Brazilian Guidelines for In-office and Out-of-office Blood Pressure Measurement ­ 2023 / 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.

Importance of 24 h ambulatory blood pressure monitoring in patients with acromegaly and correlation with cardiac magnetic resonance findings.

INTRODUCTION: Arterial hypertension (AH) is prevalent in acromegaly, but few studies using 24-h ambulatory blood pressure monitoring (24 h-ABPM) suggest that its frequency may be different from office blood pressure (OBP). Left ventricular hypertrophy (LVH) is one of the most frequent cardiac abnormalities. Cardiac magnetic resonance (CMR) is considered the gold standard to evaluate the heart. OBJECTIVES: To compare the frequency of AH when measured by 24 h-ABPM and by OBP and to correlate BP with cardiac mass. METHODS: Patients over 18 years of age with acromegaly underwent OBP evaluation and were later referred to the 24 h-ABPM. Treatment-naïve patients were submitted to CMR. RESULTS: We evaluated 96 patients. From 29 non hypertensive patients by OBP, 9 had AH on 24 h-ABPM. In the group of patients with a previous diagnosis of AH by OBP, 25 had controlled BP and 42 had abnormal BP on 24 h-ABPM, when analyzed by OBP there were 28 with controlled BP. We observed a positive correlation between diastolic BP measured in 24 h-ABPM and IGF-I levels, but we did not observe the same correlation with age, sex, body mass index and GH levels. The CMR was performed in 11 patients. We found a positive correlation of left ventricular mass (LVM) and BP of 24 h-ABPM. In contrast, there was no correlation of OBP with CMR parameters. CONCLUSIONS: We observed, that 24 h-ABPM in acromegaly allows the diagnosis of AH in some patients with normal BP in OBP and also to allow a better treatment. 24 h-ABPM shows a better correlation with VM by CMR.

Addressing global disparities in blood pressure control: perspectives of the International Society of Hypertension.

ABSTRACT: Raised blood pressure (BP) is the leading cause of preventable death in the world. Yet, its global prevalence is increasing, and it remains poorly detected, treated, and controlled in both high- and low-resource settings. From the perspective of members of the International Society of Hypertension based in all regions, we reflect on the past, present, and future of hypertension care, highlighting key challenges and opportunities, which are often region-specific. We report that most countries failed to show sufficient improvements in BP control rates over the past three decades, with greater improvements mainly seen in some high-income countries, also reflected in substantial reductions in the burden of cardiovascular disease and deaths. Globally, there are significant inequities and disparities based on resources, sociodemographic environment, and race with subsequent disproportionate hypertension-related outcomes. Additional unique challenges in specific regions include conflict, wars, migration, unemployment, rapid urbanization, extremely limited funding, pollution, COVID-19-related restrictions and inequalities, obesity, and excessive salt and alcohol intake. Immediate action is needed to address suboptimal hypertension care and related disparities on a global scale. We propose a Global Hypertension Care Taskforce including multiple stakeholders and societies to identify and implement actions in reducing inequities, addressing social, commercial, and environmental determinants, and strengthening health systems implement a well-designed customized quality-of-care improvement framework.

Swallowing outcome to speech therapy intervention in resistant hypertensive patients with obstructive sleep apnea.

PURPOSE: To evaluate (i) the outcome of swallowing therapy program on the rehabilitation of oropharyngeal dysphagia in resistant hypertensive patients with obstructive sleep apnea (OSA) and (ii) the association between the clinical and anthropometric characteristics of these individuals and this outcome. METHODS: This was a prospective interventional study in which resistant hypertensives diagnosed with OSA by polysomnography and dysphagia by fiberoptic endoscopic evaluation of swallowing (FESS) participated. All participants underwent a FEES and assessment of the risk of dysphagia (Eating Assessment Tool, EAT-10) and swallowing-related quality of life (Swal-QoL) before and after the intervention. The therapeutic program was performed daily by the participants, with weekly speech-therapist supervision for eight weeks, including the following strategies: Masako, chin tuck against resistance, and expiratory muscle training. RESULTS: A total of 26 (78.8%) of the participants exhibited improvement in the degree of dysphagia in the intervention outcome. After the intervention, there was a statistically significant improvement in the level of penetration-aspiration (p = 0.007), the degree of pharyngeal residue (p = 0.001), the site of onset of the pharyngeal phase (p = 0.001), and the severity of dysphagia (p = 0.001) compared to before intervention. The EAT-10 score was 2 (0-6) before and 0 (0-3) after intervention (p = 0.023). Swal-QoL had a score on the symptom frequency domain of 92.8 (75-100) before and 98.2 (87.5-100) after intervention (p = 0.002). CONCLUSIONS: Resistant hypertensive patients with OSA showed improved swallowing performance after swallowing therapy program.

Fiberoptic endoscopic evaluation of swallowing and the Brazilian version of the Eating Assessment Tool-10 in resistant hypertensive patients with obstructive sleep apnea

Abstract Objective: The aim of this study was to describe the prevalence and characteristics of OD through Fiberoptic Endoscopic Evaluation of Swallowing (FEES) and the Eating Assessment Tool-10 (EAT-10) in hypertensive patients with OSA, as well as to describe the sensitivity of EAT-10 for the detection of OD in this population. Methods: This study included a convenience sample in which 85 resistant hypertensive patients diagnosed with OSA in an university hospital participated. Participants were subjected to the EAT-10 (index test) and FEES (reference standard). Results: The median EAT-10 score was 2 (0-5.5). According to the FEES, 27 participants did not have dysphagia, 42 had mild dysphagia and 16 had mild to moderate dysphagia. The sensitivity of the EAT-10 was 70.7% (95% CI: 57.3-81.9) at a cutoff score ≤1, with a discriminatory power of 67.4% (p = 0.005). The most prevalent symptom in this population was "food stuck in the throat", while the most prevalent signs were delayed initiation of the pharyngeal phase of swallowing, premature bolus spillage and pharyngeal residue. Conclusion: In our study, the cutoff score for the EAT-10 for screening for OD in this population was ≥ 1. In conclusion, this population presented a high prevalence of dysphagia detected in FEES and its severity is associated with higher EAT-10 scores.

Bedtime dosing of antihypertensive medications: systematic review and consensus statement: International Society of Hypertension position paper endorsed by World Hypertension League and European Society of Hypertension.

Antihypertensive drug therapy is one of the most efficient medical interventions for preventing disability and death globally. Most of the evidence supporting its benefits has been derived from outcome trials with morning dosing of medications. Accumulating evidence suggests an adverse prognosis associated with night-time hypertension, nondipping blood pressure (BP) profile and morning BP surge, with increased incidence of cardiovascular events during the first few morning hours. These observations provide justification for complete 24-h BP control as being the primary goal of antihypertensive treatment. Bedtime administration of antihypertensive drugs has also been proposed as a potentially more effective treatment strategy than morning administration. This Position Paper by the International Society of Hypertension reviewed the published evidence on the clinical relevance of the diurnal variation in BP and the timing of antihypertensive drug treatment, aiming to provide consensus recommendations for clinical practice. Eight published outcome hypertension studies involved bedtime dosing of antihypertensive drugs, and all had major methodological and/or other flaws and a high risk of bias in testing the impact of bedtime compared to morning treatment. Three ongoing, well designed, prospective, randomized controlled outcome trials are expected to provide high-quality data on the efficacy and safety of evening or bedtime versus morning drug dosing. Until that information is available, preferred use of bedtime drug dosing of antihypertensive drugs should not be routinely recommended in clinical practice. Complete 24-h control of BP should be targeted using readily available, long-acting antihypertensive medications as monotherapy or combinations administered in a single morning dose.

Prevalence and associated factors of obstructive sleep apnea in refractory hypertension.

BACKGROUND: Refractory hypertension (RfHT) and obstructive sleep apnea (OSA) share common pathophysiological mechanisms and probably are intrinsically associated, but their prevalence, clinical profile, and polysomnography (PSG) pattern remain misunderstood. OBJECTIVE: To describe OSA prevalence and PSG pattern of patients with RfHT in a large cohort of resistant hypertension (RHT). METHODS: This is a cross-sectional study involving 418 RHT patients (30.9% male; mean age of 62.5 ±â€Š9.9 years) who were submitted to full-night PSG. RfHT was defined as uncontrolled ambulatory blood pressure monitoring using five or more antihypertensive drugs, including spironolactone. Bivariate analysis compared RHT and RfHT and multivariate analysis was performed to assess the independent correlates of OSA. RESULTS: A total of 90 patients (21.5%) were diagnosed with RfHT (26.7% male; mean age of 58.5 ±â€Š8.3 years). In comparison with resistant ones, RfHT patients were younger, with higher smoking and previous cardiovascular diseases prevalence, especially stroke. There was no difference regarding anthropometric measures. OSA prevalence (80.0 vs. 82.9%) and moderate/severe OSA (51.1 vs. 57.0%) were similar in both groups as well as apnea-hypopnea index. In its turn, refractory hypertensive patients presented better sleep efficiency (78 vs. 71%), with higher total sleep time (315 vs. 281 min) and lower sleep latency (11 vs. 17 min). There was no difference regarding rapid eye movement sleep, oxygen saturation, microarousals index, and periodic limb movement. CONCLUSION: In this large RHT cohort, resistant and refractory hypertensive patients have similar OSA prevalence, although refractory ones, which by definition use spironolactone, are younger and apparently have a better sleep pattern.

Impact of Metabolic Risk Factors on COVID-19 Clinical Outcomes: An Extensive Review.

BACKGROUND: Cardiovascular (CV) risk factors, particularly cardiometabolic, seem to be associated with heightened severity and increased morbimortality in patients infected with the novel Coronavirus disease-2019 (COVID-19). METHODS: A thorough scoping review was conducted to elucidate and summarize the latest evidence for the effects of adverse cardiac metabolic profiles on the severity, morbidity, and prognosis of COVID-19 infection. RESULTS: The pathophysiology of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is complex, being characterized by viral-induced immune dysregulation and hypercytokinemia, particularly in patients with critical disease, evolving with profound endothelial dysfunction, systemic inflammation, and prothrombotic state. Moreover, cardiovascular comorbidities such as diabetes are the most prevalent amongst individuals requiring hospitalization, raising concerns towards the clinical evolution and prognosis of these patients. The chronic proinflammatory state observed in patients with cardiovascular risk factors may contribute to the immune dysregulation mediated by SARS-CoV-2, favoring more adverse clinical outcomes and increased severity. Cardiometabolism is defined as a combination of interrelated risk factors and metabolic dysfunctions such as dyslipidemia, insulin resistance, impaired glucose tolerance, and central adiposity, which increase the likelihood of vascular events, being imperative to specifically analyze its clinical association with COVID-19 outcomes. CONCLUSION: DM and obesity appears to be important risk factors for severe COVID-19. The chronic proinflammatory state observed in patients with excess visceral adipose tissue (VAT) possibly augments COVID-19 immune hyperactivity leading to more adverse clinical outcomes in these patients.

Fiberoptic endoscopic evaluation of swallowing and the Brazilian version of the Eating Assessment Tool-10 in resistant hypertensive patients with obstructive sleep apnea.

OBJECTIVE: The aim of this study was to describe the prevalence and characteristics of OD through Fiberoptic Endoscopic Evaluation of Swallowing (FEES) and the Eating Assessment Tool-10 (EAT-10) in hypertensive patients with OSA, as well as to describe the sensitivity of EAT-10 for the detection of OD in this population. METHODS: This study included a convenience sample in which 85 resistant hypertensive patients diagnosed with OSA in an university hospital participated. Participants were subjected to the EAT-10 (index test) and FEES (reference standard). RESULTS: The median EAT-10 score was 2 (0-5.5). According to the FEES, 27 participants did not have dysphagia, 42 had mild dysphagia and 16 had mild to moderate dysphagia. The sensitivity of the EAT-10 was 70.7% (95% CI: 57.3-81.9) at a cutoff score ≥1, with a discriminatory power of 67.4% (p = 0.005). The most prevalent symptom in this population was "food stuck in the throat", while the most prevalent signs were delayed initiation of the pharyngeal phase of swallowing, premature bolus spillage and pharyngeal residue. CONCLUSION: In our study, the cutoff score for the EAT-10 for screening for OD in this population was ≥ 1. In conclusion, this population presented a high prevalence of dysphagia detected in FEES and its severity is associated with higher EAT-10 scores.

Association between arterial stiffness and sleep apnoea in patients with resistant hypertension.

Resistant Hypertension (RHT) is associated with a higher risk of Obstructive Sleep Apnoea (OSA). OSA and aortic stiffness (AS) measured by Pulse Wave Velocity (PWV) are independent risk factors for cardiovascular events. We assessed, in a cross-sectional study, the association between AS measured by PWV and OSA severity in patients with RHT. All patients were submitted to polysomnography, PWV measure and 24 h ABPM. Bivariate analysis compared patients with and without moderate/severe OSA. Multivariate analysis was performed to assess the independent correlates of moderate/severe OSA. A total of 376 patients were included, 31% were men with a mean age of 63 ± 10 years. Moderate/severe OSA was diagnosed in 214 patients (57%), 63 patients (17%) presented AS. Uncontrolled ABPM (true RHT) was found in 215 patients (57.2%) and among them 113 were diagnosed with moderate/severe OSA. Evaluating AS in patients with mild, moderate and severe apnoea, we observed a progressive increase in PWV (8.19 ± 1.55, 8.51 ± 1.84, 8.67 ± 1.68, respectively). Classifying them in 2 groups: (1) without apnoea/mild apnoea and (2) moderate/severe apnoea, we found higher values in group 2 (8.21 ± 1.52 m/s vs. 8.60 ± 1.75 m/s, p = 0.02), especially among true RHT patients (8.28 ± 1.62 vs. 8.81 ± 1.86, p = 0.029), women (8.13 ± 1.49 vs. 8.55 ± 1.73, p = 0.036), and uncontrolled nocturnal systolic BP (8.49 ± 1.63 vs. 8.58 ± 1.78, p = 0.04). In conclusion, in this RHT cohort, although with borderline results, the more severe the apnoea, the greater the arterial stiffness, mainly among women, true RHT and patients with an adverse nocturnal BP profile.

Fiberoptic Endoscopic Evaluation of Swallowing in Resistant Hypertensive Patients With and Without Sleep Obstructive Apnea.

Resistant arterial hypertension (RAH) is strongly associated with obstructive sleep apnea (OSA). Individuals with OSA may have subclinical swallow impairment, diagnosed by instrumental assessments, such as videofluoroscopy and fiberoptic endoscopic evaluation of swallowing (FEES). However, few studies have evaluated this population and included a control group of individuals without OSA. To evaluate, through FEES, the swallowing characteristics of resistant hypertensive patients with and without OSA and to investigate the association between the signs of swallow impairment and OSA. This was an observational study in which individuals with RAH underwent baseline polysomnography and were diagnosed with and without OSA. All participants underwent an initial assessment with the collection of demographic characteristics and FEES. Individuals were divided into 2 groups based on the presence or absence of OSA. Seventy-nine resistant hypertensive patients were evaluated: 60 with OSA (19 with mild OSA, 21 with moderate OSA, and 20 with severe OSA) and 19 without OSA. The most prevalent swallowing differences between groups with and without OSA were piecemeal deglutition, in 61.7% and 31.6%, respectively (p = 0.022); spillage, in 58.3% and 21.1% (p = 0.005); penetration/aspiration, in 55% and 47.4% (p = 0.561); and pharyngeal residue, in 51.5% and 26.3% (p = 0.053). The prevalence of swallow impairment among the participants in this study was 58.3% and 47.4% in the groups with OSA and without OSA, respectively (p = 0.402). This study shows a high prevalence of swallow impairment both in hypertensive patients with OSA and without OSA. The characteristics of swallowing associated with hypertensive patients with OSA are spillage, piecemeal deglutition, and the onset of the pharyngeal phase in the hypopharynx.

A review of Covid-19 and acute kidney injury: from pathophysiology to clinical results / Uma revisão da Covid-19 e lesão renal aguda: da fisiopatologia aos resultados clínicos

Abstract Acute kidney injury (AKI) in hospitalized patients with COVID-19 is associated with higher mortality and a worse prognosis. Nevertheless, most patients with COVID-19 have mild symptoms, and about 5% can develop more severe symptoms and involve hypovolemia and multiple organ dysfunction syndrome. In a pathophysiological perspective, severe SARS-CoV-2 infection is characterized by numerous dependent pathways triggered by hypercytokinemia, especially IL-6 and TNF-alpha, leading to systemic inflammation, hypercoagulability, and multiple organ dysfunction. Systemic endotheliitis and direct viral tropism to proximal renal tubular cells and podocytes are important pathophysiological mechanisms leading to kidney injury in patients with more critical infection, with a clinical presentation ranging from proteinuria and/or glomerular hematuria to fulminant AKI requiring renal replacement therapies. Glomerulonephritis, rhabdomyolysis, and nephrotoxic drugs are also associated with kidney damage in patients with COVID-19. Thus, AKI and proteinuria are independent risk factors for mortality in patients with SARS-CoV-2 infection. We provide a comprehensive review of the literature emphasizing the impact of acute kidney involvement in the evolutive prognosis and mortality of patients with COVID-19.

Resumo A lesão renal aguda (LRA) em pacientes hospitalizados com COVID-19 está associada a maior mortalidade e um pior prognóstico. No entanto, a maioria dos pacientes com COVID-19 tem sintomas leves e cerca de 5% podem desenvolver sintomas mais graves e envolver hipovolemia e síndrome de disfunção de múltiplos órgãos. Em uma perspectiva fisiopatológica, a infecção grave por SARS-CoV-2 é caracterizada por numerosas vias dependentes desencadeadas por hipercitocinemia, especialmente IL-6 e TNF-alfa, levando à inflamação sistêmica, hipercoagulabilidade e disfunção de múltiplos órgãos. A endotelite sistêmica e o tropismo viral direto às células tubulares proximais renais e podócitos são mecanismos fisiopatológicos importantes que levam à lesão renal em pacientes com infecção mais crítica, com uma apresentação clínica que varia de proteinúria e/ou hematúria glomerular a LRA fulminante, exigindo terapias renais substitutivas. Glomerulonefrite, rabdomiólise e drogas nefrotóxicas também estão associadas a danos renais em pacientes com COVID-19. Assim, a LRA e a proteinúria são fatores de risco independentes para mortalidade em pacientes com infecção por SARS-CoV-2. Fornecemos uma revisão abrangente da literatura, enfatizando o impacto do envolvimento renal agudo no prognóstico evolutivo e na mortalidade de pacientes com COVID-19.

COVID-19 and chronic kidney disease: a comprehensive review / COVID-19 e doença renal crônica: uma revisão abrangente

Abstract Kidney impairment in hospitalized patients with SARS-CoV-2 infection is associated with increased in-hospital mortality and worse clinical evolution, raising concerns towards patients with chronic kidney disease (CKD). From a pathophysiological perspective, COVID-19 is characterized by an overproduction of inflammatory cytokines (IL-6, TNF-alpha), causing systemic inflammation and hypercoagulability, and multiple organ dysfunction syndrome. Emerging data postulate that CKD under conservative treatment or renal replacement therapy (RRT) is an important risk factor for disease severity and higher in-hospital mortality amongst patients with COVID-19. Regarding RAAS blockers therapy during the pandemic, the initial assumption of a potential increase and deleterious impact in infectivity, disease severity, and mortality was not evidenced in medical literature. Moreover, the challenge of implementing social distancing in patients requiring dialysis during the pandemic prompted national and international societies to publish recommendations regarding the adoption of safety measures to reduce transmission risk and optimize dialysis treatment during the COVID-19 pandemic. Current data convey that kidney transplant recipients are more vulnerable to more severe infection. Thus, we provide a comprehensive review of the clinical outcomes and prognosis of patients with CKD under conservative treatment and dialysis, and kidney transplant recipients and COVID-19 infection.

Resumo O comprometimento renal em pacientes hospitalizados com infecção por SARS-CoV-2 está associado ao aumento da mortalidade hospitalar e pior evolução clínica, levantando preocupações em relação a pacientes com doença renal crônica (DRC). De uma perspectiva fisiopatológica, a COVID-19 é caracterizada por uma superprodução de citocinas inflamatórias (IL-6, TNF-alfa), causando inflamação sistêmica e hipercoagulabilidade, e síndrome de disfunção de múltiplos órgãos. Dados emergentes postulam que a DRC sob tratamento conservador ou terapia renal substitutiva (TRS) é um fator de risco importante para a gravidade da doença e maior mortalidade hospitalar entre pacientes com COVID-19. Em relação à terapia com bloqueadores RAAS durante a pandemia, havia uma suposição inicial de que a classe pudesse causar um aumento potencial na infectividade, e impacto deletério na gravidade da doença e mortalidade, mas que não foi confirmada na literatura médica. Além disso, o desafio de implementar o distanciamento social em pacientes que necessitam de diálise durante a pandemia incentivou sociedades nacionais e internacionais a publicar recomendações sobre a adoção de medidas de segurança para reduzir o risco de transmissão e otimizar o tratamento de diálise durante a pandemia COVID-19. Os dados atuais mostram que os receptores de transplante renal são mais vulneráveis a infecções mais graves. Assim, fizemos uma revisão abrangente dos desfechos clínicos e prognóstico de pacientes com DRC sob tratamento conservador e diálise, e receptores de transplante renal e infecção por COVID-19.

Cardiovascular Risk Profile of a Young Adult Women Population Assisted in Primary Care

Abstract Background Although cardiovascular disease is a major cause of death among women, cardiovascular risk assessment in young women is frequently postponed due to a number of factors. Objectives To assess cardiovascular risk of young adult women living in one of Rio de Janeiro's Family Health Strategy geographical units in the city's central area. Materials and Methods populational, cross-sectional study with adults between 20 and 50 years old. Sociodemographic characteristics such as educational level and employment status were recorded. Anthropometric measurements, traditional cardiovascular risk factors, gynecological and gestational history, and selected laboratory exams were assessed. The bivariate analysis compared the baseline characteristics of the population between genders and the prevalence of cardiovascular risk factors in women according to educational level and occupation status, using non-paired Student's t-test for normal continuous variables, Mann-Whitney test for asymmetrical continuous variables, and chi-square test for categorical variables. A significance level of 5% (p < 0.05) was adopted. Results A total of 710 individuals were enrolled. In women, who comprised 59.7% of our sample, central obesity and a sedentary lifestyle were more prevalent, whereas smoking and hypertension were less observed. However, women with lower educational status had a higher prevalence of smoking and hypertension. In hypertensive women, factors such as early menopause, higher prevalence of hypertensive disorders of pregnancy and higher number of pregnancies were noticed. Conclusion An adverse cardiovascular risk profile in our population of young women was particularly influenced by central obesity, sedentary lifestyle, hypertensive disorders of pregnancy and lower educational status.

Potential Impact of the New American High Blood Pressure Guidelines on Hypertension Prevalence in a Primary Health Care Unit in Rio de Janeiro - the LapARC Study

Abstract Background The new American Heart Association guidelines for hypertension (HT) proposed a reduction of the diagnostic cut-off point, leading to a substantial increase in the prevalence of HT. Objectives To assess the prevalence of HT determined by the traditional criteria, the AHA criteria, and home blood pressure monitoring (HBPM) in a population of young adults attending a primary healthcare unit, and its association with cardiovascular risk. Methods A cross-sectional population study on adults aged from 20 to 50 years attending a primary healthcare unit, in Rio de Janeiro, Brazil. Sociodemographic and anthropometric data, cardiovascular risk factors, office blood pressure and HBPM were registered. The diagnosis of HT was defined by traditional criteria (office BP ≥ 140 x 90 mmHg) and by the new (AHA) criteria (office BP ≥ 130 x 80 mmHg). Bivariate analysis was used for comparisons between the two diagnostic criteria, and Kappa coefficient was used to assess the agreement in diagnosis between office BP and HBPM. The level of significance adopted was 5% (p<0.05). Results A total of 472 individuals were evaluated (male: 39%; mean age: 38.5 ± 8.7 years). The prevalence of HT was 23.5% and raised to 41.1% with the new AHA criteria. The prevalence of HT using HBPM was 25.5%, but the diagnostic agreement was low (kappa=0.028) with changes in diagnosis in 18% of the cases. Conclusion The prevalence of HT almost doubled with the new AHA diagnostic criteria for HT. HBPM seemed to be an important instrument in HT diagnosis in this population. (Int J Cardiovasc Sci. 2021; [online].ahead print, PP.0-0)