rastreamento para diabetes em hipertensos

USPSTF Recommends Screening for Diabetes in Adults With Elevated Blood Pressure
Posted 09/11/2008
Richard Saitz, MD, MPH, FACP, FASAMAuthor Information
Summary
The U.S. Preventive Services Task Force (USPSTF) has been releasing new and updated guidelines periodically. The USPSTF grades each of its recommendations according to a system described on the USPSTF website.
In 2003, the USPSTF concluded that the evidence was insufficient to recommend screening asymptomatic adults for type 2 diabetes, but it did recommend diabetes screening for adults with hypertension or hyperlipidemia. In updated recommendations, the task force suggests screening for type 2 diabetes in asymptomatic adults with blood pressure of 135/80 mm Hg or higher. Recommendation: B (the USPSTF recommends that clinicians provide this service). It also concludes that evidence still is insufficient to assess the benefits and harms of diabetes screening in adults with blood pressure lower than 135/80 mm Hg. Recommendation: I (evidence is insufficient to assess the balance of benefits and harms; if the service is offered [e.g., based on clinical considerations], patients should understand that uncertainty exists about benefits and harms).
The USPSTF guideline cites the American Diabetes Association recommendation that measurement of fasting plasma glucose (≥126 mg/dL, repeated for confirmation) be the test of choice for diagnosing diabetes. In an evidence review, the task force identified no studies that showed whether screening asymptomatic individuals for diabetes altered health outcomes. However, fair evidence suggests that lifestyle and pharmacologic interventions can slow progression of prediabetes to type 2 diabetes. Evidence also suggests that lowering blood pressure (even below conventional targets) lowers the occurrence of cardiovascular events among people with diabetes and hypertension. For people with diabetes, but without hypertension, intensive glycemic control attenuates progression of microvascular disease among those identified clinically, but whether early identification of diabetes by screening and early treatment provide a long-term benefit over waiting until clinical diagnosis occurs is unclear. The short-term harms of diabetes screening (e.g., anxiety) are small, although the USPSTF notes that harms associated with screening and labeling large segments of the population as having diabetes might be unknown.
Comment
The American Diabetes Association recommends diabetes screening in middle-aged or older people (>45) and screening in younger people who have risk factors. But recommendations from generalist organizations (e.g., American Academy of Family Physicians diabetes screening guideline) are similar to those of the USPSTF. So, should we screen for diabetes in adults who don´t have blood pressures of 135/80 mm Hg or higher? The best evidence suggests that we should not, unless it will make a difference in management (e.g., in decisions about lipid-lowering therapy) or unless symptoms of diabetes are evident

Dieta, Ferro e Pressão Arterial

Published 15 July 2008, doi:10.1136/bmj.a258Cite this as: BMJ 2008;337:a258
Research
Relation of iron and red meat intake to blood pressure: cross sectional epidemiological study
Ioanna Tzoulaki, lecturer in epidemiology1, Ian J Brown, research assistant1, Queenie Chan, senior research officer1, Linda Van Horn, professor of preventive medicine2, Hirotsugu Ueshima, professor of medicine3, Liancheng Zhao, professor of epidemiology4, Jeremiah Stamler, professor emeritus2, Paul Elliott, professor1, for the International Collaborative Research Group on Macro-/Micronutrients and Blood Pressure
Correspondence to: I Tzoulaki I.Tzoulaki@imperial.ac.uk
Objective To investigate associations of dietary iron (total, haem, and non-haem), supplemental iron, and red meat with blood pressure.
Design Cross sectional epidemiological study.
Setting 17 population samples from Japan, China, the United Kingdom, and the United States participating in the international collaborative study on macro-/micronutrients and blood pressure (INTERMAP).
Participants 4680 adults aged 40-59.
Main outcome measure Average of eight blood pressure readings.
Results In multiple linear regression analyses dietary total iron and non-haem iron were consistently inversely associated with blood pressure. With adjustment for potential non-dietary and dietary confounders, dietary total iron intake higher by 4.20 mg/4.2 MJ (2 SD) was associated with –1.39 mm Hg (P<0.01) lower systolic blood pressure. Dietary non-haem iron intake higher by 4.13 mg/4.2 MJ (2 SD) was associated with –1.45 mm Hg (P<0.001) lower systolic blood pressure. Differences were smaller for diastolic blood pressure. In most models haem iron intake from food was positively, non-significantly associated with blood pressure. Iron intake from combined diet and supplements yielded smaller associations than dietary iron alone. Red meat intake was directly associated with blood pressure; 102.6 g/24 h (2 SD) higher intake was associated with 1.25 mm Hg higher systolic blood pressure. Associations between red meat and blood pressure persisted after adjustment for multiple confounders.
Conclusion Non-haem iron has a possible role in the prevention and control of adverse blood pressure levels. An unfavourable effect of red meat on blood pressure was observed. These results need confirmation including in prospective studies, clinical trials, and from experimental evidence on possible mechanisms.

Em Framigham: redução da pressão arterial e melhora do controle em 16 anos

Arch Intern Med. 2008 Jul 14;168(13):1450-7.
Altered blood pressure progression in the community and its relation to clinical events.

Ingelsson E, Gona P, Larson MG, Lloyd-Jones DM, Kannel WB, Vasan RS, Levy D.Framingham Heart Study, 73 Mount Wayte Ave, Ste 2, Framingham, MA 01702-5803, USA.BACKGROUND: Long-term blood pressure (BP) progression and its importance as a predictor of clinical outcome have not been well characterized across different periods. METHODS: We evaluated period trends for 3 BP variables (long-term slope and mean BP during a baseline period of 16 years, and last baseline value) in an earlier period (1953-1971; n = 1644, mean participant age, 61 years) and in a later period (1971-1990; n = 1040, mean participant age, 58 years) in participants in the Framingham Heart Study who initially did not have hypertension. In addition, we explored the relation of BP to cardiovascular disease incidence and all-cause mortality in the 2 periods, each with up to 16 years of follow-up. RESULTS: Long-term slope, mean, and last baseline BP measurements were significantly lower in the later period (P < .001). Rates of hypertension control (BP <140/90 p =" .03;" p =" .04).">

Impacto da Prevenção na Redução da Doença Cardiovascular

(Circulation. 2008;118:576-585) coraçaodobrasil/estrategiasdeprevençao

The Impact of Prevention on Reducing the Burden of Cardiovascular Disease.

Richard Kahn, PhD; Rose Marie Robertson, MD, FAHA; Robert Smith, PhD; David Eddy, MD, PhD
E-mail rkahn@diabetes.org
Objective— Cardiovascular disease (CVD) is prevalent and expensive. While many interventions are recommended to prevent CVD, the potential effects of a comprehensive set of prevention activities on CVD morbidity, mortality, and costs have never been evaluated. We therefore determined the effects of 11 nationally recommended prevention activities on CVD-related morbidity, mortality, and costs in the United States.
Research Design and Methods— We used person-specific data from a representative sample of the US population (National Health and Nutrition Education Survey IV) to determine the number and characteristics of adults aged 20-80 years in the United States today who are candidates for different prevention activities related to CVD. We used the Archimedes model to create a simulated population that matched the real US population, person by person. We then used the model to simulate a series of clinical trials that examined the effects over the next 30 years of applying each prevention activity one by one, or altogether, to those who are candidates for the various activities and compared the health outcomes, quality of life, and direct medical costs to current levels of prevention and care. We did this under two sets of assumptions about performance and compliance: 100% success for each activity and lower levels of success considered aggressive but still feasible.
Results— Approximately 78% of adults aged 20-80 years alive today in the United States are candidates for at least one prevention activity. If everyone received the activities for which they are eligible, myocardial infarctions and strokes would be reduced by 63% and 31%, respectively. If more feasible levels of performance are assumed, myocardial infarctions and strokes would be reduced 36% and 20%, respectively. Implementation of all prevention activities would add 221 million life-years and 244 million quality-adjusted life-years to the US adult population over the coming 30 years, or an average of 1.3 years of life expectancy for all adults. Of the specific prevention activities, the greatest benefits to the US population come from providing aspirin to high-risk individuals, controlling pre-diabetes, weight reduction in obese individuals, lowering blood pressure in people with diabetes, and lowering LDL cholesterol in people with existing coronary artery disease (CAD). As currently delivered and at current prices, most prevention activities are expensive when considering direct medical costs; smoking cessation is the only prevention strategy that is cost-saving over 30 years.
Conclusions— Aggressive application of nationally recommended prevention activities could prevent a high proportion of the CAD events and strokes that are otherwise expected to occur in adults in the United States today. However, as they are currently delivered, most of the prevention activities will substantially increase costs. If preventive strategies are to achieve their full potential, ways must be found to reduce the costs and deliver prevention activities more efficiently

Hipertensão e Calcificação Coronariana

Prehypertension during Young Adulthood and Coronary Calcium Later in Life Mark J. Pletcher, MD, MPH; Kirsten Bibbins-Domingo, PhD, MD; Cora E. Lewis, MD; Gina S. Wei, MD, MPH; Steve Sidney, MD, MPH; J. Jeffrey Carr, MD, MSCE; Eric Vittinghoff, PhD; Charles E. McCulloch, PhD; and Stephen B. Hulley, MD, MPH Annals of Internal Medicine 15 July 2008 Volume 149 Issue 2 Pages 91-99
Background: High blood pressure in middle age is a well-established risk factor for cardiovascular disease, but the consequences of low-level elevations during young adulthood are unknown.
Objective: To measure the association between prehypertension exposure before age 35 years and coronary calcium later in life.
Design: Prospective cohort study.
Setting: Four communities in the United States.
Participants: Black and white men and women age 18 to 30 years recruited for the CARDIA (Coronary Artery Risk Development in Young Adults) Study in 1985 through 1986 who were without hypertension before age 35 years.
Measurements: Blood pressure trajectories for each participant were estimated by using measurements from 7 examinations over the course of 20 years. Cumulative exposure to blood pressure in the prehypertension range (systolic blood pressure of 120 to 139 mm Hg, or diastolic blood pressure of 80 to 89 mm Hg) from age 20 to 35 years was calculated in units of mm Hg–years (similar to pack-years of tobacco exposure) and related to the presence of coronary calcium measured at each participant's last examination (mean age, 44 years [SD, 4]).
Results: Among 3560 participants, the 635 (18%) who developed prehypertension before age 35 years were more often black, male, overweight, and of lower socioeconomic status. Exposure to prehypertension before age 35 years, especially systolic prehypertension, showed a graded association with coronary calcium later in life (coronary calcium prevalence of 15%, 24%, and 38% for 0, 1 to 30, and >30 mm Hg–years of exposure, respectively; P < 0.001). This association remained strong after adjustment for blood pressure elevation after age 35 years and other coronary risk factors and participant characteristics.
Limitation: Coronary calcium, although a strong predictor of future coronary heart disease, is not a clinical outcome.
Conclusion: Prehypertension during young adulthood is common and is associated with coronary atherosclerosis 20 years later. Keeping systolic pressure below 120 mm Hg before age 35 years may provide important health benefits later in life.

Ingestão de Acido Linolênico e Hipertensão

elsa/dieta/aclinolenicohipertensao

Relationship of Dietary Linoleic Acid to Blood Pressure
The International Study of Macro-Micronutrients and Blood Pressure Study

Hypertension. 2008;52:408-414

Findings from observational and interventional studies on the relationship of dietary linoleic acid, the main dietary polyunsaturated fatty acid, with blood pressure have been inconsistent. The International Study of Macro-Micronutrients and Blood Pressure is an international cross-sectional epidemiological study of 4680 men and women ages 40 to 59 years from 17 population samples in China, Japan, United Kingdom, and United States. We report associations of linoleic acid intake of individuals with their blood pressure. Nutrient intake data were based on 4 in-depth multipass 24-hour dietary recalls per person and 2 timed 24-hour urine collections per person. Systolic and diastolic blood pressures were measured 8 times at 4 visits. With several models to control for possible confounders (dietary or other), linear regression analyses showed a nonsignificant inverse relationship of linoleic acid intake (percent kilocalories) to systolic and diastolic blood pressure for all of the participants. When analyzed for 2238 "nonintervened" individuals (not on a special diet, not consuming nutritional supplements, no diagnosed cardiovascular disease or diabetes, and not taking medication for high blood pressure, cardiovascular disease, or diabetes), the relationship was stronger. With adjustment for 14 variables, estimated systolic/diastolic blood pressure differences with 2-SD higher linoleic acid intake (3.77% kcal) were –1.42/–0.91 mm Hg (P<0.05>

Sal, risco cardiovascular e a cultura brasileira.

Nessa edição do British Medical Journal há artigo original e editorial reproduzido abaixo sobre o efeito da redução do sal a longo prazo: redução em 25% de eventos cardiovasculares. O artigo é de Nancy Cook e equipe com quem trabalhei no Brigham and Women´s Hospital. Para nós, brasileiros, essa é uma questão séria, visto que o consumo de sal é muito elevado, assim como a prevalência de hipertensão arterial e a incidência e mortalidade por doença cerebrovascular. Chegou o momento de pesquisa séria e dirigida ao tema. O artigo original pode ser acessado clicando no título.

BMJ 2007;334 (28 April), doi:10.1136/bmj.39196.679537.47
Fiona Godlee, editor fgodlee@bmj.com
Just over a decade ago, the BMJ found itself in the eye of the storm about dietary salt (BMJ 1996;312:1239-40). We had published the Intersalt study some years previously; it concluded that populations with high average intakes of salt were likely to have higher average blood pressures. But the salt producers' trade organisation, the Salt Institute, had criticised the study's methods and asked the investigators to hand over their raw data for reanalysis. A reanalysis was done—by the original investigators—and published in the BMJ (BMJ 1996;312:1249-53). The findings were the same.
It's worth remembering this skirmish in the war on dietary salt, now that the battle around the evidence linking salt and heart disease has largely been won. At the time we knew that dietary salt was linked to increased blood pressure, and over the next decade the link to actual cardiovascular disease grew stronger. So did the evidence from randomised trials that reducing salt in the diet reduced blood pressure. But still the food industry's fight against restrictions continued.
At the time they could argue that the long term benefits of reducing salt on cardiovascular disease had not been shown in randomised trials—but not any longer. This week the BMJ publishes what may be the final bugle call in the battle of the evidence. Nancy Cook and colleagues followed up people who took part in two randomised trials of dietary salt reduction to see whether reductions in blood pressure converted into reductions in cardiovascular events (doi: 10.1136/bmj.39147.604896.55). They gathered data on three quarters of the original participants and found that, after 10-15 years, the risk of cardiovascular events was more than 25% lower in people who had cut their salt intake for at least 18 months.
Such hard evidence is at last bringing the food industry to the negotiating table. Voluntary limits and food labelling, as adopted by the UK's Food Standards Agency and the European Union, have brought some progress from the industry, as has the "carrot" of growing markets for healthy foods, but they are unlikely to bring enough muscle to bear on a powerful industry practiced in the arts of mitigation and delay. As Francesco Cappuccio says in his editorial (doi: 10.1136/bmj.39175.364954.BE), real progress will need the additional "stick" of legislation. Most salt in developed countries is consumed in bread and processed foods, and much of it is consumed outside the home in canteens and sandwich bars, so a population-wide policy of salt reduction will come only through pressure on the food and catering industries. The current policy—encouraging consumers to make sensible choices—effectively abandons the poor and uninformed, increasing social inequities.
While we wait for mandatory food labelling and firm limits on salt in processed foods across Europe, what can health professionals do to reduce the impact of dietary salt on people's health? Cappuccio suggests that baseline assessment of salt intake should be part of the UK's National Service Framework. A 24 hour urinary collection is cheaper than testing cholesterol. You might try talking salt in your next consultation

Tekturna, algo novo da Big Pharma para hipertensão

Finallmente, algo novo da Big Pharma para hipertensão - o aliskiren - da Novartis,nome comercial Tekturna, aprovado nos Estados Unidos. Trata-se de um inibidor da renina, o primeiro produto desse grupo. Agora, é verificar o quanto adicionará ao tratamento atual e, evidentemente o custo. Abaixo uma descrição do produto.

Tekturna(R) - The First New Type of High Blood Pressure Medicine In More Than a Decade - Receives Its First Approval in the US
Mar 5 2007, 8:20 PM EST PRNEWSWIRE
EAST HANOVER, N.J., March 6 /PRNewswire/ -- Novartis announced today that the United States has become the first country in the world to approve Tekturna(R) (aliskiren) tablets, the first new type of medicine in more than a decade for treating high blood pressure -- a condition estimated to affect nearly one billion people worldwide and remains uncontrolled in nearly 70% of patients.
The Food and Drug Administration (FDA) issued the approval for Tekturna as the first in a new class of drugs called direct renin inhibitors. A once-daily oral therapy, Tekturna acts by targeting renin -- an enzyme responsible for triggering a process that can contribute to high blood pressure. This condition is a leading contributor to cardiovascular disease, considered the world's leading cause of death. Tekturna received FDA approval for treatment of high blood pressure as monotherapy or in combination with other high blood pressure medications. The use of Tekturna with maximal doses of ACE inhibitors has not been adequately studied. Tekturna is expected to be available in March in pharmacies as 150 mg and 300 mg tablets. "Renin angiotensin system activity contributes to many of the complications associated with high blood pressure," said Marc A. Pfeffer, M.D., PhD, Professor of Medicine, Harvard Medical School and Cardiologist, at Brigham & Women's Hospital. "By inhibiting this important system at its origin, renin production, a direct renin inhibitor, such as Tekturna, offers an exciting therapeutic option for treating hypertension." In an extensive clinical trial program involving more than 6,400 patients, Tekturna provided significant blood pressure reductions for a full 24 hours. Furthermore, Tekturna provided added efficacy when used in combination with other commonly used blood pressure medications. In clinical trials, the approved doses of Tekturna were generally well tolerated and the most common side effect experienced by more patients taking Tekturna than patients taking a sugar pill was diarrhea. Other less common reactions to Tekturna include cough and rash. Tekturna should be discontinued as soon as pregnancy is detected as it may harm an unborn baby, causing injury and even death. Women who plan to become pregnant should talk to their doctor about other treatment options before taking Tekturna. Angioedema has been rarely reported in patients taking Tekturna. "Many patients require two or more medicines to control their blood pressure. As a new treatment approach, Tekturna has the potential to help these patients manage their disease," said James Shannon, MD, Global Head of Development at Novartis Pharma AG. "Tekturna demonstrates our commitment to developing innovative medicines to help the millions of patients suffering from high blood pressure." Novartis is committed to conducting a large outcome trial program to evaluate the long-term effects of Tekturna and direct renin inhibition. Tekturna was developed in collaboration with Speedel