abc Arquivos Brasileiros de Cardiologia Arq. Bras. Cardiol. 0066-782X 1678-4170 Sociedade Brasileira de Cardiologia - SBC São Paulo, SP, Brazil f6qfTvNPNTWSXnTYVQszRLs 00004 S0066-782X2004001000004 S0066-782X(04)08200004 10.1590/S0066-782X2004001000004 IV Diretrizes Brasileiras de Hipertensão Arterial Mion Jr. Décio Gomes Marco Antônio Mota Nobre Fernando Amodeo Celso Kohlmann Jr. Osvaldo Praxedes José Nery Machado Carlos Alberto Machado Carlos Alberto Pascoal Istênio Magalhães Lucélia C. Sociedade Brasileira de Nefrologia Sociedade Brasileira de Hipertensão Sociedade Brasileira de Cardiologia 03 2004 82 suppl 4 7 14 This work is licensed under a Creative Commons Attribution-NonCommercial 4.0 International License. 22 04 2004

IV Diretrizes Brasileiras de Hipertensão Arterial

Realização

Sociedade Brasileira de Hipertensão – SBH

Sociedade Brasileira de Cardiologia – SBC

Sociedade Brasileira de Nefrologia – SBN

Sociedades Patrocinadoras

Academia Brasileira de Neurologia – ABN

Associação Brasileira para o Estudo da Obesidade – ABESO

Federação Brasileira das Sociedades de Ginecologia e Obstetrícia – FEBRASGO

Sociedade Brasileira de Clínica Médica – SBCM

Sociedade Brasileira de Diabetes – SBD

Sociedade Brasileira de Endocrinologia e Metabologia – SBEM

Sociedade Brasileira de Geriatria e Gerontologia – SBGG

Comissão Organizadora

Décio Mion Jr. (Coordenador)

Marco Antônio Mota Gomes (SBC)

Fernando Nobre (SBH)

Celso Amodeo (SBN)

Osvaldo Kohlmann Jr. (SBH)

José Nery Praxedes (SBN)

Carlos Alberto Machado (SBC)

Comissão de Redação

Carlos Alberto Machado

Celso Amodeo

Décio Mion Jr.

Fernando Nobre

Istênio Pascoal

José Nery Praxedes

Lucélia C. Magalhães

Marco Antônio Mota Gomes

Osvaldo Kohlmann Jr.

Apoio

AstraZeneca do Brasil Ltda.

Aventis Pharma Ltda.

Bayer S.A.

Biolab Farmacêutica Ltda.

Boehringer Ingelheim do Brasil Quím. e Farm. Ltda.

Farmalab Ind. Químicas e Farmacêuticas Ltda.

Laboratórios Biosintética

Laboratórios Pfizer Ltda.

Libbs Farmacêutica Ltda.

Merck Sharp & Dohme Farmacêutica Ltda.

Novartis Biociências S.A.

Sanofi-Synthélabo Ltda.

Servier do Brasil Ltda.

Introdução

A hipertensão é um dos principais agravos à saúde no Brasil. Eleva o custo médico-social, principalmente pelas suas complicações, como as doenças cérebro-vascular, arterial coronariana e vascular de extremidades, além da insuficiência cardíaca e da insuficiência renal crônica.

Desde 1963, as doenças cardiovasculares superaram as outras causas de morte, sendo responsáveis atualmente por 27% dos óbitos. Houve aumento do risco de morte por estas doenças de 1980 a 1984, seguido de queda até 1996.

Diferentemente do quadro norte-americano, que mostrou redução de 60% na mortalidade por doença cérebro-vascular e 53% por doença arterial coronariana, no Brasil (Figura 1) a redução verificada foi de 20% e 13%, respectivamente. As tendências de risco de morte por doenças cardiovasculares são diferentes nas diversas regiões com queda no Sudeste e Sul, aumento no Centro-Oeste e Nordeste e estabilidade no Norte1 (B).

Os estudos de prevalência são poucos e não representativos do país. Os inquéritos mostrados na Figura 2 apontam alta prevalência, da ordem de 22% a 44%2(B) 3-6 (A) 7(C). Em função desta realidade, deve-se estabelecer programas de controle em todo o país.

Diagnóstico e Classificação

O diagnóstico de hipertensão é estabelecido com medida de pressão realizada com métodos e condições descritos na Tabela 1, de acordo com os níveis tensionais relacionados na Tabela 2.

Medida da Pressão Arterial17,19(D)

O aparelho de coluna de mercúrio é o mais adequado. O aneróide deve ser testado a cada seis meses e os eletrônicos são indicados somente quando validados.

Rotina Diagnóstica (D)

Realizar no mínimo duas medidas da pressão por consulta, na posição sentada, e se as diastólicas apresentarem diferenças acima de 5 mmHg, fazer novas medidas até se obter menor diferença. Na primeira avaliação, as medições devem ser obtidas em ambos os membros superiores. Em caso de diferença, utilizar sempre o braço de maior pressão. Recomenda-se que as medidas sejam repetidas em pelo menos duas ou mais visitas antes de confirmar o diagnóstico de hipertensão.

A medida na posição ortostática deve ser feita, pelo menos, na avaliação inicial, especialmente em idosos, diabéticos, portadores de disautonomias, dependentes do álcool e usuários de medicação antihipertensiva.

Critérios Diagnósticos, Classificação e Recomendações para Seguimento20(D)

Qualquer atribuição de valor numérico é arbitrária e qualquer classificação insuficiente. Considerar, além dos níveis de pressão, a presença de fatores de risco, comorbidades e lesão de órgãos alvos relacionados na Tabela 3.

Em crianças e adolescentes, a pressão arterial é classificada de acordo com os percentis de estatura e sexo. Considera-se hipertensão arterial valores iguais ou acima do percentil 95.

Investigação Clínica e Decisão Terapêutica

São objetivos da investigação clínica confirmar a elevação persistente da pressão arterial, avaliar lesões de órgãos-alvo, identificar fatores de risco cardiovascular, diagnosticar doenças associadas e a etiologia da hipertensão. Para tanto, realiza-se: a) história clínica - considerando, além do habitual, sexo, idade, raça, condição socioeconômica, tabagismo, duração da hipertensão e níveis de pressão arterial, sobrepeso e obesidade, sintomas de doença arterial coronariana, acidente vascular cerebral ou doença arterial coronariana na família (em mulheres < 65 anos e homens < 55 anos), sintomas e sinais de insuficiência cardíaca, história familiar de hipertensão, doença vascular encefálica, morte prematura/súbita em familiares próximos, insuficiência vascular periférica, depressão, ansiedade, pânico, doença renal, situação familiar, diabete melito, ingestão de sal e álcool, consumo de medicamentos ou drogas que possam interferir com a pressão arterial, fatores de risco para aterosclerose, prática de atividade física, dislipidemias, perda de peso e indícios de hipertensão secundária, que deve ser sempre pesquisada na presença das manifestações características; b) exame físico - com ênfase para peso e estatura, sopros mitral e aórtico, circunferência abdominal, estertores, roncos, sibilos, sinais de hipertensão secundária, massas abdominais (tumores, aneurismas, hidronefrose, rins policísticos) medida da pressão arterial, sopros abdominais (renais, aorta), freqüência de pulso, pulsos braquiais, radiais, fumorais, tibiais pediosos e pediosos, palpação e ausculta de carótidas, presença de edema, estase venosa, exame neurológico sumário, palpação da tireóide, fundo de olho, ictus sugestivo de hipertrofia ventricular esquerda/dilatação do ventrículo esquerdo, 3ª bulha (disfunção sistólica do ventrículo esquerdo), hiperfonese de A2; c) avaliação laboratorial de rotina - análise de urina, dosagens de potássio, creatinina, glicemia de jejum, colesterol total, HDL-colesterol, triglicérides e eletrocardiograma, pode-se calcular o LDL-colesterol quando a dosagem de triglicérides for abaixo de 400mg/dl pela fórmula: LDL-colesterol = colesterol total - HDL-colesterol - triglicérides/5; d) avaliação complementar quando há indícios de hipertensão secundária, lesão em órgãosalvo ou doenças associadas21,22(D).

Para instituição do tratamento, deve-se considerar o nível pressórico e o risco do paciente de acordo com as Tabelas 3 e 4.

Abordagem Multiprofissional

Por ser a hipertensão arterial multifatorial e envolver orientações voltadas para vários objetivos, poderá requerer o apoio de outros profissionais de saúde além do médico. A formação da equipe multiprofissional irá proporcionar uma ação diferenciada aos hipertensos24(A).

A Equipe

Poderá ser formada por médicos, enfermeiros, auxiliares de enfermagem, nutricionistas, psicólogos, assistentes sociais, professores de educação física, farmacêuticos, funcionários administrativos e agentes comunitários. Não é necessário a existência de todo esse grupo para a formação da equipe.

Ações comuns à Equipe

Visa a promoção à saúde, ações educativas com ênfase nas mudanças do estilo de vida, correção dos fatores de risco e produção de material educativo; treinamento de profissionais; encaminhamento a outros profissionais, quando indicado; ações assistenciais individuais e em grupo; participação em projetos de pesquisa; gerenciamento do programa.

Ações Individuais

Ações próprias de cada profissional, porém haverá momentos em que as funções serão comuns e deverão ocorrer de modo natural com uniformidade de linguagem e conduta.

Programas Comunitários

A criação de ligas e associações de hipertensos pode aumentar a adesão e ser instrumento de pressão junto às autoridades constituídas visando melhoria na qualidade da assistência aos portadores de hipertensão arterial.

Tratamento não Medicamentoso

Medidas de maior Eficácia

Redução do peso corporal e manutenção do peso ideal - índice de massa corpórea (peso em quilogramas dividido pelo quadrado da altura em metros) entre 20 e 25 kg/m2 porque existe relação direta entre peso corpóreo e pressão arterial25(A).

Redução da ingestão de sódio - é saudável ingerir até 6 g/dia de sal correspondente a 4 colheres de café rasas de sal, 4g, e 2g de sal presente nos alimentos naturais, reduzindo o sal adicionado aos alimentos, evitando o saleiro à mesa e alimentos industrializados. A dieta habitual contém 10 a 12 g/dia de sal26(A).

Maior ingestão de potássio – dieta rica em vegetais e frutas contém 2 a 4g de potássio/dia e pode ser útil na redução da pressão e prevenção da hipertensão arterial27(A). Os substitutos do sal contendo cloreto de potássio e menos cloreto de sódio (30% a 50%) são úteis para reduzir a ingestão de sódio e aumentar a de potássio.

Redução do consumo de bebidas alcoólicas28,29 (D) 30,31(B) 32(A) - para os consumidores de álcool, a ingestão de bebida alcoólica deve ser limitada a 30g álcool/dia contidas em 600 ml de cerveja (5% de álcool) ou 250 ml de vinho (12% de álcool) ou 60ml de destilados (whisky, vodka, aguardente - 50% de álcool). Este limite deve ser reduzido à metade para homens de baixo peso, mulheres, indivíduos com sobrepeso e/ou triglicérides elevados.

Exercícios físicos regulares33(A) 34(D) – há relação inversa entre grau de atividade física e incidência de hipertensão; exercício físico regular reduz a pressão (Tabela 5).

Medidas sem Avaliação Científica Definitiva

Suplementação de cálcio36,37(A), magnésio38(D), dietas vegetarianas e medidas antiestresse.

Medidas Associadas

Abandono do tabagismo – deve ser recomendado devido a sua associação com maior incidência e mortalidade cardiovascular e aumento da pressão arterial medida ambulatorialmente39-41(B). A interrupção deve ser acompanhada de restrição calórica e aumento da atividade física para evitar ganho de peso que pode ocorrer. A exposição ao fumo, tabagismo passivo, também constitui fator de risco cardiovascular que deve ser evitado42(D).

Controle do diabete e das dislipidemias – intolerância à glicose e diabete estão freqüentemente associadas à hipertensão arterial, favorecendo a ocorrência de doenças cardiovasculares e complicações do diabete43(A) 44(B). Sua prevenção tem como base a dieta hipocalórica, a prática regular de atividades físicas aeróbias e a redução de ingestão de açúcar simples. Estas medidas visam também a manutenção da pressão arterial abaixo de 130/80 mmHg45(D). Hipercolesterolemia e hipertrigliceridemia, com HDL-colesterol baixo, são importantes fatores de risco cardiovascular45(D). A base do controle das dislipidemias é representada por mudanças dietéticas, com redução do consumo de gordura e substituição parcial das gorduras saturadas por gorduras mono e poliinsaturadas e redução da ingestão diária de colesterol46(D).

Evitar medicamentos que elevem a pressão arterial23(D) relacionados na Tabela 6, onde se encontram as condutas específicas a cada tipo de medicamento.

Tratamento Medicamentoso

Objetivo - Reduzir a morbidade e mortalidade cardiovasculares do hipertenso. O benefício é obtido em pacientes tratados com diuréticos47(A), betabloqueadores47(D), inibidores da enzima conversora da angiotensina - ECA48(A), antagonistas do receptor AT1 da angiotensina II - AII49(D) e em pacientes mais idosos com antagonistas de canal de cálcio48(A), sendo que a maioria dos estudos terminou por utilizar associação de fármacos.

Meta de Redução da Pressão Arterial

Deve ser, no mímimo, para valores inferiores a 140/ 90 mmHg20(D). Reduções para níveis menores que 130/ 85 mmHg propiciam maior benefício20(D) em pacientes de alto risco cardiovascular43(A), diabéticos em especial com microalbuminúria50(A), com insuficiência cardíaca, com nefropatia e na prevenção primária e secundária de acidente vascular cerebral48(A).

Princípios Gerais do Tratamento Medicamentoso (D):

• Medicamento deve ser eficaz por via oral, bem tolerado e permitir o menor número possível de tomadas diárias;

• Em pacientes em estágio 1, iniciar tratamento com as menores doses efetivas;

• Em pacientes nos estágios 2 e 3, considerar o uso associado de anti-hipertensivos para início de tratamento;

• Respeitar mínimo de quatro semanas para aumentar a dose, substituir a monoterapia ou mudar a associação de fármacos;

• Instruir o paciente sobre a doença, planificação e objetivos terapêuticos, necessidade do tratamento continuado e efeitos adversos dos fármacos;

• Considerar as condições socioeconômicas.

Esquemas Terapêuticos

O tratamento deve ser individualizado e procurar conservar a qualidade de vida do paciente. Qualquer grupo de fármacos anti-hipertensivos, com exceção dos vasodilatadores de ação direta e alfa-bloqueadores, é apropriado para o controle da pressão arterial em monoterapia inicial (Tabela 7)23(D). Os agentes anti-hipertensivos disponíveis no Brasil estão nas Tabelas 8 e 9.

A clortalidona se mostrou superior a doxazosina como escolha medicamentosa inicial em pacientes hipertensos mais velhos com outros fatores de risco50(D) 51(A).

Para o paciente hipertenso com pressão arterial controlada, a associação de baixas doses de ácido acetil salicílico pode diminuir a ocorrência de complicações cardiovasculares52(A).

Prevenção de Hipertensão e Fatores de Risco Associados

Combater a hipertensão é prevenir o aumento da pressão pela redução dos fatores de risco em toda população e nos grupos de maior risco de desenvolver a doença como o normal limítrofe (130 - 139/80 – 89 mmHg)35(D) e aqueles com história familiar de hipertensão. O aparecimento da hipertensão é facilitado pelo excesso de peso53(D), sedentarismo34(D), elevada ingestão de sal26(A), baixa ingestão de potássio46(D) e consumo excessivo de álcool31(B). No grupo com pressão normal limítrofe também contribuem para o aumento do risco cardiovascular as dislipidemias, intolerância à glicose e diabete, tabagismo, menopausa e estresse emocional54(A).

As medidas preventivas incluem: manutenção do peso ideal53(D), prática regular de atividade física35(D), redução da ingestão de sal e aumento da de potássio46(D), evitar a ingestão de bebidas alcoólicas31(B), seguir dieta saudável (Tabela 10) que deve conter baixo teor de gordura, principalmente saturadas, baixo teor de colesterol, elevado teor de potássio e fibras46(D) e baixo teor de sódio26(A). O valor calórico total deve ser ajustado para obtenção e manutenção do peso ideal. A observância global da dieta é mais importante do que o seguimento de medidas isoladas55(B).

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IV Brazilian Guidelines on Hypertension

IV Brazilian Guidelines on Hypertension

Work performed by

Brazilian Society of Hypertension – SBH

Brazilian Society of Cardiology – SBC

Brazilian Society of Nephrology – SBN

Sponsors

Brazilian Academy of Neurology – ABN

Brazilian Association for the Study of Obesity – ABESO

Brazilian Federation of Gynecology and Obstetrics Societies – FEBRASGO

Brazilian Society of Internal Medicine – SBCM

Brazilian Society of Diabetes – SBD

Brazilian Society of Endocrinology and Metabolism – SBEM

Brazilian Society of Geriatrics and Gerontology – SBGG

Organizing Commission

Décio Mion Jr. (Coordenador)

Marco Antônio Mota Gomes (SBC)

Fernando Nobre (SBH)

Celso Amodeo (SBN)

Osvaldo Kohlmann Jr. (SBH)

José Nery Praxedes (SBN)

Carlos Alberto Machado (SBC)

Editing Commission

Carlos Alberto Machado

Celso Amodeo

Décio Mion Jr.

Fernando Nobre

Istênio Pascoal

José Nery Praxedes

Lucélia C. Magalhães

Marco Antônio Mota Gomes

Osvaldo Kohlmann Jr.

Support

AstraZeneca do Brasil Ltda.

Aventis Pharma Ltda.

Bayer S.A.

Biolab Farmacêutica Ltda.

Boehringer Ingelheim do Brasil Quím. e Farm. Ltda.

Farmalab Ind. Químicas e Farmacêuticas Ltda.

Laboratórios Biosintética

Laboratórios Pfizer Ltda.

Libbs Farmacêutica Ltda.

Merck Sharp & Dohme Farmacêutica Ltda.

Novartis Biociências S.A.

Sanofi-Synthélabo Ltda.

Servier do Brasil Ltda.

Introduction

Hypertension is one of the most important health problems in Brazil. It raises the social-medical costs, mainly because of its complications such as cerebrovascular diseases, coronary artery diseases and vascular diseases of the extremities, in addition to cardiac heart failure and chronic renal failure.

Since 1963, cardiovascular diseases have outnumbered other causes of death; they presently account for 27% of all deaths. There was an increase in the mortality risk from these diseases between 1980 and 1984, followed by a decrease until 1996.

Different from North America, which showed a 60% mortality reduction from cerebrovascular causes and a 53% reduction from coronary artery causes, in Brazil (Figure 1) the reductions observed were 20% and 13%, respectively. The trends of mortality risk by cardiovascular diseases are different in the various regions of the country; there is a decrease in the Southeast and South, an increase in the Center-West and Northeast, and stable levels in the North1 (B).

There are few prevalence studies and they do not represent the reality of the country. The investigations shown in Figure 2 indicate high prevalence between 22-44%2 (B) 3-6(A) 7(C). Due to this reality, control programs should be established throughout the country.

Diagnosis and Classification

Hypertension is diagnosed by measuring blood pressure using the methods and conditions described on Table 1, according to the blood pressure levels reported on Table 2.

Measurement of Arterial Pressure17,19(D)

The mercury column manometer is the most appropriate device. The aneroid variety must be tested every 6 months and the electronic models are indicated only when validated.

Diagnostic Routine (D)

A minimum of two blood pressure measurements must be taken at each medical examination, both with the patient seated; if diastolic pressures show differences above 5 mm Hg, new measurements should be taken until a smaller difference is obtained. In a first evaluation, the measurements must be taken in both upper limbs. If a difference is noticed, the arm to be used is the one with the higher blood pressure. Measurements should be repeated in at least 2 or more appointments before the diagnosis of hypertension is confirmed.

Measurement in orthostatic position must be taken at least during the initial evaluation, especially for the elderly, or for diabetic patients with dysautonomias, alcohol addicts, and users of antihypertensive medication.

Criteria for Diagnostic Classification and Follow-up Recommendations20(D)

Any numerical value is arbitrarily attributed and any classification is insufficient. One must consider, in addition to the pressure levels, the presence of risk factors, comorbidities and target organs lesions listed on Table 3.

Children and adolescents have their arterial pressure classified according to the percentiles of height and gender. Values ? 95 percentile are regarded as arterial hypertension.

Clinical Investigation and Therapeutic Decision

The objectives of the clinical investigation include the confirmation of persistent elevation of arterial pressure, evaluation of lesions in target organs, identification of cardiovascular risk factor, diagnosis of associated diseases and etiology of hypertension. To reach this goal, one must consider: a) clinical history – in addition to the usual data of the patient's gender, age, race, socioeconomic status, smoking habits, time since onset of hypertension and blood pressure levels, overweight and obesity, symptoms of coronary artery disease, stroke, or coronary artery disease in family members (in women < 65 years old and men < 55 years old), signs and symptoms of cardiac heart failure, family history of hypertension, cerebral vascular disease, early/sudden death of close family members, peripheral vascular failure, depression, anxiety, panic, renal disease, family situation, diabetes mellitus, salt and alcohol intake, use of medication or drugs that might affect arterial blood pressure, risk factors for atherosclerosis, level of physical activity, dyslipidemia, weight loss and evidence of secondary hypertension, which must always be analyzed when characteristic manifestations are present b) physical examinations – emphasizing weight and height, mitral and aortic murmurs, abdominal circumference, rales, roaring, sibilus, signs of secondary hypertension, abdominal masses (tumors, aneurisms, hydronephrosis, polycystic kidneys), measurements of arterial blood pressure, abdominal murmurs (renal, aortic), pulse rate, brachial, radial, femoral, tibial and pedis pulses, carotid palpation and auscultation, presence of edema, venous stasis, concise neurological exam, thyroid palpation, eye ground exam, ictus suggestive of left ventricular hypertrophy/dilatation, third heart sound (systolic dysfunction of left ventricle), hyperphonesis of A2; c) routine laboratory tests – urinalysis, potassium, creatinine, fasting glucose test, total cholesterol, HDL-cholesterol, triglycerides and electrocardiogram; LDL-cholesterol may be estimated when triglycerides level are below 400mg/dl using the formula: LDL-cholesterol = total cholesterol - HDL-cholesterol - triglycerides/5; d) complementary evaluation if there is evidence of secondary hypertension, target organ injury, or associated diseases21,22(D).

To start the treatment, one must consider the blood pressure levels and the patient's risk according to Tables 3 and 4.

Multiprofessional Approach

Arterial hypertension is a multifactorial disease and as it involves guidelines directed to various objectives, it may demand help from other healthcare professionals in addition to the physician. The setup of this multiprofessional team will provide a differentiated approach to hypertensive patients24(A).

The Team

It may be composed of physicians, nurses, nurse aides, nutritionists, psychologists, social assistants, physical education teachers, pharmacists, management employees, and community agents. It is not necessary to have this whole group composing the team.

Team Actions

They intend to promote health, educational activities emphasizing lifestyle changes, correction of risk factors and production of educational material; training of professionals; referrals to other professionals, when appropriate; individual and group assistance; participation in research projects; program management.

Individual Actions

Actions characteristic to each professional; however, there are situations in which the functions are common to more than one professional and they will be performed naturally using uniform language and approach.

Community Programs

Forming leagues and associations of hypertensive patients may increase complicance and become an instrument of pressure with authorities in order to improve the quality of assistance offered to hypertensive patients.

Non-drug Treatment

Measures of better Effectiveness

Reduction of body weight and maintenance of ideal body weight – body mass index (weight in kilograms divided by square value of height in meters) between 20 and 25 kg/m2, because there is a direct association between body weight and arterial blood pressure25(A).

Reduction of sodium intake – it is healthy to ingest up to 6 g/day, which is the equivalent of 4 shallow coffee spoons of salt (4 g) and 2 g of salt present in natural food; it is important to reduce the amount of salt added to food and to avoid having the salt shaker on the table and eating industrialized food. A regular diet contains between 10-12 g/day of sodium26(A).

Greater potassium intake – a diet rich in vegetables and fruits contains 2-4 g/day and can be helpful to lower blood pressure, as well as preventing arterial hypertension27(A). Salt substitutes containing potassium chloride and a lower amount of sodium chloride (30-50%) are helpful to reduce sodium intake and increase potassium intake.

Reduction of alcoholic beverage consumption28,29 (D) 30,31(B) 32(A) – for alcohol consumers, the ingestion of alcoholic beverages must be limited to 30g of alcohol/day, contained in 600 ml of beer (5% alcohol) or 250 ml of wine (12% alcohol) or 60 ml of distilled drinks (whiskey, vodka, sugar cane liquor - 50% alcohol). This limit must be reduced to half in men with low body weight, women, overweight individuals or those who have high levels of triglycerides.

Regular physical activities33(A) 34(D) – there is an inverse relationship between the level of physical activity and the incidence of hypertension; regular physical activity reduces blood pressure (Table 5).

Measures without Definitive Scientific Evaluation

Calcium supplements 36,37(A), magnesium38(D), vegetarian diets and anti-stress measures.

Associated Measures

Quit smoking – this must be recommended because of its association with a higher incidence of cardiovascular mortality, and increased levels of arterial pressure measured on an outpatient basis39-41(B). Smoke quitting must be accompanied by caloric restriction and increase in physical activity in order to avoid possible weight gain. Exposure to smoke, passive smoking, is also a cardiovascular risk factor which must be avoided42(D).

Control of diabetes and dyslipidemias – glucose intolerance and diabetes are frequently associated with arterial hypertension, causing the occurrence of cardiovascular diseases and complications from diabetes43(A) 44(B). Prevention is based mainly on a hypocaloric diet, regular practice of aerobic physical activities and reduction of simple sugar intake. These measures also intend to keep arterial blood pressure below 130/80 mmHg45(D). Hypercholesterolemia and e hypertriglyceridemia, with low HDL-cholesterol, are important cardiovascular risk factors45(D).

The basis for controlling dyslipidemias is represented by dietary changes with reduction of fat intake and partial replacement of saturated fats by mono- and polyunsaturated fats, as well as reduction of daily cholesterol intake46(D).

Avoid medications that increase arterial blood pressure levels23(D), listed on Table 6 along with specific guidelines for each type of medication.

Drug Treatment

Objective – To reduce cardiovascular morbidity and mortality in hypertensive patients. The objective is reached in patients treated with diuretics47(A), beta blockers47(D), angiotensine-converting enzyme (ECA) inhibitors48(A), antagonists of AT1 receptor of angiotensina II – (AII)49(D) and in older patients who use calcium channel antagonists48(A); the majority of the studies ended up using an association of drugs.

Target of Arterial Blood Pressure Reduction

It should be at least to values below 140/90 mmHg20(D). Reductions to levels below 130/85 mmHg provide greater benefit20(D) to patients with high cardiovascular risk43(A), diabetic patients especially with microalbuminuria50(A) and heart failure, nephropathy and in primary and secondary prevention of stroke48(A).

General Principles of Drug Treatment (D):

• The drug must be effective orally, be well tolerated and allow the smallest possible amount of daily doses;

• With stage 1 patients, treatment should start with the lowest effective doses possible;

• With patients In stages 2 and 3, consider the associated use of an anti-hypertensive drug to start the treatment;

• Observe a minimum of four weeks before increasing the dose, replacing monotherapy or changing the drug association;

• Explain the patient about the disease, treatment plans and objectives, the importance of complying with the treatment, and adverse effects associated with the drugs;

• Consider socioeconomic conditions.

Therapeutic Planning

Treatment must be individualized and should maintain the patient's quality of life. Any group of antihypertensive drugs, except direct-acting vasodilators and alpha-blockers, is appropriate to control arterial blood pressure as initial monotherapy (Table 7)23(D). Antihypertensive agents available in Brazil are shown on Tables 8 e 9.

Chlorthalidone has shown to be superior to doxazosin as an initial treatment drug for older hypertensive patients with other risk factors50(D) 51(A).

For the hypertensive patient with arterial blood pressure under control, the association of low doses of acetylsalicylic acid may reduce the occurrence of cardiovascular complications52(A).

Prevention of Hypertension and Associated Risk Factors

Fighting hypertension means preventing the increase of blood pressure by reducing the risk factors in the overall population and in groups with higher risk of developing the disease within the normal limit values (130 - 139/ 80 - 89 mmHg)35(D) and those with a family history of hypertension. Hypertension is also stimulated by excessive body weight53(D), sedentarism34(D), high salt intake26(A), low potassium intake46(D) and excessive alcohol consumption31(B). In the group with bordering normal blood pressure levels, factors such as dyslipidemias, glucose intolerance and diabetes, smoking, menopause and emotional stress54 (A) also contribute to the increase of cardiovascular risk.

Preventive measures include: maintenance of ideal body weight53(D), regular physical activities35(D), reduction in salt intake and increase in potassium intake46(D), avoiding alcoholic beverages31(B), following a healthy diet (Table 10) which should have a low fat content, mainly saturated fats, low cholesterol, high potassium content and fibers46(D), and low sodium content 26(A). The total calorie count must be adjusted for the purpose of achieving and keeping the ideal body weight. Strictly watching the entire diet is more important than following up isolated measures55 (B).

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