2016;107(3 Suppl 3) – ABC CARDIOL

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7th Brazilian Guideline of Arterial Hypertension: Chapter 9 – Arterial Hypertension in pregnancy

MVB Malachias et al. CEP Figueiredo N Sass IC Antonello … MR Torloni MRFL Bortolotto

Epidemiology

The hypertensive syndromes of pregnancy cause expressive maternal and fetal morbidity and mortality. There is no accurate information on the incidence of preeclampsia (PE), but it is estimated to affect 4% of gestations. In Brazil, the incidence of PE is 1.5 %, while the incidence of eclampsia is 0.6%. More developed areas have an incidence of eclampsia of 0.2%, with a maternal death rate of 0.8%, while for less favored regions those indices are 8.1% and 22%, respectively. A population-based study shows AH in 7.5% of the gestations in Brazil, with 2.3% of PE and 0.5% of superimposed PE. Arterial hypertension during pregnancy accounts for 20% to 25% of all causes of maternal death, and data from SUS show a trend towards stagnation.

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7th Brazilian Guideline of Arterial Hypertension: Chapter 7 – Pharmacological Treatment

MVB Malachias et al. PCV Paulo César Veiga Jardim FA Almeida E Lima Júnior GS Feitosa

Objectives

The treatment of AH is ultimately aimed at reducing CV morbidity and mortality.^– Clinical studies of outcome have provided scientific evidence of the benefits of the use of diuretics (DIUs) (GR: I; LE: A),^,^– beta-blockers (BBs) (GR: I; LE: A),^–^, calcium-channel blockers (CCBs) (GR: I; LE: A),^,^,^,^– angiotensin-converting-enzyme inhibitors (ACEIs) (GR: I; LE: A)^,^,^,^,^,^– and angiotensin-receptor blockers (ARBs) (GR: I; LE: A).^,^,^– It is worth noting that most of those studies have used an association of drugs. Based on the information available, the protection observed does not depend on the type of drug used, but mainly on BP reduction.^,^–^, Recent meta-analyses have reported that the benefits obtained from BB are smaller^,^,^– as compared to those provided by the other drug groups, and, thus, BBs should be reserved for specific situations. Regarding alpha-blockers and direct vasodilators, there is no effective information on the outcomes of morbidity and mortality. Regarding direct renin inhibitors, only one study of outcome in diabetic patients has been early interrupted due to lack of benefits and possible harm. The higher the CV risk, the greater the benefits, which occur even for small BP elevations.^–^,^,^,

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7th Brazilian Guideline of Arterial Hypertension: Chapter 13 – Resistant Arterial Hypertension

MVB Malachias et al. CIS Rodrigues E Muxfeldt GF Salles … H Moreno Júnior M Gus

Definition and epidemiology

Resistant AH (RAH) is defined as uncontrolled office BP despite the use of at least three antihypertensive drugs at appropriate doses, including preferably one DIU, or as controlled BP using at least four drugs.^– Because it does not include the systematic assessment of therapy and adherence, that situation is better defined as apparent RAH (pseudoresistance). Identification of true RAH is fundamental to establish specific approaches. Population-based studies have estimated a 12% prevalence in the hypertensive population. In Brazil, the ReHOT study assesses prevalence and therapeutic choice. Refractory hypertension is defined as uncontrolled BP using at least five antihypertensive drugs, and corresponds to 3.6% of resistant hypertensive individuals. To diagnose RAH, ABPM is required, as well as systematic assessment of adherence. (GR: I; LE: C).

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7th Brazilian Guideline of Arterial Hypertension: Chapter 4 – Cardiovascular Risk Stratification

MVB Malachias et al. MFT Neves D Mion Júnior GV Silva … HF Lopes W Oigman

Introduction

The global CV risk should be assessed in each hypertensive individual, because it aids the professionals in therapeutic decision-making and allows prognostic analysis. The identification of hypertensive individuals prone to CV complications, especially myocardial infarction (MI) and stroke, is fundamental to a more aggressive therapy. Several algorithms and risk scores based on population studies were created in past decades, but, considering the lack of Brazilian data for a more accurate assessment of CV risk in the Brazilian population, the use of one single risk score should be avoided to support therapeutic decisions. Multifactorial models of risk stratification can be used for a more accurate individual risk classification.

Informing patients about their RF can improve the efficacy of pharmacological and non-pharmacological measures to reduce global risk. In addition, estimating indicators and using aging-related terms, such as “vascular age” or “cardiometabolic age”, can aid in the strategy to change the RF.^, See below some electronic addresses to estimate the vascular or cardiometabolic age recommended by American, Canadian and British societies.^–

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7th Brazilian Guideline of Arterial Hypertension: Chapter 2 – Diagnosis and Classification

MVB Malachias et al. MAM Gomes F Nobre A Alessi … AD Feitosa EB Coelho

Introduction

The initial assessment of a patient with systemic arterial hypertension (SAH) comprises diagnostic confirmation, suspicion and identification of the secondary cause, and assessment of CV risks. In addition, target-organ damage (TOD) and associated diseases should be investigated. Such assessment comprises BP measurement in the office and/or outside the office, by use of proper technique and validated equipment, medical history (personal and family), physical examination and clinical and laboratory investigation.

General assessments directed to all, and, in some cases, complementary assessments only for specific groups are proposed.

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7th Brazilian Guideline of Arterial Hypertension: Chapter 5 – Therapeutic Decision and Targets

MVB Malachias et al. AA Andrea Araujo Brandão S Kaiser O Moreira Filho

Introduction

The therapeutic management of elevated BP includes non-pharmacological measures and the use of antihypertensive drugs to reduce BP, protect target organs and prevent CV and renal outcomes.^– Non-pharmacological measures have proven efficient to reduce BP, although limited by medium- and long-term lack of adherence to treatment. A systematic review of studies with a minimum duration of 12-24 months, combining dietary interventions and moderate-to-high-intensity physical activity in patients using or not medications, has revealed a reduction in SBP and DBP for < 12 months of -4.47 (-7.91 to -1.04) mm Hg and -1.10 (-2.39 to 0.19) mm Hg, respectively. For 12 to 24 months, the reductions were -2.29 (-3.81 to -0.76) mm Hg and -1.00 (-3.22 to 1.22) mm Hg in SBP and DBP, respectively. The direct impact of those measures on the risk of CV outcomes is uncertain, the studies are small and short, and the effects on other RF could contribute to CV protection.

On the other hand, results of randomized placebo-controlled clinical trials on the use of antihypertensive drugs for hypertensive individuals have clearly shown a significant reduction in CV mortality, stroke, MI and HF. It is worth noting that most of those studies have assessed individuals aged ≥ 55 years, at high CV risk and for a follow-up period of 3 to 6 years, hindering, thus, the extrapolation of those benefits for long-term treatment and patients with other characteristics.

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7th Brazilian Guideline of Arterial Hypertension: Chapter 10 – Hypertension in Children and Adolescents

MVB Malachias et al. V Koch FC Colombo ACS Silva … ICB Guimarães PK Nogueira

Epidemiological context and importance of hypertension in pediatrics

Arterial hypertension was identified as the major source of combined mortality and morbidity, representing 7% of global disability-adjusted life years. The adoption of the BP definitions and normalization of the “National High Blood Pressure Education Program” (NHBPEP) 2004 has standardized the BP classification in the pediatric population. The percentage of children and adolescents diagnosed with AH is estimated to have doubled in the past two decades. The current prevalence of AH in the pediatric population is around 3% to 5%,^– while that of PH reaches 10% to 15%,^,^,^, and such values are mainly attributed to the large increase in childhood obesity. The etiology of pediatric AH can be either secondary, most often associated with nephropathies, or primary, attributed to genetic causes with environmental influence, predominating in adolescents.

Pediatric AH is usually asymptomatic, but as many as 40% of hypertensive children have LVH at the initial diagnosis of AH. Although oligosymptomatic in childhood, LVH is a precursor of arrhythmias and HF in adults. In addition, pediatric AH is associated with the development of other changes in target organs, such as increased carotid IMT, arterial compliance reduction, and retinal arteriolar narrowing. Early diagnosis and treatment of childhood AH are associated with a lower risk for AH and for increased carotid atheromatosis in adult life. Therefore, periodical BP measurements in children and adolescents are recommended, even contradicting the U.S. Preventive Services Task Force’s suggestion, which considers the evidence of benefits of primary AH screening in asymptomatic children and adolescents insufficient to prevent CVD in childhood or adulthood.

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7th Brazilian Guideline of Arterial Hypertension: Chapter 12 – Secondary Arterial Hypertension

MVB Malachias et al. LA Bortolotto LF Drager FAO Borelli … LAD Lotaif LC Martins

Introduction

Secondary AH has a prevalence of 3-5%. The treatment of the cause can cure AH or improve BP control. shows the situations in which secondary causes of AH should be investigated.

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7th Brazilian Guideline of Arterial Hypertension: Presentation

Introduction

On behalf of the Brazilian Society of Cardiology, Brazilian Society of Hypertension and Brazilian Society of Nephrology, I present to you the 7^th Brazilian Guideline of Arterial Hypertension, result of the joint work of an expert team of renowned professionals appointed by their respective medical societies.

The production of this new guideline was necessary to update the knowledge accumulated over the past years, considering the Brazilian reality and clinical practice. The guidance and recommendations contained in this document reflect the evidence of the effectiveness of the interventions. The present text does not deal specifically with cost-effectiveness analyses. The major objective of the medical societies and authors is to guide health professionals on the preventive measures and care for individuals with arterial hypertension, aiming at reducing the complications of arterial hypertension, considered the major risk factor for cardiovascular disease.

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7th Brazilian Guideline of Arterial Hypertension: Chapter 3 – Clinical and Complementary Assessment

MVB Malachias et al. RMS Póvoa AR Nogueira D Souza … LS Costa ME Magalhães

Clinical history and objectives

The major objectives of clinical and laboratory assessment are shown in . Meeting those goals allows the correct AH diagnosis and prognosis, enabling choosing the better therapy for the patient.

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7th Brazilian Guideline of Arterial Hypertension: Chapter 11 – Arterial Hypertension in the elderly

MVB Malachias et al. S Ferreira Filho WKSB Souza JM Ribeiro … RD Miranda TSV Jardim

Arterial hypertension is the most common chronic noncommunicable disease among the elderly. Its prevalence increases progressively with aging, AH being considered the major modifiable CVRF in the geriatric population. From the chronological viewpoint, elderly are individuals aged 65 years and older, living in developed countries, or individuals aged 60 years and older, living in developing countries. Within that age group, the very elderly are those in their eighth decade of life.

There is a direct and linear relationship between BP and age, the prevalence of AH being greater than 60% in the age group older than 65 years. The Framingham Study has reported that 90% of the individuals with normal BP levels up to the age of 55 years will develop AH throughout life. In addition, that study has shown that both SBP and DBP, in both sexes, increase up to the age of 60 years, when DBP begins to decrease. Systolic BP, however, continues to increase linearly. The high prevalence of other concomitant RFs in the elderly and the consequent increase in the rate of CV events, in addition to the presence of comorbidities, compound the relevance of AH with aging.

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7th Brazilian Guideline of Arterial Hypertension: Chapter 6 – Non-pharmacological treatment

MVB Malachias et al. RJS Franco CLM Forjaz AMG Pierin … MMG Gowdak MRST Klein V Matsudo

Introduction

Non-pharmacological treatment (NPT) of AH involves body weight control, nutritional measures, practice of physical activities, smoking cessation and stress control. This chapter approaches the effects and recommendations of such measures.

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7th Brazilian Guideline of Arterial Hypertension: Chapter 8 – Hypertension and Associated Clinical Conditions

MVB Malachias et al. C Amodeo RB Paula AC Cordeiro Júnior … LBNC Magalhães LC Bodanese

Diabetes mellitus

The association of AH and DM doubles the CV risk and has increased the AH prevalence, which is related to the elevation in overweight and obesity rates, as well as the increase in the elderly population. The incidence of AH in type 1 diabetic patients increases from 5%, at the age of 10 years, to 33%, at the age of 20 years, and to 70%, at the age of 40 years. There is a strict relationship between the development of AH and the presence of albuminuria in that population. That increase in the AH incidence can reach 75-80% in patients with diabetic kidney disease. Approximately 40% of patients with a recent diagnosis of DM have AH. In approximately 50% of type 2 diabetic patients, AH occurs before the development of albuminuria. All diabetic hypertensives are at high CV risk. In addition to all complementary tests recommended for hypertensives, diabetic patients require the search for urine albumin excretion, fundoscopic eye exam and assessment of probable postural hypotension, which can characterize the presence of autonomic nervous system dysfunction.

The BP targets to be achieved are still controversial. However, there is recent consensus on a BP target < 130/80 mm Hg. (GR: IIb; LE: B). For the NPT of AH in diabetic individuals, all recommendations expressed in Chapter 6 apply. The therapeutic choice should be based on drug efficacy and tolerability. Considering that all diabetic patients are at high CV risk, the initial treatment includes the association of at least two drugs of different classes. In diabetic hypertensives without nephropathy, all antihypertensive drugs can be used. In the presence of diabetic nephropathy, however, RAAS inhibitors are preferred. (GR: I; LE: A). Simultaneous use of ACEI and ARB should be avoided because of the risk of complications.^, Although worsening insulin resistance, BB are useful for BP control in diabetic patients, especially when used in combinations to treat hypertensives with CAD or HF.

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7th Brazilian Guideline of Arterial Hypertension: Chapter 1 – Concept, Epidemiology and Primary Prevention

MVB Malachias et al. FL Plavnik CA Machado D Malta … LCN Scala S Fuchs

Concept

Arterial hypertension (AH) is a multifactorial clinical condition characterized by sustained elevation of blood pressure (BP) levels ≥ 140 and/or 90 mm Hg. It is often associated with metabolic disorders, functional and/or structural changes in target organs, being worsened by the presence of other risk factors (RF), such as dyslipidemia, abdominal obesity, glucose intolerance and diabetes mellitus (DM).^, It is independently associated with events such as sudden death, stroke, acute myocardial infarction (AMI), heart failure (HF), peripheral arterial disease (PAD) and fatal and non-fatal chronic kidney disease (CKD).^–

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7th Brazilian Guideline of Arterial Hypertension: Chapter 14 – Hypertensive Crisis

MVB Malachias et al. ECD Barbosa JFV Martim GBA Rosito … JY Toledo O Passarelli Júnior

Definition

The terms HU and HE were proposed as an operational classification of HC in 1993 by the V Joint National Committee on Detection Evaluation and Treatment of High Blood Pressure. The HUs are symptomatic clinical situations in which there is significant BP elevation (arbitrarily defined as DBP ≥ 120 mm Hg) without acute and progressive TOD.^, The HEs are symptomatic clinical situations in which there is significant BP elevation (arbitrarily defined as DBP ≥ 120 mm Hg) with acute and progressive TOD.^,

Patients complaining from headache, atypical chest pain, dyspnea, acute psychological stress, and panic syndrome associated with high BP levels characterize neither HU nor HE, but rather a pseudo hypertensive crisis. Treatment comprises the optimization of antihypertensive drugs and raising awareness about treatment adherence.

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