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.

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1has shown that in patients at high cardiovascular (CV) risk a treatment regimen based on telmisartan or ramipril reduced to a similar degree clinic blood pressure (BP) and showed no significant difference in the incidence of CV morbid or fatal events. Clinic BP was reduced to a somewhat greater degree in patients treated with a combination of the 2 drugs (1.5-2.4 mm Hg systolic BP [SBP] and 0.8-1.4 mm Hg diastolic BP [DBP]), without, however, any significant difference in CV outcome. Because ramipril had been shown previously to reduce outcomes in high CV risk individuals 2 ; this led to the conclusion that telmisartan and ramipril have a similar protective effect, which is not enhanced by double blockade of the renin-angiotensin system, despite the potentially greater protection associated with a greater BP-lowering effect. Evidence is available that BP reductions induced by antihypertensive treatment cannot be precisely quantified if BP is measured in the clinic environment because clinic BP is affected to a variable degree by a transient increase known as the white coat effect. 4 Furthermore, clinic BP values are poorly reproducible, 5,6 and their treatment-induced changes reflect to only a modest degree the concomitant changes in daily life BP, 7-10 that is, a more reproducible 5 and prognostically important BP, which relates more steeply to CV morbidity and mortality. 11-17The ONTARGET included a prespecified substudy 18 focusing on ambulatory BP (ABP) to determine whether and to what extent treatment-induced changes in clinic BP correspond to daily life ABP. This article reports the results. Methods Patients and Monitoring ProceduresThe protocol of the ONTARGET has been described in detail previously.18 Briefly, men and women aged ≥55 years without symptomatic heart failure at entry and with a history of coronary Abstract-In the Ongoing Telmisartan Alone and in Combination with Ramipril Global Endpoint Trial, telmisartan (T; 80 mg daily) and ramipril (R; 10 mg daily) caused similar clinic blood pressure (BP) reductions, with a similar incidence of cardiovascular and renal events. The R+T combination lowered clinic BP somewhat more with no further cardiovascular or renal protection. The aim of this substudy was to see whether these clinic BP changes reflected the changes of 24-hour BP, a BP with a better prognostic value. In 422 patients in whom 24-hour BP monitoring was performed either before or after 6 to 24 months of treatment, demographic and clinical characteristics were similar in the 3 treated groups. Twenty-four-hour systolic BP was similarly reduced by R (−2.0 mm Hg) and T (−2.1 mm Hg), whereas the reduction was more than twice as large in the T+R group (−5.3 mm Hg), which showed a lower on-treatment 24-hour BP also in additional patients (n=408) in whom ambulatory BP was performed only on-treatment. Twenty-four-hour systolic BP was ≈14 mm Hg lower than clinic systolic BP at baseline, whereas during treatment the 2 values became progressively closer as clinic systolic BP was more tightly controll...

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SUMMARYIt has been well documented that there is an increased prevalence of standard cardiovascular (CV) risk factors in association with diabetes and with diabetes-related abnormalities. Hyperglycemia, in particular, also plays an important role. Heart failure (HF) has become a frequent manifestation of cardiovascular disease (CVD) among individuals with diabetes mellitus. Epidemiological studies suggest that the effect of hyperglycemia on HF risk is independent of other known risk factors. Analysis of datasets from populations including individuals with dysglycemia suggests the pathogenic role of hyperglycemia on left ventricular function and on the natural history of HF. Despite substantial epidemiological evidence of the relationship between diabetes and HF, data from available interventional trials assessing the effect of a glucose-lowering strategy on CV outcomes are limited. To provide some insight into these issues, we describe in this review the recent important data to understand the natural course of CV disease in diabetic individuals and the role of hyperglycemia at different times in the progression of HF. Arq Bras Endocrinol Metab. 2010;54(5):488-97 Keywords Prediabetic state; blood glucose; hyperglycemia; ventricular dysfunction, left; heart failure SUMÁRIO Já foi bem documentado um aumento da prevalência dos fatores de risco cardiovascular convencional em portadores de diabetes melito e em pessoas com as anormalidades relacionadas ao diabetes. A hiperglicemia, particularmente, teria um papel crítico. A insuficiência cardíaca (IC) tem se tornado uma manifestação frequente da doença cardiovascular em indivíduos com diabetes. Estudos epidemiológicos sugerem que o efeito da hiperglicemia no risco para IC é independente dos outros fatores de risco. A análise dos dados de populações que incluem indivíduos com disglicemia sugere um papel patogênico da hiperglicemia na função do ventrículo esquerdo na história natural da IC. A despeito de evidências epidemiológicas na relação entre diabetes e IC, os dados disponíveis de estudos clínicos de intervenção para avaliar o efeito da estratégia de redução da glicose sobre os desfechos cardiovasculares ainda são limitados. Para trazer alguma compreensão nesse tópico, descrevemos nesta revisão os dados recentes e importantes para entender a história natural da doença cardiovascular em indivíduos com diabetes e o papel da hiperglicemia em diferentes períodos na progressão da doença. Arq Bras Endocrinol Metab. 2010;54(5):488-97 Descritores

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Objectives : To analyze the accuracy of the 2 minute step test in the diagnosis of the normal functional capacity (FC) of hypertensive elderly individuals or hypertensive elderly individuals with other associated chronic conditions (ACC). Methods : An observational diagnosis type study of 101 subjects, 41 of whom were hypertensive and 60 of whom were normotensive, was carried out. Receiver Operating Characteristic curves (ROC) were constructed based on the normal FC variable. Results : For hypertensive patients, the 2MST, with an under the ROC curve area of 0.7 (95% CI: 0.50 to 0.87, p = 0.04), proved to be accurate at diagnosing FC. Among hypertensive individuals with an elevation of 69, sensitivity of 80% and specificity of 54% were observed. The 2MST was accurate at predicting normal FC among hypertensive patients with ACC, with an under the ROC curve area of 0.88 (95% CI: 0.69 to 1.00, p= 0.02). With an elevation of 65 the sensitivity was 83% and the specificity was 67%. Conclusions : The 2MST revealed good sensitivity and specificity when assessing the FC of elderly hypertensive individuals and elderly hypertensive patients with ACC, which was not the case among normotensive elderly persons.

Em sintonia com a tendência científica mundial e a orientação da Associação Médica Brasileira, as IV Diretrizes Brasileiras de Hipertensão fundamentam suas orientações segundo Graus de Recomendação baseados em níveis de evidência dos estudos clínicos de referência:Grau A -grandes ensaios clínicos aleatorizados e metanálises. Grau B -estudos clínicos e observacionais bem desenhados. Grau C -relatos e séries de casos. Grau D -publicações baseadas em consensos e opiniões de especialistas.