Marta Pereira, Ana Azevedo
Serviço de Higiene e Epidemiologia, Faculdade de Medicina da Universidade do Porto; Unidade de Investigação e Desenvolvimento Cardiovascular do Porto; Instituto de Saúde Pública da Universidade do Porto (ISPUP)
Hypertension is a leading cause of cardiovascular morbidity and mortality and its prevention and appropriate treatment are the key components of the management of this condition. The authors briefly comment on main differences in the definition of hypertension and classification of blood pressure between guidelines for the management of this condition. Then, a critical review is offered on estimates of the prevalence, awareness, treatment and control of hypertension worldwide. Despite a large body of evidence on effective therapies with proven benefits, the proportion of hypertensive patients whose blood pressure is controlled is disappointingly low. The reasons for inadequate blood pressure control are complex and arise from a combination of factors mainly related to patients’ and physicians’ “inertia”. It is unlikely that current management strategies will lead to major improvements. Time limitations, costs and other factors have been pointed out as reasons for the unfeasibility of a sustained closer follow-up with an improvement in patient-physician feedback and information exchange. Research is warranted for the identification of main barriers and usefulness of alternative strategies to improve blood pressure control, such as, for example, the effectiveness of involving other health professionals.
Key-words: hypertension; blood pressure; control; management; prevention; barriers.
Desafios para o Controlo da Hipertensão Arterial a Nível Populacional
]]> A hipertensão arterial é uma das principais causas de morte e morbilidade cardiovascular. Nesta revisão, os autores começam por comentar as principais diferenças na definição de hipertensão e na classificação da pressão arterial entre os vários documentos de recomendações para a abordagem da hipertensão arterial. De seguida, é apresentada uma revisão crítica das estimativas de prevalência, conhecimento, tratamento e controlo da hipertensão arterial. Apesar da evidência disponível sobre opções terapêuticas com efectividade comprovada, a proporção de hipertensos cuja pressão arterial está controlada é muito baixa. Os motivos subjacentes ao inadequado controlo da hipertensão são complexos e de natureza variada, mas prendem-se fundamentalmente com a “inércia” dos clínicos e dos doentes face a esta patologia. Não é provável que apenas com as estratégias actuais se possa alcançar uma melhoria notória neste panorama. As limitações de tempo, entre outros factores, têm sido apontadas como motivo para a não exequibilidade de um seguimento mais apertado, de forma sustentada, para uma melhoria da comunicação entre os clínicos e os doentes. Há necessidade de, no futuro próximo, concentrar esforços na investigação para identificar as principais barreiras e avaliar a utilidade de estratégias alternativas para melhorar o controlo da hipertensão, como, por exemplo, a efectividade do maior envolvimento de outros profissionais de saúde.Palavras-chave: hipertensão; pressão arterial; controlo; gestão; prevenção; barreiras.
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REFERENCES
1 -World Health Report 2002: Reducing risks, promoting healthy life. Geneva, Switzerland: 2002.
]]> 2 -Rodgers A, Ezzati M, Vander Hoorn S, Lopez AD, Lin RB, Murray CJ. Distribution of major health risks: findings from the Global Burden of Disease study. PLoS Med 2004;1:e 27.3 -Ezzati M, Lopez AD, Rodgers A, Vander Hoorn S, Murray CJL. Selected major risk factors and global and regional burden of disease. Lancet 2002;360:1347-60.
[ Links ]4 -Dawber TR, Meadors GF, Moore FE, Jr. Epidemiological approaches to heart disease: the Framingham Study. Am J Public Health Nations Health 1951;41:279-81.
5 -Coronary heart disease in seven countries. I. The study program and objectives. Circulation 1970;41:I1-8.
6 -MacMahon S, Peto R, Cutler J, et al. Blood pressure, stroke, and coronary heart disease. Part 1, Prolonged differences in blood pressure: prospective observational studies corrected for the regression dilution bias. Lancet 1990;335:765-74.
7 -Lawes CM, Vander Hoorn S, Rodgers A. Global burden of blood-pressure-related disease, 2001. Lancet 2008; 371:1513-8.
8 -Stokes J, 3rd. , Kannel WB, Wolf PA, D’Agostino RB, Cupples LA. Blood pressure as a risk factor for cardiovascular disease. The Framingham Study-30 years of follow-up. Hypertension 1989;13:I13-8.
9 -Vasan RS, Larson MG, Leip EP, et al. Impact of high-normal blood pressure on the risk of cardiovascular disease. N Engl J Med 2001;345:1291-7.
10 -Tocci G, Sciarretta S, Volpe M. Development of heart failure in recent hypertension trials. J Hypertens 2008;26:1477-1486.
11 -JagerA, Kostense PJ, Ruhe HG, et al. Microalbuminuria and Peripheral Arterial Disease Are Independent Predictors of Cardiovascular and All-Cause Mortality, Especially Among Hypertensive Subjects: Five-year Follow-up of the Hoorn Study. Arterioscler Thromb Vasc Biol 1999;19:617-24.
]]> 12 -Klag MJ, Whelton PK, Randall BL, et al. Blood pressure and end-stage renal disease in men. N Engl J Med 1996;334:13-8.13 -Frioes F, Azevedo A, Castro A, Alvelos M, Pimenta J, Vazquez B, Bettencourt P, Barros H. Impact of cardiovascular risk factors in an urban sample of Portuguese adults according to the Framingham risk prediction models. Rev Port Cardiol 2003;22:511-20.
14 -Report of the Joint NationalCommittee on Detection, Evaluation, and Treatment of High Blood Pressure. Acooperative study. JAMA 1977;237:255-61.
15 -Mancia G, De Backer G, Dominiczak A, et al. 2007 ESHESC Practice Guidelines for the Management of Arterial Hypertension: ESH-ESC Task Force on the Management of Arterial Hypertension. J Hypertens 2007;25:1751-62.
16 -Chobanian AV, Bakris GL, Black HR, et al. The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure: the JNC 7 report. JAMA 2003;289:2560-72.
17 -Williams B, Poulter NR, Brown MJ, et al. British Hypertension Society guidelines for hypertension management 2004 (BHS-IV): summary. BMJ 2004;328:634-40.
18 -Rodgers A, MacMahon S. Blood pressure and the global burden of cardiovascular disease. Clin Exp Hypertens 1999;21:543-52.
19 -Lewington S, Clarke R, Qizilbash N, Peto R, Collins R. Age-specific relevance of usual blood pressure to vascular mortality: a meta-analysis of individual data for one million adults in 61 prospective studies. Lancet 2002;360:1903-13.
20 -Burt VL, Whelton P, Roccella EJ, et al. Prevalence of hypertension in the US adult population. Results from the Third National Health and Nutrition Examination Survey, 1988-1991. Hypertension 1995;25:305-13.
21 -Stamler J. Epidemiologic findings on body mass and blood pressure in adults. Ann Epidemiol 1991;1:347-62.
]]> 22 -Neter JE, Stam BE, Kok FJ, Grobbee DE, Geleijnse JM. Influence of weight reduction on blood pressure: a meta-analysis of randomized controlled trials. Hypertension 2003;42:878-84.23 -Jackson R, Stewart A, Beaglehole R, Scragg R. Alcohol consumption and blood pressure. Am J Epidemiol 1985;122:1037-44.
24 -Fillmore KM, Stockwell T, Chikritzhs T, Bostrom A, Kerr W. Moderate alcohol use and reduced mortality risk: systematic error in prospective studies and new hypotheses. Ann Epidemiol 2007;17:S16-23.
25 -Adrogue HJ, Madias NE. Sodium and potassium in the pathogenesis of hypertension. N Engl J Med 2007;356:1966-78.
26 -Law MR. Epidemiologic evidence on salt and blood pressure. Am J Hypertens 1997;10:42S-45S.
27 -Dickinson HO, Mason JM, Nicolson DJ, et al. Lifestyle interventions to reduce raised blood pressure: a systematic review of randomized controlled trials. J Hypertens 2006;24:215-33.
28 -Sandvik L, Erikssen J, Thaulow E, Erikssen G, Mundal R, Rodahl K. Physical fitness as a predictor of mortality among healthy, middle-aged Norwegian men. N Engl J Med 1993;328:533-7.
29 -Cornelissen VA, Fagard RH. Effects of endurance training on blood pressure, blood pressure-regulating mechanisms, and cardiovascular risk factors. Hypertension 2005;46:667-75.
30 -Fagard RH. Exercise characteristics and the blood pressure response to dynamic physical training. Med Sci Sports Exerc 2001;33:S484-92; discussion S493-4.
31 -Groppelli A, Giorgi DM, Omboni S, Parati G, Mancia G. Persistent blood pressure increase induced by heavy smoking. J Hypertens 1992;10:495-9.
]]> 32 -Poulsen PL, Ebbehoj E, Hansen KW, Mogensen CE. Effects of smoking on 24-h ambulatory blood pressure and autonomic functionin normoalbuminuricinsulin-dependent diabetes mellitus patients. Am J Hypertens 1998;11:1093-9.33 -Bolinder G, de Faire U. Ambulatory 24-h blood pressure monitoring in healthy, middle-aged smokeless tobacco users, smokers, and nontobacco users. Am J Hypertens 1998;11:1153-63.
34 -Peters JL, Kubzansky L, McNeely E, et al. Stress as a potential modifier of the impact of lead levels on blood pressure: the normative aging study. Environ Health Perspect 2007;115:1154-9.
35 -Gerin W, Chaplin W, Schwartz JE, et al. Sustained blood pressure increase after an acute stressor: the effects of the 11 September 2001 attack on the New York City World Trade Center. J Hypertens 2005;23:279-84.
36 -Schutta MH. Diabetes and hypertension: epidemiology of the relationship and pathophysiology of factors associated with these comorbid conditions. J Cardiometab Syndr 2007;2:124-30.
37 -Kearney PM, Whelton M, Reynolds K, Whelton PK, He J. Worldwide prevalence of hypertension: a systematic review. J Hypertens 2004;22:11-9.
38 -Fields LE, Burt VL, Cutler JA, Hughes J, Roccella EJ, Sorlie P.The burden of adult hypertensionin the United States 1999 to 2000: a rising tide. Hypertension 2004;44:398-404.
39 -Antikainen RL, Moltchanov VA, Chukwuma C, et al. Trends in the prevalence, awareness, treatment and control of hypertension: the WHO MONICAProject. Eur J Cardiovasc Prev Rehabil 2006;13:13-29.
40 -Wolf-Maier K, Cooper RS, Banegas JR, et al. Hypertension Prevalence and Blood Pressure Levels in 6 European Countries, Canada, and the United States. JAMA 2003;289:2363-9.
41 -Macedo ME, Lima MJ, SilvaAO,Alcantara P, Ramalhinho V, Carmona J. Prevalence, awareness, treatment and control of hypertension in Portugal: the PAP study. J Hypertens 2005;23:1661-6.
]]> 42 -Kaur P, Rao TV, Sankarasubbaiyan S, et al. Prevalence and distribution of cardiovascular risk factors in an urban industrial population in south India: a cross-sectional study. J Assoc Physicians India 2007;55:771-6.43 -Maziak W, Rastam S, Mzayek F, Ward KD, Eissenberg T, Keil U. Cardiovascular health among adultsin Syria: a modelfrom developing countries. Ann Epidemiol 2007;17:713-20.
44 -Hoang VM, Byass P, Dao LH, Nguyen TK, Wall S. Risk factors for chronic disease among rural Vietnamese adults and the association of these factors with sociodemographic variables: findings from the WHO STEPS survey in rural Vietnam, 2005. Prev Chronic Dis 2007;4:A22.
45 -Bovet P, Ross AG, Gervasoni JP, et al. Distribution of blood pressure, body mass index and smoking habits in the urban population of Dar es Salaam, Tanzania, and associations with socioeconomic status. Int J Epidemiol 2002;31:240-7.
46 -Mensah GA. Epidemiology of stroke and high blood pressure in Africa. Heart 2008;94:697-705.
47 -Kurian AK, Cardarelli KM. Racial and ethnic differences in cardiovascular disease risk factors: a systematic review. Ethn Dis 2007;17:143-52.
48 -Burt VL, Cutler JA, Higgins M, et al. Trends in the prevalence, awareness, treatment, and control of hypertension in the adult US population. Data from the health examination surveys, 1960 to 1991. Hypertension 1995;26:60-9.
49 -Hagemeister J, Schneider CA, Barabas S, et al. Hypertension guidelines and their limitations--the impact of physicians’ compliance as evaluated by guideline awareness. J Hypertens 2001;19:2079-86.
50 -Hyman DJ, Pavlik VN. Self-reported hypertension treatment practices among primary care physicians: blood pressure thresholds, drug choices, and the role of guidelines and evidence-based medicine.Arch Intern Med 2000;160:2281-6.
51 -Kostis JB, Davis BR, Cutler J, et al. Prevention of heart failure by antihypertensive drug treatment in older persons with isolated systolic hypertension. SHEP Cooperative Research Group. JAMA 1997;278:212-6.
]]> 52 -Psaty BM, Lumley T, Furberg CD, et al. Health Outcomes Associated With Various Antihypertensive Therapies Used as First-Line Agents: A Network Meta-analysis. JAMA 2003;289:2534-2544.53 -Prevention of stroke by antihypertensive drug treatment in older persons with isolated systolic hypertension. Final results of the Systolic Hypertension in the Elderly Program (SHEP). SHEP Cooperative Research Group. JAMA 1991;265:3255-64.
54 -Neal B, MacMahon S, Chapman N. Effects of ACE inhibitors, calcium antagonists, and other blood-pressure-low-ering drugs: results of prospectively designed overviews of randomised trials. Blood Pressure Lowering Treatment Trialists’ Collaboration. Lancet 2000;356:1955-64.
55 -He J, Whelton PK. Epidemiology and prevention of hypertension. Med Clin North Am 1997;81:1077-97.
56 -Sacks FM, Svetkey LP, Vollmer WM, et al. Effects on blood pressure of reduced dietary sodium and the Dietary Approaches to Stop Hypertension (DASH) diet. DASH Sodium Collaborative Research Group. N Engl J Med 2001;344:3-10.
57 -Sacks FM, Svetkey LP, Vollmer WM, et al. Effects on Blood Pressure of Reduced Dietary Sodium and the Dietary Approaches to Stop Hypertension (DASH) Diet. N Engl J Med 2001;344:3-10.
58 -Whelton SP, Chin A, Xin X, He J. Effect of aerobic exercise on blood pressure: a meta-analysis of randomized, controlled trials. Ann Intern Med 2002;136:493-503.
59 -Xin X, He J, Frontini MG, Ogden LG, Motsamai OI, Whelton PK. Effects of alcohol reduction on blood pressure: a meta-analysis of randomized controlled trials. Hypertension2001; 38:1112-7.
60 -Materson BJ, Reda DJ, Cushman WC, et al. Single-drug therapy for hypertension in men. A comparison of six antihypertensive agents with placebo. The Department of Veterans Affairs Cooperative Study Group on Antihypertensive Agents. N Engl J Med 1993;328:914-21.
61 -Polonia J, Ramalhinho V, Martins L, Saavedra J. Portuguese Society of Cardiology recomendations, assessment and treatment of hypertension. Rev Port Cardiol 2006;25:649 -60.
]]> 62 -Direcção Geral da Saúde. Programa Nacional de Prevenção e Controlo das Doenças Cardiovasculares. Ministério da Saúde; 2006.
Correspondência:
Dr.ª Marta Pereira
Serviço de Higiene e Epidemiologia
Faculdade de Medicina da Universidade do Porto
Alameda Prof. Hernâni Monteiro
4200-319 Porto
e-mail: martasfp@med.up.pt