Tratamento da hipertensäo arterial - respostas de médicos brasileiros a um inquérito / Treatment of hypertension - answers of Brazilian physicians to a survey

O III Consenso Brasileiro de Hipertensäo Arterial recomenda o uso de tratamento farmacológico (TF) e näo-farmacológico (TNF). Em nosso meio näo se tem conhecimento como esta recomendaçäo vem sendo seguida pelos médicos. OBJETIVOS: a) caracterizar o TNF quanto à indicaçäo e aceitaçäo pelos hipertensos; b) caracterizar o TF quanto ao critério de escolha e drogas prescritas; e c) identificar a opiniäo do médico sobre o grau de adesäo do paciente ao TF e TNF. MÉTODOS: Foram enviados 37.904 questionários com carta-resposta por mala direta para médicos brasileiros e recebidas 2.519 respostas (57 por cento regiäo Sudeste, 41 por cento cardiologistas e 26 por cento clínicos). RESULTADOS: 1- 62 por cento dos médicos que responderam recomendam TNF para 25 por cento dos pacientes. 2- Os TNF mais recomendados säo: dieta hipossódica (55 por cento), perda de peso (29 por cento) e prática de exercícios (8 por cento), sendo que os médicos acreditam que 50 por cento dos pacientes seguem dieta hipossódica, 20 por cento prática de exercícios e 19 por cento perda de peso. 3- O TF é iniciado com o uso de droga isolada (88 por cento) e quando näo há controle da pressäo arterial 55 por cento indicam associaçäo de outras drogas e 33 por cento aumentam a dose. 4- As drogas mais utilizadas säo diuréticos (53 por cento) e inibidores da ECA (24 por cento). 5- Os principais critérios para escolha das drogas säo experiência pessoal (32 por cento) e características do paciente (31 por cento). 6- Os médicos (60 por cento) acreditam que a adesäo ao TF é melhor. CONCLUSÄO: As recomendaçöes do III Consenso Brasileiro de Hipertensäo Arterial estäo sendo seguidas parcialmente para o TNF e dentro do esperado para o TF

The results of the campaign for evaluating sphygmomanometers accuracy and their physical conditions.

OBJECTIVE: To evaluate the sphygmomanometers calibration accuracy and the physical conditions of the cuff-bladder, bulb, pump, and valve. METHODS: Sixty hundred and forty five aneroid sphygmomanometers were evaluated, 521 used in private practice and 124 used in hospitals. Aneroid manometers were tested against a properly calibrated mercury manometer and were considered calibrated when the error was < or = 3 mm Hg. The physical conditions of the cuffs-bladder, bulb, pump, and valve were also evaluated. RESULTS: Of the aneroid sphygmomanometers tested, 51% of those used in private practice and 56% of those used in hospitals were found to be not accurately calibrated. Of these, the magnitude of inaccuracy ranged from 4 to 8 mm Hg in 70% and 51% of the devices, respectively. The problems found in the cuffs-bladders, bulbs, pumps, and valves of the private practice and hospital devices were bladder damage (34% vs. 21%, respectively), holes/leaks in the bulbs (22% vs. 4%, respectively), and rubber aging (15% vs. 12%, respectively). Of the devices tested, 72% revealed at least one problem interfering with blood pressure measurement accuracy. CONCLUSION: Most of the manometers evaluated, whether used in private practice or in hospitals, were found to be inaccurate and unreliable, and their use may jeopardize the diagnosis and treatment of arterial hypertension.

[Single daily dose of verapamil (COER-24 180/24 mg) in mild and moderate hypertension evaluated by ambulatory blood pressure monitoring]. / Verapamil COER-24 180/240 mg na hipertensão arterial leve a moderada em dose única diária avaliado pela monitorização ambulatorial da pressão arterial.

OBJECTIVE: To evaluate the anti-hypertensive effect of verapamil COER-24 180/240 mg in a single dose at bedtime as single therapy in mild to moderate hypertensives. METHODS: A multicentric, open, placebo controlled study of 81 hypertensive patients older than 20 years-old followed to 8 weeks. Blood pressure was measured in doctor's office and by 24 h ambulatory monitoring (ABPM). RESULTS: We observed a decreased in systolic and diastolic blood pressure in doctor's office at 4th and 8th weeks. ABPM showed that both systolic, diastolic and mean blood pressure, heart rate and the mean 24-hour blood pressure load decreased after the 8-week treatment. In addition, there was a reduction of the double-product, especially in the morning and 68% of the patients didn't have any adverse events. CONCLUSION: The therapy verapamil COER-24 180/240 mg in a single dose is useful for mild and moderate hypertensive patients, with significant pressure decrease in both office blood pressure measurements and in the ABPM/24 hours, as well as showing good tolerability.

Comparison between casual blood pressure and ambulatory blood pressure monitoring parameters in healthy and hypertensive adolescents.

Casual blood pressure measurements were compared with mean ambulatory blood pressure values during wakefulness and sleep in 45 normotensive and 30 hypertensive adolescents of both sexes aged 10-18 years. Two sets of auscultatory casual blood pressure were obtained, one in a pediatric office setting (office blood pressure), performed by the physician, and one in the ambulatory blood pressure monitoring (ABPM) unit, performed by a trained nurse, prior to the initiation of ABPM (pre-ABPM blood pressure). In normotensive and hypertensive subjects of both sexes, the mean office systolic blood pressure (SBP) was lower than the mean pre-ABPM SBP, and the mean office diastolic blood pressure (DBP) was lower than the mean pre-ABPM DBP. In normotensive participants, the mean pre-ABPM SBP/DBP was lower than the mean ABPM SBP/DBP while awake, the mean ABPM SBP/DBP during sleep being lower than the mean ABPM SBP/DBP values while awake and the mean pre-ABPM SBP/DBP. No statistical difference was demonstrated between the mean office SBP and the mean ABPM SBP during sleep, the mean ABPM DBP during sleep being lower than the mean office DBP. The hypertensive adolescents presented a blood pressure profile similar to that of the normotensive group, albeit shifted upwards, with no significant difference between the mean pre-ABPM SBP and the mean ABPM SBP while awake but a higher mean pre-ABPM DBP than mean ABPM DBP while awake. This study suggests that, by evaluating the casual blood pressure in different environment/observer situations, the power of casual blood pressure to predict inadequate blood pressure control, manifested as abnormal ABPM parameters, can be enhanced. Our data indicate ABPM to be the method of choice for the early diagnosis and adequate follow-up of adolescent hypertension.

[Is blood pressure being measured?]. / A pressão arterial está sendo medida?

The blood pressure measure is part of the physical exam and it should be accomplished in every medical consultation. To verify the blood pressure measured in the accomplished medical consultations record of first they were consulted it consults 500 patient's ambulatorial being 335 (67%) coming of medical and surgical clinics and 165 (33%) of the gynecological and obstetric clinics. The blood pressure was written down in 39% of the accomplished consultations (135 + 32 mm Hg 85 + 19 mm Hg), and 11% of this annotations the pressure diastólica was above 90 mm Hg. In relation to the previous diagnosis of hypertension it was verified that: a) in 62% of the records there was not this information; b) 20% referred to have hypertension, and in 79% of these the arterial pressure was scored; and c) 18% referred not to have hypertension and 46% of these had registration of the arterial pressure. Therefore, most of the patients didn't have its logged arterial pressure.

White coat hypertension in adolescents.

BACKGROUND: Although white coat hypertension (WCH) seems to occur in 20% or more of the adult hypertensive population, this clinical condition has rarely been described in adolescents. DESIGN: Routine use of ambulatory blood pressure monitoring (ABPM) procedure as part of the investigation of arterial hypertension in adolescents. METHODS: Office blood pressure was checked after 5 minutes of rest in the seated position by the auscultation method and ABPM was performed with oscillometrical equipment (SpaceLabs 90207, Redmond, Washington, USA). RESULTS: In the present study 6 adolescents (5 females, 3 white), suspected to suffer from arterial hypertension as judged by office blood pressure measurements, mean age 15.1 years (12.2 - 17.7), mean height 164.5 cm, mean weight 77.2 kg, mean body mass index 28.8 kg/m2 (25 - 35.2), were diagnosed with WCH using ambulatory blood pressure monitoring (ABPM). CONCLUSION: White coat hypertension should also be considered in the evaluation of arterial hypertension in adolescents.

Ambulatory blood pressure monitoring of chronically dialyzed pediatric patients.

BACKGROUND: Background Ambulatory blood pressure monitoring (ABPM) has been shown to be more representative of blood pressure levels in adult patients than are casual measurements of blood pressure. OBJECTIVE: To evaluate, by means of ABPM, the behavior of blood pressure in children with chronic renal failure submitted to continuous ambulatory peritoneal dialysis and compare the results with casual blood pressure monitoring measurements. DESIGN: Evaluation of blood pressures in chronically dialyzed pediatric patients by ABPM. METHODS: Ten pediatric patients, treated by continuous ambulatory peritoneal dialysis were evaluated by ABPM using the oscillometric SpaceLabs 90207 monitor, every 10 min during the day and every 15 min during the night, for 24h. RESULTS: Six of 10 patients were found normotensive by office measurement of blood pressure; four of 10 patients were found hypertensive by casual measurements of blood pressure. With ABPM we obtained a mean success rate of 92.5%, confirmed hypertension in all the patients classified hypertensive in terms of office readings and reclassified six of six patients from normotensive to hypertensive. The mean systolic and diastolic physiologic falls in blood pressure at night were respectively by 10 and 15%. At the time of the ABPM study end-organ damage was present in two patients judged to be normotensive in terms of office blood pressures. CONCLUSION: Casual recordings of blood pressure are not representative of average blood pressure in dialyzed pediatric patients. ABPM seems to be a useful diagnostic aid for assessing treatment of hypertension in children with end-stage renal disease.

A comparison of the safety and efficacy of mibefradil and nifedipine SR in patients with renal disease and hypertension.

The antihypertensive efficacy and safety of mibefradil and nifedipine SR were compared in 143 patients with chronic renal failure and mild-to-moderate hypertension in a multicenter, double-blind, randomized, parallel-design study. At treatment week 12, a significantly greater decrease in sitting diastolic blood pressure (SDBP) was seen with mibefradil than with nifedipine SR (12.8 mmHg vs 8.1 mmHg, respectively; p = 0.014). A significantly greater number of mibefradil-treated patients achieved normalization of SDBP by week 12 (62% vs 37%; p < 0.01). The changes in renal function parameters and the incidence of adverse events were similar in both groups. In this population, 12 weeks of treatment with mibefradil were more effective than nifedipine SR for lowering blood pressure and had similar effects on renal function parameters.

Seasonal variation of blood pressure in maintenance hemodialysis.

CONTEXT: Seasonal variation in arterial blood pressure has been reported in studies with hypertensive and normotensive subjects. However, the influence of seasonal change on blood pressure of hemodialysis patients has not been reported. OBJECTIVE: To investigate the seasonal variation of blood pressure in Brazil, a tropical country, in patients on hemodialysis. DESIGN: Prospective, cohort study. SETTING: Dialysis unit of a tertiary medical center (a teaching hospital of the University of São Paulo School of Medicine, São Paulo). PATIENTS: Sixteen patients with chronic renal failure undergoing hemodialysis. OUTCOMES: Blood pressure, body weight, and ambient temperature were evaluated during 6 hemodialysis sessions carried out on 13 days during the four seasons. RESULTS: The diastolic blood pressure was lower in summer than in fall and winter (95 +/- 8 vs 107 +/- 10 and 101 +/- 10 mmHg, respectively; p < 0.05). The same was observed with mean blood pressure (116 +/- 8 vs 130 +/- 11 and 124 +/- 9 mmHg, respectively; p < 0.01). On the other hand, the ambient temperature was higher in summer than in fall and winter (23.0 +/- 1.6 vs 19.5 +/- 3.0 and 15.8 +/- 1.9 degrees C, respectively; p < 0.01). CONCLUSIONS: We concluded that for patients with chronic renal failure the blood pressure has a seasonal variation with higher pressures in fall and winter than in summer. Thus, further studies are needed to elucidate the impact of this observation on the adjustment of antihypertensive treatment and on morbidity and mortality in maintenance dialysis patients.

[Home blood pressure measurement and ambulatory blood pressure measurement versus office blood pressure measurement]. / Monitorização residencial da pressão arterial e monitorização ambulatorial da pressão arterial versus medida de pressão arterial no consultório.

PURPOSE: To compare both home blood pressure measurement (HBPM) and ambulatory blood pressure monitoring (ABPM) with office blood pressure measurement (OBP); and also to compare the correlation between HBPM and OBP with LVMI (left ventricular mass index). METHODS: Protocol 1--68 hypertensive patients (58 +/- 12 years, 37 females): a) self recorded blood pressure at home in the 7 days; b) recorded the ABPM during 24 hours; and c) the physician recorded blood pressure in the office. Protocol 2-41 hypertensive patients underwent the HBPM, OBP, and BI-dimensional echocardiogram. RESULTS: Protocol 1--OBP (153 +/- 24/96 +/- 13 mmHg) was higher (p < 0.05) than HBPM (133 +/- 18/84 +/- 12 mmHg) and ABPM (137 +/- 17/87 +/- 12 mmHg); Protocol 2--LVMI correlated better with HBPM (r = 0.39/0.49, p < 0.05, systolic and diastolic, respectively) than OBP (r = 0.02/ 0.22, p > 0.05, systolic and diastolic, respectively). CONCLUSION: This study showed that HBPM has a better correlation with LVMI than OBP.

[Captopril combined with hydrochlorothiazide in mild and moderate hypertension. A Brazilian multicenter study]. / Captopril associado à hidroclorotiazida no tratamento da hipertensão leve e moderada. Estudo multicêntrico brasileiro.

PURPOSE: To evaluate the effectiveness and tolerance of the association of captopril 50 mg and hydrochlorithiazide 25 mg in hypertensive patients with diastolic pressure between 95 and 115 mmHg. METHODS: An open, multicenter and non-comparative study was performed. After 2 weeks of placebo, the patients received 1/2 tablet of drug association. Patients were evaluated after 4, 8 and 12 weeks, and those who had diastolic pressure > 90 mmHg after 8 weeks of therapy received 1 tablet/day. RESULTS: The results of 433 patients were analyzed: 47 +/- 10 years old, 30% female, 76% white. Initial systolic and diastolic pressures were 156 +/- 16 and 103 +/- 11 mmHg and after 14 days of placebo were 156 +/- 15 and 103 +/- 9 mmHg (p > 0.05). Systolic/diastolic pressure after 4, 8 and 12 weeks of treatment reduced progressively (p < 0.05) to 143 +/- 14/95 +/- 11, 140 +/- 13/91 +/- 9 and 134 +/- 11/86 +/- 8 mmHg. Blood pressure control was observed in 45, 67 and 88% (p < 0.05) of patients after 4, 8 and 12 weeks. Cough was the most important symptom, registered in 7% of patients under placebo and 12% in patients under treatment. The tolerance was considered good for 98% of patients. CONCLUSION: The association of captopril with hydrochlorothiazide is effective with good tolerance, being indicated as a once a day monotherapy for mild and moderate hypertension.

[Ambulatory blood pressure monitoring in normal adolescents]. / Monitorização ambulatorial da pressão arterial em adolescentes normais.

PURPOSE: To evaluate technical aspects of ambulatory blood pressure monitoring (ABPM) in normal adolescents. METHODS: Forty five normal adolescents (27 female), 10-18 years old. RESULTS: ABPM recordings showed a mean of 90% successful readings; 30% of the patients complained of sleep disruption related to the functioning of the ABPM monitor; the mean systolic, diastolic and heart rate fall during sleep was 13%, 23% and 24% respectively; the mean systolic and diastolic blood pressure load, while awake, was in male adolescents 25.4 +/- 27.7% and 11.8 +/- 14.6%, and in female adolescents, 17.5 +/- 18.7% and 11.8 +/- 11.4%, respectively; the mean systolic and diastolic blood pressure load, while asleep, was in male adolescents 15.4 +/- 22.9% and 2.8 +/- 4.9% and, in female adolescents, 10.5 +/- 18.2% and 1.8 +/- 2.7%, respectively; the mean diastolic values of the first two hours of recording were higher than the ones obtained during the rest of the hours of recording while awake; different mean systolic, diastolic and heart rate values were found during the afternoon and nocturnal sleep periods. CONCLUSION: ABPM was well accepted by the adolescent population, with good technical results.

[Blood pressure measurement. Criteria employed in scientific articles published in Brazilian journals]. / Medida da pressão arterial. Critérios empregados em artigos científicos de periódicos Brasileiros.

PURPOSE: To evaluate the criteria used for the technique of blood pressure measurement in scientific articles published in Brazilian journals. METHODS: Two hundred twenty three scientific articles from 18 medical journals, published between 1989 and 1994 were evaluated, in order to identify the type of sphygmomanometer used; the state of calibration; the cuff size; the position of the patient during the measurement; whether the blood pressure measurement was obtained after a resting period; the phase used to identify the systolic and diastolic pressures; and the number of readings taken. RESULTS: There was no reference in the articles about the following data: the type of sphygmomanometer in 51%, the accuracy of calibration in 82%, the cuff size in 64%, the position of the patient in 25%, the rest period before measurement in 60%, the systolic and diastolic phases in 49%, and the number of measurements in 52%. CONCLUSION: Most of the papers analyzed did not follow or omitted important aspects cited in national and international recommendations for the correct blood pressure measurement.

[Treatment of mild and moderate hypertension with diltiazem 240mg. Brazilian multicenter trial]. / Tratamento da hipertensão arterial leve e moderada com diltiazem 240mg. Estudo multicêntrico brasileiro.

PURPOSE: The efficacy and safety of diltiazen 240mg was evaluated in essential hypertensive patients with diastolic pressure in the range of 95 to 115 mmHg. METHODS: In an open, non-comparative multicenter trial 2.165 hypertensives had the supine and orthostatic arterial blood pressure measured before, after 14 days with non pharmacologic therapy and after 40 days taking diltiazen 240mg/day. Also, the serum levels of lipids, glucose and electrolytes were measured before and after the use of the active drug. RESULTS: The systolic arterial pressure in the first day was 166 +/- 18mmHg, in the 14th day was 155 +/- 20mmHg; and, in the 54th day was 141 +/- 14mmHg (p < 0.05). Also, supine and orthostatic diastolic blood pressure was lower in the 14th and in the 54th days when compared to baseline (p < 0.05). Cholesterol, triglycerides, urea and uric acid levels decreased significantly (p < 0.05) during treatment. CONCLUSION: This study demonstrates that diltiazem 240mg/day for the treatment of hypertension is well tolerated, efficient and shows no metabolic undesirable effects.

Dyslipidaemias in white normotensive subjects and in white patients treated for essential hypertension.

Serum lipid profiles were evaluated in 143 white patients treated for essential hypertension (HT:31 men, 112 women, mean age 58.4 +/- 0.9 years) and in 54 normotensives (NT: 15 men, 39 women, 56.7 +/- 1.8 years). Mean values of LDL-C, HDL-C, TG and LDL-C/HDL-C ratio in hypertensives and normotensives were respectively 4.19 +/- 0.08 vs 4.01 +/- 0.16 mmol/l; 1.14 +/- 0.03 vs 1.22 +/- 0.05 mmol/l, 1.80 +/- 0.10 vs 1.30 +/- 0.06 mmol/l, and 4.0 +/- 0.1 vs 3.5 +/- 0.2; TG and ratio values of both groups differed significantly. Normotensives and hypertensives showed the same prevalence of IIa dyslipidaemia phenotype (37%). Hypertriglyceridaemic phenotypes and associated low HDL-C were more frequent in hypertensives than in normotensives (respectively 20% vs 6% and 14% vs 7%). The IIa phenotype was more prevalent in normotensive women than in men (44% vs 20%). This gender difference was absent in hypertensives (men, 39% vs women, 37%). Isolated low HDL-C was more prevalent in men than in women: NT, 20% vs 8%; HT, 16% vs 4%. IIa prevalence was greater in the age group > 50 years than in the age group < or = 50 years: NT, 22% vs 44%; HT, 12% vs 46%. The prevalence of hypertriglyceridaemic dyslipidaemias was similar in both age groups, in hypertensives (18% vs 21%) and normotensives (6% vs 6%). IIa, IIb and IV dyslipidaemias were more frequent in obese hypertensives. Positive correlations between BMI vs LDL-C and TG values were found in normotensives. In conclusion, the prevalence of dyslipidaemias was similarly high in both NT and HT groups (54% vs 64%), with some qualitative differences concerning phenotypes.

[Multicenter National Study for the evaluation of the efficacy and tolerance of nifedipine oral release osmotic system in mild to moderate hypertension]. / Estudo multicêntrico nacional para avaliação da eficácia e tolerabilidade da nifedipina oros em hipertensão arterial leve a moderada.

PURPOSE: Evaluation of the efficacy and tolerability of nifedipine oros in patients with mild to moderate essential hypertension without major target organ damage and the anti-hypertensive effect along the 24 hours. METHODS: Two hundred and three patients were studied. After two weeks placebo running period single dose of nifedipine oros (30 mg/day) was administered for 8 weeks. At the end of the 4th week, the non-responders (diastolic blood pressure > 90 mmHg or reduction in diastolic pressure < 10 mmHg), had the dosage increased to 60 mg/day. Laboratory tests and 24h blood pressure monitoring (60 patients) were performed at the beginning and at the end of the study. RESULTS: One hundred and ninety one patients completed the study. Fifty nine percent were considered responders at the end of the 4th week with nifedipine oros 30 mg/day and 41% needed dosage increment to 60 mg/day. At the end of the 8th week, all patients were considered responders to nifedipine oros. The blood pressure control extended throughout the 24h of the day. The most common adverse events were edema (14.6%) and headache (12.4%). Good and very good tolerability were informed by 85% of the patients. CONCLUSION: Nifedipine oros was able to control blood pressure efficaciously along the 24h period without important side effects. The possibility of once day dosage, increases the patient adherence to anti-hypertensive therapy.

Microneurografia: técnica para estudo da regulaçäo cardiovascular pelo sistema nervoso simpático em humanos / Microneurography: technique to study cardiovascular regulation through the sympathetic nervous system in humans

A microneurografia é um método eficaz e seguro para o registro intraneural direto da atividade nervosa simpática para o músculo e para pele em humanos. A técnica e suas aplicaçöes para o estudo da funçäo autonômica seräo discutidos neste artigo. Será abordada a regulaçäo da atividade nervosa simpática em diferentes situaçöes clínicas e/ou estímulos, tais como hipertensäo arterial essencial, hipertensäo experimental por mineralocorticóide, exercício, estresse mental, teste do gelo, hiperinsulinemia e ingestäo oral de álcool