Prevalence of arterial hypertension according to different diagnostic criteria, National Health Survey

ABSTRACT:

Objective:

To determine the population prevalence of arterial hypertension in adults according to different diagnostic criteria.

Methods:

This is a cross-sectional study, analyzing information from the Brazilian National Health Survey in 2013, consisted of interviews, physical and laboratory measurements (n = 60,202). The prevalence of hypertension was defined according to three diagnostic criteria: self-reported; measured by instrument (blood pressure ≥ 140/90 mmHg); measured and/or using medication. Prevalence and 95% confidence interval (95%CI) were estimated by the three diagnostic criteria of hypertension.

Results:

The high blood pressure measurements were: 21.4% (95%CI 20.8 - 22.0) using the criterion self-reported; 22.8% (95%CI 22.1 - 23.4) by measured hypertension; and 32.3% (95%CI 31.7 - 33.0) by measured hypertension and/or reported use of medication. Women presented higher prevalence for the self-reported criterion (24.2%; 95%CI 23.4 - 24.9) and men, for the measured criterion (25.8%; 95%CI 24.8 - 26.8). Hypertension increases with age and is more frequent in urban areas. Using these three criteria, the hypertension was higher in the Southeast and South regions, in relation to the average of the country and the other regions. Using these three criteria, hypertension increased with age, was more frequent in urban areas and in the Southeast and South regions, in relation to the average of the country and the other regions.

Conclusion:

These findings are important to support policies that aim to achieve the World Health Organization’s goal of reducing hypertension by 25% over the next decade.

Keywords:
Hypertension; Health surveys; Cardiovascular diseases; Chronic disease

RESUMO:

Objetivo:

Determinar a prevalência populacional de hipertensão arterial em adultos, segundo diferentes critérios diagnósticos.

Métodos:

Trata-se de um estudo transversal, que analisa informações da Pesquisa Nacional de Saúde de 2013, que consistiu em entrevistas, medidas físicas e laboratoriais da população brasileira (n = 60.202). A prevalência de hipertensão arterial foi definida segundo três critérios diagnósticos: hipertensão autorreferida; medida por instrumento (pressão arterial ≥ 140/90 mmHg); medida e/ou em uso de medicamentos anti-hipertensivos. Foram estimadas as prevalências de hipertensão arterial segundo os três critérios diagnósticos e seus respectivos intervalos de confiança de 95% (IC95%).

Resultados:

As prevalências de hipertensão arterial encontradas foram: 21,4% (IC95% 20,8 - 22,0) utilizando-se o critério autorreferido, 22,8% (IC95% 22,1 - 23,4) para hipertensão arterial medida e 32,3% (IC95% 31,7 - 33,0) para hipertensão arterial medida e/ou relato de uso de medicação. As mulheres apresentaram prevalências de hipertensão mais elevadas no critério autorreferido (24,2%; IC95% 23,4 - 24,9). Entre os homens, a prevalência foi maior no critério hipertensão arterial medida (25,8%; IC95% 24,8 - 26,7). Utilizando os três critérios, a hipertensão arterial aumentou com a idade, foi mais frequente na região urbana e maior nas regiões sudeste e sul, em relação à média do país e às demais regiões.

Conclusão:

Estes resultados são importantes para apoiar políticas que visem atingir a meta da Organização Mundial de Saúde de redução da hipertensão em 25% na próxima década.

Palavras-chave:
Hipertensão; Inquérito epidemiológico; Doenças cardiovasculares; Doença crônica

INTRODUCTION

The World Health Organization (WHO) estimates that about 600 million people have Arterial Hypertension (AH), with global increase of 60% of cases until 2025, besides the approximate number of 7.1 million annual deaths¹. AH leads to increasing costs for the health system, with major socioeconomic impact^2,3. AH represents the main risk factor for Cardiovascular Disease (CVD), and is responsible for a significant contribution in the global burden of diseases and in the missed years of life adjusted for incapacity^4,5. High levels of Blood Pressure (BP) increase the chances of coronary arterial disease, heart failure, encephalic vascular disease, chronic kidney failure and death^6,7.

In Brazil, population surveys have used questionnaires to obtain self-reported information, due to their simplicity and reduced costs in the application of the technique^8,9,10. One example is the Surveillance System for Risk and Protective Factors for Chronic Diseases by Telephone Survey (Vigitel), which pointed to the prevalence of AH in the past decade, affecting about one quarter of the Brazilian adult population^8,11. Therefore, self-reported AH is an indicator that can be used when it is not possible to measure the BP; however, this criterion may underestimate the diagnosis¹².

The use of devices to measure BP at a population scope requires the standardization of measurement techniques, consensus over the diagnostic criteria, quality of equipment and skills from the collection team, which leads to the increasing complexity of the research planning, besides higher costs^9,13,14. Thus, most population studies estimates self-reported AH, because collection is simpler⁸.

Analyses with measured BP are scarce in the Brazilian population, and most studies are local, with great variability of information, which does not allow the comparison of data¹⁵. Besides, there are different diagnostic criteria to estimate the population prevalence of AH^15,16,17,18. The WHO considers AH when the measurement is above 140 mmHg, and/or diastolic pressure equal to or higher than 90 mmHg^1,16, whereas other studies consider the measurement equal to or higher than 140 mmHg/90 mmHg, or currently using anti-hypertension medication^15,17,18.

In 2013, the Brazilian National Health Survey (NHS), national survey carried out by the Brazilian Institute of Geography and Statistics (IBGE), used both referred measurements and measured ones to calculate the AH in the Brazilian population. The inclusion of these measurements in the NHS resulted in a great advance for public health, enabling the better evaluation of the extension of the problem in the population^9,14. In the same year, the Global Action Plan to Prevent and Control Non-Communicable Diseases was approved in the Global Health Assembly, in Geneva, including a set of indicators to face non-communicable chronic diseases (NCCD), with the goal of reducing the prevalence of high BP in 25%, until 2025 ¹⁶. This goal must be continuously monitored by the countries¹⁶.

The NHS constitutes an essential instrument to monitor these indicators. Its survey included questions about self-reported AH and that previously diagnosed by doctors, the use of anti-hypertension medication, besides the measurement of BP in adults, which made it possible to compare different diagnostic criteria to analyze the different measurements^9,14.

Therefore, the objective of this study was to determine the population prevalence of AH in adults, according to different diagnostic criteria, using the information from the NHS.

METHODS

The NHS is a cross-sectional analysis conducted in 2013. The NHS is a household epidemiological survey, carried out by IBGE, together with the Ministry of Health, representative of Brazil, its great regions, Federation Units (FU), metropolitan regions and capitals^14,19.

The NHS 2013 sample was composed of 64,348 households. The residents selected, who underwent a specific interview about their health status, life style and chronic conditions, accounted for 60,202. The loss rate was 20.8%, and the non-response rate was 8.1%^14,19.

The sampling plan of the NHS had three stages: the Primary Sampling Units (PSU) were the census sectors or the set of sectors; the secondary units were the households; and the tertiary units were the adults living in the household (≥ 18 years). Since the NHS was part of the Integrated System of Household Studies (ISHS), from IBGE, the PSU considered in the research are a sub-sample of the set of PSU in the master sample of IBGE. The household selection was carried out based on the most recent version, available at the time, of the National Address Records for Statistical Purposes (NARSP). The investigation of the specific health-related subjects was performed with a single adult resident selected in each household, after a simple random sample^14,19.

Considering the different possibilities of obtaining the population diagnosis of AH in the NHF, the following criteria were compared:

• Self-reported AH: calculated according to the answers to the following question in the NHS: “Has any doctor ever told you you have arterial hypertension? (yes, no)”, and the individuals who answered yes were calculated as hypertensive;

• AH measured by instrument: BP was measured by a trained team, using a calibrated digital device. Three BP measurements were taken, with two-minute intervals in-between them. The measurements were, then, inserted in a smartphone. The mean BP between the second and the third measurements was used for this study^9,14. The missing data were input by the IBGE team, using a set of integrated computer routines of the system called CIDAQ (critic and input of quantitative data), which considered the combined behavior of all registered variables: age, sex, weight, height, and per capita family income. The routines to measure BP were in a protocol that included being at rest, emptying the bladder, not drinking or smoking for 30 minutes, not performing physical activities for one hour before the measurement, which should be taken while the person was sitting down, having rest for at least five minutes, among others. More details can be observed in other studies ^9,14. Considering that the BP can get higher while checkin, it is recommended a validation throwgh two or more ocasions in order to diagnose the AH. However, in this study it was considered hypertensive the who showed BP ≥ 140/90 mmHg in a single blood pressure checking, once it was impossible new measurement to the adapted sample.

• AH measured by an instrument and/or while using anti-hypertensive medication. The third diagnostic criterion consisted on combining the BP measurement ≥ 140/90 mmHg and/or on referring the use of drugs for arterial hypertension, calculated based on the positive responses to the following questions in the NHS: “Have you taker any medication for arterial hypertension (high blood pressure) during the last two weeks?”.

This study described the prevalence of individuals with AH according to the three diagnostic criteria: self-reported; measured BP ≥ 140/90 mmHg; BP ≥ 140/90 mmHg and/or while using anti-hypertensive medication. The prevalence rates and 95% confidence intervals (95%CI) were estimated for the three diagnostic criteria of AH for the Brazilian adult population, according to sex, Brazil, regions, urban and rural, and 27 FU. AH was also calculated by age group for each diagnostic criterion, for the total population. In the calculation of prevalence rates, the survey module of the software Stata 14 was used to correct the effect of the sampling plan caused of the PSU conglomeration in the estimates of the population surveys.

NHS was approved by the National Ethics Commission for Human Research, of the Ministry of Health. The consent form was signed in the smartphone during the NHS.

RESULTS

Table 1 presents the prevalence of AH according to the three different diagnostic criteria (self-reported AH, measured by instrument BP ≥ 140/90 mmHg and measured BP ≥ 140/90 mmHg and/or while using anti-hypertensive medication). The measurements for the Brazilian adult population were, respectively, 21.4% (95%CI 20.8 - 22.0); 22.8% (95%CI 22.1 - 23.4), and 32.3% (95%CI 31.7 - 33.0). Self-reported AH was higher in the urban region and in the Southeast and South regions. The prevalence of AH in the three diagnostic criteria was also higher in the Southeast and South regions in relation to the mean in the country and the other regions. Women presented higher prevalence rates for the self-reported criterion, and men, for the measured criterion (Table 1).

Table 1.
Arterial hypertension and 95% confidence intervals according to the criteria: self-reported blood pressure; measured blood pressure ≥ 140/90 mmHg; and blood pressure ≥ 140/90 mmHg or use of medications. Adults, Brazil, urban and rural and regions.

Regions	Self-reported BP		BP ≥ 140/90 mmHg measured		BP ≥ 140/90 mmHg measured and/or use of medications
	%	95%CI	%	95%CI	%	95%CI
Total
Brazil	21.4	20.8 - 22.0	22.8	22.1 - 23.4	32.3	31.7 - 33.0
Urban	21.7	21.0 - 22.3	22.0	21.0 - 21.9	33.1	31.5 - 32.9
Rural	19.8	18.6 - 21.0	19.3	18.6 - 21.7	32.1	31.6 - 34.6
North	14.5	13.6 - 15.5	14.6	13.4 - 15.8	20.5	19.3 - 21.8
Northeast	19.4	18.5 - 20.4	21.0	20.1 - 21.9	29.4	28.4 - 30.4
Southeast	23.3	22.3 - 24.3	25.0	23.8 - 26.1	35.5	34.4 - 36.7
South	22.9	21.5 - 24.3	25.0	23.5 - 26.1	35.0	33.5 - 36.5
Center-West	21.2	20.0 - 22.4	20.0	18.8 - 21.2	30.2	28.9 - 31.5
Male
Brazil	18.3	17.5 - 19.1	25.8	24.8 - 26.7	33.0	32.1 - 34.0
Urban	18.8	17.9 - 19.7	21.3	19.7 - 22.2	33.1	32.0 - 34.2
Rural	15.2	13.7 - 16.6	17.8	16.7 - 20.3	32.5	30.4 - 34.7
North	12.5	10.9 - 14.1	16.4	14.7 - 18.2	20.6	18.7 - 22.5
Northeast	15.5	14.1 - 16.9	24.2	22.7 - 25.8	29.5	28.0 - 31.1
Southeast	20.4	19.0 - 21.7	28.4	26.6 - 30.2	36.9	35.1 - 38.7
South	20.1	18.2 - 22.1	27.3	25.1 - 29.5	35.7	33.5 - 37.9
Center-West	18.4	16.7 - 20.2	22.8	21.0 - 24.6	30.5	28.5 - 32.6
Female
Brazil	24.2	23.4 - 24.9	20.0	19.3 - 20.8	31.7	30.9 - 32.5
Urban	24.1	23.3 - 24.9	19.6	16.7 - 20.7	31.4	30.5 - 32.3
Rural	24.7	22.6 - 26.8	17.8	15.9 - 20.2	33.6	31.6 - 35.7
North	16.5	15.0 - 17.9	12.7	11.3 - 14.3	20.4	18.8 - 22.2
Northeast	23.0	21.8 - 24.2	18.1	17.0 - 19.2	29.3	28.2 - 30.4
Southeast	25.9	24.5 - 27.2	21.9	20.6 - 23.3	34.3	32.9 - 35.9
South	25.4	23.4 - 27.3	22.8	21.0 - 24.7	34.3	32.3 - 36.4
Center-West	23.8	22.3 - 25.3	17.3	15.8 - 19.0	29.9	28.3 - 31.5

• BP: blood pressure; 95%CI: 95% confidence interval.

For the total population, the prevalence of AH according to the self-reported criterion ranged from 13.1% (95%CI 11.3 - 14.9) in Pará to 24.9% (95%CI 22.7 - 27.1) in Rio Grande do Sul. The variation of AH according to the measured criterion was 13.3% (95%CI 11.7 - 15.1) in Amazonas, to 27.6% (95%CI 25.3 - 30.0) in Rio Grande do Sul. Regarding the measured AH and/or report of use of medication criterion, the lowest prevalence was 17.8% (95%CI 16.0 - 19.7), and the highest prevalence was 39.3% (95%CI 36.8 - 41.8) in Amazonas and Rio Grande do Sul, respectively (Table 2).

Table 2.
Arterial hypertension and 95% confidence interval according to the criteria: self-reported blood pressure; measured blood pressure ≥ 140/90 mmHg; and measured blood pressure ≥ 140/90 mmHg or use of medications. Adults, per state.

States	Self-reported BP		BP ≥ 140/90 mmHg measured		BP ≥ 140/90 mmHg measured and/or use of medications
	%	95%CI	%	95%CI	%	95%CI
Rondônia	18.1	15.6 - 20.6	15.6	14.0 - 17.4	23.7	21.3 - 26.2
Acre	16.1	14.3 - 17.9	15.6	13.9 - 17.6	22.8	20.9 - 24.8
Amazonas	13.7	12.2 - 15.2	13.3	11.7 - 15.1	17.8	16.0 - 19.7
Roraima	14.2	12.1 - 16.3	15.3	13.5 - 17.3	21.4	19.5 - 23.5
Pará	13.1	11.3 - 14.9	14.5	12.5 - 16.9	19.7	17.5 - 22.1
Amapá	13.3	11.0 - 15.5	16.4	14.1 - 19.0	20.3	17.9 - 22.9
Tocantins	19.6	17.4 - 21.8	14.7	12.7 - 16.9	25.7	23.1 - 28.5
Maranhão	13.6	11.2 - 16.1	17.2	14.3 - 20.5	23.6	21.2 - 26.3
Piauí	19.3	17.0 - 21.6	18.3	15.9 - 20.9	27.8	25.4 - 30.4
Ceará	18.7	16.9 - 20.6	20.5	18.6 - 22.5	29.2	27.0 - 31.5
Rio Grande do Norte	20.8	18.8 - 22.9	19.1	16.8 - 21.7	30.3	27.8 - 32.9
Paraíba	21.6	19.7 - 23.4	21.3	19.0 - 23.9	29.8	27.5 - 32.1
Pernambuco	21.5	19.7 - 23.4	21.1	19.2 - 23.2	31.6	29.5 - 33.8
Alagoas	19.2	17.1 - 21.3	20.5	18.4 - 22.6	28.9	26.6 - 31.3
Sergipe	20.7	18.6 - 22.8	22.7	20.5 - 25.1	31.8	29.5 - 34.2
Bahia	20.0	17.3 - 22.7	23.5	21.1 - 26.1	30.3	27.6 - 33.0
Minas Gerais	24.0	21.8 - 26.1	24.8	22.1 - 27.8	36.0	33.4 - 38.8
Espírito Santo	20.6	18.2 - 23.0	22.0	19.4 - 25.0	31.6	28.6 - 34.7
Rio de Janeiro	23.9	22.2 - 25.7	27.5	25.6 - 29.4	37.8	35.8 - 39.8
São Paulo	23.0	21.5 - 24.4	24.3	22.7 - 25.9	34.8	33.1 - 36.5
Paraná	21.4	19.2 - 23.7	21.8	19.4 - 24.3	30.9	28.6 - 33.4
Santa Catarina	21.8	18.6 - 24.9	25.6	22.3 - 29.2	34.2	31.0 - 37.5
Rio Grande do Sul	24.9	22.7 - 27.1	27.6	25.3 - 30.0	39.3	36.8 - 41.8
Mato Grosso do Sul	21.1	18.9 - 23.2	26.3	24.0 - 28.7	35.0	32.5 - 37.6
Mato Grosso	20.8	18.7 - 22.9	18.2	15.5 - 21.2	27.8	25.2 - 30.6
Goiás	22.1	19.9 - 24.4	19.5	17.6 - 21.6	30.9	28.6 - 33.3
Distrito Federal	19.7	17.6 - 21.8	17.6	15.6 - 19.7	27.1	24.9 - 29.4

• BP: blood pressure; 95%CI: 95% confidence interval.

In Table 3, the prevalence among men according to the self-reported AH criterion ranged from 9.3% (95%CI 6.8 - 11.9) in Maranhão to 21.5% (95%CI 18.7 - 24.4) in Rio Grande do Sul. Using the measured AH, the variation was 15.1% (95%CI 16.4 - 13.9) in Amazonas to 31.8% (95%CI 28.3 - 35.5) in Rio Grande do Sul. Using AH and/or report of use of medication, the lowest frequency was 18.4% (95%CI 16.0 - 21.2), and the highest was 40.8% (95%CI 37.2 - 44.4), in Amazonas and Rio Grande do Sul, respectively.

Table 3.
Arterial hypertension and 95% confidence interval according to the criteria: self-reported blood pressure, measured blood pressure ≥ 140/90 mmHg; and blood pressure ≥ 140/90 mmHg or use of medications. Adult men, per state.

States	Self-reported BP		BP ≥ 140/90 mmHg measured		BP ≥ 140/90 mmHg measured and/or use of medications
	%	95%CI	%	95%CI	%	95%CI
Rondônia	15.9	11.7 - 20.1	17.2	14.3 - 20.5	23.1	19.4 - 27.3
Acre	12.6	10.3 - 15.0	18.7	15.8 - 21.9	23.4	20.3 - 26.8
Amazonas	11.7	9.7 - 13.6	15.1	16.4 - 13.9	18.4	16.0 - 21.2
Roraima	13.5	10.4 - 16.5	19.5	16.8 - 22.6	23.4	20.6 - 26.6
Pará	11.4	8.4 - 14.4	15.7	12.7 - 19.3	19.6	16.3 - 23.5
Amapá	10.6	7.3 - 13.9	17.6	14.7 - 20.9	20.3	17.4 - 23.5
Tocantins	16.9	13.2 - 20.7	16.8	13.6 - 20.5	25.3	21.5 - 29.5
Maranhão	9.3	6.8 - 11.9	19.9	15.9 - 24.6	23.1	19.2 - 27.7
Piauí	15.3	12.1 - 18.5	20.2	16.9 - 24.0	27.9	24.4 - 31.6
Ceará	16.1	13.5 - 18.6	23.9	21.0 - 27.0	30.6	27.5 - 33.8
Rio Grande do Norte	16.1	12.8 - 19.5	22.1	18.6 - 26.1	28.9	25.2 - 32.9
Paraíba	17.9	14.9 - 20.9	23.3	19.8 - 27.3	29.0	25.5 - 32.9
Pernambuco	18.0	15.2 - 20.7	23.9	21.2 - 26.8	31.8	28.8 - 35.0
Alagoas	15.8	12.7 - 19.0	22.8	19.5 - 26.3	28.6	25.1 - 32.5
Sergipe	15.1	12.0 - 18.3	25.7	22.5 - 29.2	32.0	28.4 - 35.9
Bahia	15.4	11.2 - 19.7	28.0	23.7 - 32.6	30.6	26.3 - 35.3
Minas Gerais	19.5	17.0 - 22.1	29.1	24.8 - 33.7	37.0	33.1 - 41.1
Espírito Santo	16.4	13.1 - 19.7	23.4	19.0 - 28.6	30.2	25.7 - 35.2
Rio de Janeiro	21.1	18.4 - 23.7	30.7	27.8 - 33.8	39.2	36.1 - 42.3
São Paulo	20.8	18.7 - 22.9	27.6	25.2 - 30.2	36.5	34.0 - 39.2
Paraná	19.8	16.4 - 23.2	23.2	20.2 - 26.5	31.4	28.1 - 35.0
Santa Catarina	18.4	14.5 - 22.4	26.1	21.5 - 31.3	33.9	29.6 - 38.6
Rio Grande do Sul	21.5	18.7 - 24.4	31.8	28.3 - 35.5	40.8	37.2 - 44.4
Mato Grosso do Sul	17.4	14.5 - 20.2	29.9	26.2 - 33.9	36.5	32.6 - 40.6
Mato Grosso	17.6	14.3 - 20.9	21.3	17.3 - 25.9	28.5	24.5 - 32.9
Goiás	19.8	16.6 - 23.0	21.9	19.2 - 25.0	30.8	27.3 - 34.6
Distrito Federal	17.1	14.2 - 20.0	20.2	17.0 - 23.7	26.9	23.6 - 30.4

• BP: blood pressure; 95%CI: 95% confidence interval.

Among the female participants, the prevalence of self-reported AH ranged from 14.8% (95%CI 12.1 - 15.5) in Pará to 28.0% (95%CI 24.8 - 31.1) in Minas Gerais. In the measured AH criterion, the variation was of 10.2% (95%CI 8.3 - 12.6) in Amazonas, and 25.1% (95%CI 20.7 - 30.1) in Santa Catarina. According to the measured AH criterion and/or with report of use of medication, the lowest frequency of AH was observed in Amazonas, with 17.1% (95%CI 14.9 - 19.6), and the highest frequency, in Rio Grande do Sul, with 37.9% (95%CI 34.5 - 41.4) (Table 4).

Table 4.
Arterial hypertension and 95% confidence interval according to the criteria: self-reported blood pressure; measured blood pressure ≥ 140/90 mmHg; and blood pressure ≥ 140/90 mmHg or use of medications. Adult women, per state.

States	Self-reported BP		BP ≥ 140/90 mmHg measured		PA ≥ 140/90 mmHg measured and/or use of medications
	%	95%CI	%	95%CI	%	95%CI
Rondônia	20.3	17.1 - 23.5	14.0	12.1 - 16.2	24.2	21.3 - 27.5
Acre	19.3	16.8 - 21.8	12.8	10.8 - 15.1	22.2	19.7 - 24.8
Amazonas	15.7	13.5 - 17.9	10.2	8.3 - 12.6	17.1	14.9 - 19.6
Roraima	14.9	12.4 - 17.4	11.0	8.9 - 13.5	19.4	17.0 - 22.0
Pará	14.8	12.1 - 17.5	13.4	10.8 - 16.5	19.8	16.8 - 23.2
Amapá	15.7	12.9 - 18.4	15.3	12.4 - 18.9	20.4	17.1 - 24.1
Tocantins	22.0	19.0 - 25.1	12.6	9.9 - 16.0	26.1	22.7 - 29.8
Maranhão	17.6	14.1 - 21.1	14.6	11.3 - 18.8	24.1	21.1 - 27.4
Piauí	23.0	20.1 - 25.8	16.4	13.5 - 19.8	27.8	24.7 - 31.1
Ceará	21.1	18.5 - 23.7	17.3	15.1 - 19.8	27.9	25.3 - 30.7
Rio Grande do Norte	24.9	22.3 - 27.5	16.5	13.6 - 19.9	31.5	28.4 - 34.8
Paraíba	24.8	22.2 - 27.3	19.5	16.3 - 23.1	30.4	27.4 - 33.5
Pernambuco	24.6	22.2 - 27.0	18.7	16.4 - 21.1	31.4	29.0 - 34.0
Alagoas	22.1	19.2 - 25.0	18.4	15.7 - 21.5	29.1	25.9 - 32.5
Sergipe	25.9	23.0 - 28.8	19.9	17.3 - 22.9	31.6	28.9 - 34.5
Bahia	24.0	20.7 - 27.3	19.6	17.1 - 22.4	29.9	27.3 - 32.8
Minas Gerais	28.0	24.8 - 31.1	21.0	18.0 - 24.3	35.1	31.9 - 38.5
Espírito Santo	24.4	20.9 - 28.0	20.8	18.1 - 23.8	32.9	29.5 - 36.4
Rio de Janeiro	26.3	24.2 - 28.4	24.8	22.8 - 27.0	36.6	34.5 - 38.8
São Paulo	24.8	22.8 - 26.9	21.3	19.3 - 23.4	33.2	31.0 - 35.6
Paraná	22.9	20.0 - 25.8	20.4	17.7 - 23.5	30.5	27.6 - 33.5
Santa Catarina	25.0	20.2 - 29.8	25.1	20.7 - 30.1	34.4	29.9 - 39.3
Rio Grande do Sul	27.9	24.8 - 30.9	23.8	21.2 - 26.5	37.9	34.5 - 41.4
Mato Grosso do Sul	24.4	21.6 - 27.3	22.9	20.3 - 25.7	33.7	30.7 - 36.8
Mato Grosso	24.0	20.7 - 27.2	15.1	12.0 - 18.9	27.1	23.5 - 31.0
Goiás	24.3	21.6 - 27.0	17.2	14.5 - 20.2	31.0	28.3 - 33.8
Distrito Federal	21.9	19.2 - 24.6	15.4	12.9 - 18.1	27.3	24.6 - 30.2

• PA: pressão arterial; IC95%: intervalo de confiança de 95%.

In all of the analyzed criteria, there was an increase in AH with age, reaching 71.7% for individuals aged more than 70 years, with high BP and / or reported use of medication. Self-reported AH tends to stabilize after the age of 60 or more, around 60% (Figure 1).

Figure 1.
Population prevalence of high blood pressure according to different diagnostic criteria, in adults aged 18 years or more, of both genders, according to age group, Brazil, 2013.

DISCUSSION

This is the first national study comparing three diagnostic criteria to measure the prevalence of AH at a population scope (self-reported, measured BP ≥ 140/90 mmHg, BP ≥ 140/90 mmHg or use of medication), analyzing the data from the NHS. The prevalence of hypertension ranged between one fifth and one third of the Brazilian adult population, depending on the adopted criterion, being higher for the criterion measured AH and/or in use of medication. In the general population, measured AH presents higher prevalence rates than self-reported AH, even if they are close. By analyzing by gender, self-reported AH is higher among women, whereas measured AH is higher among men. Measured AH reached one fourth of the male population and one fifth of the female population. When the diagnosis was made by a criterion measured AH and/or use of medication, the differences according to sex were not significant. There were no differences regarding urban and rural, except for measured AH, which was lower in rural, among female participants. In general, the prevalence rates of AH considering all of the criteria were higher in the Southeast and South regions, and in the states of these regions.

The treatment of hypertension has been associated with about 40% of reduction of stroke, and about 15% of reduction in acute myocardial infarction; that is why the WHO²⁰ recommends the early diagnosis and the population monitoring of AH^16,20. The NHS innovates because it allows the use of different diagnostic criteria to estimate the prevalence of high BP¹⁴. We used digital electronic devices, allowing to establish the gold-standard in relation to the population diagnosis of hypertension, constituting something new in the country^9,14. The BP measurement is recommended internationally, for being the most reliable criterion and for enabling the standardization of the results^20,21,22.

The questionnaires containing self-reported measurements have been widely used, in other countries and in Brazil, for having low cost and being easy to execute^8,22. A population study in a cohort of elderly people, in Bambuí, Minas Gerais, carried out the validation between referred and measured measurements, and the results found were valid, indicating that self-reported AH can be used as a valid population estimation¹³. A study carried out by Universidade Federal de Pelotas, aiming at validating the self-report of AH in a population-based study, has also shown that this methodology is valid and can be used in our field to monitor changes in the prevalence of NCCD²³. The NHS found close results between the self-reported and measured measurements, which may indicate that the self-reported measurement can be useful in population studies. The fact that only 3% of the Brazilian population declared never having measured BP in the country²⁴ was considered as a factor that facilitates the adoption of referred measures, as a proxy of the population prevalence rates.

The differences according to sex are also in agreement with the literature. In general, the self-reported criterion tends to increase the diagnosis among women, as already identified^8,11,24. One of the explanations can be the fact that women attend health services more often, which leads to more opportunities of diagnosis, also identified in the NHS^11,25. Among studies with diagnostic criterion of measured AH, on the contrary, men presented with higher prevalence rates. This has been described in study by the WHO, which estimated, globally, higher prevalence rates among men (29.2%), and 24.8% among women²⁶. The same was true for the region of the Americas: 26.3% for male and 19.7% for female individuals²⁶; and in Brazil: 25.8% for male versus 20.0% for female individuals⁹.

The study also identified the increasing prevalence of hypertension with age, which is in agreement with the literature and is explained by the physiological changes of aging, with stiffening of blood vessels, more peripheral vascular resistance and comorbidity among the elderly^27,28,29.

The regional differences with higher prevalence in the federative units of the Southeast and South can be explained by demographic factors, such as higher life expectancy and differences in the age structure of these regions, with more participation of the elderly³⁰. Other studies have also identified higher prevalence rates of hypertension in states like Rio de Janeiro, São Paulo and Rio Grande do Sul^9,18,31.

The NHS identified that, among the adults who reported AH (21.4%), 81.4% mentioned having taken medication, and 69.7% of the adults with self-reported AH received medical care in the past 12 months²⁴. Therefore, using the criterion of having high blood pressure or taking medication led the prevalence rate to reach more than one third of the adult population, reaching more than 70% of the population aged more than 70 years. The wide access to medication for hypertension and diabetes in the Unified Health System (SUS) stands out, as well as the gratuity programs, such as “Aqui tem Farmácia Popular” ^24,32.

The approval of the Global Plan to Face the chronic NCD, in the World Health Assembly, defined a set of global goals for the reduction of the chronic NCD and their risk factors. Among them is the relative reduction of the prevalence of high BP in 25%, among people aged 18 years or more (defined as BP ≥ 140 mmHg/≥ 90 mmHg) and, in some contexts, according to national circumstances, there is a goal of restricting the growth of AH¹⁶. Therefore, it is important to monitor these indicators, since countries will have to periodically report their results to the WHO, aiming at the evaluation of the goal in 2025¹⁶. The goal adopted by the WHO explains the criterion of measured AH as the international reference standard, showing the importance of the NHS having verified that measurement, enabling an international comparison¹⁶.

The global indicator of reduction in 25% of the AH¹⁶ is not a consensus in the literature, especially regarding the institution of a drug treatment for all hypertensive individuals^33,34. Beaglehole et al.³⁵ defend that reduced levels of BP in the population will be reached faster with population measures, such as the reduction in the consumption of salt, the stimulus to physical activities and healthy diets. The drug treatment would be prioritized for people with high global risk of cardiovascular disease³⁵. However, MacMahon et al.³⁶ defend that the control of AH in the United States, in the past decades, was owed to the increasing availability of the drug treatment. Another argument that is contrary to the population mass treatment would be the size of the cost and effort, which, in the case of Brazil, would include one third of the adults, according to a current study^34,35. In the case of China, treating the entire population with levels of BP > 140/90 mmHg with medication could cost about one tenth of the health budget of the country³⁵. Beaglehole et al.³⁵ state that not always the population with BP levels > 140/90 mmHg would present with risks of cardiovascular diseases, since half of all cardiovascular conditions affects non-hypertensive people³⁶. Therefore, hypertensive people who also have cardiovascular risk should be prioritized for the drug treatment³⁵.

Among the limitations, this is an epidemiological study, using data from the NHS, which uses a standardized technique for measured BP by trained interviewers, who are not health professionals, so there could be errors in measurement³⁷. Besides, the literature describes that the measurements of BP may range due to different techniques used, and the anxiety for measuring BP, possibly resulting in a sudden rise³⁸. Probably, this must have been a minimum fact, since the procedure was performed by non-physicians, in the household of the participants. Regarding the previous diagnosis and the use of medication, for being information that was self-reported by the interviewees, there may have been differences in the understanding of the interviewees, memory bias, among others. These factors may affect the prevalence rates described here. It is also worth noting that the criterion AH measured by instrument is related to high BP at the time of measurement, which differs somewhat from arterial hypertension, which is defined as presenting this measure systematically.

CONCLUSION

The matter of chronic NCD became a priority in global agendas. However, there are still many challenges, such as the monitoring of the chronic NCD through valid methodologies, that are easy to measure and have low cost, elucidating a reliable population diagnosis for the development of effective policies. The current study presents three different valid diagnostic criteria to measure the prevalence of population AH. Self-reported and measured AH presented close prevalence rates, confirming that the self-reported measurement is useful in population studies. However, the monitoring of global goals of AH reduction¹⁶ will be carried out using measured measurements, showing the right choice of the NHS to include the BP measurement in its scope. The measured AH criterion and/or use of anti-hypertensive medications included a high number of individuals with AH, pointing to the challenge of supply and cost of anti-hypertensive drugs for almost one third of the Brazilian population.

Knowing and monitoring indicators referring to chronic NCD, including the goals of AH reduction, is important in a national and global context. The NHS constitutes the baseline for the indicator of measured hypertension reduction. To reach the goal of relative reduction of 25% in the prevalence of high blood pressure it will be necessary to intervene for the reduction of the intake of salt, saturated fats and for the increasing intake of vegetables and fruits; efforts to reduce overweight/obesity and screening for the detection and early treatment of hypertensive individuals. The current study can support this AH monitoring and identify priorities for action.

ACKNOWLEDGMENTS

Malta DC would like to thank Conselho Nacional de Desenvolvimento Científico e Tecnológico (CNPQ) for the research productivity scholarship; Machado IE thanks CNPQ for the Junior Postdoctoral Scholarship.

REFERÊNCIAS

• ¹
  World Health Organization. Global status report on noncommunicable diseases 2010 [Internet]. Genebra: World Health Organization; 2011 [citado em 26 nov. 2017]. Disponível em: Disponível em: http://www.who.int/nmh/publications/ncd_report2010/en/
  » http://www.who.int/nmh/publications/ncd_report2010/en/
• ²
  Balu S, Thomas J 3rd. Incremental expenditure of treating hypertension in the United States. Am J Hypertens [Internet]. 2006 [citado em 30 nov. 2017]; 19(8): 810-6. Disponível em: Disponível em: https://www.ncbi.nlm.nih.gov/pubmed/16876679 https://doi.org/10.1016/j.amjhyper.2005.12.013
  » https://doi.org/10.1016/j.amjhyper.2005.12.013» https://www.ncbi.nlm.nih.gov/pubmed/16876679
• ³
  Kearney PM, Whelton M, Reynolds K, Muntner P, Whelton PK, He J. Global burden of hypertension: analysis of worldwide data. Lancet [Internet]. 2005 [citado em 30 nov. 2017]; 365(9455): 217-23. Disponível em: Disponível em: http://www.sciencedirect.com/science/article/pii/S0140673605177411?via%3Dihub https://doi.org/10.1016/S0140-6736(05)17741-1
  » https://doi.org/10.1016/S0140-6736(05)17741-1» http://www.sciencedirect.com/science/article/pii/S0140673605177411?via%3Dihub
• ⁴
  Simone G, Devereux RB, Chinali M, Roman MJ, Best LG, Welty TK, et al. Risk factors for arterial hypertension in adults with initial optimal blood pressure: the Strong Heart Study. Hypertension [Internet]. 2006 [citado em 30 nov. 2017]; 47(2): 162-7. Disponível em: Disponível em: https://www.ncbi.nlm.nih.gov/pubmed/16380527 https://doi.org/10.1161/01.HYP.0000199103.40105.b5
  » https://doi.org/10.1161/01.HYP.0000199103.40105.b5» https://www.ncbi.nlm.nih.gov/pubmed/16380527
• ⁵
  Malta DC, Mendes-Felisbino MS, Machado IE, Passos VMA, Abreu DMX, Ishitani LH, et al. Fatores de risco relacionado à carga global de doença do Brasil e Unidades Federadas, 2015. Rev Bras Epidemiol [Internet] 2017 [citado em 1º dez. 2017]; 20(Supl. 1): 217-32. Disponível em: Disponível em: http://www.scielo.br/scielo.php?pid=S1415-790X2017000500217&script=sci_abstract&tlng=pt http://dx.doi.org/10.1590/1980-5497201700050018
  » https://doi.org/10.1590/1980-5497201700050018» http://www.scielo.br/scielo.php?pid=S1415-790X2017000500217&script=sci_abstract&tlng=pt
• ⁶
  Chobanian AV, Bakris GL, Black HR, Cushman WC, Green LA, Izzo JL Jr., et al. The seventh report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure: The JNC 7 Report. JAMA [Internet]. 2003 [citado em 1º dez. 2017]; 289(19): 2560-71. Disponível em: Disponível em: https://jamanetwork.com/journals/jama/fullarticle/196589 http://dx.doi.org/10.1001/jama.289.19.2560
  » https://doi.org/10.1001/jama.289.19.2560» https://jamanetwork.com/journals/jama/fullarticle/196589
• ⁷
  Malachias MVB, Plavnik FL, Machado CA, Malta D, Nazario LCS, Fuchs S. 7ª Diretriz Brasileira de Hipertensão Arterial: Capítulo 1 - Conceituação, Epidemiologia e Prevenção Primária. Arq Bras Cardiol [Internet]. 2016 [citado em 1º dez. 2017]; 107(3 Supl. 3): 1-6. Disponível em: Disponível em: http://www.scielo.br/scielo.php?script=sci_arttext&pid=S0066-782X2016004800002&lng=es http://dx.doi.org/10.5935/abc.20160151
  » https://doi.org/10.5935/abc.20160151» http://www.scielo.br/scielo.php?script=sci_arttext&pid=S0066-782X2016004800002&lng=es
• ⁸
  Brasil. Ministério da Saúde. Secretaria de Vigilância em Saúde. Departamento de Vigilância de Doenças e Agravos não Transmissíveis e Promoção da Saúde. Vigitel Brasil 2016: vigilância de fatores de risco e proteção para doenças crônicas por inquérito telefônico. Brasília: Ministério da Saúde; 2017.
• ⁹
  Malta DC, Santos NB, Perillo RD, Szwarcwald CL. Prevalence of high blood pressure measured in the Brazilian population, National Health Survey, 2013. São Paulo Med J [Internet]. 2016 [citado em 1º dez. 2017]; 134(2): 163-70. Disponível em: Disponível em: http://www.scielo.br/scielo.php?script=sci_arttext&pid=S1516-31802016000200163 http://dx.doi.org/10.1590/1516-3180.2015.02090911
  » https://doi.org/10.1590/1516-3180.2015.02090911» http://www.scielo.br/scielo.php?script=sci_arttext&pid=S1516-31802016000200163
• ¹⁰
  Muraro AP, Santos DF, Rodrigues PRM, Braga JU. Fatores associados à Hipertensão Arterial Sistêmica autorreferida segundo VIGITEL nas 26 capitais brasileiras e no Distrito Federal em 2008. Ciênc Saúde Colet [Internet]. 2013 [citado em 1º dez. 2017]; 18(5): 1387-98. Disponível em: Disponível em: http://www.scielo.br/scielo.php?pid=S1413-81232013000500024&script=sci_abstract&tlng=pt http://dx.doi.org/10.1590/S1413-81232013000500024
  » https://doi.org/10.1590/S1413-81232013000500024» http://www.scielo.br/scielo.php?pid=S1413-81232013000500024&script=sci_abstract&tlng=pt
• ¹¹
  Malta DC, Bernal RTI, Andrade SSCA, Silva MMA, Velasquez-Melendez G. Prevalência e fatores associados com hipertensão arterial autorreferida em adultos brasileiros. Rev Saúde Pública [Internet]. 2017 [citado em 1º dez. 2017]; 51(Supl. 1): 11s. Disponível em: Disponível em: http://www.scielo.br/scielo.php?script=sci_arttext&pid=S0034-89102017000200313&lng=pt&nrm=iso&tlng=pt http://dx.doi.org/10.1590/s1518-8787.2017051000006
  » https://doi.org/10.1590/s1518-8787.2017051000006» http://www.scielo.br/scielo.php?script=sci_arttext&pid=S0034-89102017000200313&lng=pt&nrm=iso&tlng=pt
• ¹²
  Ferreira AF, Barreto SM, Giatti L. Hipertensão arterial referida e utilização de medicamentos de uso contínuo no Brasil: um estudo de base populacional. Cad Saúde Pública [Internet]. 2014 [citado em 30 nov. 2017]; 30(4): 815-26. Disponível em: Disponível em: http://www.repositorio.ufop.br/bitstream/123456789/6295/1/ARTIGO_Hipertens%C3%A3oArterialReferida.pdf http://dx.doi.org/10.1590/0102-311X0016051
  » https://doi.org/10.1590/0102-311X0016051» http://www.repositorio.ufop.br/bitstream/123456789/6295/1/ARTIGO_Hipertens%C3%A3oArterialReferida.pdf
• ¹³
  Lima-Costa MF, Peixoto SV, Firmo JOA. Validade da hipertensão arterial auto-referida e seus determinantes (projeto Bambuí). Rev Saúde Pública [Internet] 2004 [citado em 1º dez. 2017]; 38(5): 637-42. Disponível em: Disponível em: http://www.scielo.br/pdf/rsp/v38n5/21750.pdf
  » http://www.scielo.br/pdf/rsp/v38n5/21750.pdf
• ¹⁴
  Brasil. Ministério da Saúde. Instituto Brasileiro de Geografia e Estatística. Ministério do Planejamento, Orçamento e Gestão. Pesquisa Nacional de Saúde: 2013. Percepção do estado de saúde, estilos de vida e doenças crônicas. Brasil, grandes regiões e unidades da federação [Internet]. Rio de Janeiro: Instituto Brasileiro de Geografia e Estatística; 2014 [citado em 15 fev. 2016]. Disponível em: Disponível em: ftp://ftp.ibge.gov.br/PNS/2013/pns2013.pdf
  » ftp://ftp.ibge.gov.br/PNS/2013/pns2013.pdf
• ¹⁵
  Passos VMA, Assis TD, Barreto SM. Hipertensão arterial no Brasil: estimativa de prevalência a partir de estudos de base populacional. Epidemiol Serv Saúde [Internet]. 2006 [citado em 30 nov. 2017]; 15(1): 35-45. Disponível em: Disponível em: http://scielo.iec.pa.gov.br/pdf/ess/v15n1/v15n1a03.pdf http://dx.doi.org/10.5123/S1679- 49742006000100003
  » https://doi.org/10.5123/S1679- 49742006000100003» http://scielo.iec.pa.gov.br/pdf/ess/v15n1/v15n1a03.pdf
• ¹⁶
  World Health Organization. Global Action Plan for the Prevention and Control of NCDs 2013-2020. Geneva: World Health Organization; 2013 [citado em 30 nov. 2017]. Disponível em: Disponível em: http://www.who.int/nmh/events/ncd_action_plan/en/
  » http://www.who.int/nmh/events/ncd_action_plan/en/
• ¹⁷
  Chor D, Ribeiro ALP, Carvalho MS, Duncan BB, Lotufo PA, Nobre AA, et al. Prevalence, Awareness, Treatment and Influence of Socioeconomic Variables on Control of High Blood Pressure: Results of the ELSA-Brasil Study. PLoS One [Internet]. 2015 [citado em 1º dez. 2017]; 10(6): e0127382. Disponível em: Disponível em: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4478044/pdf/pone.0127382.pdf
  » https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4478044/pdf/pone.0127382.pdf
• ¹⁸
  Lotufo PA. Melhorando o controle da hipertensão arterial. Dados iniciais do Estudo Longitudinal de Saúde do Adulto (ELSA-Brasil). Diagn Tratamento [Internet]. 2015 [citado em 1º dez. 2017]; 20(3): 85-7. Disponível em: Disponível em: http://files.bvs.br/upload/S/1413-9979/2015/v20n3/a4893.pdf
  » http://files.bvs.br/upload/S/1413-9979/2015/v20n3/a4893.pdf
• ¹⁹
  Souza-Júnior PRB, Freitas MPS, Antonaci GA, Szwarcwald CL. Desenho da amostra da Pesquisa Nacional de Saúde 2013. Epidemiol. Serv Saúde [Internet]. 2015 [citado em 1º dez. 2017]; 24(2): 207-16. Disponível em: Disponível em: http://www.scielo.br/pdf/ress/v24n2/2237-9622-ress-24-02-00207.pdf
  » http://www.scielo.br/pdf/ress/v24n2/2237-9622-ress-24-02-00207.pdf
• ²⁰
  World Health Organization. International Society of Hypertension. Statement on management of Hypertension. WHO/ISH Hypertension guidelines. J Hypertension [Internet]. 2003 Nov [citado em 1º dez. 2017]; 21(11): 1983-92. Disponível em: Disponível em: http://www.who.int/cardiovascular_diseases/guidelines/hypertension_guidelines.pdf
  » http://www.who.int/cardiovascular_diseases/guidelines/hypertension_guidelines.pdf
• ²¹
  Cooper R, Puras A, Tracy J, Kaufman J, Asuzu M, Ordunez P, et al. Evaluation of an electronic blood pressure device for epidemiological studies. Blood Press Monit [Internet]. 1997 [citado em 1º dez. 2017]; 2: 35-40. Disponível em: Disponível em: https://www.ncbi.nlm.nih.gov/pubmed/10234089
  » https://www.ncbi.nlm.nih.gov/pubmed/10234089
• ²²
  Ramsey F, Ussery-Hall A, Garcia D, McDonald G, Easton A, Kambon M, et al. Prevalence of selected risk behaviors and chronic diseases - Behavioral Risk Factor Surveillance System (BRFSS), 39 steps communities, United States, 2005. MMWR Surveill Summ [Internet]. 2008 [citado em 1º dez. 2017]; 57(11): 1-22. Disponível em: Disponível em: https://www.ncbi.nlm.nih.gov/pubmed/18971922
  » https://www.ncbi.nlm.nih.gov/pubmed/18971922
• ²³
  Chrestani MAD, Santos IS, Matijasevich AM. Hipertensão arterial sistêmica auto-referida: validação diagnóstica em estudo de base populacional. Cad Saúde Pública [Internet]. 2009 [citado em 1º dez. 2017]; 25(11): 2395-406. Disponível em: Disponível em: http://www.scielo.br/pdf/csp/v25n11/10.pdf
  » http://www.scielo.br/pdf/csp/v25n11/10.pdf
• ²⁴
  Malta DC, Stopa SR, Andrade SSCA, Szwarcwald CL, Silva-Júnior JB, Reis AAC. Cuidado em saúde em adultos com hipertensão arterial autorreferida no Brasil segundo dados da Pesquisa Nacional de Saúde, 2013. Rev Bras Epidemiol [Internet]. 2015 [citado em 1º dez. 2017]; 18(Supl. 2): 109-22. Disponível em: Disponível em: http://www.scielo.br/scielo.php?script=sci_arttext&pid=S1415-790X2015000600109&lng=en http://dx.doi.org/10.1590/1980-5497201500060010
  » https://doi.org/10.1590/1980-5497201500060010» http://www.scielo.br/scielo.php?script=sci_arttext&pid=S1415-790X2015000600109&lng=en
• ²⁵
  Stopa SR, Malta DC, Monteiro CN, Szwarcwald CL, Goldbaum M, Cesar CLG. Acesso e uso de serviços de saúde pela população brasileira, Pesquisa Nacional de Saúde 2013. Rev Saúde Pública [Internet]. 2017 [citado em 1º dez. 2017]; 51(Supl. 1): 11s. Disponível em: Disponível em: http://www.scielo.br/pdf/rsp/v51s1/pt_0034-8910-rsp-S1518-87872017051000074.pdf https://doi.org/10.1590/S1518-8787.2017051000074
  » https://doi.org/10.1590/S1518-8787.2017051000074» http://www.scielo.br/pdf/rsp/v51s1/pt_0034-8910-rsp-S1518-87872017051000074.pdf
• ²⁶
  World Health Organization. Health statistics and information systems [Internet]. Genebra: World Health Organization ; 2015 [citado em 15 out. 2015]. Disponível em: Disponível em: http://www.who.int/healthinfo/global_burden_disease/estimates/en/index1.html
  » http://www.who.int/healthinfo/global_burden_disease/estimates/en/index1.html
• ²⁷
  Firmo JOA, Uchôa E, Lima-Costa MF. Projeto Bambuí: fatores associados ao conhecimento da condição de hipertensos entre idosos. Cad Saúde Pública [Internet]. 2004 [citado em 1º dez. 2017]; 20(2): 512-21. Disponível em: Disponível em: http://www.scielo.br/pdf/csp/v20n2/19.pdf http://dx.doi.org/10.1590/S0102-311X2004000200019
  » https://doi.org/10.1590/S0102-311X2004000200019» http://www.scielo.br/pdf/csp/v20n2/19.pdf
• ²⁸
  Barreto SM, Passos VMA, Firmo JOA, Guerra HL, Vidigal PG, Lima-Costa MF. Hypertension and clustering of cardiovascular risk factors in a community in Southeast Brazil-The Bambuí Health and Ageing Study. Arq Bras Cardiol [Internet]. 2001 [citado em 1º dez. 2017]; 77(6): 576-81. Disponível em: Disponível em: http://www.scielo.br/pdf/abc/v77n6/a08v77n6.pdf http://dx.doi.org/10.1590/S0066-782X2001001200008
  » https://doi.org/10.1590/S0066-782X2001001200008» http://www.scielo.br/pdf/abc/v77n6/a08v77n6.pdf
• ²⁹
  Paulucci TD, Velasquez-Mendelez G, Bernal RI, Lana FF, Malta DC. Análise do cuidado dispensado a portadores de hipertensão arterial em Belo Horizonte, segundo inquérito telefônico. Rev Bras Epidemiol [Internet]. 2014 [citado em 1º dez. 2017]; 17 (Supl. 1): 227-40. Disponível em: Disponível em: http://www.scielo.br/pdf/rbepid/v17s1/pt_1415-790X-rbepid-17-s1-00227.pdf http://dx.doi.org/10.1590/1809-4503201400050018
  » https://doi.org/10.1590/1809-4503201400050018» http://www.scielo.br/pdf/rbepid/v17s1/pt_1415-790X-rbepid-17-s1-00227.pdf
• ³⁰
  Instituto Brasileiro de Geografia e Estatística. Sinopse do censo demográfico: 2010 [Internet]. Rio de Janeiro: IBGE; 2010 [citado em 1º dez. 2017]. Disponível em: Disponível em: https://biblioteca.ibge.gov.br/visualizacao/livros/liv49230.pdf
  » https://biblioteca.ibge.gov.br/visualizacao/livros/liv49230.pdf
• ³¹
  Nogueira D, Faerstein E, Coeli CM, Chor D, Lopes CS, Werneck GL. Reconhecimento, tratamento e controle da hipertensão arterial: Estudo Pró-Saúde. Rev Panam Salud Publica [Internet]. 2010 [citado em 1º dez. 2017]; 27(2): 103-9. Disponível em: Disponível em: https://scielosp.org/pdf/rpsp/2010.v27n2/103-109/PT
  » https://scielosp.org/pdf/rpsp/2010.v27n2/103-109/PT
• ³²
  Costa KS, Francisco PMSB, Malta DC, Barros MBA. Fontes de obtenção de medicamentos para hipertensão e diabetes no Brasil: resultados de inquérito telefônico nas capitais brasileiras e no Distrito Federal, 2011. Cad Saúde Pública [Internet]. 2016 [citado em 1º dez. 2017]; 32(2): e00090014. Disponível em: Disponível em: http://www.scielo.br/pdf/csp/v32n2/0102-311X-csp-0102-311X00090014.pdf http://dx.doi.org/10.1590/0102-311X00090014
  » https://doi.org/10.1590/0102-311X00090014» http://www.scielo.br/pdf/csp/v32n2/0102-311X-csp-0102-311X00090014.pdf
• ³³
  Mancia G, Parati G. Office compared with ambulatory blood pressure in assessing response to antihypertensive treatment: a meta-analysis. J Hypertens [Internet]. 2004 [citado em 1º dez. 2017]; 22(3): 435-45. Disponível em: Disponível em: https://www.ncbi.nlm.nih.gov/pubmed/15076144
  » https://www.ncbi.nlm.nih.gov/pubmed/15076144
• ³⁴
  Malta DC, Silva Jr. JB. O Plano de Ações Estratégicas para o Enfrentamento das Doenças Crônicas Não Transmissíveis no Brasil e a definição das metas globais para o enfrentamento dessas doenças até 2025: uma revisão. Epidemiol Serv Saúde [Internet]. 2013 Mar [citado em 3 dez. 2017]; 22(1): 151-64. Disponível em: Disponível em: http://scielo.iec.gov.br/scielo.php?script=sci_arttext&pid=S1679-49742013000100016&lng=pt http://dx.doi.org/10.5123/S1679-49742013000100016
  » https://doi.org/10.5123/S1679-49742013000100016» http://scielo.iec.gov.br/scielo.php?script=sci_arttext&pid=S1679-49742013000100016&lng=pt
• ³⁵
  Beaglehole R, Bonita R, Horton R, Ezzati M, Bhala N, Amuyunzu-Nyamongo M, et al. Measuring progress on NCDs: one goal and five targets. Lancet. 2012; 380 (9850): 1283-5. https://doi.org/10.1016/S0140-6736(12)61692-4
  » https://doi.org/10.1016/S0140-6736(12)61692-4
• ³⁶
  MacMahon S, Neal B, Rodgers A. Hypertension: time to move on. Lancet. 2005; 365: 1108-9. https://doi.org/10.1016/S0140-6736(05)71148-X
  » https://doi.org/10.1016/S0140-6736(05)71148-X
• ³⁷
  Damacena GI, Szwarcwald CL, Malta DC , Souza-Junior PRB, Vieira MLFP, Pereira CA, et al. O processo de desenvolvimento da Pesquisa Nacional de Saúde no Brasil, 2013. Epidemiol Serv Saúde [Internet]. 2015 Abr-Jun [citado em 3dez. 2017]; 24(2): 197-206. Disponível em: Disponível em: http://www.scielo.br/pdf/rsp/v47s2/0034-8910-rsp-47-00-2-0113.pdf
  » http://www.scielo.br/pdf/rsp/v47s2/0034-8910-rsp-47-00-2-0113.pdf
• ³⁸
  Nascimento LRl, Molina MCB, Faria CP, Cunha RS, Mill JG. Reprodutibilidade da pressão arterial medida no ELSA-Brasil com a monitorização pressórica de 24h. Rev Saúde Pública [Internet]. 2013 [citado em 1º dez. 2017]; 47 (Supl. 2): 113-21. Disponível em: Disponível em: http://www.scielo.br/pdf/rsp/v47s2/0034-8910-rsp-47-00-2-0113.pdf http://dx.doi.org/10.1590/S0034-8910.2013047003825
  » https://doi.org/10.1590/S0034-8910.2013047003825» http://www.scielo.br/pdf/rsp/v47s2/0034-8910-rsp-47-00-2-0113.pdf

• Financial support: none.

Publication Dates

• Publication in this collection
  29 Nov 2018
• Date of issue
  2018

History

• Received
  08 Dec 2017
• Reviewed
  04 Jan 2018
• Accepted
  08 Jan 2018