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.

Can blood pressure decrease after maximal exercise test predict the blood pressure lowering effect of aerobic training in treated hypertensive men?

The acute decrease in blood pressure (BP) observed after a session of exercise (called post-exercise hypotension) has been proposed as a tool to predict the chronic reduction in BP induced by aerobic training. Therefore, this study investigated whether post-exercise hypotension observed after a maximal exercise test is associated to the BP-lowering effect of aerobic training in treated hypertensives. Thirty hypertensive men (50 ± 8 years) who were under consistent anti-hypertensive treatment underwent a maximal exercise test (15 watts/min until exhaustion), and post-exercise hypotension was determined by the difference between BP measured before and at 30 min after the test. Subsequently, the patients underwent 10 weeks of aerobic training (3 times/week, 45 min/session at moderate intensity), and the BP-lowering effect of training was assessed by the difference in BP measured before and after the training period. Pearson correlations were employed to evaluate the associations. Post-maximal exercise test hypotension was observed for systolic and mean BPs (-8 ± 6 and -2 ± 4 mmHg, all P < 0.05). Aerobic training reduced clinic systolic/diastolic BPs (-5 ± 6/-2 ± 3 mmHg, both P < 0.05) as well as awake and 24 h mean BPs (-2 ± 6 and -2 ± 5 mmHg, all P < 0.05). No significant correlation was detected between post-exercise hypotension and the BP-lowering effect of training either for clinic or ambulatory BPs (r values ranging from 0.00 to 0.32, all p > 0.05). Post-exercise hypotension assessed 30 min after a maximal exercise test cannot be used to predict the BP-lowering effect of aerobic training in treated hypertensive men.

Comparison of morning versus evening aerobic-exercise training on heart rate recovery in treated hypertensive men: a randomized controlled trial.

Heart rate recovery (HRR) is a marker of cardiac autonomic regulation and an independent predictor of mortality. Aerobic-exercise training conducted in the evening (evening training) produces greater improvement in resting cardiac autonomic control in hypertensives than morning training, suggesting it may also result in a faster autonomic restoration postexercise. This study compared the effects of morning training and evening training on HRR in treated hypertensive men. Forty-nine treated hypertensive men were randomly allocated into three groups: morning training, evening training and control. Training was conducted three times/week for 10 weeks. Training groups cycled (45 min, moderate intensity) while control group stretched (30 min). In the initial and final assessments of the study, HRR60s and HRR300s were evaluated during the active recovery (30 W) from cardiopulmonary exercise tests (CPET) conducted in the morning and evening. Between-within ANOVAs were applied (P ≤ 0.05). Only evening training increased HRR60s and HRR300 differently from control after morning CPET (+4 ± 5 and +7 ± 8 bpm, respectively, P < 0.05) and only evening training increased HRR300s differently from morning training and control after evening CPET (+8 ± 6 bpm, P < 0.05). Evening training improves HRR in treated hypertensive men, suggesting that this time of day is better for eliciting cardiac autonomic improvements via aerobic training in hypertensives.

Significado clínico da hipertensão durante o sono / Clinical meaning of hypertension during sleep

A anormalidade da pressão arterial durante o período de sono identificada como médias ≥ 120 x 70 mm Hg, por meio de registros da Monitorização Ambulatorial da Pressão Arterial de 24 horas (MAPA), está relacionada a pior prognóstico e maior risco de eventos. Essa alteração pode ser decorrência de vários fatores, mas, geralmente, independentemente da causa está fortemente relacionada a maior probabilidade de eventos e mortalidade cardiovasculares. Ainda restam dúvidas, embora evidências começam a ser oferecidas, se o tratamento medicamentoso desse estado de comportamento peculiar da pressão arterial nas 24 horas deva ser instituído. Nessa revisão esses aspectos são amplamente discutidos com base nas melhores evidências disponíveis

The abnormality of blood pressure during the sleep period identified as means ≥ 120 x 70 mm Hg, through 24-hour Ambulatory Blood Pressure Monitoring (ABPM) records, is related to a worse prognosis and greater risk of events. This change can be due to several factors, but, generally, regardless of the cause, it is strongly related to a higher probability of cardiovascular events and mortality. Doubts remain, although evidence is beginning to be offered, whether drug treatment of this peculiar behavioral state of blood pressure within 24 hours should be instituted. In this review, these aspects are widely discussed based on the best available evidence

Poor sleep quality is associated with cardiac autonomic dysfunction in treated hypertensive men.

Hypertensives present cardiac autonomic dysfunction. Reduction in sleep quality increases blood pressure (BP) and favors hypertension development. Previous studies suggested a relationship between cardiovascular autonomic dysfunction and sleep quality, but it is unclear whether this association is present in hypertensives. Thus, this study evaluated the relationship between sleep quality and cardiac autonomic modulation in hypertensives. Forty-seven middle-aged hypertensive men under consistent anti-hypertensive treatment were assessed for sleep quality by the Pittsburgh Sleep Quality Index (PSQI-higher score means worse sleep quality). Additionally, their beat-by-beat BP and heart rate (HR) were recorded, and cardiac autonomic modulation was assessed by their variabilities. Mann-Whitney and t tests were used to compare different sleep quality groups: poor (PSQI > 5, n = 24) vs good (PSQI ≤ 5, n = 23), and Spearman's correlations to investigate associations between sleep quality and autonomic markers. Patients with poor sleep quality presented lower cardiac parasympathetic modulation (HR high-frequency band = 26 ± 13 vs 36 ± 15 nu, P = .03; HR total variance = 951 ± 1373 vs 1608 ± 2272 ms2 , P = .05) and cardiac baroreflex sensitivity (4.5 ± 2.3 vs 7.1 ± 3.7 ms/mm Hg, P = .01). Additionally, sleep quality score presented significant positive correlation with HR (r = +0.34, P = .02) and negative correlations with HR high-frequency band (r = -0.34, P = .03), HR total variance (r = -0.35, P = .02), and cardiac baroreflex sensitivity (r = -0.42, P = .01), showing that poor sleep quality is associated with higher HR and lower cardiac parasympathetic modulation and baroreflex sensitivity. In conclusion, in treated hypertensive men, poor sleep quality is associated with cardiac autonomic dysfunction.

Effects of postexercise cooling on heart rate recovery in normotensive and hypertensive men.

BACKGROUND: Postexercise heart rate recovery (HRR) is determined by cardiac autonomic restoration after exercise and is reduced in hypertension. Postexercise cooling accelerates HRR in healthy subjects, but its effects in a population with cardiac autonomic dysfunction, such as hypertensives (HT), may be blunted. This study assessed and compared the effects of postexercise cooling on HRR and cardiac autonomic regulation in HT and normotensive (NT) subjects. METHODS: Twenty-three never-treated HT (43 ± 8 years) and 25 NT (45 ± 8 years) men randomly underwent two exercise sessions (30 min of cycling at 70% VO2peak ) followed by 15 min of recovery. In one randomly allocated session, a fan was turned on in front of the subject during the recovery (cooling), while in the other session, no cooling was performed (control). HRR was assessed by heart rate reductions after 60 s (HRR60s) and 300 s (HRR300s) of recovery, short-term time constant of HRR (T30) and the time constant of the HRR after exponential fitting (HRRτ). HRV was assessed using time- and frequency-domain indices. RESULTS: HRR and HRV responses in the cooling and control sessions were similar between the HT and NT. Thus, in both groups, postexercise cooling equally accelerated HRR (HRR300s = 39±12 versus 36 ± 10 bpm, P≤0·05) and increased postexercise HRV (lnRMSSD = 1·8 ± 0·7 versus 1·6 ± 0·7 ms, P≤0·05). CONCLUSION: Differently from the hypothesis, postexercise cooling produced similar improvements in HRR in HT and NT men, likely by an acceleration of cardiac parasympathetic reactivation and sympathetic withdrawal. These results suggest that postexercise cooling equally accelerates HRR in hypertensive and normotensive subjects.

Morning versus Evening Aerobic Training Effects on Blood Pressure in Treated Hypertension.

INTRODUCTION: The acute blood pressure (BP) decrease is greater after evening than morning exercise, suggesting that evening training (ET) may have a greater hypotensive effect. OBJECTIVE: This study aimed to compare the hypotensive effect of aerobic training performed in the morning versus evening in treated hypertensives. METHODS: Fifty treated hypertensive men were randomly allocated to three groups: morning training (MT), ET, and control (C). Training groups cycled for 45 min at moderate intensity (progressing from the heart rate of the anaerobic threshold to 10% below the heart rate of the respiratory compensation point), while C stretched for 30 min. Interventions were conducted 3 times per week for 10 wk. Clinic and ambulatory BP and hemodynamic and autonomic mechanisms were evaluated before and after the interventions. Clinic assessments were performed in the morning (7:00-9:00 AM) and evening (6:00-8:00 PM). Between-within ANOVA was used (P ≤ 0.05). RESULTS: Only ET decreased clinic systolic BP differently from C and MT (morning assessment -5 ± 6 mm Hg and evening assessment -8 ± 7 mm Hg, P < 0.05). Only ET reduced 24 h and asleep diastolic BP differently from C and MT (-3 ± 5 and -3 ± 4 mm Hg, respectively, P < 0.05). Systemic vascular resistance decreased from C only in ET (P = 0.03). Vasomotor sympathetic modulation decreased (P = 0.001) and baroreflex sensitivity (P < 0.02) increased from C in both training groups with greater changes in ET than MT. CONCLUSIONS: In treated hypertensive men, aerobic training performed in the evening decreased clinic and ambulatory BP due to reductions in systemic vascular resistance and vasomotor sympathetic modulation. Aerobic training conducted at both times of day increases baroreflex sensitivity, but with greater after ET.

Metaboreflex activation delays heart rate recovery after aerobic exercise in never-treated hypertensive men.

KEY POINTS: Recent evidence indicates that metaboreflex regulates heart rate recovery after exercise (HRR). An increased metaboreflex activity during the post-exercise period might help to explain the reduced HRR observed in hypertensive subjects. Using lower limb circulatory occlusion, the present study showed that metaboreflex activation during the post-exercise period delayed HRR in never-treated hypertensive men compared to normotensives. These findings may be relevant for understanding the physiological mechanisms associated with autonomic dysfunction in hypertensive men. ABSTRACT: Muscle metaboreflex influences heart rate (HR) regulation after aerobic exercise. Therefore, increased metaboreflex sensitivity may help to explain the delayed HR recovery (HRR) reported in hypertension. The present study assessed and compared the effect of metaboreflex activation after exercise on HRR, cardiac baroreflex sensitivity (cBRS) and heart rate variability (HRV) in normotensive (NT) and hypertensive (HT) men. Twenty-three never-treated HT and 25 NT men randomly underwent two-cycle ergometer exercise sessions (30 min, 70% V̇O2 peak ) followed by 5 min of inactive recovery performed with (occlusion) or without (control) leg circulatory occlusion (bilateral thigh cuffs inflated to a suprasystolic pressure). HRR was assessed via HR reduction after 30, 60 and 300 s of recovery (HRR30s, HRR60s and HRR300s), as well as by the analysis of short- and long-term time constants of HRR. cBRS was assessed by sequence technique and HRV by the root mean square residual and the root mean square of successive differences between adjacent RR intervals on subsequent 30 s segments. Data were analysed using two- and three-way ANOVA. HRR60s and cBRS were significant and similarly reduced in both groups in the occlusion compared to the control session (combined values: 20 ± 10 vs. 26 ± 9 beats min-1 and 2.1 ± 1.2 vs. 3.2 ± 2.4 ms mmHg-1 , respectively, P < 0.05). HRR300s and HRV were also reduced in the occlusion session, although these reductions were significantly greater in HT compared to NT (-16 ± 11 vs. -8 ± 15 beats min-1 for HRR300s, P < 0.05). The results support the role of metaboreflex in HRR and suggest that increased metaboreflex sensitivity may partially explain the delayed HRR observed in HT men.

Doença renal crônica e fatores de risco para morte súbita cardíaca ­ denervação renal simpática: um sopro de esperança? / Chronic kidney disease and risk factors responsible for sudden cardiac death ­ renal sympathetic denervation: a whiff of hope?

Vários estudos têm demonstrado forte associação independente entre doença renal crônica e eventos cardiovasculares, incluindo morte, insuficiência cardíaca e infarto do miocárdio. Ensaios clínicos recentes estendem essa gama de eventos adversos cardiovasculares, incluindo também arritmias ventriculares e morte súbita cardíaca. Além disso, outros estudos sugerem remodelação estrutural do coração e alterações eletrofisiológicas nessa população. Esses processos podem explicar o aumento do risco de arritmia na doença renal crônica e ajudam a identificar os pacientes que possuem maior risco de morte súbita cardíaca. A hiperatividade simpática é bem conhecida por aumentar o risco cardiovascular em pacientes com doença renal crônica e é uma marca registrada do estado hipertensivo essencial, que ocorre precocemente no curso clínico da doença. Nessa afecção, a hiperatividade simpática parece ser expressa em sua fase clínica mais precoce, mostrando relação direta com a gravidade do estágio da insuficiência renal, sendo mais acentuada em sua fase terminal. A atividade nervosa simpática eferente e aferente na insuficiência renal é mediadora-chave para manutenção e progressão da doença. O objetivo desta revisão foi mostrar que o circuito fechado de realimentação do ciclo, em decorrência da hiperatividade adrenérgica, também agrava muitos dos fatores de risco responsáveis por causar morte súbita cardíaca, podendo ser um alvo potencial modificável pela denervação renal simpática percutânea. Pouco se sabe, ainda, sobre a viabilidade e a eficácia da denervação renal simpática percutânea na doença renal terminal

Several studies have shown a strong independent association between chronic kidney disease and cardiovascular events, including death, heart failure, and myocardial infarction. Recent clinical trials extend this array of adverse cardiovascular events, also including ventricular arrhythmias and sudden cardiac death. Furthermore, other studies suggest structural remodeling of the heart and electrophysiological alterations in this population. These processes may explain the increased risk of arrhythmia in kidney disease and help to identify patients who are at increased risk of sudden cardiac death. Sympathetic hyperactivity is well known to increase cardiovascular risk in chronic kidney disease patients and is typical of the essential hypertensive state that occurs early in the clinical course of the disease. In chronic kidney disease, sympathetic hyperactivity seems to be expressed at the earliest clinical stage of the disease, showing a direct relationship with the severity of renal failure, being more pronounced in the end stage of chronic kidney disease. Efferent and afferent sympathetic neural activity in kidney failure is a key mediator for the maintenance and progression of the disease. The aim of this review was to demonstrate that the feedback loop of this cycle, due to adrenergic hyperactivity, also aggravates many of the risk factors for sudden cardiac death and may be a potential target modifiable by percutaneous sympathetic renal denervation. Little is known whether it is feasible and effective in end-stage renal disease.

Ambulatory Blood Pressure Monitoring: Five Decades of More Light and Less Shadows / Monitorização Ambulatorial da Pressão Arterial: Cinco Décadas de mais Luzes e Menos Sombras

Abstract Casual blood pressure measurements have been extensively questioned over the last five decades. A significant percentage of patients have different blood pressure readings when examined in the office or outside it. For this reason, a change in the paradigm of the best manner to assess blood pressure has been observed. The method that has been most widely used is the Ambulatory Blood Pressure Monitoring - ABPM. The method allows recording blood pressure measures in 24 hours and evaluating various parameters such as mean BP, pressure loads, areas under the curve, variations between daytime and nighttime, pulse pressure variability etc. Blood pressure measurements obtained by ABPM are better correlated, for example, with the risks of hypertension. The main indications for ABPM are: suspected white coat hypertension and masked hypertension, evaluation of the efficacy of the antihypertensive therapy in 24 hours, and evaluation of symptoms. There is increasing evidence that the use of ABPM has contributed to the assessment of blood pressure behaviors, establishment of diagnoses, prognosis and the efficacy of antihypertensive therapy. There is no doubt that the study of 24-hour blood pressure behavior and its variations by ABPM has brought more light and less darkness to the field, which justifies the title of this review.

Resumo Nas últimas cinco décadas muito têm sido questionadas as medidas casuais da pressão arterial (PA). Significativa porcentagem de pacientes apresenta PA muito diversa quando examinados na clínica ou fora dela. Por isso, é hoje observada uma mudança de paradigma com relação ao melhor modo de se avaliar a PA. O método que mais se consolidou é a Monitorização Ambulatorial da Pressão Arterial - MAPA. É possível obter-se o registro de medidas de PA durante 24 horas avaliando-se vários parâmetros como: médias de PA, cargas de pressão, áreas sob as curvas, variações entre vigília e sono, variabilidade de pressão de pulso etc. As medidas de PA obtidas pela MAPA são mais bem correlacionadas, por exemplo, com os riscos da hipertensão arterial. As principais indicações para a MAPA são: suspeita de hipertensão do avental branco e da hipertensão mascarada, avaliação da eficácia terapêutica nas 24 horas e avaliação de sintomas. Crescem as evidências de que o emprego da MAPA contribui para avaliar os comportamentos da PA, estabelecer diagnósticos, prognóstico e avaliar a eficácia terapêutica anti-hipertensiva. Sem dúvidas, o estudo do comportamento da PA e suas variações durante as 24 horas pela MAPA nos deixaram com menos sombras e mais luzes, e justifica o título desta revisão.

Ambulatory Blood Pressure Monitoring: Five Decades of More Light and Less Shadows.

Casual blood pressure measurements have been extensively questioned over the last five decades. A significant percentage of patients have different blood pressure readings when examined in the office or outside it. For this reason, a change in the paradigm of the best manner to assess blood pressure has been observed. The method that has been most widely used is the Ambulatory Blood Pressure Monitoring - ABPM. The method allows recording blood pressure measures in 24 hours and evaluating various parameters such as mean BP, pressure loads, areas under the curve, variations between daytime and nighttime, pulse pressure variability etc. Blood pressure measurements obtained by ABPM are better correlated, for example, with the risks of hypertension. The main indications for ABPM are: suspected white coat hypertension and masked hypertension, evaluation of the efficacy of the antihypertensive therapy in 24 hours, and evaluation of symptoms. There is increasing evidence that the use of ABPM has contributed to the assessment of blood pressure behaviors, establishment of diagnoses, prognosis and the efficacy of antihypertensive therapy. There is no doubt that the study of 24-hour blood pressure behavior and its variations by ABPM has brought more light and less darkness to the field, which justifies the title of this review.

Hipotensão pós-exercício resistido entre homens jovens e de meia idade / Post-resistance exercise hypotension is similar between Young and middle-aged men

A hipotensão pós-exercício foi extensivamente descrita em jovens. Entretanto, os parâmetros hemodinâmicos mudam com a idade e as respostas pós-exercício também podem variar. Assim, o objetivo deste estudo foi comparar a hipotensão pós-exercício resistido em sujeitos jovens e de meia idade. Método: Nove homens jovens (24 ± 1 anos) e oito de meia idade (42 ± 3 anos) participaram de duas sessões experimentais realizadas em ordem aleatória: controle (C: 40 minutos sentado em repouso) e exercício (E: seis exercícios, três séries, repetições até a fadiga moderada, em 50% de uma repetição máxima). Antes e 60 minutos após as intervenções, a pressão arterial clínica (PA) e frequência cardíaca (FC) foram medidas. Além disso, a PA e FC ambulatoriais foram mensuradas por 24 h após as sessões. O duplo produto (DP) foi calculado. Resultados: Os valores pré-intervenções foram semelhantes entre as sessões e os grupos. As respostas ao exercício também não diferiram entre os jovens e idosos. Assim, as PAs sistólica, diastólica e média diminuíram significante e similarmente pós-exercício nos dois grupos (valores combinados = -6,4 ± 1,6; -4,5 ± 1,8; -5,1 ± 1,5 mmHg, respectivamente, p ≤ 0,05) enquanto que a FC e o DP aumentaram (valores combinados = +11 ± 2 bpm e +803 ± 233 mmHg.bpm, respec¬tivamente, p ≤ 0,05). A PA e FC ambulatoriais pós-exercício foram semelhantes nas duas sessões e nos dois grupos. Conclusão: Uma única sessão de exercício resistido promove hipotensão pós-exercício semelhante em homens jovens e de meia-idade. A redução da PA se acompanha de aumento da FC e do trabalho cardíaco pós-exercício. Porém, estas respostas não se mantêm em condições ambulatoriais...

Post-resistance exercise hypotension has been extensively described in young subjects. However, hemodynamic parameters change with aging, and post-exercise responses may also vary. Thus, this study was designed to compare post-resistance exercise hypotension in young and middle-aged subjects. Method: Nine young (24 ± 1years) and eight middle-aged (42 ± 3years) healthy subjects underwent 2 experimental sessions conducted in a randomized order: control (C: 40 minutes of seated rest) and exercise (E: 6 exercises, 3 sets, repetitions until moderate fatigue, at 50% of 1-repetition maximum). Before and 60 minutes after the interventions, clinic blood pressure (BP) and heart rate (HR) were measured. In addition, ambulatory BP and HR were assessed for 24h after both sessions. Rate pressure product (RPP) was calculated. Results: Pre-interventions values were similar in both sessions and groups. Physiological responses to exercise were also similar between young and middle-aged subjects. Thus, clinic systolic, diastolic and mean BP decreased significantly and similarly after exercise in both groups (combined values = -6.4 ± 1.6, -4.5 ± 1.8, -5.1 ± 1.5 mmHg, respectively, p ≤ 0.05), while HR and RRP increased (combined values = +11 ± 2 bpm and +803 ± 233 mmHg. bpm, respectively, p ≤ 0.05). Ambulatory data were similar between sessions and groups. Conclusion: A single bout of resistance exercise promotes similar post-exercise hypotension in young and middle aged men. BP response is accompanied by an increase in HR and cardiac work. All these responses are not sustained under ambulatory conditions...

Avaliação da segurança e eficácia da combinação ramipril/ anlodipino versus anlodipino em monoterapia no tratamento da hipertensão arterial pela monitorização ambulatorial da pressão arterial: estudo ATAR-MAPA / Evaluation of security and efficiency of the combination ramipril/amlopidine versus amlopidine in monotherapy for the treatment of arterial hypertension by the outpatient monitoring of blood pressure: study ATAR-ABPM

O objetivo do estudo é comparar a eficácia e a tolerabilidade da combinação fixa ramipril/anlodipino e do anlodipino em monoterapia para o tratamento de hipertensão arterial. Após um período de duas semanas de retirada de anti-hipertensivos e uso de placebo (washout), 265 pacientes hipertensos com idades entre 40 e 79 anos foram randomizados para iniciar tratamento com 2,5/2,5 mg de ramipril/anlodipino em combinação fixa ou 2,5 mg de anlodipino, que foram titulados para 5/5 mg e 10/10 mg de ramipril/anlodipino, ou 5 e 10 mg de anlodipino, se necessário. No total, 131 pacientes foram randomizados para terapia combinada e 134 para monoterapia sem diferenças significativas entre os grupos nas características basais e nos níveis de pressão arterial (PA) inicial. A redução média da PA sistólica nos períodos do dia (20,36 ± 13,42 versus 15,86 ± 12,71 mmHg; p = 0,003) e da noite (17,6 ± 17,61 versus 14,09 ± 14,32 mmHg; p = 0,051), avaliada pela monitorização ambulatorial de pressão arterial (MAPA), foi significativamente maior no grupo tratamento com combinação fixa. A redução média da PA diastólica durante o dia à MAPA (11,28 ± 8,29 versus 8,96 ± 8,16 versus mmHg; p = 0,009) foi maior no grupo terapia combinada, mas não durante a noite (8,42 ± 11,16 mmHg versus 7,70 ± 8,63; p = 0,567). A redução média da PA sistólica e diastólica em 24 horas à MAPA também foi maior no grupo tratamento combinado. Ambas as opções terapêuticas promoveram redução significativa da PA sistólica e diastólica; porém, os resultados observados foram melhores no grupo de combinação fixa ramipril/anlodipino

This study aims to compare the efficacy and tolerability of a fixed-dose ramipril/amlodipine combination and amlodipine monotherapy for the treatment of hypertension. After a 2-week placebo washout, 265 hypertensive patients aged 40 to 79 years were randomized for 2.5/2.5 mg ramipril/amlodipine or 2.5 mg amlodipine, titrated to ramipril/amlodipine 5/5 mg and 10/10 mg , or amlodipine 5 and 10 mg, if necessary. A total of 131 patients were assigned to combination therapy, and 134 to monotherapy with no significant differences among them in basal characteristics and blood pressure (BP) levels at the ambulatory blood pressure monitoring (ABPM). Mean reduction in daytime (20.36 ± 13.42 versus 15.86 ± 12.71 mmHg; p = 0.003) and night-time systolic BP on ABPM (17.6 ± 17.61 versus 14.09 ± 14.32 mmHg; p = 0.051) were significantly higher in the combination therapy. Mean daytime diastolic BP reduction on ABPM (11.28 ± 8.29 versus 8.96 ± 8.16 versus mmHg; p = 0.009) was greater in the combination group, but not at night-time (8.42 ± 11.16 mmHg versus 7.70 ± 8.63; p = 0.567). Mean change in 24-h systolic and diastolic BP on ABPM were also greater in the combination treatment. Both treatments promoted a marked reduction in systolic and diastolic BP, and the results observed were better in the ramipril/amlodipine combination group.

Hipertensão arterial nos pacientes com doença renal crônica / Hypertension in patients with chronic kidney disease

A hipertensão arterial é o maior fator de risco para doença cardiovascular e renal. Inversamente, a doença renal crônica é a forma mais comum de hipertensão secundária e várias evidências sugerem que é um fator de risco independente para mortalidade e morbidade cardiovascular. Balanço de sal positivo é o fator dominante, mas não único na gênese da hipertensão na doença renal crônica. As evidências experimentais demonstraram , claramente que a hipertensão devido à retenção de sal e água é mantida pelos aumento da resistência periférica.O diagnóstico da hipertensão é criticamente dependente das medidas adequadas da pressão arterial, principalmente em pacientes com doença renal crônica, cujo tratamento anti-hipertensivo precoce é mandatório para a prevenção de eventos cardiovasculares. A monitorização ambulatorial da pressão arterial permitiu identificar pacientes hipertensos de risco elevado. O tratamento da hipertensão em pacientes com doença renal crônica deve levar em consideração a natureza da doença renal subjacente. Pacientes com nefropatia diabética ou doença renal não diabética proteinúrica se beneficiam do tratamento com inibidores da enzima de conversãoda angiotensina ou bloqueadores do receptor de angiotensina II para a meta de pressão arterial < 130/80 mmHG, se tolerado. A meta abaixo de 140/90 mmHg é aceitável para muitos pacientes com outras formas de doença renal. Bloqueio duplo ou triplo do sistema renina angiotensina deve ser evitado.

Hypertension is a major risk factor for cardiovascular and renal disease. Conversely, chronic kidney disease is the most common form of secondary hypertension and mounting evidence suggest it is independent risk factor for cardiovascular morbidity and mortality. positive salt balance is the dominant but not the sole factor in the genesis of hypertension in chronic kidney disease. The experimental evidences have clearly demonstrated that hypertension due to retention of salt and water is maintained by increased peripheral resistance. The diagnosis of hypertension is critically dependent on accurate blood pressure measurement, especially in patients with chronic kidney disease, in whom early antihypertensive treatment is imperative to prevent cardiovascular events. Ambulatory blood pressure monitoring has successfully identified hypertensive patients at increased risk. The treatment of hypertension in chronic kidney disease patients should take into consideration the nature of the underlying kidney disease. Patients with diabetic nephropathy or proteinuric nondiabetic kidney disease benefit from treatment with angiotensin-converting enzyme inhibitors or angiotensin-receptor blockers to a goal blood pressure of < 140/90 mmHg is acceptable for most patients with other forms of chronic kidney disease. Dual or triple blockade of the renin-angiotensin system should generally be avoided.

An economic evaluation of antihypertensive therapies based on clinical trials.

OBJECTIVE: Hypertension is a major issue in public health, and the financial costs associated with hypertension continue to increase. Cost-effectiveness studies focusing on antihypertensive drug combinations, however, have been scarce. The cost-effectiveness ratios of the traditional treatment (hydrochlorothiazide and atenolol) and the current treatment (losartan and amlodipine) were evaluated in patients with grade 1 or 2 hypertension (HT1-2). For patients with grade 3 hypertension (HT3), a third drug was added to the treatment combinations: enalapril was added to the traditional treatment, and hydrochlorothiazide was added to the current treatment. METHODS: Hypertension treatment costs were estimated on the basis of the purchase prices of the antihypertensive medications, and effectiveness was measured as the reduction in systolic blood pressure and diastolic blood pressure (in mm Hg) at the end of a 12-month study period. RESULTS: When the purchase price of the brand-name medication was used to calculate the cost, the traditional treatment presented a lower cost-effectiveness ratio [US$/mm Hg] than the current treatment in the HT1-2 group. In the HT3 group, however, there was no difference in cost-effectiveness ratio between the traditional treatment and the current treatment. The cost-effectiveness ratio differences between the treatment regimens maintained the same pattern when the purchase price of the lower-cost medication was used. CONCLUSIONS: We conclude that the traditional treatment is more cost-effective (US$/mm Hg) than the current treatment in the HT1-2 group. There was no difference in cost-effectiveness between the traditional treatment and the current treatment for the HT3 group.

An economic evaluation of antihypertensive therapies based on clinical trials

OBJECTIVE: Hypertension is a major issue in public health, and the financial costs associated with hypertension continue to increase. Cost-effectiveness studies focusing on antihypertensive drug combinations, however, have been scarce. The cost-effectiveness ratios of the traditional treatment (hydrochlorothiazide and atenolol) and the current treatment (losartan and amlodipine) were evaluated in patients with grade 1 or 2 hypertension (HT1-2). For patients with grade 3 hypertension (HT3), a third drug was added to the treatment combinations: enalapril was added to the traditional treatment, and hydrochlorothiazide was added to the current treatment. METHODS: Hypertension treatment costs were estimated on the basis of the purchase prices of the antihypertensive medications, and effectiveness was measured as the reduction in systolic blood pressure and diastolic blood pressure (in mm Hg) at the end of a 12-month study period. RESULTS: When the purchase price of the brand-name medication was used to calculate the cost, the traditional treatment presented a lower cost-effectiveness ratio [US$/mm Hg] than the current treatment in the HT1-2 group. In the HT3 group, however, there was no difference in cost-effectiveness ratio between the traditional treatment and the current treatment. The cost-effectiveness ratio differences between the treatment regimens maintained the same pattern when the purchase price of the lower-cost medication was used. CONCLUSIONS: We conclude that the traditional treatment is more cost-effective (US$/mm Hg) than the current treatment in the HT1-2 group. There was no difference in cost-effectiveness between the traditional treatment and the current treatment for the HT3 group.

Post-concurrent exercise hemodynamics and cardiac autonomic modulation.

Concurrent training is recommended for health improvement, but its acute effects on cardiovascular function are not well established. This study analyzed hemodynamics and autonomic modulation after a single session of aerobic (A), resistance (R), and concurrent (A + R) exercises. Twenty healthy subjects randomly underwent four sessions: control (C:30 min of rest), aerobic (A:30 min, cycle ergometer, 75% of VO(2) peak), resistance (R:6 exercises, 3 sets, 20 repetitions, 50% of 1 RM), and concurrent (AR: A + R). Before and after the interventions, blood pressure (BP), heart rate (HR), cardiac output (CO), and HR variability were measured. Systolic BP decreased after all the exercises, and the greatest decreases were observed after the A and AR sessions (-13 ± 1 and -11 ± 1 mmHg, respectively, P < 0.05). Diastolic BP decreased similarly after all the exercises, and this decrease lasted longer after the A session. CO also decreased similarly after the exercises, while systemic vascular resistance increased after the R and AR sessions in the recovery period (+4.0 ± 1.7 and +6.3 ± 1.9 U, respectively, P < 0.05). Stroke volume decreased, while HR increased after the exercises, and the greatest responses were observed after the AR session (SV, A = -14.6 ± 3.6, R = -22.4 ± 3.5 and AR = -23.4 ± 2.4 ml; HR, A =+13 ± 2, R =+15 ± 2 vs. AR =+20 ± 2 bpm, P < 0.05). Cardiac sympathovagal balance increased after the exercises, and the greatest increase was observed after the AR session (A = +0.7 ± 0.8, R = +1.0 ± 0.8 vs. AR = +1.2 ± 0.8, P < 0.05). In conclusion, the association of aerobic and resistance exercises in the same training session did not potentiate post-exercise hypotension, and increased cardiac sympathetic activation during the recovery period.

Variáveis biopsicossociais e atitudes frente ao tratamento influenciam a hipertensão complicada / Biopsychosocial variables and attitudes towards treatment influence complicated hypertension

FUNDAMENTO: A hipertensão complicada pode ser influenciada pelas características dos pacientes hipertensos. OBJETIVO: Associar a condição de hipertensão complicada com variáveis biossociais, tais como as atitudes e as crenças sobre a doença e o tratamento e o bem-estar subjetivo. MÉTODOS: Foram estudados 251 hipertensos não complicados (PAS > 140 mmHg e/ou 90 < PAD < 110 mmHg para pacientes sem tratamento e PAD < 110 mmHg para pacientes com tratamento, sem lesões em órgãos-alvo e outras doenças) e 260 hipertensos complicados (PAD > 110 mmHg com ou sem tratamento, com lesões em órgãos-alvo ou outras doenças). RESULTADOS: Os hipertensos complicados foram significativamente diferentes dos não complicados (p < 0,05) em relação a: 1 - Predomínio de homens, não brancos (53,0 por cento), maior índice de massa corporal (29,5 ± 4,6 vs 28,5 ± 4,0 kg/m²), mais de 10 anos de doença (54,0 por cento), realização de tratamento anterior (53,0 por cento) e referência de tristeza em relação a sua vida como um todo (74,0 por cento); 2 - Os hipertensos complicados nunca levam os remédios quando viajam (59,0 por cento), nem os providenciam antes de acabarem (71,0 por cento) e raramente seguem as orientações sobre alimentação (69,0 por cento); 3 - Os hipertensos não complicados apontaram mais enxaqueca, dor articular e, entre as mulheres, presença de menopausa e tratamento de reposição hormonal; 4 - Dos que tinham a pressão controlada (< 140/90 mmHg), 61,9 por cento eram hipertensos não complicados; e 5 - Os hipertensos complicados desconheciam que o tratamento pode evitar problemas renais e desconheciam ainda que a hipertensão também pode acometer pessoas jovens. CONCLUSÃO: Hipertensos complicados apresentaram mais características estruturais e psicossociais desfavoráveis, mais atitudes negativas frente ao tratamento e desconhecem a doença.

BACKGROUND: Complicated hypertension can be influenced by the characteristics of hypertensive patients. OBJECTIVE: To associate the condition of complicated hypertension with biosocial variables such as attitudes and beliefs about the disease and treatment and subjective well-being. METHODS: We studied 251 uncomplicated hypertensive patients (SBP > 140 mmHg and/or 90 < DBP < 110 mmHg for patients under no treatment and DBP <110mmHg for patients under treatment without target organ damage and other diseases) and 260 complicated hypertensive patients (DBP > 110 mmHg with or without treatment, with target organ damage or other diseases). RESULTS: Complicated hypertensive patients were significantly different from uncomplicated ones (p <0.05) in relation to: 1 - Prevalence of men, not white (53.0 percent), higher body mass index (29.5 ± 4.6 vs 28.5 ± 4.0 kg/m²), over 10 years of disease (54.0 percent), completion of previous treatment (53.0 percent) and reports of sadness about life as a whole (74.0 percent) 2 - Complicated hypertensive patients never bring the drugs when they travel (59.0 percent), nor do they buy them before running out the drugs (71.0 percent) and rarely follow eating guidelines (69.0 percent) 3 - Uncomplicated hypertensive patients showed no more migraines, joint pain and, among women, menopausal status and hormone replacement therapy, and 4 - Of those who had pressure control (< 140/90 mmHg), 61.9 percent were uncomplicated hypertensive patients; and 5 - Complicated hypertensive patients were not aware that treatment can prevent kidney problems and they thought that young people do not have high blood pressure. CONCLUSION: Complicated hypertensive patients showed more negative structural and psychosocial characteristics, more negative attitudes towards treatment and are unaware of the disease.