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Hipertensão

Hipertensão
• Prevalência
Hipertensão em PORTUGAL
5023 adultos, idade dos 18-90 anos

Tratada
Nãotratada
HTA
11%
Não afectada
Controlada

42,1% 39% 89% Não Controlada

57% 61%

acedo M, et al. Prevalence, awareness, treatment and control of hypertension in


tudy. J Hypertens. 2005 Sep;23(9):1661-6.
Estratificação
Outros
do
Normal
risco CV em 4
Normal HT Grau 1 HT Grau 2
categorias
factores
de risco PAS 120-
alta PAS
130-139 PAS 140- PAS 160-
HT Grau 3
PAS ≥180
de risco 130-139
129 ou 159 ou 179 ou PAD ou PAD
OD ou ou PAD
PAD 80-84 PAD 90-99 100-109 ≥110
doença
Sem 85-89
outros Risco Risco Moderado
Baixo risco Alto risco
factores médio médio risco
de risco
1-2
Baixo risco Baixo Moderado Moderado Muito alto
factores
risco risco risco risco
de risco
3 ou
mais Risco
Alto risco
factores moderado Alto risco Muito alto
risco, SM Alto risco
risco
Risco
Diabetes Alto risco
Doença moderado
CV ou
Muito alto Muito alto Muito alto Muito alto Muito alto
renal
risco risco risco risco risco
estabele
2007
cida Guidelines ESC/ESH; Journal of Hypertension
2007;25:1105-1187
Monoterapia versus Estratégia de
Combinação
Elevação Ligeira PA Elevação marcada
Risco CV PA
baixo/moderado Escolha entre Alto/muito alto
PA alvo convencional riscoCV
< 140/90 mm Hg PA alvo menor
< 130/80 mm Hg

Agente único em Combinação de 2 fármacos


baixa dose em baixa dose
Se PA alvo não é atingida
Combinação prévia Adicione um 3º
Mesmo Mude para outro
em dose máxima fármaco em baixa
fármaco em fármaco em baixa
dose
alta dose dose
Se a PA alvo não é atingido

Combinação de 2 - Combinação de 2-3


3 fármacos em Monoterapia fármacos em dose
dose máxima em dose máxima
máxima
2007 Guidelines ESC/ESH; Journal of Hypertension 2007;25:1105-
1187
eia de Eventos que Conduzem à Morte C
Arritmias
Trombose Enfarte de
Coronária Miocárdio
Isquemia Morte
Perda de
Miocárdica súbita
músculo

DCA Duplicação
Neurohormonal
Aterosclerose Remodelação
DCV
LVH
Morte Dilatação
Factores de Risco Ventricular
•Dislipidemia
•Hipertensão
•Diabetes Insuficiência
•Tabagismo Cardíaca
Mort
e
Dzau V, et al. Am Heart J 1991; 121:1244
Age-standardized mortality from ischaemic heart disease in European regions (men; age group
45-74 years; year 2000)

Muller-Nordhorn, J. et al. Eur Heart J 2008 0:ehm604v2-11;


doi:10.1093/eurheartj/ehm604

Copyright restrictions may apply.


Age-standardized mortality from ischaemic heart disease in European regions (women; age
group 45-74 years; year 2000)

Muller-Nordhorn, J. et al. Eur Heart J 2008 0:ehm604v2-11;


doi:10.1093/eurheartj/ehm604

Copyright restrictions may apply.


Age-standardized mortality from cerebrovascular disease in European regions (men; age group
45-74 years; year 2000)

Muller-Nordhorn, J. et al. Eur Heart J 2008 0:ehm604v2-11;


doi:10.1093/eurheartj/ehm604

Copyright restrictions may apply.


Age-standardized mortality from cerebrovascular disease in European regions (women; age
group 45-74 years; year 2000)

Muller-Nordhorn, J. et al. Eur Heart J 2008 0:ehm604v2-11;


doi:10.1093/eurheartj/ehm604

Copyright restrictions may apply.


Age-standardized mortality from cerebrovascular disease in European regions (women; age
group 45-74 years; year 2000)

Muller-Nordhorn, J. et al. Eur Heart J 2008 0:ehm604v2-11;


doi:10.1093/eurheartj/ehm604

Copyright restrictions may apply.


Age-standardized mortality from cardiovascular disease, i.e. ischaemic heart disease and
cerebrovascular disease combined, in European regions (women; age group 45-74 years; year
2000)

Muller-Nordhorn, J. et al. Eur Heart J 2008 0:ehm604v2-11;


doi:10.1093/eurheartj/ehm604

Copyright restrictions may apply.


Componentes do Nefrónio
Normal
Cápsula
Bowman Glomérulo

Túbulo Contornado Matrix Mesangial


Próximal

Macrófagos/ Células Mesangiais


Mastócitos da Cél. Musculares Lisas
Adventícia Vasculares

Mácula
Densa
Túbulo Contornado
Nervos Simpáticos Arteríola Eferente
Cél. Distal
Renais
Justaglomerulares
• Ensaio TONHS
• Ensaio DASH
• Ensaio DASH hiposalina
• Ensaio PREMIER
• Dieta versus antihipertensores
Modificação do Estilo de vida
DASH
• Abordagem diferente
• Em vez de avaliar ingestão de Na ou Perda de Peso,
• DASH distribuiu aleatoriamente
• 459 doentes com PA < 160/80-95 mmHg
• grupo controlo dieta baixa frutas e vegetais,
• dieta rica em frutas e vegetais,
• ou uma combinação dieta rica em frutas e vegetais e baixa em
produtos lácteos e baixa em gorduras saturadas e gordura total.
• A Dieta DASH compreende 4-5 porções de fruita, 4-5 porções
vegetais, 2-3 porções de produtos lácteos magros/dia, e <25 % de
gordura.
• Resultados:
• A dieta de frutas e vegetais reduzem a PA em 2,8/1,1 mmHg e a
dieta de combinação reduziu a PA em 5,5/3,0.
• Estes efeitos erma mais pronunciados em doentes hipertensos
– Na dieta combinada a PA reduziu 11.4/5.5 mmHg nos hipertensos
versus 3.5/2.1 mmHg nos normotensos.
• Os efeitos antihipertensores erma máximos ao fim de 2 semanas
com qualquer das dietas e foram matidos por 8 semanas.
Dieta DASH e hiposalina
• Dieta DASH e hipossalina
• Avaliou o efeito de variados graus de ingestão de sódio combinação com consumo
da dieta DASH
• 412 participantes aleatoriamente distribuídos para um grupo controlo ou dieta DASH
e, dentro de cada, ingeriam alimentos com 3 níveis de Na (3,5, 2,3, e 1,2 g) durante
30 dias.
• Resultados:
• Independentemnet doconteúdo em sódio, a dieta DASH induziu redução da PA.
• Na ingestão alta, intermédia ou baixa, a PA sistólica era 5.9, 5.0, e 2.2 mmHg inferior
com a dieta DASH do que a controlo, respectivamente. Valorse PAD eram 2.9, 2.5, e
1.0 mmHg inferior com dieta DASH.
• Com qualquer dieta, a reduçãoa ingestão de sal reduz os níveis de PA, efeito
observado com ou S/ hipertensão, com diferentes raças e géneros.

• When different phases of diet were compared, the most significant decrease in blood
pressure was observed between the high sodium control diet and low sodium DASH
diets, as a comparative overall reduction of 8.9 and 4.5 mmHg in systolic and
diastolic blood pressures, respectively, was noted with the low sodium DASH diet.
• This benefit was even more significant among hypertensive individuals. The mean fall
in systolic blood pressure was 11.5 mmHg.
• Thus, the combination of a low sodium and DASH diet resulted in the most significant
benefit, with decreases in blood pressure comparable to those observed with
antihypertensive agents.
Ensaio PREMIER
• Avaliar o efeito aditivo sobre a PA de 2 intervenções de comportamento.
• 810 doentes with above optimal blood pressure (120 to 159 mmHg systolic pressure and/or 80 to
95 mmHg diastolic pressure) were randomly assigned to one of three groups:
• 1) "established behavioral intervention" (eg, weight loss, physical activity, and limitations in
sodium and alcohol intake),
• 2) the DASH diet plus "established behavioral intervention",
• and 3) one-time advice only.
• Unlike the original DASH study, the subjects prepared their own food. To assess the effects on
blood pressure of the interventions, the effect of advice only (6.6/3.8 mmHg decrease) was
subtracted from the blood pressure change in the intervention groups.
• At six months, the DASH diet plus behavioral intervention produced a small additional decrease
in blood pressure versus that observed with behavioral intervention alone (4.3/2.6 mmHg and
3.7/1.7 mmHg, respectively).
• The prevalence of mild hypertension at study end was significantly less in the two intervention
groups (12 and 17 percent in DASH plus established and established group, respectively) than in
the advice only arm (26 percent). At 18-month follow-up, the prevalence of hypertension had
increased in all three groups but remained lowest in the two intervention groups (22 and 24
percent in DASH plus established and established group, respectively, versus 32 percent in the
advice only)
• Overall, the absolute effects on blood pressure of DASH plus those of behavioral intervention
were not additive. Possible reasons for this less than expected effect of the DASH diet included
the requirement that the subjects prepared their own food, so there was less rigorous adherence
to the diet than in the other DASH studies where all the food was provided: a large blood
pressure decrease in the advice only control group, and a possible similar physiologic
mechanism for blood pressure lowering for both interventions.
TOMHS – Treatment of Mild Hypertension Study
Diminuição da Adesão às Modificações do Estilo
de vida com o tempo
• OTHER DIETARY INTERVENTIONS
Potassium
• Fish oil-
• Fish intake
• Calcium Vegetarian or high fiber diet
Protein intake
• Others
Potássio
• Potassium — Potassium supplementation
may modestly lower the blood pressure.
Suplementos de Óleos de Peixe
• High dose, but not low dose, fish oil supplements may reduce
systemic blood pressure (BP) by up to 6/4 mmHg.
• A metaregression analysis of 36 trials of fish oil, of which 22 had a
double-blind design, found that the intake of a median dose of 3.7
g/day of fish oil provided statistically significant reductions of both
systolic and diastolic pressures (2.1/1.6 mmHg)
• The long-term safety of fish oil in doses high enough to lower the
blood pressure are at present unknown. Potential toxicities include a
bleeding tendency due to prolongation of the bleeding time, a
possible decline in renal function due to decreased production of the
renal vasodilator prostaglandin E2, eructations, the sensation of a
fishy taste, and a possible deleterious effect on lipid metabolism.
• These considerations plus the generally modest antihypertensive
effect argue against the routine use of fish oil supplements.
Ingestão de Peixe
• Fish intake in combination with weight loss
may have additive effects on blood
pressure reduction. In one 16 week
randomized trial, fish intake plus weight
loss was associated with a reduction in
blood pressure from 133/77 mmHg to
119/68 mmHg, twice that observed with
either intervention alone .
Cálcio
• Although there appears to be an inverse relation between dietary
calcium intake and BP, both dietary calcium and calcium
supplements have a relatively small effect on BP. This was
illustrated in a meta-analysis including all 42 randomized controlled
trials available up to May 1997 relating to the relationship between
hypertension and either dietary (dairy) or nondietary supplements of
calcium, which found a reduction in BP of 1.44/0.84 mmHg, with a
trend toward larger effects with dietary supplements .
• Studies published since mid-1997 also show a limited effect of
calcium supplements (in the range of 1 to 2 g/day) on BP . If some
patients do respond to calcium, they are most likely to be those with
lower serum calcium concentrations and higher parathyroid
hormone levels.
• The effect of supplemental calcium on blood pressure is too small to
recommend the use of calcium supplements for the therapy or
prevention of hypertension.
Dieta vegetariana
• Ingestion of a vegetarian diet may have a variety of health benefits,
including a fall in the systemic blood pressure (BP).
• In one randomised trial of 58 patients with mild essential
hypertension, the BP was mildly reduced by a mean of 5/0 mmHg
during the vegetarian diet .
• One major feature of a vegetarian diet that may affect blood
pressure is the amount of dietary fiber, with an increased amount
being associated with decreased systemic pressures.
• Multiple meta-analyses have shown benefits with dietary fiber intake
on blood pressure.
• Meta-analysis 2005 of 24 randomized placebo-controlled trials
published between 1966 and 2003 on the effects of fiber
supplementation found an average fall of 1.2/1.3 mmHg with fiber
intake (average dose of 11.5 g/day). More significant reductions
were observed in older (greater than 40 years) and hypertensive
individuals
Vegetariana
• One postulated explanation for the beneficial effect of vegetarian
diets on blood pressure was the reduction in animal protein intake.
However, the effect of dietary protein on blood pressure is unclear.
In a review of observational studies on dietary protein intake and
blood pressure, an inverse relationship was noted, whereas
intervention studies found little if any effect of protein on blood
pressure.
• Soja
• Soy (vegetable) protein intake may reduce blood pressure. As an
example, one study randomly assigned 302 Chinese subjects with
untreated hypertension (systolic blood pressure between 130 to 159
mmHg) to soybean protein or carbohydrate complex control. After
12 weeks, systolic and diastolic blood pressures were 4.3 and 2.8
mmHg lower among those taking the protein supplement compared
to the control group. There was a greater effect among those with
hypertension at baseline (blood pressure >140/90 mmHg).
Flavonóides
• The beneficial effect of fruits and vegetables on blood
pressure may be due in part to an increased intake of
polyphenols (eg, flavonoids).
• Significant sources of these compounds in Western
countries include tea and cocoa products.
• The effect of cocoa on blood pressure was evaluated in
a 2007 meta-analysis of five studies consisting of 173
subjects.
• At a median duration of intake of two weeks, the mean
systolic and diastolic blood pressure had decreased
significantly by 4.7 and 2.8 mmHg, respectively,
compared with cocoa-free controls.
Conclusões
• Dieta papel importante na génese da
hipertensão
• A perda de peso e a restrição de sal
podem baixar a PA com efeito aditivo aos
antihipertensores
• Uma dieta rica em fruta e vegetais e
produtos lácteos magros pode também
ser benéfica