S Fuchs

Capítulo 3 - Avaliação Clínica e Complementar

Clinical assessment Clinical history Complete clinical history with questions about time since AH diagnosis, course and previous treatment should be obtained. Information on the family history is essential to increase the chance of an accurate diagnosis of primary AH.1 (GR: I; LE: B). The patient should be asked about specific RF for CVD, comorbidities, socioeconomic aspects and lifestyle,2 in addition to previous and current use of medications or other substances that can interfere with BP measurement and/or AH treatment. Similarly, evidence of a secondary cause of AH should be investigated.

Capítulo 7 – Tratamento Medicamentoso

The treatment of AH is ultimately aimed at reducing CV morbidity and mortality.1-11 Clinical studies of outcome have provided scientific evidence of the benefits of the use of diuretics (DIUs) (GR: I; LE: A),5,10-15 beta-blockers (BBs) (GR: I; LE: A),1013,16 calcium-channel blockers (CCBs) (GR: I; LE: A),10,11,15,17-23 angiotensin-converting-enzyme inhibitors (ACEIs) (GR: I; LE: A)10,11,15,17,18,24-26 and angiotensin-receptor blockers (ARBs) (GR: I; LE: A).10,11,27-33 It is worth noting that most of those studies have used an association of drugs. Based on the information available, the protection observed does not depend on the type of drug used, but mainly on BP reduction.7,9-11,34 Recent metaanalyses have reported that the benefits obtained from BB are smaller10,11,35-37 as compared to those provided by the other drug groups, and, thus, BBs should be reserved for specific situations. Regarding alpha-blockers and direct vasodilators, there is no effective information on the outcomes of morbidity and mortality. Regarding direct renin inhibitors, only one study of outcome in diabetic patients has been early interrupted due to lack of benefits and possible harm.38 The higher the CV risk, the greater the benefits, which occur even for small BP elevations.3-6,8,9,39

Capítulo 5 - Decisão e Metas Terapêuticas

The therapeutic management of elevated BP includes nonpharmacological measures and the use of antihypertensive drugs to reduce BP, protect target organs and prevent CV and renal outcomes.1-3 Non-pharmacological measures have proven efficient to reduce BP, although limited by mediumand long-term lack of adherence to treatment. A systematic review4 of studies with a minimum duration of 12-24 months, combining dietary interventions and moderate-to-highintensity physical activity in patients using or not medications, has revealed a reduction in SBP and DBP for < 12 months of -4.47 (-7.91 to -1.04) mm Hg and -1.10 (-2.39 to 0.19) mm Hg, respectively. For 12 to 24 months, the reductions were -2.29 (-3.81 to -0.76) mm Hg and -1.00 (-3.22 to 1.22) mm Hg in SBP and DBP, respectively. The direct impact of those measures on the risk of CV outcomes is uncertain, the studies are small and short, and the effects on other RF could contribute to CV protection.

Capítulo 2 - Diagnóstico e Classificação.

The initial assessment of a patient with systemic arterial hypertension (SAH) comprises diagnostic confirmation, suspicion and identification of the secondary cause, and assessment of CV risks. In addition, target-organ damage (TOD) and associated diseases should be investigated. Such assessment comprises BP measurement in the office and/or outside the office, by use of proper technique and validated equipment, medical history (personal and family), physical examination and clinical and laboratory investigation. n nGeneral assessments directed to all, and, in some cases, complementary assessments only for specific groups are proposed. n nMeasurement of BP n n nIn the office nBlood pressure should be measured in all assessments performed by physicians of any specialty and other health care professionals properly trained. n nBlood pressure should be measured at least every two years for adults with BP levels ≤ 120/80 mm Hg, and annually for those with BP levels > 120/80 mm Hg and < 140/90 mm Hg.1 Manual, semi-automated or automated sphygmomanometers can be used. They should be validated, and calibrated annually following the INMETRO recommendations (Chart 1). The BP should be taken in the arm, with a cuff size adequate to arm circumference (Chart 2). When AH secondary to coarctation of the aorta is suspected, BP should be measured in the lower limbs with proper cuffs.2 n nChart 1 n nINMETRO ordinances n. 24, of February 22, 1996, for mechanical aneroid sphygmomanometers, and n. 96, of March 20, 2008, for digital electronic sphygmomanometers for non-invasive measurement.

Capítulo 9 - Hipertensão Arterial na gestação

The hypertensive syndromes of pregnancy cause expressive maternal and fetal morbidity and mortality. There is no accurate information on the incidence of preeclampsia (PE), but it is estimated to affect 4% of gestations. In Brazil, the incidence of PE is 1.5 %, while the incidence of eclampsia is 0.6%.1 More developed areas have an incidence of eclampsia of 0.2%, with a maternal death rate of 0.8%, while for less favored regions those indices are 8.1% and 22%, respectively.2 A population-based study shows AH in 7.5% of the gestations in Brazil, with 2.3% of PE and 0.5% of superimposed PE.3 Arterial hypertension during pregnancy accounts for 20% to 25% of all causes of maternal death, and data from SUS show a trend towards stagnation.4

Capítulo 4 - Estratificaçã o de Risco Cardiovascular

The global CV risk should be assessed in each hypertensive individual, because it aids the professionals in therapeutic decision-making and allows prognostic analysis. The identification of hypertensive individuals prone to CV complications, especially myocardial infarction (MI) and stroke, is fundamental to a more aggressive therapy. Several algorithms and risk scores based on population studies were created in past decades,1 but, considering the lack of Brazilian data for a more accurate assessment of CV risk in the Brazilian population, the use of one single risk score should be avoided to support therapeutic decisions. Multifactorial models of risk stratification can be used for a more accurate individual risk classification.

Capítulo 8 - Hipertensão e Condições Clínicas Associadas

The association of AH and DM doubles the CV risk and has increased the AH prevalence, which is related to the elevation in overweight and obesity rates, as well as the increase in the elderly population.1 The incidence of AH in type 1 diabetic patients increases from 5%, at the age of 10 years, to 33%, at the age of 20 years, and to 70%, at the age of 40 years.2 There is a strict relationship between the development of AH and the presence of albuminuria in that population.3 That increase in the AH incidence can reach 75-80% in patients with diabetic kidney disease.4 Approximately 40% of patients with a recent diagnosis of DM have AH.5 In approximately 50% of type 2 diabetic patients, AH occurs before the development of albuminuria. All diabetic hypertensives are at high CV risk. In addition to all complementary tests recommended for hypertensives, diabetic patients require the search for urine albumin excretion, fundoscopic eye exam and assessment of probable postural hypotension, which can characterize the presence of autonomic nervous system dysfunction.6

Capítulo 6 - Tratamento não medicamentoso.

The DASH (Dietary Approaches to Stop Hypertension) diet emphasizes the consumption of fruits, vegetables and lowfat dairy products, includes the ingestion of whole cereals, chicken, fish and nuts, and recommends a reduction in the ingestion of red meat, candies and sugary beverages. That diet is rich in potassium, calcium, magnesium and fibers, and contains reduced amounts of cholesterol and of total and saturated fat. Adopting that dietary pattern reduces BP.8,9 (GR: I; LE: A).

Capítulo 13 - Hipertensão Arterial Resistente

Resistant AH (RAH) is defined as uncontrolled office BP despite the use of at least three antihypertensive drugs at appropriate doses, including preferably one DIU, or as controlled BP using at least four drugs.1-3 Because it does not include the systematic assessment of therapy and adherence, that situation is better defined as apparent RAH (pseudoresistance). Identification of true RAH is fundamental to establish specific approaches.2 Population-based studies have estimated a 12% prevalence in the hypertensive population.2 In Brazil, the ReHOT study assesses prevalence and therapeutic choice.4 Refractory hypertension is defined as uncontrolled BP using at least five antihypertensive drugs,5 and corresponds to 3.6% of resistant hypertensive individuals. To diagnose RAH, ABPM is required, as well as systematic assessment of adherence. (GR: I; LE: C).

Capítulo 1 - Conceituação, Epidemiologia e Prevenção Primária

Concept Arterial hypertension (AH) is a multifactorial clinical condition characterized by sustained elevation of blood pressure (BP) levels ≥ 140 and/or 90 mm Hg. It is often associated with metabolic disorders, functional and/or structural changes in target organs, being worsened by the presence of other risk factors (RF), such as dyslipidemia, abdominal obesity, glucose intolerance and diabetes mellitus (DM).1,2 It is independently associated with events such as sudden death, stroke, acute myocardial infarction (AMI), heart failure (HF), peripheral arterial disease (PAD) and fatal and non-fatal chronic kidney disease (CKD).1-4