Therapeutic Adherence According to the Morisky Scale in Patients with Hypertension

Abstract Background In view of the high prevalence of hypertension and the importance of adequate drug therapy in the prevention of complications, it is necessary to know the adherence to drug treatment in this population. Objective To verify adherence to antihypertensive drug treatment in Brazilian patients with hypertension using the Morisky-Green Test (MGT), relating it with demographic data. Methods Prospective, observational, multicenter, national registry study, with 2,578 hypertensive patients participating in study I, the Brazilian Cardiovascular Registry of Arterial Hypertension (I-RBH), recruited in the five regions of Brazil. The analyses carried out on the data were descriptive statistics, qui-square tests, ANOVA, and logistic regression, adopting 5% as the significance level for the tests. Results The research shows that 56.13% of patients in the sample were female; 56.71% were elderly (≥ 65 years); 55.86% were White; 52.37% were from the Southeast Region; and 59.74% were non-adherent. Logistic regression showed an independent relationship between patients' age, ethnicity, and region with medication adherence. Conclusion Adherence to treatment is the key to reducing high rates of cardiovascular complications. The study brings a successful outcome in the relationship between the factors ethnicity, age, and region of patients with hypertension and medication adherence. To this end, it is necessary to understand these factors, considering systematic evaluation in the care of patients with hypertension and other chronic non-communicable diseases. This study is a significant contribution to multidisciplinary teams, as it highlights which risk factors interfere with medication adherence, incorporating better strategies in health education.

Escore SAGE em Normotensos e Pré-Hipertensos: Uma Prova de Conceito / SAGE Score in Normotensive and Pre-Hypertensive Patients: A Proof of Concept

Resumo Fundamento O SAGE foi desenvolvido para identificar hipertensos com chance de velocidade de onda de pulso (VOP) aumentada. Até o momento, as publicações do escore foram em hipertensos. Objetivo Verificar a capacidade do SAGE de identificar os normotensos ou pré-hipertensos com chance de aumento da VOP. Métodos Transversal retrospectivo, incluiu exames de normotensos e pré-hipertensos que realizaram a medida central da pressão arterial e apresentavam os parâmetros para o cálculo do escore. Para cada pontuação do escore, foi analisada a sensibilidade, especificidade, valor preditivo positivo e negativo utilizando como ponto de corte para o diagnóstico positivo VOP ≥ 10m/s, ≥9,08 m/s (percentil 75) e ≥7,30 m/s (percentil 50). Um valor de p<0,05 foi adotado como estatisticamente significante. Resultados A amostra foi de 100 participantes normotensos ou pré-hipertensos, com média (DP) de 52,64 (14,94) anos e VOP mediana de 7,30 m/s (6,03 - 9,08). O SAGE apresentou correlação com idade (r=0,938, p<0,001), glicemia (r=0,366, p<0,001) e taxa de filtração de glomerular (r=-0,658, p<0,001). A área sob a curva ROC foi de 0,968 (p<0,001) para VOP≥10 m/s, 0,977 (p<0,001) para VOP≥9,08 m/s e 0,967 (p<0,001) para VOP≥7,30 m/s. O escore 7 apresentou especificidade de 95,40% e sensibilidade de 100% para VOP≥10 m/s. O ponto de corte seria cinco para VOP≥9,08 m/s (s=96,00%, e= 94,70%), e dois para VOP≥7,30 m/s. Conclusão O SAGE foi capaz de identificar indivíduos com maior chance de apresentar rigidez arterial, utilizando diferentes pontos de corte de VOP. Entretanto, o desenvolvimento de um escore específico para normontensos e pré-hipertensos faz-se necessário.

Abstract Background The SAGE score was developed to detect individuals at risk for increased pulse wave velocity (PWV). So far, studies have been focused on hypertensive patients. Objective To assess the ability of the score to detect non-hypertensive and pre-hypertensive patients at risk for increased PWV. Methods Retrospective cross-sectional study of analysis of central blood pressure data and calculation of the SAGE score of non-hypertensive and pre-hypertensive patients. Each score point was analyzed for sensitivity, specificity, positive and negative predictive values, using the cut-off point for positive diagnosis a PVW ≥ 10m/s, ≥9.08 m/s (75thpercentile) and ≥7.30 m/s (50thpercentile). A p<0.05 was considered statistically significant. Results The sample was composed of 100 normotensive and pre-hypertensive individuals, with mean age of 52.64 ± 14.94 years and median PWV of 7.30 m/s (6.03 - 9.08). The SAGE score was correlated with age (r=0.938, p<0.001), glycemia (r=0.366, p<0.001) and glomerular filtration rate (r=-0.658, p<0.001). The area under the ROC curve was 0.968 (p<0.001) for PWV ≥ 10 m/s, 0.977 (p<0.001) for PWV ≥ 9.08 m/s and 0.967 (p<0.001) for PWV ≥ 7.30 m/s. The score 7 showed a specificity of 95.40% and sensitivity of 100% for PWV≥10 m/s. The cut-off point would be of five for a PWV≥9.08 m/s (sensitivity =96.00%, specificity = 94.70%), and two for a PWV ≥ 7.30 m/s. Conclusion The SAGE score could identify individuals at higher risk of arterial stiffness, using different PWV cutoff points. However, the development of a specific score for normotensive and pre-hypertensive subjects is needed.

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.

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.

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.

Implementation of a Telecardiology Service in a Health Unit in the City of Porto Alegre, Brazil: A Pilot Study

Abstract Background: The implementation of Telecardiology in primary care in the city of Porto Alegre, Brazil, is a viable and promising strategy. It would decrease the distance between patient and specialized professional services by reducing unnecessary referrals and improving the quality of primary care and satisfaction of patients and health professionals. Objective: To implement a Telecardiology service and assess user satisfaction using the CARDIOSATIS scale. Methods: This was a pilot study developed by a partnership between the Institute of Cardiology and the Telehealth Center of Rio Grande do Sul. The study was carried out at Eri Flores-Vila Vargas health center in the city of Porto Alegre, from May to October 2019, and included 21 patients attending the health center. The descriptive analysis of data was performed using the SPSS program (Statistical Package for the Sciences) version 23. Data normality was checked using the Kolmogorov-Smirnov test. Statistical significance was set at 10%. Results: Mean age of participants was 43.8 ± 16.1 years. The most common risk factors in the sample were physical inactivity (81%) and smoking (43%). Most patients had normal electrocardiogram (ECG) readings. The time elapsed from the performance of the ECG test, transmission of the ECG traces to Telehealth, and return of the final ECG report to the health center was 0-7 days. The CARDIOSATIS scale revealed a high prevalence of "very satisfied" users for the general satisfaction domain, and only 14.3% of patients were dissatisfied with their health. Conclusions: Telecardiology reduced the distance between patient and the specialized professional, with a high level of patient and health professional satisfaction. Our study can serve as a basis for the implementation of a telecardiology network in the city of Porto Alegre in the future.

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.

Lipoma Arborescente: uma causa de sinovite crônica? / Lipoma Arborescens: a cause of chronic synovitis?

O lipoma arborescente é uma causa incomum de lesão intra-articular que se apresenta como aumento de volume articular indolor, lentamente progressivo, que persiste por muitos anos e é acompanhado por derrames articulares intermitentes. O envolvimento de sítios extra-articulares é incomum, mas pode ocorrer em bainhas tendíneas e bursas. A ressonância magnética é o melhor exame para o diagnóstico, embora a biópsia sinovial possa ser necessária em alguns casos. Relatamos três casos com o objetivo de destacar o espectro clínico da doença, as características da imagem e a resposta ao tratamento imunossupressor.

Lipoma arborescens is an uncommon cause of intra-articular masses that presents as slowly progressive painless swelling of the joint, which persists for many years and is accompanied by intermittent effusions. Extra-articular site(s) involvement is unusual, but can occur in tendon sheaths and bursas. Magnetic resonance imaging is the best diagnostic exam, although synovial biopsy may be necessary. We report three cases in order to highlight the clinical spectrum and imaging features of the disease, so that early diagnosis and appropriate treatment can be given.

Chronic use of hydroxychloroquine did not protect against COVID-19 in a large cohort of patients with rheumatic diseases in Brazil

Abstract Background: There is a lack of information on the role of chronic use of hydroxychloroquine during the SARS-CoV-2 outbreak. Our aim was to compare the occurrence of COVID-19 between rheumatic disease patients on hydroxychloroquine with individuals from the same household not taking the drug during the first 8 weeks of community viral transmission in Brazil. Methods: This baseline cross-sectional analysis is part of a 24-week observational multi-center study involving 22 Brazilian academic outpatient centers. All information regarding COVID-19 symptoms, epidemiological, clinical, and demographic data were recorded on a specific web-based platform using telephone calls from physicians and medical students. COVID-19 was defined according to the Brazilian Ministry of Health (BMH) criteria. Mann-Whitney, Chi-square and Exact Fisher tests were used for statistical analysis and two binary Final Logistic Regression Model by Wald test were developed using a backward-stepwise method for the presence of COVID-19. Results: From March 29th to May 17st, 2020, a total of 10,443 participants were enrolled, including 5166 (53.9%) rheumatic disease patients, of whom 82.5% had systemic erythematosus lupus, 7.8% rheumatoid arthritis, 3.7% Sjögren's syndrome and 0.8% systemic sclerosis. In total, 1822 (19.1%) participants reported flu symptoms within the 30 days prior to enrollment, of which 3.1% fulfilled the BMH criteria, but with no significant difference between rheumatic disease patients (4.03%) and controls (3.25%). After adjustments for multiple confounders, the main risk factor significantly associated with a COVID-19 diagnosis was lung disease (OR 1.63; 95% CI 1.03-2.58); and for rheumatic disease patients were diagnosis of systemic sclerosis (OR 2.8; 95% CI 1.19-6.63) and glucocorticoids above 10 mg/ day (OR 2.05; 95% CI 1.31-3.19). In addition, a recent influenza vaccination had a protective effect (OR 0.674; 95% CI 0.46-0.98). Conclusion: Patients with rheumatic disease on hydroxychloroquine presented a similar occurrence of COVID-19 to household cohabitants, suggesting a lack of any protective role against SARS-CoV-2 infection. Trial registration Brazilian Registry of Clinical Trials (ReBEC; RBR - 9KTWX6).

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.

Stress and Food Consumption Relationship in Hypertensive Patients / Estresse e Consumo Alimentar em Pacientes Hipertensos

Abstract Background: Stress is a state of threat to the balance of the organism, which can cause biological and psychological changes. In hypertensive patients, stress can interfere with blood pressure levels, influence on food choices and neglect of the diet. Objective: This study aims to describe the relationship between stress and dietary intake of hypertensive patients. Methods: A transversal study was carried out at the Arterial Hypertension Clinic of the Cardiology Institute of Rio Grande do Sul, Brazil. The participants were aged ≥ 18 years and hypertensive. Blood pressure, food consumption and anthropometric measurements were collected. The variables related to stress were evaluated by the Lipp's Stress Symptoms Inventory (LSSI) for adults. Significance level of 5% has been considered for all analyzed data. Results: The number of participants was 100. There was a higher prevalence of the female sex (67%), the mean age of the study population was 55.87 ± 12.55 years. Among the participants, 86% were classified in some of the stress phases, on which 57% were in the resistance phase. It was observed that there was no correlation between the presence of stress (as well as their actions), pressure levels and food consumption. The consumption of foods rich in lipids and individuals with a prevalence of psychological symptoms of stress displayed a significant association. Conclusions: Rich in fat dietary has been the first choice in patients with psychological symptoms of stress. Further studies regarding remodeled dietary intake and blood pressure levels in relation to the stress phases are suggested. These findings are important to contribute to the development of prevention and treatment strategies for cardiovascular diseases.

Resumo Fundamento: O estresse é um estado de ameaça ao equilíbrio do organismo, podendo causar alterações biológicas e psicológicas. No paciente hipertenso o estresse pode interferir nos níveis pressóricos e gerar influência nas escolhas alimentares e negligência da dieta. Objetivo: Este estudo tem como objetivo descrever a relação entre o estresse e consumo alimentar de pacientes hipertensos. Métodos: Estudo transversal, desenvolvido no Ambulatório de Hipertensão Arterial do Instituto de Cardiologia do Rio Grande do Sul. Participaram da pesquisa indivíduos hipertensos com idade > 18 anos. Foram coletados dados de pressão arterial, consumo alimentar e medidas antropométricas. As variáveis relacionadas ao estresse foram avaliadas pelo inventário de sintomas de stress para adultos de Lipp (ISSL). Em todas as análises foi considerando um nível de significância 5% (p < 0,05). Resultados: O número de participantes foi de 100. Houve maior prevalência no sexo feminino (67%), a idade média da população estudada foi 55,87 ± 12,55 anos. Dos participantes, 86% se classificaram em alguma das fases do estresse, sendo que destes, 57% estavam na fase de resistência. Observou-se que não houve correlação entre a presença de estresse (bem como suas fases), níveis pressóricos e consumo alimentar. O consumo de alimentos ricos em lipídios em hipertensos com sintomas de estresse apresentou significância estatística. Conclusão: Os alimentos ricos em gordura prevaleceram entre as escolhas alimentares nos pacientes com sintomas psicológicos de estresse. Sugere-se mais estudos em relação a alteração do consumo alimentar e níveis pressóricos em relação às fases do estresse.

Guia prático para o manejo da dor / Guia prático para o manejo da dor

O estudo da dor e suas particularidades é de grande importância para o tratamento de diversas patologias e para a melhora na qualidade de vida dos pacientes. A maioria das disfunções orgânicas tem a dor como um ponto importante da sua manifestação. Dessa maneira, é justificável a elaboração de conteúdo para auxiliar os profissionais da saúde no entendimento e tratamento das principais causas de dores agudas e crônicas. Este livro foi elaborado com o objetivo de servir como um guia prático para o manejo da dor por profissionais e acadêmicos de Medicina. Engloba temas como conceitos e aspectos biopsicossociais da dor, além de questões mais complexas como a fisiologia da dor e o tratamento medicamentoso com o arsenal terapêutico existente. Finalmente, também trata dos diversos tipos de dor mais prevalentes e o conhecimento básico que envolve seu manejo.

Efeitos de um programa de acompanhamento multidisciplinar em hipertensos sobre o controle autonômico cardiovascular: ensaio clínico randomizado / Effects of a multidisciplinary monitoring program in hypertensive patients on the cardiovascular autonomic control: randomized clinical trial

Introdução: A hipertensão arterial sistêmica (HAS) é uma doença crônica, considerada como principal fator de risco para mortalidade por acidente vascular cerebral (AVC) e doença coronariana (DC) (40% óbitos). Apesar disso e da alta prevalência na população não existe um bom controle dos valores da pressão arterial (PA) dentro de metas pressóricas determinadas pelas Diretrizes nos indivíduos acometidos. Acredita-se que a disponibilização de um programa de atenção e acompanhamento do paciente hipertenso de natureza multidisciplinar (MULTIHAS), possa colaborar para a adesão e, consequentemente, para o melhor controle da PA. Além disso, a possibilidade de avaliar nesses pacientes a Variabilidade da Frequência Cardíaca (VFC) pode fornecer informações sobre o Sistema Nervoso Autônomo (SNA) e seu controle sobre o coração. Objetivo: Avaliar o efeito de um programa de assistência multiprofissional (MULTIHAS) sobre o controle autonômico cardiovascular e a PA em pacientes em hipertensos. Métodos: Ensaio clínico randomizado, controlado, em hipertensos submetidos a dois tipos de tratamentos: o multiprofissional grupo MULTIHAS composto pelos profissionais (médico, enfermeiro, nutricionista, fisioterapeuta e psicólogo) e o convencional (grupo Controle) (médico e o enfermeiro). Foram avaliadas variáveis como uso de medicações, bioquímica do sangue, índice de massa corporal (IMC), escore de qualidade de vida (QV), PA e VFC. As visitas no grupo MULTIHAS eram efetuadas a cada dois meses a todos os profissionais. No grupo Controle as visitas também ocorriam a cada dois meses acompanhados, somente, pelo médico e pelo enfermeiro. Ao final de um ano todas as variáveis foram novamente avaliadas em ambos grupos. Resultados: Após um ano de tratamento o grupo MULTIHAS apresentou diferença significativa no escore da QV(p<0,005) e nos valores do IMC (p<0,001); na posição supina tiveram melhora a PAS (p=0,015), a PAM (p=0,034), a VFC (p= 0,051) e no componente de alta frequência da VFC - HFabs (p= 0,042) em relação ao grupo Controle. No registro da FC pelo frequencímetro (Polar RS800 CX da Finlândia) esta respondeu à manobra ortostática nos valores da PAS (p=0,016), PAD (p=0,028), sendo a variância total da FC (p= 0,047) bem como o componente de baixa frequência da VFC - LFabs (p= 0,045) significativamente diferentes em relação ao grupo Controle. Conclusão: O atendimento multiprofissional deve ser considerado como um potencial recurso no manejo da pressão arterial, do IMC, do escore de QV bem como do sistema nervoso autônomo, pois esses parâmetros foram otimizados quando comparados ao grupo Controle.

Introduction: Systemic arterial hypertension (SAH) is a chronic high prevalent disease and a major risk factor for cardiovascular events such stroke (CVA) and coronary heart disease (CHD) (40% of deaths). Despite this, there is a lack of adequate control of blood pressure (BP) levels according with those described on guidelines for hypertensive patients. It is believed that specific care programs and multidisciplinary monitoring of the hypertensive patient (MULTIHAS) can contribute to improved BP control in this population. Moreover, the autonomic nervous system and its control over cardiovascular function are alter in this patients and can contribute to poor prognostic and outcomes in this population. Objective: To evaluate the effect of a multidisciplinary assistance program (MULTIHAS) on the cardiovascular autonomic control and BP levels in hypertensive patients, with one year follow-up. Methods: Randomized controlled trial, conducted in hypertensive patients undergoing two different interventions: multi professional attention (MULTIHAS group) of different health time members (doctor, nurse, dietitian, physical therapist and psychologist) and conventional attention (control group) of doctor and nurse. The variables evaluated were BP and HRV (Heart rate variability), and secondary: body mass index (BMI), quality of life score (QOL), medication use and blood biochemistry The visits of MULTIHAS occurred every two months with all the multi professional team. Control group visits also occurred every two months accompanied only by the doctor and the nurse. After one year, all variables were assessed again in both groups. Results: After 1 year of treatment, the MULTIHAS group had a significant difference in the QOL score (p <0.005) and in the BMI values (p <0.001) ; the BP and HRV showed a small improvement in supine SBP (p = 0.015), in MBP (p = 0.034), in HRV (p = 0.051), and in the high frequency component of HRV - HFabs (p = 0.042) compared to the control group. During the recording of FC the frequency meter (Polar RS800 CX of Finland), it responded to the orthostatic maneuver in the values of SBP (p = 0.016), DBP (p = 0.028), the total HR variance (p = 0.047) LFabs (p = 0.045) were significantly different in relation to the control group. Conclusion: Multidisciplinary care should be considered as a potential resource in the management of blood pressure, BMI, QOL score as well as the autonomic nervous system, since these parameters were optimized when compared to the Control group.