Pharmacological treatment of hypertension guided by peripheral or central blood pressure: a comparison between the two strategies.

Background: Arterial hypertension treatment guided by central blood pressures (CPB) rather than peripheral blood pressures (PBP) measurement has the potential to show greater effectiveness in preventing or even regressing stiffness and target organ damage (TOD). Objective: This study aimed to compare the parameters of CBP and PBP measurements, arterial stiffness, TOD and renal profile in patients with anti-hypertensive treatment guided by CBP or PBP targets. Methods: A randomized clinical trial was conducted in central group (CG) and peripheral group (PG). Patients were randomized, evaluated every 3 months for BP and antihypertensive adjustments during a one-year follow up. The procedures in V1 and V5: anthropometric assessment; CBP/PBP measurements, carotid ultrasound; echocardiography; laboratory tests. Paired and unpaired t-tests and the χ2 were used (significance level: 5%). Results: The study evaluated 59 participants (30CG/29PG). The augmentation index (AIx) was higher in the CG (27.3% vs. 20.3%, p = 0.041). Intergroup analysis has found central diastolic BP lower in the CG (78.9 vs. 84.3 mmHg, p = 0.024) and the Alx difference between groups ceased to exist after a one-year follow-up. Intragroup comparisons, after intervention, showed a lower frequency of changed PWV (p < 0.001) and LVMI (p = 0.018) in the CG. The PG showed a higher frequency of changed PWV (p < 0.001) and LVMI (p = 0.003). Conclusion: The intervention guided by central BP reduced the central diastolic BP and AIx compared to the PG. There was a reduction in the frequency of changed PWV and LVMI in the CG.

Brazilian Guidelines for In-office and Out-of-office Blood Pressure Measurement ­ 2023 / Diretrizes Brasileiras de Medidas da Pressão Arterial Dentro e Fora do Consultório ­ 2023

Hypertension is one of the primary modifiable risk factors for morbidity and mortality worldwide, being a major risk factor for coronary artery disease, stroke, and kidney failure. Furthermore, it is highly prevalent, affecting more than one-third of the global population. Blood pressure measurement is a MANDATORY procedure in any medical care setting and is carried out by various healthcare professionals. However, it is still commonly performed without the necessary technical care. Since the diagnosis relies on blood pressure measurement, it is clear how important it is to handle the techniques, methods, and equipment used in its execution with care. It should be emphasized that once the diagnosis is made, all short-term, medium-term, and long-term investigations and treatments are based on the results of blood pressure measurement. Therefore, improper techniques and/or equipment can lead to incorrect diagnoses, either underestimating or overestimating values, resulting in inappropriate actions and significant health and economic losses for individuals and nations. Once the correct diagnosis is made, as knowledge of the importance of proper treatment advances, with the adoption of more detailed normal values and careful treatment objectives towards achieving stricter blood pressure goals, the importance of precision in blood pressure measurement is also reinforced. Blood pressure measurement (described below) is usually performed using the traditional method, the so-called casual or office measurement. Over time, alternatives have been added to it, through the use of semi-automatic or automatic devices by the patients themselves, in waiting rooms or outside the office, in their own homes, or in public spaces. A step further was taken with the use of semi-automatic devices equipped with memory that allow sequential measurements outside the office (ABPM; or HBPM) and other automatic devices that allow programmed measurements over longer periods (HBPM). Some aspects of blood pressure measurement can interfere with obtaining reliable results and, consequently, cause harm in decision-making. These include the importance of using average values, the variation in blood pressure during the day, and short-term variability. These aspects have encouraged the performance of a greater number of measurements in various situations, and different guidelines have advocated the use of equipment that promotes these actions. Devices that perform HBPM or ABPM, which, in addition to allowing greater precision, when used together, detect white coat hypertension (WCH), masked hypertension (MH), sleep blood pressure alterations, and resistant hypertension (RHT) (defined in Chapter 2 of this guideline), are gaining more and more importance. Taking these details into account, we must emphasize that information related to diagnosis, classification, and goal setting is still based on office blood pressure measurement, and for this reason, all attention must be given to the proper execution of this procedure.

La hipertensión arterial (HTA) es uno de los principales factores de riesgo modificables para la morbilidad y mortalidad en todo el mundo, siendo uno de los mayores factores de riesgo para la enfermedad de las arterias coronarias, el accidente cerebrovascular (ACV) y la insuficiencia renal. Además, es altamente prevalente y afecta a más de un tercio de la población mundial. La medición de la presión arterial (PA) es un procedimiento OBLIGATORIO en cualquier atención médica o realizado por diferentes profesionales de la salud. Sin embargo, todavía se realiza comúnmente sin los cuidados técnicos necesarios. Dado que el diagnóstico se basa en la medición de la PA, es claro el cuidado que debe haber con las técnicas, los métodos y los equipos utilizados en su realización. Debemos enfatizar que una vez realizado el diagnóstico, todas las investigaciones y tratamientos a corto, mediano y largo plazo se basan en los resultados de la medición de la PA. Por lo tanto, las técnicas y/o equipos inadecuados pueden llevar a diagnósticos incorrectos, subestimando o sobreestimando valores y resultando en conductas inadecuadas y pérdidas significativas para la salud y la economía de las personas y las naciones. Una vez realizado el diagnóstico correcto, a medida que avanza el conocimiento sobre la importancia del tratamiento adecuado, con la adopción de valores de normalidad más detallados y objetivos de tratamiento más cuidadosos hacia metas de PA más estrictas, también se refuerza la importancia de la precisión en la medición de la PA. La medición de la PA (descrita a continuación) generalmente se realiza mediante el método tradicional, la llamada medición casual o de consultorio. Con el tiempo, se han agregado alternativas a través del uso de dispositivos semiautomáticos o automáticos por parte del propio paciente, en salas de espera o fuera del consultorio, en su propia residencia o en espacios públicos. Se dio un paso más con el uso de dispositivos semiautomáticos equipados con memoria que permiten mediciones secuenciales fuera del consultorio (AMPA; o MRPA) y otros automáticos que permiten mediciones programadas durante períodos más largos (MAPA). Algunos aspectos en la medición de la PA pueden interferir en la obtención de resultados confiables y, en consecuencia, causar daños en las decisiones a tomar. Estos incluyen la importancia de usar valores promedio, la variación de la PA durante el día y la variabilidad a corto plazo. Estos aspectos han alentado la realización de un mayor número de mediciones en diversas situaciones, y diferentes pautas han abogado por el uso de equipos que promuevan estas acciones. Los dispositivos que realizan MRPA o MAPA, que además de permitir una mayor precisión, cuando se usan juntos, detectan la hipertensión de bata blanca (HBB), la hipertensión enmascarada (HM), las alteraciones de la PA durante el sueño y la hipertensión resistente (HR) (definida en el Capítulo 2 de esta guía), están ganando cada vez más importancia. Teniendo en cuenta estos detalles, debemos enfatizar que la información relacionada con el diagnóstico, la clasificación y el establecimiento de objetivos todavía se basa en la medición de la presión arterial en el consultorio, y por esta razón, se debe prestar toda la atención a la ejecución adecuada de este procedimiento.

A hipertensão arterial (HA) é um dos principais fatores de risco modificáveis para morbidade e mortalidade em todo o mundo, sendo um dos maiores fatores de risco para doença arterial coronária, acidente vascular cerebral (AVC) e insuficiência renal. Além disso, é altamente prevalente e atinge mais de um terço da população mundial. A medida da PA é procedimento OBRIGATÓRIO em qualquer atendimento médico ou realizado por diferentes profissionais de saúde. Contudo, ainda é comumente realizada sem os cuidados técnicos necessários. Como o diagnóstico se baseia na medida da PA, fica claro o cuidado que deve haver com as técnicas, os métodos e os equipamentos utilizados na sua realização. Deve-se reforçar que, feito o diagnóstico, toda a investigação e os tratamentos de curto, médio e longo prazos são feitos com base nos resultados da medida da PA. Assim, técnicas e/ou equipamentos inadequados podem levar a diagnósticos incorretos, tanto subestimando quanto superestimando valores e levando a condutas inadequadas e grandes prejuízos à saúde e à economia das pessoas e das nações. Uma vez feito o diagnóstico correto, na medida em que avança o conhecimento da importância do tratamento adequado, com a adoção de valores de normalidade mais detalhados e com objetivos de tratamento mais cuidadosos no sentido do alcance de metas de PA mais rigorosas, fica também reforçada a importância da precisão na medida da PA. A medida da PA (descrita a seguir) é habitualmente feita pelo método tradicional, a assim chamada medida casual ou de consultório. Ao longo do tempo, foram agregadas alternativas a ela, mediante o uso de equipamentos semiautomáticos ou automáticos pelo próprio paciente, nas salas de espera ou fora do consultório, em sua própria residência ou em espaços públicos. Um passo adiante foi dado com o uso de equipamentos semiautomáticos providos de memória que permitem medidas sequenciais fora do consultório (AMPA; ou MRPA) e outros automáticos que permitem medidas programadas por períodos mais prolongados (MAPA). Alguns aspectos na medida da PA podem interferir na obtenção de resultados fidedignos e, consequentemente, causar prejuízo nas condutas a serem tomadas. Entre eles, estão: a importância de serem utilizados valores médios, a variação da PA durante o dia e a variabilidade a curto prazo. Esses aspectos têm estimulado a realização de maior número de medidas em diversas situações, e as diferentes diretrizes têm preconizado o uso de equipamentos que favoreçam essas ações. Ganham cada vez mais espaço os equipamentos que realizam MRPA ou MAPA, que, além de permitirem maior precisão, se empregados em conjunto, detectam a HA do avental branco (HAB), HA mascarada (HM), alterações da PA no sono e HA resistente (HAR) (definidos no Capítulo 2 desta diretriz). Resguardados esses detalhes, devemos ressaltar que as informações relacionadas a diagnóstico, classificação e estabelecimento de metas ainda são baseadas na medida da PA de consultório e, por esse motivo, toda a atenção deve ser dada à realização desse procedimento.

A SAGE score cutoff that predicts high-pulse wave velocity as measured by oscillometric devices in Brazilian hypertensive patients.

We aimed to identify the optimal cutoff SAGE score for Brazilian hypertensive patients who had their pulse wave velocity (PWV) measured with oscillometric devices. A retrospective analysis of patients who underwent central blood pressure measurement using a validated oscillometric device, the Mobil-O-Graph® (IEM, Stolberg, Germany), between 2012 and 2019 was performed. Patients with arterial hypertension and available data on all SAGE parameters were selected. An ROC curve was constructed using the Youden index to define the best score to identify patients at high risk for high PWV. A total of 837 patients met the criteria for SAGE and diagnosis of hypertension. The median age was 59.0 years (interquartile range [IQR]: 47.0-68.0), and 50.7% of the patients were women. The following comorbidities and conditions were present: dyslipidemia (37.4%), diabetes (20.7%), a body mass index score ≥30 kg/m2 (36.6%), use of antihypertensive drugs (69.5%), and smoking (18.3%). The median peripheral blood pressure was 128 mmHg (IQR: 117-138 mmHg) for systolic and 81 mmHg (IQR: 73-90 mmHg) for diastolic blood pressure. The median PWV was 8.3 m/s (7.1-9.8 m/s), and the prevalence of high PWV (≥10 m/s) was 22.9% (192 patients). A cutoff SAGE score ≥8 was effective at identifying a high risk of PWV ≥ 10 m/s, achieving 67.19% sensitivity (95% CI: 60.1-73.8) and 93.95% specificity (95% CI: 91.8-95.7). With this cutoff point, 1 out of every 5 treated hypertensive patients would be referred for a PWV measurement. A SAGE score of ≥8 identified Brazilian hypertensive patients with a high risk of future cardiovascular events (PWV ≥ 10 m/s).

Hormonal assessment of participants in a long distance walk.

BACKGROUND: Exercise can disrupt homeostasis and trigger many adaptive responses in different hormonal axes. The study of hormonal interactions with physical activity is highly complex due to the number of variables, such as exercise duration, exercise intensity, individual level of training, circadian rhythm, nutritional status, and environmental conditions. METHODS: This study was performed to assess daily variations of thyroid hormones, cortisol, testosterone, insulin and glucose during moderate to high intensity aerobic physical activity for 5 consecutive days. Sample collection was performed at baseline in the morning and in the evening, immediately after finishing the activity, on the 4 initial days of the activity. Statistical analysis was performed using software STATA V14. Continuous variables are presented as means and standard deviations, while categorical variables are presented as absolute and percentage values. We used Shapiro-Wilk, Wilcoxon Sign, Mann-Whitney and Student's T test, according the needs. RESULTS: The adrenocorticotropic axis showed an initial increase in the evening cortisol level compared to the baseline level in the morning (17.46 µg/dL and 15.97 µg/dL, respectively) and then exhibited a significant reduction between the 1st and 4th day of activity (17.46 µg/dL and 8.39 µg/dL, respectively; P = 0.001). The same pattern was observed for free thyroxine (T4) between the 1st and 4th day (1.31 and 1.14, respectively; P < 0.001). CONCLUSIONS: Moderate to intense long duration physical activity resulted in little variation in the hormones assessed, with a trend toward reduced levels of cortisol and free T4. These findings highlight an adaptive hormonal mechanism in response to stress that is repeated daily, as shown by cortisol and thyroid function in our study.

Comparison Between Supervised and Partly Supervised Cardiac Rehabilitation Protocols in Hypertensive Patients: A Randomized Controlled Trial.

BACKGROUND: Hypertension (HTN) is the main cause of cardiovascular diseases accounting for one-third of global mortality. Physical exercise reduces the incidence and prevalence of HTN and cardiovascular morbidity and mortality. Exercises recommended for hypertensive patients include supervised cardiac rehabilitation, which occurs in rehabilitation centers, and partly supervised rehabilitation, with the individual prescription of exercises conducted at patients' residences. OBJECTIVE: Compare clinical and functional parameters of hypertensive patients subjected to two cardiac rehabilitation protocols: supervised and partly supervised. METHOD: Hypertensive patients stage I or II were randomly divided into group one (G1) (partly supervised cardiac rehabilitation) and group two (G2) (supervised cardiac rehabilitation). All patients performed a warm-up, aerobic exercise, strength training and cool-down. Participants' assessments conducted before and after intervention included: physical examination, six-minute walk test, cardiac stress test, metabolic tests, and central and peripheral blood pressure measurements. RESULTS: A total of 61 patients (mean age 60.3±11.3 years, 78.7% women) were randomized (30 in G1 and 31 in G2). At the end of the intervention, G1 increased 30.6 meters (p=0.004) and G2 increased 55.0 meters (p>0.001) the distance covered in the six-minute walk test. G2 showed an increase in the maximum oxygen consumption from 24.7±8.6 mlO2/Kg/min to 28.4±7.5 mlO2/Kg/min (p=0.003). Compliance with the intervention was similar in G1 and G2 (77.5±11% x 82±10%; p=0.654). CONCLUSION: Participants from both groups improved their physical fitness and showed satisfactory compliance and tolerability to the interventions. The supervised exercise was more effective in improving muscle strength and some physical fitness parameters.