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.

Prevalence and Factors Associated with Metabolic Syndrome in Patients at a Psychosocial Care Center: A Cross-Sectional Study.

BACKGROUND: Metabolic syndrome (MS) is associated with greater risk of morbimortality and it has high prevalence in people with mental illness. OBJECTIVE: Estimate the prevalence of Metabolic Syndrome (MS) and its associated factors in the patients of a Psychosocial Care Center (CAPS in Brazilian Portuguese) in the city of Salvador, state of Bahia, Brazil. METHOD: Cross-sectional study set at CAPS in the city of Salvador-Bahia between August 2019 and February 2020. MS was evaluated according to the National Cholesterol Education Program's Adult Treatment Panel III. In addition to descriptive statistics, gross and adjusted prevalence ratios were described. RESULTS: MS was found in 100 (35.2%) individuals, 116 (40.9%) were obese and 165 (58.1%) had increased waist circumference. Polypharmacy was identified in 63 (22.3%) patients and 243 (85.9%) used antipsychotics. Under gross evaluation, women (PR = 1.88; 95%CI: 1.35-2.63) and those who used antidepressants (PR = 1.41; 95%CI: 1.05-1.88) showed an association with MS. After logistic regression, depression (PR = 1.86; 95%CI: 1.38-2.51), acanthosis (PR = 1.50; 95%CI: 1.18-1.90), use of antipsychotics (PR = 1.88; 95%CI: 1.13-2.75), and hypertriglyceridemic waist (PR = 3.33; 95%CI: 2.48-4.46) were associated with MS. CONCLUSION: The prevalence of MS signals multimorbidity among individuals with mental disorders and suggests a need for clinical screening.

Mortality from Cardiovascular Diseases: A Comparative Analysis between the Medical and Non-Medical Populations in Brazil

Abstract Background: Cardiovascular disease (CVD) is the leading cause of death worldwide, including among physicians. Professional peculiarities increase cardiovascular risk in this population, making it relevant to analyze mortality in the medical population (MPop) and non-medical population (NMPop). Objectives: To compare the CVD mortality coefficient (MC) in between MPop and NMPop in Brazil by analyzing the epidemiological profile and the main causes of deaths from CVD. Methods: Time-series study with data obtained from the Mortality Information System of the Federal Council of Medicine and the Brazilian Institute of Geography and Statistics, from 2014 to 2018. The variables age group, sex, race, occupation, and CVD that caused the death were assessed in MPop and NMPop. MC, relative risk and odds ratio between the populations were calculated. Tests for difference in proportions, with approximation to the normal distribution, and chi-squared tests were performed, assuming p<0.01 as statistically significant. Results: Both MPop and NMPop had a predominance of men (86.7% and 52.3%), senior citizens (85.9% and 79.7%) and white individuals (86.4% and 52.2%). The MCs of the MPop and NMPop was 92.2 and 255.1 deaths/100,000 individuals, respectively. The main cause of death was acute myocardial infarction (AMI) (32.5% and 24.6% in MPop and NMPop, respectively) followed by cerebrovascular accident (CVA) (5.1% and 10.5% in MPop and NMPop, respectively). Conclusion: In Brazil, mortality from CVD was more prevalent in white elderly males, and mainly caused by AMI and CVA. Being a doctor, man and over 60 years old represents a greater chance of death from CVD in comparison with non-physicians.

Interaction between Work and Metabolic Syndrome: A Population-Based Cross-Sectional Study.

Metabolic syndrome (MS) is a clinical condition and a relevant risk factor in the development of cardiovascular diseases; it occurs as a result of lifestyle factors, e.g., work. The aim of this research was to estimate the interaction between work and MS among primary health care (PHC) nursing professionals in the state of Bahia, Brazil. A sectional multicentered study carried out in 43 municipalities in Bahia, whose study population consisted of nursing professionals. The exposure variables were occupation, professional exhaustion, and working time, and the outcome variable was MS. Interaction measures based on the additivity criteria were verified by calculating the excess risks due to the interactions and according to the proportion of cases attributed to the interactions and the synergy index. The global MS prevalence is 24.4%. There was a greater magnitude in the exposure group regarding the three investigated factors (average level occupation, professional exhaustion, and working time in PHC for more than 5 years), reaching an occurrence of 44.9% when compared to the prevalence of 13.1% in the non-exposure group (academic education, without professional burnout, and working time in PHC for up to 5 years). The study's findings showed a synergistic interaction of work aspects for MS occurrence among PHC nursing professionals.

Prevalência de síndrome metabólica e rigidez arterial em uma amostra populacional de Salvador, Bahia / Prevalence of metabolic syndrome and arterial stiffness in a population sample from Salvador, Bahia

As Doenças Cardiovasculares (DCV) são alterações nos vasos sanguíneos decorrentes, principalmente, da aterosclerose, e representam 28% dos óbitos anuais no Brasil. Em 2013, a prevalência de DCV era de 4,2% na população adulta e 11,4% nos idosos. A Síndrome Metabólica (SM), cuja prevalência é estimada entre 25 e 30%, é um dos principais fatores de risco para a instalação das DCV, assim como a Rigidez Arterial (RA), determinada pela Velocidade de Onda de Pulso (VOP) alterada. O Sistema Sphygmocor é utilizado para mensuração da VOP através da razão entre enrijecimento arterial, elasticidade e complacência vascular, considerando valores normais aqueles abaixo de 10m/s. A VOP foi o método de escolha, junto a medidas antropométricas e exames laboratoriais, para avaliar a prevalência de SM e RA numa amostra populacional de Salvador, Bahia. O teste T de Student foi utilizado para comparar as variáveis e o teste Qui Quadrado, para comparar as proporções das variáveis qualitativas. O cálculo das prevalências foi realizado com o número de indivíduos com RA ou SM no numerador e o número total da amostra no denominador, com resultado multiplicado por 102 . O estudo foi aprovado pelo Comitê de Ética em Pesquisa através do parecer número 1.827.621 de 21 de novembro de 2016. A amostra de 162 participantes demonstrou prevalência de 25,93% de Síndrome Metabólica e 26,57% de Rigidez Arterial, expondo a importância de maior atenção à prevenção das DCV na atenção primária à Saúde.

Cardiovascular Diseases (CVD) are modifications in blood vessels resulting mainly from atherosclerosis and represent 28% of annual deaths in Brazil. In 2013, the prevalence of CVD was 4.2% in the adult population and 11.4% in the elderly. Metabolic Syndrome (MS), whose prevalence is estimated between 25 and 30%, is one of the main risk factors for the settlement of CVD, as well as Arterial Stiffness (AS), determined by altered Pulse Wave Velocity (PWV). The Sphygmocor System is used to measure PWV through the ratio between arterial stiffening, elasticity, and vascular complacency, considering normal valor those below 10m/s. PWV was the method of choice, with anthropometric measurements and laboratory tests, to evaluate the prevalence of MS and AS in a population sample from Salvador, Bahia. The Student's T test was used to compare the variables and the Chi Square test to compare the proportions of the qualitative variables. The calculation of prevalence was made with the number of individuals with AS or MS in the numerator and the total number of sample in the denominator, with the result multiplied by 102. The study was approved by the Research Ethics Committee through opinion number 1,827,621 of November 21, 2016. The sample of 162 participants showed a prevalence of 25.93% of Metabolic Syndrome and 26.57% of Arterial Stiffness, exposing the importance of greater attention to the prevention of CVD in primary health care.

Impacto da hipertensão arterial na prevalência do pé diabético no Brasil: uma análise de 10 anos / Impact of hypertension on the prevalence of diabetic foot in Brazil: a 10-year analysis

Introdução: O diabetes mellitus é uma doença de alta prevalência, tanto em países em desenvolvimento quanto nos países desenvolvidos tendo como um dos seus principais fatores risco a hipertensão arterial e como uma de suas complicações vasculares o desenvolvimento do pé diabético. Objetivo: Realizar uma comparação entre a prevalência do pé diabético entre indivíduos diabéticos normotensos e indivíduos diabéticos hipertensos para definir se a hipertensão atua como fator agravador dessa complicação. Método: Estudo epidemiológico, descritivo e retrospectivo, com dados retirados do departamento de informática do sistema único de saúde (DATASUS), através do TABNET pelo programa HIPERDIA, que acompanha indivíduos hipertensos e/ou diabéticos. O período analisado foi janeiro de 2002 até janeiro de 2012, totalizando 10 anos de análise. Os dados referentes às variáveis "diabetes tipo 01" e "diabetes tipo 02" foram somadas, formando o grupo de indivíduos diabéticos normotensos. E os dados referentes à variável "hipertensão com diabetes" formou o grupo de indivíduos diabéticos hipertensos. Desses grupos, foi selecionado os indivíduos com pé diabéticos e esses dados foram sumarizados, a partir de cálculos de proporção, agrupados no Excel® e foi aplicado o teste exato de Fisher. Resultados: A proporção do pé diabético em indivíduos diabéticos normotensos foi de 3,14%, já em indivíduos diabéticos hipertensos foi de 4,38%, sendo seus dados estatisticamente significante (OR: 1,43; IC 95%, 1,34-1,51; p <0,001). O perfil epidemiológico de diabéticos normotensos tem maior prevalência no sexo masculino, em 50-54 anos, 24,05% tabagistas e 30,41% com sobrepeso. Os diabéticos hipertensos apresentam maior prevalência no sexo feminino, em 60-64 anos, 30,48% tabagistas e 46,51% com sobrepeso. Conclusão: Conclui-se que a hipertensão arterial atua como um significante fator agravador para o desenvolvimento do pé diabético. Sendo assim, diante da escassez de estudos, o presente trabalho mostra-se relevante, servindo como base na compreensão dos aspectos epidemiológicos acerca da relação entre diabetes e hipertensão.

Introduction: Diabetes mellitus is a disease of high prevalence, both in developing and developed countries, having as one of its main risk factors hypertension and as one of its vascular complications the development of diabetic foot. Objective: To compare the prevalence of diabetic foot between normotensive diabetic and hypertensive diabetic individuals to define if hypertension acts as an aggravating factor of this complication. Method: Epidemiological, descriptive and retrospective study, with data taken from the informatics department of the single health system (DATASUS), through TABNET, where was accessed the HIPERDIA program, which follows hypertensive and / or diabetic individuals. The period analyzed was from January 2002 to January 2012, totaling 10 years of analysis. Data referring to the variables "type 01 diabetes" and "type 02 diabetes" were summed, forming the group of normotensive diabetic individuals. And data regarding the variable "hypertension with diabetes" formed the group of hypertensive diabetic individuals. From these groups, we selected individuals with diabetic foot and these data were summarized from proportion calculations, grouped in Excel® and Fisher's exact test was applied. Results: The proportion of diabetic foot in normotensive diabetic individuals was 3.14%, while in hypertensive diabetic individuals it was 4.38%, with statistically significant data (OR: 1.43; 95% CI 1.34- 1.51; p <0.001). The epidemiological profile of normotensive diabetics is more prevalent among males, aged 50-54 years, 24.05% smokers and 30.41% overweight. Hypertensive diabetics are more prevalent in females, aged 60-64 years, 30.48% smokers and 46.51% overweight. Conclusion: It is concluded that hypertension acts as a significant aggravating factor for the development of diabetic foot. Thus, given the scarcity of studies, the present study is relevant, serving as a basis for understanding the epidemiological aspects of the relationship between diabetes and hypertension.

The Prevalence of Abdominal Adiposity among Primary Health Care Physicians in Bahia, Brazil: An Epidemiological Study.

BACKGROUND: Labor activities are demanding for workers and can induce occupational stress. Primary health care (PHC) workers have faced problems that can lead to the development of stress and abdominal obesity. The aim of this study was to estimate the prevalence of abdominal adiposity among primary health care physicians in the metropolitan mesoregion of Salvador, Bahia. METHODS: This is a cross-sectional study conducted with physicians from the family health units (FHUs) of the metropolitan mesoregion of Salvador, Bahia, Brazil. The number of FHUs corresponded to 41 teams (52 physicians). Anamnesis was performed and a questionnaire was applied. The clinical examination consisted of measuring waist circumference (WC), blood pressure levels (BP), and body mass index (BMI), as well as examining for acanthosis nigricans. Blood samples were collected for biochemical dosages. The data obtained were analyzed by SPSS version 22.0. RESULTS: The sample included 41 physicians (response rate: 78.8%), of which 18 were women (44.0%). The percentage of overweight participants represented by BMI was 31.7%. The hypertriglyceridemia prevalence was 29.2%. HDL-c was low in 48.7% of the participants. The waist circumference measurement revealed a prevalence of abdominal adiposity of 38.8% (women) and 34.8% (men). CONCLUSIONS: Medical professionals in PHC are more susceptible to having higher abdominal adiposity, especially female physicians.

Association between metabolic syndrome and work: an integrative review of the literature.

The aim of this study was to highlight the association between occupational aspects and the occurrence of metabolic syndrome among various occupational groups. This is an integrative review of the literature that included articles indexed in the following databases: LILACS, SciELO, PubMed, and CINAHL. We evaluated 32 articles, most of which were published in Englishlanguage medical journals and with level 4 scientific evidence. The occupational aspects most commonly reported as associated with metabolic syndrome were occupation, work shift, and occupational stress. Our results indicated that occupational aspects could negatively interfere with workers' health; more robust longitudinal studies should contribute to further uncovering the reported associations.

Metabolic Syndrome Among Primary Health Care Nursing Professionals: A Cross-Sectional Population-Based Study.

This research aims at evaluating prevalence and factors associated with metabolic syndrome (MS) in primary health care (PHC) nursing professionals. A multicenter, population-based and cross-sectional study was conducted in a team-tested sample of 1125 PHC nurses in the state of Bahia, Brazil. Sociodemographic, labor, lifestyle and human biology variables were investigated by mean of anamnesis. MS was evaluated according to the criteria of the first Brazilian Guideline for Metabolic Syndrome, which fully adopts the criteria of the National Cholesterol Education Program's Adult Treatment Panel III. MS-associated factors were tested by using robust Poisson Regression. The prevalence of MS found was 24.4%; low High Density Lipoprotein (HDL) cholesterol was the most prevalent component of the syndrome. In the multivariate analysis, physical inactivity (PR = 1.25, 95% CI = 1.02-1.53), alcohol use (PR = 1.84, 95% CI = 1.22-2.77), acanthosis nigricans (PR = 3.23, 95% CI = 2.65-3.92), burnout syndrome (PR = 1.45, 95% CI = 1.17-1.81), (PR = 1.37, 95% CI = 1.12-1.69), working as a nursing technician (PR = 1.43, 95% CI = 1.14-1.80), were associated to MS. It was found that the prevalence of MS was high, which evidences the need for interventions in the PHC environment, improvement of working conditions, monitoring of worker safety and health, diet programs and physical activity.

Conceito e aspectos epidemiológicos da hipertensão arterial / Concepts and epidemiological aspects of arterial hypertension

Este artigo trata na primeira parte dos conceitos fisiológicos de pressão arterial, depois dos conceitos patológicos da Hipertensão Arterial Sistêmicas (HAS), sua importância seus desafios. Incorporamos conceitos de Epidemiologia Básica. As medidas de ocorrências mais importantes como prevalência de HAS, no Brasil e no mundo, as proporções das mortes cardiovasculares em nosso meio com suas taxas proporcionais. Concluindo que é alta a prevalência de HAS sua mortalidade vem crescente e dentre muitas causas pode perceber os crescentes fatores de risco cardiovasculares bem como o subfinancia mento do Sistema único de saúde (SUS).

This article deals in the first part of the physiological concepts of blood pressure, after the pathological concepts of Systemic Arterial Hypertension (SAH), its importance its challenges. We incorporate concepts of Basic Epidemiology. The most important measures such as the prevalence of SAH in Brazil and in the world, the proportions of cardiovascular deaths in our country with their proportional rates. Concluding that the prevalence of hypertension is high, its mortality is increasing and among many causes can perceive the increasing cardiovascular risk factors as well as the underfunding of the single health system (SUS).