Post-traumatic stress disorder as a predictor for incident hypertension: a 3-year retrospective cohort study.

BACKGROUND: The goal of the present study was to investigate the association between PTSD and the onset of hypertension in previously normotensive individuals in a population living in the stressful environment of the urban slums while controlling for risk factors for cardiovascular disease (CVD). METHODS: Participants were 320 normotensive individuals who lived in slums and were attending a family doctor program. Measurements included a questionnaire covering sociodemographic characteristics, clinical status and life habits, the Posttraumatic Stress Disorder Checklist - Civilian Version, and the Beck Depression Inventory. Incident hypertension was defined as the first occurrence at the follow-up review of the medical records of (1) systolic blood pressure of 140 mm Hg or higher or diastolic blood pressure of 90 mm Hg or higher, (2) the participant started taking antihypertensive medication, or (3) a new diagnosis of hypertension made by a physician. Differences in sociodemographic, clinical, and lifestyle characteristics between hypertensive and non-hypertensive individuals were compared using the χ2 and t tests. Multivariate Cox proportional hazards models were used to calculate hazard ratios (HR) and 95% confidence intervals (CI). RESULTS: Six variables - age, educational level, body mass, smoking, diabetes, and PTSD diagnosis - showed a statistically significant (p ≤ 0.20) association with the hypertensive status. In the Cox regression, only PTSD diagnosis was significantly associated with incident hypertension (multivariate HR = 1.94; 95% CI 1.11-3.40). CONCLUSIONS: The present findings highlight the importance of considering a diagnostic hypothesis of PTSD in the prevention and treatment of cardiovascular diseases.

Uric acid and salt intake as predictors of incident hypertension in a primary care setting / Ácido úrico e ingesta de sal como factores predictivos de la hipertensión arterial incidental en un centro de atención primaria

Abstract Background: Hypertension is responsible for a substantial number of deaths due to cardiovascular disease and stroke. A crucial step toward its control is the identification of modifiable predictors of hypertension. Objectives: To estimate the relationship between salt intake, serum uric acid and incident hypertension in a primary care setting. Methods: Retrospective cohort of the CAMELIA study in which a non-randomized sample of 1098 participants who were ≥ 20 year-old was recruited from a primary care program. Originally, the sample consisted of hypertensive, diabetic and non-diabetic/non-hypertensive subjects. For the analysis, 258 participants with blood pressure (BP) lower than 140/90 mm Hg not using antihypertensive drugs and without diabetes mellitus were included. Five years after the first visit, their medical records were reviewed. Patients were divided into two groups according to BP in the first visit: normal BP group (systolic BP ≤ 120 mm Hg and diastolic BP ≤ 80 mm Hg) and high-normal BP group (systolic BP 121-139 mm Hg and/or diastolic BP 81-89 mm Hg). Results: In multivariate analysis, high-normal BP, hyperuricemia and salt intake ≥ 6 g/day predicted incident hypertension. In participants of thenormal BP group, high salt intake conferred the highest risk. In the high-normal BP group, smoking and serum uric acid were found to be the most important ones. Conclusion: In a healthy, multiethnic, and normotensive population from an urban primary care program, high-normal BP, hyperuricemia and high salt intake were found to be predictors of incident hypertension.

Resumen Antecedentes: La hipertensión es responsable de un gran número de muertes debido a cardiopatías e ictus. Un paso esencial para su control es la identificación de factores modificables predictivos de la hipertensión. Objetivos: Calcular la relación entre ingesta de sal, ácido úrico sérico e hipertensión incidental en un centro de atención primaria. Métodos: Cohorte retrospectiva del estudio CAMELIA, en el que se incluyó una muestra no aleatorizada de 1.098 participantes con edades ≥ 20 años, obtenida de un programa de atención primaria. Originalmente, la muestra incluía sujetos hipertensos, diabéticos y no diabéticos/no hipertensos. Para el análisis, se estudiaron 258 participantes con presión arterial (PA) inferior a 140/90 mm Hg, sin prescripción de fármacos antihipertensivos, y no diabéticos. Transcurridos cinco años de la primera visita, se revisaron sus historias médicas. Se dividió a los pacientes en dos grupos, con arreglo a su PA en la primera visita: grupo con PA normal (PA sistólica ≤ 120 mm Hg y PA diastólica ≤ 80 mm Hg), y grupo con PA alta-normal BP (PA sistólica 121-139 mm Hg y/o PA diastólica 81-89 mm Hg). Resultados: En el análisis multivariante, la PA alta-normal, hiperuricemia e ingesta de sal ≥ 6 g/día predijeron la hipertensión incidental. En los participantes del grupo de PA normal, la ingesta elevada de sal confirió el mayor riesgo. En el grupo de PA alta-normal, el tabaquismo y el ácido úrico sérico fueron los factores más importantes. Conclusión: En una población sana, multiétnica y normotensa, procedente de un programa de atención primaria urbana la PA alta-normal, hiperuricemia e ingesta elevada de sal constituyeron los factores predictivos de la hipertensión incidental.

PTSD Predicts Smoking Cessation Failure in a Trauma-Exposed Population.

OBJECTIVE: The objective of the study was to investigate whether a diagnosis of posttraumatic stress disorder (PTSD; full or partial) or specific PTSD symptom clusters predicted failure in quitting smoking in a trauma-exposed population. Methods: Participants were 310 smokers who attempted quitting smoking, either successfully (quitters, n = 213) or not (relapsers, n = 97), who lived in slums and were attending a family doctor program. Measurements included a general questionnaire covering sociodemographic characteristics, clinical status and life habits, and the Posttraumatic Stress Disorder Checklist - Civilian Version. Differences in sociodemographic, clinical and lifestyle characteristics between quitters and relapsers were compared using a chi-square test. Because of the small sample size, full and partial PTSD were collapsed into a single category. Results: Significant differences (p ≤ .15) between quitters and relapsers were found in age, body mass index (BMI), income, alcohol consumption, and in the presence of full/partial PTSD diagnosis and of all three symptom clusters separately. Four logistic regression models predicting smoking cessation were modeled to control for confounding factors and included as independent variables a full/partial PTSD diagnosis and the three posttraumatic symptom clusters. The avoidance/numbing cluster presented the strongest association with relapse status (ORa 2.04, 95% CI [1.15, 3.63], p = .015), followed by the full/partial PTSD (ORa 1.80, 95% CI [1.04, 3.14], p = .038). The re-experiencing and the hyperarousal clusters were non-significantly associated with smoking cessation (ORa 1.34, 95% CI [0.80, 2.31], ns and ORa 1.65, 95% CI [0.96, 2.84], ns, respectively). Conclusions: Full/partial PTSD and posttraumatic symptom clusters uniquely predict risk for smoking relapse and thus may be a useful therapeutic target in trauma-exposed smokers.

Risk of Obstructive Sleep Apnea and Echocardiographic Parameters / Correlação entre Risco de Apneia Obstrutiva do Sono e Parâmetros do Ecocardiograma

Abstract Background: Obstructive sleep apnea (OSA) is a chronic progressive disorder with high mortality and morbidity rate, associated with cardiovascular diseases (CVD), especially heart failure (HF). The pathophysiological changes related to OSA can directly affect the diastolic function of the left ventricle. Objectives: To assess the association of the risk of OSA, evaluated by the Berlin Questionnaire (BQ), and echocardiographic (ECHO) parameters related to diastolic dysfunction in individuals without HF assisted in primary care. Methods: A cross-sectional study that included 354 individuals (51% women) aged 45 years or older. All individuals selected were submitted to an evaluation that included the following procedures: consultation, filling out the BQ, clinical examination, laboratory examination and transthoracic Doppler echocardiography (TDE). Continuous data are presented as medians and interquartile intervals, and categoric variables in absolute and relative frequencies. The variables associated with risk of OSA and at the 0.05 level integrated the gamma regression models with a log link function. A value of p < 0.05 was considered an indicator of statistical significance. Exclusion criteria were presence of HF, to fill out the BQ and patients with hypertension and obesity not classified as high risk for OSA by other criteria. All individuals were evaluated on a single day with the following procedures: medical appointment, BQ, laboratory tests and ECHO. Results: Of the 354 individuals assessed, 63% were classified as having high risk for OSA. The patients with high risk for OSA present significantly abnormal diastolic function parameters. High risk for OSA confirmed positive and statistically significant association, after adjustments, with indicators of diastolic function, such as indexed left atrium volume LAV-i (p = 0.02); E'/A' (p < 0.01), A (p = 0.02), E/A (p < 0.01). Conclusion: Our data show that patients at high risk for OSA present worsened diastolic function parameters measured by TDE.

Resumo Fundamento: A apneia obstrutiva do sono (AOS) é um transtorno crônico, progressivo, com alta morbimortalidade e associado às doenças cardiovasculares (DCV), entre elas a insuficiência cardíaca (IC). As alterações fisiopatológicas relacionadas com a AOS podem impactar diretamente a função diastólica do ventrículo esquerdo. Objetivo: Estimar a associação entre risco de AOS, avaliada pelo Questionário de Berlim (QB), e parâmetros do ecocardiograma, relacionados com a função diastólica, em indivíduos sem IC na atenção primária. Métodos: Estudo transversal que incluiu 354 indivíduos (51% mulheres) com idade igual ou superior a 45 anos. Todos os indivíduos selecionados foram submetidos a uma avaliação que constou dos seguintes procedimentos: consulta, preenchimento do QB e exame clínico, realização de exames laboratoriais e ecocardiograma Doppler transtorácico (EDT). Os dados contínuos são apresentados em medianas e intervalos interquartílicos e os categóricos em frequências absolutas e relativas. As variáveis que apresentaram associação ao risco de AOS em nível de 0,05 integraram os modelos de regressão gama com função de ligação log link. Análise bruta: Um valor de p < 0,05 foi considerado como indicador de significância estatística. Resultados: Dos 354 indivíduos analisados, 63% foram classificados como tendo alto risco para AOS. Os pacientes com alto risco para AOS apresentam alterações significativas dos parâmetros que avaliam a função diastólica. Alto risco para AOS confirmou sua associação positiva e estatisticamente significativa, após ajuste, a indicadores de disfunção diastólica - VAE-i (p = 0,02); E'/A' (p < 0,01); A (p = 0,02); E/A (p < 0,01). Conclusão: Nossos dados mostram que pacientes com alto risco de AOS apresentam piora dos parâmetros de função diastólica medidos pelo EDT.

Risk of Obstructive Sleep Apnea and Echocardiographic Parameters.

BACKGROUND: Obstructive sleep apnea (OSA) is a chronic progressive disorder with high mortality and morbidity rate, associated with cardiovascular diseases (CVD), especially heart failure (HF). The pathophysiological changes related to OSA can directly affect the diastolic function of the left ventricle. OBJECTIVES: To assess the association of the risk of OSA, evaluated by the Berlin Questionnaire (BQ), and echocardiographic (ECHO) parameters related to diastolic dysfunction in individuals without HF assisted in primary care. METHODS: A cross-sectional study that included 354 individuals (51% women) aged 45 years or older. All individuals selected were submitted to an evaluation that included the following procedures: consultation, filling out the BQ, clinical examination, laboratory examination and transthoracic Doppler echocardiography (TDE). Continuous data are presented as medians and interquartile intervals, and categoric variables in absolute and relative frequencies. The variables associated with risk of OSA and at the 0.05 level integrated the gamma regression models with a log link function. A value of p < 0.05 was considered an indicator of statistical significance. Exclusion criteria were presence of HF, to fill out the BQ and patients with hypertension and obesity not classified as high risk for OSA by other criteria. All individuals were evaluated on a single day with the following procedures: medical appointment, BQ, laboratory tests and ECHO. RESULTS: Of the 354 individuals assessed, 63% were classified as having high risk for OSA. The patients with high risk for OSA present significantly abnormal diastolic function parameters. High risk for OSA confirmed positive and statistically significant association, after adjustments, with indicators of diastolic function, such as indexed left atrium volume LAV-i (p = 0.02); E'/A' (p < 0.01), A (p = 0.02), E/A (p < 0.01). CONCLUSION: Our data show that patients at high risk for OSA present worsened diastolic function parameters measured by TDE.

Association of types of dyspnea including 'bendopnea' with cardiopulmonary disease in primary care. / Associação dos tipos de dispneia e da "flexopneia" com as patologias cardiopulmonares nos cuidados de saúde primários.

INTRODUCTION: Dyspnea is the symptom most commonly reported by patients with heart failure (HF) and/or pulmonary disease, the obese and the elderly. Recently 'bendopnea' (shortness of breath when bending forward) has been described in patients with HF. OBJECTIVE: To determine the association of exertional dyspnea, orthopnea, paroxysmal nocturnal dyspnea and bendopnea with chronic disease, especially heart failure, and their phenotypes in primary care. METHODS: This cross-sectional study included 633 individuals aged between 45 and 99 years enrolled in a primary care program in Niteroi, Brazil. Participants underwent clinical assessment and laboratory tests and completed a questionnaire, all on the same day. RESULTS: Paroxysmal nocturnal dyspnea and bendopnea were associated with HF (unadjusted OR 2.42, 95% CI 1.10-5.29 and OR 2.59, 95% CI 1.52-4.44, respectively). In multivariate models, chronic obstructive pulmonary disease, coronary heart disease and myocardial infarction were not associated with bendopnea. CONCLUSIONS: Bendopnea was the only type of dyspnea not linked to respiratory disease or coronary heart disease. Even after adjusting for depression and body mass index, the association remained with HF with or without preserved ejection fraction, and bendopnea thus appears to be a promising symptom to differentiate HF from the other two disease groups.

Desafios para o cuidado da insuficiência cardíaca: pesquisa exploratória com enfermeiras em Ontario / Challenges for the heart failure care: exploratory research with nurses in Ontario / Desafíos para el cuidado de la insuficiencia cardíaca: investigación exploratoria con las enfermeras en Ontario

Objectives: To observe the implementation of Canadian protocols for patients with heart failure, and identify with nurses, health education aspects. Method: exploratory research in the period from August to December 2013, where the data collection was carried out by observation during the Shadow Experience and interview of Canadian nurses. For data analysis, we used descriptive statistics. Results: 28 patients were observed in the Shadow Experience strategy at different levels of care, and 13 nurses interviewed. In health education, interpersonal contact was the most used strategy (69.23%), treatment was the priority share (76.92%), followed by prevention (30.77%). There are challenges with respect to harmful lifestyle habits, and self-care considered ineffective (38.46%). Conclusion: interpersonal interaction, which involved professionals and Canadian individuals at different levels of care, helped to identify in their implementation, basic actions and challenges for heart failure.

Objetivos: Observar a implementação de protocolos canadenses aos pacientes com insuficiência cardíaca, assim como identificar junto às enfermeiras, aspectos de educação em saúde. Método: pesquisa exploratória no período de agosto a dezembro de 2013, onde a coleta de dados deu-se por observação durante a Shadow Experience, e por entrevista de enfermeiras canadenses. Para análise dos dados, utilizou-se a estatística descritiva. Resultados: 28 pacientes foram observados na estratégia Shadow Experience em diferentes níveis de atendimento, e 13 enfermeiras entrevistadas. Em Educação em Saúde, o contato interpessoal foi a estratégia mais utilizada (69,23%), o tratamento foi a ação prioritária (76,92%), seguida da prevenção (30,77%). Há desafios com relação aos hábitos de vida prejudiciais, e para o autocuidado considerado pouco eficaz (38,46%). Conclusão: A interação interpessoal, a qual envolveu profissionais e indivíduos canadenses em diferentes níveis de atendimento, contribuiu para identificar em sua implementação, ações básicas e desafios para insuficiência cardíaca.

Objetivos: Observar la implementación de protocolos canadienses para los pacientes con insuficiencia cardíaca, y se identifican con las enfermeras, los aspectos de educación sanitaria. Método: investigación exploratoria en el período de agosto a diciembre de 2013, donde la recogida de datos se llevó a cabo mediante la observación durante la experiencia de la sombra y la entrevista de las enfermeras canadienses. Para el análisis de datos se utilizó la estadística descriptiva. Resultados: Se observaron 28 pacientes en la estrategia de la experiencia de la sombra a diferentes niveles de atención, y 13 enfermeras entrevistadas. En la educación sanitaria, el contacto interpersonal fue la estrategia más utilizada (69,23%), el tratamiento fue la cuota de prioridad (76,92%), seguido de la prevención (30,77%). Hay desafíos con respecto a los hábitos de vida nocivos, y el autocuidado considerados ineficaces (38,46%). Conclusión: la interacción interpersonal, que involucró a profesionales y particulares canadienses en diferentes niveles de atención, ayudó a identificar en su aplicación, las acciones básicas y los desafíos para la insuficiencia cardíaca.

Racial differences in HbA1c: a cross-sectional analysis of a Brazilian public primary care population.

BACKGROUND: Blacks show higher levels of HbA1c in studies with different populations and are disproportionately affected by most diabetes-related complications. AIMS: The study aims to investigate if the prevalence of altered glycated hemoglobin (HbA1c) varies with skin color and if there is a familial aggregation of either skin color and HbA1c. METHODS: The study used the CAMELIA study (Cardio-Metabolic-Renal familiar) population, conducted between June 2006 and December 2007 (cross sectional). Families were recruited from 13 Family Doctor Program Unities of Niteroi, Brazil, a highly miscegenated population. The visits included questionnaire, medical consultation, anthropometric and nutritional assessment. Blood pressure, blood/urine samples were collected. The dosage of HbA1c was performed by immunoturbidimetry in Labmax 240 equipment. RESULTS: We compare data of 241 (25.5%) Blacks, versus 422 (44.7%) Mulattos or 272 (28.8%) Whites. The groups did not differ significantly with regard to most measures. Blacks had the lowest levels of income/education, higher frequency of diabetes and hypertension (p<0.20) as higher levels of HbA1c (p<0.05) that persisted after adjusting for possible confounders. Among blacks, the correlations between siblings of HbA1c were higher than among white/mulatto, reaching 86% versus 50%, respectively. CONCLUSION: Those results indicate that Brazilian Blacks patients must have more attention, focusing on diabetes preventive care. Longitudinal studies are needed to address the question if the altered level of HbA1c has a real clinical impact.

Low quality of life as an additional criterion for the clinical diagnosis of heart failure in primary care.

OBJECTIVE: The aim of this study is to estimate the association of shortness of breath (SOB), fatigue and bilateral lower limb edema (LLE) - typical symptoms of HF - with quality of life (QOL) dimensions, measured by the Medical Outcomes Study 36-Item Short Form Health Survey (SF-36). METHODS: This cross-sectional study was conducted as part of the CAMELIA study (Cardiometabolic Renal Familial Study), which involved families covered by the Family Doctor Program (FDP) in Niteroi, Rio de Janeiro, Brazil. The study included 455 patients aged 30 and over, assessed by questionnaire, medical consultation, and blood and urine tests. RESULTS: The prevalence of symptoms was: fatigue 56.9%, SOB 22.6% and LLE 16.9%. There were independent and statistically significant associations between SOB and fatigue and all SF-36 dimensions, excepting emotional performance and SOB (p<0.10). CONCLUSION: The combination of SOB and fatigue with low QOL can increase the positive predictive value for a clinical diagnosis of HF and is a possible alternative for prioritizing patients for closer investigation in a primary care setting.

Relationship between ultra-processed foods and metabolic syndrome in adolescents from a Brazilian Family Doctor Program.

OBJECTIVE: To estimate the association between food intake and metabolic syndrome (MetS). DESIGN: Cross-sectional design conducted from July 2006 to December 2007. SETTING: Adolescents assisted by the Family Doctor Program (FDP) in Niterói, a metropolitan area in Rio de Janeiro State, Brazil. SUBJECTS: Survey of 210 adolescents. Individuals with three or more of the following components of MetS were classified as having this syndrome: TAG ≥ 110 mg/dl; HDL cholesterol < 50 mg/dl for girls aged 12-19 years and boys aged 12-14 years or <45 mg/dl for boys aged 15-19 years; waist circumference ≥75th percentile; serum glucose >100 mg/dl; and blood pressure ≥90th percentile. A semi-quantitative FFQ was used, and foods were grouped as: unprocessed or minimally processed foods (Group 1), processed culinary and food industry ingredients (Group 2) and ultra-processed foods (Group 3). The associations between food consumption and MetS were adjusted for sociodemographic, behavioural and family history covariates and were estimated using generalized estimation equations with the Poisson regression model. RESULTS: MetS was diagnosed in 6·7 % of the adolescents; the most frequent diagnostic criteria included the reduction of HDL cholesterol (46·7 %), elevated serum glucose (17·1 %) and the elevation of waist circumference (16·7 %). Crude analysis showed higher average daily intakes of energy, carbohydrates and ultra-processed foods among adolescents with MetS. After statistical adjustment, the intake of ultra-processed foods (≥3rd quartile) remained associated with MetS (prevalence ratio = 2·5; P = 0·012). CONCLUSIONS: High consumption of ultra-processed foods was associated with the prevalence of MetS in this adolescents group.

Confirmatory factor analysis of posttraumatic stress symptoms in Brazilian primary care patients: an examination of seven alternative models.

The DSM-IV-TR postulates that PTSD symptoms are organized into 3 clusters. This assumption has been challenged by growing number of factor analytical studies, which tend to favor 4-factor, first-order models. Our objective was to investigate whether the clusters of PTSD symptoms identified in North American and European studies could be replicated in a Brazilian sample composed of 805 primary care patients living in hillside slums. Volunteers were asked to fill out the Brazilian version of the Posttraumatic Stress Disorder Checklist-Civilian Version and a confirmatory factor analysis of this scale was conducted with the software LISREL 8.80. Seven models were tested and a 4-factor, first-order solution including an emotional numbing cluster was found to provide the best fit. Although PTSD has been characterized by some critics as a Western culture-specific disorder lacking universal validity, our results seem to uphold the cross-cultural validity of the 4-factor, first-order model.

Dietary habits and inadequate control of blood pressure in hypertensive adults assisted by a Brazilian Family Doctor Program.

OBJECTIVE: To estimate dietary habits and other factors associated with inadequate blood pressure (BP) control in hypertensive patients adherent to antihypertensive drug treatment assisted by a Brazilian Family Doctor Program (FDP). DESIGN: A cross-sectional study. SETTING: FDP units, Niterói, Rio de Janeiro, Brazil. SUBJECTS: We included data from both male and female participants aged ≥20 years. Participants completed a standardized questionnaire containing questions related to demographics, socio-economic factors, comorbidities and lifestyle, as well as a validated FFQ and eleven additional qualitative questions to investigate dietary habits. Food items were divided into sixteen groups. Medical consultations were performed, BP measurements were taken, blood and urine samples were assessed and anthropometric and nutritional status was evaluated. RESULTS: Individuals with inadequate BP control presented higher BMI values (prevalence ratio (PR) = 1·027, 95% CI 1·009, 1·045) and also consumed more meat (PR = 1·091, 95% CI 1·022, 1·165), which are potentially modifiable variables. Higher levels of serum creatinine (PR = 1·894, 95% CI 1·241, 2·892) were also associated with inadequate BP control, as were skin colour (white). After inclusion of the Na excretion index, which is an indirect measure of salt intake, a slight decrease was observed in the PR for meat, which resulted in loss of statistical significance. CONCLUSIONS: The results indicate that salt consumption, skin colour, BMI and serum creatinine are associated with inadequate BP control.