IV Brazilian Guidelines on Hypertension
Work performed by
Brazilian Society of Hypertension SBH
Brazilian Society of Cardiology SBC
Brazilian Society of Nephrology SBN
Sponsors
Brazilian Academy of Neurology ABN
Brazilian Association for the Study of Obesity ABESO
Brazilian Federation of Gynecology and Obstetrics Societies FEBRASGO
Brazilian Society of Internal Medicine SBCM
Brazilian Society of Diabetes SBD
Brazilian Society of Endocrinology and Metabolism SBEM
Brazilian Society of Geriatrics and Gerontology SBGG
Organizing Commission
Décio Mion Jr. (Coordenador)
Marco Antônio Mota Gomes (SBC)
Fernando Nobre (SBH)
Celso Amodeo (SBN)
Osvaldo Kohlmann Jr. (SBH)
José Nery Praxedes (SBN)
Carlos Alberto Machado (SBC)
Editing Commission
Carlos Alberto Machado
Celso Amodeo
Décio Mion Jr.
Fernando Nobre
Istênio Pascoal
José Nery Praxedes
Lucélia C. Magalhães
Marco Antônio Mota Gomes
Osvaldo Kohlmann Jr.
Support
AstraZeneca do Brasil Ltda.
Aventis Pharma Ltda.
Bayer S.A.
Biolab Farmacêutica Ltda.
Boehringer Ingelheim do Brasil Quím. e Farm. Ltda.
Farmalab Ind. Químicas e Farmacêuticas Ltda.
Laboratórios Biosintética
Laboratórios Pfizer Ltda.
Libbs Farmacêutica Ltda.
Merck Sharp & Dohme Farmacêutica Ltda.
Novartis Biociências S.A.
Sanofi-Synthélabo Ltda.
Servier do Brasil Ltda.
Introduction
Hypertension is one of the most important health problems in Brazil. It raises the social-medical costs, mainly because of its complications such as cerebrovascular diseases, coronary artery diseases and vascular diseases of the extremities, in addition to cardiac heart failure and chronic renal failure.
Since 1963, cardiovascular diseases have outnumbered other causes of death; they presently account for 27% of all deaths. There was an increase in the mortality risk from these diseases between 1980 and 1984, followed by a decrease until 1996.
Different from North America, which showed a 60% mortality reduction from cerebrovascular causes and a 53% reduction from coronary artery causes, in Brazil (Figure 1) the reductions observed were 20% and 13%, respectively. The trends of mortality risk by cardiovascular diseases are different in the various regions of the country; there is a decrease in the Southeast and South, an increase in the Center-West and Northeast, and stable levels in the North1 (B).
There are few prevalence studies and they do not represent the reality of the country. The investigations shown in Figure 2 indicate high prevalence between 22-44%2 (B) 3-6(A) 7(C). Due to this reality, control programs should be established throughout the country.
Diagnosis and Classification
Hypertension is diagnosed by measuring blood pressure using the methods and conditions described on Table 1, according to the blood pressure levels reported on Table 2.
Measurement of Arterial Pressure17,19(D)
The mercury column manometer is the most appropriate device. The aneroid variety must be tested every 6 months and the electronic models are indicated only when validated.
Diagnostic Routine (D)
A minimum of two blood pressure measurements must be taken at each medical examination, both with the patient seated; if diastolic pressures show differences above 5 mm Hg, new measurements should be taken until a smaller difference is obtained. In a first evaluation, the measurements must be taken in both upper limbs. If a difference is noticed, the arm to be used is the one with the higher blood pressure. Measurements should be repeated in at least 2 or more appointments before the diagnosis of hypertension is confirmed.
Measurement in orthostatic position must be taken at least during the initial evaluation, especially for the elderly, or for diabetic patients with dysautonomias, alcohol addicts, and users of antihypertensive medication.
Criteria for Diagnostic Classification and Follow-up Recommendations20(D)
Any numerical value is arbitrarily attributed and any classification is insufficient. One must consider, in addition to the pressure levels, the presence of risk factors, comorbidities and target organs lesions listed on Table 3.
Children and adolescents have their arterial pressure classified according to the percentiles of height and gender. Values ? 95 percentile are regarded as arterial hypertension.
Clinical Investigation and Therapeutic Decision
The objectives of the clinical investigation include the confirmation of persistent elevation of arterial pressure, evaluation of lesions in target organs, identification of cardiovascular risk factor, diagnosis of associated diseases and etiology of hypertension. To reach this goal, one must consider: a) clinical history in addition to the usual data of the patient's gender, age, race, socioeconomic status, smoking habits, time since onset of hypertension and blood pressure levels, overweight and obesity, symptoms of coronary artery disease, stroke, or coronary artery disease in family members (in women < 65 years old and men < 55 years old), signs and symptoms of cardiac heart failure, family history of hypertension, cerebral vascular disease, early/sudden death of close family members, peripheral vascular failure, depression, anxiety, panic, renal disease, family situation, diabetes mellitus, salt and alcohol intake, use of medication or drugs that might affect arterial blood pressure, risk factors for atherosclerosis, level of physical activity, dyslipidemia, weight loss and evidence of secondary hypertension, which must always be analyzed when characteristic manifestations are present b) physical examinations emphasizing weight and height, mitral and aortic murmurs, abdominal circumference, rales, roaring, sibilus, signs of secondary hypertension, abdominal masses (tumors, aneurisms, hydronephrosis, polycystic kidneys), measurements of arterial blood pressure, abdominal murmurs (renal, aortic), pulse rate, brachial, radial, femoral, tibial and pedis pulses, carotid palpation and auscultation, presence of edema, venous stasis, concise neurological exam, thyroid palpation, eye ground exam, ictus suggestive of left ventricular hypertrophy/dilatation, third heart sound (systolic dysfunction of left ventricle), hyperphonesis of A2; c) routine laboratory tests urinalysis, potassium, creatinine, fasting glucose test, total cholesterol, HDL-cholesterol, triglycerides and electrocardiogram; LDL-cholesterol may be estimated when triglycerides level are below 400mg/dl using the formula: LDL-cholesterol = total cholesterol - HDL-cholesterol - triglycerides/5; d) complementary evaluation if there is evidence of secondary hypertension, target organ injury, or associated diseases21,22(D).
To start the treatment, one must consider the blood pressure levels and the patient's risk according to Tables 3 and 4.
Multiprofessional Approach
Arterial hypertension is a multifactorial disease and as it involves guidelines directed to various objectives, it may demand help from other healthcare professionals in addition to the physician. The setup of this multiprofessional team will provide a differentiated approach to hypertensive patients24(A).
The Team
It may be composed of physicians, nurses, nurse aides, nutritionists, psychologists, social assistants, physical education teachers, pharmacists, management employees, and community agents. It is not necessary to have this whole group composing the team.
Team Actions
They intend to promote health, educational activities emphasizing lifestyle changes, correction of risk factors and production of educational material; training of professionals; referrals to other professionals, when appropriate; individual and group assistance; participation in research projects; program management.
Individual Actions
Actions characteristic to each professional; however, there are situations in which the functions are common to more than one professional and they will be performed naturally using uniform language and approach.
Community Programs
Forming leagues and associations of hypertensive patients may increase complicance and become an instrument of pressure with authorities in order to improve the quality of assistance offered to hypertensive patients.
Non-drug Treatment
Measures of better Effectiveness
Reduction of body weight and maintenance of ideal body weight body mass index (weight in kilograms divided by square value of height in meters) between 20 and 25 kg/m2, because there is a direct association between body weight and arterial blood pressure25(A).
Reduction of sodium intake it is healthy to ingest up to 6 g/day, which is the equivalent of 4 shallow coffee spoons of salt (4 g) and 2 g of salt present in natural food; it is important to reduce the amount of salt added to food and to avoid having the salt shaker on the table and eating industrialized food. A regular diet contains between 10-12 g/day of sodium26(A).
Greater potassium intake a diet rich in vegetables and fruits contains 2-4 g/day and can be helpful to lower blood pressure, as well as preventing arterial hypertension27(A). Salt substitutes containing potassium chloride and a lower amount of sodium chloride (30-50%) are helpful to reduce sodium intake and increase potassium intake.
Reduction of alcoholic beverage consumption28,29 (D) 30,31(B) 32(A) for alcohol consumers, the ingestion of alcoholic beverages must be limited to 30g of alcohol/day, contained in 600 ml of beer (5% alcohol) or 250 ml of wine (12% alcohol) or 60 ml of distilled drinks (whiskey, vodka, sugar cane liquor - 50% alcohol). This limit must be reduced to half in men with low body weight, women, overweight individuals or those who have high levels of triglycerides.
Regular physical activities33(A) 34(D) there is an inverse relationship between the level of physical activity and the incidence of hypertension; regular physical activity reduces blood pressure (Table 5).
Measures without Definitive Scientific Evaluation
Calcium supplements 36,37(A), magnesium38(D), vegetarian diets and anti-stress measures.
Associated Measures
Quit smoking this must be recommended because of its association with a higher incidence of cardiovascular mortality, and increased levels of arterial pressure measured on an outpatient basis39-41(B). Smoke quitting must be accompanied by caloric restriction and increase in physical activity in order to avoid possible weight gain. Exposure to smoke, passive smoking, is also a cardiovascular risk factor which must be avoided42(D).
Control of diabetes and dyslipidemias glucose intolerance and diabetes are frequently associated with arterial hypertension, causing the occurrence of cardiovascular diseases and complications from diabetes43(A) 44(B). Prevention is based mainly on a hypocaloric diet, regular practice of aerobic physical activities and reduction of simple sugar intake. These measures also intend to keep arterial blood pressure below 130/80 mmHg45(D). Hypercholesterolemia and e hypertriglyceridemia, with low HDL-cholesterol, are important cardiovascular risk factors45(D).
The basis for controlling dyslipidemias is represented by dietary changes with reduction of fat intake and partial replacement of saturated fats by mono- and polyunsaturated fats, as well as reduction of daily cholesterol intake46(D).
Avoid medications that increase arterial blood pressure levels23(D), listed on Table 6 along with specific guidelines for each type of medication.
Drug Treatment
Objective To reduce cardiovascular morbidity and mortality in hypertensive patients. The objective is reached in patients treated with diuretics47(A), beta blockers47(D), angiotensine-converting enzyme (ECA) inhibitors48(A), antagonists of AT1 receptor of angiotensina II (AII)49(D) and in older patients who use calcium channel antagonists48(A); the majority of the studies ended up using an association of drugs.
Target of Arterial Blood Pressure Reduction
It should be at least to values below 140/90 mmHg20(D). Reductions to levels below 130/85 mmHg provide greater benefit20(D) to patients with high cardiovascular risk43(A), diabetic patients especially with microalbuminuria50(A) and heart failure, nephropathy and in primary and secondary prevention of stroke48(A).
General Principles of Drug Treatment (D):
The drug must be effective orally, be well tolerated and allow the smallest possible amount of daily doses;
With stage 1 patients, treatment should start with the lowest effective doses possible;
With patients In stages 2 and 3, consider the associated use of an anti-hypertensive drug to start the treatment;
Observe a minimum of four weeks before increasing the dose, replacing monotherapy or changing the drug association;
Explain the patient about the disease, treatment plans and objectives, the importance of complying with the treatment, and adverse effects associated with the drugs;
Consider socioeconomic conditions.
Therapeutic Planning
Treatment must be individualized and should maintain the patient's quality of life. Any group of antihypertensive drugs, except direct-acting vasodilators and alpha-blockers, is appropriate to control arterial blood pressure as initial monotherapy (Table 7)23(D). Antihypertensive agents available in Brazil are shown on Tables 8 e 9.
Chlorthalidone has shown to be superior to doxazosin as an initial treatment drug for older hypertensive patients with other risk factors50(D) 51(A).
For the hypertensive patient with arterial blood pressure under control, the association of low doses of acetylsalicylic acid may reduce the occurrence of cardiovascular complications52(A).
Prevention of Hypertension and Associated Risk Factors
Fighting hypertension means preventing the increase of blood pressure by reducing the risk factors in the overall population and in groups with higher risk of developing the disease within the normal limit values (130 - 139/ 80 - 89 mmHg)35(D) and those with a family history of hypertension. Hypertension is also stimulated by excessive body weight53(D), sedentarism34(D), high salt intake26(A), low potassium intake46(D) and excessive alcohol consumption31(B). In the group with bordering normal blood pressure levels, factors such as dyslipidemias, glucose intolerance and diabetes, smoking, menopause and emotional stress54 (A) also contribute to the increase of cardiovascular risk.
Preventive measures include: maintenance of ideal body weight53(D), regular physical activities35(D), reduction in salt intake and increase in potassium intake46(D), avoiding alcoholic beverages31(B), following a healthy diet (Table 10) which should have a low fat content, mainly saturated fats, low cholesterol, high potassium content and fibers46(D), and low sodium content 26(A). The total calorie count must be adjusted for the purpose of achieving and keeping the ideal body weight. Strictly watching the entire diet is more important than following up isolated measures55 (B).
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Publication Dates
-
Publication in this collection
22 Apr 2004 -
Date of issue
Mar 2004
