Misleading guidelines for the diagnosis and management of hypertension

The new international guidelines for the diagnosis and management of hypertension proposed higher thresholds for the diagnosis of hypertension in patients with higher cardiovascular risk, such as patients with diabetes, chronic kidney disease, and the elderly. The premise for the new recommendations was the results of randomized clinical trials, such as the ACCORD trial. Nonetheless, the results of the ACCORD trial were within the predicted by the meta-analysis of risk and confirmed by metaanalysis of clinical trials, particularly for stroke. The decision to use 140 mmHg as the therapy goal would be to deny diabetic patients the benefit of preventing a large proportion of strokes. In addition, the meta-analysis conducted in the United States did not address prehypertension, ignoring many trials performed with patients presenting prehypertension and cardiovascular disease, showing the benefit of further lowering blood pressure. The guidelines recommended angiotensin receptor blockers as one of the first options for all patients and particularly patients with diabetes and chronic kidney disease. Three recently published meta-analyses and review showed that these agents are practically inert in the prevention of allcause death and cardiovascular events. In conclusion, there is evidence showing that hypertension should be more aggressively prevented and treated, and that angiotensin receptor blockers should not be the first option to start the treatment

Diuretics: again the first step in the treatment of most patients with hypertension

The results and interpretations of the most recent controlled clinical trials on antihypertensive drugs have fuelled the debate about the drug that should be used to begin treatment for hypertension. Every comparison of diuretics with other drugs has shown that the benefits of diuretics are equivalent to, or better than, other options. These findings, together with other practical reasons, such as left ventricular mass reducing effect, easy administration, few side effects and low cost, suggest that diuretics should regain their primacy as the first step in drug management of hypertension

Misleading guidelines for the diagnosis and management of hypertension

International guidelines for the diagnosis and management of hypertension were recently released [1,2]. A historical trend of lowering the blood pressure (BP) thresholds to diagnose hypertension in high risk individuals was unexpectedly reversed. BP targets for the treatment were modified accordingly. Therefore some individuals who were hypertensive before are now normotensive. Other guidelines still recommend the previous diagnostic limits and goals of treatment [3-5], resulting that an individual may be hypertensive in some countries and normotensive in others. The guidelines are more homogeneous in the recommendations for treatment, particularly in regard to the liberal options of drugs to starting the treatment. Unfortunately, in my view, this liberal view includes drugs without unbiased evidences of effectiveness, such as Angiotensin Receptor Blockers (ARB). In this point of view, I discuss the reasons and misconceptions in the establishment of diagnostic thresholds and the shortcomings in the recommendations of antihypertensive drugs

Insuficiência Cardíaca com Função Sistólica Preservada: uma condição freqüente e pouco entendida

Médicos antigos, mas nem tanto, aprenderam e decoraram que a história natural de cardiopatias que levavam à insuficiência cardíaca passava obrigatoriamente por deterioração da função sistólica. Nesta história, o agravo miocárdico levava à hipertrofia, perda da capacidade ejetiva, dilatação (a clássica lei de Frank-Starling), aumento das pressões a montante, edema pulmonar, dispnéia e, como freqüente nas enfermarias da Santa Casa naqueles anos, a insuficiência cardíaca congestiva, com anasarca. Com o advento do ecocardiograma, verificouse que em muitos pacientes faltava um elo nesta clássica seqüência, o déficit na função ejetiva, capturada no ecocardiograma pela fração de ejeção. Os céticos, como eu, demoraram a acreditar nesta nova entidade, a despeito de já vermos, àquela época, pacientes idosos em franca insuficiência cardíaca com coração pequeno. Fui plenamente convencido, há alguns bons anos, por atendimento de paciente em franco edema agudo refratário, em que o ecocardiograma identificava, na hora, fração de ejeção superior a 70%, com função segmentar preservada. Não estive sozinho em meu ceticismo, pois até recentemente se questionava se presumíveis casos de insuficiência cardíaca com função sistólica preservada não decorriam de erro diagnóstico

Efeitos da variação na ingestão de cloreto de sódio sobre a pressão arterial e outros parâmetros fisiológicos, em indivíduos normais, com e sem risco genético de desenvolvimento de hipertensão arterial sistêmica essencial

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O papel das prostaglandinas renais na hipertensão arterial sistêmica induzida por sal

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Misleading guidelines for the diagnosis and management of hypertension

International guidelines for the diagnosis and management of hypertension were recently released [1,2]. A historical trend of lowering the blood pressure (BP) thresholds to diagnose hypertension in high risk individuals was unexpectedly reversed. BP targets for the treatment were modified accordingly. Therefore some individuals who were hypertensive before are now normotensive. Other guidelines still recommend the previous diagnostic limits and goals of treatment [3-5], resulting that an individual may be hypertensive in some countries and normotensive in others. The guidelines are more homogeneous in the recommendations for treatment, particularly in regard to the liberal options of drugs to starting the treatment. Unfortunately, in my view, this liberal view includes drugs without unbiased evidences of effectiveness, such as Angiotensin Receptor Blockers (ARB). In this point of view, I discuss the reasons and misconceptions in the establishment of diagnostic thresholds and the shortcomings in the recommendations of antihypertensive drugs

Angiotensin receptor blockers for prevention of cardiovascular disease : where does the evidence stand?

Angiotensin receptor blockers (ARBs) are the most commonly used among blood pressure-lowering drugs worldwide, despite the absence of sound evidence of effectiveness in large and unbiased clinical trials. Metaanalyses published in recent years and reviewed here have not given support to this preference, suggesting that ARBs may be ineffective in the prevention of all cause mortality and major cardiovascular events (particularly myocardial infarction). There is evidence that ARB can be harmful for the kidney, particularly in patients with diabetes and in the elderly. It may be time to call for a moratorium on the preference for ARB in the management of hypertension and in patients with high cardiovascular risk