Trends in prevalence of hypertension in Brazil: a systematic review with meta-analysis

Adherence to antihypertensive drug treatment in Brazil: a systematic review and meta-analysis

This article aims to evaluate the adherence to antihypertensive treatment prevalence in the Brazilian population based on peer-reviewed studies which used instruments exclusively designed and/or adapted for this purpose. A systematic review with meta-analysis based on the recommendations of the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA). The search was carried out in the BDENF, SciELO, Cuiden, PsycINFOe, CINAHL, Embase, LILACS, and MEDLINE databases, as well as the AgeLine, Google Scholar and ScienceDirect academic search engines. The protocol was registered with PROSPERO (CRD42021292689). Random effects models were used for a meta-analysis of the prevalence obtained from individual studies. A total of 104 studies were included in the meta-analysis on antihypertensive treatment in the Brazilian population, totaling 38,299 patients. The most used instrument was the four-item Morisky-Green Test (49.5%). The adherence prevalence estimated by the meta-analysis was 44.4% (95%CI: 39.12%-49.94%, I2 = 91.17, p < 0.001), showing high heterogeneity. The adherence to antihypertensive treatment prevalence found in national studies was unsatisfactory, demonstrating that this problem continues to be a major challenge.

Carotid intima-media thickness and incident hypertension: the Brazilian Longitudinal Study of Adult Health

BACKGROUND

High blood pressure (BP) increases carotid intima-media thickness (CIMT). On the other hand, it is not clear whether the vascular abnormalities reflected in high CIMT may predict incident hypertension. The present study aims to investigate the association between CIMT and incident hypertension after 4 years of follow-up in the Brazilian Longitudinal Study of Adult Health (ELSA-Brasil), a multiethnic sample of middle-aged adults from six Brazilian cities.

METHODS

We analyzed data from 6682 ELSA-Brasil participants (aged 35-74) without hypertension and with complete CIMT data at baseline. After 4 years of follow-up, we describe hypertension incidence, stratifying the sample according to age, sex, and race-specific CIMT quartiles. We also built crude and adjusted Poisson regression models to analyze the association between mean and maximal CIMT values and incident hypertension.

RESULTS

We found incident hypertension in 987 (14.8%) participants. According to mean CIMT quartile groups, hypertension incidence varied from 10.2% (first quartile group) to 22.4% (fourth quartile group; P for trend <0.001). In fully adjusted models, 0.1 mm increments in mean CIMT values were associated with a 16% [relative risk (RR):1.16; 95% confidence interval (95% CI) 1.10-1.21; P  < 0.001] higher risk of incident hypertension, respectively. Results were similar when maximal CIMT values were considered instead of mean CIMT values.

CONCLUSION

CIMT values at baseline strongly predicted incident hypertension after 4 years of follow-up in this large multiethnic cohort. This highlights the relationship between CIMT and BP and may provide important insights into the significance of this ultrasound measurement.

Cerebrovascular Disease Mortality Trends in Brazil: An In-Depth Joinpoint Analysis

Background Cerebrovascular disease is the second leading cause of death and the third leading cause of disability following heart disease. In 2019, there were over 101 million people living with a stroke and 12.2 million incidents of stroke globally. For the past three decades, stroke has remained the leading cause of death in Brazil, causing over 100,000 fatalities annually, along with numerous functional impairments among those who survive. The Brazilian healthcare system has witnessed notable advancements in the last decade, including the establishment of additional hospitals and a rise in the count of healthcare professionals specializing in cardiovascular and neurological surgery. However, there exists a gap in the research landscape for continuous comprehensive studies aimed at exploring the evolving mortality rates related to cerebrovascular diseases, of which the last one included data up to 2019. This study aimed to address this gap by meticulously analyzing the trends in cerebrovascular disease mortality in Brazil from 2000 to 2021, for the variables age, sex, state of residence, and geographic region. Methods This is a descriptive, ecological, and time series study. Nationwide data for annual cerebrovascular mortality from Brazil were used for the period 2000-2021. Age-adjusted mortality rates (AAMRs) by direct standardization, encompassing people above 20 years of age, were calculated and expressed per 100,000 persons. Mortality trends were assessed using joinpoint regression analysis by calculating the annual percentage change (APC) and its corresponding 95% confidence interval (CI) across categories of age, sex, and state and region of residence. Results The mortality rates decreased for the sex categories over the analyzed years. The AAMR for the categories decreased as follows: males and females (95 deaths/100,000 to 52 deaths/100,000 inhabitants), males (108 deaths/100,000 to 63 deaths/100,000 inhabitants), and females (83 deaths/100,000 to 44 deaths/100,000 inhabitants). The most substantial reduction in AAMR for males occurred in the 30-39-year age group (APC: -4.10), while the smallest decline was observed in the 20-29-year age group (APC: -1.44). All five macro-regions demonstrated statistically significant and downward AAPC values in mortality rates. The south and midwest regions decreased at a stable rate, as denoted by the same APC and AAPC values (-4.05 and -3.11, respectively). The north and northeast regions exhibited an increase in AAMR, followed by a decrease (APC: 0.68 to -1.42 and 2.63 to -2.35, respectively). Conclusions Our comprehensive analysis revealed a downward trend in cerebrovascular disease mortality rates across diverse demographic groups and macro-regions. Females experienced a more substantial reduction compared to males. Despite higher mortality rates among individuals aged 50 and above, all age groups displayed a marked decrease. The continuous decline can be attributed to policy interventions aimed at enhancing healthcare delivery, increased awareness, and healthier diets and lifestyles. With regard to the macro-regions, the regions in the southern zone demonstrated a more significant decrease as compared to the northern part. In Brazil, a more significant decline in cerebrovascular disease mortality rates could be achieved through increased focus on prevention measures and efforts toward mitigating disparities and inequalities between macro-regions.

Multigenomic modifications in human circulating immune cells in response to consumption of polyphenol-rich extract of yerba mate (Ilex paraguariensis A. St.-Hil.) are suggestive of cardiometabolic protective effects

Mate is a traditional drink obtained from the leaves of yerba mate and rich in a diversity of plant bioactive compounds including polyphenols, particularly chlorogenic acids. Studies, even though limited, suggest that consumption of mate is associated with health effects, including prevention of cardiometabolic disorders. Molecular mechanisms underlying the potential health properties are still largely unknown, especially in humans. The aim of this study was to investigate nutrigenomic effects of mate consumption and identify regulatory networks potentially mediating cardiometabolic health benefits. Healthy middle-aged men at risk for CVD consumed a standardised mate extract or placebo for 4 weeks. Global gene expression, including protein coding and non-coding RNA profiles, was determined using microarrays. Biological function analyses were performed using integrated bioinformatic tools. Comparison of global gene expression profiles showed significant change following mate consumption with 2635 significantly differentially expressed genes, among which six are miRNA and 244 are lncRNA. Functional analyses showed that these genes are involved in regulation of cell interactions and motility, inflammation or cell signalling. Transcription factors, such as MEF2A, MYB or HNF1A, could have their activity modulated by mate consumption either by direct interaction with polyphenol metabolites or by interactions of metabolites with cell signalling proteins, like p38 or ERK1/2, that could modulate transcription factor activity and regulate expression of genes observed. Correlation analysis suggests that expression profile is inversely associated with gene expression profiles of patients with cardiometabolic disorders. Therefore, mate consumption may exert cardiometabolic protective effects by modulating gene expression towards a protective profile.

The impact of urbanisation on the cardiometabolic health of Indigenous Brazilian peoples: a systematic review and meta-analysis, and data from the Brazilian Health registry

BACKGROUND

Indigenous Brazilian peoples have faced an unparalleled increase in the rate of cardiovascular diseases following rapid nutritional transition to more urban diets. We aimed to conduct a systematic review and meta-analysis to evaluate the association between urbanisation (including data from Amazon rainforest deforestation) and cardiometabolic risk factors and outcomes.

METHODS

In this systematic review and meta-analysis, we searched Pubmed, Embase, Web of Science, and Scopus for articles published in any language between the year 1950 and March 10, 2022. Studies conducted in Indigenous Brazilian adults that evaluated metabolic health were included. Data for deforestation was obtained by the Amazon Deforestation Monitoring Project. Cardiovascular mortality was obtained from the Brazilian Health registry. Two independent reviewers evaluated studies for risk of bias, according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses recommendations. The main outcomes assessed were the prevalence of obesity and related cardiometabolic risk factors among Indigenous Brazilian peoples and its association with urbanisation. Summary data were extracted from published reports for the meta-analyses. We calculated pooled estimates of the prevalence of each cardiometabolic outcome by using a random-effects model (DerSimonian-Laird method). This study is registered with the International Prospective Register of Systematic Reviews, CRD42021285480.

FINDINGS

46 studies were identified, including a total of 20 574 adults from at least 33 Indigenous Brazilian ethnicities. Meta-analyses of the prevalence of obesity showed that there were higher rates of obesity (midwest region: 23% [95% CI 17-29]; and south region 23% [13-34]) and hypertension (south region: 30% [10-50]) in Indigenous peoples living in urban regions of Brazil, while the lowest rates of obesity (11% [95% CI 8-15]) and hypertension (1% [1-2]) were observed in those in the less urbanised (north) regions of Brazil. The prevalence of obesity was 3·5 times higher in participants living in urbanised Indigenous territories (28%) than in those living in lands with >80% native Amazon rainforest (8%). In meta-analyses that evaluated blood pressure level, there was no incremental change in blood pressure with ageing in Indigenous peoples who lived according to traditional lifestyle, in contrast to those living in urbanised regions. For Indigenous men with traditional lifestyles, systolic blood pressure changed from 109·8 mm Hg to 104·4 mm Hg between the youngest (<30 years) and the oldest (>60 years) age groups, and diastolic blood pressure changed from 69·8 mm Hg to 66·1 mm Hg. For Indigenous women with traditional lifestyles, systolic blood pressure was 100·0 mm Hg for the youngest age group with no changes for older age groups, and diastolic blood pressure was 62 mm Hg for the youngest age group with no changes for older age groups. For Indigenous men with urbanised lifestyles, systolic blood pressure changed from 117·3 mm Hg to 124·9 mm Hg between the youngest and the oldest age groups, and diastolic blood pressure changed from 72·7 mm Hg to 76·4 mm Hg. For Indigenous women with urbanised lifestyles, systolic blood pressure changed from 110·0 mm Hg to 116·0 mm Hg between the youngest and the oldest age groups, and diastolic blood pressure changed from 68·3 mm Hg to 74·0 mm Hg. For the years 1997 and 2019, the cardiovascular mortality rate in individuals living in the southeast region (the most urbanised) was 2·5 times greater than that observed in the north. Conversely, the incremental rise in cardiovascular mortality in the past two decades among Indigenous Brazilians living in the north or northeast (2·7 times increase) stands in stark contrast to the stable rates in those living in already urbanised regions.

INTERPRETATION

The macrosocial changes of Indigenous peoples' traditional ways of living consequent to urbanisation are associated with an increased prevalence of adverse cardiometabolic outcomes. These data highlight the urgent need for environmental policies to ensure the conservation of the natural ecosystem within Indigenous territories, as well as the development of socio-health policies to improve the cardiovascular health of Indigenous Brazilians peoples living in urban areas.

FUNDING

None.

The NO-cGMP-K+ Channel Pathway Participates in Diuretic and Cardioprotective Effects of Blutaparon portulacoides in Spontaneously Hypertensive Rats

Blutaparon portulacoides is a Brazilian plant species that is widely used in folk medicine. The present study investigated the role of an aqueous extract of B. portulacoides against hypertension in spontaneously hypertensive rats. The aqueous extract of B. portulacoides was obtained from the whole plant. Its chemical profile was analyzed by ultraperformance liquid chromatography-tandem mass spectrometry. The acute toxicity of the aqueous extract of B. portulacoides was evaluated in female Wistar rats. Male 6-month-old spontaneously hypertensive rats then received the aqueous extract of B. portulacoides (30, 100, and 300 mg/kg), hydrochlorothiazide (25 mg/kg), or vehicle once daily for 28 days. On days 1, 14, and 28, the diuretic effects of the aqueous extract of B. portulacoides were evaluated. The role of prostaglandins and the nitric oxide-cyclic guanosine monophosphate-potassium channel pathway in the diuretic activity of the aqueous extract of B. portulacoides was also investigated. At the end of the treatment, hepatic and renal biochemical markers, serum nitrotyrosine, malondialdehyde, nitrite, and aldosterone levels, and angiotensin-converting enzyme activity were measured. The electrocardiographic profile, blood pressure, and renal vascular reactivity were also assessed. The heart, kidneys, and liver were collected to determine relative organ weight, histopathology, and cardiac morphometry. Caffeic acid, ferulic acid, and several flavonoids were identified in the aqueous extract of B. portulacoides. No signs of toxicity were observed. Prolonged treatment with the aqueous extract of B. portulacoides (300 mg/kg) induced significant diuretic activity by activating the nitric oxide-cyclic guanosine monophosphate-potassium channel pathway. These effects reduced blood pressure and oxidative stress and prevented renal vascular dysfunction and left ventricular hypertrophy that was induced by hypertension. Overall, the present data suggest that the aqueous extract of B. portulacoides has important diuretic and cardioprotective effects by activation of the nitric oxide-cyclic guanosine monophosphate-potassium channel pathway.

Variabilidade da Pressão Arterial em Única Visita e Risco Cardiovascular em Participantes do ELSA-Brasil

Fundamento

A variabilidade da pressão arterial (VPA) tem valor prognóstico para desfechos cardiovasculares fatais e não fatais.

Objetivos

Este estudo teve como objetivo avaliar a associação entre a VPA em uma única visita e o risco cardiovascular em participantes do Estudo Longitudinal de Saúde do Adulto (ELSA-Brasil).

Métodos

O presente estudo transversal foi conduzido com dados basais (2008-2010) de 14.357 participantes do ELSA-Brasil, sem história de doença cardiovascular. A VPA foi quantificada pelo coeficiente de variação de três medidas padronizadas da pressão arterial sistólica (PAS) realizadas com um oscilômetro. Medidas antropométricas e exames laboratoriais também foram realizados. O risco cardiovascular foi avaliado pelo estimador de risco de doença cardiovascular aterosclerótica (ASCVD), e se empregou a análise de regressão logística multivariada com nível de significância de 5%.

Resultados

Um risco cardiovascular significativamente maior foi determinado por uma VPA elevada para ambos os sexos. Uma prevalência significativamente maior de alto risco foi observada mais em homens que em mulheres em todos os quartis, com a maior diferença observada no quarto quartil de variabilidade (48,3% vs. 17,1%). Comparações entre quartis por sexo revelaram um risco significativamente mais alto para homens no terceiro (OR=1,20; IC95%: 1,02 - 1,40) e no quarto quartis OR=1,46; IC95%: 1,25 -1,71), e para mulheres no quarto quartil (OR=1,27; IC95%: 1,03 - 1,57).

Conclusão

Análises de dados basais de participantes do ELSA-Brasil revelaram que a variabilidade da pressão arterial se associou com risco cardiovascular aumentado, especialmente nos homens.

Body mass index is superior to other body adiposity indexes in predicting incident hypertension in a highly admixed sample after 10-year follow-up: The Baependi Heart Study

Hypertension is the leading cause of overall mortality in low- and middle-income countries. In Brazil, there is paucity of data on the determinants of incident hypertension and related risk factors. We aimed to determine the incidence of hypertension in a sample from the Brazilian population and investigate possible relationships with body adiposity indexes. We assessed risk factors associated with cardiovascular disease, including adiposity body indexes and biochemical analysis, in a sample from the Baependi Heart Study before and after a 10-year follow-up. Hypertension was defined by the presence of systolic blood pressure (SBP) ≥140 mmHg and/or diastolic blood pressure ≥90 mmHg or the use of antihypertensive drugs. From an initial sample of 1693 participants, 498 (56% women; mean age 38 ± 13 years) were eligible to be included. The overall hypertension incidence was 24.3% (22.3% in men and 25.6% in women). Persons who developed hypertension had higher prevalence of obesity, higher levels for blood pressure, higher frequency of dyslipidemia, and higher body adiposity indexes at baseline. The best prediction model for incident hypertension includes age, sex, HDL-c, SBP, and Body Mass Index (BMI) [AUC = 0.823, OR = 1.58 (95% CI 1.23-2.04)]. BMI was superior in its predictive capacity when compared to Body Adiposity Index (BAI), Body Roundness Index (BRI), and Visceral Adiposity Index (VAI). Incident hypertension in a sample from the Brazilian population was 24.3% after 10-year follow-up and BMI, albeit the simpler index to be calculated, is the best anthropometric index to predict incident hypertension.

Challenges faced by patients with dyslipidemia and systemic arterial hypertension in Brazil: a design of the patient journey

BACKGROUND AND OBJECTIVE

Non-communicable diseases like systemic arterial hypertension (SAH) and dyslipidemia are poorly studied in terms of patient journey aspects. This semi-systematic review provides evidence synthesis for the management of SAH and dyslipidemia in Brazil and also discusses challenges faced by patients at the local level along with a suggested care approach by local experts.

METHODS

A semi-systematic review using both structured literature databases (Embase and Medline) and unstructured scientific records (WHO, IPD, MOH and Google) on hypertension and dyslipidemia in the English language from 2010 to 2019 was performed by reviewers. After two-level screening based on pre-defined criteria, patient journey touchpoints and prevalence information were extracted from the included articles. Data gaps were bridged through the insights of local experts.

RESULTS

Prevalence of hypertension and dyslipidemia in Brazil were 23% and 40.8%, respectively. Awareness of dyslipidemia was found in a larger proportion (58.1%) than in SAH (22.2%). Similarly, screening for hypertension (97%) and dyslipidemia (55.4%) were found to be effective, while treatment was (62.9%) and (30.0%) for hypertension and dyslipidemia, respectively.

CONCLUSION

There were important gaps on patient awareness and treatment of dyslipidemia and hypertension. Limited patient education, regional disease distribution, and treatment allocation, along with limited resources for diagnosis and treatment are the key challenges.

Temporal Trend of the Prevalence of Modifiable Risk Factors of Stroke: An Ecological Study of Brazilians between 2006 and 2012

Stroke is one of the leading causes of death worldwide, including in Brazil. This study aimed to analyze the temporal trend of the prevalence of modifiable risk factors of stroke from 2006 to 2012. This ecological study was conducted by secondary analysis in May 2018, using data from the surveillance of risk factors and protection for chronic diseases by telephone inquiry (VIGITEL) available in the Department of Informatics of the Unified Health System (DATASUS). The modifiable risk factors of stroke in Brazilians were systemic arterial hypertension, diabetes mellitus, abusive alcohol consumption, overweight, and obesity. Overall, there was a significant increase in the risk factors of diabetes (β = 0.30, P = 0.001, r2 = 0.99), overweight (β = 0.50, P = 0.002, r2 = 0.98), and obesity (β = 0.88, P < 0.001, r2 = 0.96). However, there was a stability in the prevalence of hypertension (β = 0.25, P = 0.320, r2 = 0.88) and alcohol abuse (β = 0.32, P = 0.116, r2 = 0.49). There was an increase in the prevalence of diabetes mellitus, overweight, and obesity, but stability in systemic arterial hypertension and abusive alcohol consumption in the Brazilian population.

A Concise and Useful Guide to Understand How Alpha1 Adrenoceptor Antagonists Work

Adrenoceptors are the receptors for the catecholamines, adrenaline and noradrenaline. They are divided in α (α1 and α2) and β (β1, β2 and β3). α1-Adrenoceptors are subdivided in α1A, α1B and α1D. Most tissues express mixtures of α1-adrenoceptors subtypes, which appear to coexist in different densities and ratios, and in most cases their responses are probably due to the activation of more than one type. The three subtypes of α1-adrenoceptors are G-protein-coupled receptors (GPCR), specifically coupled to Gq/11. Additionally, the activation of these receptors may activate other signaling pathways or different components of these pathways, which leads to a great variety of possible cellular effects. The first clinically used α1 antagonist was Prazosin, for Systemic Arterial Hypertension (SAH). It was followed by its congeners, Terazosin and Doxazosin. Nowadays, there are many classes of α-adrenergic antagonists with different selectivity profiles. In addition to SAH, the α1-adrenoceptors are used for the treatment of Benign Prostatic Hyperplasia (BPH) and urolithiasis. This antagonism may be part of the mechanism of action of tricyclic antidepressants. Moreover, the activation of these receptors may lead to adverse effects such as orthostatic hypotension, similar to what happens with the antidepressants and with some antipsychotic. Structure-activity relationships can explain, in part, how antagonists work and how selective they can be for each one of the subtypes. However, it is necessary to develop new molecules which antagonize the α1-adrenoceptors or make chemical modifications in these molecules to improve the selectivity, pharmacokinetic profile and/or reduce the adverse effects of known drugs.

ELSA-Brasil: a 4-year incidence of hearing loss in adults with and without hypertension

OBJECTIVE

To compare the incidence of hearing loss among adults stratified by the occurrence of hypertension, and to investigate the association between hypertension and hearing loss.

METHODS

Longitudinal observational study, part of the Estudo Longitudinal da Saúde do Adulto (ELSA-Brasil, Longitudinal Study on Adult's Health). Data from the first and second waves were analyzed, including information from audiological assessment and general health of the subjects. As outcome, we considered the presence of hearing loss (hearing thresholds above 25 dBHL at frequencies from 500 Hz to 8 kHz) and, as exposure variable, hypertension (report of medical diagnosis of hypertension; and/or use of drugs to treat hypertension; and/or pressure systolic blood pressure ≥ 140 mmHg; or diastolic blood pressure ≥ 90 mmHg). As covariables for adjustment were considered: sex, age, education, race / ethnicity, income, smoking, diabetes, and occupational exposure to noise. Poisson regression analysis was conducted, estimating the crude and adjusted relative risks, with 95% confidence intervals, in order to assess the factors associated with hearing loss.

RESULTS

In crude analyses, the incidence of hearing loss was higher for subjects with hypertension (9.7% versus 5.4%). The crude relative risks for hearing loss was almost double (1.93; 95%CI: 1.10-3.39) for subjects with hypertension in the right ear. In the adjusted analyses, the relative risks was not significant for the hypertension variable (1.42; 95%CI: 0.75-2.67). Being 60 years or older (RR: 5.41; 95%CI: 2.79-10.50) showed a statistically significant association with hearing loss, indicating that older adults have higher relative risks for hearing loss.

CONCLUSION

In the adjusted analyses controlled for multiple risk factors there was no association between hypertension and hearing loss. The dichotomous variable age (being 60 years or older), on the other hand, has shown a significant association with hearing loss.

Recruitment methods and yield rates in a clinical trial of physical exercise for older adults with hypertension-HAEL Study: a study within a trial

Background

Although the prevalence of hypertension is high in older adults, clinical trial recruitment is a challenge. Our main aim was to describe the HAEL Study recruitment methods and yield rates. The secondary objectives were to explore the reasons for exclusion and to describe the characteristics of the enrolled participants.

Methods

This is a descriptive study within a trial. The HAEL Study was a Brazilian randomized two-center, parallel trial with an estimated sample of 184 participants. The recruitment strategy was based on four methods: electronic health records, word of mouth, print and electronic flyer, and press media. The yield rate was the ratio of the number of participants who underwent randomization to the total number of volunteers screened, calculated for overall, per recruitment method, by study center and by age group and sex. Additionally, we described the reasons for exclusion in the screening phase, as well as the demographic characteristics of those enrolled. The data are presented in absolute/relative frequencies and mean ± standard deviation.

Results

A total of 717 individuals were screened, and 168 were randomized over 32 months. The yield rate was higher for word of mouth (30.1%) in the overall sample. However, press media contributed the most (39.9%) to the absolute number of participants randomized in the trial. The coordinating center and participating center differed in methods with the highest yield ratios and absolute numbers of randomized participants. The main reason for exclusion in the screening phase was due to the physically active status in those intending to participate in the study (61.5%). Out of 220 participants included, 52 were excluded mainly because they did not meet the eligibility criteria (26.9%). Most of the screened volunteers were women (60.2%) age 60–69 years (59.5%), and most of the randomized participants were Caucasian/white (78.0%).

Conclusions

Multiple recruitment methods constituted effective strategies. We observed that approximately one of every four individuals screened was allocated to an intervention group. Even so, there were limitations in obtaining a representative sample of older Brazilian adults with hypertension. Data show an underrepresentation of race and age groups.

Trial registration

This SWAT was not registered.

Blood Pressure Control and Adherence to Drug Treatment in Patients with Hypertension Treated at a Specialized Outpatient Clinic: A Cross-Sectional Study

OBJECTIVE

To evaluate and identify variables associated with the control of hypertension and adherence to antihypertensive drug treatment in a group of patients with hypertension monitored in a specialized, highly complex outpatient service.

METHODS

A prospective, cross-sectional study was carried out in the hypertension unit of a tertiary teaching hospital. Patients diagnosed with hypertensive aged 18 years and over and accompanied for at least six months were included in the study. Patients with secondary hypertension and pregnant women were excluded. The sample consisted of 253 patients. Adherence/concordance to antihypertensive treatment was assessed using the Morisky Green Levine Scale. Blood pressure control was set for values less than 140/90 mmHg. Variables with p≤0.20 in univariate analysis were included in multiple logistic regression. The level of significance adopted was p ≤0.05.

RESULTS

Most of patients were white, married and women, with a mean age of 65 (13.3) years old, low income, and education levels. Blood pressure control and adherence were observed in 69.2% and 90.1% of the patients, respectively. Variables that were independently associated with blood pressure control were (OR, odds ratio; CI, 95% confidence interval): married marital status (OR 2.3; CI 1.34-4.28), use of calcium channel blockers (OR 0.4; CI 0.19-0.92) and number of prescribed antihypertensive drugs (OR 0.78; CI 0.66-0.92). Adherence was not associated with any of the variables studied.

CONCLUSION

There was a high frequency of patients with satisfactory adherence to antihypertensive drug treatment. Blood pressure control was less frequent and was associated with social and treatment-related factors.

Difficulty in taking medication and stroke among older adults with systemic arterial hypertension: the Fibra Study

This article aims to investigate whether difficulty in taking medication is associated with stroke among older adults with Systemic Arterial Hypertension (SAH) and to explore their association with living arrangements. Cross-sectional study was based on 3,502 older adults with SAH from the four universities pole of Frailty in Brazilian Older People (Fibra) Study, Brazil, including 14 municipalities of the five Brazilian regions. We used the medical diagnosis of stroke and difficulty in taking medications (self-reported difficulty and financial difficulty affording prescribed medications). Multivariate analysis was performed using logistic regression. Differently from women, older men with SAH, which report difficulty in taking medication (unintentional non-adherence), have higher odds of stroke. When stratified by living arrangements, those living with a partner have even higher odds of stroke compared to those without difficulty in taking medication and living alone. None association was found for difficulty affording prescribed medication for both men and women. Unintentional difficulty in taking medication plays a role in SAH treatment among men. Primary care strategies for controlling blood pressure should not be focus only on patients but targeting spouses as well.

Development, Validation, and Reproducibility of Food Group-Based Frequency Questionnaires for Clinical Use in Brazil: A Pre-Hypertension and Hypertension Diet Assessment

The Blood pressure control diet is well described; however, it has not been implemented in clinical care, possibly due to the impracticability of the diet assessment in these contexts. In order to facilitate the dietary assessment, we developed and assessed the validity and reproducibility of two food group-based food frequency questionnaires (FG-FFQs), with a one-week (7-day FG-FFQ) and a one-month (30-day FG-FFQ) period of coverage for patients with pre-hypertension or hypertension. In 2010, 155 men and women, 30–70 years old, were invited to participate in a prospective study in two outpatient clinics in Porto Alegre, southern Brazil. The participants responded to two 30-day, two 7-day FG-FFQ, four 24-h dietary recalls, and underwent demographic, anthropometric, and blood pressure assessments. The validity and reproducibility were assessed using partial correlation coefficients adjusted for sex and age, and the internal validity was tested using the intra-class correlation coefficient. The participants were aged 61 (±10) years and 60% were women. The validity correlation coefficient was higher than r = 0.80 in the 30-day FG-FFQ for whole bread (r = 0.81) and the 7-day FG-FFQ for diet/light/zero soda and industrialized juices (r = 0.84) in comparison to the 24-h dietary recalls. The global internal validity was α = 0.59, but it increased to α = 0.76 when 19 redundant food groups were excluded. The reproducibility was higher than r = 0.80 for pasta, potatoes and manioc, bakery goods, sugar and cocoa, and beans for both versions. The 30-day had a slightly higher validity, both had good internal validity, and the 7-day FG-FFQ had a higher reproducibility.

Nitric Oxide as a Central Molecule in Hypertension: Focus on the Vasorelaxant Activity of New Nitric Oxide Donors

Cardiovascular diseases include all types of disorders related to the heart or blood vessels. High blood pressure is an important risk factor for cardiac complications and pathological disorders. An increase in circulating angiotensin-II is a potent stimulus for the expression of reactive oxygen species and pro-inflammatory cytokines that activate oxidative stress, perpetuating a deleterious effect in hypertension. Studies demonstrate the capacity of NO to prevent platelet or leukocyte activation and adhesion and inhibition of proliferation, as well as to modulate inflammatory or anti-inflammatory reactions and migration of vascular smooth muscle cells. However, in conditions of low availability of NO, such as during hypertension, these processes are impaired. Currently, there is great interest in the development of compounds capable of releasing NO in a modulated and stable way. Accordingly, compounds containing metal ions coupled to NO are being investigated and are widely recognized as having great relevance in the treatment of different diseases. Therefore, the exogenous administration of NO is an attractive and pharmacological alternative in the study and treatment of hypertension. The present review summarizes the role of nitric oxide in hypertension, focusing on the role of new NO donors, particularly the metal-based drugs and their protagonist activity in vascular function.

Discrepancies in Observed and Predicted Longitudinal Change in Central Hemodynamic Measures: The Framingham Heart Study

[Figure: see text].

Resistant hypertension: Prevalence and profile of patients followed in a university ambulatory

BACKGROUND

Hypertension affects about 36 million Brazilians. It is estimated that 10%-20% of these have resistant hypertension. These patients are at an increased risk of early target organ damage, as well as cardiovascular and renal events.

OBJECTIVE

To estimate the prevalence of resistant hypertension in a specialized outpatient clinic, to describe the sociodemographic and clinical characteristics of these patients, and to identify possible factors associated with resistant hypertension.

METHODS

Data collection from medical records of hypertensive patients treated using oral antihypertensive drugs in optimized doses at a specialized university clinic from March 2014 to December 2014, after ethical approval statement. All patients were using appropriate antihypertensive drugs in optimized doses and assisted at a teaching-assistance clinic of internal medicine of the Bahiana School of Medicine and Public Health in Brazil.

RESULTS

A total of 104 patients were enrolled and 31.7% (n = 33) had criteria for resistant hypertension. Of the total participants, 75.7% were female and 54.8% were black or brown. The average age was 61.7 years (SD ± 10.1). In the resistant hypertension group, 63.6% had diabetes, compared to 32.4% in the hypertension group. Among resistant hypertensive patients, 51.5% had dyslipidemia. Regarding drug treatment, 75.8% of the resistant hypertension group and 51.4% of the hypertension group used statins. Among patients with resistant hypertension, 90.9% used angiotensin II receptor blockers and 66.7%, dihydropyridine calcium channel blockers. In the resistant hypertension group, 75.8% used beta-blockers, against 25.4% in the hypertension group.

CONCLUSION

The prevalence of hypertension was higher than that described in the global literature, which may be associated with the high percentage of black and brown ("pardos") patients in the population studied, and also because the study was performed in a specialized outpatient clinic.

Recent Trends in Cardiovascular Mortality in Rio de Janeiro State Health Regions and Capital

Fundamento:

A mortalidade por doenças cardiovasculares (DCV) vem mostrando tendência à estabilização em alguns países, incluindo o Brasil e o estado do Rio de Janeiro, após décadas de queda. Não encontramos análises detalhadas dessa tendência para o estado do Rio de Janeiro.

Objetivo:

Analisar as tendências da mortalidade prematura e tardia por doenças do aparelho circulatório (DAC), doença isquêmica do coração (DIC) e doença cerebrovascular (DCBV) por sexo nas regiões de saúde do estado do Rio de Janeiro e capital (1996-2016).

Métodos:

Dados de óbitos e população foram obtidos no DATASUS/MS. Taxas foram compensadas por códigos mal definidos, corrigidos pelos códigos cardiovasculares mal definidos e ajustadas por sexo e idade pelo método direto. O Joinpoint Trend Analysis Software foi empregado para calcular a variação percentual anual (APC) e variação percentual anual média (AAPC). Foram consideradas para o estudo APC e AAPC significativamente diferentes de zero, calculadas por um teste de student com significância de 5%.

Resultados:

A mortalidade por DIC estabilizou ou até aumentou em pelo menos 50% das localidades analisadas (EAPC ≥0). Nas regiões Norte e Noroeste, nenhuma mudança foi observada. Para DCBV, apenas uma região apresentou estabilidade na mortalidade (EAPC próximo a 0). Para as outras regiões, a taxa continuou a diminuir (APC <0) até 2016.

Conclusão:

Esses resultados observados no Rio de Janeiro devem se repetir em várias regiões brasileiras e apontam para a necessidade de uma resposta na abordagem dos comportamentos no estilo de vida. Os médicos da atenção primária devem estar familiarizados com a tendência desfavorável da doença isquêmica do coração entre os adultos mais jovens e rastrear ativamente os fatores de risco para DCV, com atenção especial às mulheres.

Cardiovascular Risk Factors in Cardiology Specialists from the Brazilian Society of Cardiology

BACKGROUND

A major cause of death worldwide, cardiovascular diseases and their prevalence in cardiologists are little known.

OBJECTIVES

To describe life habits and cardiovascular risk factors (CVRF) and to investigate the prevalence of diagnosis, awareness, and control of these CVRF among cardiologists members affiliated to and specialists from the Brazilian Society of Cardiology.

METHODS

National multicenter cross-sectional study to assess Brazilian cardiologists using a questionnaire on life habits, preexisting diseases, current medications, anthropometric measurements, blood pressure, and levels of glucose and lipids.

RESULTS

A total of 555 cardiologists were evaluated, of which 67.9% were male, with a mean age of 47.2±11.7 years. Most were non-smoker (88.7%) and physically active (77.1%), consumed alcohol (78.2%), had normal weight circumference (51.7%), and were overweight (56.1%). The prevalence of systemic arterial hypertension (SAH), diabetes mellitus (DM), and dyslipidemia (DLP) were 32.4%, 5.9%, and 49.7%, respectively, of which only 57.2%, 45.5%, and 49.6%, respectively, were aware of the diseases.

CONCLUSIONS

The Brazilian cardiologists participating in the study had a high prevalence of SAH, DM and DLP, but only a half of participants were aware of these conditions and, among these, the rates of controlled disease were low for SAH and DLP, although cardiologists are professionals with great knowledge about these CVRF. These findings represent a warning sign for the approach of CVRF in Brazilian cardiologists and encourage the conduction of future studies.

Blood pressure control of hypertensive patients followed in a high complexity clinic and associated variables

INTRODUCTION

Arterial hypertension is a disease that has a high impact on cardiovascular mortality and morbidity; however, it is still insufficiently controlled.

OBJECTIVES

To assess hypertension control in patients seen at a specialized clinic and to identify associated variables.

METHOD

Cross-sectional study involving the analysis of medical records from 782 patients treated in a highly complex outpatient clinic. Inclusion criteria: age ≥18 years, diagnosed with hypertension, in treatment ≥6 months. Patients with secondary hypertension (104) and incomplete data (64) were excluded. The main outcome was blood pressure control (systolic <140 and diastolic <90 mmHg). The independent variables studied were: sociodemographic and clinical characteristics (use of drugs, comorbidities and laboratory tests). Pearson's χ2 tests, Fisher's test, Student's t and Wilcoxon-Mann-Whitney tests were performed in the bivariate analysis and logistic regression in the multiple analyses, adopting p≤0.05.

RESULTS

The prevalence of hypertensive control was 51.1%. It was associated with a lack of control: body mass index (OR = 1.038; 95% CI = 1.008 - 1.071), history of stroke (OR = 0.453; 95% CI = 0.245 - 0.821), left ventricular hypertrophy (OR = 1.765; 95% CI = 1.052 - 3.011), and number of medications (OR = 1.082; 95% CI = 1.033 - 1.136).

CONCLUSION

About half of the hypertensive patients had their blood pressure controlled; clinical variables and target organ damage were associated with the control.

Adherence to antihypertensive medication after referral to secondary healthcare: A prospective cohort study

BACKGROUND

Nonadherence (NAd) to antihypertensive medication is associated with lack of blood pressure control and worsened long-term outcomes. Increased access to a programme for high-risk cardiovascular patients has the potential to reduce NAd and improve clinical outcomes. We evaluated implementation NAd prevalence and risk factors among severely hypertensive patients after 12-month-long access to secondary healthcare centres.

METHODS

The Morisky Green Levine Scale (MGLS) was used to analyse antihypertensive medication NAd in a prospective cohort of 485 patients. Logistic regression models evaluated the influence of ecological model factors on NAd.

RESULTS

The majority of patients were female, had low health literacy, a low family income and a mean age of 61.8 ± 12.5 years. Prevalence of NAd fell from 57.1% at programme entry to 28.3% (P < .001) at the end of the study. After access to a secondary healthcare centre, we observed better blood pressure control, an increase in the number of pills/day and a higher number of antihypertensive medications. Predictive variables of NAd were age (OR 1.027; CI 1.003-1.051; P = .023), low health literacy (OR 1.987; CI 1.009-3.913; P = .047), systolic blood pressure (OR 1.010; CI 1.003-1.021; P = .049), dosages ≥ 2 times/day (OR 1.941; CI 1.091-3.451; P = .024) and patient satisfaction with the healthcare team (OR 0.711; IC 0.516-0.980; P = .037).

CONCLUSIONS

Greater access to health services is associated with a reduction in NAd to antihypertensive medication and better blood pressure control. NAd was correlated with modifiable variables such as treatment complexity and, for the first time, team satisfaction, suggesting that implementation of similar programmes may limit NAd in similar patient groups.

Evidence of Nonadherence in Cases of Pseudoresistant Hypertension

Resistant hypertension (RH) is characterized by the use of three or more antihypertensive drugs without reaching the goal of controlling blood pressure (BP). For a definitive diagnosis of RH, it is necessary to exclude causes of pseudoresistance, including the white-coat effect, errors in BP measurement, secondary hypertension, therapeutic inertia, and poor adherence to lifestyle changes and pharmacological treatment. Herein, we report the history of a patient with long-standing uncontrolled BP, even when using seven antihypertensive drugs. Causes of secondary hypertension that justified the high BP levels were investigated, in addition to the other causes of pseudo-RH. In view of the difficult-to-control BP situation, it was decided to hospitalize the patient for better investigation. After 5 days, he had BP control with practically the same medications previously used. Finally, all factors related to the presence of pseudo-RH are discussed, especially poor adherence to treatment. Poor adherence to antihypertensive treatment is common in daily medical practice, and its investigation is of fundamental importance for better management of BP.

Hemodynamic responses of resistance exercise performed with repetitions to failure and not to failure in adults with hypertension

OBJECTIVE

To evaluate and compare the hemodynamic responses of resistance exercise (RE) performed with repetitions to failure vs. not to failure in individuals with hypertension.

METHODS

Twenty participants were randomly allocated to perform three experimental sessions: a RE session performed with repetitions to failure (RF); a RE session performed with repetitions not to failure (NRF); and a non-exercise control session (Con). RE sessions were composed of four sets of 10 repetitions in four exercises involving large muscle groups. To ensure that the sets could be performed with RF or NRF, intensities corresponding to 75% and 50% of one-repetition maximum test were adopted in RF and NRF sessions, respectively. The Con was performed in seated rest. Blood pressure and rate-pressure product were measured before, during and after the experimental sessions for 1 h.

RESULTS

SBP and DBP decreased after NRF compared with Con (systolic post 1 h: -7.7 ± 1.1 mmHg, P < 0.001; diastolic post 1 h: -4.2 ± 0.7 mmHg, P = 0.001), and after RF compared with Con (systolic post 1 h: -8.2 ± 1.3 mmHg, P < 0.001; diastolic post 1 h: -7.4 ± 1.4 mmHg, P < 0.001). No significant difference was found in blood pressure between RF and NRF sessions after 1 h. Rate-pressure product was lower during NRF compared with RF (P = 0.001), suggesting a higher cardiovascular demand during the RF session.

CONCLUSION

The RF and NRF sessions are equally effective to promote post-exercise hypotension. In addition, NRF session can reduce cardiac demand during the exercise and should be recommended in adults with hypertension.

The prevalence and associated factors of nonadherence to antihypertensive medication in secondary healthcare

PURPOSE

Non-adherence (NA) to medication is a major contributor to treatment failure in hypertensive patients. Factors of the ecological model, at family/healthcare professional, service, and system levels, are rarely evaluated as correlates of NA in hypertensive patients.

METHODS

This crossectional study assessed the prevalence of and associated factors of NA to antihypertensive medication among 485 hypertensive patients upon receiving secondary healthcare. The Morisky Green Levine Scale (MGLS) measured the implementation phase of adherence, and the Short Assessment of Health Literacy for Portuguese-speaking Adults (SAHLPA) instrument, health literacy. Multivariate analysis to NA included variables according to the levels of the ecological model.

RESULTS

Most patients were female (56.3%), white (53.2%), mean age of 62.0 ± 12.6 years, illiterate (61.6%), with low health literacy (70.9%), and low income (65.4%). Uncontrolled BP was frequent (75.2%); 57.1% of patients were nonadherent. In multivariate analysis based on the ecological model, adjusted for micro, meso- and macro-level correlates, NA was associated only with variables of patient-level: low health literacy (OR 1.62, CI 1.07-2.44, p = 0.020), income ≥ two reference wages (OR 0.46, CI 0.22-0.93, p = 0.031), lack of homeownership (OR 1.99, CI 1.13-3.51, p = 0.017), sedentarism (OR 1.78, CI 1.12-2.83, p = 0.014), and complexity of treatment (number of medications taken ≥ two times/day) (OR 1.56, CI 1.01-2.41, p = 0.042).

CONCLUSION

In this group of severely hypertensive patients with high cardiovascular risk, only patient-related characteristics were associated with NA. Our findings highlight the need for effective actions to optimize clinical outcomes in similar healthcare programs.

Effect of recreational beach tennis on ambulatory blood pressure and physical fitness in hypertensive individuals (BAH study): rationale and study protocol

BACKGROUND

Different physical activities are widely recommended as non-pharmacological therapies to reduce blood pressure. However, the effectiveness of exercise programs is associated with its continuity and regularity, and the long-term adherence to traditional exercise interventions is often low. Recreational sports emerge as an alternative, being more captivating and able to retain individuals for longer periods. Besides, sport interventions have demonstrated improvements in physical fitness components that are associated with a lower incidence of hypertension. However, no studies have investigated the effects of recreational sports on 24 h ambulatory blood pressure. The aim of the present study is to evaluate the effect of beach tennis training on ambulatory blood pressure and physical fitness in individuals with hypertension.

METHODS

This study will be a randomized, single-blinded, two-arm, parallel, and superiority trial. Forty-two participants aged 35-65 years with previous diagnosis of hypertension will be randomized to 12 weeks of beach tennis training group (two sessions per week lasting 45-60 min) or a non-exercising control group. Ambulatory (primary outcome) and office blood pressures, cardiorespiratory fitness, muscle strength/power and quality of life will be assessed at baseline and after the intervention period.

DISCUSSION

Our conceptual hypothesis is that beach tennis training will reduce ambulatory blood pressure and improve fitness parameters in middle-aged individuals with hypertension. The results of this trial are expected to provide evidences of efficacy of recreational beach tennis practice on blood pressure management and to support sport recommendations for clinical scenario in higher risk populations.

TRIAL REGISTRATION

ClinicalTrials.gov, NCT03909321 . Registered on April 10, 2019.

Intergenerational educational mobility, discrimination, and hypertension in adults from Southern Brazil

Systemic arterial hypertension (SAH) or high blood pressure a serious global public health problem marked by social inequalities. There are few studies on SAH in Brazil with a life-course theoretical perspective. The current article aims to analyze the relationship between intergenerational educational mobility (IEM) and SAH in Brazilian adults, verifying the impact of interpersonal and color/"race" discrimination on this relationship. The authors analyzed data from 1,720 adults (20-59 years) and their parents in the EpiFloripa Adult Study. Random-effects multilevel regression models were estimated. The fixed effects showed an inverse relationship between IEM and odds of SAH, with statistical significance for high IEM (paternal model: OR = 0.39, p = 0.006; maternal model: OR = 0.35, p = 0.002; and family model: OR = 0.35, p = 0.001). Meanwhile, interaction models showed that situations of discrimination can act jointly with unfavorable IEM, increasing the odds of SAH, especially among black and brown individuals. The study concludes that persistently high IEM is capable of significantly reducing the odds of SAH, while discrimination can intensify the effect of low education, especially in socially marginalized population segments.

Clinical and epidemiological aspects of chronic Chagas disease from Southern Brazil

INTRODUCTION

Patients with Chagas disease (CD), caused by Trypanosoma cruzi, present a higher risk of developing other chronic diseases, which may contribute to CD severity. Since CD is underreported in the southern state of Paraná, Brazil, we aimed to characterize clinical and epidemiological aspects of individuals chronically infected with T. cruzi in Southern Brazil.

METHODS

A community hospital-based study was performed, recording clinical/demographic characteristics of 237 patients with CD from Southern Brazil. To estimate the association between different forms of CD and sociodemographic and clinical variables, multiple logistic regression models were built using the Akaike information criterion.

RESULTS

Mean age was 57.5 years and 59% were females. Most patients' (60%) place of origin/birth was within Paraná and they were admitted to the CD outpatient clinic after presenting with cardiac/digestive symptoms (64%). The predominant form of CD was cardiac (53%), followed by indeterminate (36%), and digestive (11%). The main electrocardiographic changes were in the right bundle branch block (39%) and left anterior fascicular block (32%). The average number of comorbidities per patient was 3.9±2.3; systemic arterial hypertension was most common (64%), followed by dyslipidemia (34%) and diabetes (19%); overlapping comorbidities were counted separately. Male sex was associated with symptomatic cardiac CD (OR=2.92; 95%CI: 1.05-8.12; p=0.040).

CONCLUSIONS

This study provided greater understanding of the distribution and clinical profile of CD patients in Southern Brazil, indicating a high prevalence of comorbidities among these patients who are a vulnerable group due to advanced age and substantial risk of morbidity.

Association of self-reported sleep disturbances with ideal cardiovascular health in Brazilian adults: A cross-sectional population-based study

OBJECTIVE

To examine the association between sleep disturbances and cardiovascular health in Brazilian adults.

METHODS

We analyzed cross-sectional data from a nationally representative sample of 36,480 Brazilian adults ages 18 and over. Multivariate Poisson regression models were used to assess the association between sleep disturbances (difficulty falling asleep, frequent interruptions in sleep, or sleeping more than usual) and Life's Simple 7 (LS7) cardiovascular health (CVH) scores through consideration of four behaviors (smoking, physical activity, body mass index, and diet) and three biological factors (hypercholesterolemia, hypertension, and diabetes).

RESULTS

Adults with no sleep disturbances had better CVH, with higher mean LS7 CVH scores (4.2, 95% confidence interval [CI]: 4.1; 4.2) when compared to those experiencing some level of sleep disturbance within a 2-week timespan (3.8, 95% CI: 3.7; 3.8). Specifically, compared to those with no sleep disturbance, adults reporting sleep disturbances for half of the weekdays had significantly lower LS7 CVH mean scores (β = -0.02, 95% CI: -0.04; 0.01). Adults who had disturbances more than half of the weekdays had even lower scores (β = -0.06, 95% CI: -0.09; -0.02), followed by those who reported disturbances almost every day (β = -0.08, 95% CI: -0.11; -0.04), even after adjusting for age, sex, education status, depressive symptoms, and night shift work.

CONCLUSION

Brazilian adults with sleep disturbances are less likely to achieve ideal CVH. Given that sleep disturbances seem to be increasingly common in Brazil, recent gains in CVH mortality may be affected.

Trends in prevalence, mortality, and morbidity associated with high systolic blood pressure in Brazil from 1990 to 2017: estimates from the "Global Burden of Disease 2017" (GBD 2017) study

Background

Hypertension remains the leading risk factor for cardiovascular disease (CVD) worldwide, and its impact in Brazil should be assessed in order to better address the issue. We aimed to describe trends in prevalence and burden of disease attributable to high systolic blood pressure (HSBP) among Brazilians ≥ 25 years old according to sex and federal units (FU) using the Global Burden of Disease (GBD) 2017 estimates.

Methods

We used the comparative risk assessment developed for the GBD study to estimate trends in attributable deaths and disability-adjusted life-years (DALY), by sex, and FU for HSBP from 1990 to 2017. This study included 14 HSBP-outcome pairs. HSBP was defined as ≥ 140 mmHg for prevalence estimates, and a theoretical minimum risk exposure level (TMREL) of 110–115 mmHg was considered for disease burden. We estimated the portion of deaths and DALYs attributed to HSBP. We also explored the drivers of trends in HSBP burden, as well as the correlation between disease burden and sociodemographic development index (SDI).

Results

In Brazil, the prevalence of HSBP is 18.9% (95% uncertainty intervals [UI] 18.5–19.3%), with an annual 0.4% increase rate, while age-standardized death rates attributable to HSBP decreased from 189.2 (95%UI 168.5–209.2) deaths to 104.8 (95%UI 94.9–114.4) deaths per 100,000 from 1990 to 2017. In spite of that, the total number of deaths attributable to HSBP increased 53.4% and HSBP raised from 3rd to 1st position, as the leading risk factor for deaths during the period. Regarding total DALYs, HSBP raised from 4th in 1990 to 2nd cause in 2017. The main driver of change of HSBP burden is population aging. Across FUs, the reduction in the age-standardized death rates attributable to HSBP correlated with higher SDI.

Conclusions

While HSBP prevalence shows an increasing trend, age-standardized death and DALY rates are decreasing in Brazil, probably as results of successful public policies for CVD secondary prevention and control, but suboptimal control of its determinants. Reduction was more significant in FUs with higher SDI, suggesting that the effect of health policies was heterogeneous. Moreover, HSBP has become the main risk factor for death in Brazil, mainly due to population aging.

Effects of a single bout of power exercise training on ambulatory blood pressure in older adults with hypertension: A randomized controlled crossover study

OBJECTIVE

To evaluate the effect of a single bout of power exercise training (PT) on office and ambulatory blood pressure (BP).

METHODS

Twenty-four older adults with essential hypertension participated in two experimental sessions in a randomized order: the PT composed of 3 sets of 8-10 repetitions in 5 power training exercises and the non-exercise control at seated rest (Con). Both experimental sessions lasted 40 min. Office BP was measured continuously for 1 h in the laboratory and 24 h BP through ambulatory blood pressure monitoring.

RESULTS

Compared with Con, office systolic/diastolic BP decreased after PT (Systolic BP: 10 mmHg, p < 0.001; Diastolic BP: 4 mmHg, p = 0.015). A trend toward decrease (p = 0.06) was found in diastolic ambulatory BP during daytime (2 mmHg; p = 0.062) and nighttime (3 mmHg; p = 0.063) after PT. No differences were found between PT and Con sessions for systolic and mean ambulatory BP.

CONCLUSION

A single bout of PT decreases office BP but this hypotensive effect is not sustained under ambulatory conditions in older patients with essential hypertension.

Postexercise Hypotension After Muscle Power Training Session in Older Adults With Hypertension

The aim of the present study was to determine the acute effects of a muscle power training (PT) session on arterial blood pressure (BP) in older adults with hypertension. Thirteen participants (64 ± 4 years) with essential hypertension were randomly assigned to a PT session and control session without exercise. During PT, the participants performed three sets of eight repetitions at 50% of the one-repetition maximum tests. The concentric phase during each repetition was performed as fast as possible. The systolic BP (post-15 min: -1.7 ± 1.8 mmHg [p = .048; d = 0.22]; post-30 min: -3.6 ± 1.7 mmHg [p = .010; d = 0.48]; post-45 min: -3.3 ± 1.3 mmHg [p = .002; d = 0.42]; post-60 min: -3.9 ± 1.7 mmHg [p = .003; d = 0.49]) and diastolic BP (post-15 min: -1.5 ± 1.5 mmHg [p = .053; d = 0.20]; post-30 min: -2.2 ± 1.7 mmHg [p = .001; d = 0.29]; post-45 min: -2.0 ± 2.0 mmHg [p = .001; d = 0.27]; post-60 min: -2.0 ± 1.3 mmHg [p < .001; d = 0.26]) reductions were observed at all times after the PT session, compared with the preexercise and control session. PT is an effective strategy to acutely reduce BP in older patients with essential hypertension.

Health Characteristics of the Madeira Riverine Population

Introduction

The Amazon River Basin is the largest and the most complex fluvial system in the world. The Brazilian government provides dental and medical care to the riverine populations in this region in part through medical assistance missions, conducted by four hospital ships. The Brazilian Navy invited U.S. Navy medical personnel to join the February 2019 mission aboard Navio de Assistência Hospitalar (NAsH) Carlos Chagas to provide care along the Madeira River.

Materials and Methods

In the course of providing primary care services, demographic, health, and dental data of the Madeira Riverine population were collected. Descriptive statistics were used to generate average health and dental data. Chi-square tests were used to compare population prevalence data. Linear regression was used to evaluate dental caries per patient with proximity to nearest large population center and village population. This project was approved by Naval Medical Center Portsmouth Institutional Review Board.

Results

The Madeira Riverine population has similar dental health to Brazilians living in urban centers. Their prevalence of hypertension and diabetes compared favorably with the U.S. averages (17.7% vs. 34.3% [P &lt; 0.001] and 3% vs. 9.4% [P &lt; 0.001], respectively). Based on the most prevalent ICD-10 code diagnoses, future missions can expect high volumes of patients with intestinal parasites, hypertension, common skin infections, women’s health concerns, and musculoskeletal complaints.

Conclusions

This study adds to the limited health data currently available on Brazilian Riverine populations. It demonstrates the effectiveness of the Hospital Assistance missions in providing dental care and documents some unique aspects of Riverine health that warrant further study.

LRADO, Cunha EHM, Maioli TU, Vieira AT, Speziali E, Corrêa-Oliveira R, Martins-Filho OA, Teixeira-Carvalho A, Franceschi C, Rampelli S, Turroni S, Brigidi P, Faria AMC. Hypertension Is Associated With Intestinal Microbiota Dysbiosis and Inflammation in a Brazilian Population

Hypertension is a major global health challenge, as it represents the main risk factor for stroke and cardiovascular disease. It is a multifactorial clinical condition characterized by high and sustained levels of blood pressure, likely resulting from a complex interplay of endogenous and environmental factors. The gut microbiota has been strongly supposed to be involved but its role in hypertension is still poorly understood. In an attempt to fill this gap, here we characterized the microbial composition of fecal samples from 48 hypertensive and 32 normotensive Brazilian individuals by next-generation sequencing of the 16S rRNA gene. In addition, the cytokine production of peripheral blood samples was investigated to build an immunological profile of these individuals. We identified a dysbiosis of the intestinal microbiota in hypertensive subjects, featured by reduced biodiversity and distinct bacterial signatures compared with the normotensive counterpart. Along with a reduction in Bacteroidetes members, hypertensive individuals were indeed mainly characterized by increased proportions of Lactobacillus and Akkermansia while decreased relative abundances of well-known butyrate-producing commensals, including Roseburia and Faecalibacterium within the Lachnospiraceae and Ruminococcaceae families. We also observed an inflamed immune profile in hypertensive individuals with an increase in TNF/IFN-γ ratio, and in TNF and IL-6 production when compared to normotensive ones. Our work provides the first evidence of association of hypertension with altered gut microbiota and inflammation in a Brazilian population. While lending support to the existence of potential microbial signatures of hypertension, likely to be robust to age and geography, our findings point to largely neglected bacteria as potential contributors to intestinal homeostasis loss and emphasize the high vulnerability of hypertensive individuals to inflammation-related disorders.

Impact of Coming Demographic Changes on the Number of Adults in Need of Care for Hypertension in Brazil, China, India, Indonesia, Mexico, and South Africa

Over the coming decades, middle-income countries are expected to undergo substantial demographic changes. We estimated the consequences of these changes on the number of adults in need of hypertension care between 2015 and 2050 using nationally representative household-survey data collected in Brazil, China, India, Indonesia, Mexico, and South Africa (N=770 121). To reflect unmet need for healthcare, we defined hypertension as systolic blood pressure ≥140 mm Hg or diastolic blood pressure ≥90 mm Hg regardless of treatment status. Using a mathematical disease projection equation, we calculated the change in the number of individuals in need of hypertension care in each country that was due to changes in population size, age composition, and age-specific prevalence under various epidemiological scenarios. If the current age-specific prevalence schedule of hypertension remains unchanged until 2050, demographic changes alone will increase the number of adults in need of hypertension care by 319.7 million individuals, ranging from a relative growth of 55% in China to 151% in Mexico. Even if the age-specific prevalence of hypertension is reduced by 25% by 2050 among adults aged ≥40 years, the number of individuals in need of hypertension care will still increase by 145.9 million individuals, with relative increases ranging from 16% in China to 88% in Mexico. Overall, our results suggest that coming demographic changes in middle-income countries will overpower even ideal prevention efforts. Middle-income countries will need to massively expand healthcare services for aging-related diseases, such as hypertension, if they are to meet the virtually inevitable future increase in care needs for these conditions.

The Xavante Longitudinal Health Study in Brazil: Objectives, design, and key results

OBJECTIVE

The Xavante Longitudinal Health Study was developed to permit granular tracking of contemporary health challenges faced by indigenous communities in Brazil, taking into consideration ongoing historical processes that may be associated with increases in child undernutrition, adult obesity, and cardiovascular disease risks.

METHODS

This was an open-cohort study with six semiannual data collection waves from 2009 to 2012. The study was undertaken in two Xavante villages, Pimentel Barbosa and Etênhiritipá, State of Mato Grosso, Central Brazil. No sampling technique was used. Data collection placed emphasis on growth and nutrition of children under five and nutrition status, blood pressure, and blood glucose levels of adolescents and adults.

RESULTS

Baseline data collection began in July/August 2009 with a population census (656 individuals). Between the first and final waves, the study population increased by 17%. At baseline, stunting and wasting was elevated for most age groups <10 years. Overweight, obesity, and increased risk of metabolic complications were expressive among individuals >17 years, disproportionately affecting females. Anemia was elevated in most age groups, especially among females. Mean systolic and diastolic blood pressure was moderate. The overall prevalence of high blood pressure was relatively low.

CONCLUSIONS

Our findings reveal marked health disparities relative to the Brazilian national population and a complex dietary health epidemiology involving the double burden of malnutrition, rapidly changing nutritional indicators, and elevated metabolic disease risk. The topically broad multidisciplinary focus permitted construction of the richest longitudinal data set of socio-epidemiological information for an indigenous population in Brazil.

Estimation of salt intake in the Brazilian population: results from the 2013 National Health Survey

OBJECTIVE

To estimate the salt intake in the Brazilian population according to their urinary sodium excretion.

METHODS

The National Health Survey (2013) aimed to gather data on the health of adults (≥ 18 years) through a random selection of households. In each household, one adult was selected to have their biological data collected (anthropometry, blood pressure, and blood and urine tests). The urine sample was sent to a central laboratory to determine sodium (ion-selective electrode) and creatinine (Jaffé method) concentrations. Sodium excretion was estimated with the Tanaka equation.

RESULTS

Urinary sodium and creatinine concentrations were measured in 8,083individuals (58% women). The mean salt intake was estimated at 9.34 g/day (95% confidence interval - 95%CI 9.27 - 9.41) and was higher in males (9.63 g/day; 95%CI 9.52 - 9.74) than in females (9.08 g/day; 95%CI 8.99 - 9.17). Wefound no significant differences regarding age group, ethnicity, or schooling. Salt intake was higher in the Southeast and South regions and lower in the Northeast and North. Only 2.4% (95%CI 2.0 - 2.8) of the sample consumed less than 5 g/day, and 58.2% (95%CI 56.7 - 59.6) of participants had an estimated intake of 8 to 12 g/day.

CONCLUSION

The mean salt intake in the Brazilian population is approximately twice the recommended by the World Health Organization (5g/day).Given the association of high salt intake with hypertension and decreased renal function, these data indicate the need to adopt comprehensive public policies to reduce the consumption in the Brazilian population.

Prevalence of Systemic Arterial Hypertension and Associated Factors Among Adults from the Semi-Arid Region of Pernambuco, Brazil

Background

Systemic arterial hypertension is a substantial public health problem responsible for millions of deaths per year worldwide. However, little is known about the epidemiology of this disease in areas distant from large urban centers in Brazil. Such information is necessary to plan health promotion strategies.

Objective

To estimate the prevalence of hypertension and determine its associated factors in adults residing in the semi-arid region of the state of Pernambuco, Northeastern Brazil.

Method

This is a cross-sectional study conducted with a random sample of male and female adults. Individuals with systolic blood pressure ≥ 140 mm/Hg and/or diastolic blood pressure ≥ 90 mm/Hg and those who reported being under treatment with antihypertensive drugs were considered hypertensive. We collected data on demographic, socioeconomic, behavioral, and anthropometric characteristics, as well as health and nutrition. The statistical analysis used Pearson’s chi-square test, the chi-square test for trend, and multivariate Poisson regression analysis. A p-value < 0.05 in the final model was considered indicative of statistical significance.

Results

The sample consisted of 416 individuals, and the prevalence of hypertension was 27.4% (95%CI 23.2 - 32.0). In the final model, the independent predictors of hypertension were age of 40 years or older (p = 0.000), low economic class (p = 0.007), smoking (p = 0.023), overweight determined by the body mass index (p = 0.003), and reduced glucose tolerance/diabetes mellitus (p = 0.012).

Conclusion

The prevalence of hypertension was high and related to important risk factors. Thus, prevention and control strategies are recommended.

The trend in blood pressure and hypertension prevalence in the general population of South Kivu between 2012 and 2016: Results from two representative cross-sectional surveys-The Bukavu observational study

Objective

Data on blood pressure trends are scarce or unavailable in Sub-Saharan Africa in general and especially in the Democratic Republic of the Congo. This work addresses this gap by analyzing the dynamics in the prevalence and control of hypertension in a cohort of Congolese adults in South Kivu.

Methods

Two phases of data collection were conducted including a baseline at the beginning in 2012 and a follow up in 2016. The subjects were ≥ 18 years old living in urban (n = 4413) or rural areas (n = 6453). Hypertension was defined as a blood pressure ≥ 140/90 mmHg and/or taking antihypertensive medications. The crude prevalence of hypertension was age-adjusted to the WHO population.

Results

Between 2012 and 2016, there was a significant increase in blood pressure (+2.5/+1.4 mmHg; p = 0.001), age standardized prevalence of hypertension [19.0% vs. 18.0%; OR = 1.05 (1.02–1.08); p<0.0001], and obesity (7.9% to 9.8%; p<0.0001) as well as the proportion of subjects > 60 years old (8.8% to 11.3%; p<0.0001) and those with tachycardia (10.5% to 14.4%; p<0.0001). The number of subjects under treatment of hypertension were statistically non-significant [16.1% vs. 14.3%; p = 0.29), but the level of control of hypertension was significantly reduced by 32.4% in 2016 compared in 2012 (43.5% vs. 64.4%; p = 0.0008).

Conclusion

There was an increase in the prevalence of hypertension as well as cardiovascular-associated risk factors in the population. However, this trend did not increase for treated subjects with no improvements in the level of AHT control. Therefore, improved strategies for the prevention and management of non-communicable diseases are very important in Sub-Saharan Africa.

Association of TV Viewing and All-Cause Mortality in Older Adults With Hypertension: A 6-Year Longitudinal Study

The purpose of this study was to examine the longitudinal association between television (TV) viewing and all-cause mortality in older adults with hypertension. Sedentary behavior, physical activity, hypertension, and other chronic diseases were assessed by face-to-face interviews and confirmed by medical history. Mortality was reported by relatives and confirmed in medical records of the National Health System. The fully adjusted model showed a direct association between high TV viewing time and all-cause mortality; hazard ratio: 1.65 (95% confidence interval [1.02-2.68]). Women with high TV viewing were more likely to die than men. Higher TV viewing time was associated with all-cause mortality among those with diabetes and hypertension; hazard ratio: 3.54 (95% confidence interval [1.64-7.66]). The findings from this longitudinal study show that higher TV viewing time is associated with higher risk for all-cause mortality among older adults with hypertension, independently of physical activity, and other potential confounders.

Hypertension is the underlying cause of death assessed at the autopsy of individuals

OBJECTIVE

To analyze hypertension and its relationship with the causes of death identified by the autopsy.

METHOD

Cross-sectional study analyzed 356 participants belonging to the Brazilian Aging Brain Study Group, over 50 years of age, autopsied at the Sao Paulo Autopsy Service between 2004 to 2014. A clinical interview was conducted with the informant of the deceased. Hypertension was defined by reporting the disease and/or use of antihypertensive medication, by the informant of the deceased. Descriptive analyzes and bivariate and multivariable associations were performed.

RESULTS

The prevalence of hypertension was 66.2% and it was the second leading cause of death (25.6%) identified by autopsy, preceded by atherosclerosis (37.8%). The variables associated with hypertension were: female gender (OR=2.30 (1.34-3.90)); living with partner [OR=0.55 (0.32-0.92)]; Body Mass Index [OR=1.14 (1.08-1.22)] and history of diabetes [OR=2.39 (1.34-4.27)].

CONCLUSION

The prevalence of hypertension was high, and it was the second most common underlying cause of death. The gold standard for the definition of cause of death, the autopsy, shows important results, which confirmed the relevance of hypertension as a public health problem.