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.

Non-Additive Entropic Forms and Evolution Equations for Continuous and Discrete Probabilities.

Increasing interest has been shown in the subject of non-additive entropic forms during recent years, which has essentially been due to their potential applications in the area of complex systems. Based on the fact that a given entropic form should depend only on a set of probabilities, its time evolution is directly related to the evolution of these probabilities. In the present work, we discuss some basic aspects related to non-additive entropies considering their time evolution in the cases of continuous and discrete probabilities, for which nonlinear forms of Fokker-Planck and master equations are considered, respectively. For continuous probabilities, we discuss an H-theorem, which is proven by connecting functionals that appear in a nonlinear Fokker-Planck equation with a general entropic form. This theorem ensures that the stationary-state solution of the Fokker-Planck equation coincides with the equilibrium solution that emerges from the extremization of the entropic form. At equilibrium, we show that a Carnot cycle holds for a general entropic form under standard thermodynamic requirements. In the case of discrete probabilities, we also prove an H-theorem considering the time evolution of probabilities described by a master equation. The stationary-state solution that comes from the master equation is shown to coincide with the equilibrium solution that emerges from the extremization of the entropic form. For this case, we also discuss how the third law of thermodynamics applies to equilibrium non-additive entropic forms in general. The physical consequences related to the fact that the equilibrium-state distributions, which are obtained from the corresponding evolution equations (for both continuous and discrete probabilities), coincide with those obtained from the extremization of the entropic form, the restrictions for the validity of a Carnot cycle, and an appropriate formulation of the third law of thermodynamics for general entropic forms are discussed.

Entropic form emergent from superstatistics.

The Beck-Cohen superstatistics became an important theory in the scenario of complex systems because it generates distributions representing regions of a nonequilibrium system, characterized by different temperatures T≡ß^{-1}, leading to a probability distribution f(ß). In superstatistics, some classes have been most frequently considered for f(ß), like χ^{2}, χ^{2} inverse, and log-normal ones. Herein we investigate the superstatistics resulting from a χ_{η}^{2} distribution through a modification of the usual χ^{2} by introducing a real index η (0<η≤1). In this way, one covers two common and relevant distributions as particular cases, proportional to the q-exponential (e_{q}^{-ßx}=[1-(1-q)ßx]^{1/1-q}) and the stretched exponential (e^{-(ßx)^{η}}). Furthermore, an associated generalized entropic form is found. Since these two particular-case distributions have been frequently found in the literature, we expect that the present results should be applicable to a wide range of classes of complex systems.

First-Principle Validation of Fourier's Law: One-Dimensional Classical Inertial Heisenberg Model.

The thermal conductance of a one-dimensional classical inertial Heisenberg model of linear size L is computed, considering the first and last particles in thermal contact with heat baths at higher and lower temperatures, Th and Tl (Th>Tl), respectively. These particles at the extremities of the chain are subjected to standard Langevin dynamics, whereas all remaining rotators (i=2,⋯,L-1) interact by means of nearest-neighbor ferromagnetic couplings and evolve in time following their own equations of motion, being investigated numerically through molecular-dynamics numerical simulations. Fourier's law for the heat flux is verified numerically, with the thermal conductivity becoming independent of the lattice size in the limit L→∞, scaling with the temperature, as κ(T)∼T-2.25, where T=(Th+Tl)/2. Moreover, the thermal conductance, σ(L,T)≡κ(T)/L, is well-fitted by a function, which is typical of nonextensive statistical mechanics, according to σ(L,T)=Aexpq(-Bxη), where A and B are constants, x=L0.475T, q=2.28±0.04, and η=2.88±0.04.

Finite-size scaling of quasi-stationary-state temperature.

We numerically study, from first principles, the temperature T_{QSS} and duration t_{QSS} of the longstanding initial quasi-stationary state of the isolated d-dimensional classical inertial α-XY ferromagnet with two-body interactions decaying as 1/r_{ij}^{α} (α≥0). It is shown that this temperature T_{QSS} (defined proportional to the kinetic energy per particle) depends, for the long-range regime 0≤α/d≤1, on (α,d,U,N) with numerically negligible changes for dimensions d=1,2,3, with U the energy per particle and N the number of particles. We verify the finite-size scaling T_{QSS}-T_{∞}∝1/N^{ß} where T_{∞}≡2U-1 for U≲U_{c}, and ß appears to depend sensibly only on α/d. Our numerical results indicate that neither the scaling with N of T_{QSS} nor that of t_{QSS} depend on U.

External Stimuli on Neural Networks: Analytical and Numerical Approaches.

Based on the behavior of living beings, which react mostly to external stimuli, we introduce a neural-network model that uses external patterns as a fundamental tool for the process of recognition. In this proposal, external stimuli appear as an additional field, and basins of attraction, representing memories, arise in accordance with this new field. This is in contrast to the more-common attractor neural networks, where memories are attractors inside well-defined basins of attraction. We show that this procedure considerably increases the storage capabilities of the neural network; this property is illustrated by the standard Hopfield model, which reveals that the recognition capacity of our model may be enlarged, typically, by a factor 102. The primary challenge here consists in calibrating the influence of the external stimulus, in order to attenuate the noise generated by memories that are not correlated with the external pattern. The system is analyzed primarily through numerical simulations. However, since there is the possibility of performing analytical calculations for the Hopfield model, the agreement between these two approaches can be tested-matching results are indicated in some cases. We also show that the present proposal exhibits a crucial attribute of living beings, which concerns their ability to react promptly to changes in the external environment. Additionally, we illustrate that this new approach may significantly enlarge the recognition capacity of neural networks in various situations; with correlated and non-correlated memories, as well as diluted, symmetric, or asymmetric interactions (synapses). This demonstrates that it can be implemented easily on a wide diversity of models.

Criticality in the duration of quasistationary state.

The duration of the quasistationary states (QSSs) emerging in the d-dimensional classical inertial α-XY model, i.e., N planar rotators whose interactions decay with the distance r_{ij} as 1/r_{ij}^{α} (α≥0), is studied through first-principles molecular dynamics. These QSSs appear along the whole long-range interaction regime (0≤α/d≤1), for an average energy per rotator UU_{c}. They are characterized by a kinetic temperature T_{QSS}, before a crossover to a second plateau occurring at the Boltzmann-Gibbs temperature T_{BG}>T_{QSS}. We investigate here the behavior of their duration t_{QSS} when U approaches U_{c} from below, for large values of N. Contrary to the usual belief that the QSS merely disappears as U→U_{c}, we show that its duration goes through a critical phenomenon, namely t_{QSS}∝(U_{c}-U)^{-ξ}. Universality is found for the critical exponent ξ≃5/3 throughout the whole long-range interaction regime.

Quasi-stationary-state duration in the classical d-dimensional long-range inertial XY ferromagnet.

A classical α-XY inertial model, consisting of N two-component rotators and characterized by interactions decaying with the distance r_{ij} as 1/r_{ij}^{α} (α≥0) is studied through first-principle molecular-dynamics simulations on d-dimensional lattices of linear size L (N≡L^{d} and d=1,2,3). The limits α=0 and α→∞ correspond to infinite-range and nearest-neighbor interactions, respectively, whereas the ratio α/d>1 (0≤α/d≤1) is associated with short-range (long-range) interactions. By analyzing the time evolution of the kinetic temperature T(t) in the long-range-interaction regime, one finds a quasi-stationary state (QSS) characterized by a temperature T_{QSS}; for fixed N and after a sufficiently long time, a crossover to a second plateau occurs, corresponding to the Boltzmann-Gibbs temperature T_{BG} (as predicted within the BG theory), with T_{BG}>T_{QSS}. It is shown that the QSS duration (t_{QSS}) depends on N, α, and d, although the dependence on α appears only through the ratio α/d; in fact, t_{QSS} decreases with α/d and increases with both N and d. Considering a fixed energy value, a scaling for t_{QSS} is proposed, namely, t_{QSS}∝N^{A(α/d)}e^{-B(N)(α/d)^{2}}, analogous to a recent analysis carried out for the classical α-Heisenberg inertial model. It is shown that the exponent A(α/d) and the coefficient B(N) present universal behavior (within error bars), comparing the XY and Heisenberg cases. The present results should be useful for other long-range systems, very common in nature, like those characterized by gravitational and Coulomb forces.

The impact of changing home blood pressure monitoring cutoff from 135/85 to 130/80 mmHg on hypertension phenotypes.

This study investigated the impact of changing abnormal home blood pressure monitoring (HBPM) cutoff from 135/85 to 130/80 mmHg on the prevalence of hypertension phenotypes, considering an abnormal office blood pressure cutoff of 140/90 mmHg. We evaluated 57 768 individuals (26 876 untreated and 30 892 treated with antihypertensive medications) from 719 Brazilian centers who performed HBPM. Changing the HBPM cutoff was associated with increases in masked (from 10% to 22%) and sustained (from 27% to 35%) hypertension, and decreases in white-coat hypertension (from 16% to 7%) and normotension (from 47% to 36%) among untreated participants, and increases in masked (from 11% to 22%) and sustained (from 29% to 36%) uncontrolled hypertension, and decreases in white-coat uncontrolled hypertension (from 15% to 8%) and controlled hypertension (from 45% to 34%) among treated participants. In conclusion, adoption of an abnormal HBPM cutoff of 130/80 mmHg markedly increased the prevalence of out-of-office hypertension and uncontrolled hypertension phenotypes.

Effectiveness of chlorthalidone/amiloride versus losartan in patients with stage I hypertension and diabetes mellitus: results from the PREVER-treatment randomized controlled trial.

AIMS: To compare the blood pressure (BP)-lowering efficacy of a chlorthalidone/amiloride combination pill with losartan, during initial management of JNC 7 Stage I hypertension in patients with type 2 diabetes mellitus. METHODS: In an a priori subgroup analysis of a randomized, double-blind, controlled trial, volunteers aged 30-70 years, with stage I hypertension and diabetes mellitus, were randomized to 12.5/2.5 mg of chlorthalidone/amiloride (N = 47) or 50 mg of losartan (N = 50), and followed for 18 months in 21 clinical centers. If BP remained uncontrolled after three months, study medication dose was doubled, and if uncontrolled after six months, amlodipine (5 and 10 mg) and propranolol (40 and 80 mg BID) were added as open label drugs in a progressive fashion. RESULTS: Systolic BP decreased to a greater extent in participants allocated to diuretics compared to losartan (P < 0.001). After 18 months of follow-up, systolic BP was 128.4 ± 10.3 mmHg in the diuretic group versus 133.5 ± 8.0 in the losartan group (P < 0.01). In the diuretic group, 36 out of 43 participants (83.7%) had a JNC 7 normal BP, compared to 31/47 (66%) in the losartan group (P = 0.089). Serum cholesterol was higher in the diuretic arm at the end of the trial. Other biochemical parameters and reports of adverse events did not differ by treatment. CONCLUSIONS: Treatment of hypertension based on a combination of chlorthalidone and amiloride is more effective for BP lowering compared to losartan in patients with diabetes mellitus and hypertension. TRIAL REGISTRATION: Clinical trials registration number: NCT00971165.