Regular source of primary care and health services utilisation among Brazilian elderly with mental-physical multimorbidity.

BACKGROUND: In ageing populations, multimorbidity is a complex challenge to health systems, especially when the individuals have both mental and physical morbidities. Although a regular source of primary care (RSPC) is associated with better health outcomes, its relation with health service utilisation in elderly patients with mental-physical multimorbidity (MP-MM) is scarce. OBJECTIVE: This study explored the relations among health service utilisation, presence of RSPC and MP-MM among elderly Brazilians. METHODS: A national cross-sectional study performed with data from national representative samples from the Brazilian National Health Research (PNS, in Portuguese; Pesquisa Nacional de Saúde) carried out in 2013 with 11,177 elderly Brazilian people. MP-MM was defined as the presence of two or more morbidities, including at least one mental morbidity, and was evaluated using a list of 16 physical and mental morbidities. The RSPC was analysed by the presence of regular font of care in primary care and health service utilisation according to the demand for health services ≤ 15 days, medical consultation ≤ 12 months, and hospitalisation ≤ 1 year. Frequency description of variables and bivariate association were performed using Stata v.15.2 software. RESULTS: The majority of individuals was female (56.4%), and their mean age was 69.8 years. The observed prevalence of MP-MM was 12.2%. Individuals with MP-MM had higher utilisation of health services when compared to those without MP-MM. RSPC was present at 36.5% and was higher in women (37.8% vs. 34.9%). There was a lower occurrence of hospitalisation ≤ 1 year among MP-MM individuals with RSPC and without a private plan of health. CONCLUSION: Our findings demonstrate that RSPC can be an important component of care in elderly individuals with MP-MM because it was associated with lower occurrence of hospitalisation, mainly in those that have not a private plan of health. Longitudinal studies are necessary to confirm these findings.

Management of early breast cancer during the COVID-19 pandemic in Brazil.

PURPOSE: The COVID-19 pandemic has impacted early breast cancer (EBC) treatment worldwide. This study analyzed how Brazilian breast specialists are managing EBC. METHODS: An electronic survey was conducted with members of the Brazilian Society of Breast Cancer Specialists (SBM) between April 30 and May 11, 2020. Bivariate analysis was used to describe changes in how specialists managed EBC at the beginning and during the pandemic, according to breast cancer subtype and oncoplastic surgery. RESULTS: The response rate was 34.4% (503/1462 specialists). Most of the respondents (324; 64.4%) lived in a state capital city, were board-certified as breast specialists (395; 78.5%) and either worked in an academic institute or one associated with breast cancer treatment (390; 77.5%). The best response rate was from the southeast of the country (240; 47.7%) followed by the northeast (128; 25.4%). At the beginning of the pandemic, 43% changed their management approach. As the outbreak progressed, this proportion increased to 69.8% (p < 0.001). The southeast of the country (p = 0.005) and the state capital cities (p < 0.001) were associated with changes at the beginning of the pandemic, while being female (p = 0.001) was associated with changes during the pandemic. For hormone receptor-positive tumors with the best prognosis (Ki-67 < 20%), 47.9% and 17.7% of specialists would recommend neoadjuvant endocrine therapy for postmenopausal and premenopausal women, respectively. For tumors with poorer prognosis (Ki-67 > 30%), 34% and 10.9% would recommend it for postmenopausal and premenopausal women, respectively. Menopausal status significantly affected whether the specialists changed their approach (p < 0.00001). For tumors ≥ 1.0 cm, 42.9% of respondents would recommend neoadjuvant systemic therapy for triple-negative tumors and 39.6% for HER2 + tumors. Overall, 63.4% would recommend immediate total breast reconstruction, while only 3.4% would recommend autologous reconstruction. In breast-conserving surgery, 75% would recommend partial breast reconstruction; however, 54.1% would contraindicate mammoplasty. Furthermore, 84.9% of respondents would not recommend prophylactic mastectomy in cases of BRCA mutation. CONCLUSIONS: Important changes occurred in EBC treatment, particularly for hormone receptor-positive tumors, as the outbreak progressed in each region. Systematic monitoring could assure appropriate breast cancer treatment, mitigating the impact of the pandemic.

Predictors of overweight/obesity in a Brazilian cohort after 13 years of follow-up.

BACKGROUND: Obesity is a chronic complex disease with an increasing prevalence around the world. Prospective studies in adult cohorts are needed to provide information about predictors of new-onset overweight/obesity on population-based levels. The aim of this study was to identify factors associated with the risk of an adult individual become overweight/obese after 13 years of follow-up. METHODS: Second phase of an observational population-based prospective cohort study in a small town in the Midwest region of Brazil. A representative sample of the adult population (≥18 years) was assessed in 2002 (phase 1). Anthropometric, sociodemographic, dietary intake and lifestyle data were collected. After 13 years of follow-up (2015), the same variables were re-evaluated (phase 2). New-onset overweight/obesity was the outcome variable. RESULTS: A total of 685 subjects were included with a mean age in phase 1 of 42.7 ± 13.8 years and 56.1 ± 13.8 years in phase 2, the mean follow-up time was 13.2 years and female sex counted for 66.3% of the sample. Total weight gain was 5.9 ± 10.2 Kg, body mass index increased 2.6 ± 3.8 Kg/m2 and waist circumference (WC) values increased 8.0 ± 10.5 cm. The prevalence of overweight/obesity went from 49.1% in phase 1 to 69.8% in phase 2 (p < 0.001). The factors associated with a decreased risk of new-onset overweight/obesity were ages between 50 and 64 (RR 0.40; CI 0.24-0.67 - p = 0.001) and ≥65 years (RR 0.15; CI 0.06-0.35 - p < 0.001), being part of the second quartile of fat consumption (RR 0.59; CI 0.35-0.97 - p = 0.041), no alcohol consumption (RR 0.59; CI 0.37-0.93 - p = 0.024) and smoking (RR 0.58; CI 0.39-0.86 - p = 0,007) in phase 1. CONCLUSIONS: We identified in thirteen years of follow-up that older ages, a moderate fat consumption compared to low consumption, no alcohol consumption and smoking habit were related to a decreased risk of new-onset overweight/obesity. Obesity prevention actions must focus on subjects at younger ages and include policies to reduce alcohol consumption.

Is waist-to-height ratio the best predictive indicator of hypertension incidence? A cohort study.

BACKGROUND: The best anthropometric indicator to verify the association between obesity and hypertension (HTN) has not been established. We conducted this study to evaluate and compare the discriminatory power of waist-to-height ratio (WHtR) in relation to body mass index (BMI) and waist circumference (WC) in predicting HTN after 13 years of follow-up. METHODS: This study was an observational prospective cohort study performed in the city of Firminópolis, in Brazilian's midwest. The cohort baseline (phase 1) was initiated in 2002 with the evaluation of a representative sample of the normotensive population (≥ 18 years of age). The incidence of HTN was evaluated as the outcome (phase 2). Sociodemographic, dietary and lifestyle variables were used to adjust proportional hazards models and evaluate risk of HTN according to anthropometric indices. The areas under the receiver operating characteristic (ROC) curves were used to compare the predictive capacity of these indices. The best HTN predictor cut-offs were obtained based on sensitivity and specificity. RESULTS: A total of 471 patients with a mean age of 38.9 ± 12.3 years were included in phase 1. The mean follow-up was 13.2 years, and 207 subjects developed HTN. BMI, WC and WHtR were associated with risk of HTN incidence and had similar power in predicting the disease. However, the associations were only significant for women. The cut-off points with a better HTN predictive capacity were in agreement with current recommendations, except for the WC in men. CONCLUSIONS: The results suggest that both overall obesity (BMI) and central obesity (WC and WHtR) anthropometric indicators can be used in this population to evaluate the risk of developing hypertension.

White-coat, masked and sustained hypertension detected by home blood pressure monitoring in adolescents: prevalence and associated factors.

PURPOSE: Population-based studies estimating prevalence's of white-coat, masked and sustained hypertension in non-European adolescents are needed, particularly in developing countries. Aiming to determine these estimates and, additionally identify factors associated to these conditions this study was conducted. MATERIALS AND METHODS: Cross-sectional study with a representative sample of secondary school students from a Brazilian state capital. Office measurements were performed with validated semi-automatic devices. Home BP (blood pressure) monitoring protocol included two day-time and two evening-time measurements over 6 days. Adolescents' were classified as: normotensives (office and home BP <95th percentile); sustained hypertensives (office and home BP ≥95th percentile); white-coat hypertensives (office BP ≥95th percentile and home BP <95th percentile) and masked hypertensives (office BP <95th percentile and home BP ≥95th percentile). Logistic regression models were built to identify if sex, age, BMI and family history of HTN were independently associated with white-coat, masked and sustained hypertension. RESULTS: In a sample of 1024 adolescents, prevalence of white-coat, masked and sustained hypertension was 7.5%, 2.2% and 1.7%, respectively. Male sex was positively associated with white-coat hypertension (OR 2.68; 95%CI 1.58-4.54; p < 0.001). BMI was positively associated with both white-coat (OR 1.23; 95%CI 1.16-1.30; p < 0.001) and sustained hypertension (OR 1.19; 95%CI 1.11-1.29; p < 0.001). None of the independent variables were associated with masked hypertension in this population. CONCLUSION: The estimated prevalence of white-coat hypertension, masked and sustained hypertension in a population of non-European adolescents assessed by home BP monitoring was 7.5%, 2.2% and 1.7% respectively. Male sex was positively associated with white-coat hypertension in these adolescents while BMI was positively associated with both white-coat and sustained hypertension.

Office blood pressure measurements with oscillometric devices in adolescents: a comparison with home blood pressure.

PURPOSE: Compare multiple in office BP measurements in adolescents using an oscillometric device with out-of-office blood pressure measurements (home blood pressure monitoring - HBPM). MATERIALS AND METHODS: Office measurements were performed with validated semi-automatic devices twice (3 minutes interval) in two different moments (1 week apart), with a total of four readings. These BP readings were named R1, R2, R3 and R4 (following the sequence they were performed), FDM (mean of two readings on first day) and SDM (mean of two readings on second day) and SRM (R2-R4 means). The HBPM protocol included two day-time and two evening-time measurements over 6 days. RESULTS: A total of 1024 students between 12 and 17 years were included (mean age 14.68 years; 52.4% females). The mean systolic blood pressure (SBP) values of R2, SDM and SRM were similar to HBPM values. Regarding diastolic blood pressure (DBP) HBPM value was different than R4. High SBP and DBP correlation coefficients with HBPM values were found for R2, SDM and SRM values. CONCLUSION: The second office BP measurement performed with an oscilometric device in adolescents was comparable to HBPM values, suggesting that two office readings might be suitable to rule out hypertension in this age group.

Sedentary lifestyle and its associated factors among adolescents from public and private schools of a Brazilian state capital.

BACKGROUND: Adolescence is a transition stage between childhood and adulthood and is an important phase for the acquisition of future lifestyles, including the practice of physical activity (PA). The prevalence of sedentary lifestyle in adolescents is often high, creating the need for studies addressing the practice of PA and its associated factors for a better understanding of the phenomenon and possible interventions that would encourage positive changes. METHODS: Cross-sectional study of a representative sample of students aged 14-18 years enrolled in both public and private schools of a large Brazilian city to determine the level of physical activity (PA) and its associated factors. Sedentary lifestyle was measured by applying the International Physical Activity Questionnaire. The independent variables were gender, age, race, tobacco use and alcohol consumption in the past 30 days, socioeconomic status, body mass index, waist circumference and blood pressure. The crude prevalence ratio was used as a measure of association and was estimated from a Poisson regression. RESULTS: The sample consisted of 862 adolescents with a mean age of 15.4 ± 1.1 years. Females were predominant (52.8%), and the age between 14 and 15 years was the most frequent (52.2%). The majority of the group reported themselves as Caucasians (51.2%), belonging to socioeconomic class C (52.5%) and were attending to public schools (69.1%). The prevalence of sedentary lifestyle was 66.8% (95% confidence interval [CI]: 63.5-69.9), where values of 65.4% and 69.9% were observed among students from public and private schools, respectively (p = 0.196). Sedentary lifestyle was more frequent in females (78.0% vs 54.3%; p < 0.001). The factor directly associated with sedentary lifestyle was female gender both in public and private schools and the only independent variable related to sedentarism was also female gender. CONCLUSION: The prevalence of sedentary lifestyle was extremely high in the population of adolescents studied both in public and private schools. Female sex was directly associated with sedentary lifestyle.

Temporal trends in female breast cancer mortality in Brazil and correlations with social inequalities: ecological time-series study.

BACKGROUND: Breast cancer is the most common cause of death from cancer in women in less developed regions. Therefore, the objective of this study was to provide data on the temporal trends in female breast cancer mortality between 1990 and 2011 and to evaluate its association with the social inequalities present in Brazil. METHODS: Breast cancer mortality data and estimates for the resident population were obtained from the Brazilian National Health Service database for the 1990-2011 period. Age-standardized mortality rates were calculated (20-39, 40-49, 50-69 and ≥70 years) by direct standardization using the 1960 standard world population. Trends were modeled using joinpoint regression model and linear regression. The Social Exclusion Index and the Human Development Index were used to classify the 27 Brazilian states. Pearson's correlation was used to describe the association between the Social Exclusion Index and the Human DeveIopment and the variations in mortality rates in each state. RESULTS: Age-standardized mortality rates in Brazil were found to be stable (annual percent change [APC] = 0.3; 95% CI: -0.1 - 0.7) between 1994 and 2011. Considering the Brazilian states, significant decreases in mortality rates were found in Rio Grande do Sul, Rio de Janeiro and São Paulo. Increases in mortality rates were most notable in the states of Maranhão (APC = 11.2; 95 %CI: 5.8 - 16.9), Piauí (APC = 9.8; 95% CI: 7.6 - 12.1) and Paraíba (APC = 9.3; 95% CI: 6.0 - 12.8). There was a statistically significant correlation between Social Exclusion Index and a change in female breast cancer mortality rates in the Brazilian states between 1990 and 2011 and between Human Development Index and mortality between 2001 and 2011. CONCLUSIONS: Female breast cancer mortality rates are stable in Brazil. Reductions in these rates were found in the more developed states, possibly reflecting better healthcare.

The natural history of cardiovascular risk factors in health professionals: 20-year follow-up.

BACKGROUND: The knowledge of the presence and evolution of cardiovascular risk factors in young people may significantly contribute to actions to modify the natural history of these risks and prevent the onset of cardiovascular disease. OBJECTIVES: To assess the presence and evolution of cardiovascular risk factors in health professionals over a 20-year period. METHODS: A group of individuals was evaluated when they first started graduate programs in medicine, nursing, nutrition, dentistry, and pharmacy, and 20 years later. Data obtained in the two phases were compared. Questionnaires about hypertension, diabetes, hypercholesterolemia, family history of early-onset cardiovascular disease, smoking, alcohol consumption, and sedentary lifestyle were administered. Cholesterol, blood glucose, blood pressure, weight, height, and body mass index (BMI) were measured. RESULTS: Of the 281 individuals (62.9 % women; mean age 19.7 years) initially analyzed, 215 (59.07 % women; mean age 39.8 years) were analyzed 20 years later. An increase in mean values of systolic (111.6 vs 118.7 mmHg- p < 0.001) and diastolic blood pressure (71 vs 77.1 mmHg - p < 0.001), cholesterol (150.1 vs 182.4 mg/dL - p < 0.001), blood glucose (74.3 vs 81.4 mg/dL - p < 0.001) and BMI (20.7 vs 23.7 kg/m(2) - p = 0.017) was observed. Despite the decrease of sedentarism (50.2 vs 38.1 % - p = 0.015), the prevalence of hypertension (4.6 vs 18.6 % - p < 0.001), excessive weight (8.2 vs 32.1 % - p < 0.001), hypercholesterolemia (7.8 vs 24.2 % - p < 0.001), and alcohol consumption (32.7 vs 34.9 % - p = 0.037) increased. There was no change in the prevalence of smoking. CONCLUSION: Health professionals presented an increase in systolic and diastolic blood pressure, blood glucose, body mass index, and cholesterol over the 20-year study period. Regarding the prevalence of cardiovascular risk factors, increased blood pressure, overweight, hypercholesterolemia and alcohol consumption, and a decrease in sedentary lifestyle were observed.

A Program to Optimize the Detection of Paroxysmal Atrial Fibrillation: The RITMO Study. / Programa para Otimizar a Detecção da Fibrilação Atrial Paroxística: Estudo Ritmo.

BACKGROUND: Atrial fibrillation (AF) is the most common sustained arrythmia, but still underdiagnosed especially among asymptomatic patients. OBJECTIVES: To evaluate a simple strategy to optimize the identification of AF. METHODS: Asymptomatic patients aged 65 years or older, with hypertension or heart failure (HF), were included. Data were inserted into the REDCap software platform. Patients were assessed for the risk for AF using the Stroke Risk Analysis (SRA) mathematical algorithm, which was applied on a one-hour electrocardiogram (ECG). All patients at high risk for AF were instructed to follow a home ECG protocol for seven days using a portable Kardia 6 (OMRON, AliveCor®). The Kolmogorov-test was used to test the normality of quantitative variables; those with normal distribution were expressed as mean and standard deviation. A p<0.05 was set as statistically significant. RESULTS: A total of 423 patients were assessed; 15 were excluded due to absence of SRA, yielding a sample of 408 patients. In 13 (3.2%), AF was identified, 120 (29.4%) were considered at high risk and 275 (67.4%) without increased risk for AF. Of the 120 high-risk patients, 111 successfully completed the seven-day protocol with Kardia; at least one episode of AF was identified in 43 patients. CONCLUSION: The strategy adopted in the RITMO study was shown to be effective in identifying AF in asymptomatic elderly patients with hypertension or HF, with an incidence of 13.7% (56/408).

FUNDAMENTO: A fibrilação atrial (FA) é a arritmia cardíaca sustentada mais frequente, mas ainda é subdiagnosticada especialmente em pacientes assintomáticos. OBJETIVO: Avaliar uma estratégia simples para otimizar a identificação da FA. MÉTODOS: Avaliados indivíduos assintomáticos com 65 anos ou mais, portadores de hipertensão arterial (HA) ou insuficiência cardíaca (IC). Os dados foram inseridos e armazenados em plataforma REDCap. Inicialmente foram realizadas análise de risco de FA com o algoritmo matemático Stroke Risk Analysis (SRA) aplicado em eletrocardiograma (ECG) de 1 hora. Todos os pacientes de alto risco de FA foram orientados a realizar o protocolo de ECG domiciliar por sete dias com o equipamento portátil Kardia 6L OMRON, AliveCor®. O teste de Kolmogorov-Smirnov foi usado para verificar a normalidade da distribuição das variáveis quantitativas; aquelas com distribuição normal foram expressas em média e desvio-padrão. Adotou-se como significativo o valor de p<0,05. RESULTADOS: Foram avaliados 423 pacientes; 15 foram excluídos por não terem realizado o SRA, resultando em uma amostra de 408 pacientes. A avaliação evidenciou que 13 (3,2%) pacientes apresentaram FA, 120 (29,4%) foram considerados de alto risco para FA e 275 (67,4%) sem risco aumentado. Dos 120 pacientes de alto risco, 111 realizaram adequadamente o protocolo de sete dias com o Kardia, tendo sido identificados um ou mais registros de FA em 43 pacientes. CONCLUSÃO: A estratégia adotada no estudo RITMO mostrou-se eficaz para identificar, com uma incidência de 13,7% (56/408), episódios de FA em pacientes idosos assintomáticos e portadores de HA ou IC.

Intracranial pressure waveform in patients with essential hypertension.

Background: There is a strong association between hypertension and cerebrovascular diseases, but most of the mechanistic bases to justify this correlation remains misunderstood. Objective: To evaluate intracranial pressure waveform in long-term essential hypertensive patients with a non-invasive device, brain4care (b4c). Methods: Cross-sectional study in patients with hypertension. Office blood pressure was measured with an automatic oscillometric device. Intracranial pressure evaluation was acquired through a strain sensor that could detect and monitor nanometric skull bone displacements for each cardiac cycle. Under normal physiological conditions, P1 is greater than P2, and the normal P2/P1 ratio is <1. Time to peak (TTP) is the measurement in seconds of the beginning of waveform inscription until P1 and normal values are <0.20 s. The cut-off points ≥1.2 and ≥0.25 s were used to define intracranial hypertension (ICHT). Results: 391 consecutive patients were evaluated (75% female, mean age 64.3 ± 12.0 years). Mean value of P2/P1 ratio was 1.18 ± 0.25 and TTP 0.18 ± 0.63 s The obtained P2/P1 ratios were divided in three categories according to results of previous studies of normalcy (<1.0), intracranial compliance disturbance (1.0-1.19) and ICHT (≥1.2). Normal intracranial pressure was observed in 21.7% of patients, intracranial compliance disturbance in 32.7% and intracranial hypertension in 45.6%. Females showed a higher prevalence of ICHT (50.3%). Conclusion: The prevalence of 45.6% intra-cranial hypertension in patients with long-term hypertension, particularly in women, and in those over 65 years old, emphasizes the importance of evaluate intracranial pressure behaviour in these patients and raise a question concerning the real ability of cerebral autoregulation and vascular barriers to protect the brain.

SAGE Score in Normotensive and Pre-Hypertensive Patients: A Proof of Concept. / Escore SAGE em Normotensos e Pré-Hipertensos: Uma Prova de Conceito.

BACKGROUND: The SAGE score was developed to detect individuals at risk for increased pulse wave velocity (PWV). So far, studies have been focused on hypertensive patients. OBJECTIVE: To assess the ability of the score to detect non-hypertensive and pre-hypertensive patients at risk for increased PWV. METHODS: Retrospective cross-sectional study of analysis of central blood pressure data and calculation of the SAGE score of non-hypertensive and pre-hypertensive patients. Each score point was analyzed for sensitivity, specificity, positive and negative predictive values, using the cut-off point for positive diagnosis a PVW ≥ 10m/s, ≥9.08 m/s (75thpercentile) and ≥7.30 m/s (50thpercentile). A p<0.05 was considered statistically significant. RESULTS: The sample was composed of 100 normotensive and pre-hypertensive individuals, with mean age of 52.64 ± 14.94 years and median PWV of 7.30 m/s (6.03 - 9.08). The SAGE score was correlated with age (r=0.938, p<0.001), glycemia (r=0.366, p<0.001) and glomerular filtration rate (r=-0.658, p<0.001). The area under the ROC curve was 0.968 (p<0.001) for PWV ≥ 10 m/s, 0.977 (p<0.001) for PWV ≥ 9.08 m/s and 0.967 (p<0.001) for PWV ≥ 7.30 m/s. The score 7 showed a specificity of 95.40% and sensitivity of 100% for PWV≥10 m/s. The cut-off point would be of five for a PWV≥9.08 m/s (sensitivity =96.00%, specificity = 94.70%), and two for a PWV ≥ 7.30 m/s. CONCLUSION: The SAGE score could identify individuals at higher risk of arterial stiffness, using different PWV cutoff points. However, the development of a specific score for normotensive and pre-hypertensive subjects is needed.

FUNDAMENTO: O SAGE foi desenvolvido para identificar hipertensos com chance de velocidade de onda de pulso (VOP) aumentada. Até o momento, as publicações do escore foram em hipertensos. OBJETIVO: Verificar a capacidade do SAGE de identificar os normotensos ou pré-hipertensos com chance de aumento da VOP. MÉTODOS: Transversal retrospectivo, incluiu exames de normotensos e pré-hipertensos que realizaram a medida central da pressão arterial e apresentavam os parâmetros para o cálculo do escore. Para cada pontuação do escore, foi analisada a sensibilidade, especificidade, valor preditivo positivo e negativo utilizando como ponto de corte para o diagnóstico positivo VOP ≥ 10m/s, ≥9,08 m/s (percentil 75) e ≥7,30 m/s (percentil 50). Um valor de p<0,05 foi adotado como estatisticamente significante. RESULTADOS: A amostra foi de 100 participantes normotensos ou pré-hipertensos, com média (DP) de 52,64 (14,94) anos e VOP mediana de 7,30 m/s (6,03 ­ 9,08). O SAGE apresentou correlação com idade (r=0,938, p<0,001), glicemia (r=0,366, p<0,001) e taxa de filtração de glomerular (r=-0,658, p<0,001). A área sob a curva ROC foi de 0,968 (p<0,001) para VOP≥10 m/s, 0,977 (p<0,001) para VOP≥9,08 m/s e 0,967 (p<0,001) para VOP≥7,30 m/s. O escore 7 apresentou especificidade de 95,40% e sensibilidade de 100% para VOP≥10 m/s. O ponto de corte seria cinco para VOP≥9,08 m/s (s=96,00%, e= 94,70%), e dois para VOP≥7,30 m/s. CONCLUSÃO: O SAGE foi capaz de identificar indivíduos com maior chance de apresentar rigidez arterial, utilizando diferentes pontos de corte de VOP. Entretanto, o desenvolvimento de um escore específico para normontensos e pré-hipertensos faz-se necessário.

Hypertension evaluated in the public and private Brazilian health system hypertension in public and private service.

Introduction: Hypertension (HT) remains the leading cause of death worldwide. In Brazil it is estimated that 35% of the adult population has HT and that about 20% of these have blood pressure values within the targets recommended for the reduction of cardiovascular risk. There are some data that point to different control rates in patients treated by cardiologists in public and private referral center and this is an important point to be investigated and discussed. Objective: To compare sociodemographic characteristics, body mass index (BMI), antihypertensive (AH) drugs, blood pressure (BP) and control rate in public (PURC) and private (PRRC) referral centers. Methodology: A cross-sectional multicenter study that analyzed data from hypertensive patients assisted by the PURC (one in Midwest Region and other in Northeast region) and PRRC (same distribution). Variables analyzed: sex, age, BMI, classes, number of AH used and mean values of systolic and diastolic BP by office measurement and home blood pressure measurement (HBPM). Uncontrolled hypertension (HT) phenotypes and BP control rates were assessed. Descriptive statistics and χ2 tests or unpaired t-tests were performed. A significance level of p < 0.05 was considered. Results: A predominantly female (58.9%) sample of 2.956 patients and a higher prevalence of obesity in PURC (p < 0.001) and overweight in PRRC (p < 0.001). The mean AH used was 2.9 ± 1.5 for PURC and 1.4 ± 0.7 for PRRC (p < 0.001). Mean systolic and diastolic BP values were higher in PURC as were rates of uncontrolled HT of 67.8% and 47.6% (p < 0.001) by office measurement and 60.4% and 35.3% (p < 0.001) by HBPM in PURC and PRRC, respectively. Conclusion: Patients with HT had a higher prevalence of obesity in the PURC and used almost twice as many AH drugs. BP control rates are worse in the PURC, on average 15.3 mmHg and 12.1 mmHg higher than in the PRRC by office measurement.

Cardiovascular risk factors in the elderly: a 10-year follow-up survival analysis.

AIMS: Cardiovascular risk factors present a high prevalence and have an impact on the morbimortality of the elderly; however, studies evaluating the impact of cardiovascular risk factors in the elderly have had short follow-up times and have not allowed specific analyses of the effects of these factors in the aged population, including how they affect the survival of the elderly. This study aimed to analyse the survival of elderly individuals living in the community, considering the presence of cardiovascular risk factors. METHODS AND RESULTS: A prospective 10-year follow-up was initiated in 2008 with a cohort of 418 elderly people living in a community in Central Brazil. The Kaplan-Meier method and the Cox proportional hazards model were used to examine the association between survival and cardiovascular risk factors. The mean age of the participants was 70.6 (±7.1) years; most participants were hypertensive (81.6%) and participated in irregular physical activity (44%), and 43.3% smoked. After a mean follow-up of 8.38 (±2.82) years, 59.3% had survived and 34.1% had died; among the deaths, 14.1% were due to cardiovascular causes. Age [hazard ratio (HR) 1.067, 95% confidence interval (CI) 1.027-1.109], hypertension (HR 3.178, 95% CI 1.144-8.826), and smoking (HR 2.235, 95% CI 1.253-3.987) were confirmed as risk factors for reduced survival, whereas physical activity was a protective factor (HR 0.456, 95% CI 0.206-1.007). CONCLUSION: The results from this study highlight the need for educational policies towards hypertension and smoking prevention among elderly people, and participation in physical activity needs to be encouraged.

Pulse Wave Velocity of 8.2 m/s as a Threshold Associated with Cardiovascular Target Organ Damage Presence. / Velocidade de Onda de Pulso de 8,2m/s como Limiar Associado à Presença de Lesão de Órgão Alvo Cardiovascular.

BACKGROUND: Previous studies have established normal and reference values for Pulse Wave Velocity (PWV). However, the PWV value that has the strongest association with cardiovascular biomarkers remains poorly understood. OBJECTIVE: This study aimed to determine the PWV value more likely to be associated with left ventricular hypertrophy (LVH), increased intima-media thickness (IMT), and presence of carotid plaques in patients with hypertension. METHODS: This cross-sectional study included 119 patients. Analysis of receiver operating characteristic (ROC) curves was performed for each cardiovascular biomarker. Statistical significance was set at p < 0.05. RESULTS: According to the ROC curve analysis, the PWV values were 8.1 m/s, 8.2 m/s, and 8.7 for the LVH, IMT, and presence of carotid plaques, respectively. A PWV value of 8.2 m/s was identified as the best parameter to determine the three TOD biomarkers. PWV above 8.2 m/s was associated with increased CIMT (p = 0.004) and the presence of carotid plaques (p = 0.003) and LVH (p<0.001). PWV above 8.2 showed greater sensitivity for increased CIMT (AUC = 0.678, sensitivity = 62.2), LVH (AUC = 0.717, sensitivity = 87.2), and the presence of plaques (AUC = 0.649, sensitivity = 74.51) in the ROC curve analysis. CONCLUSION: The PWV value 8.2 m/s was more sensitive in early identifying the existence of cardiovascular biomarkers of TOD.

FUNDAMENTO: Estudos prévios estabeleceram valores de normalidade e de referência da Velocidade de Onda de Pulso (VOP). Porém, qual valor de VOP que apresenta a associação mais forte com biomarcadores cardiovasculares ainda é pouco conhecido. OBJETIVO: Identificar o valor de VOP com maior possibilidade de estar associado com hipertrofia ventricular esquerda (HVE), aumento da espessura íntima-média carotídea (EIMC), e presença de placas carotídeas em pacientes hipertensos. MÉTODOS: Este é um estudo transversal de 119 pacientes. Análise de curvas características de operação do receptor (ROC) foi realizada para cada biomarcador cardiovascular. A diferença estatística foi estabelecida em p<0,05. RESULTADOS: Segundo análises das curvas ROC, valores de VOP de 8,1m/s para HVE, 8,2m/s para EMIC aumentada e 8,7m/s para a presença de placa carotídea foram encontrados, respectivamente. O valor de VOP de 8,2m/s foi definido como melhor o parâmetro para encontrar os três biomarcadores de LOA. A VOP acima de 8,2m/s associou-se ao aumento da EMIC (p = 0,004), à presença de placas carotídeas (p = 0,003) e à HVE (p < 0,001). A VOP acima de 8,2m/s apresentou maior sensibilidade para EMIC aumentada (AUC = 0,678, sensibilidade 62,2), HVE (AUC = 0,717, sensibilidade 87,2), e presença de placas (AUC = 0,649, sensibilidade 74,51) na análise das curvas ROC. CONCLUSÃO: O valor de 8,2m/s de VOP foi mais sensível em identificar, precocemente, a existência de biomarcadores cardiovasculares de LOA.

Identifying multimorbidity clusters among Brazilian older adults using network analysis: Findings and perspectives.

In aging populations, multimorbidity (MM) is a significant challenge for health systems, however there are scarce evidence available in Low- and Middle-Income Countries, particularly in Brazil. A national cross-sectional study was conducted with 11,177 Brazilian older adults to evaluate the occurrence of MM and related clusters in Brazilians aged ≥ 60 years old. MM was assessed by a list of 16 physical and mental morbidities and it was defined considering ≥ 2 morbidities. The frequencies of MM and its associated factors were analyzed. After this initial approach, a network analysis was performed to verify the occurrence of clusters of MM and the network of interactions between coexisting morbidities. The occurrence of MM was 58.6% (95% confidence interval [CI]: 57.0-60.2). Hypertension (50.6%) was the most frequent morbidity and it was present all combinations of morbidities. Network analysis has demonstrated 4 MM clusters: 1) cardiometabolic; 2) respiratory + cancer; 3) musculoskeletal; and 4) a mixed mental illness + other diseases. Depression was the most central morbidity in the model according to nodes' centrality measures (strength, closeness, and betweenness) followed by heart disease, and low back pain. Similarity in male and female networks was observed with a conformation of four clusters of MM and cancer as an isolated morbidity. The prevalence of MM in the older Brazilians was high, especially in female sex and persons living in the South region of Brazil. Use of network analysis could be an important tool for identifying MM clusters and address the appropriate health care, research, and medical education for older adults in Brazil.

A SAGE score cutoff that predicts high-pulse wave velocity as measured by oscillometric devices in Brazilian hypertensive patients.

We aimed to identify the optimal cutoff SAGE score for Brazilian hypertensive patients who had their pulse wave velocity (PWV) measured with oscillometric devices. A retrospective analysis of patients who underwent central blood pressure measurement using a validated oscillometric device, the Mobil-O-Graph® (IEM, Stolberg, Germany), between 2012 and 2019 was performed. Patients with arterial hypertension and available data on all SAGE parameters were selected. An ROC curve was constructed using the Youden index to define the best score to identify patients at high risk for high PWV. A total of 837 patients met the criteria for SAGE and diagnosis of hypertension. The median age was 59.0 years (interquartile range [IQR]: 47.0-68.0), and 50.7% of the patients were women. The following comorbidities and conditions were present: dyslipidemia (37.4%), diabetes (20.7%), a body mass index score ≥30 kg/m2 (36.6%), use of antihypertensive drugs (69.5%), and smoking (18.3%). The median peripheral blood pressure was 128 mmHg (IQR: 117-138 mmHg) for systolic and 81 mmHg (IQR: 73-90 mmHg) for diastolic blood pressure. The median PWV was 8.3 m/s (7.1-9.8 m/s), and the prevalence of high PWV (≥10 m/s) was 22.9% (192 patients). A cutoff SAGE score ≥8 was effective at identifying a high risk of PWV ≥ 10 m/s, achieving 67.19% sensitivity (95% CI: 60.1-73.8) and 93.95% specificity (95% CI: 91.8-95.7). With this cutoff point, 1 out of every 5 treated hypertensive patients would be referred for a PWV measurement. A SAGE score of ≥8 identified Brazilian hypertensive patients with a high risk of future cardiovascular events (PWV ≥ 10 m/s).

Comparison between the Effects of Hymalaian Salt and Common Salt Intake on Urinary Sodium and Blood Pressure in Hypertensive Individuals. / Comparação entre os Efeitos da Ingestão de Sal do Himalaia e de Sal Comum sobre os Valores de Sódio Urinário e Pressão Arterial em Indivíduos Hipertensos.

BACKGROUND: The Himalayan salt (HS) has become a popular alternative for the traditional table salt (TS) due to its health benefit claims, particularly for individuals with arterial hypertension. However, despite the increase in HS consumption, there is still a lack of clinical evidence to support a recommendation for its consumption by health professionals. OBJECTIVE: This cross-over study aimed to compare the impact of HS and TS intake on systolic blood pressure (SBP) and diastolic blood pressure (DBP), and urinary sodium concentration in individuals with arterial hypertension. METHODS: This study recruited 17 female patients with arterial hypertension who ate out no more than once a week. Participants were randomized into two groups, to receive and consume either HS or TS. Before and after each intervention, participants had their blood pressure measured and urine collected for mineral analysis. A p-value < 0.05 was considered statistically significant. RESULTS: There were no statistically significant differences before and after the HS intervention for DBP (70mmHg vs. 68.5mmHg; p=0.977), SBP (118.5 mmHg vs. 117.5 mmHg; p= 0.932) and sodium urinary concentration (151 mEq/24h vs. 159 mEq/24; p=0.875). Moreover, the between-group analysis showed no significant differences after the intervention regarding SBP (117mmHg vs 119 mmHg; p=0.908), DBP (68.5 mmHg vs. 71mmHg; p= 0,645) or sodium urinary concentration (159 mEq/24h vs. 155 mEq/24h; p=0.734). CONCLUSION: This study suggests that there are no significant differences on the impact of HS consumption compared to TS on blood pressure and sodium urinary concentration in individuals with arterial hypertension.

FUNDAMENTO: O sal do Himalaia (SH) tornou-se uma alternativa popular para o sal de mesa (SM) devido às suas alegações de benefícios à saúde, principalmente para indivíduos com hipertensão arterial. Porém, apesar do aumento do consumo de SH, ainda faltam evidências clínicas que sustentem a recomendação de seu consumo por profissionais de saúde. OBJETIVO: Este estudo teve como objetivo comparar o impacto da ingestão de SH e SM sobre a pressão arterial sistólica (PAS), pressão arterial diastólica (PAD) e concentração de sódio urinário em indivíduos com PA. MÉTODOS: Este estudo recrutou 17 pacientes do sexo feminino com hipertensão arterial que comiam fora de casa no máximo uma vez por semana. Os participantes foram divididos aleatoriamente em dois grupos, para receber e consumir SH ou SM. Antes e depois de cada intervenção, os participantes tiveram sua pressão arterial medida e urina coletada para análise mineral. Um valor de p <0,05 foi considerado estatisticamente significativo. RESULTADOS: Não houve diferenças estatisticamente significativas antes e depois da intervenção SH para PAD (70 mmHg vs. 68,5 mmHg; p = 0,977), PAS (118,5 mmHg vs. 117,5 mmHg; p = 0,932) e concentração urinária de sódio (151 mEq / 24h vs. 159 mEq / 24; p = 0,875). Além disso, a análise entre os grupos não mostrou diferenças significativas após a intervenção em relação a PAS (117 mmHg vs 119 mmHg; p = 0,908), PAD (68,5 mmHg vs 71 mmHg; p = 0,645) ou concentração urinária de sódio (159 mEq / 24h vs 155 mEq / 24h; p = 0,734). CONCLUSÃO: Este estudo sugere que não há diferenças significativas no impacto do consumo de SH em relação ao SM na PA e concentração urinária de sódio em indivíduos com hipertensão arterial.