Arq Bras Cardiol abc Arquivos Brasileiros de Cardiologia Arq. Bras. Cardiol. 0066-782X 1678-4170 Sociedade Brasileira de Cardiologia - SBC WTZYFr6wqkp3Cz3SWTyd5fm S0066-782X2016004800014 10.5935/abc.20160153 Diretrizes 7th Brazilian Guideline of Arterial Hypertension: Chapter 3 - Clinical and Complementary Assessment Malachias MVB Póvoa RMS Nogueira AR Souza D Costa LS Magalhães ME 09 2016 107 3 Suppl 3 14 17 This is an Open Access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Clinical history and objectives

The major objectives of clinical and laboratory assessment are shown in Chart 1. Meeting those goals allows the correct AH diagnosis and prognosis, enabling choosing the better therapy for the patient.

Objectives of clinical and laboratory assessment
Confirmation of AH diagnosis by use of BP measurement
Identification of CVRF
Search for TOD, both subclinically and clinically manifested
Search for other associated diseases
Stratification of global CV risk
Assessment of evidence for suspected secondary AH
Clinical assessment Clinical history

Complete clinical history with questions about time since AH diagnosis, course and previous treatment should be obtained. Information on the family history is essential to increase the chance of an accurate diagnosis of primary AH.1 (GR: I; LE: B). The patient should be asked about specific RF for CVD, comorbidities, socioeconomic aspects and lifestyle,2 in addition to previous and current use of medications or other substances that can interfere with BP measurement and/or AH treatment. Similarly, evidence of a secondary cause of AH should be investigated.

 Physical examination

Blood pressure should be measured with proper technique (Chapter 2). Anthropometric data, such as weight, height [for body mass index (BMI) calculation], abdominal circumference (AC) and heart rate (HR), should be recorded. The normal values of AC and BMI are those recommended by the International Diabetes Federation (IDF) in 2006, and can vary according to ethnicity.3,4 (GR: IIa; LE: C).

Assessment (Chart 2) should comprise palpation and auscultation of the heart, carotid arteries and pulses, ankle-brachial index (ABI) measurement and retinal exam.

Clinical assessment
Physical Examination
BP measurement in both arms
Weight, height, BMI and HR
Abdominal circumference
Signs of TOD
Brain: motor or sensorial deficits
Retina: lesions on retinal exam
Arteries: pulse absence, asymmetry or reduction, skin lesions and murmurs
Heart: apical beat displaced, presence of S3 or S4, murmurs, arrhythmias, peripheral edema, pulmonary rales
Suggestive signs of secondary causes*
Cushingoid characteristics
Abdominal palpation: enlarged kidneys (polycystic kidney)
Abdominal or thoracic murmurs (renovascular, coarctation of the aorta, disease of the aorta or its branches)
Decreased femoral pulses (coarctation of the aorta, disease of the aorta or its branches)
Difference of BP between arms (coarctation of the aorta and subclavian stenosis)

For further information, see Chapter 12.

To calculate ABI, measure SBP in the arm and ankle, in both sides. An arm SBP/ankle SBP ratio greater than 0.90 is defined as normal, while PAD is defined as mild, if that ratio is 0.71-0.90, moderate, if 0.41-0.70, and severe, if 0.00-0.40.

 Basic laboratory investigation, assessment of subclinical and clinical target-organ damage

Complementary assessment is aimed at detecting subclinical or clinical TOD to better stratify CV risk. To stratify global CV risk, the classical RF (Chart 3), as well as the new ones identified, should be considered, although they have not been incorporated to the clinical scores of risk stratification.4,5

Additional cardiovascular risk factors
Age (men > 55 years, women > 65 years)
Smoking habit
Dyslipidemias: triglycerides > 150 mg/dL; LDL-C > 100 mg/dL; HDL-C < 40 mg/dL
DM
Family history of premature CVD: men < 55 years, women < 65 years

Of the new RF, the following stand out: fasting glycemia between 100 mg/dL and 125 mg/dL, abnormal glycated hemoglobin (HbA1c), abdominal obesity (metabolic syndrome - MS), PP (SBP-DBP) > 65 mm Hg in the elderly,5 history of preeclampsia, and family history of AH (for borderline hypertensive patients).

The laboratory assessment shown in Chart 4 should be part of the initial routine of all hypertensive patients.4

Routine tests for hypertensive patients
Urinalysis (GR: I; LE: C)
Serum potassium (GR: I; LE: C)
Fasting glycemia (GR: I; LE: C) and HbA1c (GR: I; LE: C)
Estimated glomerular filtration rate (GR: I; LE: B)
Serum creatinine (GR: I; LE: B)
Total cholesterol, HDL-C and serum triglycerides (GR: I; LE: C)*
Serum uric acid (GR: I; LE: C)
Conventional electrocardiogram (GR: I; LE: B)

LDL-C is calculated by use of the formula: LDL-C = total cholesterol - (HDL-C + triglycerides/5) (when triglycerides < 400 mg/dL).

The Cockroft-Gault formula is used to calculate creatinine clearance:6 CrCl (mL/min) = [140 - age] x weight (kg) /serum creatinine (mg/dL) x 72 for men; for women, multiply the result by 0.85.

To estimate glomerular filtration rate (GFR) use the CKD-EPI equation.7 The interpretation of the GFR values to classify CKD (stages) is performed according to the National Kidney Foundation (NKF).7

The CKD-EPI equation8 used to estimate GFR is available at: www.nefrocalc.net

GFR (mL/min/1.73m2:

Stage 1: ≥ 90 = normal or high;

Stage 2: 60-89 = mildly decreased;

Stage 3a: 45-59 = mildly to moderately decreased;

Stage 3b: 30-44 = moderately to severely decreased;

Stage 4: 15-29 = severely decreased;

Stage 5: < 15 = end-stage kidney disease (KDIGO).

Certain clinical situations, discussed in Chart 5, require more detailed complementary tests.

Tests recommended for certain populations
Test/assessment Recommended population and indication
Chest X ray Follow-up of patients with clinical suspicion of cardiac (GR: IIa; LE: C) and/or pulmonary impairment. Assessment of hypertensive individuals with aorta impairment when echocardiogram is not available.9
Echocardiogram More sensitive than ECG to diagnose LVH. Important in the assessment of the geometrical forms of left atrial hypertrophy and size, analysis of systolic and diastolic function. Consider LVH when left ventricular mass corrected for body surface is equal to or greater than 116 g/m2 for men and 96 g/m2 for women.10 Evidence of LVH on ECG or patients with clinical suspicion of HF (GR: I; LE: C).
Albuminuria Predicts fatal and non-fatal CV events. Normal values < 30 mg/24h (GR: I; LE: C).7,11 * Diabetic hypertensive patients, with MS or at least two RF.
Carotid US The carotid IMT and/or identification of plaques predict the occurrence of stroke and MI independently of other CVRF. IMT values > 0.9 mm, as well as the presence of atherosclerotic plaques, have been considered abnormal (GR: IIa; LE: B).12 Carotid murmur, CbVD signs or atherosclerotic disease in other sites.
Renal US or with Doppler Patients with abdominal masses or abdominal murmur (GR: IIa; LE: B).13
HbA1c - When fasting glycemia > 99 mg/dL - Family history of type 2 DM or previous diagnosis of type 2 DM and obesity (GR: IIa; LE: B).14
Exercise test - Suspicion of stable CAD, DM or family antecedent of CAD in patients with controlled BP (GR: IIa; LE: C).15
ABPM/HBPM - According to the conventional indication of those methods (GR: IIa; LE: B).
PWV “Standard” for assessing arterial stiffness. Values greater than 12 m/s are abnormal (GR: IIa; LE: B).16 - Intermediate-to-high-risk hypertensive patients.
MRI of the brain: to detect silent infarctions and micro hemorrhages (GR: IIa; LE: C).17 - Patients with cognitive disorders and dementia.

LVH: left ventricular hypertrophy; CV: cardiovascular; RF: risk factor; US: ultrasonography; IMT: intima-media thickness; MS: metabolic syndrome; MI: myocardial infarction; CVRF: cardiovascular risk factor; CbVD: cerebrovascular disease; HbA1c: glycated hemoglobin; DM: diabetes mellitus; CAD: coronary arterial disease; ABPM: ambulatory blood pressure monitoring; HBPM: home blood pressure monitoring; PWV: pulse wave velocity; MRI: magnetic resonance imaging.

Next figure shows the current classification and nomenclature for albuminuria and GFR according to KDIGO, 2012.7

Prognosis of CKD according to the category of GFR and albuminuria. Green: low risk; yellow: moderately increased risk; orange: high risk; red: extremely high risk.

References 1 Murabito JM, Nam BH, D'Agostino RB Sr, Lloyd-Jones DM, O'Donnell CJ, Wilson PW. Accuracy of offspring reports of parental cardiovascular disease history: the Framingham Offspring Study. Ann Intern Med. 2004;140(6):434-40. Murabito JM Nam BH D'Agostino RB Sr Lloyd-Jones DM O'Donnell CJ Wilson PW D'Agostino RB Sr.Lloyd-Jones DM.O'Donnell CJ.Wilson PW Accuracy of offspring reports of parental cardiovascular disease history: the Framingham Offspring Study Ann Intern Med 2004 140 6 434 440 2 International Diabetes Federation. (IDF). The IDF consensus worldwide definition of the metabolic syndrome. [Internet]. [Cited in 2016 May 15]. Available from: http://www.idf.org/webdata/docs/MetSyndrome_FINAL.pdf International Diabetes Federation The IDF consensus worldwide definition of the metabolic syndrome Internet 2016 May 15 Available from: http://www.idf.org/webdata/docs/MetSyndrome_FINAL.pdf 3 Simão AF, Precoma DB, Andrade JP, Correa FH, Saraiva JF, Oliveira GM, et al; Sociedade Brasileira de Cardiologia. [I Brazilian Guidelines for cardiovascular prevention]. Arq Bras Cardiol. 2013;101(6 Suppl 2):1-63. Erratum in: Arq Bras Cardiol. 2014;102(4):415. Simão AF Precoma DB Andrade JP Correa FH Saraiva JF Oliveira GM Sociedade Brasileira de Cardiologia ENT#091I Brazilian Guidelines for cardiovascular prevention I Brazilian Guidelines for cardiovascular prevention nullErratum in Arq Bras Cardiol. 2014;102(4):415. Arq Bras Cardiol 2013 101 6 Suppl 2 1 63 4 Mancia G, Fagard R, Narkiewicz K, Redón J, Zanchetti A, Böhm M, et al; Task Force Members. 2013 ESH/ESC guidelines for the management of arterial hypertension: the Task Force for the management of arterial hypertension of the European Society of Hypertension (ESH) and of the European Society of Cardiology (ESC) J Hypertens. 2013;31(7):1281-357. Mancia G Fagard R Narkiewicz K Redón J Zanchetti A Böhm M Task Force Members 2013 ESH/ESC guidelines for the management of arterial hypertension: the Task Force for the management of arterial hypertension of the European Society of Hypertension (ESH) and of the European Society of Cardiology (ESC) J Hypertens 2013 31 7 1281 1357 5 D'Agostino RB Sr, Vasan RS, Pencina MJ, Wolf PA, Cobain M, Massaro JM, et al. General cardiovascular risk profile for use in primary care: the Framingham Heart Study. Circulation. 2008;117(6):743-53. D'Agostino RB Sr Vasan RS Pencina MJ Wolf PA Cobain M Massaro JM General cardiovascular risk profile for use in primary care: the Framingham Heart Study Circulation 2008 117 6 743 753 6 Cockcroft DW, Gault MH. Prediction of creatinine clearance from serum creatinine. Nephron. 1976;16(1):31-41. Cockcroft DW Gault MH Prediction of creatinine clearance from serum creatinine Nephron 1976 16 1 31 41 7 Kidney Disease Improvement Global Outcomes (KDIGO). KDIGO 2012 Clinical practice guideline for the evaluation and management of chronic kidney disease. Kidney Int Suppl. 2013;3(1):1-150. Kidney Disease Improvement Global Outcomes KDIGO 2012 Clinical practice guideline for the evaluation and management of chronic kidney disease Kidney Int Suppl 2013 3 1 1 150 8 Matsushita K, Mahmodi BK, Woodward M, Emberson JR, Jafar TH, Jee SH, et al; Chronic Kidney Disease Prognosis Consortium. Comparison of risk prediction using the CKD-EPI equation and the MDRD study equation for estimated glomerular filtration rate. JAMA. 2012;307(18):1941-51. Matsushita K Mahmodi BK Woodward M Emberson JR Jafar TH Jee SH Chronic Kidney Disease Prognosis Consortium Comparison of risk prediction using the CKD-EPI equation and the MDRD study equation for estimated glomerular filtration rate JAMA 2012 307 18 1941 1951 9 Rayner BL, Goodman H, Opie LH. The Chest Radiograph. A useful investigationin the evaluation of hypertensive patients. Am J Hypertens. 2004;17(6):507-10. Rayner BL Goodman H Opie LH The Chest Radiograph. A useful investigationin the evaluation of hypertensive patients Am J Hypertens 2004 17 6 507 510 10 Lang RM, Bierig M, Devereux RB, Flachskampf FA, Foster E, Pellika PA, et al; Chamber Quantification Writing Group; American Society of Echocardiography's Guidelines and Standards Committee; European Association of Echocardiography. Recommendations for chamber quantifications. A report from the American Society of Echocardiography's Guidelines and Standards Committee and the chamber quantifications writing group, developed in conjunction with the European Association of Echocardiography, a branch of the European Society of Cardiology. J Am Soc Echocardiogr. 2005;18(12):1440-63. Lang RM Bierig M Devereux RB Flachskampf FA Foster E Pellika PA Chamber Quantification Writing GroupAmerican Society of Echocardiography's Guidelines and Standards CommitteeEuropean Association of Echocardiography Recommendations for chamber quantifications. A report from the American Society of Echocardiography's Guidelines and Standards Committee and the chamber quantifications writing group, developed in conjunction with the European Association of Echocardiography, a branch of the European Society of Cardiology J Am Soc Echocardiogr 2005 18 12 1440 1463 11 Tsioufis C, Kokkinos P, Macmanus C, Thomopoulos C, Faselis C, Doumas M, et al. Left ventricular hypertrophy as a determinant of renal outcome in patients with high cardiovascular risk. J Hypertens. 2010;28(11):2299-308. Tsioufis C Kokkinos P Macmanus C Thomopoulos C Faselis C Doumas M Left ventricular hypertrophy as a determinant of renal outcome in patients with high cardiovascular risk J Hypertens 2010 28 11 2299 2308 12 Nambi V, Chambless L, Folsom AR, He M, Hu Y, Mosley T, et al. Carotid intima-media thickness and presence or absence of plaque improves prediction of coronary heart disease risk: the ARIC (Atherosclerosis Risk In Communities) study. J Am Coll Cardiol. 2010;55(15):1600-7. Nambi V Chambless L Folsom AR He M Hu Y Mosley T Carotid intima-media thickness and presence or absence of plaque improves prediction of coronary heart disease risk: the ARIC (Atherosclerosis Risk In Communities) study J Am Coll Cardiol 2010 55 15 1600 1607 13 Vasbinder GB, Nelemans PJ, Kessels AG, Kroon AA, de Leeuw PW, van Engelshoven JM. Diagnostic tests for renal artery stenosis in patients suspected of having renovascular hypertension: a meta-analysis. Ann Intern Med. 2001;135(6):401-11. Vasbinder GB Nelemans PJ Kessels AG Kroon AA de Leeuw PW van Engelshoven JM Diagnostic tests for renal artery stenosis in patients suspected of having renovascular hypertension: a meta-analysis Ann Intern Med 2001 135 6 401 411 14 Selvin E, Steffes MW, Zhu H, Matsushita K, Wagenknecht L, Pankow J, et al. Glycated hemoglobin, diabetes, and cardiovascular risk in nondiabetic adults. N Engl J Med. 2010; 362(9):800-11. Selvin E Steffes MW Zhu H Matsushita K Wagenknecht L Pankow J Glycated hemoglobin, diabetes, and cardiovascular risk in nondiabetic adults N Engl J Med 2010 362 9 800 811 15 Chin D, Battistoni A, Tocci G, Passerini J, Parati G, Volpe M. Non-invasive diagnostic testing for coronary artery disease in the hypertensive patient: potential advantages of a risk estimation-based algorithm. Am J Hypertens. 2012;25(12):1226-35. Chin D Battistoni A Tocci G Passerini J Parati G Volpe M Non-invasive diagnostic testing for coronary artery disease in the hypertensive patient: potential advantages of a risk estimation-based algorithm Am J Hypertens 2012 25 12 1226 1235 16 Safar ME, Levy BI, Struijker-Boudier H. Current perspectives on arterial stiffness and pulse pressure in hypertension and cardiovascular diseases. Circulation. 2003;107(22):2864-9. Safar ME Levy BI Struijker-Boudier H Current perspectives on arterial stiffness and pulse pressure in hypertension and cardiovascular diseases Circulation 2003 107 22 2864 2869 17 de Leeuw FE, de Groot JC, Oudkerk M, Witteman JC, Hofman A, van Gijn J, et al. Hypertension and cerebral white matter lesions in a prospective cohort study. Brain. 2002;125(Pt 4):765-72. de Leeuw FE de Groot JC Oudkerk M Witteman JC Hofman A van Gijn J Hypertension and cerebral white matter lesions in a prospective cohort study Brain 2002 125 4 765 772 7ª Diretriz Brasileira de Hipertensão Arterial: Capítulo 3 - Avaliação Clínica e Complementar Malachias MVB Póvoa RMS Nogueira AR Souza D Costa LS Magalhães ME História clínica e objetivos

Os principais objetivos da avaliação clínica e laboratorial são apresentados no Quadro 1. Atingir essas metas permite o diagnóstico correto da HA e seu prognóstico, possibilitando a escolha da melhor terapêutica para o paciente.

Objetivos da avaliação clínica e laboratorial
Confirmação do diagnóstico de HA por medição da PA
Identificação dos FRCV
Pesquisa de LOAs, sejam elas subclínicas ou clinicamente manifestas
Pesquisa da presença de outras doenças associadas
Estratificação do risco CV global
Avaliação de indícios para a suspeita de HA secundária
Avaliação clínica Anamnese

Deve-se obter história clínica completa com perguntas sobre o tempo de diagnóstico, evolução e tratamento prévio. As informações sobre a história familiar são fundamentais para aumentar a certeza do diagnóstico de HA primária.1 (GR: I; NE: B). O paciente deve ser interrogado sobre FR específicos para DCV, comorbidades, aspectos socioeconômicos e estilo de vida,2 além do uso prévio e atual de medicamentos ou outras substâncias que possam interferir na medição da PA e/ou no tratamento da HA. Da mesma forma, devem ser pesquisados indícios que sugiram uma causa secundária para a HA.

 Exame físico

A PA deve ser medida com técnica adequada (ver Capítulo 2). Dados antropométricos, como peso, altura (para cálculo do índice de massa corporal [IMC]), circunferência abdominal (CA) e frequência cardíaca (FC), devem ser registrados. Os valores de normalidade da CA e do IMC são aqueles recomendados pela IDF de 2006, podendo variar de acordo com a origem étnica.3,4 (GR: IIa; NE: C).

A avaliação (Quadro 2) deve englobar palpação e ausculta do coração, carótidas e pulsos, medida do índice tornozelo-braquial (ITB) e realização da fundoscopia.

Avaliação clínica
Exame Físico
Medição da PA nos dois braços
Peso, altura, IMC e FC
CA
Sinais de LOA
Cérebro: déficits motores ou sensoriais
Retina: lesões à fundoscopia
Artérias: ausência de pulsos, assimetrias ou reduções, lesões cutâneas, sopros
Coração: desvio do ictus, presença de B3 ou B4, sopros, arritmias, edema periférico, crepitações pulmonares
Sinais que sugerem causas secundárias*
Características cushingóides
Palpação abdominal: rins aumentados (rim policístico)
Sopros abdominais ou torácicos (renovascular, coartação de aorta, doença da aorta ou ramos)
Pulsos femorais diminuídos (coartação de aorta, doença da aorta ou ramos)
Diferença da PA nos braços (coartação de aorta e estenose de subclávia)

Para maior detalhamento, consulte Capítulo 12.

Para o cálculo do ITB, utiliza-se a medição da PAS no braço e no tornozelo, em ambos os lados. Define-se como normal uma relação PAS braço/PAS tornozelo acima de 0,90, definindo-se a presença de DAP como: leve, se a relação é 0,71-0,90; moderada, 0,41-0,70; e grave, 0,00-0,40.

 Investigação laboratorial básica, avaliação de lesões subclínicas e clínicas em órgãos-alvo

A avaliação complementar tem como objetivo detectar lesões subclínicas ou clínicas em órgãos-alvo, no sentido de melhorar a estratificação de risco CV. Para a estratificação do risco CV global, deverão ser levados em conta os FR clássicos (Quadro 3), assim como novos FR que foram identificados, apesar de ainda não incorporados nos escores clínicos de estratificação de risco.4,5

Fatores de risco cardiovascular adicionais
Idade (homem > 55 e mulheres > 65 anos)
Tabagismo
Dislipidemias: triglicérides > 150 mg/dl; LDL-C > 100 mg/dl; HDL-C < 40 mg/dl
DM
História familiar prematura de DCV:
homens < 55 anos e mulheres < 65 anos

Entre os novos FR destacam-se glicemia de jejum entre 100 mg/dL e 125 mg/dL, hemoglobina glicada (HbA1c) anormal, obesidade abdominal (síndrome metabólica), PP (PAS-PAD) > 65 mmHg em idosos,5 história de pré-eclâmpsia e história familiar de HA (em hipertensos limítrofes).

A avaliação laboratorial em seguida (Quadro 4) deve fazer parte da rotina inicial de todo paciente hipertenso.4

Exames de rotina para o paciente hipertenso
Análise de urina (GR: I; NE: C)
Potássio plasmático (GR: I; NE: C)
Glicemia de jejum (GR: I; NE: C) e HbA1c (GR: I; NE: C)
Ritmo de filtração glomerular estimado (RFG-e) (GR: I; NE: B)
Creatinina plasmática (GR: I; NE: B)
Colesterol total, HDL-C e triglicérides plasmáticos (GR: I; NE: C)*
Ácido úrico plasmático (GR: I; NE: C)
Eletrocardiograma convencional (GR: I; NE: B)

O LDL-C é calculado pela fórmula: LDL-C = colesterol total - (HDL-C + triglicérides/5) (quando a dosagem de triglicérides for menor que 400 mg/dL).

Para o cálculo da depuração de creatinina, utiliza-se a fórmula de Cockroft-Gault:6 RFG-e (ml/min) = [140 - idade] x peso (kg) /creatinina plasmática (mg/ dL) x 72 para homens; para mulheres, multiplicar o resultado por 0,85.

Para o cálculo do ritmo de filtração glomerular estimado (RFG-e) preconiza-se a utilização da fórmula CKD-EPI.7 A interpretação dos valores (estágios) para classificação de DRC é feita de acordo com a National Kidney Foundation (NKF).7

RFG-e calculado pela fórmula do CKD-EPI,8 que pode ser acessada em: www.nefrocalc.net

RFG-e (ml/min/1,73m2)

Estágio 1: ≥ 90 = normal ou alto;

Estágio 2: 60-89 = levemente diminuído;

Estágio 3a: 45-59 = leve a moderadamente diminuído;

Estágio 3b: 30-44 = moderada a extremamente diminuído;

Estágio 4: 15-29 = extremamente diminuído;

Estágio 5: < 15= doença renal terminal (KDIGO).

Prognóstico de DRC de acordo com a categoria do RFG e a albuminúria. Verde: baixo risco; Amarelo: risco moderadamente aumentado; Laranja: risco alto; Vermelho: risco muito alto.

Em algumas situações clínicas, há indicação de exames complementares mais detalhados, discutidos no Quadro 5.

Exames recomendados em populações indicadas
Exame/ avaliação População recomendada e indicação
Radiografia de tórax Acompanhamento de pacientes com suspeita clínica de comprometimento cardíaco (GR: IIa; NE: C) e/ou pulmonar. Avaliação de hipertensos com comprometimento da aorta quando o ecocardiograma não está disponível.9
Ecocardiograma Mais sensível do que o ECG no diagnóstico de HVE. Agrega valor na avaliação das formas geométricas de hipertrofia e tamanho do átrio esquerdo, análise da função sistólica e diastólica. Considera-se HVE quando a massa ventricular esquerda indexada para a superfície corpórea é igual ou superior a 116 g/m2 em homens e 96 g/m2 em mulheres.10 Presença de indícios de HVE ao ECG ou pacientes com suspeita clínica de IC (GR: I; NE: C).
Albuminúria Mostrou prever eventos CV fatais e não fatais. Valores normais < 30 mg/24h (GR: I; NE: C).7,11 * Pacientes hipertensos diabéticos, com síndrome metabólica ou com dois ou mais FR.
US das carótidas A medida da EMI das carótidas e/ou a identificação de placas predizem a ocorrência de AVE e IM independente de outros FRCV. Valores da EMI > 0,9 mm têm sido considerados como anormais, assim como o encontro de placas ateroscleróticas (GR: IIa; NE: B).12 Presença de sopro carotídeo, sinais de DCbV ou presença de doença aterosclerótica em outros territórios.
US renal ou com Doppler Pacientes com massas abdominais ou sopro abdominal (GR: IIa; NE: B).13
HbA1c - Quando glicemia de jejum > 99 mg/dl - História familiar de DM tipo 2 ou diagnóstico prévio de DM tipo 2 e obesidade (GR: IIa; NE: B).14
Teste ergométrico - Suspeita de DAC estável, DM ou antecedente familiar para DAC em pacientes com PA controlada (GR: IIa; NE: C).15
MAPA/medidas residenciais de pressão arterial. - Segue a indicação convencional dos métodos (GR: IIa; NE: B).
VOP Considerado “padrão” para avaliação da rigidez arterial. Valores acima de 12m/s são considerados anormais (GR: IIa; NE: B).16 - Hipertensos de médio e alto risco.
RNM do cérebro: para detecção de infartos silenciosos e micro hemorragias (GR: IIa; NE: C).17 - Pacientes com distúrbios cognitivos e demência

HVE: hipertrofia ventricular esquerda; CV: cardiovascular; FR: fator de risco; US: ultrassonografia; EMI: espessura mediointimal; AVE: acidente vascular encefálico; IM: infarto do miocárdio; FRCV: fator de risco cardiovascular; DCbV: doença cerebrovascular; HbA1c: hemoglobina glicada; DM: diabetes figmelito; DAC: doença arterial coronariana; MAPA: monitorização ambulatorial da pressão arterial; VOP: velocidade da onda de pulso; RNM: ressonância nuclear magnética.

A figura a seguir apresenta a classificação e a nomenclatura atual para albuminúria e RFG de acordo com KDIGO, 2012.7