 and K5 are based on the mean of the 6 measurements.

more strongly correlated with the childhood

level of K5 than with K4. Additional analyses
that used regression models to express levels
of childhood blood pressure relative to children of the same sex, age, height, and weight
yielded very similar results (data not shown).
We then examined the cross-classification of
childhood
blood
pressure
with
adult
hypertension (Table 4). Based on the use of the
80th percentile of the blood pressure z scores
as the cut point for a high childhood level,
the sensitivities (33%) and specificities (83%)
of SBP and K4 were almost identical. In
contrast, the use of K5 resulted

in a lower sensitivity (28%) at approximately

the same specificity (82%). The use of the 75th
percentile as the cut point (bottom of table)
resulted in a sensitivity of K4 that was 4
percentage points higher (38% vs. 34%) than
that of K5.

The performance of childhood blood pressure

levels in identifying those who had adult

hypertension is shown in Figure 2, which plots the

specificity (x-axis) vs. sensitiv-ity (y-axis) across
all possible cut points of the childhood z scores
for SBP, K4, and K5. At all levels of specificity, the
sensitivities of both SBP and K4 were higher than
that of K5.

1498 American Journal of Hypertension 27(12) December 2014

Differences between the 4th and 5th

Phases
Table 3. Longitudinal relation of fourth Korotoff phase and fifth Korotoff phase levels among children to adult blood pressure levels a

Category

Overall
Sex
Race
Childhood age, y

Adult age, y

Abbreviations: DBP, diastolic blood pressure; SBP, systolic blood pressure.

a
Analysis is restricted to the 1,848 of the 2,156 adults who did not report using antihypertensive medications. Values are correlation coefficients between child and adult levels of specified blood pressure z scores. Childhood fourth Korotoff phase (K4) and fifth Korotoff phase (K5)
measurements represent the mean of the 3 measurements from the first observer averaged over all examinations.
b
K5 was used as the adult DBP.
*P < 0.01 for difference in the correlation between K4 and K5.

Table 4. Classification of adult hypertension by childhood levels of systolic and diastolic blood pressure

Childhood cut pointa

80th percentile

75th percentile

A high childhood blood pressure z score was defined so that the upper 20% or 25% of the children would be classified as having a high
level. The prevalence of adult hypertension was 18.6% and was based on a systolic blood pressure (SBP) 140 mm Hg, a diastolic blood
pressure 90 mm Hg, or reported use of antihypertensive medications. The childhood blood pressure level represents the mean of the 3
measurements from the first observer averaged over all examinations for that subject.
b

Standard errors are shown in parentheses.

The predictive accuracies, as assessed by the

AUCs (Table 5), were 0.63 (SBP), 0.63 (K4), and
0.57 (K5); The P values were 0.73 for the
difference between SBP and K4 and <0.001 for
the difference between K4 and K5. In this
analysis, the mean K5 was calculating by
including the 0 mm Hg measurements. We found,
however, that substituting the recorded K4 value
for either the 0 mm Hg K5 values or for those K5
values <20 mm Hg, as well as omitting the 0 mm
American Journal of Hypertension 27(12) December 2014

Hg K5 recordings, increased the calculated

AUC for K5 only slightly (lines 46 in Table 5).
DiSCUSSiON

Although K5 is recommended as the

indicator of1 DBP among children and
adolescents, our results indicate that K4 is a
better predictor of adult hypertension.
Although
1499

Freedman et al.

Figure 2. Receiver operator characteristic (ROC) curves for the classification of adult hypertension by childhood levels of
systolic blood pressure (SBP), fourth Korotoff phase (K4), and fifth Korotkoff phase (K5). The 3 curves show the sensitivity (yaxis) and specificity (x-axis) of each blood pressure measure at all possible cut points, and a better classifier would have a
curve that is shifted upwards (higher sensitivity at the same specificity). Both SBP and K4 were more strongly ( P < 0.001)
associated with adult hypertension than was K5. The dashed line, which has a slope of 1, indicates the curve that would be
expected if there was no relation of childhood blood pressure levels to adult hypertension.
Table 5. Areas under the receiver operator characteristic curve for the classification of adult hypertension by childhood blood pressure levels
Childhood blood pressure predictor a

SBP
K4 (reference)
K5b
K5 values of 0 mm Hg replaced by K4 value
K5 values <20 mm Hg replaced by K4 value
K5 values of 0 mm Hg deleted from calculation of mean K5c
Abbreviations: K4, fourth Korotoff phase; K5, fifth Korotoff phase; SBP, systolic blood pressure.
a
All childhood levels were expressed as z scores that accounted for sex, age, and height. Childhood measurements represent the mean of
the 3 measurements from the first observer.
b
Individuals measurements of 0 mm Hg were included in the calculation of the mean.
c
Six children were excluded because the 3 K5 measurements were recorded as 0 mm Hg.
*P for the difference between the area under the curve for K4 (reference) and the area under the curve for SBP or K5 < 0.05; *P for the difference between the area under the curve for K4 (reference) and the area under the curve for SBP or K5 < 0.001.

the differences in the screening performance of

K4 and K5 were not large (a 4% difference in
sensitivity) at specificities 75%, K4 showed a
higher sensitivity at all levels of specific-ity
than did K5. Approximately 7% of the
examined children had at least 1 (of 6) K5
measurement of 0 mm Hg, and we found that
the predictive accuracy of K5 was improved
only slightly by either replacing very low K5
readings with the corresponding K4 or by
excluding the 0 mm Hg readings from the
calculation of mean K5.

The guidelines for DBP measurement have

changed many times since 1939 when a USUK
25
committee recommended using K4. The current
recommendations to use K5 among children and
adolescents is largely based not on the abil-ity of
K5 to predict adult levels of DBP or hypertension
but on the reported similarity of K4 and K5 levels
among

most children, and the26ease with which K5 can be

heard. Sinaiko et al.,
for example, concluded
that the choice of K4 or K5 was relatively
inconsequential because of the small differences
they observed among youth aged 1015 years.
However, the generalizability of these results,
particularly to younger children, is uncertain, and
it is likely that exam-iner training greatly
infuences the accuracy and precision of DBP
measurements. Recent analyses of DBP levels
27
among
children have been based on either K4
28
or K5, with little justification of either decision.
In our analyses, we found that the K4 vs. K5
difference was
<5 mm Hg for only 4% of the 26,000
examinations and that the mean difference was
13 mm Hg. Other studies of school-aged children
have reported mean K4 K5 differences of
26
29,30
31
approximately 5,
7,
810,
and 10 mm
9,32
Hg.
Several

1500 American Journal of Hypertension 27(12) December 2014

Differences between the 4

Phases

13,14

33,36

investigators
have
also
observed that
it
is
more
difficult
to
measure
levels of both
K4 and 3335
K5
than SBP.
Although
it
has also been
suggested
that
the
assessment
of K5 (complete
disappearanc
e) is easier
than
K4
(muffling36 of
sounds),
others have
emphasized
that the K5
measurement
s
can
be
more difficult
because
K4
sounds
frequently
fade
rather
than abruptly
34
cease.
Based
on
audio
recordings of
Korotkoff
phases
among youth
aged
11
years (n =
20),
OSullivan
et
34
al.
reported
that 20% had
sounds
that
persisted to
the end of
defation (30
mm Hg).
Few studies
of
children
have
examined the
relation of K4
and K5 to
intra-arterial
DBP. A 1963
study of 120
chil-dren
concluded
that the intraarterial DBP
of
children
was between5
K4 and K5
but
that
neither
was
strongly
corre-lated
with the true
DBP.
However,
a
more recent
study
of
infants
and
children
(aged
36
months)
found
that
both K4 and
K5
overestimate
d the intraarterial DBP,
with K4 showing a 5 mm
Hg
larger4
mean bias.
A
relatively
low
correlation between
direct
and
indirect DBP
levels
has
also
been
observed
in
37
adults.

Another
consideratio
n is that K5
may
be
absent

th

and 5

th

among
children, and
7.4% of the
examinations
in our study
had at least
1 (of 6) K5
values
recorded as
0 mm Hg.
Although this
prevalence
may
seem
high, in the
20072010
cycles of the
National
Health
and
Nutrition
Examination
Survey
(NHANES;
http://www.c
dc.gov/nchs/
nhanes/
nhanes20092010/BPX_F.h
tm),
approximatel
y
5%
of
youth aged
818
year
had at least
1 (of 3) K5
measuremen
ts recorded
as 0 mm Hg.
Although the
current
recommendation is to
replace
persistent,
very low K5
values with1
K4 values,
the
classification
of very low
values
is
uncertain. As
assessed by
the ability to
predict adult
hypertension
, we found
that
the
inclusion of
very low K5
values
or
their
substitution with
K4
made
little
difference
when
estimating
the
sensitivity
and
specificity of
the mean of
3
measuremen
ts.
Recent
NHANES
data exclude
K5
measuremen
ts of 0 mm
Hg from the
calculation38
of
mean DBP.
Our results
concerning
the
association of
blood
pressure
levels
in
childhood and
adulthood
agree
well
with previous
2,9,17,3
reports.
9
A
2008

meta-analysis
of
50
2
studies,
for
exam-ple,
found
that
the childhood
level of K4
tended to be
more strongly
associated
with
adult
DBP
levels
than
childhood levels of K5, but
the difference
between
correlation
coefficients
( = 0.035)
was
not
statistically
significant. A
limitation,
how-ever, of
this type of
analysis
is
that
those
adults taking
antihypertensive
medications
are typically
excluded,
resulting in a
nonrepresent
ative sample.
Furthermore,
only 2 of the
50
studies
included
in
this analysis
measured
both K4 and
K5
with
a
follow-up that
occurred after
age 18 years.
In our study,
58% of the
adults
classified as
having
hypertension
were
using
antihypertens
ive
medications
and did not
have
elevated
blood
pressure
levels at the
examination,
and this type
of analysis is
likely to be
superior
to
excluding
those
using
antihypertens
ive
medications.
However,
because only
2,156
(of
11,525) children were in
the
longitudinal
analyses and
no
other
cohort study
has
compared the
tracking of K4
and K5 from
child-hood to
adulthood, it
would
be
helpful
to

know
DBP

if

the

differences
that we
observed
also exist in
other
cohorts.

cross-sectional
examinations.
Six
measurement
s
were
obtained in a
relaxed
environment,
resulting
in
blood
pressures that
are generally
lower
than
those in other
studies
of
children,13
many of which
are based on a
sin-gle
measurement.
However,
because
our
focus was the
K4

K5
difference, it is
uncertain how
this
could
have
biased
our results. In
addition, the
observer
training
included
recurring
audiometric
testing,
the
use of tapes
and films, and
interobserver
comparisons
using double
stethoscopes.
There may,
however, have
been meth-

odological
differences
over
the
period of data
collection, and
there
was
evidence
of
digit
preference,
with readings
that ended in
0
being
recorded 23
times
as
frequently as
other values.
It
is
also
possible that
the observer
training, which
emphasized
the change in
pitch at K4,
was unable to
sensitize
observers for
the
disappearance
of sounds.40 It
is also known
that
even
small amounts
of pressure on

the
stethoscope
head can lead
to
artificially
low K5 measurements.
Although it is also
possible that our
longi-

tudinal
analyses
were subject
to
a
participation
bias,
this
seems
unlikely
because
participation
would have
to be related
to the K4
K5
difference.

Recommen
dations
concerning
the use of K4
or K5 as the
DBP
of
children and
adolescents
have changed
consider-ably
over
time.
Although the
assessment
of K4 and K5
can
be
strongly
infuenced by
examiner
training, our
data sug-gest
that
K4
should
be
used as the
indicator
of
DBP
among
children and
adolescents
because
it
shows
less
interobserver
variability
and is more
predictive of
adult
hypertension.

ACKNOWLED
GMENT

This work
was
supported by
grant
AG16592 from
the National
Institutes of
Aging.
DiSCLOSURE

The
authors

declared
no confict
of interest.

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7. T
a
s
k
F
o
r
c
e
o
n
B
l
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d
P
r
e
s
s
u
r
e
C
o
n
t
r
o
l
i
n
C
h
i
l
d
r
e
n
.
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p
o
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t
o
f
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o
n
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T
a
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o
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o
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B
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o
o
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s
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o
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o

l
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n
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1
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8
7
.
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e
d
i
a
t
r
i
c
s

1
9
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;
7
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:
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.
8. N
a
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i
o
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l
H
i
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B
l
o
o
d
P
r
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s
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o
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s
i
o
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o
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o
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C
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i
l
d
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e
n
a
n
d
A
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o
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e
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c
e
n
t
s
.
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p
d
a
t
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o
n
t
h
e
1
9
8
7
T
a
s
k
F
o
r
c
e
r
e
p
o
r
t
o
n
h
i
g
h
b
l
o
o
d
p
r
e
s
s
u
r
e
i
n
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24.

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36.
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cs
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.
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40.

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(
B
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)
1
9

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;
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:
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4
9
9
.

1502 American Journal of Hypertension 27(12)

December 2014