Avaliação clínica e laboratorial e estratificação de risco

Consolim-Colombo, Fernanda; Bortolotto, Luiz Aparecido; Alessi, Alexandre; Brandão, Ayrton Pires; Rosa, Eduardo Cantoni; Lima, Eliuden Galvão de; Ayoub, José Carlos Aidar; Santello, José Luiz; Ribeiro, José Márcio; Bodanese, Luiz Carlos; Toscano, Paulo Roberto B.; Santos, Raul Dias dos; Franco, Roberto Jorge da Silva; Oigman, Wille

doi:10.1590/S0101-28002010000500005

Avaliação clínica e laboratorial e estratificação de risco

Coordenadora: Fernanda Consolim-Colombo (SP)

Secretário: Luiz Aparecido Bortolotto (SP)

Participantes: Alexandre Alessi (PR); Ayrton Pires Brandão (RJ); Eduardo Cantoni Rosa (SP); Eliuden Galvão de Lima (ES); José Carlos Aidar Ayoub (SP); José Luiz Santello (SP); José Márcio Ribeiro (MG); Luiz Carlos Bodanese (RS); Paulo Roberto B. Toscano (PA); Raul Dias dos Santos (SP); Roberto Jorge da Silva Franco (SP); Wille Oigman (RJ)

AVALIAÇÃO CLÍNICA E LABORATORIAL

OBJETIVOS

Os principais objetivos da avaliação clínica e laboratorial estão apresentados na Tabela 1.

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Para atingir tais objetivos é fundamental considerar os aspectos apresentados a seguir, levando-se em conta que o tempo necessário para a avaliação inicial de um paciente com suspeita de hipertensão arterial é de, pelo menos, 30 minutos.¹

AVALIAÇÃO CLÍNICA

Deve-se obter história clínica completa, com especial atenção aos dados relevantes referentes ao tempo e tratamento prévio de hipertensão, fatores de risco, indícios de hipertensão secundária e de lesões de órgãos-alvo, aspectos socioeconómicos e características do estilo de vida do paciente e ao consumo pregresso ou atual de medicamentos ou drogas que podem interferir em seu tratamento (anti-inflamatórios, anorexígenos, descongestionantes nasais etc). Além da medida da PA, a frequência cardíaca deve ser cuidadosamente medida, pois sua elevação está relacionada a maior risco cardiovascular.²

Para avaliação de obesidade visceral, recomenda-se a medida da circunferência da cintura (CC) (IIB), dado que a medida da relação cintura-quadril não se mostrou superior à medida isolada da CC na estratificação de risco.³ Os valores de normalidade da CC adotados nestas diretrizes foram os utilizados no NCEP III⁴ (88 cm para mulheres e 102 cm para homens) e previamente recomendados pela Diretriz Brasileira de Síndrome Metabólica (IIa, C), já que ainda não dispomos de dados nacionais que representem nossa população como um todo.⁵

O exame físico deve ser minucioso, buscando sinais sugestivos de lesões de órgãos-alvo e de hipertensão secundária. O exame de fundo de olho deve ser sempre feito ou solicitado na primeira avaliação, em especial em pacientes com HAS estágio 3, que apresentam diabetes ou lesão em órgãos-alvo⁶ (Classe IIa, Nível C).

No exame físico a obstrução do índice tornozelo braquial (ITB) pode ser útil. A Tabela 2 traz considerações sobre o ITB.

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A INVESTIGAÇÃO LABORATORIAL BÁSICA (TABELAS 3 E 4) É INDICADA PARA TODOS OS PACIENTES HIPERTENSOS

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A avaliação complementar é orientada para detectar lesões clínicas ou subclínicas com o objetivo de melhor estratificação do risco cardiovascular (Tabela 5). Está indicada na presença de elementos indicativos de doença cardiovascular e doenças associadas, em pacientes com dois ou mais fatores de risco, e em pacientes acima de 40 anos de idade com diabetes.¹ (Nível de evidência I, Classe C).

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ESTRATIFICAÇÃO DE RISCO

Para a tomada da decisão terapêutica é necessária a estratificação do risco cardiovascular global (Tabela 9) que levará em conta, além dos valores de PA, a presença de fatores de risco adicionais (Tabela 6), de lesões em órgãos-alvo (Tabela 7) e de doenças cardiovasculares (Tabela 8).^25-27

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Além dos fatores clássicos de risco cardiovascular expostos na Tabela 6, novos fatores de risco cardiovascular vêm sendo identificados, e ainda que não tenham sido incorporados em escores clínicos de estratificação de risco (Framingham,²⁹ Score³⁰) têm sido sugeridos como marcadores de risco adicional em diferentes diretrizes: glicemia de jejum (100 a 125 mg/dL) e hemoglobina glicada anormal,³¹ obesidade abdominal (circunferência da cintura > 102 cm para homens e > 88 cm para mulheres), pressão de pulso > 65 mmHg (em idosos),²⁴ história de pré-eclampsia na gestação,³² história familiar de hipertensão arterial (em hipertensos limítrofes).³³

1. Mancia G, De Backer G, Dominiczak A et al. ESH-ESC Task Force on the Management of Arterial Hypertension. 2007 ESH-ESC Practice Guidelines for the Management of Arterial Hypertension: ESH-ESC Task Force on the Management of Arterial Hypertension. J Hypertens 2007; 25(9):1751-1762.
2. Benetos A, Rudnichi A, Thomas F, Safar M, Guize L. Influence of heart rate on mortality in a French population: role of age, gender, and blood pressure. Hypertension 1999; 33:44-52.
3. Pouliot MC, Després J P, Lemieux S et al Waist circumference and abdominal sagital diameter: best simple anthropometric indexes of abdominal visceral adipose tissues accumulation and related cardiovascular risk in men and women. Am J Cardiol 1994; 73(7):460-468.
4. Third Report of the 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.
5. Alberti KG, Eckel RH, Grundy SM et al. Harmonizing the metabolic syndrome: a joint interim statement of the International Diabetes Federation Task Force on Epidemiology and Prevention; National Heart, Lung, and Blood Institute; American Heart Association; World Heart Federation; International Atherosclerosis Society; and International Association for the Study of Obesity. Circulation 2009; 120(16):1640-1645.
6. Van den Born BJ, Hulsman CA, Hoekstra JB, Schlingemann RO, van Montfrans GA. Value of routine funduscopy in patients with hypertension: systematic review. BMJ 2005; 331(7508):73.
7. Obisesan TO, Obisesan A, Martins S et al. High blood pressure, hypertension, and high pulse pressure are associated with poorer cognitive function in persons aged 60 and older: the Third National Health and Nutrition Examination Survey. J Am Geriatr Soc 2008; 56(3):501-509.
8. Beckman JA, Higgins CO, Gerhard-Herman. Automated oscillometric determination of the ankle-brachial index provides accuracy necessary for office practice. Hypertension 2006; 47:35-38.
9. Ankle Brachial Index Collaboration, Fowkes FG, Murray GD, Butcher I et al. Ankle brachial combined with Framingham Risk Score to predict cardiovascular events and mortality: a meta-analysis. JAMA. 2008; 300(2):197-208.
10. Sarnak MJ, Levey AS, Schoolwerth AC et al. Kidney disease as a risk factor for development of cardiovascular disease: a statement from the American Heart Association Councils on Kidney in Cardiovascular Disease, High Blood Pressure Research, Clinical Cardiology, and Epidemiology and Prevention. Hypertension 2003; 42(5):1050-1065.
11. Culleton BF, Larson MG, Wilson PW, Evans JC, Parfrey PS, Levy D. Cardiovascular disease and mortality in a community-based cohort with mild renal insufficiency. Kidney Int 1999; 56:2214-2219.
12. Levey AS, Coresh J, Balk E et al. National Kidney Foundation. National Kidney Foundation practice guidelines for chronic kidney disease: evaluation, classification, and stratification. Ann Intern Med 2003 Jul 15; 139(2):137-147.
13. Cockcroft DW, Gault MH . Prediction of creatinine clearance from serum creatinine. Nephron 1976; 16:31-41.
14. Levey AS, Coresh J, Greene T et al. Using standardized serum creatinine values in the Modification of Diet in Renal Disease study equation for estimating glomerular filtration rate. Ann Intern Med 2006; 145:247-254.
15. Moe S, Drueke T, Cunningham J et al. Kidney Disease: Improving Global Outcomes (KDIGO). Definition and classification of chronic kidney disease: a position statement from Kidney Disease: Improving Global Outcomes (KDIGO). Kidney Int 2005; 67:2089-2100.
16. Rayner BL, Goodman H, Opie LH. The Chest Radiograph. A useful investigation in the evaluation of hypertensive patients. Am J Hypertens 2004; 17:507-510.
17. Martinez MA, Sancho T, Armada E et al. Prevalence of left ventricular hypertrophy in patients with mild hypertension in primary care: impact of echocardiography on cardiovascular risk stratification. Am J Hypertens 2003; 16:556-563.
18. Koren MJ, Devereux RB, Casale PN, Savage DD, Laragh J. Relation of left ventricular mass and geometry to morbidity and mortality in uncomplicated essential hypertension. Ann Intern Med 1991; 114:345-352.
19. Hsu CC, Brancati FL, Astor BC et al. Blood pressure, atherosclerosis, and albuminuria in 10,113 participants in the atherosclerosis risk in communities study. J Hypertens 2009; 27(2):397-409.
20. Volpe M, Consentino F, Ruilope LM. Is it to measure microalbuminuria in hypertension. J Hypertens 2003; 21:1213-1220.
21. Gerstein HC, Mann JF, Yi Q et al. HOPE Study Investigators. Albuminuria and risk of cardiovascular events, death, and heart failure in diabetic and nondiabetic individuals. JAMA 2001; 286:421-426.
22. Cuspidi C, Ambrosioni E, Mancia G, Pessina AC, Trimarco B, Zanchetti A. Role of echocardiography and carotid ultrasonography in stratifying risk in patients with essential hypertension: the Assessment of Prognostic Risk Observational Survey. J Hypertens 2002; 20:1307-1314.
23. Selvin E, Steffes MW, Zhu H et al. Brancati Glycated hemoglobin, diabetes, and cardiovascular risk in nondiabetic adults. N Engl J Med. 2010 Mar 4; 362(9):800-811.
24. Safar ME, Levy BI, Struijker-Boudier H. Current perspectives on arterial stiffness and pulse pressure in hypertension and cardiovascular diseases. Circulation 2003; 107:2864-2869.
25. Vasan RS, Larson MG, Leip EP et al. Impact of highnormal blood pressure on the risk of cardiovascular disease. N Engl J Med 2001; 345(18):1291-1297.
26. Kshisagar AV, Carpenter M, Bang H, Wyatt SB, Colindres RE. Blood pressure usually considered normal is associated with an elevated risk of cardiovascular disease. Am J Med 2006; 119:133-141.
27. Zanchetti A, Hansson L, Dahlof B et al. Effects of individual risk factors on the incidence of cardiovascular events in the treated hypertensive patients of the Hypertension Optimal Treatment Study. HOT Study Group. J Hypertens 2001; 19:1149-1159.
28. Mancia G, Laurent S, Agabiti-Rosei E, et al. Reappraisal of European Guidelines on Hypertension Management. A European Society of Hypertension Task Force document. J Hypertens 2009; 27:2121-2158.
29. D'Agostino RB Sr, Vasan RS, Pencina MJ et al. General cardiovascular risk profile for use in primary care: the Framingham Heart Study. Circulation 2008, 12; 117(6):743-753.
30. Graham I, Atar D, Borch-Johnsen K et al. European guidelines on cardiovascular disease prevention in clinical practice: executive summary. Fourth Joint Task Force of the European Society of Cardiology and other Societies on Cardiovascular Disease Prevention in Clinical Practice (constituted by representatives of nine societies and by invited experts). Eur J Cardiovasc Prev Rehabil 2007; 14 (Suppl 2):S1-S113.
31. Standi E, Bartnik M, Van den Berghe G et al. Task Force on Diabetes and Cardiovascular Diseases of the European Society of Cardiology (ESC); European Association for the Study of Diabetes (EASD). Guidelines on diabetes, pre-diabetes, and cardiovascular diseases: executive summary: The Task Force on Diabetes and Cardiovascular Diseases of the European Society of Cardiology (ESC) and of the European Association for the Study of Diabetes (EASD). Eur Heart J 2007; 28:88-136.
32. Magnussen EB, Vatten LJ, Smith GD, Romundstad PR. Hypertensive disorders in pregnancy and subsequently measured cardiovascular risk factors. Obstet Gynecol. 2009;114:961-970.
33. Gu D, Chen J, Wu X, et al. Prehypertension and risk of cardiovascular disease in Chinese adults. J Hypertens 2009; 27:721-72

Datas de Publicação

Publicação nesta coleção
16 Jan 2012
Data do Fascículo
Set 2010

This work is licensed under a Creative Commons Attribution-NonCommercial 4.0 International License.

[1] 1. Mancia G, De Backer G, Dominiczak A et al. ESH-ESC Task Force on the Management of Arterial Hypertension. 2007 ESH-ESC Practice Guidelines for the Management of Arterial Hypertension: ESH-ESC Task Force on the Management of Arterial Hypertension. J Hypertens 2007; 25(9):1751-1762.

[2] 2. Benetos A, Rudnichi A, Thomas F, Safar M, Guize L. Influence of heart rate on mortality in a French population: role of age, gender, and blood pressure. Hypertension 1999; 33:44-52.

[3] 3. Pouliot MC, Després J P, Lemieux S et al Waist circumference and abdominal sagital diameter: best simple anthropometric indexes of abdominal visceral adipose tissues accumulation and related cardiovascular risk in men and women. Am J Cardiol 1994; 73(7):460-468.

[4] 4. Third Report of the 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.

[5] 5. Alberti KG, Eckel RH, Grundy SM et al. Harmonizing the metabolic syndrome: a joint interim statement of the International Diabetes Federation Task Force on Epidemiology and Prevention; National Heart, Lung, and Blood Institute; American Heart Association; World Heart Federation; International Atherosclerosis Society; and International Association for the Study of Obesity. Circulation 2009; 120(16):1640-1645.

[6] 6. Van den Born BJ, Hulsman CA, Hoekstra JB, Schlingemann RO, van Montfrans GA. Value of routine funduscopy in patients with hypertension: systematic review. BMJ 2005; 331(7508):73.

[7] 7. Obisesan TO, Obisesan A, Martins S et al. High blood pressure, hypertension, and high pulse pressure are associated with poorer cognitive function in persons aged 60 and older: the Third National Health and Nutrition Examination Survey. J Am Geriatr Soc 2008; 56(3):501-509.

[8] 8. Beckman JA, Higgins CO, Gerhard-Herman. Automated oscillometric determination of the ankle-brachial index provides accuracy necessary for office practice. Hypertension 2006; 47:35-38.

[9] 9. Ankle Brachial Index Collaboration, Fowkes FG, Murray GD, Butcher I et al. Ankle brachial combined with Framingham Risk Score to predict cardiovascular events and mortality: a meta-analysis. JAMA. 2008; 300(2):197-208.

[10] 10. Sarnak MJ, Levey AS, Schoolwerth AC et al. Kidney disease as a risk factor for development of cardiovascular disease: a statement from the American Heart Association Councils on Kidney in Cardiovascular Disease, High Blood Pressure Research, Clinical Cardiology, and Epidemiology and Prevention. Hypertension 2003; 42(5):1050-1065.

[11] 11. Culleton BF, Larson MG, Wilson PW, Evans JC, Parfrey PS, Levy D. Cardiovascular disease and mortality in a community-based cohort with mild renal insufficiency. Kidney Int 1999; 56:2214-2219.

[12] 12. Levey AS, Coresh J, Balk E et al. National Kidney Foundation. National Kidney Foundation practice guidelines for chronic kidney disease: evaluation, classification, and stratification. Ann Intern Med 2003 Jul 15; 139(2):137-147.

[13] 13. Cockcroft DW, Gault MH . Prediction of creatinine clearance from serum creatinine. Nephron 1976; 16:31-41.

[14] 14. Levey AS, Coresh J, Greene T et al. Using standardized serum creatinine values in the Modification of Diet in Renal Disease study equation for estimating glomerular filtration rate. Ann Intern Med 2006; 145:247-254.

[15] 15. Moe S, Drueke T, Cunningham J et al. Kidney Disease: Improving Global Outcomes (KDIGO). Definition and classification of chronic kidney disease: a position statement from Kidney Disease: Improving Global Outcomes (KDIGO). Kidney Int 2005; 67:2089-2100.

[16] 16. Rayner BL, Goodman H, Opie LH. The Chest Radiograph. A useful investigation in the evaluation of hypertensive patients. Am J Hypertens 2004; 17:507-510.

[17] 17. Martinez MA, Sancho T, Armada E et al. Prevalence of left ventricular hypertrophy in patients with mild hypertension in primary care: impact of echocardiography on cardiovascular risk stratification. Am J Hypertens 2003; 16:556-563.

[18] 18. Koren MJ, Devereux RB, Casale PN, Savage DD, Laragh J. Relation of left ventricular mass and geometry to morbidity and mortality in uncomplicated essential hypertension. Ann Intern Med 1991; 114:345-352.

[19] 19. Hsu CC, Brancati FL, Astor BC et al. Blood pressure, atherosclerosis, and albuminuria in 10,113 participants in the atherosclerosis risk in communities study. J Hypertens 2009; 27(2):397-409.

[20] 20. Volpe M, Consentino F, Ruilope LM. Is it to measure microalbuminuria in hypertension. J Hypertens 2003; 21:1213-1220.

[21] 21. Gerstein HC, Mann JF, Yi Q et al. HOPE Study Investigators. Albuminuria and risk of cardiovascular events, death, and heart failure in diabetic and nondiabetic individuals. JAMA 2001; 286:421-426.

[22] 22. Cuspidi C, Ambrosioni E, Mancia G, Pessina AC, Trimarco B, Zanchetti A. Role of echocardiography and carotid ultrasonography in stratifying risk in patients with essential hypertension: the Assessment of Prognostic Risk Observational Survey. J Hypertens 2002; 20:1307-1314.

[23] 23. Selvin E, Steffes MW, Zhu H et al. Brancati Glycated hemoglobin, diabetes, and cardiovascular risk in nondiabetic adults. N Engl J Med. 2010 Mar 4; 362(9):800-811.

[24] 24. Safar ME, Levy BI, Struijker-Boudier H. Current perspectives on arterial stiffness and pulse pressure in hypertension and cardiovascular diseases. Circulation 2003; 107:2864-2869.

[25] 25. Vasan RS, Larson MG, Leip EP et al. Impact of highnormal blood pressure on the risk of cardiovascular disease. N Engl J Med 2001; 345(18):1291-1297.

[26] 26. Kshisagar AV, Carpenter M, Bang H, Wyatt SB, Colindres RE. Blood pressure usually considered normal is associated with an elevated risk of cardiovascular disease. Am J Med 2006; 119:133-141.

[27] 27. Zanchetti A, Hansson L, Dahlof B et al. Effects of individual risk factors on the incidence of cardiovascular events in the treated hypertensive patients of the Hypertension Optimal Treatment Study. HOT Study Group. J Hypertens 2001; 19:1149-1159.

[28] 28. Mancia G, Laurent S, Agabiti-Rosei E, et al. Reappraisal of European Guidelines on Hypertension Management. A European Society of Hypertension Task Force document. J Hypertens 2009; 27:2121-2158.

[29] 29. D'Agostino RB Sr, Vasan RS, Pencina MJ et al. General cardiovascular risk profile for use in primary care: the Framingham Heart Study. Circulation 2008, 12; 117(6):743-753.

[30] 30. Graham I, Atar D, Borch-Johnsen K et al. European guidelines on cardiovascular disease prevention in clinical practice: executive summary. Fourth Joint Task Force of the European Society of Cardiology and other Societies on Cardiovascular Disease Prevention in Clinical Practice (constituted by representatives of nine societies and by invited experts). Eur J Cardiovasc Prev Rehabil 2007; 14 (Suppl 2):S1-S113.

[31] 31. Standi E, Bartnik M, Van den Berghe G et al. Task Force on Diabetes and Cardiovascular Diseases of the European Society of Cardiology (ESC); European Association for the Study of Diabetes (EASD). Guidelines on diabetes, pre-diabetes, and cardiovascular diseases: executive summary: The Task Force on Diabetes and Cardiovascular Diseases of the European Society of Cardiology (ESC) and of the European Association for the Study of Diabetes (EASD). Eur Heart J 2007; 28:88-136.

[32] 32. Magnussen EB, Vatten LJ, Smith GD, Romundstad PR. Hypertensive disorders in pregnancy and subsequently measured cardiovascular risk factors. Obstet Gynecol. 2009;114:961-970.

[33] 33. Gu D, Chen J, Wu X, et al. Prehypertension and risk of cardiovascular disease in Chinese adults. J Hypertens 2009; 27:721-72