Pharmacological treatment of hypertension guided by peripheral or central blood pressure: a comparison between the two strategies

BackgroundArterial hypertension treatment guided by central blood pressures (CPB) rather than peripheral blood pressures (PBP) measurement has the potential to show greater effectiveness in preventing or even regressing stiffness and target organ damage (TOD).ObjectiveThis study aimed to compare the parameters of CBP and PBP measurements, arterial stiffness, TOD and renal profile in patients with anti-hypertensive treatment guided by CBP or PBP targets.MethodsA randomized clinical trial was conducted in central group (CG) and peripheral group (PG). Patients were randomized, evaluated every 3 months for BP and antihypertensive adjustments during a one-year follow up. The procedures in V1 and V5: anthropometric assessment; CBP/PBP measurements, carotid ultrasound; echocardiography; laboratory tests. Paired and unpaired t-tests and the χ2 were used (significance level: 5%).ResultsThe study evaluated 59 participants (30CG/29PG). The augmentation index (AIx) was higher in the CG (27.3% vs. 20.3%, p = 0.041). Intergroup analysis has found central diastolic BP lower in the CG (78.9 vs. 84.3 mmHg, p = 0.024) and the Alx difference between groups ceased to exist after a one-year follow-up. Intragroup comparisons, after intervention, showed a lower frequency of changed PWV (p < 0.001) and LVMI (p = 0.018) in the CG. The PG showed a higher frequency of changed PWV (p < 0.001) and LVMI (p = 0.003).ConclusionThe intervention guided by central BP reduced the central diastolic BP and AIx compared to the PG. There was a reduction in the frequency of changed PWV and LVMI in the CG

Diretrizes Brasileiras de Medidas da Pressão Arterial Dentro e Fora do Consultório – 2023

Hypertension is one of the primary modifiable risk factors for morbidity and mortality worldwide, being a major risk factor for coronary artery disease, stroke, and kidney failure. Furthermore, it is highly prevalent, affecting more than one-third of the global population. Blood pressure measurement is a MANDATORY procedure in any medical care setting and is carried out by various healthcare professionals. However, it is still commonly performed without the necessary technical care. Since the diagnosis relies on blood pressure measurement, it is clear how important it is to handle the techniques, methods, and equipment used in its execution with care. It should be emphasized that once the diagnosis is made, all short-term, medium-term, and long-term investigations and treatments are based on the results of blood pressure measurement. Therefore, improper techniques and/or equipment can lead to incorrect diagnoses, either underestimating or overestimating values, resulting in inappropriate actions and significant health and economic losses for individuals and nations. Once the correct diagnosis is made, as knowledge of the importance of proper treatment advances, with the adoption of more detailed normal values and careful treatment objectives towards achieving stricter blood pressure goals, the importance of precision in blood pressure measurement is also reinforced. Blood pressure measurement (described below) is usually performed using the traditional method, the so-called casual or office measurement. Over time, alternatives have been added to it, through the use of semi-automatic or automatic devices by the patients themselves, in waiting rooms or outside the office, in their own homes, or in public spaces. A step further was taken with the use of semi-automatic devices equipped with memory that allow sequential measurements outside the office (ABPM; or HBPM) and other automatic devices that allow programmed measurements over longer periods (HBPM). Some aspects of blood pressure measurement can interfere with obtaining reliable results and, consequently, cause harm in decision-making. These include the importance of using average values, the variation in blood pressure during the day, and short-term variability. These aspects have encouraged the performance of a greater number of measurements in various situations, and different guidelines have advocated the use of equipment that promotes these actions. Devices that perform HBPM or ABPM, which, in addition to allowing greater precision, when used together, detect white coat hypertension (WCH), masked hypertension (MH), sleep blood pressure alterations, and resistant hypertension (RHT) (defined in Chapter 2 of this guideline), are gaining more and more importance. Taking these details into account, we must emphasize that information related to diagnosis, classification, and goal setting is still based on office blood pressure measurement, and for this reason, all attention must be given to the proper execution of this procedure.La hipertensión arterial (HTA) es uno de los principales factores de riesgo modificables para la morbilidad y mortalidad en todo el mundo, siendo uno de los mayores factores de riesgo para la enfermedad de las arterias coronarias, el accidente cerebrovascular (ACV) y la insuficiencia renal. Además, es altamente prevalente y afecta a más de un tercio de la población mundial. La medición de la presión arterial (PA) es un procedimiento OBLIGATORIO en cualquier atención médica o realizado por diferentes profesionales de la salud. Sin embargo, todavía se realiza comúnmente sin los cuidados técnicos necesarios. Dado que el diagnóstico se basa en la medición de la PA, es claro el cuidado que debe haber con las técnicas, los métodos y los equipos utilizados en su realización. Debemos enfatizar que una vez realizado el diagnóstico, todas las investigaciones y tratamientos a corto, mediano y largo plazo se basan en los resultados de la medición de la PA. Por lo tanto, las técnicas y/o equipos inadecuados pueden llevar a diagnósticos incorrectos, subestimando o sobreestimando valores y resultando en conductas inadecuadas y pérdidas significativas para la salud y la economía de las personas y las naciones. Una vez realizado el diagnóstico correcto, a medida que avanza el conocimiento sobre la importancia del tratamiento adecuado, con la adopción de valores de normalidad más detallados y objetivos de tratamiento más cuidadosos hacia metas de PA más estrictas, también se refuerza la importancia de la precisión en la medición de la PA. La medición de la PA (descrita a continuación) generalmente se realiza mediante el método tradicional, la llamada medición casual o de consultorio. Con el tiempo, se han agregado alternativas a través del uso de dispositivos semiautomáticos o automáticos por parte del propio paciente, en salas de espera o fuera del consultorio, en su propia residencia o en espacios públicos. Se dio un paso más con el uso de dispositivos semiautomáticos equipados con memoria que permiten mediciones secuenciales fuera del consultorio (AMPA; o MRPA) y otros automáticos que permiten mediciones programadas durante períodos más largos (MAPA). Algunos aspectos en la medición de la PA pueden interferir en la obtención de resultados confiables y, en consecuencia, causar daños en las decisiones a tomar. Estos incluyen la importancia de usar valores promedio, la variación de la PA durante el día y la variabilidad a corto plazo. Estos aspectos han alentado la realización de un mayor número de mediciones en diversas situaciones, y diferentes pautas han abogado por el uso de equipos que promuevan estas acciones. Los dispositivos que realizan MRPA o MAPA, que además de permitir una mayor precisión, cuando se usan juntos, detectan la hipertensión de bata blanca (HBB), la hipertensión enmascarada (HM), las alteraciones de la PA durante el sueño y la hipertensión resistente (HR) (definida en el Capítulo 2 de esta guía), están ganando cada vez más importancia. Teniendo en cuenta estos detalles, debemos enfatizar que la información relacionada con el diagnóstico, la clasificación y el establecimiento de objetivos todavía se basa en la medición de la presión arterial en el consultorio, y por esta razón, se debe prestar toda la atención a la ejecución adecuada de este procedimiento.A hipertensão arterial (HA) é um dos principais fatores de risco modificáveis para morbidade e mortalidade em todo o mundo, sendo um dos maiores fatores de risco para doença arterial coronária, acidente vascular cerebral (AVC) e insuficiência renal. Além disso, é altamente prevalente e atinge mais de um terço da população mundial. A medida da PA é procedimento OBRIGATÓRIO em qualquer atendimento médico ou realizado por diferentes profissionais de saúde. Contudo, ainda é comumente realizada sem os cuidados técnicos necessários. Como o diagnóstico se baseia na medida da PA, fica claro o cuidado que deve haver com as técnicas, os métodos e os equipamentos utilizados na sua realização. Deve-se reforçar que, feito o diagnóstico, toda a investigação e os tratamentos de curto, médio e longo prazos são feitos com base nos resultados da medida da PA. Assim, técnicas e/ou equipamentos inadequados podem levar a diagnósticos incorretos, tanto subestimando quanto superestimando valores e levando a condutas inadequadas e grandes prejuízos à saúde e à economia das pessoas e das nações. Uma vez feito o diagnóstico correto, na medida em que avança o conhecimento da importância do tratamento adequado, com a adoção de valores de normalidade mais detalhados e com objetivos de tratamento mais cuidadosos no sentido do alcance de metas de PA mais rigorosas, fica também reforçada a importância da precisão na medida da PA. A medida da PA (descrita a seguir) é habitualmente feita pelo método tradicional, a assim chamada medida casual ou de consultório. Ao longo do tempo, foram agregadas alternativas a ela, mediante o uso de equipamentos semiautomáticos ou automáticos pelo próprio paciente, nas salas de espera ou fora do consultório, em sua própria residência ou em espaços públicos. Um passo adiante foi dado com o uso de equipamentos semiautomáticos providos de memória que permitem medidas sequenciais fora do consultório (AMPA; ou MRPA) e outros automáticos que permitem medidas programadas por períodos mais prolongados (MAPA). Alguns aspectos na medida da PA podem interferir na obtenção de resultados fidedignos e, consequentemente, causar prejuízo nas condutas a serem tomadas. Entre eles, estão: a importância de serem utilizados valores médios, a variação da PA durante o dia e a variabilidade a curto prazo. Esses aspectos têm estimulado a realização de maior número de medidas em diversas situações, e as diferentes diretrizes têm preconizado o uso de equipamentos que favoreçam essas ações. Ganham cada vez mais espaço os equipamentos que realizam MRPA ou MAPA, que, além de permitirem maior precisão, se empregados em conjunto, detectam a HA do avental branco (HAB), HA mascarada (HM), alterações da PA no sono e HA resistente (HAR) (definidos no Capítulo 2 desta diretriz). Resguardados esses detalhes, devemos ressaltar que as informações relacionadas a diagnóstico, classificação e estabelecimento de metas ainda são baseadas na medida da PA de consultório e, por esse motivo, toda a atenção deve ser dada à realização desse procedimento

Multidisciplinary treatment of patients with diabetes and hypertension: experience of a Brazilian center

Abstract Background Although multidisciplinary treatment is recommended for type 2 diabetes mellitus and hypertension (HTN), there is a lack of scientific literature supporting the hypothesis of extending this treatment strategy to patients with both diabetes and HTN. Aiming to report results of long-term multidisciplinary treatment for these patients and identify strategies to improve their management, we conducted this study. Methods Data of patients with diabetes and HTN with regular follow-up visits in a multidisciplinary HTN treatment center from Brazil’s Midwest were retrospectively assessed. Patients ≥ 18 years enrolled in the service by June 2017 with a minimum of three visits were included. Anthropometric, blood pressure (BP), laboratory, pharmacological treatment, lifestyle, and cardiovascular events data were collected from first (V1), intermediate (V2) and most recent (V3) visits to the service. BP < 130 × 80 mmHg, LDL-cholesterol (LDL-C) < 70 mg/dL and HbA1C < 7.0% were defined as treatment targets. Wilcoxon signed-rank test was used to compare variables along study visits. A linear regression model was built to identify variables associated with better overall patient control. Results A total of 162 patients were included (mean age of 56.5 ± 10.8 years). Median follow-up time was 60 (IQR 40–109) months, 80.2% of the sample was female and 83.3% had no cardiovascular event history. BP, total cholesterol, LDL-C, triglycerides and HbA1C values showed a significant trend to improve along the study visits (p < 0.001). Growing trend in aspirin (p = 0.045) and statins (p < 0.001) use was found, in addition to treatment compliance increase (p < 0.001). Significant improvement trends in BP (p < 0.001), LDL-C (p = 0.004) and HbA1C (p = 0.002) control were also found across visits. Control rates of BP, LDL-C and HbA1C in combination were low in V1, V2 and V3 (1.2, 1.9 and 6.8%, respectively), but showed significant improvement trend (p < 0.001). Treatment compliance (β-coefficient = 1.20; 95% CI 1.07–1.34; p < 0.001) was positively associated with better overall patients control. Conclusions Multidisciplinary treatment of patients with diabetes and HTN significantly improved clinical and laboratory parameters, despite ageing of population evaluated. Although combined control of HbA1C, BP and LDL-cholesterol increased along follow-up, management of all these three conditions needs to improve, and focus on treatment compliance should be given to attain this goal

Self-rated health status and illiteracy as death predictors in a Brazilian cohort - Fig 3

<p>Kaplan-Meier survival curves comparing all causes of death (A), CVD death (B) and Non-CVD death (C) between illiterate and non-illiterate individuals.</p

Self-rated health status and illiteracy as death predictors in a Brazilian cohort

<div><p>Cohort studies assessing predictive values of self-rated health (SRH) and illiteracy on mortality in low-to-middle income countries are missing in the literature. Aiming to determine if these two variables were death predictors, an observational prospective population-based cohort study was conducted in a Brazilian small city. The cohort was established in 2002 with a representative sample of adults living in the city, and re-assessed in 2015. Sociodemographic (including illiteracy), anthropometric, lifestyle, previous CVD, and SRH data were collected. Cox proportional hazard models were designed to assess SRH and illiteracy in 2002 as death (all causes, CVD and non-CVD) predictors in 2015. From a total of 1066 individuals included in this study, 95(9%) died of non-CVD causes and 53(5%) from CVD causes. Mortality rates were higher among those with worse SRH in comparison to better health status categories for all causes of death, CVD and non-CVD deaths (p<0.001 for all outcomes). Similarly, illiterate individuals had higher mortality rates in comparison to non-illiterate for all causes of death (p<0.001), CVD (p = 0.004) and non-CVD death (p<0.001). Higher SRH negatively predicted CVD death (HR 0.44; 95%CI 0.44–0.95; p = 0.027) and all causes of death (OR 0.40; 95%CI 0.20–0.78; p = 0.008) while illiteracy positively predicted Non-CVD death (OR 1.59; 95%CI 1.03–2.54; p = 0.046). In conclusion, we found in this large Brazilian cohort followed for 13 years that better health perception was a negative predictor of death from all causes and CVD deaths, while illiteracy was a positive predictor of non-CVD deaths.</p></div

Baseline cohort characteristics according to vital status in 2015 (n = 1066).

<p>Baseline cohort characteristics according to vital status in 2015 (n = 1066).</p

Baseline cohort characteristics according to cause of death in 2015 (n = 148).

<p>Baseline cohort characteristics according to cause of death in 2015 (n = 148).</p

Baseline cohort self-rated health status distribution (n = 1,066).

<p>Baseline cohort self-rated health status distribution (n = 1,066).</p

Self-rated health status and illiteracy as death predictors in a Brazilian cohort - Fig 2

<p>Kaplan-Meier survival curves comparing all causes of death (A), CVD death (B) and Non-CVD death (C) between sub-groups of self-rated health status (poor/fair, good and very good/excellent).</p

Simple and adjusted cox proportional hazard models assessing self-rated health status and illiteracy as predictors of death from all causes, non-CVD deaths and CVD deaths.

<p>Simple and adjusted cox proportional hazard models assessing self-rated health status and illiteracy as predictors of death from all causes, non-CVD deaths and CVD deaths.</p