Guidelines HA 2017 (língua Portuguesa)

 2017 Guidelines for Arterial Hypertension Management in Primary Health Care in Portuguese Language Countries

Osni Moreira Filho

2017, Arquivos brasileiros de cardiologia

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Primary Health Care,

Brazil,

Southern Africa,

Risk assessment,

Portugal

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Special Article

Oliveira et alGuidelines for Hypertension Management in Primary Health Care in Portuguese Language Countries

Arq Bras Cardiol. 2017; 109(5):389-396

Table 7 –

 Clinical situations with indication for or contraindication to specic drugs

Drugs with specic indication

Clinical situationInitial therapy indicated

Heart failureACEI/ARB, diuretics and BB

 AMI, angina pectoris, percutaneous or surgical myocardial revascularization

 ACEI/ARB, BB, ASA, statinsDiabetes mellitusThiazide diuretics, ACEI/CCB, BB

Chronic renal failure

 ACEI/ARB, loop diuretics

Metabolic syndrome

CCB, ACEI/ARB

 Aortic aneurysmBBPeripheral arterial diseaseACEI, CCBPregnancyMethyldopa, CCB

Contraindicated drugs

Clinical situationContraindicated therapy Asthma and chronic bronchitisNon-cardioselective BBPregnancyACEI, ARB AV blockBB, nondihydropyridine CCBGout

Diuretics

Bilateral stenosis of the renal arteryACEI, ARB

 ACEI: angiotensin-converting-enzyme inhibitor; ARB: angiotensin-receptor blocker; CCB: calcium-channel blocker; BB: beta-blockers; AMI: acute myocardialinfarction; ASA: acetylsalicylic acid; AV: atrioventricular. * ACEI and ARB should not be associated, because of the ONTARGET study. Adapted from

2,4

Table 7 depicts the clinical situations with indication foror contraindication to specific drugs. For chronic kidneydisease, ACEI and ARB reduce albuminuria, and thiazidediuretics are used for stages 1 to 3, while loop diuretics, forstages 4 and 5.

2,11-14

Arterial hypertension in pregnancy

Pregnant women with uncomplicated chronic hypertensionshould have BP levels lower than 150/100 mmHg, but DBPshould not be < 80 mmHg.

1,2,11-14

The use of ACEI and ARBis contraindicated during pregnancy, and atenolol and prazosinshould be avoided. Methyldopa, beta-blockers (except atenolol),hydralazine and CCBs (nifedipine, amlodipine and verapamil)can be safely used.

2,11-14

In chronic gestational hypertension with TOD, BP levelsshould be maintained under 140/90 mmHg, and the pregnantwoman should be referred to a specialist for proper careduring delivery and to avoid teratogenicity. Delivery shouldnot be hastened if BP < 160/110 mmHg (with or withoutanti-hypertensive drugs) up to the 37

th

 week. The fetalgrowth and amount of amniotic fluid should be monitoredwith ultrasonography between the 28

th

and 30

th

weeks andbetween the 32

nd

and 34

th

weeks, and with umbilical arteryDoppler. During delivery, BP levels should be monitoredcontinuously.

1,2,12-14

During the puerperium period, BPlevels should be maintained under 140/90 mmHg,preferably with the following drugs, whose use is safeduring lactation: hydrochlorothiazide, spironolactone,alpha-methyldopa, propranolol, hydralazine, minoxidil,verapamil, nifedipine, nimodipine, nitrendipine, benazepril,captopril and enalapril.

1,2,12-15

Preeclampsia (PE) is defined by the presence of SAH afterthe 20

th

gestational week, associated with significant proteinuriaor presence of headache, blurred vision, abdominal pain, low

Table 8 –

 Possible reasons of not achieving proper blood pressure control

•Inadequate adherence to medications, diet, physical activity practice, and consumption of salt, tobacco and alcohol.•Associated conditions: overweight and obesity, obstructive sleep apnea, chronic pain, blood volume overload, chronic kidney disease, thyroid disease.•

Drug interaction: nonsteroidal anti-inammatory drugs, corticosteroids, anabolic steroids, sympathomimetic drugs, decongestants, amphetamine, erythropoietin,

cyclosporine, tacrolimus, licorice, monoamine oxidase inhibitors, serotonin and norepinephrine reuptake inhibitors.•Suboptimal therapeutic regimen, low doses of drugs, inappropriate combinations of anti-hypertensive drugs, renal sodium retention (pseudotolerance).•Secondary hypertension: renovascular disease, primary hyperaldosteronism, pheochromocytoma.

Source: Leung et al.

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Special Article

Oliveira et alGuidelines for Hypertension Management in Primary Health Care in Portuguese Language Countries

Arq Bras Cardiol. 2017; 109(5):389-396

Table 9 – Causes of secondary SAH, signs and complementary diagnostic tests

Clinical ndings

Diagnostic suspicionAdditional studies

Snoring, daytime sleepiness, MS

OSAHS

Berlin questionnaire, polysomnography or homerespiratory polygraphy with at least 5 episodes of

apnea and/or hypopnea per sleep hour RAH and/or hypopotassemia (not necessary) and/or

adrenal nodulePrimary hyperaldosteronism (adrenal hyperplasiaor adenoma)

Measurements of aldosterone (> 15 ng/dL) andplasma renin activity/concentration; aldosterone/renin> 30. Conrmatory tests (furosemide and captopril).

Imaging tests: thin-sliced CT or MRIEdema, anorexia, fatigue, high creatinine and urea,urine sediment changes

Kidney parenchymal disease

Urinalysis, eGFR calculation, renal US, search for

albuminuria/proteinuria

 Abdominal murmur, sudden APE, renal functionchanges due to drugs that block the RAASRenovascular disease

Renal Doppler US and/or renogram, angiography via

MRI or CT, renal arteriography Absent or decreased femoral pulses, decreased bloodpressure in the lower limbs, chest X ray changesCoarctation of the aorta

Echocardiogram and/or chest angiography via CT

Weight gain, decreased libido, fatigue, hirsutism,amenorrhea, ‘moon face’, ‘buffalo hump’, purplestriae, central obesity, hypopotassemiaCushing’s syndrome (hyperplasia, adenoma and

excessive production of ACTH)

Salivary cortisol, 24-h urine free cortisol andsuppression test: morning cortisol (8h) and 8 hoursafter administration of dexamethasone (1 mg)at 12PM. MRI

Paroxysmal AH with headache, sweating

and palpitationsPheochromocytomaFree plasma metanephrines, plasma catecholaminesand urine metanephrines. CT and MRI

Fatigue, weight gain, hair loss, DAH,

muscle weakness

Hypothyroidism (20%)TSH and free T4

Intolerance to heat, weight loss, palpitations,

exophthalmos, hyperthermia, hyperreexia,

tremors, tachycardia

HyperthyroidismTSH and free T4

Renal lithiasis, osteoporosis, depression, lethargy,muscle weakness or spasms, thirst, polyuria

Hyperparathyroidism (hyperplasia or adenoma)Plasma calcium and PTHHeadache, fatigue, visual disorders, enlarged hands,

feet and tongue Acromegaly

IGF-1 and GH levels at baseline and during oral

glucose tolerance test

MS: metabolic syndrome; OSAHS: obstructive sleep apnea-hypopnea syndrome; RAH: resistant arterial hypertension; CT: computed tomography; MRI: magneticresonance imaging; eGFR: estimated glomerular ltration rate; US: ultrasonography; APE: acute pulmonary edema; RAAS: renin-angiotensin-aldosterone system; ACTH: adrenocorticotropin; AH: arterial hypertension; DAH: diastolic arterial hypertension; TSH: thyroid stimulating hormone; PTH: parathormone; IGF-1: insulin-like

growth factor type 1; GH: growth hormone. Source: Malachias et al.

1

platelet count (< 100,000/mm³), elevation of liver enzymes(twice the baseline level), kidney impairment (creatinine> 1.1 mg/dL or twice the baseline level), pulmonary edema,visual or cerebral disorders and scotomas. Eclampsia occurswhen grand mal seizure associates with PE. The use ofmagnesium sulfate is recommended to prevent and treateclampsia, at an attack dose of 4-6 g IV for 10-20 minutes,followed by infusion of 1-3 g/h, usually for 24 hours afterthe seizure. In case of relapse, 2-4 g IV can be administered.The use of corticosteroids, IV anti-hypertensives (hydralazine,labetalol) and blood volume expansion are recommended.Patients should be admitted to the intensive care unit.

1,2,11-15

Table 8 lists the reasons for not achieving proper BP control.It is worth noting the importance of ruling pseudoresistanceout (WCH).

Secondary arterial hypertension

The prevalence of secondary SAH in the hypertensivepopulation is around 3-5%. The most common cause ofsecondary SAH is renal parenchymal disease, responsiblefor 2-5% of the SAH cases. The adrenal causes of SAH andpheochromocytoma occur in less than 1% of all cases of SAH.However, 80% of the patients with Cushing’s syndrome haveSAH. Physicians must keep a high level of clinical suspicionwhen managing hypertensives of difficult control. Table 9 liststhe clinical findings of the major etiologies of secondary SAH,associating them with the complementary tests that should beused to establish the diagnosis.Similarly to CNCD, lifelong adherence to the SAHtreatment is poor. In the first year, 40% of the patients quitregular treatment, which prevent them from profiting froma reduction in both TOD and cardiovascular events, suchas myocardial infarction and stroke. The following factorsare related to non-adherence to treatment: adverse effects,number of daily doses and drug tolerance. Fixed drugcombinations increase adherence by enabling better individualadequacy, reducing the likelihood of irregular use of dailydoses. The involvement of patients and families, as well as amultidisciplinary approach enhance adherence to treatment.The use of interactive apps that increase the participationof patients in BP control is suggested to encourage theirpersistence and regular medication use.

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Special Article

Oliveira et alGuidelines for Hypertension Management in Primary Health Care in Portuguese Language Countries

Arq Bras Cardiol. 2017; 109(5):389-396

1. Malachias MV, Souza WK, Plavnik FL, Rodrigues CI, Brandão AA, NevesMF, et al; Sociedade Brasileira de Cardiologia; Sociedade Brasileira de

Hipertensão; Sociedade Brasileira de Nefrologia. 7th Brazilian Guideline

of Arterial Hypertension. Arq Bras Cardiol. 2016;107(3 Suppl 3):1-83. doi:http://dx.doi.org/10.5935/abc.20160140

2. Mancia G, Fagard R, Narkiewicz K, Redón J, Zanchetti A, Böhm M, et al; Task ForceMembers. 2013 ESH/ESC Guidelines for the management of arterial hypertension:

the Task Force for the management of arterial hypertension of the European Societyof Hypertension (ESH) and of the European Society of Cardiology (ESC). Eur Heart J.2013;34(28):2159-219. doi: 10.1093/eurheartj/eht151.3. Nelumba JE, Vidigal MS, Fernandes M, Luanzo L. Normas Angolanas deHipertensão arterial - 2017. [Acesso em 2017 maio 5]. Disponível em: http:// www.angola-portal.ao/MINSA/Default.aspx.4. República de Moçambique. Ministério da Saúde. Normas para o

diagnóstico, tratamento e controlo da hipertensão arterial e outros factores

de risco cardiovasculares. Misau; 2011.

5. GBD 2015 Risk Factors Collaborators. Global, regional, and national

comparative risk assessment of 79 behavioral, environmental andoccupational, and metabolic risks or clusters of risks, 1990-2015: a

systematic analysis for the Global Burden of Disease Study 2015. Lancet.

2016;388(10053):1659-724.doi: 10.1016/S0140-6736(16)31679-8.6. NCD Risk Factor Collaboration (NCD-RisC). Worldwide trends in bloodpressure from 1975 to 2015: a pooled analysis of 1479 population-based measurement studies with 19·1 million participants. Lancet.2017;389(10064):37-55. doi: 10.1016/S0140-6736(16)31919-5.7. World Health Organization. (WHO). World health statistics 2017: monitoring

health for the SDGs: Sustainable Development Goals. Geneva; 2017.

8. United Nations, Department of Economic and Social Affairs, PopulationDivision (2015). World Population Prospects: the 2015 revision, key findingsand advance. [Accessed in 2017 May 5]. Available from: https://www.un.org/ development/desa/en/ 

9. Global Health Data Exchange. [Accessed in 2016 Jul 16]. Available from:

http://www.healthdata.org/ 10. James PA, Oparil S, Carter BL, Cushman WC, Dennison-Himmelfarb C,Handler J, et al. 2014 Evidence-based guideline for the management of highblood pressure in adults: report from the panel members appointed to theEighth Joint National Committee (JNC 8). JAMA. 2014;311(5):507-20. doi:10.1001/jama.2013.284427.Erratum in:JAMA.2014;311(17):1809.11. Leung AA, Daskalopoulou SS, Dasgupta K, McBrien K, Butalia S,

Zarnke KB, et al; Hypertension Canada. Hypertension Canada’s 2017Guidelines for diagnosis, risk assessment, prevention, and treatment

of hypertension in adults. Can J Cardiol. 2017;33(5):557-76. doi:10.1016/j.cjca.2017.03.005.

12. Krause T, Lovibond K, Caulfield M, McCormack T, Williams B; GuidelineDevelopment Group. Management of hypertension: summary of NICE

guidance.BMJ.2011 Aug 25;343:d4891. doi: 10.1136/bmj.d4891.13. Ritchie LD, Campbell NC, Murchie P. New NICE guidelines for hypertension.BMJ. 2011 Sep 7;343:d5644. doi: 10.1136/bmj.d5644.14. Redman CW

.

Hypertension in pregnancy: the NICE guidelines. Heart.2011;97(23):1967-9. doi: 10.1136/heartjnl-2011-300949.

15. Task Force of the Latin American Society of Hypertension. Guidelines

on the management of arterial hypertension and related comorbiditiesin Latin America. J Hypertens.2017;35(8):1529-45. doi: 10.1097/ HJH.0000000000001418.16. Naderi SH, Bestwick JP, Wald DS. Adherence to drugs that preventcardiovascular disease: meta-analysis on 376,162 patients. Am J Med.2012;125(9):882-7. doi: 10.1016/j.amjmed.2011.12.013