Carlos Alberto Machado

Metabolic syndrome prevalence is increased in rheumatoid arthritis patients and is associated with disease activity

Objectives: To evaluate the prevalence of metabolic syndrome (MetS) in patients with rheumatoid arthritis (RA) vs. controls, and to verify possible associations of MetS with specific disease-related factors. Methods: The subjects were 283 RA patients and 226 healthy controls, frequency matched by age and sex. MetS was defined according to National Cholesterol Education Program (NCEP) criteria. Disease activity was evaluated with the Disease Activity Score using 28 joints (DAS28). A standardized clinical evaluation was performed and cardiovascular risk factors were assessed. Results: The criteria for MetS were met by 39.2% RA patients vs. 19.5% in the control group (p < 0.001). Increased waist circumference, elevated blood pressure (BP), and fasting glucose were more frequent in RA patients than controls (p < 0.001 for all associations). By multiple logistic regression analysis (adjusted for age, sex, and years at school), the risk of having MetS was significantly higher for RA patients than for controls [odds ratio (OR) 1.87, 95% confidence interval (CI) 1.17–3.00, p = 0.009]. The DAS28 was significantly higher in RA patients with MetS than in those without MetS (3.59 ± 1.27 vs. 3.14 ± 1.53; p = 0.01). Disease duration, the presence of rheumatoid factor, and extra-articular manifestations were similar for patients with and without MetS. Conclusions: MetS frequency was higher in RA patients than in controls. Among RA patients, MetS was associated with disease activity. The higher prevalence of cardiovascular risk factors in RA suggests that inflammatory processes play a notable role in the development of cardiovascular disease (CVD), and indicates that tight control of systemic inflammatory activity and CVD modifiable risk factors should be recommended.

Os médicos brasileiros seguem as diretrizes brasileiras de hipertensão

OBJECTIVE To evaluate whether procedures adopted by Brazilian physicians in the diagnosis and treatment of hypertension are in compliance with those advocated by the IV Brazilian Hypertension Guidelines. METHOD Survey carried out by means of telephone interviews with Brazilian physicians. The survey featured application of a questionnaire aimed to assess receipt of and compliance with the guidelines, and to evaluate various aspects regarding the treatment of hypertensive patients. RESULTS 68.3% of the respondents had received the guidelines and answered the questionnaire in full. The total sample consisted of 483 physicians--47% cardiologists, 31.7% internists, and 21.3% nephrologists. The survey showed high compliance with certain guideline topics such as more than one measurement at different times for the diagnosis of hypertension (94%), and providing guidance regarding lifestyle changes as a therapeutic strategy. As to arterial pressure levels used for diagnosis and therapeutic target, compliance with guideline recommendations lacks uniformity. The survey showed a clear preference for pressure levels lower than those recommended, especially in patients with comorbidities. Attempts to assess cardiovascular risk also proved to be low. Only 64.7% of the respondents reported that they seek to determine the presence of diabetes mellitus, and 56.4% check for dyslipidemia. The majority (59.3%) mentioned diuretics as the preferred drug class for initial drug treatment of hypertension. CONCLUSION We concluded that there is only partial compliance with Brazilian Hypertension Guidelines and that certain factors should be taken into consideration when drawing up future guidelines, such as: improved distribution; standardization of values for diagnosis and therapeutic target; more extensive coverage of ways for physicians to approach hypertensive patients to better evaluate their overall cardiovascular risk.

Spironolactone Versus Clonidine as a Fourth-Drug Therapy for Resistant Hypertension: The ReHOT Randomized Study (Resistant Hypertension Optimal Treatment)

The aim of this study is to compare spironolactone versus clonidine as the fourth drug in patients with resistant hypertension in a multicenter, randomized trial. Medical therapy adherence was checked by pill counting. Patients with resistant hypertension (no office and ambulatory blood pressure [BP] monitoring control, despite treatment with 3 drugs, including a diuretic, for 12 weeks) were randomized to an additional 12-week treatment with spironolactone (12.5–50 mg QD) or clonidine (0.1–0.3 mg BID). The primary end point was BP control during office (<140/90 mm Hg) and 24-h ambulatory (<130/80 mm Hg) BP monitoring. Secondary end points included BP control from each method and absolute BP reduction. From 1597 patients recruited, 11.7% (187 patients) fulfilled the resistant hypertension criteria. Compared with the spironolactone group (n=95), the clonidine group (n=92) presented similar rates of achieving the primary end point (20.5% versus 20.8%, respectively; relative risk, 1.01 [0.55–1.88]; P=1.00). Secondary end point analysis showed similar office BP (33.3% versus 29.3%) and ambulatory BP monitoring (44% versus 46.2%) control for spironolactone and clonidine, respectively. However, spironolactone promoted greater decrease in 24-h systolic and diastolic BP and diastolic daytime ambulatory BP than clonidine. Per-protocol analysis (limited to patients with ≥80% adherence to spironolactone/clonidine treatment) showed similar results regarding the primary end point. In conclusion, clonidine was not superior to spironolactone in true resistant hypertensive patients, but the overall BP control was low (≈21%). Considering easier posology and greater decrease in secondary end points, spironolactone is preferable for the fourth-drug therapy. Clinical Trial Registration— URL: http://www.clinicaltrials.gov. Unique identifier: NCT01643434.

Diabetes and Cardiovascular Events In High-Risk Patients: Insights from a Multicenter Registry in a Middle-Income Country

AIMS The aim of this study was to determine the rate of major clinical events and its determinants in patients with previous cardiovascular event or not, and with or without diabetes from a middle-income country. METHODS REACT study is a multicenter registry conducted between July 2010 and May 2013 in Brazil. Patients were eligible if they were over 45years old and high cardiovascular risk. Patients were followed for 12months; data were collected regarding adherence to evidence-based therapies and occurrence of clinical events (all-cause mortality, non-fatal cardiac arrest, myocardial infarction, or stroke). RESULTS A total of 5006 subjects was included and analyzed in four groups: No diabetes and no previous cardiovascular event, n=430; diabetes and no previous cardiovascular event, n=1138; no diabetes and previous cardiovascular event, n=1747; and diabetes and previous cardiovascular event, n=1691. Major clinical events in one-year follow-up occurred in 332 patients. A previous cardiovascular event was associated with a higher risk of having another event in the follow-up (HR 2.31 95% CI 1.74-3.05, p<0.001), as did the presence of diabetes (HR 1.28 95% CI 1.10-1.73, p=0.005). In patients with diabetes,failure to reach HbA1c targetswas related topoorer event-free survival compared to patients with good metabolic control (HR 1.70 95% CI 1.01-2.84, p=0.044). CONCLUSIONS In Brazil, diabetes confers high risk for major clinical events, but this condition is not equivalent to having a previous cardiovascular event. Moreover, not so strict targets for HbA1c in patients with diabetes and previous cardiovascular events might be considered.

The association between socioeconomic characteristics and consumption of food items among brazilian industry workers

Background. Dietary pattern plays a causative role in the rising of noncommunicable diseases. The SESI (Serviço Social da Indústria) study was designed to evaluate risk factors for noncommunicable diseases. We aimed to describe food items consumed by Brazilian workers and to assess their association with socioeconomic status. Methods. Cross-sectional study was carried out among Brazilian industrial workers, selected by multistage sampling, from 157 companies. Interviews were conducted at the work place using standardized forms. Results. 4818 workers were interviewed, aged 35.4 ± 10.7 years, 76.5% were men. The workers had an average of 8.7 ± 4.1 years of schooling and 25.4 ± 4.1 kg/m2 of BMI. Men and individuals with less than high school education were less likely to consume dairy products, fruits, and vegetables daily, even after control for confounding factors. Men consumed rice and beans daily more often than women. In comparison to workers aged 50–76 years, those under 30 years old consumed less fruits and green leafy vegetables daily. Conclusion. The food items consumed by Brazilian workers show that there are insufficient consumption according to the guidelines of healthy foods, particularly of dairy products, vegetables, and fruits.

Conceituação, epidemiologia e prevenção primária

CONCEITUACAO A hipertensao arterial sistemica (HAS) e uma condicao clinica multifatorial caracterizada por niveis elevados e sustentados de pressao arterial (PA). Associa-se frequentemente a alteracoes funcionais e/ou estruturais dos orgaos-alvo (coracao, encefalo, rins e vasos sanguineos) e a alteracoes metabolicas, com consequente aumento do risco de eventos cardiovasculares fatais e nao fatais.1-4 IMPACTO MEDICO E SOCIAL DA HIPERTENSAO ARTERIAL SISTEMICA HIPERTENSAO ARTERIAL SISTEMICA E AS DOENCAS CARDIOVASCULARES NO BRASIL E NO MUNDO A HAS tem alta prevalencia e baixas taxas [...]

Sociedade Brasileira de Cardiologia: carta do Rio de Janeiro - III Brasil Prevent / I América Latina Prevent

The final document will be published as a special article in the Arquivos Brasileiros de Cardiologia and as an editorial note in scientific journals of societies and their affiliates supporting this documentThe document aims to provide an overview of cardiovascular diseases and outline strategic actions to reduce the prevalence of risk factors that contribute to high morbidity and mortality.Acknowledging the Political Declaration of the United Nations High-Level Meeting on the Prevention and Control of Non-communicable Diseases (NCD’s)

Prescrição de terapias baseadas em evidências para pacientes de alto risco cardiovascular: estudo REACT

BACKGROUND Data on outpatient care provided to patients at high cardiovascular risk in Brazil are insufficient. OBJECTIVE To describe the profile and document the clinical practice of outpatient care in patients at high cardiovascular risk in Brazil, regarding the prescription of evidence-based therapies. METHODS Prospective registry that documented the ambulatory clinical practice in individuals at high cardiovascular risk, which was defined as the presence of the following factors: coronary artery disease, cerebrovascular and peripheral vascular diseases, diabetes, or those with at least three of the following factors: hypertension, smoking, dyslipidemia, age > 70 years, family history of coronary artery disease, chronic kidney disease or asymptomatic carotid artery disease. Basal characteristics were assessed and the rate of prescription of pharmacological and non-pharmacological interventions was analyzed. RESULTS A total of 2364 consecutive patients were included, of which 52.2% were males, with a mean age of 66.0 years (± 10.1). Of these, 78.3% used antiplatelet agents, 77.0% used statins and of patients with a history of myocardial infarction, 58.0% received beta-blockers. Concomitant use of these three classes of drugs was 34%; 50.9% of hypertensive, 67% of diabetic and 25.7% of dyslipidemic patients did not achieve the goals recommended by guidelines. The main predictors of prescription therapies with proven benefit were centers with a cardiologist and history of coronary artery disease. CONCLUSION This national and representative registry identified important gaps in the incorporation of therapies with proven benefit, offering a realistic outlook of patients at high cardiovascular risk.

Qual a diretriz de hipertensão arterial os médicos brasileiros devem seguir? Análise comparativa das diretrizes brasileiras, européias e norte-americanas (JNC VII)

Hospital das Clinicas da FMUSP e Comissao Permanente das IV DiretrizesBrasileiras de Hipertensao ArterialEndereco para Correspondencia: Decio Mion Junior - Av. Dr. Eneas deCarvalho Aguiar, 255 - Inst. Central do HC - 7o andar, s/ 7032Cep 05403-000 - Sao Paulo - SP - E-mail: deciomion@uol.com.brRecebido para Pulbicacao em 02/12/2003Aceito em 9/03/2004

Association of workplace and population characteristics with prevalence of hypertension among Brazilian industry workers : a multilevel analysis

Background Exposure to risk factors for hypertension may be influenced by the characteristics of the workplace, where workers spend most of their daily time. Objectives To evaluate the association between features of the companies, particularly the presence of facilities to provide meals, and of population characteristics and the prevalence of hypertension, taking into account individual risk factors for hypertension. Material and methods This multilevel analysis was based on a cross-sectional study with individual and company data from the SESI (Serviço Social da Indústria–Social Service of Industries) study and population-based data from the national census statistics. Workers aged ≥15 years were randomly selected from small (20–99), medium (100–499) and large (≥500 employees) companies per state using multistage sampling. Logistic regression was used to analyse the association between hypertension and individual, workplace and population variables, with odds ratios (ORs; 95% CI) adjusted for three-level variables. Results 4818 Workers from 157 companies were interviewed and their blood pressure, weight and height were measured. Overall, 77% were men, aged 35.4 ±10.7 years, with 8.7 ±4.1 years of schooling and mostly worked in companies with a staff canteen (66%). Besides individual characteristics—being male, ageing, low schooling, alcohol abuse and higher BMI—a workplace with no staff canteen (OR=1.28; 95% CI 1.08 to 1.52), small companies (OR=1.31; 95% CI 1.07 to 1.60) and living in cities with higher economic inequality (OR=1.47; 95% CI 1.23 to 1.76) were associated with a higher risk for hypertension. Conclusion Among Brazilian workers, the prevalence of hypertension is associated with individual risk factors, lack of a canteen at the workplace, small companies and higher economic inequalities of cities. These three-level characteristics help to interpret differences in the prevalence of hypertension between regions or countries.