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

Efeitos da ventilação espontânea e ventilação mandatória intermitente sincronizada em cães anestesiados com infusão contínua de propofol

Objetivou-se avaliar os efeitos da ventilação mandatória intermitente sincronizada (SIMV) e da ventilação espontânea associadas à ventilação com pressão de suporte, sobre as variáveis hemodinâmicas, hemogasométricas e ventilatórias em cães anestesiados com propofol. Para tal, foram utilizados 10 cães adultos, machos ou fêmeas, sadios, os quais foram distribuídos em dois grupos de igual número, sendo denominados GE (submetidos à ventilação espontânea associada a PSV) e GM (SIMV associada a PSV) . Os cães foram induzidos à anestesia geral pela administração intravenosa de propofol na dose média de 9,2 ± 6,6 mg/kg, e mantidos com infusão contínua na dose de 0,6 mg/kg/min do mesmo fármaco. Os parâmetros foram mensurados 30 minutos após a indução (M0) e a cada 15 minutos (M15 até M60), por um período de 60 minutos. O método estatístico utilizado foi à Análise de Perfil, com p<0,05. A SIMV resultou em aumentos da PaO2, PAO2, Vt, Vm, Tinsp, MAP, PIP, WoBvt, Vdalv, Vdaw, IRVP,IRPT e em redução da FC, DC, PAM, PAPm, PaCO2, Qs/Qt e AaDO2. Concluiu-se que ambas as modalidades ventilatórias foram eficientes quanto à oxigenação arterial sendo igualmente eficazes na manutenção da estabilidade respiratória e cardiovascular e que a SIMV promoveu melhores trocas gasosas, nas condições experimentais propostas.The hemodynamic, ventilatory and blood gases parameters were evaluated in adult dogs undergoing either spontaneous breathing or synchronized intermittent mandatory ventilation (SIMV) associated with ventilation pressure support. Ten healthy adult dogs (male and female) were used. Anesthesia was induced with propofol (9.2 ± 6.6 mg/kg), and maintained with propofol 0.6 mg/kg/min. Two groups were constituted with different ventilatory methods, namely: GE - spontaneous breathing and GM - synchronized intermittent mandatory ventilation. The initial measurement was record thirty minutes after induction (M0). Additional recordings were performed at 15 minute intervals for 60 minutes (M15-M60). Data were assessed by Profile Analysis; p<0.05 was adopted as significant. The SIMV resulted in an increase of PaO2, PAO2, Vt, Vm, Tinsp, MAP, PIP, WoBvt, Vdalv, Vdaw, IRVP, IRPT and decrease FC, DC, PAM, PAPm, PaCO2, Qs/Qt, AaDO2. It was concluded that both ventilatory methods were had been efficient how much to the arterial oxygenation and were shown to be reliable in maintaining respiratory and cardiovascular stability and that the SIMV promoted better exchanges gaseous, under the proposed experimental conditions.Fundação de Amparo à Pesquisa do Estado de São Paulo (FAPESP

Diferentes frações inspiradas de oxigênio em coelhos hipovolêmicos anestesiados com propofol e submetidos à ventilação mecânica

Avaliaram-se os efeitos do fornecimento de diferentes frações inspiradas de oxigênio (FiO²) em coelhos hipovolêmicos, anestesiados com infusão contínua de propofol e mantidos em ventilação controlada sobre os parâmetros respiratórios, hemogasométricos e hemodinâmicos. Foram utilizados 50 coelhos (Nova Zelândia), pesando 3,5±0,3kg, distribuídos em 5 grupos: G100 (FiO²=1), G80 (FiO²=0,8), G60 (FiO²=0,6), G40 (FiO²=0,4) e G21 (FiO²=0,21), os quais receberam xilazina (1mg kg-1) e cetamina (15mg kg-1) pela via intramuscular. Transcorridos 20 minutos, foi administrado propofol (8mg kg-1 bolus e 0,5mg kg-1 min-1) e rocurônio (0,6mg kg-1 bolus e 0,6mg kg-1 h-1). Iniciou-se então, a ventilação mecânica no modo pressão controlada. Após 30 minutos, os animais foram submetidos à hipovolemia aguda, retirando-se sangue arterial (12mL kg-1). Os parâmetros foram mensurados 30 minutos após a indução anestésica (M0) e a cada dez minutos depois da exsanguinação (M1- M7). As variáveis foram submetidas à análise de variância seguida pelo teste de Tukey (P<0,05). Os valores de PaO², SaO², P A O², AaDO² diminuíram quanto mais baixas foram as FiO². Após a indução da hipovolemia, as variáveis DC, PAM, PaO², SaO², Vt, AaDO² diminuíram significativamente. Nenhuma alteração foi notada nos parâmetros FC e PaCO². As FiO² de 0,8 e 1,0 mostraram-se as mais indicadas por manter melhor estabilidade ventilatória e adequada troca gasosa.The effects of several inspired oxygen fractions (FiO²) on the blood gases, respiratory and hemodynamic parameters in mechanical ventilation hypovolemic rabbits anesthetized with continuous infusion of propofol were evaluated. A total of 50 rabbits (New Zealand), weighing 3.5±0.3kg, were divided into five groups: G100 (FiO²=1), G80 (FiO²=0.8), G60 (FiO²=0.6), G40 (FiO²=0.4) and G21 (FiO²=0.21), which received xylazine (1mg kg-1) and ketamine (15mg kg-1) intramuscularly. Exactly after 20 minutes, it was administered propofol (8mg kg-1 bolus and 0.5mg kg-1 min-1) and rocuronium (0.6mg kg-1 bolus and 0.6mg kg-1 h-1. Then, the mechanical ventilation by controlled pressure mode began. After 30 minutes, the animals underwent acute hypovolemia, withdrawing arterial blood (12mL kg-1). The parameters were measured 30 minutes after anesthetic induction (M0) and every ten minutes after exsanguination (M1-M7). The variables were subjected to analysis of variance followed by Tukey test (P<0.05). The values of PaO², SaO², PAO², AaDO² decreased as lower were the FiO². After the induction of hypovolemia, the variables CO, MAP, PaO², SaO², Vt, AaDO² decreased significantly. No change was noted in the parameters HR and PaCO². The FiO² of 0.8 and 1.0 proved to be the most suitable for maintaining stability, better ventilation and adequate gas exchange.Fundação de Amparo à Pesquisa do Estado de São Paulo (FAPESP

Factors associated with uncontrolled blood pressure in hypertensive Brazilians

Abstract Uncontrolled hypertension has a high prevalence and is related to numerous negative health outcomes. This study aimed to investigate the factors associated with the lack of blood pressure control in hypertensive Brazilians treated in public and private services. This is an analytical, multicentric, and national cross‐sectional study, carried out with adult hypertensive patients, monitored in 45 outpatient clinics (September 2013 to October 2015) in a prospective record interview, clinical, and anthropometric assessment. Outcome variables included uncontrolled pressure (systolic blood pressure ≥ 140 mmHg and/or diastolic blood pressure ≥ 90 mmHg). Simple and multiple logistic regression analyses were performed. Two thousand six hundred forty‐three participants were assessed with a mean age of 61.6 ± 11.9 years, 55.7% of women, and 46.4% with uncontrolled blood pressure (BP). The following were associated with uncontrolled BP: age over 60 years (OR: 1.31 [1.11–1.55]); practice of irregular physical activity (OR: 1.28 [1.06–1.55]); attending the emergency room for hypertensive crises in the last six months (OR: 1.80 [1.46–2.22]); increased body mass index (OR: 1.02 [1.01–1.04]); low adherence to drug treatment (OR: 1.22 [1.04–1.44]) and menopause (OR: 1.36 [1.07–1.72]). The following were negatively associated: fruit consumption (OR: 0.90 [0.85–0.94]); presence of dyslipidemia (OR: 0.75 [0.64–0.89]), acute myocardial infarction (OR: 0.59 [0.46–0.76]), and peripheral arterial disease (OR: 0.52 [0.34‐0.78]). Factors associated with difficult‐to‐control blood pressure are the same that increase the risk for hypertension, while the presence of atherosclerotic disease and its outcomes were associated with better control

Implementation of a Brazilian Cardioprotective Nutritional (BALANCE) Program for improvement on quality of diet and secondary prevention of cardiovascular events: A randomized, multicenter trial

Background: Appropriate dietary recommendations represent a key part of secondary prevention in cardiovascular disease (CVD). We evaluated the effectiveness of the implementation of a nutritional program on quality of diet, cardiovascular events, and death in patients with established CVD. Methods: In this open-label, multicenter trial conducted in 35 sites in Brazil, we randomly assigned (1:1) patients aged 45 years or older to receive either the BALANCE Program (experimental group) or conventional nutrition advice (control group). The BALANCE Program included a unique nutritional education strategy to implement recommendations from guidelines, adapted to the use of affordable and regional foods. Adherence to diet was evaluated by the modified Alternative Healthy Eating Index. The primary end point was a composite of all-cause mortality, cardiovascular death, cardiac arrest, myocardial infarction, stroke, myocardial revascularization, amputation, or hospitalization for unstable angina. Secondary end points included biochemical and anthropometric data, and blood pressure levels. Results: From March 5, 2013, to Abril 7, 2015, a total of 2534 eligible patients were randomly assigned to either the BALANCE Program group (n = 1,266) or the control group (n = 1,268) and were followed up for a median of 3.5 years. In total, 235 (9.3%) participants had been lost to follow-up. After 3 years of follow-up, mean modified Alternative Healthy Eating Index (scale 0-70) was only slightly higher in the BALANCE group versus the control group (26.2 ± 8.4 vs 24.7 ± 8.6, P <.01), mainly due to a 0.5-serving/d greater intake of fruits and of vegetables in the BALANCE group. Primary end point events occurred in 236 participants (18.8%) in the BALANCE group and in 207 participants (16.4%) in the control group (hazard ratio, 1.15; 95% CI 0.95-1.38; P =.15). Secondary end points did not differ between groups after follow-up. Conclusions: The BALANCE Program only slightly improved adherence to a healthy diet in patients with established CVD and had no significant effect on the incidence of cardiovascular events or death. © 2019 The Author

Extraprensa. Cultura e comunicação na América Latina (Edição Especial sep 2019)

A revista Extraprensa é um periódico destinado à publicação da produção científica nas áreas da cultura e da comunicação no Brasil e América Latina, abrangendo temas como a diversidade cultural, cidadania, expressões das culturas populares, artes, mídias alternativas, epistemologia e metodologia em cultura e comunicação

Neotropical freshwater fisheries : A dataset of occurrence and abundance of freshwater fishes in the Neotropics

The Neotropical region hosts 4225 freshwater fish species, ranking first among the world's most diverse regions for freshwater fishes. Our NEOTROPICAL FRESHWATER FISHES data set is the first to produce a large-scale Neotropical freshwater fish inventory, covering the entire Neotropical region from Mexico and the Caribbean in the north to the southern limits in Argentina, Paraguay, Chile, and Uruguay. We compiled 185,787 distribution records, with unique georeferenced coordinates, for the 4225 species, represented by occurrence and abundance data. The number of species for the most numerous orders are as follows: Characiformes (1289), Siluriformes (1384), Cichliformes (354), Cyprinodontiformes (245), and Gymnotiformes (135). The most recorded species was the characid Astyanax fasciatus (4696 records). We registered 116,802 distribution records for native species, compared to 1802 distribution records for nonnative species. The main aim of the NEOTROPICAL FRESHWATER FISHES data set was to make these occurrence and abundance data accessible for international researchers to develop ecological and macroecological studies, from local to regional scales, with focal fish species, families, or orders. We anticipate that the NEOTROPICAL FRESHWATER FISHES data set will be valuable for studies on a wide range of ecological processes, such as trophic cascades, fishery pressure, the effects of habitat loss and fragmentation, and the impacts of species invasion and climate change. There are no copyright restrictions on the data, and please cite this data paper when using the data in publications

NEOTROPICAL CARNIVORES: a data set on carnivore distribution in the Neotropics

Mammalian carnivores are considered a key group in maintaining ecological health and can indicate potential ecological integrity in landscapes where they occur. Carnivores also hold high conservation value and their habitat requirements can guide management and conservation plans. The order Carnivora has 84 species from 8 families in the Neotropical region: Canidae; Felidae; Mephitidae; Mustelidae; Otariidae; Phocidae; Procyonidae; and Ursidae. Herein, we include published and unpublished data on native terrestrial Neotropical carnivores (Canidae; Felidae; Mephitidae; Mustelidae; Procyonidae; and Ursidae). NEOTROPICAL CARNIVORES is a publicly available data set that includes 99,605 data entries from 35,511 unique georeferenced coordinates. Detection/non-detection and quantitative data were obtained from 1818 to 2018 by researchers, governmental agencies, non-governmental organizations, and private consultants. Data were collected using several methods including camera trapping, museum collections, roadkill, line transect, and opportunistic records. Literature (peer-reviewed and grey literature) from Portuguese, Spanish and English were incorporated in this compilation. Most of the data set consists of detection data entries (n = 79,343; 79.7%) but also includes non-detection data (n = 20,262; 20.3%). Of those, 43.3% also include count data (n = 43,151). The information available in NEOTROPICAL CARNIVORES will contribute to macroecological, ecological, and conservation questions in multiple spatio-temporal perspectives. As carnivores play key roles in trophic interactions, a better understanding of their distribution and habitat requirements are essential to establish conservation management plans and safeguard the future ecological health of Neotropical ecosystems. Our data paper, combined with other large-scale data sets, has great potential to clarify species distribution and related ecological processes within the Neotropics. There are no copyright restrictions and no restriction for using data from this data paper, as long as the data paper is cited as the source of the information used. We also request that users inform us of how they intend to use the data

Geoeconomic variations in epidemiology, ventilation management, and outcomes in invasively ventilated intensive care unit patients without acute respiratory distress syndrome: a pooled analysis of four observational studies

Background: Geoeconomic variations in epidemiology, the practice of ventilation, and outcome in invasively ventilated intensive care unit (ICU) patients without acute respiratory distress syndrome (ARDS) remain unexplored. In this analysis we aim to address these gaps using individual patient data of four large observational studies. Methods: In this pooled analysis we harmonised individual patient data from the ERICC, LUNG SAFE, PRoVENT, and PRoVENT-iMiC prospective observational studies, which were conducted from June, 2011, to December, 2018, in 534 ICUs in 54 countries. We used the 2016 World Bank classification to define two geoeconomic regions: middle-income countries (MICs) and high-income countries (HICs). ARDS was defined according to the Berlin criteria. Descriptive statistics were used to compare patients in MICs versus HICs. The primary outcome was the use of low tidal volume ventilation (LTVV) for the first 3 days of mechanical ventilation. Secondary outcomes were key ventilation parameters (tidal volume size, positive end-expiratory pressure, fraction of inspired oxygen, peak pressure, plateau pressure, driving pressure, and respiratory rate), patient characteristics, the risk for and actual development of acute respiratory distress syndrome after the first day of ventilation, duration of ventilation, ICU length of stay, and ICU mortality. Findings: Of the 7608 patients included in the original studies, this analysis included 3852 patients without ARDS, of whom 2345 were from MICs and 1507 were from HICs. Patients in MICs were younger, shorter and with a slightly lower body-mass index, more often had diabetes and active cancer, but less often chronic obstructive pulmonary disease and heart failure than patients from HICs. Sequential organ failure assessment scores were similar in MICs and HICs. Use of LTVV in MICs and HICs was comparable (42·4% vs 44·2%; absolute difference -1·69 [-9·58 to 6·11] p=0·67; data available in 3174 [82%] of 3852 patients). The median applied positive end expiratory pressure was lower in MICs than in HICs (5 [IQR 5-8] vs 6 [5-8] cm H2O; p=0·0011). ICU mortality was higher in MICs than in HICs (30·5% vs 19·9%; p=0·0004; adjusted effect 16·41% [95% CI 9·52-23·52]; p&lt;0·0001) and was inversely associated with gross domestic product (adjusted odds ratio for a US$10 000 increase per capita 0·80 [95% CI 0·75-0·86]; p&lt;0·0001). Interpretation: Despite similar disease severity and ventilation management, ICU mortality in patients without ARDS is higher in MICs than in HICs, with a strong association with country-level economic status