Brazilian Society of Cardiology Updates Three Guidelines

The Brazilian Society of Cardiology (SBC) has just updated its guidelines on hypertension and ambulatory blood pressure monitoring (ABPM), ergometry, and hypertrophic cardiomyopathy (HCM). The new versions of the recommendations were presented at the SBC’s 1st Meeting of Cardiology Departments in São Paulo. The event was attended by 12 departments of the society and the Brazilian Society of Cardiac Arrhythmias.

The Medscape Portuguese edition interviewed authors who collaborated on updating the three guidelines about the main changes.

Blood Pressure (BP) and ABPM

“The new document on blood pressure (BP) is the result of the review and update of the 6th Brazilian ABPM Guideline and the 4th Brazilian Home BP Monitoring Guideline, which was published in 2018,” explained cardiologist Audes Diógenes de Magalhães Feitosa, MD, of the Federal University of Pernambuco, Recife, Brazil. Magalhães was one of the coordinators of the team of 67 specialists who produced the document “Updates and Changes in the Brazilian Guidelines for Blood Pressure Measurement Inside and Outside the Office.”

In its introduction, the team highlighted the scope of the guidelines and their impact on clinical practice. Among the most relevant modifications, according to the specialists, are the emphasis on the accuracy and quality of BP measurements in the office and the new guidelines on the measurement of uncompensated BP. The document also emphasizes BP measurement during physical exercise and new behaviors identified in individuals under drug treatment.

“We highlighted measurements inside and outside the office because blood pressure changes with each heartbeat,” said Magalhães. “There are people whose pressure rises during the consultation because they become tense in the presence of the doctor and then drops. And there are situations of masked hypertension, where pressure remains at normal levels in the office and rises when patients stress at work or at home.”

“We need to expand our resources so that people who may have pressure changes seek a specialist to be properly diagnosed,” he advised.

The emphasis on measuring pressure outside the office, such as in pharmacies and at home, is intended to raise awareness among the population and increase opportunities for monitoring pressure variations.

“No one will be diagnosed at the pharmacy or in the public park, but these are measurements that can help us a lot to screen possible hypertensive patients who would be far from our radar,” said Magalhães.

The team emphasized the need for a more rigorous evaluation of orthostatic (or postural) hypotension, which is characterized by excessive BP drop when the individual is standing. “This measurement has always been more neglected, but we suggest that it be done more forcefully now, as one of the routine measures in medical care,” said Magalhães.

The guideline provides a revised flowchart for evaluating and managing masked hypertension and white coat hypertension. It also brings an update on the indications, limitations, advantages, and disadvantages of ABPM and home BP monitoring (HBPM), as well as a new classification of normal BP values obtained by ABPM in children. The certification and validation of monitors are also addressed.

Other topics found in the document include the update of the protocol for HBPM, the values related to the effects of the white coat and masked hypertension, and a new protocol for patients on hemodialysis.

“The gold standard for diagnosis, in many cases, will be ABPM. The gold standard for monitoring patients using antihypertensive medications is HBPM,” said Magalhães.

The current normal pressure values in each situation are as follows:

  • Office: ≥ 140 (systolic BP) and/or ≥ 90 (diastolic BP)
  • 24-hour ABPM: ≥ 130 (systolic BP) and/or ≥ 80 (diastolic BP)
  • Wake ABPM: ≥ 135 (systolic BP) and/or ≥ 85 (diastolic BP)
  • Sleep ABPM: ≥ 120 (systolic BP) and/or ≥ 70 (diastolic BP)
  • HBPM-ABPM: ≥ 130 (systolic BP) and/or ≥ 80 (diastolic BP)

The new guideline is also the first to have a specific protocol for patients on hemodialysis. “There is a 7-day protocol, excluding measurements taken on hemodialysis days and averaging for the other days,” said Magalhães.

Finally, there is a chapter on central blood pressure (CBP), pulse wave velocity (PWV), and augmentation index (AIx), which includes possible indications, definition of protocols, and reference values for PWV, CBP, and AIx measurements.

“The modifications were made to reinforce the commitment to diagnostic accuracy and improvement of care related to blood pressure, promoting clinical practices aligned with the latest advances in the field,” the authors wrote.

Increasing Hypertension Prevalence

About 30% of the Brazilian adult population has hypertension. “But with the growth of the number of people with sedentary habits, the expansion of obesity, and more stress, the tendency is for hypertension and diabetes to affect more people in the coming years,” said Magalhães. The general rule is that only half of hypertensive individuals know they have the disease. Of these, only half are treated. Among those who are treated, only half effectively control their pressure. According to Magalhães, in the end, between 10% and 12.5% of patients with diagnosed hypertension have their pressure successfully treated.

Magalhães recalled that April 26th is National Hypertension Awareness Day. “The Brazilian Society of Cardiology conducts voluntary campaigns across Brazil on this date. Therefore, dissemination depends a lot on the press and everyone involved. We need to motivate people to be more attentive to their blood pressure,” he explained.

HCM

HCM, also known as hypertrophic myocardial disease, made headlines recently as the cause of the death of businessman João Paulo Diniz at the age of 58 years. At the beginning of the new Brazilian guideline, which was published on April 12th, cardiologists pointed to the urgent need to incorporate new knowledge into practice.

“The present guideline aims to present the most current recommendations for the diagnosis, staging, prognosis, and treatment of HCM, based on the critical review of current scientific evidence,” says the introduction text of the Guidelines for the Diagnosis and Treatment of Hypertrophic Cardiomyopathy.

In an interview with Medscape Medical News, Marcus Vinicius Simões, MD, professor of cardiology at the Medical School of Ribeirão Preto at the University of São Paulo, São Paulo, Brazil, highlighted what he considers important points in the guideline that he helped update. He was one of the coordinators of the group of more than 70 specialists who produced the new guidelines.

“The first highlight is the aspects related to the natural history of the disease. Several recent cohorts show that it is not so malignant. Most patients may be asymptomatic or have a life course like that of the general population,” said Simões.

The number of patients with HCM is about 20 million worldwide. In Brazil, it is estimated that the congenital disease affects about 400,000 people, and 90% of cases are asymptomatic. These patients do not suspect that they have the problem. Therefore, it is essential for all patients to undergo an evaluation before starting any physical activity, whether high intensity or low, to prevent future complications, according to Simões.

The guideline recommends performing tests on athletes, as well as relatives of patients suspected of having the disease, and performing tests to investigate and confirm the diagnosis. The diagnosis of HCM requires echocardiography, exercise testing, Holter monitoring, and MRI. Genetic analysis ends up being an important tool for counseling and characterizing a portion of patients, said Simões.

Another aspect of the new guideline to be highlighted is that almost 90% of symptomatic patients present obstruction of the left ventricular outflow tract as the mechanism responsible for symptoms. “This makes it essential, in clinical practice, to look for obstruction. This is done using the Valsalva maneuver or physical stress test with echocardiography to catch obstructive patients,” said Simões. He noted that there are already new treatments, including drug treatments (such as a cardiac myosin inhibitor) to treat obstruction, relieve symptoms, and change the clinical course of the disease.

Sudden Death

According to the new guideline, the risk for sudden death should be estimated in all patients to identify those at high risk. Once diagnosed, these patients should receive appropriate prophylactic treatment and be evaluated for potential implantation of an implantable cardioverter-defibrillator (ICD).

The guideline presents a new algorithm for stratifying patients. “It is based on scientific evidence and risk factors to determine the risk of sudden death and distinguish who really needs to receive [the device],” said Simões. The doctor emphasized that the decision to implant the ICD should be shared with all patients, even those classified as at highest risk. “We can use risk calculators to provide elements and information about the risks and benefits of ICD implantation to talk to the patient and make a shared decision,” he explained.

Ergometric Tests (ETs)

Hypertension and HCM are among the cardiovascular changes that can be identified and evaluated during the ET or cardiopulmonary exercise test (CPET). “They are complementary or concomitant tests,” Tales de Carvalho, MD, retired full professor at the State University of Santa Catarina in Florianópolis, Brazil, told Medscape Medical News.

De Carvalho was the general coordinator of a group of just over 30 researchers who analyzed over 8000 published works in the field of ergometry to consolidate the Brazilian Guideline for Ergometry in Adult Population — 2024.

“We were able to review and update, in a single document, the information and recommendations present in the previous guidelines and address new aspects,” he said.

According to De Carvalho, the previously published guidelines presented the ET in a restrictive way. “They did not show its relevance and scope in the context of sports medicine, epidemiology, endocrinology, and even cardiology,” he explained.

“In ET or CPET, the individual undergoes a scheduled and individualized physical effort, with the purpose of evaluating clinical, hemodynamic, autonomic, electrocardiographic, indirect metabolic, and eventually, enzymatic responses,” he added. These data can be obtained and analyzed.

With 139 pages and 1132 references, the new guideline highlights information related to tests in the adult population and the necessary adaptations of the test in acute respiratory syndrome scenarios.

“We assessed the consequences of diseases that systematically attack the body. Long COVID, for example, can not only cause lung impairment but also attack the cardiovascular system and impair cellular metabolism,” said de Carvalho. In addition, a well-performed test on a patient experiencing shortness of breath can help better establish the cause, which can be a cardiovascular deficiency, pulmonary deficiency, or both, thus contributing to more appropriate treatment with more precise rehabilitation, he added.

The document explains the best indications for the ET and complementary tests that can be associated with it, such as scintigraphy. It also describes tests that can be done in a semi-supine position and on equipment such as the exercise bike and the arm ergometer.

In general, said de Carvalho, the test has been underutilized. “It can provide a lot of information, allowing for prognosis, diagnosis, and adjustments to pharmacological and nonpharmacological treatment, such as rehabilitation.” However, many situations are well resolved with a simpler ET, done by someone who knows how.

“Due to its characteristics, the ergometric test must be performed by a specialized physician. We have a department at the SBC where it is possible to undergo an examination to present oneself as a specialist in ergometry,” said de Carvalho. The occurrences during the test are directly proportional to the quality of care provided. “There should always be a qualified physician in the ergometry room,” he advised.

This story was translated from the Medscape Portuguese edition using several editorial tools, including AI, as part of the process. Human editors reviewed this content before publication.

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