Aggressive blood pressure reduction in patients at high vascular risk: is it dangerous?

Summary Introduction The aim of this review was to summarize the current state of evidence regarding the optimal blood pressure goals in patients with high vascular risk. In particular, this review critically addresses the issue of the "J-curve" paradox – a hypothesis indicating that low treatment-induced blood pressure values are characterized by an increase, rather than a decrease, in the incidence of cardiovascular events. Materials and methods We reviewed evidence from studies published in peer-reviewed journals indexed in Medline, EMBASE and CINAHL that compared different BP goals. Results Post-hoc analyses of randomized trials specifically conducted to test the hypothesis of the "J-shaped curve" yielded conflicting results. However, trials directly comparing different blood pressure goals and meta-analyses showed that in-treatment blood pressure values below the usual goal of less than 140/90 mmHg improve outcomes in patients at increased vascular risk. Discussion The fear that an excessive reduction in blood pressure may be dangerous is inconsistent with the available data and probably conditioned by the adverse impact of other risk factors that may be more frequent in patients with low values of achieved blood pressure. The association between blood pressure reduction and cardiovascular risk seems to be linear and not J-shaped

Aggressive blood pressure reduction in patients at high vascular risk: is it dangerous?

Introduction The aim of this review was to summarize the current state of evidence regarding the optimal blood pressure goals in patients with high vascular risk. In particular, this review critically addresses the issue of the “J-curve” paradox – a hypothesis indicating that low treatment-induced blood pressure values are characterized by an increase, rather than a decrease, in the incidence of cardiovascular events. Materials and methods We reviewed evidence from studies published in peer-reviewed journals indexed in Medline, EMBASE and CINAHL that compared different BP goals. Results Post-hoc analyses of randomized trials specifically conducted to test the hypothesis of the “J-shaped curve” yielded conflicting results. However, trials directly comparing different blood pressure goals and meta-analyses showed that in-treatment blood pressure values below the usual goal of less than 140/90 mmHg improve outcomes in patients at increased vascular risk. Discussion The fear that an excessive reduction in blood pressure may be dangerous is inconsistent with the available data and probably conditioned by the adverse impact of other risk factors that may be more frequent in patients with low values of achieved blood pressure. The association between blood pressure reduction and cardiovascular risk seems to be linear and not J-shaped

Tributação no Brasil: características marcantes e diretrizes para a reforma

Bibliografia: p. 49-50Apesar da estabilização decorrente do Plano Real ter proporcionado uma apreciável elevação da receita pública, as enormes carências sociais do país e sua frágil situação fiscal, dentre outros fatores, apontam para a necessidade de manter, pelo menos por alguns anos ainda, o atual nível de tributação. Para tanto, é preciso que se empreenda uma reforma tributária com o objetivo de assegurar uma melhor distribuição da carga entre os contribuintes, bem como a harmonização fiscal requerida pelo atual contexto internacional. Aliam-se a estes fatores as dificuldades impostas pela situação político-institucional do país e pelos distintos interesses que cercam o tema. Assim, tendo em vista tais desafios e o reconhecimento de que a reforma tributária deve ser percebida como componente de um processo maior de ajuste estrutural do Estado, este trabalho esboça algumas diretrizes para o processo de reforma a partir da avaliação da qualidade e da capacidade de geração de receita do nosso sistema tributário.Although the stabilization resulting from the introduction of the Real Plan have provided an appreciable increase in tax revenue, the huge magnitude of the social requirements in Brazil and the fragile fiscal situation - among other factors - point to the need for maintaining, at least for some years to come, the current level of taxation. Thus, fiscal reform is necessary in order to assure improvement in the distribution of the fiscal burden among taxpayers as well as the fiscal reconciliation required by the current international context. Other important factors are the current political and institutional situation in Brazil and the distinct interests that surround this matter. In view of these challenges and the realization that fiscal reform must be viewed as a component of a greater process of structural adjustment of government in Brazil, this paper outlines some guidelines for the reform process, beginning with an evaluation of the quality and capacity of revenue generation of Brazil's fiscal system