Cardiovascular risk in women with nonclassical congenital adrenal hyperplasia.

CONTEXT: The outcomes related to cardiovascular risk (CVR) in patients with nonclassical form of congenital adrenal hyperplasia (NCAH) are unknown, especially those related to therapeutic options, including low doses of glucocorticoids (GCs) or oral contraceptive pills. OBJECTIVES: to analyze CVR by markers of atherosclerosis in females with nonclassical form according to therapeutic options. DESIGN AND SETTING: a cross-sectional study at a tertiary center. PATIENTS AND METHODS: Forty-seven females with NCAH (33.4 ± 10 years) were subdivided into: G1 (n = 28) treated with dexamethasone (0.14 ± 0.05 mg/m2/day); G2 (n = 19) with oral contraceptive pills; and G3 (30 matched controls). CVR was analyzed through serum lipids, HOMA-IR, inflammatory cytokines levels and quantitative image evaluations (pulse wave velocity-PWV, endothelial function by flow mediated dilatation-FMD, carotid intima media thickness-CIMT and visceral fat-VAT by abdominal tomography. RESULTS: There were no statistically significant differences in BMI, HOMA-IR, HDL-cholesterol, or triglyceride levels among groups (p > 0.05). Serum interleukin-6 levels ​​were higher in G1 than in G2 (p = 0.048), and interleukin-8 levels were higher in G1 than in G2/3 (p = 0.008). There were no statistically significant differences in VAT, PWV, FMD or CIMT among groups (p > 0.05). In multivariable regression analysis, there was no statistically significant association between glucocorticoid dose and evaluated outcomes. CONCLUSION: Adult females with NCAH did not show increased CVR using methodologies for detection of precocious atherosclerosis. Although patients receiving dexamethasone therapy had increased IL-6 and 8 levels, these data were not associated with radiological markers of atherosclerosis. Our cohort was composed of young adults and should be reevaluated in a long-term follow-up.

A real-world analysis of outcomes and healthcare costs of patients on perindopril/indapamide/amlodipine single-pill vs. multiple-pill combination in Italy.

OBJECTIVES: This analysis compared adherence, cardiovascular (CV) events and all-cause mortality incidence, and healthcare costs among hypertensive patients treated with perindopril (PER)/indapamide (IND)/amlodipine (AML) in single-pill combination (SPC) vs. multiple-pill combination, in a real-world setting in Italy. METHODS: In this observational retrospective analysis of Italian administrative databases, adult patients treated with PER/IND/AML between 2010 and 2020 were divided into two cohorts: single-pill vs. multiple-pill. Patient data were available for at least one year before and after index date. Propensity score matching (PSM) was applied to reduce selection bias. Adherence was defined as proportion of days covered: non-adherence, <40%; partial adherence, 40-79%, and adherence ≥80%. Mortality incidence and CV events as single, or composite, endpoints were evaluated after first year of follow-up. Healthcare cost analyses were performed from the perspective of the Italian National Health Service. RESULTS: Following PSM, the single-pill cohort included 12 150 patients, and the multiple-pill cohort, 6105. The SPC cohort had a significantly higher percentage of adherent patients vs. the multiple-pill cohort (59.9% vs. 26.9%, P  < 0.001). Following the first year of follow-up, incidence of all-cause mortality, and combined endpoint of all-cause mortality and CV events were lower in the SPC cohort compared with multiple-pill cohort. Average annual direct healthcare costs were lower in the single-pill cohort (€2970) vs. multiple-pill cohort (€3642); cost of all drugs and all-cause hospitalizations were major contributors. CONCLUSION: The SPC of PER/IND/AML, compared with multiple-pill combination, is associated with higher adherence to medication, lower incidence of CV events and mortality, and reduced healthcare costs.

Coronary Artery Disease Assessment and Cardiovascular Events in Middle-Aged Patients on Hemodialysis.

OBJECTIVE: To explore whether, in younger patients on dialysis with longer life expectancy, assessment of coronary artery disease (CAD) could identify individuals at higher risk of events and revascularization might improve outcomes in selected patients contrary to what had been observed in elderly patients. METHODS: From August 1997 to January 2019, 2265 patients with stage 5 chronic kidney disease were prospectively referred for cardiovascular assessment. For this study, we selected 1374 asymptomatic patients aged between 18 and 64 years. After clinical risk stratification and cardiac scintigraphy by single-photon emission computed tomography, 866 patients underwent coronary angiography. The primary end point was the composite incidence of nonfatal/fatal major adverse cardiovascular events during a follow-up period of 0.1 to 189.7 months (median, 26 months). The secondary end point was all-cause mortality. RESULTS: The primary end point occurred in 327 (23.8%) patients. Clinically stratified high-risk patients had a 3-fold increased risk of the primary end point. The prevalence of abnormal findings on perfusion scans was 29.2% (n=375), and significant CAD was found in 449 (51.8%) of 866 patients who underwent coronary angiography. An abnormal finding on myocardial perfusion scan and the presence of CAD were significantly associated with a 74% and 22% increased risk of cardiovascular events, respectively. In patients undergoing percutaneous coronary intervention or coronary artery bypass grafting (n=99), there was an 18% reduction in the risk of all-cause death relative to patients receiving medical treatment (P=.03). CONCLUSION: In this cohort of middle-aged, asymptomatic patients on dialysis, assessment of CAD identified individuals at higher risk of events, and coronary intervention was associated with reducing the risk of death in selected patients.

Measurement of resistance-area product by transcranial Doppler: An alternative tool for cognitive screening in hypertensive on drug treatment?

Introduction: Arterial hypertrophy and remodeling are adaptive responses present in systemic arterial hypertension that can result in silent ischemia and neurodegeneration, compromising brain connections and cognitive performance (CP). However, CP is affected differently over time, so traditional screening methods may become less sensitive in assessing certain cognitive domains. The study aimed to evaluate whether cerebrovascular hemodynamic parameters can serve as a tool for cognitive screening in hypertensive without clinically manifest cognitive decline. Methods: Participants were allocated into groups: non-hypertensive (n = 30) [group 1], hypertensive with systolic blood pressure (SBP) < 140 and diastolic blood pressure (DBP) < 90 mmHg (n = 54) [group 2] and hypertensive with SBP ≥ 140 or DBP ≥ 90 (n = 31) [group 3]. Measurements of blood pressure and middle cerebral artery blood flow velocity were obtained from digital plethysmography and transcranial Doppler. For the cognitive assessment, the Mini Mental State Examination (MMSE), the Montreal Cognitive Assessment (MoCA) and a broad neuropsychological battery were applied. Results: Patients in groups 2 and 3 show no significant differences in most of the clinical-epidemiological variables or pulsatility index (p = 0.361), however compared to group 1 and 2, patients in group 3 had greater resistance-area product [RAP] (1.7 [±0.7] vs. 1.2 [±0.2], p < 0.001). There was a negative correlation between RAP, episodic memory (r = -0.277, p = 0.004) and cognitive processing speed (r = -0.319, p = 0.001). Conclusion: RAP reflects the real cerebrovascular resistance, regardless of the direct action of antihypertensive on the microcirculation, and seems to be a potential alternative tool for cognitive screening in hypertensive.

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.

Computerized working memory training for hypertensive individuals with executive function impairment: a randomized clinical trial.

Background: Hypertension is associated with working memory (WM) impairment. However, the benefits of Cogmed WM training for the hypertensive population are unknown. Therefore, we aimed to evaluate Cogmed's effects on the WM performance of hypertensive individuals with executive function (EF) impairment. Methods: We included 40 hypertensive patients (aged 40-70 years, 68% female) with EF impairment. They were randomized in a 1:1 ratio to receive 10 weeks of adaptive Cogmed training or a non-adaptive control training based on online games. The primary outcome was the WM performance. The secondary outcomes were verbal memory, visuospatial ability, executive function, global cognition, and the neuronal activity measured using functional magnetic resonance imaging (fMRI) under two WM task conditions: low (memorization of 4 spatial locations) and high (memorization of 6 spatial locations). An intention-to-treat (ITT) and per-protocol (PP) analysis were performed. Results: Cogmed did not show a significant effect on WM or any other cognitive outcome post-training. However, under the WM-low load and WM-high load conditions of the fMRI, respectively, the Cogmed group had an activation decrease in the right superior parietal lobe (ITT and PP analyses) and left inferior frontal lobe (PP analysis) in comparison to the control group. Conclusion: The Cogmed showed no effects on the WM performance of hypertensive individuals with EF impairment. However, activation decreases were observed in frontoparietal areas related to the WM network, suggesting a more efficient neuronal activity after training.

Population health impact and economic evaluation of the CARDIO4Cities approach to improve urban hypertension management.

Cardiovascular disease (CVD) is the leading cause of mortality worldwide, with 80% of that mortality occurring in low- and middle-income countries. Hypertension, its primary risk factor, can be effectively addressed through multisectoral, multi-intervention initiatives. However, evidence for the population-level impact on cardiovascular (CV) event rates and mortality, and the cost-effectiveness of such initiatives is scarce as long-term longitudinal data is often lacking. Here, we model the long-term population health impact and cost-effectiveness of a multisectoral urban population health initiative designed to reduce hypertension, conducted in Ulaanbaatar (Mongolia), Dakar (Senegal), and in the district of Itaquera in São Paulo (Brazil) in collaboration with the local governments. We based our analysis on cohort-level data among hypertensive patients on treatment and control rates from a real-world effectiveness study of the CARDIO4Cities approach (built on quality of care, early access, policy reform, data and digital, Intersectoral collaboration, and local ownership). We built a decision tree model to estimate the CV event rates during implementation (1-2 years) and a Markov model to project health outcomes over 10 years. We estimated the number of CV events averted and quality-adjusted life-years gained (QALYs through the initiative and assessed its cost-effectiveness based on the costs reported by the funder using the incremental cost effectiveness ratio (ICER) and published thresholds. A one-way sensitivity analysis was performed to assess the robustness of the results. The modelled patient cohorts included 10,075 patients treated for hypertension in Ulaanbaatar, 5,236 in Dakar, and 5,844 in São Paulo. We estimated that 3.3-12.8% of strokes and 3.0-12.0% of coronary heart disease (CHD) events were averted during 1-2 years of implementation in the three cities. We estimated that over the subsequent 10 years, 3.6-9.9% of strokes, 2.8-7.8% of CHD events, and 2.7-7.9% of premature deaths would be averted. The estimated ICER was USD 748 QALY gained in Ulaanbaatar, USD 3091 in Dakar, and USD 784 in São Paulo. With that, the intervention was estimated to be cost-effective in Ulaanbaatar and São Paulo. For Dakar, cost-effectiveness was met under WHO-CHOICE standards, but not under more conservative standards adjusted for purchasing power parity (PPP) and opportunity costs. The findings were robust to the sensitivity analysis. Our results provide evidence that the favorable impact of multisector systemic interventions designed to reduce the hypertension burden extend to long-term population-level CV health outcomes and are likely cost-effective. The CARDIO4Cities approach is predicted to be a cost-effective solution to alleviate the growing CVD burden in cities across the world.

Arterial Stiffness in Transgender Men Receiving Long-term Testosterone Therapy.

Context: The effects of androgen therapy on arterial function in transgender men (TM) are not fully understood, particularly concerning long-term androgen treatment. Objective: To evaluate arterial stiffness in TM receiving long-term gender-affirming hormone therapy by carotid-femoral pulse wave velocity (cf-PWV). Methods: A cross-sectional case-control study at the Gender Dysphoria Unit of the Division of Endocrinology, HC-FMUSP, Sao Paulo, Brazil. Thirty-three TM receiving intramuscular testosterone esters as regular treatment for an average time of 14 ± 8 years were compared with 111 healthy cisgender men and women controls matched for age and body mass index. Aortic stiffness was evaluated by cf-PWV measurements using Complior device post-testosterone therapy. The main outcome measure was aortic stiffness by cf-PWV as a cardiovascular risk marker in TM and control group. Results: The cf-PWV after long-term testosterone therapy was significantly higher in TM (7.4 ± 0.9 m/s; range 5.8-8.9 m/s) than in cisgender men (6.6 ± 1.0 m/s; range 3.8-9.0 m/s, P < .01) and cisgender women controls (6.9 ± .9 m/s; range 4.8-9.1 m/s, P = .02). The cf-PWV was significantly and positively correlated with age. Analysis using blood pressure as a covariate showed a significant relationship between TM systolic blood pressure (SBP) and cf-PWV in relation to cisgender women but not to cisgender men. Age, SBP, and diagnosis of hypertension were independently associated with cf-PWV in the TM group. Conclusion: The TM group on long-term treatment with testosterone had higher aging-related aortic stiffening than the control groups. These findings indicate that aortic stiffness might be accelerated in the TM group receiving gender-affirming hormone treatment, and suggest a potential deleterious effect of testosterone on arterial function. Preventive measures in TM individuals receiving testosterone treatment, who are at higher risk for cardiovascular events, are highly recommended.

Adherence to Triple Single-Pill Combination of Perindopril/Indapamide/Amlodipine: Findings from Real-World Analysis in Italy.

INTRODUCTION: Single-pill combination therapy for hypertension is recognized to improve adherence to treatment. However, less is known about the benefits of triple single-pill combinations. This retrospective observational analysis aimed to assess changes in adherence when treatment was switched from perindopril (PER)/indapamide (IND) + amlodipine (AML) to PER/IND/AML single-pill combination, in Italian clinical practice. METHODS: This analysis used data extracted from administrative databases of Italian healthcare entities. Adult patients receiving PER/IND/AML were selected, and the prescription date was considered as the index date. Among them, those who had a prescription for PER/IND + AML during the 12 months before the index date and a prescription of PER/IND/AML during 6 months of follow-up were included. Adherence was calculated as the proportion of days covered (PDC: PDC < 40%, non-adherent; PDC = 40-79%, partially adherent; PDC ≥ 80%, adherent). RESULTS: Among the identified patients, 158 were exposed users and were included in the analysis. When patients were compared before and after switch to triple single-pill combination, the proportion of adherent patients was significantly higher with PER/IND/AML single-pill combination (75.3%) than with PER/IND + AML combination (44.3%) (P < 0.05). Conversely, the proportion of non-adherent patients was lower with the PER/IND/AML single-pill combination (14.6%) vs PER/IND + AML (17.7%) (P < 0.001). CONCLUSION: This real-world analysis showed that switching to a triple single-pill combination could offer an opportunity to improve adherence to antihypertensive treatment in real-life clinical practice.

Medication adherence is defined by the World Health Organization as the "extent to which a person's behavior (in taking medication) corresponds with agreed recommendations from a healthcare provider". Low levels of medication adherence in hypertension have been linked with increased disease burden and with higher costs for patients. Patients with hypertension whose blood pressure is poorly controlled often need to receive more than one pill. Nevertheless, having to take many pills may result in poor adherence, i.e., patients not taking their treatment as prescribed. Combining multiple drugs into a single pill for the management of hypertension is known to improve adherence; however, limited evidence exists about the benefits of triple single-pill combinations compared with equivalent free combinations in real clinical practice. This analysis evaluated changes in adherence before and after patients switched from a three-drug therapy of perindopril/indapamide single-pill + amlodipine (PER/IND + AML) to perindopril/indapamide/amlodipine (PER/IND/AML) taken as a single pill. In this analysis, real-world data from Italian administrative databases covering around 11% of the Italian population were used. Overall, 158 patients were included. More patients were found to be adherent after switch to PER/IND/AML single pill (75.3% vs 44.3% of PER/IND + AML combination). Partially adherent and poorly adherent patients were fewer with PER/IND/AML single-pill combination (10.1% and 14.6%, respectively) compared to PER/IND + AML combination (38.0% and 17.7%, respectively). These findings indicate that switching to a simplified therapy in which all three drugs are taken in one pill may offer an opportunity for increasing the number of patients that are adherent to their medication.

Incor Residency Program in Adult Cardiology in 2022: 40 Years Preparing Cardiologists for the Demands in Brazil. / Programa de Residência Médica em Cardiologia de Adultos do InCor em 2022: 40 Anos Formando Cardiologistas para as Demandas do Brasil.

BACKGROUND: Considering demographic data related to the cardiologist's fields of work in Brazil, the administrative board of the InCor medical residency program decided for an update of its curriculum content, to adapt the educational process to the cardiologist's work reality. OBJECTIVE: This article aimed to describe the recent updates applied to the InCor medical residency program. METHODS: In the article, we described the recent updates on the InCor residency program, and compared the current curriculum track with the previous one. We also presented the rationale for these changes, based on the literature on the participation of cardiologists in the labor market. RESULTS: There was a reduction in the working hours of residents in training in the intensive care unit, and an increase in the outpatient activities of primary and secondary prevention. Also, the didactic content was reformulated and became organized by the corresponding division. CONCLUSION: The update of the curriculum track of the InCor medical residency program was required in order to adapt it to the Brazilian labor market. The commission in charge of this update is aware that this is a dynamic process that may need changes over time.

FUNDAMENTO: Diante de dados demográficos referentes às áreas de atuação dos cardiologistas no Brasil, a coordenação do Programa de Residência Médica em Cardiologia do Instituto do Coração (PRM INCOR) entendeu a necessidade de uma atualização de seu conteúdo programático, a fim de adaptar o processo de formação à realidade profissional do cardiologista. OBJETIVO: O presente artigo tem como objetivo descrever à comunidade científica as atualizações recentemente implementadas no PRM INCOR. MÉTODOS: No artigo, descrevemos as atualizações recentes do PRM INCOR, comparando a grade teórica pregressa e a atual. Expomos também o racional por trás de tais mudanças com dados de literatura relacionados à atuação do médico cardiologista no mercado de trabalho. RESULTADO: Houve uma redução da carga horária destinada a estágios de terapia intensiva, e um incremento nas atividades ambulatoriais relacionadas a medidas de prevenção primária e secundária. Além disso, o programa passou por uma reformulação de seu conteúdo didático, organizado agora por núcleos de competência. CONCLUSÃO: A atualização da grade curricular decorre da necessidade de adequar o PRM INCOR à realidade atual do mercado de trabalho brasileiro. O grupo envolvido na atualização está ciente que se trata de um processo dinâmico e que pode exigir modificações no decorrer do tempo.

Programa de Residência Médica em Cardiologia de Adultos do InCor em 2022: 40 Anos Formando Cardiologistas para as Demandas do Brasil / Incor Residency Program in Adult Cardiology in 2022: 40 Years Preparing Cardiologists for the Demands in Brazil

Resumo Fundamento Diante de dados demográficos referentes às áreas de atuação dos cardiologistas no Brasil, a coordenação do Programa de Residência Médica em Cardiologia do Instituto do Coração (PRM INCOR) entendeu a necessidade de uma atualização de seu conteúdo programático, a fim de adaptar o processo de formação à realidade profissional do cardiologista. Objetivo O presente artigo tem como objetivo descrever à comunidade científica as atualizações recentemente implementadas no PRM INCOR. Métodos No artigo, descrevemos as atualizações recentes do PRM INCOR, comparando a grade teórica pregressa e a atual. Expomos também o racional por trás de tais mudanças com dados de literatura relacionados à atuação do médico cardiologista no mercado de trabalho. Resultado Houve uma redução da carga horária destinada a estágios de terapia intensiva, e um incremento nas atividades ambulatoriais relacionadas a medidas de prevenção primária e secundária. Além disso, o programa passou por uma reformulação de seu conteúdo didático, organizado agora por núcleos de competência. Conclusão A atualização da grade curricular decorre da necessidade de adequar o PRM INCOR à realidade atual do mercado de trabalho brasileiro. O grupo envolvido na atualização está ciente que se trata de um processo dinâmico e que pode exigir modificações no decorrer do tempo.

Abstract Background Considering demographic data related to the cardiologist's fields of work in Brazil, the administrative board of the InCor medical residency program decided for an update of its curriculum content, to adapt the educational process to the cardiologist's work reality. Objective This article aimed to describe the recent updates applied to the InCor medical residency program. Methods In the article, we described the recent updates on the InCor residency program, and compared the current curriculum track with the previous one. We also presented the rationale for these changes, based on the literature on the participation of cardiologists in the labor market. Results There was a reduction in the working hours of residents in training in the intensive care unit, and an increase in the outpatient activities of primary and secondary prevention. Also, the didactic content was reformulated and became organized by the corresponding division. Conclusion The update of the curriculum track of the InCor medical residency program was required in order to adapt it to the Brazilian labor market. The commission in charge of this update is aware that this is a dynamic process that may need changes over time.

Melhorando o controle da pressão arterial com a adoção da automedição da pressão arterial­ AMPA / Improving blood pressure control with blood pressur self-measurement ­ BPSM

A Automedição da Pressão Arterial (AMPA) tem ganho interesse ultimamente e sua prática pode contribuir para o diagnóstico e seguimento da hipertensão arterial. Em nosso meio, devido a dificuldades de realização da Monitorização Residencial da Pressão Arterial (MRPA) e da indisponibilidade da Monitorização Ambulatorial da Pressão Arterial (MAPA) na maioria dos serviços, a AMPA, que difere dos métodos supracitados, tem uso disseminado em nosso país. Assim, nos parece importante discorrer sobre esse método, tão utilizado e tão pouco estudado. Neste trabalho vamos descrever os métodos de medida de pressão arterial, auscultatório e oscilométrico, além de listar vantagens e desvantagens da medida da pressão arterial no consultório, comparando-as com AMPA. Vamos também fazer um alerta sobre a necessidade de que o paciente receba orientações para a medida da pressão e, por fim, citar as Diretrizes Brasileiras e Europeias no que tange à menção que elas fazem a esse método.

Blood Pressure Self-Measurement (BPSM) has gained interest lately and its practice can contribute to the diagnosis and follow-up of arterial hypertension. In Brazil, due to difficulties in carrying out Home Blood Pressure Monitoring (HBPM) and the unavailability of Ambulatory Blood Pressure Monitoring (ABPM) in most facilities, AMPA, which differs from the aforementioned methods, has widespread use in our country. Therefore, it seems important to discuss this method, which is largely used and poorly studied. In this paper, we will describe the methods for measuring blood pressure, auscultatory and oscillometric, in addition to listing the advantages and disadvantages of measuring blood pressure in the office, comparing them with AMPA. We will also make an alert about the need for the patient to receive guidance on blood pressure measurement and, finally, we will cite the Brazilian and European Guidelines regarding the mention they make about this method.

Arterial stiffness and atrial fibrillation: A review.

Arterial stiffness has been investigated as part of the physiopathology of arterial hypertension since the 1970s. Its role in increasing the "pulsatile load" imposed over the Left Ventricle (LV) has been intensely studied recently and has helped in understanding the mechanisms of Atrial Fibrillation (AF) in hypertensive patients. This paper aims to review the main evidence on this issue and establish possible mechanisms involved in the development of AF in patients with arterial stiffness. A PubMed search was performed, and selected articles were searched for references focusing on this topic. In the long term, lower blood pressure levels allow for arterial wall remodeling, leading to a lower stiffness index. To this day, however, there are no available treatments that directly promote the lowering of arterial wall stiffness. Most classes of anti-hypertensive drugs ‒ with stronger evidence for beta-blockers and diuretics ‒ could be effective in reducing arterial stiffness. There is strong evidence demonstrating an association between arterial stiffness and AF. New studies focusing on arterial stiffness and pre-fibrillatory stages would strengthen this causality relation.

Educação tecnológica hibrida blended learning adesão ao paciente hipertenso: ensaio clinico randomizado / Hybrid technology education blended learning hypertension patient support: randomized clinical trial

Avaliar a influência do uso da tecnologia educacional híbrida blended learning (ensino presencial associado por meio do ambiente virtual de aprendizado "E-Care da Hipertensão") na melhoria do controle da pressão arterial. Métodos: Ensaio Clinico Randomizado Controlado, realizado no período de novembro de 2015 a março de 2016,dividido em dois grupos: a) Grupo Hibrido com 14 pacientes submetidos a orientação individual por meio da consulta de Enfermagem a cada 20 dias com a utilização do recurso tecnológico educacional digital "E-Care da Hipertensão" ; b) Grupo Controle com 16 pacientes em que se utilizou da consulta com orientação individual por meio da consulta de Enfermagem a cada 20 dias sem o uso da tecnologia educacional. Os grupos foram acompanhados por 120 dias, utilizando o Teste de Morisk-Green, e exame da MAPA e WHOQOL-bref na randomização e aos 120 dias. Resultados: Para o Grupo Hibrido quando realizadas as comparações no início do estudo (momento da randomização) ao final 120 dias observou-se diferenças estatísticas em relação a diversas variáveis, a saber: a) circunferência abdominal, na randomização 99,61±10 vs. 96,69±8 (p=0,006); b) em relação a MAPA na pressão arterial sistólica PAS de vigília (PAS) 159,61±15mmHg vs. 143,30±19mmHg (p=< 0,001); c) pressão arterial diastólica na vigília (PAD) 106,61±12mmHg vs. 95,92±15mmHg (p= < 0,001); d) quanto a carga pressórica da MAPA na randomização para PAS na vigília obteve-se 93,28±7mmHg vs. 66,38±31mmHg (p=0,003); e) quanto aos valores da PAD 92,63±11mmHg vs. 70,96±28mmHg (p=0,002). Conclusão: Não foram observadas diferenças significativas nos resultados analisados em 120 dias com o uso da tecnologia educacional na modalidade hibrida quando comparada com o grupo controle que realizou apenas consulta individual pelo enfermeiro

The Hypertension is a chronic manageable, however, in clinical practice several difficulties in joining the therapeutic plan. In this regard, several studies analyze the influence of different educational technologies in therapeutic adhesion, but little is known about educational technology hybrid. Objective: Evaluate the influence of the use of educational technology hybrid (face-to-face education associated through the virtual environment of learning "E-Care of hypertension") in improving blood pressure control. Method: Clinical Randomized Controlled Study divided into two groups: the Hybrid Group with 14) patients undergoing individual guidance through the nursing consultation every 20 days with the use of educational technology digital feature "E-Care of hypertension"; In hybrid mode b) control group with 16 patients in which the query was used with individual guidance through the nursing consultation every 20 days without the use of educational technology. All patients in both groups were followed for 120 days and 7 queries. The research took place in the period of December 2014 to March 2017. Approved by the CEP under CAAE 08625112.7.0000.0068. Results: There were no differences with statistical significance between the groups on randomization and at the end of 120 days as socio demographic and hemodynamic variables. However when held Control Group comparison in 120 days and randomization in relation to your perception about the WHOQOL quality of lifestatistical difference was observed between the beginning of the study (randomization) 2,73±0,9 vs. 3,80±0,94 to 120 days (p=0,012). For the Hybrid Group when performed comparisons at the beginning of the study (time of randomization) the end 120 days statistics differences were observed in relation to several variables, namely: a) abdominal circumference the randomization 99,61±10 vs. 96,69±8 (p=0,006); b) for Ambulatory Blood Pressure Monitoring (ABPM) in systolic blood pressure, SBP in awake 159.61± 15mmHg vs. 143.30 ± 19mmHg (p = < 0.001); c) diastolic blood pressure (DBP) on the eve 106,61±12mmHg vs. 95,92±15mmHg (p = < 0,001);d) as the pressure load of the (ABPM) on randomization to SBP on vigiía was obtained 93,28±7mmHg vs. 66,38±31mmHg (p=0,003); e) as for the values of the SBP 92,63±11mmHg vs. 70,96±28mmHg (p=0,002); f) for the period of sleep SBP obtained value of 140,61± 15mmHg vs. 131,38± 21mmHg (p = 0,044); g) with respect to DBP the values were 86,37± 24mmHg vs. 71,06±31mmHg (p=0,039). As for the test of Morisky-Gren, was not with statistical significance differences between the Hybrid Group and the Control Group. Conclusion: There were no significant differences in the results analyzed in 120 days with the use of educational technology in hybrid mode when compared with the control group which held only individual consultation by a nurse. On the other hand, the comparison between the study group itself, proved to be effective with satisfactory results and may be an alternative to be perfected as an educational tool

Melhorando o controle da pressão arterial com a adoção da automedição da pressão arterial ­ AMPA / Improving blood pressure control with blood pressur self-measurement ­ BPSM

A Automedição da Pressão Arterial (AMPA) tem ganho interesse ultimamente e sua prática pode contribuir para o diagnóstico e seguimento da hipertensão arterial. Em nosso meio, devido a dificuldades de realização da Monitorização Residencial da Pressão Arterial (MRPA) e da indisponibilidade da Monitorização Ambulatorial da Pressão Arterial (MAPA) na maioria dos serviços, a AMPA, que difere dos métodos supracitados, tem uso disseminado em nosso país. Assim, nos parece importante discorrer sobre esse método, tão utilizado e tão pouco estudado. Neste trabalho vamos descrever os métodos de medida de pressão arterial, auscultatório e oscilométrico, além de listar vantagens e desvantagens da medida da pressão arterial no consultório, comparando-as com AMPA. Vamos também fazer um alerta sobre a necessidade de que o paciente receba orientações para a medida da pressão e, por fim, citar as Diretrizes Brasileiras e Europeias no que tange à menção que elas fazem a esse método (AU).

Blood Pressure Self-Measurement (BPSM) has gained interest lately and its practice can contribute to the diagnosis and follow-up of arterial hypertension. In Brazil, due to difficulties in carrying out Home Blood Pressure Monitoring (HBPM) and the unavailability of Ambulatory Blood Pressure Monitoring (ABPM) in most facilities, AMPA, which differs from the aforementioned methods, has widespread use in our country. Therefore, it seems important to discuss this method, which is largely used and poorly studied. In this paper, we will describe the methods for measuring blood pressure, auscultatory and oscillometric, in addition to listing the advantages and disadvantages of measuring blood pressure in the office, comparing them with AMPA. We will also make an alert about the need for the patient to receive guidance on blood pressure measurement and, finally, we will cite the Brazilian and European Guidelines regarding the mention they make about this method (AU).

Arterial stiffness and atrial fibrillation: A review

ABSTRACT Arterial stiffness has been investigated as part of the physiopathology of arterial hypertension since the 1970s. Its role in increasing the "pulsatile load" imposed over the Left Ventricle (LV) has been intensely studied recently and has helped in understanding the mechanisms of Atrial Fibrillation (AF) in hypertensive patients. This paper aims to review the main evidence on this issue and establish possible mechanisms involved in the development of AF in patients with arterial stiffness. A PubMed search was performed, and selected articles were searched for references focusing on this topic. In the long term, lower blood pressure levels allow for arterial wall remodeling, leading to a lower stiffness index. To this day, however, there are no available treatments that directly promote the lowering of arterial wall stiffness. Most classes of anti-hypertensive drugs ‒ with stronger evidence for beta-blockers and diuretics ‒ could be effective in reducing arterial stiffness. There is strong evidence demonstrating an association between arterial stiffness and AF. New studies focusing on arterial stiffness and pre-fibrillatory stages would strengthen this causality relation.

May Measurement Month 2019: an analysis of blood pressure screening results from Brazil.

The aim of this study is to describe the results of the May Month Measurement (MMM) campaign implemented in Brazil, in 2019. Questionnaire data were collected and three measures of blood pressure (BP) were performed. The sample consisted of 13 476 individuals, 58.2% were white, 60.8% were women. The average age was 46.3 (18.6) years. Of all 13 476 participants, 6858 (50.9%) had hypertension defined as a systolic BP ≥140 mmHg or a diastolic BP ≥90 mmHg or being on anti-hypertensive medication. Of those with hypertension, 68.8% were aware of their diagnosis, 65.3% were on antihypertensive medication, and 36.1% had controlled BP (<140/90 mmHg). In addition, of 4479 participants on anti-hypertensive medication, 55.2% had controlled BP. The use of anti-hypertensive medication was associated with higher systolic (P < 0.001) and diastolic BP (P < 0.001) and having diabetes with higher systolic BP (P < 0.001). Previous hypertension in pregnancy was associated with higher systolic (P = 0.038) and diastolic BP (P = 0.003), and smoking was associated with higher systolic BP (P < 0.001). Lastly, obese and overweight individuals showed significantly higher systolic (P < 0.001) and diastolic (P < 0.001) BP. The Brazilian MMM19 data demonstrate that strategies to increase awareness of hypertension and a better control of the risk factors are still needed.