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 innervation by the parasympathetic nervous system (PNS) and the sympathetic nervous system (SNS) modulates the heart rate (HR) (chronotropic activity) and the contraction of the cardiac muscle (inotropic activity). The peripheral vasculature is controlled only by the SNS, which is responsible for peripheral vascular resistance. This also mediates the baroreceptor reflex (BR), which in turn mediates blood pressure (BP). Hypertension (HTN) and the autonomic nervous system (ANS) are closely related, such that derangements can lead to vasomotor impairments and several comorbidities, including obesity, hypertension, resistant hypertension, and chronic kidney disease. Autonomic dysfunction is also associated with functional and structural changes in target organs (heart, brain, kidneys, and blood vessels), increasing cardiovascular risk. Heart rate variability (HRV) is a method of assessing cardiac autonomic modulation. This tool has been used for clinical evaluation and to address the effect of therapeutic interventions. The present review aims (a) to approach the heart rate (HR) as a CV risk factor in hypertensive patients; (b) to analyze the heart rate variability (HRV) as a “tool” to estimate the individual risk stratum for Pre-HTN (P-HTN), Controlled-HTN (C-HTN), Resistant and Refractory HTN (R-HTN and Rf-HTN, respectively), and hypertensive patients with chronic renal disease (HTN+CKD).

Malignant hypertension is a syndrome consisting of severe arterial hypertension, retinopathy with papilledema (with or without renal failure) and fibrinoid necrosis of renal arterioles, which may present a rapidly progressive and fatal clinical course. In this pathology may occur vascular lesions that consist mainly of myointimal proliferation and arteriolar fibrinoid necrosis, which can develop acutely and compromise the light from the small blood vessels. The prognosis of malignant hypertension is almost always fatal if it is not recognized or not adequately treated, with a mortality rate of about 80% in 2 years, mainly as a result of progression into heart failure syndrome and end-stage renal failure syndrome

Blood Pressure Self-Measurement (BPSM) has gained interest lately and its practice can contribute to the diagnosis and follow-up of arterial hypertension. In Brazil, due to difficulties in carrying out Home Blood Pressure Monitoring (HBPM) and the unavailability of Ambulatory Blood Pressure Monitoring (ABPM) in most facilities, AMPA, which differs from the aforementioned methods, has widespread use in our country. Therefore, it seems important to discuss this method, which is largely used and poorly studied. In this paper, we will describe the methods for measuring blood pressure, auscultatory and oscillometric, in addition to listing the advantages and disadvantages of measuring blood pressure in the office, comparing them with AMPA. We will also make an alert about the need for the patient to receive guidance on blood pressure measurement and, finally, we will cite the Brazilian and European Guidelines regarding the mention they make about this method.

In Cardiology, we classify hypertensive patients as resistant to treatment, pseudo-resistant, or hyperreactivity subjects, including the WCH (white-coat or masked hypertension). Compliance is another cause of failure in antihypertensive therapy. Hypertension is a complex clinical syndrome and many variables that interfere in BP depend on “The Theory of Chaos” and are not considered. We do not know how many variations the Chaos on BP levels can be. Still, as we have around 30% of “uncontrolled” patients, the Chaos and effects on BP regulation as taking part in this high rates of “uncontrolled” subjects. Chaos is a complicated issue to study, but multi-professional efforts must keep the attention to this relevant “cause” of hypertension. Finally, Chaos theory is well known and accepted in Maths, Economy, Philosophy, Meteorology, Ecology, and other areas of knowledge, but not in the Health area. Crescent attention to Chaos may help better understand some mechanisms and clinical expression of Chaos in pseudo-resistant hypertension and correlated hypertensive syndromes.

BP assessed by ABPM is better related to TOD than office measurement. Evaluate TOD patients presented at a Hypertension Lab for first screening. Methods: 278 hypertensive (147 Female, aged 19-89) by 24h-ABPM (SpaceLabs 90307), lab. tests, LVMI by Echo (Terason M3000); Divided in two groups: Controlled [C] by 24h-BP (<130x80 mmHg) and Not controlled [NC] (>130/80 mmHg), albuminuria (ALB) was log transformed in order to allow proper analysis. Dipping pattern 24h-ABPM: dipper (DP) (>10- 20%), nondipper-absente (NDP) (<10%), reverse dipper (RDP)(> 20%). Results: Table 1 and 2 : Demography and ALB,LVMI. No differences detected in lab panel, except Glu, Trygl, ALB and LVMI. Discussion: Expected Higher LVMI, Glu, trygl, ALB levels, in NC group, with significant statistical differences comparing C group. Expected reverse dipping pattern would show differences when compared with dipper pattern but probably the small number of subjects didn’t allow detect such differences. Conclusion: Screening with 24-h ABPM is a valuable tool to hypertensives and dipper pattern should be achived to prevent TOD progression.

Introduction: BP assessed by ABPM is better related to TOD than office measurement. Evaluate TOD patients presented at a Hypertension Lab for first screening. Methods: 353 hypertensive (188 Female, aged 19-89) by 24h-ABPM (SpaceLabs 90307), lab. tests, LVMIU by Echo (Terason, M3000), Divided in two groups: Controlled [C] by 24h-BP (<130x80 mmHg) and Not controlled [NC] (>130/80 mmHg), albuminuria (ALB). Results: Table shows no difference detected in lab panel, except Glu, Trygl, ALB and LVMI. Discussion: Expected Higher, Glu, trygl, ALB levels and LVMI, in NC group, with significant statistical differences comparing C group. Expected because the high blood pressure are the trigger to TOD. Conclusion: Screening with 24-h ABPM is a valuable tool to hypertensives patients and should be used more frequently to prevent TOD progression.

Introduction: Left ventricular hypertrophy (LVH) is an important cardiocerebrovascular risk factor and due to this fact, when present , in hypertensive patients should plan a more elaborate therapeutic treatment. The hsCRP is systemic inflammatory marker associated with increased risk of myocardial infarction and vascular diseases. Objective: Identify hsCRP as a strong biomarker with correlation with LVH in resistant hypertensive patients (RHTN). Methodology: A total of 180 patients: 60 RHTN and 60 RHTN with LVH with echocardiographic diagnosis (LVH-RHTN), compared to 60 normal subjects (control), with equal distribution of gender and age. The hs-CPR was measured using nephelometry method. Results: In LVH-RHTN hsCRP was 3.96 ± 1.11 mg/L and was significantly higher when compared with RHTN, which was 2.20 ± 0.53 mg/L, and with hsCRP 0.56 ± 0.23 in CON (p <0.001). There is a strong correlation between elevated hsCRP and LVH in patients with resistant hypertension, as shown by the Pearson coefficient (r = 0.74). Conclusion: hsCRP can be considered a strong predictor biomarker in presence of LVH in RHTN.