Documentos de Académico
Documentos de Profesional
Documentos de Cultura
ASPECTOS EPIDEMIOLOGICOS:
c) Coartacin de aorta.
d) Enfermedades
endocrinas:
Acromegalia,
hipo
e
hipertiroidismo,
hiperparatiroidismo,
sndrome
de
Cushing,
hiperaldosteronismo,
feocromocitoma, tumor carcinoide.
e) Hipertensin inducida por el embarazo.
f) Apnea del sueo.
g) Medicamentos:
anticonceptivos
orales,
corticosteroides,
agentes
vasoconstrictores, simpticomimticos, antidepresivos tricclicos, inhibidores
de la monoaminoxidasa, anfetaminas, AINES, ciclosporina, eritropoyetina.
h) Otros : enfermedad de Paget oseo, enfermedades del SNC (con hipertensin
intracraneal), estrs agudo (cirugas, quemaduras, post-resuscitacin,
pancreatitis, hiperventilacin psicgena).
Situaciones clnicas que sugieren HTA secundaria :
Inicio de la hipertensin antes de los 30 aos o despus de los 50.
HTA severa o refractaria al tratamiento.
Palpitaciones, sudoracin y cefalea
feocromocitoma.
Uso de frmacos y drogas que elevan la presin arterial.
Facies o biotipo que cursa con hipertensin
nefropata, hipertiroidismo
acromegalia, sndrome de Cushing.
Soplo abdominal
enfermedad renovascular.
Masa abdominal
rin poliqustico.
Disminucin de la amplitud o retardo del pulso femoral
coartacin de
aorta.
Incremento de la creatinina srica
enfermedad renal parenquimal.
Hipokalemia espontnea
hiperaldosteronismo.
Examen de orina anormal ( proteinuria o hematuria ).
"
"
Los factores de riesgo cardiovascular (3) pueden ser agrupados en:
3.1. FACTORES DE RIESGO CARDIOVASCULAR
3.1.1.FACTORES DE RIESGO MAYORES:
Hipertensin arterial.
Tabaquismo.
Obesidad (Indice de Masa Corporal*: IMC > = 30; Circunferencia de
cintura > 102cm en varones y > 88cm en mujeres).
Indice cintura / cadera > 0.85 en mujeres > 0.98 en hombres.
Inactividad fsica (sedentarismo).
Dislipidemia (hipercolesterolemia, hipertrigliceridemia y/o colesterol
bajo).
Diabetes mellitus.
Microalbuminuria o TFG estimada < 60 ml/min.
Edad (varones > 55 aos, mujeres > 65 aos).
HDL
Otros FR y
Enfermedad
Sin FR
PA Normal
Normal alta
PAS 120-129
O
PAD 80-84
PAS 130-139
O
PAD 85-89
Riesgo
Promedio
Grado 1
PAS 140-()159
O
PAD 90-99
Riesgo
Promedio
Bajo Riesgo
Agregado
Grado 2
PAS 160-179
O
PAD 100-109
Moderado
Riesgo
Agregado
Grado 3
1 2 FR
Bajo Riesgo
Agregado
Moderado
Riesgo
Agregado
Bajo Riesgo
Agregado
Moderado
Riesgo
Agregado
Muy Alto
Riesgo
Agregado
3 ms FR o
DOB o DM
Condicin
Clnica
Asociada
Moderado
Riesgo
Agregado
Alto Riesgo
Agregado
Alto Riesgo
Agregado
Alto Riesgo
Agregado
Muy Alto
Riesgo
Agregado
Alto Riesgo
Agregado
Muy Alto
Riesgo
Agregado
Muy Alto
Riesgo
Agregado
Muy Alto
Riesgo
Agregado
Muy Alto
Riesgo
Agregado
Normal
Prehipertensin
Hipertensin grado 1
Hipertensin grado 2
SISTOLICA (mmHg)
< 120
120 139
140 159
> = 160
DIASTOLICA
(mmHg)
< 80
80 89
90 99
> = 100
!
Los procedimientos diagnsticos tienen los siguientes objetivos:
a) Establecer los niveles de presin arterial.
b) Identificar causas secundarias de hipertensin.
c) Evaluar el riesgo cardiovascular global investigando otros factores de riesgo, dao
de rgano blanco y enfermedades concomitantes.
Estos procedimientos comprenden la historia mdica, mediciones repetidas de la
presin arterial, examen fsico y exmenes de laboratorio e instrumentales.
5.1. Evaluacin clnica
%
%
%
%
%
%
%
%
%
'
(
*
)
"
"
Objetivos:
Promocionar estilos de vida saludables en la poblacin.
Prevenir la morbilidad por hipertensin arterial.
&
Tabaquismo
Abandonar el hbito de fumar.
7.
HTA ESTADIO 1 :
(PAS 140-159
PAD 90-99 mmHg)
HTA ESTADIO 2 :
(PAS > 160
PAD > 100 mmHg)
Combinacin de dos
frmacos para casi
,
todos.
Usualmente una Tiazida
y un IECA ( ARA II)
Beta bloqueador
Bloqueador de canal de
calcio
Frmacos para
indicaciones
especiales
(complicaciones
especficas)
Otros antihipertensivos
segn necesidad
(diurticos, IECA, ARA
II, Beta bloqueador,
Bloqueador de canal de
calcio)
PA objetivo no alcanzada
7.1
Modificacin (*)
Reduccin de
peso
Adopcin de
dieta DASH
Reduccin del
sodio en la dieta
Recomendacin
Mantener un peso corporal normal:
IMC 18.5 24.9
Rango aproximado de
reduccin de PAS y PAD
5 20 mmHg/ 10 kg de
prdida de peso (23, 24)
Nivel de
evidencia
B
Actividad fsica
Limitar el
consumo de
alcohol
No al Tabaco
#
Datos de excelentes ensayos clnicos han probado que la reduccin en la PA
con varias clases de frmacos incluyendo inhibidores de enzima convertidora de
angiotensina (IECA), bloqueadores de los receptores de angiotensina (BRA),
beta bloqueadores, bloqueadores de los canales de calcio (BCC) y diurticos tipo
tiazidas reducen las complicaciones de la hipertensin (7, 32-38).
Adems de la terapia antihipertensiva se ha recomendado el uso de agentes
antiplaquetarios como el cido acetil saliclico (aspirina) a bajas dosis (75 a 100
mg/da) en la prevencin secundaria de pacientes con cardiopata isqumica y
enfermedad cerebro vascular. En prevencin primaria la aspirina puede ser
usada en pacientes hipertensos con diabetes tipo 2 y probablemente tambin
sea beneficioso en pacientes hipertensos con riesgo cardiovascular alto siempre
que su hipertensin arterial est bien controlada (99, 100,101).
DIURTICOS
Los diurticos son frmacos de primera lnea por su bajo costo, buena tolerancia,
escasez de efectos metablicos adversos a la dosis utilizadas actualmente, y por
sus efectos beneficiosos sobre la morbilidad cerebrovascular y en menor medida
sobre la cardiopata isqumica (Nivel de evidencia A).
Los diurticos tipo tiazidas:
% Reducen la presin arterial por disminucin del volumen plasmtico y la
resistencia arterial perifrica.
% Son la base de la terapia antihipertensiva en la mayora de estudios (38).
% En estos estudios incluyendo el recientemente publicado Antihypertensive
and Lipid-Lowering Treatment to Prevent Heart Attack Trial (ALLHAT) los
diurticos no han sido superados en la prevencin de las complicaciones
cardiovasculares de la hipertensin (34).
% Los diurticos incrementan la eficacia antihipertensiva de esquemas con
multifrmacos, tiles en lograr el control de la PA y son ms asequibles y
menos costosos que otros agentes.
% A pesar de los resultados aun estn siendo subutilizados (39).
% Las tiazidas deberan ser la terapia inicial para la mayora de pacientes con
hipertensin ya sea solos o en combinacin con IECAs, BRA, beta
bloqueadores BCC (Nivel de evidencia A).
% Las tiazidas no deberan ser usadas en pacientes con funcin renal menor
del 30%. Para este grupo los diurticos de asa constituyen una alternativa.
BETA BLOQUEADORES
%
%
%
%
%
%
%
%
%
%
CLASE
Diurticos:
a) Tiazidas
CONDICIONES QUE
FAVORECEN SU USO
Insuficiencia cardiaca congestiva,
CONTRAINDICACIONES
DEFINIDAS
POSIBLES
Gota
Embarazo
hipertensin en ancianos,
hipertensin sistlica aislada
b) De asa
Insuficiencia renal, insuficiencia
cardiaca congestiva
c) Anti-aldosterona Insuficiencia cardiaca congestiva,
post-infarto de miocardio
Beta bloqueadores
Angina de pecho, post-infarto de
miocardio, insuficiencia cardiaca
congestiva (titulacin creciente),
embarazo, taquiarritmias
Bloqueadores de los
canales de calcio :
Dihidropiridinas
Pacientes ancianos, hipertensin
sistlica aislada, angina de
pecho, enfermedad vascular
perifrica, aterosclerosis
carotidea, embarazo
No dihidropirinas Angina de pecho, aterosclerosis
(verapamilo,
carotidea.
diltiazen)
Inhibidores ECA
Antagonistas de los
receptores de
angiotensina II (
ARA II )
Bloqueadores alfa
Hiperplasia prosttica,
hiperlipidemia
Insuficiencia renal,
hiperkalemia
Asma
Enfermedad
EPOC
vascular perifrica,
BAV 2 3er grado intolerancia a la
glucosa
Taquiarritmias,
insuficiencia
cardiaca
congestiva
BAV 2 3er
grado, insuficiencia
cardiaca
congestiva
Embarazo,
hiperkalemia,
estenosis de
arteria renal
bilateral
Embarazo,
hiperkalemia,
estenosis de
arteria renal
bilateral
Hipotensin
ortosttica
Insuficiencia
cardiaca
congestiva
"! #
"
!
$
"
! " ,
- ! "
/ 0
"
"!
/ !
0
"
! #
"
"
-!
"
"
."!
%&'( ) &(
%&'( ) (*
%
%
&* ) +*
&
( ) %*
(* ) %**
&( ) (*
%)&
%)&
%)&
&( ) %**
1 1 /" ! -
/ !
0
!6
- !
8 9
!
.
1
"
!
0
! 7 "
"
"
"
!
-!
!
/ 0
"
"
"
/ 0
,
/ 0
"
-
"
"
7
"
"
-! "
"
:
# .
" !
" !
" !
.
" !
; " !
! #
! #
;
;
" "!
8
-
8
1
.
"! "
9 ! "
!
; "
7.3
"! "
"
"
!
"
"
"
2 " "!
2 -
2
2 -
> # "
# "
# "
&
4* ) %+*
&'( ) %*
(* ) %**
3* ) %&*
&* 5 3*
&** ) +**
%* ) 3*
%
%
%)&
%
&
&
&
%&'( ) (*
&** ) +**
&( ) %**
&'( ) 3*
%* ) 3*
%* ) 3*
%* ) 3*
&'( ) &*
%'&( ) (
%53
+ ) <&
%(* ) <**
&( ) %**
&* ) +*
+* 5 <&*
=* ) <4*
%+* ) <4*
+* ) <&*
%&* ) <4*
&'( ) %*
&'( ) &*
4* ) %&*
<* ) 4*
&* 5 3*
&
&
&
)
%
%
%
%
%
%
%
%
)
%
%
)
%
&
)
%
%
&
%
%
% ) %4
& ) &*
% 5 &*
8 &
2
! "
3* ) %4*
2
!
$ " -#
>
&
&
<
&
%
&)<
%)&
*'% 5 *'+
&
&(* ) %***
*'*( ) *'&(
&( ) %**
&'( 5 +*
&
%
&
%5&
&
ANT ALD
BCC
ARA II
Diabetes
IECA
Post-infarto de
miocardio
Enfermedad
coronaria
de alto riesgo
Beta
Bloqueador
Insuficiencia
cardiaca
Diurticos
CONDICIN DE
ALTO RIESGO
+
+
+
ENSAYOS CLNICOS
BSICOS
ACC/AHA Heart Failure Guideline (40), MERIT-HF (41),
COPERNICUS (42), CIBIS (43), SOLVD (44), AIRE (45),
TRACE (46), ValHEFT (47), RALES (48)
ACC/AHA Post-MI Guideline (49), BHAT (50), SAVE
(51), CAPRICORN (52), EPHESUS (53)
ALLHAT (34), HOPE (35), ANBP2 (37), LIFE (33),
CONVINCE (32)
NKF-ADA Guideline (21,22), UKPDS (54), ALLHAT (34)
Enfermedad renal
NKF Guideline (22), Captopril Trial (55), RENAL (56),
IDNT (57), REIN (58), AASK (59)
Crnica
+ +
Prevencin de
PROGRESS (36)
ictus recurrente.
+
+
*DIUR = diurticos ; B BLOQ = beta bloqueadores ; IECA = inhibidores de enzima convertidora
de andiotensina ; ARA II = antagonistas de los receptores de angiotensina II ; BCC =
bloqueadores de los canales de calcio ; ANT ALD = antagonistas de aldosterona.
$%&'(&)*$+) '&*$*(&)(&
-
7.3.2.
',&)-$.* / &0&',&)-$.* 1$%&'(&)*$2.*
- Urgencias hipertensivas:
PAD> 120-130 mmHg
Asociado a disfuncin de rganos vitales.
Requiere disminucin de HTA inmediato.
Emergencia hipertensiva:
PAD> 120-130 mmHg
Ausencia de disfuncin de rgano blanco.
Disminucin de HTA dentro de las 12 a 24 horas.
3
Primer Nivel
- Realizar actividades de informacin, educacin, y comunicacin en la poblacin
general y/o con factores de riesgo cardiovascular.
- Promover los cambios de estilo de vida en personas con factores de riesgo
cardiovascular.
- Realizar tamizaje de hipertensin arterial en la poblacin asegurada.
- Manejo integral de hipertensos de estadio 1 y 2 (JNC 7) no complicados.
Segundo Nivel
- Identificacin y captacin de pacientes hipertensos atendidos en las diferentes
especialidades.
- Promover los cambios de estilo de vida en pacientes hipertensos con factores de
riesgo cardiovascular.
- Manejo de pacientes con hipertensin arterial no controlada, complicada y no
complicada.
- Manejo de hipertensin arterial con dao de rgano blanco (hipertrofia ventricular
izquierda, disfuncin ventricular izquierda, insuficiencia renal crnica no terminal).
Tercer Nivel
- Estudio de pacientes con sospecha de hipertensin arterial secundaria.
- Promover los cambios de estilo de vida en pacientes hipertensos con factores de
riesgo cardiovascular.
- Manejo de pacientes con hipertensin arterial secundaria.
- Manejo de pacientes con complicaciones vasculares agudas (sndromes
coronarios agudos, Insuficiencia cardiaca descompensada , eventos cerebro
vasculares, diseccin de aorta, etc).
- Manejo de paciente con insuficiencia renal crnica terminal.
- Manejo de pacientes con hipertensin severa o refractaria al tratamiento.
4
Del primer al segundo nivel
- Pacientes con hipertensin arterial no controlada a pesar del tratamiento
adecuado.
- Paciente con sospecha de compromiso de rgano blanco.
- Paciente con urgencia hipertensiva no resuelta.
- Paciente con aparicin de complicaciones de HTA
Del segundo al tercer nivel
- Hipertensin arterial severa o refractaria al tratamiento.
- Disfuncin ventricular izquierda aguda.
- Insuficiencia renal crnica terminal.
- Paciente con emergencia hipertensiva.
&
5
1. Ari Timerman. Manual de Cardiologa. Sociedad de Cardiologa del Estado de Sao Paulo.
Editora Atheneu, 2000. (Texto)
2. Braunwald Eugene. Heart Disease . A Textbook of Cardiovascular Medicine. W.B. Saunders
Company. 5th edition, 1997. (Texto)
3. The Seventh Report of the Join National Committee on Prevention, Detection, Evaluation, and
Treatment of High Blood Pressure (The JNC Report ). JAMA 2003; 289(19): 2560-72.
(Consenso)
4. 2003 European Society of Hypertension European Society of Cardiology guidelines for the
management of arterial hypertension (Guidelines Committee). Journal of Hypertension 2003;
21(6) : 1011-53. (Consenso)
5. 1999 W ord Health Organization International Society of Hypertension (Guidelines Subcommittee. Journal of Hypertension 1999; 17 : 151-83. (Consenso)
6. Lewington S, Clarke R, Qizilbash N, Peto R, Collins R. Age specific relevance of usual blood
pressure to vascular mortality. Lancet 2002; 360 : 1903-13. (Meta-anlisis)
7. Neal B, MacMahon S, Chapman N. Effects of ACE inhibitors, calcium antagonists, and other
blood pressure lowering drugs. Lancet 2000; 356 : 1955-64. (Meta-anlisis)
8. Ogden LG, He J, Lydick E, Whelton PK. Longterm absolute benefit of lowering blood pressure
in hypertensive patients according to the JNC VI risk stratification. Hypertension 2000; 35:
539-43. (Estudio de prevalencia)
9. Burt VL, Cutler JA, Higgoins M, et al. Trends in the prevalence, awareness, treatment, and
control of hypertension in the adult US population; data from the Health Examination Surveys,
1960-1991. Hypertension 1995; 26: 60-69. (Estudio de prevalencia)
10. Anderson KM, W ilson PW, Odell PM, Kannel WB. An updated coronary risk profile. A
statement for health professionals. Circulation 1991; 83: 356-362. (Estudio observacional)
11. Conroy RM, Pyrl K, Fitzgerald AP, Sans S, et al on behalf of the SCORE project group.
Prediction of ten-year risk of fatal cardiovascular disease in Europe: The SCORE project. Eur
Heart J 2003 ( en prensa ). (Estudio observacional)
12. Pickering TG, Cotas A, Mallion JM, Mancia G, Verdecchia P. Task Force V. White-coat
hypertension. Blood Press Monit 1999; 4 : 333-341. (Consenso)
13. Pickering TG, James GD, Boddie C, Harshfield GA, Blank S Larga JH. How Common is white
coat hypertension ?. JAMA 1988; 259: 225 228. (Estudio de prevalencia)
14. Mancia G, Parati G, Pommidosi G, Gras G, Casadei R, Zanchetti A. Alerting reaction and rise
in blood pressure during measurement by physician and nurse. Hypertension 1987; 9 : 209215. (Estudio observacional)
15. Pickering TG. Recommendations for the use of home (self) and ambulatory blood pressure
monitoring. Am J Hypertens 1996; 9: 1-11. (Consenso)
16. Staessen J, Fagard RH, Lijnen PJ, Van Hoof R, Amery AK. Mean ang range of the ambulatory
pressure in normotensive subjects from a meta-analysis of 23 studies. Am J Cardiol 1991; 67:
723-727. (Mata-analysis)
17. Ohkubo T, Imai y, Tsuji I,Nagai K, Ito S, Satoh H, Hisamichi S. Reference values for 24-hour
ambulatory blood pressure monitoring based on a prognostic criterion : the Ohasama Study.
Hypertension 1988; 32: 255-259. (Estudio observacional)
18. American Heart Association. Home monitoring of high blood pressure. Disponible en:
http://www.americanheart.org/presenter.jhtml?identifier=576.
Accessed
April
2003.
(Consenso)
19. Gonzlez-Juanatey JR, Mazn P, Soria F,Barrios V, Rodrguez L, Bertomeu V. Actualizacin
2003 de las Guas de Prctica Clnica de la Sociedad Espaola de Cardiologa en
Hipertensin Arterial. Rev Esp Cardiol 2003; 56(5): 487-497. (Consenso)
20. Schilaci G, Verdecchia P, Borgioni C, Ciucci A,, Guerrieri M, Zampi L, et al. Improved
electrocardiography diagnosis of left ventricular hypertrophy. Am J Cardiol. 1994; 74: 714-9.
(Consenso)
21. American Diabetes Association. Treatment of hypertension in adults with diabetes. Diabetes
Care 2003; 26 (suppl. 1): S80-S82. (Consenso)
22. National Kidney FoundationGuideline. K/DOQI clinical practice guidelines for chronic kidney
disease: Kidney Disease Outcome Quality Initiative.Am J Kidney Dis. 2002; 39 (suppl. 2): S1S246. (Consenso)
23. The Trials of Hypertension Prevention Collaborative Research Group. Effects of weight loss
and sodium reduction intervention on blood pressure and hypertension incidence in
overweight people with high normal blood pressure. Arch Intern Med 1997; 157: 657 667.
(Randomizado)
24. He J, W helton PK, Appel LJ, Charleston J, Klag MJ. Long-term effects of weight loss and
dietary sodium reduction on incidence of hypertension. Hipertensin 2000; 35: 544 549.
(Estudio observacional)
25. Sacks FM, Svetkey LP, Vollmer WM,, et al, for the DASH sodium collaborative Research
Group. Effects on blood pressure of reduced dietary sodium and the Dietary Approaches to
Stop Hypertension (DASH) diet. N Engl J Med 2001; 344: 3 10. (Randomizado)
26. Vollmer WM, Sacks FM, Ard J, et al. Effects of diet and sodium intake on blood pressure. Ann
Intern Med 2001; 135: 1019 1028. (Randomizado)
27. Chobanian AV, Hill M. National Herat, Lung, and Blood Institute W orkshop on Sodium and
Blood Pressure: a critical review of current scientific evidence. Hipertensin 2000; 35: 858
863. (Revisin)
28. Kelley GA, Kelley KS. Progressive Resistance exercise and resting blood pressure.
Hypertension 2000; 35: 838 843. (Meta-anlisis)
29. Whelton SP,, Chin A, Xin X, He J. Effect of aerobic exercise on blood pressure. Ann Intern
Med 2002; 136: 493 503. (Meta-analysis)
30. Xin X, He J, Frontini MG, et al. Effects of alcohol reduction on blood pressure. Hypertension
2001; 38: 1112 1117. (Meta-anlisis)
31. Doll R, Peto R, W heatley K, Gray R, Sutherland I. Mortality in relation to smoking: 40 years
observational study on male British doctors. BMJ 1994; 309: 901 911. (Estudio
observacional)
32. Black HR, Elliot WJ, Grandits G, et al. Principal results of the Controlled Onset Verapamil
Investigation of Cardiovascular End Points ( CONVINCE ) trial. JAMA 2003; 289: 20732082.(Randomizado)
33. Dahlof B, Devereux RB, Kjeldsen SE, et al. Cardiovascular morbidity and mortality in the
Losartan Intervention For End Point Reduction in Hypertension Study (LIFE). Lancet 2002;
359: 995-1003.(Randomizado)
34. The ALLHAT Officers and Coordinators for the ALLHAT Collaborative Research Group. Major
outcomes in high-risk hypertensive patients randomized to angiotensin conventing enzyme
inhibitor or calcium channel blocker vs diuretic. JAMA 2002; 288: 2981-2997. (Randomizado)
35. The Heart Outcomes Prevention Evaluation (HOPE) Study Investigators. Effects of an
angiotensin-converting enzyme inhibitor, ramipril, on cardiovascular events in high-risk
patients. N Eng J Med 2000; 342: 145-153. (Randomizado)
36. PROGRESS Collaborative Group. Randomized trial of perindopril-based blood-pressurelowering regimen among 6105 individuals with previous stroke or transient ischaemic attack.
Lancet 2001; 358: 1033-1041. (Randomizado)
37. Wing LMH, Reid CM,, Ryan P, et al, for Second Australian National Blood Pressure Study
Group. A comparison of outcomes with angiotensin-converting enzyme inhibitors and diuretics
for hypertension in the elderly. N Eng J Med 2003; 348: 583-592. (Randomizado)
38. Psaty BM, Smith NL, Siscovick DS, et al. Health outcomes associated with antihypertensive
therapies used as first-line agents. JAMA 1997; 277: 739-745. (Meta analysis)
39. Psaty BM, Manolio TA, Smith NL, et al. Time trends in high blood pressure control and the
use of antihypertensive medications in older adults. Arch Intern Med 2002; 162: 2325-2332.
(Estudio
de
prevalencia)
40. Hunt SA, Baker DW, Chin MH, et al. ACC / AHA guidelines for the evaluation and
management of chronic heart failure in the adult. J Am Coll Cardiol 2001; 38: 2101-13.
(Consenso)
41. Tepper D. Frontiers in congestive heart failure: effect of metoprolol CR/XL in chronic heart
failure. Congest Heart Fail 1999; 5: 184-185. (Randomizado)
42. Packer M, Coats AJ, et al. Effect of carvedilol on survival in severe chronic heart failure. N
Engl J Med 2001; 344: 1651-58. (Randomizado)
43. CIBIS investigators and committees. A randomized trial of beta-blockade in heart failure: the
Cardiac Insufficiency Bisoprolol Study (CIBIS). Circulation 1994; 90: 1765-73. (Randomizado)
44. The SOLVD investigators. Effect of enalapril on survival in patients with reduced left
ventricular ejection fractions and congestive heart failure. N Engl. J Med 1991; 325: 293-302.
(Randomizado)
45. The Acute Infarction Ramipril Efficacy (AIRE) Study Investigators. Effect of ramipril on
mortality and morbidity of survivors of acute myocardial infarction with clinical evidence of
heart failure. Lancet 1993; 342: 821-28. (Randomizado)
46. Kober L, Torp-PedersenC, Carlsen JE, et al, for Trandolapril Cardiac Evaluation (T RACE)
Study
Group. A clinical trial of the angiotensin-converting-enzyme inhibitor trandola patients
prilwith
in
left ventricular dysfunction after myocardial infarction. N Engl J Med 1995; 333:
1670-76. (Randomizado)
47. Cohn JN, Tognoni G. A randomized trial of the angiotensin-receptor blocker valsartan in
chronic heart failure. N Engl J Med 2001; 345: 1667-75. (Randomizado)
48. Pitt B, Zannad F, Remme WJ, et al, for Randomized Aldactone Evaluation Study (RALES)
Investigators. The effect of spironolactone on morbidity and mortality in patients with severe
heart failure. N Engl. J Med 1999; 341: 709-17. (Randomizado)
49. Braunwald E, Antman EM, Beasley JW, et al. ACC / AHA 2002 guideline update for the
management of patients with unstable angina and non-ST-segment elevation myocardial
infarction. J Am Coll Cardiol 2002; 40: 1366-74. (Consenso)
50. Beta-Blocker Heart Attack Trial (BHAT) Research Group. A randomized trial of propranolol in
patients with acute myocardial infarction, I : mortality results. JAMA 1982; 247: 1707-14.
(Randomizado)
51. Hager W D, Davis BR, Riva A, et al, for the Survival and Ventricular Enlargement (SAVE)
Investigators. Absence of a deleterious effect of calcium channel blockers in patients with left
ventricular dysfunction after myocardial infarction: the SAVE Study Experience. Am Heart J
1998; 135: 406-13. (Randomizado)
52. The Capricorn Investigators. Effect of carvedilol on outcome after myocardial infarction in
patients with left-ventricular dysfunction: the CAPRICORN randomized trial. Lancet 2001; 357:
1385-90. ( Randomizado )
53. Pitt B, Remme W, Zannad F, et al. Eplerenone, a selective aldosterone blocker, in patients
with with left ventricular dysfunction after myocardial infarction. N Engl J Med 2003; 348:
1309-21. (Randomizado)
54. UK Prospective Diabetes Study Group. Efficacy of atenolol and captopril in reducing risk of
macrovascular and microvascular complications in type 2 diabetes: UKPDS 39. BMJ 1998;
317: 713-20. (Randomizado)
55. Lewis EJ, Hunsicker LG, Bain RP, Rohde RD. The effect of angiotensin-converting-enzyme
inhibition on diabetic nephropathy: The Collaborative Study Group. N Engl J Med 1993; 329:
1456-62. (Randomizado)
56. Brenner BM, Cooper ME, de Zeeuw D, et al. Effects of losartan on renal and cardiovascular
outcomes in patients with type 2 diabetes and nephropathy. N Engl J Med 2001; 345: 861-69.
(Randomizado)
57. Lewis EJ, Hunsicker LG, Clarke WR, et al. Renoprotective effect of the angiotensin-receptor
antagonist irbesartan in patients with nephropathy due to tipe 2 diabetes. N Engl J Med 2001;
345: 851-60. (Randomizado)
58. The GISEN (Gruppo Italiano di Studi Epidemiologici in Nefrologia) Group. Randomised
placebo-controlled trial of effect of ramipril on decline in glomerular filtration rate and risk of
terminal ranal failure in proteinuric, non-diabetic nephropathy. Lancet 1997; 349: 1857-63.
(Randomizado)
59. Wright JT Jr, Agodoa L, Contreras G, et al. Succesful blood pressure control in the African
American Study of Kidney Disease and Hypertension. Arch Intern Med 2002; 162: 1636-43.
(Randomizado)
60. Staessen JA, Gasowski J, Wang JG, et al. Risk of untreated and treated isolated systolic
hypertension in the elderly: meta-analysis of outcome trials. Lancet 2000; 355: 865-72. (Metaanlisis)
61. Hansson L, Lindholm LH, Ekbom T, Dahlf, et al. Randomised trial of old and new
antihypertensive drugs in elderly patients: cardiovascular mortality and morbidity in the
Swedish Trial in Old Patients with Hypertension-2 study. Lancet 1999; 354: 1751-56.
(Randomizado)
62. Lithell H, Hansson L, Skogg I, et al. For the SCOPE Study Group. The Study on Cognition
and Prognosis in the Elderly (SCOPE). Principal results of randomised double-blind
intervention trial. J Hypertens 2003; 21: 875-86. (Randomizado)
63. Somes GW, Pahor M, Shorr RI, et al. The rol of diastolic blood pressure when treating isolated
systolic hypertension. Arch Int Med 1999; 159: 2004-09. (Randomizado)
64. Simonson DC. Etiology and prevalence of hypertension in diabetic patients. Diabetes Care
1988; 11: 821-27. (Revisin)
65. Dillon JJ. The quantitative relationship between treated blood pressure and progression of
diabetic renal disease. Am J Kidney Dis. 1993; 22: 798-802. (Revision)
66. Walker WG. Hypertension related renal injury: major contributor to end-stage renal disease.
Am J Kidney Dis. 1993; 22: 164-73. (Revisin)
67. Mogensen CE. Long-term antihypertensive treatment inhibiting progression of diabetic
nephropathy. BMJ 1982; 285: 685-88. (Randomizado)
68. Hansson L, Lindholm LH, Niskanen L, et al. Effect of angiotensin-converting-enzyme inhibition
compared with conventional therapy on cardiovascular morbidity and mortality in
hypertension: the Captopril Prevention Project (CAPPP) randomised trial. Lancet 1999; 353:
611-16. (Randomizado)
69. Estacio RO, Jeffers BW, Hiatt WR, et al. The effect of nisoldipine as compared with enalapril
on cardiovascular outcomes in patients with non-insulin independent diabetes and
hypertension. N Engl. J Med 1998; 338: 645-52. (Randomizado)
70. Lindholm LH, Ibsen H, Dahlf B, et al. Cardiovascular morbidity and mortality in patients with
diabetes in the Losartan Intervention For Endpoint reduction in hypertension study (LIFE): a
randomised trial against atenolol. Lancet 2002; 359: 1004-10. (Randomizado)
71. PATS Collaborative Group. Post-stroke antihypertensive treatment study. Clin. Med J 1995;
108: 710-17. (Randomizado)
72. Wright JT, Bakris G, Greene T, et al. For the African American Study of Kidney Disease and
Hypertension Study Group. Effect of blood pressure lowering and antihypertensive drug class
on progression of hypertensive kidney disease: results from the AASK Trial. JAMA 2002; 288:
2421-31. (Randomizado)
73. Bakris GL, Williams M, Dworkin L, et al. for National Kidney Foundation Hypertension and
Diabetes Executive Committees Working Group. Preserving renal function in adults with
hypertension and diabetes. Am J kidney Dis 2000; 36: 646-61. (Consenso)
74. Bakris GL, Weir MR. Angiotensin-converting enzyme inhibitor-associated elevations in serum
creatinine. Arch Intern Med 2000; 160: 685-93. (Meta-anlisis)
75. Pfeffer MA, Braunwald E, Moye LA, et al, for the SAVE Investigators. Effect of captopril on
mortality and morbidity in patients with left ventricular dysfunction after myocardial infarction.
N Engl. J Med. 1992; 327: 669-77. (Randomizado)
76. Joint National Committee on Prevention Detection, Evaluation, and Treatment of High Blood
pressure. The sixth report of the Joint National Committee on Prevention, Detection,
Evaluation, and Treatment of High Blood Pressure. Arch Intern Med 1997; 157: 2413-46.
(Consenso)
77. Kjeldsen SE, Dahlof B, Devereux RB, et al. Effects of losartan on cardiovascular morbidity and
mortality in patients with isolated hypertension and left ventricular hypertrophy: a Losartan
Intervention For Endpoint Reduction (LIFE) substudy. JAMA 2002; 288: 1491-98.
(Randomizado)
78. National Cholesterol Education Program (NCEP) Expert Panel on Detection, Evaluation, and
Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel III) final report.
Circulation 2002; 106: 3143-3421. (Consenso)
79. National High Blood Pressure Education Program Working Group on Hypertension Control in
Children and Adolescents. Update on the 1987 Task Force Report on high blood pressure in
children and adolescents. Pediatrics 1996; 98: 649-58. (Consenso)
80. Barlow SE, Dietz W H. Obesity evaluation and treatment: expert committee recommendations.
Pediatrics 1998; 102: e29. (Consenso)
81. MoutquinJM, Garner PR, Burrows RF, et al. Report of the Canadian Hypertension Society
Consensus Conference: 2. Nonpharmacologic management and prevention of hypertensive
disorders in pregnancy. Can Med Assoc J 1997; 157: 907-19. (Consenso)
82. Sibai BM, Mabie WC, Shamsa F, Vilnar MA, Anderson GD. A comparison of no medication
versus methyldopa o labetalol in chronic hypertension during pregnancy. Am J Obstetric
Gynecologic 1990; 162: 960-67. (Randomizado)
83. Gruppo di Studio Ipertensione in Gravidanza. Nifedipine versus expectorant management in
mild to moderate hypertension in pregnancy. Br J Obst. Gynaecol 1998; 105: 718-22.
(Randomizado)
84. de Suite M. Maternal blood pressure and birth weight. Lancet 2000; 355: 81-82.
85. von Dadelszen P, Omstein MP, Bull SB, et al. Fall in a mean arterial pressure and fetal growth
restriction in pregnancy hypertension: a meta-analysis. Lancet 2000; 355: 87-92. (Metaanalysis)
86. Atallah AN, Hofmeyr GJ, Duley L. Calcium supplementation during pregnancy for preventing
hypertensive disorders and related problems (Cochrane review). In: The Cochrane Library,
Issue 1. Oxford: Update Software; 2000. (Meta-analysis)
87. Olsen S, Secher NJ, Tabor A, W eber T, et al. Randomised clinical trials of fish oil
supplementation in high risk pregnancies. Br J Obstet Gynaecol 2000; 107: 382-95. (Metaanalysis)
88. Knight M, Duley L, Henderson-Smart DJ, King JF. Antiplatelet agents and pre-eclampsia
(Cochrane review). In: The Cochrane Library, Issue 1. Oxford, Update Software, 2000. (metaanalysis)
89. Khedun SM, Moodley J, Naicker T, et al. Drug management of hypertensive disorders of
pregnancy. Pharmacol Ther 1997; 74: 221-58. (Revision)
90. National High Blood Pressure Education Program Working Group Report on High Blood
Pressure in Pregnancy. NIH publication No. 00-3029; originally printed 1990; revised July
2000. (Consenso)
91. Dekker G, Sibai B. Primary, secondary, and tertiary prevention of pre-eclampsia. Lancet
2001; 357: 209-15. (Consenso)
92. Magee LA, Omstein MP, von Dadelszen P. Fortnightly review : management hypertension in
pregnancy. BMJ 1999; 318: 1332-36. (Consenso)
93. The Magpie Trial Collaborative Group. Do women with pre-eclampsia, and their babies,
benefit from magnesium sulphate? The Magpie Trial: a randomized placebo-controlled trial.
Lancet 2002; 359: 1877-90. (Randomizado)
94. Grossman E, Messerli FH, Grodzicki T. Should a moratorium be placed on sublingual
nifedipine capsules given for hypertensive emergencies and pseudoemergencies ?. JAMA
1996; 276: 1328 31 (Prospectivo).
95. Furberg CD, Psaty BM, Meyer JV. Nifedipine : dose related increase in mortality in patients
with coronary heart disease. Circulation 1995; 92: 1326 31. (metanlisis)
96. Brown MJ, Palmer CR, Castaigne A, et al.: Morbidity and mortality in patients randomized to
double-blind treatment with a long-acting calcium-channel blocker or diuretic in the
international nifedipine GITS study: intervention as a goal in hypertension treatment
(INSIGHT). Lancet 2000; 356: 366-72 (Randomizado)
97. Hansson L, Hedner T, Lund-Johansen P, Kjeldesen SE, et al: Randomized trial of effects of
calcium antagonists compared with diuretic and beta-blockers on cardiovascular morbidity and
mortality in hypertension: the Nordic Diltiazem (NORDIL) study. Lancet 2000; 356: 359-65
(randomizado)
98. Izzo JL, Black HR: Hypertension Primer. Second Edition. From the Council on High Blood
Pressure Research, American Heart Association. 1999
99. Meade TW, Brennan PJ. Determination of who may derive most benefit from aspirin in primary
prevention: subgroup results from a randomized controlled trial. BMJ 2000;321:13-7.
100. Lauer MS. Clinical practice. Aspirin for primary prevention of coronary events. N Engl. J
med 2002;346:1468-74.
101. Antithrombotic Trialist Collaboration. Collaborative meta-analysis of randomized trials of
antiplatelet therapy for prevention of death, myocardial infarction, and stroke in high risk
patients. BMJ. 2002;324:71-86.M.