Dialysis parameters associated with SARS-CoV-2 infection and prognosis in end-stage kidney disease.

BACKGROUND: The Covid-19 pandemic has affected patients with end-stage kidney disease (ESKD). Whether dialysis parameters have a prognostic value in ESKD patients with Covid-19 remains unclear. MATERIALS AND METHODS: We retrospectively evaluated clinical characteristics, blood pressure (BP) and dialysis parameters in ESKD patients undergoing maintenance outpatient hemodialysis, with (Covid-ESKD) and without (No-Covid-ESKD) Covid-19, at four Brazilian hemodialysis facilities. The Covid-ESKD (n = 107; 54% females; 60.8 ± 17.7 years) and No-Covid-ESKD (n = 107; 62% females; 58.4 ± 14.6 years) groups were matched by calendar time. The average BP and dialysis parameters were calculated during the pre-infection, acute infection, and post-infection periods. The main outcomes were Covid-19 hospitalization and all-cause mortality. RESULTS: Covid-ESKD patients had greater intradialytic and postdialysis systolic BP and lower predialysis weight, postdialysis weight, ultrafiltration rate, and interdialytic weight gain during acute-illness compared to 1-week-before-illness, while these changes were not observed in No-Covid-ESKD patients. After 286 days of follow-up (range, 276-591), there were 18 Covid-19-related hospitalizations and 28 deaths among Covid-ESKD patients. Multivariable logistic regression analysis showed that increases in predialysis systolic BP from 1-week-before-illness to acute-illness (OR, 95%CI = 1.06, 1.02-1.10; p = .004) and Covid-19 vaccination (OR, 95%CI = 0.16, 0.04-0.69; p = .014) were associated with hospitalization in Covid-ESKD patients. Multivariable Cox-regression analysis showed that Covid-19-related hospitalization (HR, 95%CI = 5.17, 2.07-12.96; p < .001) and age (HR, 95%CI = 1.05, 1.01-1.08; p = .008) were independent predictors of all-cause mortality in Covid-ESKD patients. CONCLUSION: Acute Covid-19 illness is associated with variations in dialysis parameters of volume status in patients with ESKD. Furthermore, increases in predialysis BP during acute Covid-19 illness are associated with an adverse prognosis in Covid-ESKD patients.

Dialysis parameters were influenced by SARS-CoV-2 infection and may have prognostic value in patients with Covid-19.Increases in blood pressure during acute Covid-19 illness and the lack of vaccination for Covid-19 were predictors of hospitalization for Covid-19.Hospitalization for Covid-19 and age were independent risk factors for all-cause death.

Cutoffs for white-coat and masked blood pressure effects: an ambulatory blood pressure monitoring study.

The values used to define white-coat and masked blood pressure (BP) effects are usually arbitrary. This study aimed at investigating the accuracy of various cutoffs based on the differences (ΔBP) between office BP (OBP) and 24h-ambulatory BP monitoring (ABPM) to identify white-coat (WCH) and masked (MH) hypertension, which are phenotypes coupled with adverse prognosis. This cross-sectional study included 11,350 [Derivation cohort; 45% men, mean age = 55.1 ± 14.1 years, OBP = 132.1 ± 17.6/83.9 ± 12.5 mmHg, 24 h-ABPM = 121.6 ± 11.4/76.1 ± 9.6 mmHg, 25% using antihypertensive medications (AH)] and 7220 (Validation cohort; 46% men, mean age = 58.6 ± 15.1 years, OBP = 136.8 ± 18.7/87.6 ± 13.0 mmHg, 24 h-ABPM = 125.5 ± 12.6/77.7 ± 10.3 mmHg; 32% using AH) unique individuals who underwent 24 h-ABPM. We compared the sensitivity, specificity, positive and negative predictive values and area under the curve (AUC) of diverse ΔBP cutoffs to detect WCH (ΔsystolicBP/ΔdiastolicBP = 28/17, 20/15, 20/10, 16/11, 15/9, 14/9 mmHg and ΔsystolicBP = 13 and 10 mmHg) and MH (ΔsystolicBP/ΔdiastolicBP = -14/-9, -5/-2, -3/-1, -1/-1, 0/0, 2/2 mmHg and ΔsystolicBP = -5 and -3mmHg). The 20/15 mmHg cutoff showed the best AUC (0.804, 95%CI = 0.794-0.814) to detect WCH, while the 2/2 mmHg cutoff showed the highest AUC (0.741, 95%CI = 0.728-0.754) to detect MH in the Derivation cohort. Both cutoffs also had the best accuracy to detect WCH (0.767, 95%CI = 0.754-0.780) and MH (0.767, 95%CI = 0.750-0.784) in the Validation cohort. In secondary analyses, these cutoffs had the best accuracy to detect individuals with higher and lower office-than-ABPM grades in both cohorts. In conclusion, the 20/15 and 2/2 mmHg ΔBP cutoffs had the best accuracy to detect hypertensive patients with WCH and MH, respectively, and can serve as indicators of marked white-coat and masked BP effects derived from 24 h-ABPM.

The influence of sex on left ventricular remodeling in patients with aortic dissection.

AIMS: Patients with aortic dissection have a high prevalence of left ventricular structural alterations, including left ventricular hypertrophy (LVH), but little is known about the impact of sex on this regard. This study compared clinical, cardiac, and prognostic characteristics between men and women with aortic dissection. METHODS: We retrospectively assessed clinical and echocardiographic characteristics, and 1-year mortality in 367 aortic dissection patients (30% women; 66% with Stanford-A) who underwent echocardiography 60 days before or after the diagnosis of aortic dissection from three Brazilian centers. RESULTS: Men and women had similar clinical characteristics, except for higher age (59.4 ±â€Š13.4 vs. 55.9 ±â€Š11.6 years; P  = 0.013) and use of antihypertensive classes (1.4 ±â€Š1.3 vs. 1.1 ±â€Š1.2; P  = 0.024) and diuretics (32 vs. 19%; P  = 0.004) in women compared with men. Women had a higher prevalence of LVH (78 vs. 65%; P  = 0.010) and lower prevalence of normal left ventricular geometry (20 vs. 10%; P  = 0.015) than men. Logistic regression analysis adjusted for confounding factors showed that women were less likely to have normal left ventricular geometry (odds ratio, 95% confidence interval = 0.42, 0.20-0.87; P  = 0.019) and were more likely to have LVH (odds ratio, 95% confidence interval = 1.91, 1.11-3.27; P  = 0.019). Conversely, multivariable Cox-regression analysis showed that women had a similar risk of death compared to men 1 year after aortic dissection diagnosis (hazard ratio, 95% confidence interval = 1.16, 0.77-1.75; P  = 0.49). CONCLUSION: In aortic dissection patients, women were typically older, had higher use of antihypertensive medications, and exhibited a greater prevalence of LVH compared with men. However, 1-year mortality after aortic dissection diagnosis did not differ between men and women.

Registro Nacional do Controle da Hipertensão Arterial Avaliado pela Medida de Consultório e Residencial no Brasil: Registro LHAR / National Registry of Hypertension Control Evaluated by Office and Home Measurements: The LHAR National Registry

Resumo Fundamento Sabe-se que em torno de 30% dos pacientes apresentam valores de pressão arterial (PA) mais elevados quando examinados no consultório do que em suas residências. No mundo, admite-se que apenas 35% dos hipertensos já tratados tenham alcançado meta pressórica. Objetivo Fornecer dados epidemiológicos sobre o controle da PA nos consultórios, em uma amostra de cardiologistas brasileiros, avaliado pela medida de consultório e monitorização residencial da pressão arterial (MRPA). Métodos Análise transversal. Observou-se pacientes com diagnóstico de hipertensão arterial, em tratamento anti-hipertensivo, podendo ou não estar com a PA controlada. A PA foi verificada no consultório por profissional médico, e no domicílio através da MRPA. A associação entre variáveis categóricas se deu por meio do teste do qui-quadrado (p < 0,05). Resultados Foram incluídos 2.540 pacientes, com idade média 59,7 ± 15,2 anos. A maioria dos pacientes eram mulheres (62%; n = 1.575). O estudo mostrou uma prevalência de 15% (n = 382) de hipertensão do avental branco não controlada, e 10% (n = 253) de hipertensão mascarada não controlada. A taxa de controle da PA no consultório foi 56,3%, e no domicílio, de 61%; 46,4% dos pacientes tiveram PA controlada no consultório e fora dele. Observou-se maior controle no sexo feminino e na faixa etária 49-61 anos. Observando o controle domiciliar com o novo ponto de corte das Diretrizes Brasileiras de Hipertensão Arterial de 2020, a taxa de controle foi de 42,4%. Conclusão O controle pressórico nos consultórios em uma amostra de cardiologistas brasileiros foi de 56,3%; 61% quando a PA foi obtida no domicílio, e 46,4% quando o controle foi observado tanto no consultório como no domicílio.

Abstract Background It is known that around 30% of patients have higher blood pressure (BP) values when examined at the office than at home. Worldwide, only 35% of patients with hypertension undergoing treatment have reached their BP targets. Objective To provide epidemiological data on BP control in the offices of a sample of Brazilian cardiologists, considering office and home BP measurement. Methods This is a cross-sectional analysis of patients with a hypertension diagnosis and undergoing antihypertensive treatment, with controlled BP or not. BP was assayed in the office by a medical professional and at home using home BP monitoring (HBPM). The association between categorical variables was verified using the chi-square test (p<0.05). Results The study included 2540 patients, with a mean age of 59.7 ± 15.2 years. Most patients were women (62%; n=1575). Prevalence rates of 15% (n=382) for uncontrolled white coat hypertension and 10% (n=253) for uncontrolled masked hypertension were observed. The rate of BP control in the office was 56.3% and at home, 61%. Meanwhile, 46.4% of the patients had controlled BP in and outside of the office. Greater control was observed in women and in the 49-61 years age group. Considering the new DBHA 2020 threshold for home BP control, the control rate was 42.4%. Conclusion BP control in the offices of a sample of Brazilian cardiologists was 56.3%; this rate was 61% when BP was measured at home and 46.4% when considering both the office and home.

Bloqueadores do Receptor de Angiotensina Avaliados por Medida de Consultório e Residencial da Pressão Arterial. Estudo TeleMRPA / Angiotensin Receptor Blockers Evaluated by Office and Home Blood Pressure Measurements. TeleHBPM Study

Resumo Fundamento O tratamento adequado e a obtenção das metas na hipertensão arterial são importantes na redução dos desfechos cardiovasculares. Objetivos Descrever os bloqueadores do receptor de angiotensina (BRA) em monoterapia ou combinação dupla e a taxa de controle da hipertensão arterial. Métodos Estudo transversal que avaliou pacientes em uso de BRA entre 2017 e 2020. Foram excluídos aqueles em uso de três ou mais anti-hipertensivos. As variáveis analisadas foram: sexo, idade, índice de massa corporal, medidas válidas da medida residencial da pressão arterial (MRPA); pressão arterial sistólica (PAS) e diastólica (PAD) obtidas pela MRPA e de forma casual; variabilidade pressórica; classe dos anti-hipertensivos e dos BRAs. Foram utilizados testes de t pareado, qui-quadrado e Fisher, além de sobreposição dos intervalos de confiança de 95% com nível de significância de 5% (p < 0,05). Resultados Foram selecionados 17.013 pacientes; destes, 12.813 preencheram os critérios, dos quais 62,1% eram do sexo feminino. O número médio de medidas válidas foi de 23,3 (±2,0), com médias para a PAS de 126,8±15,8 mmHg e 133,5±20,1 mmHg (p < 0,001) e para a PAD de 79,1±9,7 mmHg e 83,6±11,9 mmHg (p < 0,001) pela MRPA e medida casual, respectivamente. Losartana foi o BRA mais utilizado e o que apresentou comportamentos mais elevados da pressão arterial. As combinações de BRA com diuréticos ou com antagonistas de canal de cálcio tiveram menores valores de pressão arterial. Conclusões Losartana foi utilizada em mais da metade dos pacientes, apesar de ser a menos eficiente na redução e no controle da pressão arterial.

Abstract Background Adequate treatment of arterial hypertension and achieving arterial hypertension goals in are important in reducing cardiovascular outcomes. Objectives To describe angiotensin receptor blockers in monotherapy or double combination therapy and the rate of arterial hypertension control. Methods This cross-sectional study evaluated patients who were using angiotensin receptor blockers between 2017 and 2020. Those using three or more antihypertensive drugs were excluded. The analyzed variables included sex, age, body mass index, valid home blood pressure monitoring (HBPM) measurements, casual and HBPM systolic and diastolic blood pressure measurements, blood pressure variability, and antihypertensive and angiotensin receptor blocker class. Paired t, chi-square, and Fisher's exact tests were used, as well as overlapping 95% confidence intervals and a significance level of 5% (p < 0.05). Results Of 17,013 patients, 12,813 met the inclusion criteria, 62.1% of whom were female. The mean number of valid measurements was 23.3 (SD, 2.0). The mean HBPM and casual measurements for systolic blood pressure were 126.8 (SD, 15.8) mmHg and 133.5 (SD, 20.1) mmHg (p <0.001), respectively, while those for diastolic blood pressure were 79.1 (SD, 9.7 mmHg) and 83.6 (SD, 11.9) mmHg (p <0.001), respectively. Losartan was the most common angiotensin receptor blocker and resulted in the highest blood pressure values. Combinations of angiotensin receptor blockers with diuretics or calcium channel antagonists resulted in lower blood pressure values. Conclusions More than half of the patients used losartan, although it was the least efficient drug for reducing and controlling blood pressure.

Envelhecimento Vascular e Rigidez Arterial / Vascular Aging and Arterial Stiffness

Resumo O envelhecimento biológico é reflexo da interação entre genética, idade cronológica e fatores externos; é a base para novos conceitos em envelhecimento vascular, cuja progressão é determinada pela diferença entre idade biológica e cronológica. Do ponto de vista estrutural, os efeitos do envelhecimento vascular são mais evidentes na camada média das grandes artérias elásticas e resultam em aumento da rigidez arterial, da dilatação do lúmen e da espessura da parede. Esses efeitos são descritos no continuum de envelhecimento cardiovascular (proposto por Dzau em 2010) em que as etapas progressivas de lesões da microvasculatura de coração, rins e cérebro, têm início a partir do processo de envelhecimento. O aumento da rigidez arterial pode ser verificado de forma não invasiva por vários métodos. Os eventos cardiovasculares têm sido tradicionalmente previstos utilizando escores que combinam fatores de risco convencionais para aterosclerose. No continuum cardiovascular clássico (Dzau, 2006), é desafiador avaliar o peso exato da contribuição de cada fator de risco; entretanto, por refletir o dano precoce e cumulativo desses fatores de riscos cardiovascular, a rigidez arterial reflete o verdadeiro dano à parede arterial. Este artigo fornece uma visão geral dos mecanismos da fisiopatogenia, alterações estruturais das artérias e consequências hemodinâmicas do envelhecimento arterial; métodos não invasivos para a avaliação da rigidez arterial e da medida central da pressão arterial; o continuum de envelhecimento cardiovascular, e aplicação do conceito de rigidez arterial na estratificação de risco cardiovascular.

Abstract Biological aging occurs as a result of the interaction between genetics, chronological age and external factors. It is the basis for new concepts of vascular aging, whose progression is determined by the difference between biological and chronological age. From the structural point of view, the effects of vascular aging are more evident in the tunica media of large elastic arteries, marked by increased arterial stiffness, lumen dilation and wall thickness. These effects are described in the continuum of cardiovascular aging (proposed by Dzau in 2010), in which the progressive steps of microvasculature lesions of the heart, kidney and brain are initiated from the aging process. The increase of arterial stiffness can be detected by several non-invasive methods. Cardiovascular events have been traditionally described using scores that combine conventional risk factors for atherosclerosis. In the classic cardiovascular continuum (Dzau, 2006), to determine the exact contribution of each risk factor is challenging; however, since arterial stiffness reflects both early and cumulative damage of these cardiovascular risk factors, it is an indicator of the actual damage to the arterial wall. This article provides a general overview of pathophysiological mechanisms, arterial structural changes, and hemodynamic consequences of arterial stiffness; non-invasive methods for the assessment of arterial stiffness and of central blood pressure; the cardiovascular aging continuum, and the application of arterial stiffness in cardiovascular risk stratification.

Sleep quality in COPD patients: correlation with disease severity and health status / Qualidade do sono em pacientes com DPOC: correlação com gravidade da doença e estado de saúde

To evaluate clinical predictors of poor sleep quality in COPD patients with and without obstructive sleep apnea (OSA). Methods: Consecutive stable patients with COPD were evaluated for OSA by means of overnight polysomnography; for sleep quality by means of the Pittsburgh Sleep Quality Index (PSQI); and for disease impact by means of the COPD Assessment Test. COPD severity was graded in accordance with the 2020 GOLD guidelines. Predictors of poor sleep quality were evaluated by multivariate logistic regression analysis. Results: We studied 51 patients with COPD alone and 51 patients with COPD and OSA. Both groups had similar age (66.2 ± 9.2 years vs. 69.6 ± 10.7, p = 0.09) and airflow limitation (p = 0.37). Poor sleep quality was present in 74.8% of the study participants, with no significant difference between COPD patients with and without OSA regarding PSQI scores (p = 0.73). Polysomnography showed increased stage 1 non-rapid eye movement sleep and arousal index, as well as reduced sleep efficiency and stage 3 non-rapid eye movement sleep, in the group of patients with COPD and OSA (p < 0.05). Independent predictors of poor sleep quality were GOLD grade C/D COPD (OR = 6.4; 95% CI, 1.79-23.3; p < 0.01), a COPD Assessment Test score ≥ 10 (OR = 12.3; 95% CI, 4.1-36.5; p < 0.01), and lowest SaO2 < 80% (p < 0.0001). Conclusions: Poor sleep quality is quite common in patients with COPD and is associated with severe COPD and poor health status, having a negative impact on overall quality of life. Despite changes in polysomnography, OSA appears to have no impact on subjective sleep quality in COPD patients.

Avaliar os preditores clínicos de má qualidade do sono em pacientes com DPOC, com e sem apneia obstrutiva do sono (AOS). Métodos: Pacientes estáveis consecutivos com DPOC foram avaliados quanto à AOS por meio de polissonografia noturna; quanto à qualidade do sono por meio do Índice de Qualidade do Sono de Pittsburgh (IQSP) e quanto ao impacto da doença por meio do Teste de Avaliação da DPOC. A gravidade da DPOC foi classificada conforme as diretrizes de 2020 da GOLD. Os preditores de má qualidade do sono foram avaliados por meio de análise de regressão logística multivariada. Resultados: Foram estudados 51 pacientes com DPOC apenas e 51 pacientes com DPOC e AOS. Ambos os grupos eram semelhantes quanto à idade (66,2 ± 9,2 anos vs. 69,6 ± 10,7, p = 0,09) e limitação do fluxo aéreo (p = 0,37). Sono de má qualidade esteve presente em 74,8% dos participantes, sem diferença significativa entre os pacientes com DPOC, com e sem AOS, quanto à pontuação no IQSP (p = 0,73). A polissonografia mostrou aumento do estágio 1 do sono non-rapid eye movement e do índice de despertares, bem como redução da eficiência do sono e do estágio 3 do sono non-rapid eye movement nos pacientes com DPOC e AOS (p < 0,05). Os preditores independentes de má qualidade do sono foram DPOC grau C/D da GOLD (OR = 6,4; IC95%: 1,79-23,3; p < 0,01), pontuação ≥ 10 no Teste de Avaliação da DPOC (OR = 12,3; IC95%: 4,1-36,5; p < 0,01) e menor SaO2 < 80% (p < 0,0001). Conclusões: O sono de má qualidade é bastante comum em pacientes com DPOC e apresenta relação com DPOC grave e estado de saúde ruim, além de ter impacto negativo na qualidade de vida global. Não obstante as alterações na polissonografia, a AOS aparentemente não tem impacto na qualidade do sono referida por pacientes com DPOC.

Factors associated with uncontrolled blood pressure in hypertensive Brazilians

ABSTRACT: Uncontrolled hypertension has a high prevalence and is related to numerous negative health outcomes. This study aimed to investigate the factors associated with the lack of blood pressure control in hypertensive Brazilians treated in public and private services. This is an analytical, multicentric, and national cross-sectional study, carried out with adult hypertensive patients, monitored in 45 outpatient clinics (September 2013 to October 2015) in a prospective record interview, clinical, and anthropometric assessment. Outcome variables included uncontrolled pressure (systolic blood pressure ≥ 140 mmHg and/or diastolic blood pressure ≥ 90 mmHg). Simple and multiple logistic regression analyses were performed. Two thousand six hundred forty-three participants were assessed with a mean age of 61.6 ± 11.9 years, 55.7% of women, and 46.4% with uncontrolled blood pressure (BP). The following were associated with uncontrolled BP: age over 60 years (OR: 1.31 [1.11­1.55]); practice of irregular physical activity (OR: 1.28 [1.06­1.55]); attending the emergency room for hypertensive crises in the last six months (OR: 1.80 [1.46­2.22]); increased body mass index (OR: 1.02 [1.01­1.04]); low adherence to drug treatment (OR: 1.22 [1.04­1.44]) and menopause (OR: 1.36 [1.07­1.72]). The following were negatively associated: fruit consumption (OR: 0.90 [0.85­0.94]); presence of dyslipidemia (OR: 0.75 [0.64­0.89]), acute myocardial infarction (OR: 0.59 [0.46­0.76]), and peripheral arterial disease (OR: 0.52 [0.34-0.78]). Factors associated with difficult-to-control blood pressure are the same that increase the risk for hypertension, while the presence of atherosclerotic disease and its outcomes were associated with better control.

Hipertensão mascarada: qual a importância da mrpa neste contexto? / Masked hypertension: how important is hbpm in this context?

A hipertensão arterial (HA) é o principal fator contributivo para as doenças cardiovasculares, as quais constituem a mais importante causa de morte prevenível no mundo. A falta de conhecimento da população acerca da doença, e consequentemente de um diagnóstico adequado, torna baixo o número de pessoas que se tratam. O aspecto silencioso da HA, e a má adesão ao tratamento proposto, dentre outros fatores, contribuem para o elevado risco de complicações. A medida da pressão arterial (PA) neste contexto apresenta grande importância não apenas no diagnóstico, mas também no acompanhamento de portadores de HA, podendo ser realizada de forma casual, em consultório, ou fora do mesmo com a utilização de outros métodos para tal. Dentre as medidas de PA, a monitorização residencial da PA (MRPA) se destaca. É um método destinado a fazer registro da PA fora do ambiente de consultório, obedecendo a um protocolo previamente estabelecido e normatizado. Além disto, a MRPA apresenta custos menores do que a monitorização ambulatorial da PA (MAPA). De acordo com a atual Diretriz Brasileira de HA, são considerados anormais valores de PA consultório ≥ 140/90 mmHg e de MRPA ≥ 130/80 mmHg. Sob esta perspectiva, a MRPA é um exame que permite que se faça o diagnóstico de HA verdadeira (PA elevada no consultório e na MRPA), normotensão verdadeira (PA normal no consultório e na MRPA), HA do avental branco (HAB) (PA elevada no consultório e normal na MRPA) e HA mascarada (HM) (PA normal no consultório e elevada na MRPA). O diagnóstico de HM é bastante relevante na prática clínica, pois em termos prognósticos, a HM apresenta um risco cardiovascular maior que a HAB e a normotensão verdadeira. Além disto, a incidência de eventos cardiovasculares na HM é similar ou até superior à da HA verdadeira.

Hypertension is the main contributing factor to cardiovascular diseases, which are the most important cause of death in the world. The lack of proper diagnosis, mainly due to the silent aspect of hypertension, makes the rate of people undergoing treatment low, contributing to the high risk of complications. The measurement of blood pressure (BP) in this context is important not only in the diagnosis, but also in the follow-up of patients with hypertension, and it can be performed casually, in the office, or outside the office, using other methods for this purpose. Home blood pressure monitoring (HBPM) is a method designed to record BP outside the office environment, following a previously established and standardized protocol and has a lower cost than ambulatory blood pressure monitoring (ABPM) According to the current Brazilian hypertension guideline, office BP values ≥ 140/90 mmHg and HBPM values ≥ 130/80 mmHg are considered abnormal. From this perspective, HBPM is a test that allows the diagnosis of true hypertension (high BP in the office and in HMBP), true normotension (normal BP in the office and in the HBPM), white coat hypertension (high BP in the office and normal BP in HBPM) and masked hypertension (normal BP in the office and high in HBPM). The diagnosis of masked hypertension is quite relevant in clinical practice, because this phenotype has greater cardiovascular risk than true normotension and white coat hypertension. On the other hand, the incidence of cardiovascular events is similar or even greater in masked hypertension in comparison with true hypertension.

Hipertensos Tratados e Avaliados por Telemonitoramento Residencial da Pressão Arterial. Estudo TeleMRPA / Treated Hypertensive Patients Assessed by Home Blood Pressure Telemonitoring. TeleMRPA Study

Resumo Fundamento: Hipertensos tratados avaliados apenas com a medida casual da pressão arterial (PA) podem estar sujeitos a decisões equivocadas. Objetivos: Avaliar o comportamento da PA pela medida casual e residencial (MRPA), o comportamento das classes de anti-hipertensivos e as prevalências de hipertensão do avental branco (HABNC) e mascarada não-controladas (HMNC). Métodos: Estudo transversal que avaliou pacientes pela plataforma TeleMRPA entre 2017 e 2019. Foram excluídos aqueles sem medicamentos, com 3 ou mais, em uso de espironolactona e alfa-2 agonistas. As variáveis analisadas foram: idade, sexo, índice de massa corporal (IMC), número de medidas válidas da PA, médias da PA sistólica (PAS) e diastólica (PAD) pela medida casual e MRPA, e as classes de anti-hipertensivos. Utilizados os testes t pareado e não pareado e qui-quadrado. Adotado nível de significância de 5%. Resultados: Selecionados 22.446 pacientes, dos quais 6.731 preencheram os critérios, sendo 61,3% do sexo feminino, com idade média de 57,8 (±12,6) anos e IMC médio de 29,0 (±5,1) kg/m2. Os valores médios de PAS e PAD foram 6,6 mmHg (p<0,001) e 4,4 mmHg (p<0,001) maiores na medida casual que na MRPA. As taxas de controle da PA foram de 57,0% pela medida casual e 61,3% pela MRPA (p<0,001), com prevalência de HABNC e HMNC de 15,4% e 11,1%, respectivamente. O bloqueio do sistema renina-angiotensina-aldosterona ocorreu em 74,6% das vezes e 54,8% estavam em monoterapia. Conclusões: O uso da MRPA deve ser considerado no acompanhamento de hipertensos tratados em virtude das elevadas prevalências de HABNC e HMNC. Os anti-hipertensivos tiveram comportamentos distintos nas medidas domiciliares. (Arq Bras Cardiol. 2021; [online].ahead print, PP.0-0)

Abstract Background: Hypertensive patients undergoing treatment and assessed only by casual blood pressure (BP) measurement may be subject to mistaken decisions. Objective: To assess BP behavior by measuring its levels at the office (casual) and at home (HBPM), the behavior of different classes of antihypertensive drugs, and the prevalence of uncontrolled white-coat hypertension (UCWCH) and uncontrolled masked hypertension (UCMH). Methods: Cross-sectional study assessing patients who underwent BP monitoring in the TeleMRPA platform between 2017 and 2019. The exclusion criteria were: use of no antihypertensive drug; combined use of 3 or more antihypertensive drugs; and use of spironolactone and alpha-2 agonist. The variables analyzed were: age, sex, body mass index (BMI), number of valid BP measurements, means of systolic and diastolic blood pressure (SBP and DBP, respectively) obtained from HBPM and casual measurement, and the classes of antihypertensive drugs. Paired and unpaired t tests, as well as chi-square test, were used. The 5% significance level was adopted. Results: This study selected 22 446 patients, 6731 of whom met the inclusion criteria [61.3%, female sex; mean age, 57.8 (±12.6) years; mean BMI, 29.0 (±5.1) kg/m2]. Mean SBP and DBP were 6.6 mm Hg (p<0.001) and 4.4 mm Hg (p<0.001) higher in casual measurement than in HBPM. The rates of BP control were 57.0% in casual measurement and 61.3% in HBPM (p<0.001), and the prevalence of UCWCH and UCMH was 15.4% and 11.1%, respectively. Renin-angiotensin-aldosterone system blockade was observed in 74.6% of the patients, and 54.8% were on single-drug therapy. Conclusions: HBPM should be considered for the follow-up of treated hypertensive patients because of the high prevalence of UCWCH and UCMH. Antihypertensive drugs behaved differently in HBPM. (Arq Bras Cardiol. 2021; [online].ahead print, PP.0-0)

Fatores de Risco Cardiovascular em Cardiologistas Especialistas pela Sociedade Brasileira de Cardiologia / Cardiovascular Risk Factors in Cardiology Specialists from the Brazilian Society of Cardiology

Resumo Fundamento: Principal causa de morte em todo o mundo, as doenças cardiovasculares (DCV) e sua prevalência nos médicos cardiologistas são pouco conhecidas. Objetivos: Descrever os hábitos de vida e os fatores de risco cardiovascular e verificar a prevalência de diagnóstico, conhecimento e controle dos fatores de risco cardiovasculares (FRCV) de médicos cardiologistas associados e especialistas pela Sociedade Brasileira de Cardiologia. Métodos: Estudo multicêntrico nacional transversal que avaliou cardiologistas brasileiros por meio de questionário sobre hábitos de vida, doenças preexistentes, medicações em uso, medidas antropométricas, pressão arterial e dosagens de glicose e lípideos sanguíneos. Resultados: Foram avaliados 555 cardiologistas, 67,9% do sexo masculino, média de idade de 47,2±11,7 anos. A maioria era não tabagista (88,7%), fisicamente ativa (77,1%), consumia bebida alcóolica (78,2%), com circunferência abdominal normal (51,7%) e excesso de peso (56,1%). As prevalências de hipertensão arterial sistêmica (HAS), diabetes mellitus (DM) e dislipidemia (DLP) foram de 32,4%, 5,9% e 49,7%, respectivamente e, destes, apenas 57,2%, 45,5% e 49,6% sabiam ter as doenças. Conclusões: Os cardiologistas brasileiros participantes do estudo apresentaram prevalências significativas de HAS, DM e DLP, mas apenas a metade dos participantes sabia ser portador dessas condições e, entre eles, as taxas de controle eram baixas para HAS e DLP, apesar de os cardiologistas serem profissionais detentores de conhecimento diferenciado sobre esses FRCV. Os achados representam um alerta para a abordagem dos FRCV em cardiologistas brasileiros e estimulam a realização de estudos futuros.

Abstract Background: A major cause of death worldwide, cardiovascular diseases and their prevalence in cardiologists are little known. Objectives: To describe life habits and cardiovascular risk factors (CVRF) and to investigate the prevalence of diagnosis, awareness, and control of these CVRF among cardiologists members affiliated to and specialists from the Brazilian Society of Cardiology. Methods: National multicenter cross-sectional study to assess Brazilian cardiologists using a questionnaire on life habits, preexisting diseases, current medications, anthropometric measurements, blood pressure, and levels of glucose and lipids. Results: A total of 555 cardiologists were evaluated, of which 67.9% were male, with a mean age of 47.2±11.7 years. Most were non-smoker (88.7%) and physically active (77.1%), consumed alcohol (78.2%), had normal weight circumference (51.7%), and were overweight (56.1%). The prevalence of systemic arterial hypertension (SAH), diabetes mellitus (DM), and dyslipidemia (DLP) were 32.4%, 5.9%, and 49.7%, respectively, of which only 57.2%, 45.5%, and 49.6%, respectively, were aware of the diseases. Conclusions: The Brazilian cardiologists participating in the study had a high prevalence of SAH, DM and DLP, but only a half of participants were aware of these conditions and, among these, the rates of controlled disease were low for SAH and DLP, although cardiologists are professionals with great knowledge about these CVRF. These findings represent a warning sign for the approach of CVRF in Brazilian cardiologists and encourage the conduction of future studies.

Espironolactona ou clonidina como quarto fármaco na hipertensão resistente? / Spironolactone or clonidine as the fourth drug to treat resistant hypertension?

A hipertensão arterial resistente (HAR) é definida como a ausência de controle pressórico nas medidas de pressão arterial (PA) de consultório a despeito do uso de três ou mais anti-hipertensivos em doses adequadas, incluindo-se preferencialmente um diurético, ou o controle pressórico atingido às custas do uso de quatro ou mais medicamentos. O uso de espironolactona, um antagonista dos receptores de aldosterona, como quarto fármaco no tratamento da HAR é indicado pelas principais diretrizes sobre o assunto, e tem a sua eficácia comprovada em ensaios clínicos e meta análises. Um estudo comparou o uso de clonidina, um agonista adrenérgico alfa-2, como quarto fármaco para tratamento da HAR em comparação com a espironolactona. Embora o desfecho primário (taxa de controle da PA no consultório ou na medida ambulatorial da PA) tenha sido similar com as duas medicações, a espironolactona mostrou maior redução na PA de 24h quando comparada à clonidina. Neste contexto, a clonidina pode ser uma alternativa à espironolactona, particularmente em grupos específicos de pacientes que tenham contraindicação ao uso de espironolactona, como os que apresentam hipercalemia ou doença renal crônica pré dialítica.

Resistant Hypertension (RH) is defined as the absence of blood pressure (BP) control despite the use of three antihypertensive drugs in adequate doses, or the achievement of BP control with the use of four or more medications. The use of spironolactone, an antagonist of aldosterone receptors, as the fourth medication in the treatment of RH is recommended by current Management of Hypertension Guidelines, and its efficacy has been proved in clinical trials and meta-analysis. One clinical trial compared the use of clonidine, an adrenergic alpha-2 agonist, versus spironolactone as an option as the fourth drug in the treatment of RH. The results showed similar rates of the primary outcome (BP control at the office and at ambulatory monitoring) with both drugs, although spironolactone promoted greater reduction in 24h BP when compared with clonidine. In this context, clonidine can be used as an alternative to spironolactone, particularly among specific groups of patients that have contraindications to the use of spironolactone, such as patients with hyperkalemia or end stage renal disease.

Prevalence of Masked and White-Coat Hypertension in Pre-Hypertensive and Stage 1 Hypertensive patients with the use of TeleMRPA / Prevalência de Hipertensão Mascarada e do Avental Branco em Pré-Hipertensos e Hipertensos Estágio 1 com o uso da TeleMRPA

Abstract Background: The diagnosis of arterial hypertension based on measurements of blood pressure in the office has low accuracy. Objective: To evaluate the prevalence of masked hypertension (MH) and white-coat hypertension through home blood pressure monitoring (HBPM) in pre-hypertensive and stage 1 hypertensive patients. Method: Retrospective study, of which sample consisted of individuals with BP ≥ 120/80 mmHg and < 160/100 mmHg at the medical office without the use of antihypertensive medication and who underwent exams on the HBPM platform by telemedicine (TeleMRPA) between May 2017 and September 2018. The four-day MRPA protocol was used, with 24 measurements, using automated, validated, calibrated equipment with a memory function. Results: The sample consisted of 1,273 participants, of which 739 (58.1%) were women. The mean age was 52.4 ± 14.9 years, mean body mass index (BMI) 28.4 ± 5.1 kg/m2. The casual BP was higher than the HBPM in 7.6 mmHg for systolic blood pressure (SBP) and 5.2 mmHg for diastolic blood pressure (DBP), both with statistical significance (p < 0.001). There were 558 (43.8%) normotensive individuals; 291 (22.9%) with sustained hypertension; 145 (11.4%) with MH and 279 (21.9%) with white-coat hypertension (WCH), with a diagnostic error by casual BP in the total sample in 424 (33.3%) patients. In stage 1 hypertensive individuals, the prevalence of WCH was 48.9%; in prehypertensive patients, the prevalence of MH was 20.6%. Conclusion: MH and WCH have a high prevalence rate in the adult population; however, in prehypertensive or stage 1 hypertensive patients, the prevalence is higher. Out-of-office BP measurements in these subgroups should be performed whenever possible to prevent misdiagnosis.

Resumo Fundamento: O diagnóstico de hipertensão arterial baseado nas medidas do consultório tem baixa acurácia. Objetivo: Avaliar a prevalência de hipertensão mascarada (HM) e do avental branco pela monitorização residencial da pressão arterial (MRPA) em pacientes pré-hipertensos e hipertensos estágio. Método: Estudo retrospectivo com amostra constituída de indivíduos com pressão arterial (PA) na clínica ≥ 120/80 mmHg e < 160/100 mmHg sem uso de medicação anti-hipertensiva e que realizaram exames na plataforma de MRPA por telemedicina (TeleMRPA) entre maio de 2017 e setembro de 2018. Foi utilizado o protocolo MRPA de quatro dias, com 24 medidas, com equipamentos automáticos, validados, calibrados e com memória. Resultados: A amostra foi constituída de 1.273 participantes, sendo 739 (58,1%) mulheres. A idade média foi 52,4 ± 14,9 anos, índice de massa corporal (IMC) médio 28,4 ± 5,1 kg/m2. A PA casual foi maior que a MRPA em 7,6 mmHg para pressão arterial sistólica (PAS) e 5,2 mmHg para a pressão arterial diastólica (PAD), ambas com significância estatística (p < 0,001). Foram diagnosticados 558 (43,8%) normotensos; 291 (22,9%) hipertensos sustentados; 145 (11,4%) com HM e 279 (21,9%) com hipertensão do avental branco (HAB), com erro diagnóstico pela PA casual na amostra total em 424 (33,3%) pacientes. Em hipertensos estágio 1, a prevalência de HAB foi de 48,9%; nos pré-hipertensos a prevalência de HM foi de 20,6%. Conclusão: HM e HAB têm elevada prevalência na população adulta; entretanto, na população de pré-hipertensos ou hipertensos estágio 1 a prevalência é maior. Medidas da PA fora do consultório, nestes subgrupos, devem ser realizadas sempre que possível para evitar erro diagnóstico.

Gênese e fatores de risco para a hipertensão arterial / Genesis and risk factors for hypertension

A patogênese da hipertensão arterial primária é multifatorial e altamente complexa, envolvendo a interação de numerosos mecanismos independentes ou interdependentes. Fatores genéticos, ativação de sistemas neuro-hormonais, obesidade e aumento da ingestão de sal na dieta, dentre outros, são implicados no desenvolvimento desta patologia. A hipertensão arterial, condição de elevada prevalência na população mundial, constitui-se no principal fator de risco para doença cardiovascular, sendo responsável direta por elevada morbimortalidade. O conhecimento mais aprofundado dos possíveis contribuintes para sua gênese e perpetuação é fundamental, servindo de guia para o desenvolvimento e instituição de terapias mais direcionadas, visando à redução do enorme impacto social desta doença.

The pathogenesis of essential hypertension is multifactorial and highly complex, involving the interaction of numerous independent or interdependent mechanisms. Genetic factors, activation of neurohormonal systems, obesity and increased dietary salt intake, among others, are implicated in the development of this pathology. Essential hypertension, a condition of high prevalence in the world population, is the main risk factor for cardiovascular disease, being directly responsible for high morbidity and mortality. It is fundamental to have more thorough knowledge of the possible contributors to its genesis and perpetuation, serving as a guide for the development and institution of more targeted therapies, aiming at reducing the enormous social impact of this disease.