Arq Bras Cardiol abc Arquivos Brasileiros de Cardiologia Arq. Bras. Cardiol. 0066-782X 1678-4170 Sociedade Brasileira de Cardiologia - SBC sfxJ3Qjn5FvL5kC5R4QFKKM S0066-782X2016004800030 10.5935/abc.20160156 Diretrizes 7th Brazilian Guideline of Arterial Hypertension: Chapter 6 - Non-pharmacological treatment Malachias MVB Franco RJS Forjaz CLM Pierin AMG Gowdak MMG Klein MRST Matsudo V 09 2016 107 3 Suppl 3 30 34 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. 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.

Body weight

The increase in body weight is directly related to BP increase in adults1 and children.2 The relationship between overweight and BP changes can be observed from as early as 8 years of age.2 In addition, the increase in visceral fat is considered a risk factor for AH.2,3 Reductions in body weight and AC correlate with BP reductions and metabolic improvement (Table 1).4 (GR: I; LE: A).

Changes in body weight and in dietary ingestion and their effects on BP
Measure Approximate SBP/DBP reduction Recommendation
Body weight control 20%-30% BP decrease for every 5% of weight loss1 Maintain BMI < 25 kg/m2 up to 65 years of age. Maintain BMI < 27 kg/m2 after the age of 65 years. Maintain AC < 80 cm in women and < 94 cm in men
Dietary pattern Reduction of 6.7/3.5 mm Hg35 Adopt DASH diet
Sodium intake restriction Reduction of 2-7 mm Hg in SBP and 1-3 mm Hg in DBP with progressive reduction of 2.4-1.5 g of sodium/day, respectively12 Limit daily sodium intake to 2.0 g (5 g of sodium chloride)
Moderation in alcohol intake Reduction of 3.31/2.04 mm Hg with the reduction from 3-6 to 1-2 doses/day34 Limit daily alcohol intake to 1 dose for women and low-weight individuals, and 2 doses for men

BMI: body mass index; AC: abdominal circumference; SBP: systolic blood pressure; DBP: diastolic blood pressure.

* One dose contains 14g of ethanol, and is equivalent to 350 mL of beer, 150 mL of wine, and 45 mL of distilled beverage.36

Nutritional aspects Dietary pattern

The success of AH treatment with nutritional measures depends on the adoption of a healthy and sustainable dietary plan.5 The use of radical diets results in treatment dropout.6 The focus on one single nutrient or food has given space to the total dietary pattern analysis, which allows assessing the synergism between nutrients/foods.7

The DASH (Dietary Approaches to Stop Hypertension) diet emphasizes the consumption of fruits, vegetables and low-fat dairy products, includes the ingestion of whole cereals, chicken, fish and nuts, and recommends a reduction in the ingestion of red meat, candies and sugary beverages. That diet is rich in potassium, calcium, magnesium and fibers, and contains reduced amounts of cholesterol and of total and saturated fat. Adopting that dietary pattern reduces BP.8,9 (GR: I; LE: A).

The Mediterranean diet is rich in fruits, vegetables and whole cereals, but has large amounts of olive oil (source of monounsaturated fats) and includes the consumption of fish and nuts, in addition to the moderate ingestion of wine.7 Despite the limited number of studies, the adoption of the Mediterranean diet seems to low BP.10 (GR: IIa; LE: B).

Vegetarian diets recommend the consumption of foods of plant origin, specially fruits, vegetables, grains and pulses. They exclude or rarely include meats, and some include dairy products, eggs and fish. They have been associated with lower BP levels.11 (GR: IIa; LE: B).

 Reduction in sodium intake

The increase in sodium intake is related to BP elevation.12 However, the impact of sodium intake on CV health is controversial. Some studies have suggested that very low sodium intake increases the risk for CVD, while others argue that the decrease in sodium intake decreases the CV risk,13 and that benefit is even higher with marked restriction of sodium intake.14

Limiting daily sodium intake to 2.0 g is associated with BP reduction.15 The Brazilian mean sodium intake is 11.4 g/day.16 (GR: IIa; LE: B).

 Unsaturated fatty acids

Omega-3 fatty acids originating from fish oils (eicosapentaenoic and docosahexaenoic acids, EPA and DHA, respectively) are associated with a mild reduction in BP. Recent studies have indicated that the EPA+DHA ingestion ≥ 2 g/day reduces BP, and lower doses (1-2 g/day) reduce only SBP.17 (GR: IIa; LE: B).

In addition, the consumption of monounsaturated fatty acids has been associated with BP reduction.18 (GR: IIb; LE: B).

 Fibers

Soluble fibers are present in oat bran, pectin (fruits) and starch (oat, barley and pulses: beans, chickpeas, lentils and green peas), while insoluble fibers are present in cellulose (wheat), hemicellulose (whole grains) and lignin (vegetables). The ingestion of fibers, mainly beta-glucan originating from oat and barley, causes a mild decrease in BP.19 (GR: IIb; LE: B).

 Nuts

The consumption of nuts helps control several CVRF, but few studies have related that consumption to BP reduction.20 A meta-analysis has concluded that the ingestion of different types of nuts could reduce BP.21 (GR: IIb; LE: B).

 Dairy products and vitamin D

There is evidence that the ingestion of dairy products, especially low-fat ones, reduces BP.22 Milk contains several components, such as calcium, potassium and bioactive peptides, that can decrease BP.23 (GR: IIb; LE: B).

Some studies have shown that low serum levels of vitamin D are associated with a greater incidence of AH.24 However, studies on vitamin D supplementation have failed to show BP reduction.25 (GR: III; LE: B).

 Garlic

Garlic has innumerous bioactive components, such as allicin (found in raw garlic) and s-allyl cysteine (found in processed garlic). Mild BP decrease has been reported with supplementation with several forms of garlic.26,27 (GR: IIb; LE: B).

 Coffee and green tea

Coffee, although rich in caffeine, substance with an acute pressor effect, has polyphenols that can favor BP reduction.28 Recent studies have suggested that coffee intake at usual doses is associated with neither higher AH incidence nor BP elevation.29 Coffee intake should not exceed low to moderate amounts. (GR: IIa; LE: B).

In addition to being rich in polyphenols, especially catechins, green tea has caffeine. There is no consensus, but some studies have suggested that green tea might reduce BP when consumed at low doses, because greater doses have a higher caffeine content and can increase BP.30 Green tea consumption is recommended at low doses. (GR: IIb; LE: B).

 Bitter chocolate

Chocolate at least 70% cacao can cause mild BP reduction, because of its high polyphenol content.31 (GR: IIb; LE: B).

 Alcohol

Usual alcohol consumption increases BP linearly, and its excessive consumption associates with an increase in the AH incidence.32,33 A 10-g/day increment in alcohol ingestion is estimated to increase BP by 1 mm Hg,32 and a decrease in that consumption reduces BP.3 Moderation in alcohol intake is recommended. (GR: I; LE: B).

 Physical activity/physical exercise

Physical activity refers to any body movement that increases energy expenditure, such as street walking, stair climbing, domestic chores, and recreational activities. The term 'physical exercise' refers to planned, structured, repetitive and purposeful physical activity. In addition, sedentary lifestyle, measured by the time spent sitting, has CV health implications (Tables 2 and 3).

Evidence of physical activity and physical exercise for BP reduction
Measure Approximate SBP/DBP reduction
Daily physical activity 3.6/5.4 mm Hg42
Aerobic exercise 2.1/1.7 in prehypertensives8.3/5.2 mm Hg in hypertensives43
Dynamic resistance exercise 4.0/3.8 mm Hg in prehypertensivesNo reduction in hypertensives43
Recommendations regarding physical activity and physical exercise
For all hypertensives - Population recommendation – Physical activity practice
Moderate, continuous (1 x 30 min) or cumulative (2 x 15 min or 3 x 10 min) physical activity: at least 30 min/day, 5 - 7 days/week.
For greater benefits - Individual recommendation - Physical exercise
Aerobic training complemented with resistance training
Aerobic training
Several modalities: walking, running, dancing, swimming.
At least 3 times/week. Ideally: 5 times/week.
Minimum of 30 min. Ideally: 40 - 50 min.
Moderate intensity defined as:
1) Higher intensity, but still being able to talk (without being breathless)
2) Feeling mildly to moderately tired
3) Maintain training HR calculated as follows: Training HR = (maximum HR – resting HR) x % + resting HR where:maximum HR: obtained either on a maximum exercise test, using the regular medications, or by calculating maximum HR estimated according to age (220 - age). The formula cannot be applied to hypertensives with heart disease or on beta-blockers or nondihydropyridine calcium channel blockers. Resting HR: measured after 5-minute resting lying down. %: use 50% as lower threshold, and 70% as upper threshold.
Resistance training
2 - 3 times/week.
8 - 10 exercises for the large muscle groups, prioritizing unilateral execution, when possible.
1 - 3 sets
10 - 15 repetitions up to moderate fatigue (reduction in the velocity of movement and tendency towards apnea)
Long passive pauses - 90 - 120 s
Physical inactivity/activity

Physical inactivity is "a major public health problem",37 because it is the most prevalent RF and the second cause of death worldwide.38 Survival is shorter among individuals who spend most of their time sitting than among those who do not.39 There is a direct relationship between the time spent sitting or watching TV and BP.40 To reduce the sitting time and to stand up for at least 5 minutes for every 30 minutes sited are recommended. (GR: IIb; LE: B).

Regular physical activity can benefit both AH prevention and treatment, and reduces CV morbidity and mortality. Active individuals have a 30% lower risk of developing AH as compared to those with a sedentary lifestyle.41 The increase in daily physical activity reduces BP.42 Physical activity practice should be encouraged for the entire population, and no previous test is required. The individual should be instructed to seek a doctor if any discomfort occurs during the physical activity practice. (GR: I; LE: A).

 Physical exercise

The AH treatment can derive additional benefits from structured physical exercise practice, characterizing a customized training.

Aerobic exercise

Aerobic training reduces casual BP of prehypertensive and hypertensive individuals.43 In addition, it reduces BP during wakefulness for hypertensives44 and lowers BP in situations of physical, mental and psychological stress.45 Aerobic training is recommended as the preferential exercise type for AH prevention and treatment. (GR: I; LE: A).

 Dynamic and static resistance exercise

Dynamic or isotonic resistance training (contraction of localized body segments with joint movement) reduces BP of prehypertensive individuals, but has no effect in hypertensives. However, there are only four randomized, controlled studies on that exercise type for AH.43 Static or isometric resistance training (contraction of localized body segments without joint movement) reduces BP of hypertensives, but the studies have used small muscle masses, thus, further information is required prior to its recommendation.46 Dynamic resistance training is recommended to complement aerobic training for AH. (GR: IIa; LE: B).

 Caution

Hypertensives with higher BP levels or with more than three RF, DM, TOD or heart disease should undergo exercise testing before engaging in moderate-intensity physical exercises. In addition, every hypertensive engaging in competitive sports or high-performance exercise should undergo complete CV assessment.45 (GR: IIa; LE: C).

 Smoking cessation

Smoking increases the risk for more than 25 diseases, including CVD.47,48 The smoking habit hinders AH control,49 knowledge about SAH50 and adherence to antihypertensive medications.51 However, there is no evidence that smoking cessation reduces BP. (GR: III, LE: B).

Slow breathing

Slow or guided breathing requires respiratory rate reduction to 6-10 breaths/minute for 15-20 minutes/day to promote casual BP reduction (SBP: -3.67; 95% confidence interval: -5.99 to -1.39; and DBP: -2.51; 95% confidence interval: -4.15 to 0.87) after 8 weeks of treatment.52 (GR: IIa; LE: B).

 Stress control

Studies on stress management techniques emphasize the importance of behavioral psychotherapies and meditation,53-55 biofeedback and relaxation56 practices in AH treatment. Despite methodological contradictions, clinical indications have revealed a strong trend towards BP reduction when those techniques are performed separately or combined.56 (GR: IIa; LE: B).

 Multiprofessional team

The multiprofessional approach is mainly aimed at AH control, which is not satisfactory in our setting. Epidemiological studies have shown a 10% to 57.6% variation57 in that control. The multiprofessional team promotes better AH control,58 which is directly related to adherence to pharmacological and non-pharmacological treatment. The multiprofessional team can consist of all professionals managing hypertensive patients: doctors, nurses, technicians and nurse aides, nutritionists, psychologists, social workers, physical therapists, physical education coaches, music therapists, chemists, educators, media professionals, administrative workers and community health agents.

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Carlson DJ Dieberg G Hess NC Millar PJ Smart NA Isometric exercise training for blood pressure management: a systematic review and meta-analysis Mayo Clin Proc 2014 89 3 327 334 47 Nobre F, Ribeiro AB, Mion D Jr. [Control of arterial pressure in patients undergoing anti-hypertensive treatment in Brazil: Controlar Brazil]. Arq Bras Cardiol. 2010;94(5):663-70. Nobre F Ribeiro AB Mion D Jr Control of arterial pressure in patients undergoing anti-hypertensive treatment in Brazil: Controlar Brazil Arq Bras Cardiol 2010 94 5 663 670 48 Yun M, Li S, Sun D, Ge S, Lai CC, Fernandez C, et al. Tobacco smoking strengthens the association of elevated blood pressure with arterial stiffness: the Bogalusa Heart Study. J Hypertens. 2015;33(2):266-74. Yun M Li S Sun D Ge S Lai CC Fernandez C Tobacco smoking strengthens the association of elevated blood pressure with arterial stiffness: the Bogalusa Heart Study J Hypertens 2015 33 2 266 274 49 De Giusti M, Dito E, Pagliaro B, Burocchi S, Laurino FI, Tocci G, et al. A survey on blood pressure levels and hypertension control in a sample of the Italian general population. High Blood Press Cardiovasc Prev. 2012;19(3):129-35. De Giusti M Dito E Pagliaro B Burocchi S Laurino FI Tocci G A survey on blood pressure levels and hypertension control in a sample of the Italian general population High Blood Press Cardiovasc Prev 2012 19 3 129 135 50 Guessous I, Bochud M, Theler JM, Gaspoz JM, Pechere-Bertschi A. 1999-2009 Trends in prevalence, unawareness, treatment and control of hypertension in Geneva, Switzerland. PLoS One. 2012;7(6):e39877. Guessous I Bochud M Theler JM Gaspoz JM Pechere-Bertschi A 1999-2009 Trends in prevalence, unawareness, treatment and control of hypertension in Geneva, Switzerland PLoS One 2012 7 6 e39877 51 Mion D Jr, Pierin AM, Bensenor IM, Marin JC, Costa KR, Henrique LF, et al. Hypertension in the city of Sao Paulo: self-reported prevalence assessed by telephone surveys. Arq Bras Cardiol. 2010;95(1):99-106. Mion D Jr Pierin AM Bensenor IM Marin JC Costa KR Henrique LF Hypertension in the city of Sao Paulo: self-reported prevalence assessed by telephone surveys Arq Bras Cardiol 2010 95 1 99 106 52 Mahtani KR, Nunan D, Heneghan CJ. Device-guided breathing exercises in the control of human blood pressure: systematic review and meta-analysis. J Hypertens. 2012;30(5):852-60. Mahtani KR Nunan D Heneghan CJ Device-guided breathing exercises in the control of human blood pressure: systematic review and meta-analysis J Hypertens 2012 30 5 852 860 53 Bai Z, Chang J, Chen C, Li P, Yang K, Chi I. Investigating the effect of transcendental meditation on blood pressure: a systematic review and meta-analysis. J Hum Hypertens. 2015;29(11):653-62. Bai Z Chang J Chen C Li P Yang K Chi I Investigating the effect of transcendental meditation on blood pressure: a systematic review and meta-analysis J Hum Hypertens 2015 29 11 653 662 54 Campbell TS, Labelle LE, Bacon SL, Faris P, Carlson LE. Impact of Mindfulness-Based Stress Reduction (MBSR) on attention, rumination and resting blood pressure in women with cancer: a waitlist-controlled study. J Behav Med. 2012;35(3):262-71. Campbell TS Labelle LE Bacon SL Faris P Carlson LE Impact of Mindfulness-Based Stress Reduction (MBSR) on attention, rumination and resting blood pressure in women with cancer: a waitlist-controlled study J Behav Med 2012 35 3 262 271 55 Sharma M, Rush SE. Mindfulness-based stress reduction as a stress management intervention for healthy individuals: a systematic review. J Evid Based Complementary Altern Med. 2014;19(4):271-86. Sharma M Rush SE Mindfulness-based stress reduction as a stress management intervention for healthy individuals: a systematic review J Evid Based Complementary Altern Med 2014 19 4 271 286 56 Brook RD, Appel LJ, Rubenfire M, Ogedegbe G, Bisognano JD, Elliott WJ, et al. Beyond medications and diet: alternative approaches to lowering blood pressure: a scientific statement from the american heart association. Hypertension. 2013;61(6):1360-83. Brook RD Appel LJ Rubenfire M Ogedegbe G Bisognano JD Elliott WJ Beyond medications and diet: alternative approaches to lowering blood pressure: a scientific statement from the american heart association Hypertension 2013 61 6 1360 1383 57 Pinho Nde A, Pierin AM. Hypertension control in brazilian publications. Arq Bras Cardiol. 2013;101(3):e65-73. Pinho Nde A Pierin AM Hypertension control in brazilian publications Arq Bras Cardiol 2013 101 3 e65 e73 58 Glynn LG, Murphy AW, Smith SM, Schroeder K, Fahey T. Interventions used to improve control of blood pressure in patients with hypertension. Cochrane Database Syst Rev. 2010 Mar 17;(3):CD005182. Glynn LG Murphy AW Smith SM Schroeder K Fahey T Interventions used to improve control of blood pressure in patients with hypertension Cochrane Database Syst Rev 2010 3 17 3 CD005182 CD005182 7ª Diretriz Brasileira de Hipertensão Arterial: Capítulo 6 - Tratamento não medicamentoso Malachias MVB Franco RJS Forjaz CLM Pierin AMG Gowdak MMG Klein MRST Matsudo V Introdução

O tratamento não medicamentoso (TNM) da HA envolve controle ponderal, medidas nutricionais, prática de atividades físicas, cessação do tabagismo, controle de estresse, entre outros. Os efeitos e as recomendações dessas medidas são apresentados em textos e tabelas ao longo deste capítulo.

Peso corporal

O aumento de peso está diretamente relacionado ao aumento da PA tanto em adultos1 quanto em crianças.2 A relação entre sobrepeso e alteração da PA já pode ser observada a partir dos 8 anos.2 O aumento da gordura visceral também é considerado um fator de risco para HA.2,3 Reduções de peso e de CA correlacionam-se com reduções da PA e melhora metabólica (Tabela 1).4 (GR: I; NE: A).

Modificações no peso corporal e na ingestão alimentar e seus efeitos sobre a PA
Redução aproximada da PAS/PAD Recomendação
Controle do peso 20-30% de diminuição da PA para cada 5% de perda ponderal1 Manter IMC < 25 kg/m2 até 65 anos. Manter IMC < 27 kg/m2 após 65 anos. Manter CA < 80 cm nas mulheres e < 94 cm nos homens
Padrão alimentar Redução de 6,7/3,5 mmHg35 Adotar a dieta DASH
Restrição do consumo de sódio Redução de 2 a 7 mmHg na PAS e de 1 a 3 mmHg na PAD com redução progressiva de 2,4 a 1,5 g sódio/dia, respectivamente12 Restringir o consumo diário de sódio para 2,0 g, ou seja, 5 g de cloreto de sódio
Moderação no consumo de álcool Redução de 3,31/2,04 mmHg com a redução de 3-6 para 1-2 doses/dia34 Limitar o consumo diário de álcool a 1 dose nas mulheres e pessoas com baixo peso e 2 doses nos homens

IMC: índice de massa corporal; CA: circunferência abdominal; PAS: pressão artrerial sistólica; PAD: pressão artrerial diastólica.

* Uma dose contém cerca de 14g de etanol e equivale a 350 ml de cerveja, 150 ml de vinho e 45 ml de bebida destilada.36

 Aspectos nutricionais Padrão alimentar

O sucesso do tratamento da HA com medidas nutricionais depende da adoção de um plano alimentar saudável e sustentável.5 A utilização de dietas radicais resulta em abandono do tratamento.6 O foco em apenas um único nutriente ou alimento tem perdido espaço para a análise do padrão alimentar total, que permite avaliar o sinergismo entre os nutrientes/alimentos.7

A dieta DASH ( Dietary Approaches to Stop Hypertension) enfatiza o consumo de frutas, hortaliças e laticínios com baixo teor de gordura; inclui a ingestão de cereais integrais, frango, peixe e frutas oleaginosas; preconiza a redução da ingestão de carne vermelha, doces e bebidas com açúcar. Ela é rica em potássio, cálcio, magnésio e fibras, e contém quantidades reduzidas de colesterol, gordura total e saturada. A adoção desse padrão alimentar reduz a PA.8,9 (GR: I; NE: A).

A dieta do Mediterrâneo também é rica em frutas, hortaliças e cerais integrais, porém possui quantidades generosas de azeite de oliva (fonte de gorduras monoinsaturadas) e inclui o consumo de peixes e oleaginosas, além da ingestão moderada de vinho.7 Apesar da limitação de estudos, a adoção dessa dieta parece ter efeito hipotensor.10 (GR: IIa; NE: B).

As dietas vegetarianas preconizam o consumo de alimentos de origem vegetal, em especial frutas, hortaliças, grãos e leguminosas; excluem ou raramente incluem carnes; e algumas incluem laticínios, ovos e peixes. Essas dietas têm sido associadas com valores mais baixos de PA.11 (GR: IIa; NE: B).

 Redução do consumo de sódio

O aumento do consumo de sódio está relacionado com o aumento da PA.12 No entanto, o impacto do consumo de sódio na saúde CV é controverso. Alguns estudos sugerem que o consumo muito baixo eleva o risco de DCV, enquanto outros sustentam que a diminuição de sódio diminui o risco CV,13 sendo esse benefício maior com a restrição acentuada.14 O limite de consumo diário de sódio em 2,0 g está associado à diminuição da PA.15 No entanto, o consumo médio do brasileiro é de 11,4 g/dia.16 (GR: IIa; NE: B).

 Ácidos graxos insaturados

Os ácidos graxos ômega-3 provenientes dos óleos de peixe (eicosapentaenoico - EPA e docosaexaenoico - DHA) estão associados com redução modesta da PA. Estudos recentes indicam que a ingestão ≥ 2g/dia de EPA+DHA reduz a PA e que doses menores (1 a 2 g/dia) reduzem apenas a PAS.17 (GR: IIa; NE: B).

O consumo de ácidos graxos monoinsaturados também tem sido associado à redução da PA.18 (GR: IIb; NE: B).

 Fibras

As fibras solúveis são representadas pelo farelo de aveia, pectina (frutas) e pelas gomas (aveia, cevada e leguminosas: feijão, grão-de-bico, lentilha e ervilha), e as insolúveis pela celulose (trigo), hemicelulose (grãos) e lignina (hortaliças). A ingestão de fibras promove discreta diminuição da PA, destacando-se o beta glucano proveniente da aveia e da cevada.19 (GR: IIb; NE: B).

 Oleaginosas

O consumo de oleaginosas auxilia no controle de vários FRCV, mas poucos estudos relacionam esse consumo com a diminuição da PA.20 Uma meta-análise concluiu que o consumo de diferentes tipos de castanha foi eficiente em diminuir a PA.21 (GR: IIb; NE: B).

 Laticínios e vitamina D

Existem evidências que a ingestão de laticínios, em especial os com baixo teor de gordura, reduz a PA.22 O leite contém vários componentes como cálcio, potássio e peptídeos bioativos que podem diminuir a PA.23 (GR: IIb; NE: B).

Em alguns estudos, níveis séricos baixos de vitamina D se associaram com maior incidência de HA.24 Entretanto, em estudos com suplementação dessa vitamina, não se observou redução da PA.25 (GR: III; NE: B).

 Alho

O alho possui inúmeros componentes bioativos, como a alicina (encontrada no alho cru) e a s-alil-cisteína (encontrada no alho processado). Discreta diminuição da PA tem sido relatada com a suplementação de várias formas do alho.26,27 (GR: IIb; NE: B).

 Café e chá verde

O café, apesar de rico em cafeína, substância com efeito pressor agudo, possui polifenóis que podem favorecer a redução da PA.28 Estudos recentes sugerem que o consumo de café em doses habituais não está associado com maior incidência de HA nem com elevação da PA.29 Recomenda-se que o consumo não exceda quantidades baixas a moderadas. (GR: IIa; NE: B).

O chá verde, além de ser rico em polifenóis, em especial as catequinas, possui cafeína. Ainda não há consenso, mas alguns estudos sugerem que esse chá possa reduzir a PA quando consumido em doses baixas, pois doses elevadas contêm maior teor de cafeína e podem elevar a PA.30 Recomenda-se o consumo em doses baixas. (GR: IIb; NE: B).

 Chocolate amargo

O chocolate com pelo menos 70% de cacau pode promover discreta redução da PA, devido às altas concentrações de polifenóis.31 (GR: IIb; NE: B).

 Álcool

O consumo habitual de álcool eleva a PA de forma linear e o consumo excessivo associa-se com aumento na incidência de HA.32,33 Estima-se que um aumento de 10 g/dia na ingestão de álcool eleve a PA em 1 mmHg,32 sendo que a diminuição nesse consumo reduz a PA.34 Recomenda-se moderação no consumo de álcool. (GR: I; NE: B).

 Atividade física/exercício físico

Atividade física refere-se a qualquer movimento corporal que aumente o gasto energético, o que inclui andar na rua, subir escada, fazer trabalhos físicos domésticos, fazer práticas físicas de lazer. O termo exercício físico refere-se à atividade física realizada de forma estruturada, organizada e com objetivo específico. Além disso, o comportamento sedentário, medido pelo tempo sentado, também tem implicações na saúde CV (Tabelas 2 e 3).

Evidências da atividade física e do exercício físico na redução da PA
Medida Redução aproximada da PAS/PAD
Atividade física diária 3,6/5,4 mmHg42
Exercício aeróbico 2,1/1,7 em pré-hipertensos 8,3/5,2 mmHg em hipertensos43
Exercício resistido dinâmico 4,0/3,8 mmHg em pré-hipertensos Não reduz em hipertensos43
Recomendações em relação à atividade física e exercício físico
Para todos os hipertensos - Recomendação populacional – Prática de atividade física
Fazer, no mínimo, 30 min/dia de atividade física moderada, de forma contínua (1 x 30 min) ou acumulada (2 x 15 min ou 3 x 10 min) em 5 a 7 dias da semana.
Para maiores benefícios - Recomendação individual - Exercício físico
Treinamento aeróbico complementado pela resistido
Treinamento Aeróbico
Modalidades diversas: andar, correr, dançar, nadar, entre outras.
Pelo menos 3 vezes/semana. Ideal 5 vezes/semana.
Pelo menos 30 min. Ideal entre 40 e 50 min.
Intensidade moderada definida por:
1) Maior intensidade conseguindo conversar (sem ficar ofegante)
2) Sentir-se entre ligeiramente cansado e cansado
3) Manter a FC de treino na faixa calculada por:
FC treino = (FC máxima – FC repouso) x % + FC repouso
Onde:
FC máxima: deve ser obtida num teste ergométrico máximo feito em uso dos medicamentos regulares ou pelo cálculo da FC máxima prevista pela idade (220 - idade). Essa última não pode ser usada em hipertensos com cardiopatias ou em uso de betabloqueadores (BB) ou bloqueadores de canais de cálcio (BCC) não di-idropiridínicos. FC repouso: deve ser medida após 5 min de repouso deitado. %: utilizar 50% como limite inferior e 70% como superior.
Treinamento resistido
2 a 3 vezes/semana.
8 a 10 exercícios para os principais grupos musculares, dando prioridade para execução unilateral, quando possível.
1 a 3 séries
10 a 15 repetições até a fadiga moderada (redução da velocidade de movimento e tendência a apneia)
Pausas longas passivas - 90 a 120 s
Inatividade/atividade física

A inatividade física tem sido considerada "o maior problema de saúde pública"37 por ser o mais prevalente dos FR e a segunda causa de morte no mundo.38 A sobrevivência é menor em pessoas que passam a maior parte do tempo sentadas do que naquelas que passam pouco tempo sentadas.39 Há relação direta entre o tempo sentado ou o tempo de televisão com a PA.40 Recomenda-se a redução do tempo sentado, levantando-se por pelo menos 5 min a cada 30 min sentado. (GR: IIb; NE: B).

A prática regular de atividade física pode ser benéfica tanto na prevenção quanto no tratamento da HA, reduzindo ainda a morbimortalidade CV. Indivíduos ativos apresentam risco 30% menor de desenvolver HA que os sedentários,41 e o aumento da atividade física diária reduz a PA.42 A prática de atividade física deve ser incentivada em toda a população, não havendo necessidade de nenhum exame prévio. O indivíduo deve ser orientado a procurar um médico se sentir algum desconforto durante a execução. (GR: I; NE: A).

 Exercícios físicos

No tratamento da HA, benefícios adicionais podem ser obtidos com exercícios físicos estruturados, caracterizando um treinamento individualizado.

 Exercícios aeróbicos

O treinamento aeróbico reduz a PA casual de pré-hipertensos e hipertensos.43 Ele também reduz a PA de vigília de hipertensos44 e diminui a PA em situações de estresse físico, mental e psicológico.45 O treinamento aeróbico é recomendado como forma preferencial de exercício para a prevenção e o tratamento da HA. (GR: I; NE: A).

 Exercícios resistidos dinâmicos e estáticos

O treinamento resistido dinâmico ou isotônico (contração de segmentos corporais localizados com movimento articular) reduz a PA de pré-hipertensos, mas não tem efeito em hipertensos. Existem, porém, apenas quatro estudos randomizados e controlados com esse tipo de exercício na HA.43 O treinamento resistido estático ou isométrico (contração de segmentos corporais localizados sem movimento articular) reduz a PA de hipertensos, mas os estudos utilizam massas musculares pequenas, havendo necessidade de mais informação antes de sua recomendação.46 O treinamento resistido dinâmico é recomendado na HA, em complemento ao aeróbico. (GR: IIa; NE: B).

 Cuidados

Recomenda-se que hipertensos com níveis de PA mais elevados ou que possuam mais de 3 FR, diabetes, LOA ou cardiopatias façam um teste ergométrico antes de realizar exercícios físicos em intensidade moderada. Além disso, todo hipertenso que for se engajar em esportes competitivos ou exercícios de alta performance deve fazer uma avaliação CV completa.45 (GR: IIa; NE: C).

 Cessação do tabagismo

O tabagismo aumenta o risco para mais de 25 doenças, incluindo a DCV.47,48 O hábito de fumar é apontado como fator negativo no controle de hipertensos,49 no desconhecimento da HAS50 e na interrupção do uso de medicamentos anti-hipertensivos.51 No entanto, não há evidências que a cessação do tabagismo reduza a PA. (GR: III, NE: B).

 Respiração lenta

A respiração lenta ou guiada requer a redução da frequência respiratória para menos de 6 a 10 respirações/minuto durante 15-20 minutos/dia para promover redução na PA casual (PAS: -3,67; intervalo de confiança 95%: -5,99 a -1,39; e PAD: -2,51; intervalo de confiança 95%: -4,15 a 0,87) após 8 semanas de tratamento.52 (GR: IIa; NE: B).

 Controle do estresse

Estudos sobre as práticas de gerenciamento de estresse apontam a importância das psicoterapias comportamentais e das práticas de técnicas de meditação,53-55biofeedback e relaxamento56 no tratamento da HA. Apesar de incoerências metodológicas, as indicações clínicas revelam forte tendência de redução da PA quando essas técnicas são realizadas separadamente ou em conjunto.56 (GR: IIa; NE: B).

 Equipe multiprofissional

A atenção numa abordagem multiprofissional tem como objetivo principal o controle da HA, que não é satisfatório em nosso meio. Estudos de base epidemiológica demonstraram variação de 10% a 57,6%57 nesse controle. A atuação da equipe multiprofissional promove melhor controle da HA,58 o que está diretamente relacionado à adesão ao tratamento medicamentoso e não medicamentoso. A equipe multiprofissional pode ser constituída por todos os profissionais que lidem com pacientes hipertensos: médicos, enfermeiros, técnicos e auxiliares de enfermagem, nutricionistas, psicólogos, assistentes sociais, fisioterapeutas, professores de educação física, musicoterapeutas, farmacêuticos, educadores, comunicadores, funcionários administrativos e agentes comunitários de saúde.