Nota: Estas diretrizes se prestam a informar e não a substituir o julgamento clínico do médico que, em última análise, deve determinar o tratamento apropriado para seus pacientes.

Cardiac injury in patients infected with the novel Coronavirus (COVID-19) seems to be associated with higher morbimortality. We provide a broad review of the clinical evolution of COVID-19, emphasizing its impact and implications on the cardiovascular system. The pathophysiology of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is characterized by overproduction of inflammatory cytokines (IL-6 and TNF-α) leading to systemic inflammation and multiple organ dysfunction syndrome, acutely affecting the cardiovascular system. Hypertension (56.6%) and diabetes (33.8%) are the most prevalent comorbidities among individuals with COVID-19, who require hospitalization. Furthermore, cardiac injury, defined as elevated us-troponin I, significantly relates to inflammation biomarkers (IL-6 and C-reactive protein (CRP), hyperferritinemia, and leukocytosis), portraying an important correlation between myocardial injury and inflammatory hyperactivity triggered by viral infection. Increased risk for myocardial infarction, fulminant myocarditis rapidly evolving with depressed systolic left ventricle function, arrhythmias, venous thromboembolism, and cardiomyopathies mimicking STEMI presentations are the most prevalent cardiovascular complications described in patients with COVID-19. Moreover, SARS-CoV-2 tropism and interaction with the RAAS system, through ACE2 receptor, possibly enhances inflammation response and cardiac aggression, leading to imperative concerns about the use of ACEi and ARBs in infected patients. Cardiovascular implications result in a worse prognosis in patients with COVID-19, emphasizing the importance of precocious detection and implementation of optimal therapeutic strategies.

Background:The prognostic value of office and ambulatory blood pressures (BPs) in patients with resistant hypertension is uncertain.Methods: This prospective study investigates the importance of office and ambulatory BPs as predictors of cardiovascular morbidity and mortality. At baseline, 556 resistant hypertensive patients underwent clinicallaboratory and 24-hour ambulatory BP monitoring examinations. Primary end points were a composite of fatal and nonfatal cardiovascular events and all-cause and cardiovascular mortalities. Multiple Cox regression was used to assess associations between BP and subsequent end points.Results: After median follow-up of 4.8 years, 109 patients (19.6%) reached the primary end point, and 70 allcause deaths (12.6%) occurred (46 had cardiovascular causes). After adjustment for age, sex, body mass index, diabetes mellitus, smoking, physical inactivity, dyslipidemia, previous cardiovascular diseases, serum creati-

Abstract-The role of spironolactone in resistant hypertension management is unclear. The aim of this prospective trial was to evaluate the antihypertensive effect of spironolactone in patients with true resistant hypertension diagnosed by ambulatory blood pressure monitoring. A total of 175 patients had clinical and complementary exams obtained at baseline and received spironolactone in doses of 25 to 100 mg/d. A second ambulatory blood pressure monitoring was performed after a median interval of 7 months. Paired Student t test was used to assess differences in blood pressure before and during spironolactone administration, and multivariate analysis adjusted for age, sex, and number of antihypertensive drugs to assess the predictors of blood pressure fall. There were mean reductions of 16 and 9 mm Hg, respectively, in 24-hour systolic and diastolic blood pressures (95% CIs: 13 to 18 and 7 to 10 mm Hg; PϽ0.001). Office systolic blood pressure and diastolic blood pressure also decreased (14 and 7 mm Hg). Controlled ambulatory blood pressure was reached in 48% of patients. Factors associated with better response were higher waist circumference, lower aortic pulse wave velocity, and lower serum potassium. No association with plasma aldosterone or aldosterone:renin ratio was found. Adverse effects were observed in 13 patients (7.4%). A third ambulatory blood pressure monitoring performed in 78 patients after a median of 15 months confirmed the persistence of the spironolactone effect. In conclusion, spironolactone administration to true resistant hypertensive patients is safe and effective in decreasing blood pressure, especially in those with abdominal obesity and lower arterial stiffness. Its addition to an antihypertensive regimen as the fourth or fifth drug is recommended. (Hypertension. 2010;55:147-152.)Key Words: ambulatory blood pressure monitoring Ⅲ resistant hypertension Ⅲ spironolactone R esistant hypertension (RH) is a common clinical condition defined as the failure to control office blood pressure (BP) despite a treatment with Ն3 different classes of antihypertensive drugs in optimal dosages, ideally including a diuretic. 1 Previous surveys have shown prevalence ranges from 10% to Ϸ30%. 1 Although there is no consensus about the better therapeutic scheme for resistant hypertensive patients, in general, diuretics, angiotensin-blocking agents, calciumchannel blockers, and ␤-blockers are used as the first-line choices. However, there is a lack of evidence about the optimal choice of a fourth-or fifth-line antihypertensive drug, and in this context there has been increasing interest in the role of aldosterone antagonists, particularly spironolactone.The efficacy and safety of spironolactone in reducing BP were demonstrated Ͼ2 decades ago. 2 Over the past 15 years, after many reports had suggested that primary hyperaldosteronism is probably more common than it was regarded previously, 3,4 several studies have been dedicated to evaluate the spironolactone effect in patients with refractoriness to treatment, mo...

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The nocturnal BP variability patterns provide valuable prognostic information for stratification of cardiovascular morbidity and mortality risk in patients with RH, above and beyond other traditional cardiovascular risk factors and mean ambulatory BP levels.

Ambulatory blood pressure monitoring is a fundamental tool to diagnose RH, and to check treatment efficacy. The presence of a greater pulse pressure and a lower nocturnal blood pressure reduction in true RH patients may be responsible for this increased cardiovascular risk profile.

True RH can be recognized in the office in selected RH patients. We propose a simple scoring system with these variables that can be used in clinical practice.