Arq Bras Cardiol abc Arquivos Brasileiros de Cardiologia Arq. Bras. Cardiol. 0066-782X 1678-4170 Sociedade Brasileira de Cardiologia - SBC qQX3t4DMQfzJfxdFMQNC67z S0066-782X2023000900207 00207 10.36660/abc.20230608 Minieditorial Ascensão Matinal da Pressão Arterial e Obesidade em Pacientes Hipertensos 0000-0002-5784-9991 Inuzuka Sayuri 1 0000-0002-1265-1930 Barroso Weimar Kunz Sebba 1 2 Programa de Pós-Graduação em Ciências da Saúde Faculdade de Medicina Universidade Federal de Goiás Goiânia GO Brasil Liga de Hipertensão – Seção Cardiovascular e Programa de Pós-Graduação em Ciências da Saúde - Faculdade de Medicina da Universidade Federal de Goiás, Goiânia, GO – Brasil Hospital Israelita Albert Einstein Goiânia GO Brasil Hospital Israelita Albert Einstein, Goiânia, GO – Brasil Correspondência: Weimar Kunz Sebba Barroso • Universidade Federal de Goiás – Liga de Hipertensão Arterial – Av. Universitária Hospital das Clínicas. CEP 74605-220, Goiânia, GO – Brasil E-mail: sebbabarroso@gmail.com 03 11 2023 10 2023 120 9 e20230608 29 08 2023 06 09 2023 06 09 2023 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. Hipertensão Obesidade Monitorização Ambulatorial da Pressão Arterial

A obesidade e a hipertensão são duas das doenças mais comuns que estão geralmente interrelacionadas. Estima-se que os cinco principais fatores de risco modificáveis – dislipidemia, diabetes, hipertensão, obesidade e tabagismo sejam responsáveis por mais de 50% da mortalidade cardiovascular.1 Há muitos pacientes hipertensos com lesões subclínicas nos estágios iniciais da doença que em geral não são identificadas pelo modelo de avaliação tradicional.2,3 A presença de hipertrofia ventricular esquerda (HVE) determina a estratificação de risco geral e é um importante alvo terapêutico na hipertensão. Tanto a obesidade como a hipertensão podem ter efeitos adicionais e interativos sobre a HVE.4 Para identificar lesão precoce no sistema cardiovascular, exames complementares mais específicos têm sido recomendados por diretrizes de hipertensão.5-7

Diferentes métodos têm sido propostos para determinar a ascensão matinal da pressão arterial (AMPA),8-11 mas ainda existem várias lacunas quanto ao estabelecimento de pontos de corte e recomendações de significância clínica.12 Alguns estudos mostraram que a AMPA tem um valor prognóstico adverso, independentemente da média da pressão arterial de 24 horas.7 Contudo, dada a dificuldade de se padronizar o cálculo desse parâmetro, o valor preditivo incremental ainda não está claro, e sua baixa reprodutibilidade indica que, de acordo com as diretrizes, a AMPA não deve ser usada na prática clínica.5,7

Tanto a AMPA como a obesidade mostraram-se estar associadas com HVE em um estudo transversal com 203 pacientes hipertensos nesta edição dos Arquivos Brasileiros de Cardiologia, Palmeira et al.13 Os pesquisadores da EPM/UNIFESP - Escola Paulista de Medicina da Universidade Federal de São Paulo encontraram uma AMPA de 16mmHg como limiar associado com HVE no grupo obeso, e o limiar de 22mmHg no grupo não obeso.

Um grande estudo longitudinal com 2020 pacientes e 19,7 anos de acompanhamento sugere que a inclinação da regressão linear de medidas da Pressão Arterial Sistólica (PAS) em intervalos de tempo no descenso do sono (calculado como a diferença entre a PAS matinal e a PAS mais baixa à noite) poderia identificar independentemente indivíduos com risco cardiovascular aumentado.8 O estudo J-HOP calculou a AMPA como uma variável contínua e mostrou sua associação independente com ocorrência de acidente vascular cerebral.9 Outro estudo de Kario et al.10 sugere que a inclinação da ascensão matinal reflete a taxa de mudança da pressão arterial do período noturno para a manhã, e mostrou que a atenuação dessa inclinação pode indicar possíveis benefícios.10 No estudo discutido neste editorial, a ascensão matinal foi calculada como a diferença entre a PAS matinal e a PAS mais baixa durante o sono. Os autores também estabeleceram pontos de corte para a AMPA que se correlacionaram com HVE em pacientes hipertensos obesos e não obesos.

De acordo com as principais diretrizes de hipertensão, testes complementares mais específicos para análise de biomarcadores são usados para a identificação precoce de dano cardiovascular.5,7 A identificação de pacientes em maior risco permite melhor tratamento, menos eventos cardiovasculares, e melhor qualidade de vida. Biomarcadores cardiovasculares são importantes na medicina de precisão. A definição de pontos de corte é importante para a aplicação desses valores na nossa rotina.

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Vlachopoulos C Xaplanteris P Aboyans V Brodmann M Cífková R Cosentino F et al The Role of Vascular Biomarkers for Primary and Secondary Prevention. A Position Paper from the European Society of Cardiology Working Group on Peripheral Circulation: Endorsed by the Association for Research into Arterial Structure and Physiology (ARTERY) Society Atherosclerosis 2015 241 2 507 532 10.1016/j.atherosclerosis.2015.05.007 3. Sehestedt T, Jeppesen J, Hansen TW, Wachtell K, Ibsen H, Torp-Pedersen C, et al. Risk Prediction is Improved by Adding Markers of Subclinical Organ Damage to SCORE. Eur Heart J. 2010;31(7):883-91. doi: 10.1093/eurheartj/ehp546. Sehestedt T Jeppesen J Hansen TW Wachtell K Ibsen H Torp-Pedersen C et al Risk Prediction is Improved by Adding Markers of Subclinical Organ Damage to SCORE Eur Heart J 2010 31 7 883 891 10.1093/eurheartj/ehp546 4. Woodiwiss AJ, Norton GR. Obesity and Left Ventricular Hypertrophy: The Hypertension Connection. Curr Hypertens Rep. 2015;17(4):539. doi: 10.1007/s11906-015-0539-z. Woodiwiss AJ Norton GR Obesity and Left Ventricular Hypertrophy: The Hypertension Connection Curr Hypertens Rep 2015 17 4 539 10.1007/s11906-015-0539-z 5. Barroso WKS, Rodrigues CIS, Bortolotto LA, Mota-Gomes MA, Brandão AA, Feitosa ADM, et al. Brazilian Guidelines of Hypertension - 2020. Arq Bras Cardiol. 2021;116(3):516-658. doi: 10.36660/abc.20201238. Barroso WKS Rodrigues CIS Bortolotto LA Mota-Gomes MA Brandão AA Feitosa ADM et al Brazilian Guidelines of Hypertension - 2020 Arq Bras Cardiol 2021 116 3 516 658 10.36660/abc.20201238 6. Whelton PK, Carey RM, Aronow WS, Casey DE Jr, Collins KJ, Dennison Himmelfarb C, et al. 2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA Guideline for the Prevention, Detection, Evaluation, and Management of High Blood Pressure in Adults: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. Hypertension. 2018;71(6):e13-e115. doi: 10.1161/HYP.0000000000000065. Whelton PK Carey RM Aronow WS Casey DE Jr Collins KJ Dennison Himmelfarb C et al 2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA Guideline for the Prevention, Detection, Evaluation, and Management of High Blood Pressure in Adults: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines Hypertension 2018 71 6 e13 e115 10.1161/HYP.0000000000000065 7. Mancia Chairperson G, Kreutz Co-Chair R, Brunström M, Burnier M, Grassi G, Januszewicz A, et al. 2023 ESH Guidelines for the Management of Arterial Hypertension The Task Force for the Management of Arterial Hypertension of the European Society of Hypertension Endorsed by the European Renal Association (ERA) and the International Society of Hypertension (ISH). J Hypertens. 2023. doi: 10.1097/HJH.0000000000003480. Mancia Chairperson G Kreutz Co-Chair R Brunström M Burnier M Grassi G Januszewicz A et al 2023 ESH Guidelines for the Management of Arterial Hypertension The Task Force for the Management of Arterial Hypertension of the European Society of Hypertension Endorsed by the European Renal Association (ERA) and the International Society of Hypertension (ISH) J Hypertens 2023 10.1097/HJH.0000000000003480 8. Cheng HM, Wu CL, Sung SH, Lee JC, Kario K, Chiang CE, et al. Prognostic Utility of Morning Blood Pressure Surge for 20-Year All-Cause and Cardiovascular Mortalities: Results of a Community-Based ‘y. J Am Heart Assoc. 2017;6(12):e007667. doi: 10.1161/JAHA.117.007667. Cheng HM Wu CL Sung SH Lee JC Kario K Chiang CE et al Prognostic Utility of Morning Blood Pressure Surge for 20-Year All-Cause and Cardiovascular Mortalities: Results of a Community-Based ‘y J Am Heart Assoc 2017 6 12 e007667 10.1161/JAHA.117.007667 9. Kario K, Pickering TG, Umeda Y, Hoshide S, Hoshide Y, Morinari M, et al. Morning Surge in Blood Pressure as a Predictor of Silent and Clinical Cerebrovascular Disease in Elderly Hypertensives: A Prospective Study. Circulation. 2003;107(10):1401-6. doi: 10.1161/01.cir.0000056521.67546.aa. Kario K Pickering TG Umeda Y Hoshide S Hoshide Y Morinari M et al Morning Surge in Blood Pressure as a Predictor of Silent and Clinical Cerebrovascular Disease in Elderly Hypertensives: A Prospective Study Circulation 2003 107 10 1401 1406 10.1161/01.cir.0000056521.67546.aa 10. Kario K, Weber MA, Böhm M, Townsend RR, Mahfoud F, Schmieder RE, et al. Effect of Renal Denervation in Attenuating the Stress of Morning Surge in Blood Pressure: Post-Hoc Analysis from the SPYRAL HTN-ON MED Trial. Clin Res Cardiol. 2021;110(5):725-31. doi: 10.1007/s00392-020-01718-6. Kario K Weber MA Böhm M Townsend RR Mahfoud F Schmieder RE et al Effect of Renal Denervation in Attenuating the Stress of Morning Surge in Blood Pressure: Post-Hoc Analysis from the SPYRAL HTN-ON MED Trial Clin Res Cardiol 2021 110 5 725 731 10.1007/s00392-020-01718-6 11. Mokwatsi GG, Schutte AE, Mels CMC, Kruger R. Morning Blood Pressure Surge in Young Black and White Adults: The African-PREDICT Study. J Hum Hypertens. 2019;33(1):22-33. doi: 10.1038/s41371-018-0089-3. Mokwatsi GG Schutte AE Mels CMC Kruger R Morning Blood Pressure Surge in Young Black and White Adults: The African-PREDICT Study J Hum Hypertens 2019 33 1 22 33 10.1038/s41371-018-0089-3 12. Hansen TW, Li Y, Boggia J, Thijs L, Richart T, Staessen JA. Predictive Role of the Nighttime Blood Pressure. Hypertension. 2011;57(1):3-10. doi: 10.1161/HYPERTENSIONAHA.109.133900. Hansen TW Li Y Boggia J Thijs L Richart T Staessen JA Predictive Role of the Nighttime Blood Pressure Hypertension 2011 57 1 3 10 10.1161/HYPERTENSIONAHA.109.133900 13. Palmeira NGF, Bianco HT, Bombig MTN, Povoa FF, Fonseca FAH, Izar MC, et al. Association between Morning Surge and Left Ventricular Hypertrophy in Obese Hypertensive Patients. Arq Bras Cardiol. 2023; 120(9):e20230050. DOI: https://doi.org/10.36660/abc.20230050. Palmeira NGF Bianco HT Bombig MTN Povoa FF Fonseca FAH Izar MC et al Association between Morning Surge and Left Ventricular Hypertrophy in Obese Hypertensive Patients Arq Bras Cardiol 2023 120 9 e20230050 https://doi.org/10.36660/abc.20230050 Short Editorial Morning Surge Blood Pressure and Obesity in Hypertensive Patients 0000-0002-5784-9991 Inuzuka Sayuri 1 0000-0002-1265-1930 Barroso Weimar Kunz Sebba 1 2 Brasil Liga de Hipertensão – Seção Cardiovascular e Programa de Pós-Graduação em Ciências da Saúde - Faculdade de Medicina da Universidade Federal de Goiás, Goiânia, GO – Brasil Brasil Hospital Israelita Albert Einstein, Goiânia, GO – Brasil Mailing Address: Weimar Kunz Sebba Barroso • Universidade Federal de Goiás – Liga de Hipertensão Arterial – Av. Universitária Hospital das Clínicas. CEP 74605-220, Goiânia, GO – Brazil E-mail: sebbabarroso@gmail.com Hypertension obesity ambulatory blood pressure monitoring

Obesity and hypertension are two of the most common diseases and they are usually interrelated. The five main modifiable risk factors – dyslipidemia, diabetes, hypertension, obesity and smoking are estimated to account for more than 50% of cardiovascular mortality.1 There are many hypertensive patients with subclinical lesions in the early stages of the disease that are not generally identified by the traditional assessment model.2,3 The presence of left ventricular hypertrophy (LVH) determines general risk stratification and is a major therapeutic target in hypertension. Both obesity and hypertension may have additive and interactive effects on LVH.4 In order to identify early cardiovascular system damage, more specific complementary exams for biomarker analysis have been recommended by hypertension guidelines.5-7

Different methods to determine morning surge blood pressure (MSBP) elevation have been proposed,8-11 but there are still several gaps regarding the establishment of cutoffs and clinical meaningful recommendations.12 Some studies showed that MSBP have an adverse prognostic value, independently of 24h mean blood pressure.7 However, due to the difficulty in standardizing the calculation of this parameter, the incremental predictive value is still unclear and its low reproducibility indicate that, according to guidelines, it should not be used in clinical practice.5,7

Both MSBP and obesity have been shown to be associated with LVH in a cross-sectional study of 203 hypertensive patients in this issue of Arquivos Brasileiros de Cardiologia, Palmeira et al.13 The researchers of the EPM/UNIFESP - Escola Paulista de Medicina da Universidade Federal de São Paulo have found elevated morning surge of 16mmHg as a threshold associated with LVH in the obese group, and the threshold of 22mmHg in the non-obese group.

A large longitudinal study with 2020 patients, 19.7-year follow-up, suggests that the rate of sleep-trough MS. The rate of STMS was derived as the slope of linear regression of sequential systolic blood pressure (SBP) measures on time intervals within the sleep-trough (calculated as the difference between morning SBP and lowest nighttime SBP) could identify independently subjects with an increased cardiovascular risk.8 The J-HOP study calculated MSBP as a continuous variable and showed that it was independently associated with stroke events.9 Another study by Kario et al.,10 suggests that the morning surge slope reflects the rate of change of blood pressure from night time to morning, and that the attenuation of this slope may indicate possible benefits.10 In the study discussed in this editorial, morning surge was calculated as the difference between morning SBP and the lowest SBP during sleep. The authors also established MSBP cutoff points that were correlated with LVH in obese and non-obese hypertensive patients.

According to the main hypertension guidelines, more specific complementary tests for biomarker analysis are used for the early identification of cardiovascular damage.5,7 The identification of patients at higher risk allows better treatment, fewer cardiovascular events and better quality of life. Cardiovascular biomarkers are important in precision medicine. The definition of cutoff points is important for the usability of these values in our routine.