Paciente hipertenso de difícil controle: algumas dicas para abordagem inicial

Dicas de como abordar hipertensão refratária

Fonte: lookfordiagnosis.com

Não é incomum encontrar em ambulatórios e unidades básicas de saúde alguns pacientes que se apresentam, via de regra, com níveis pressóricos elevados, alguns até grau III (≥180x110 mmHg - classificação VI Diretrizes Brasileiras de Hipertensão - Arq Bras Cardiol 2010; 95(1 supl.1): 1-51), mesmo com a prescrição de múltiplos antihipertensivos. 

Hipertensão resistente ou refratária é definida como a manutenção de níveis pressóricos inadequados a despeito do uso de 3 ou mais medicações de classes diferentes sendo uma delas um diurético adequado à função renal.

Muitas vezes poderá ser necessário encaminhamento para tratamento especializado, mas antes de encaminhar com esse fim (que no nosso sistema público pode demorar meses), é interessante atentar algumas coisas. Prescrição não é sinônimo de uso adequado de medicações, bem como orientações dietéticas ser não ser sinônimo de aderência a ela. Esses e outros itens seguem abaixo em um algoritmo publicado no Current Cardiology 4ª edição junto a trechos interessantes. É curto e vale a pena ler.

Alguns trechos do texto:

"Resistant hypertension is defined as failure to achieve BP target goal despite three or more drugs, one of which should be a diuretic. The first simple step in managing resistant hypertension, after excluding WCE, nonadherence to medications, and secondary hypertension, is to determine whether patients are on an appropriate class of diuretics based on renal function. Patients with estimated glomerular filtration rate (eGFR) > 50 mL/min/1.73 m² should be treated with thiazide diuretics, particularly chlorthalidone, rather than loop diuretics because of longer half-life and proven efficacy in lowering BP. Patients with an eGFR of 30–40 mL/min/1.73 m² or less should be on loop diuretics because the ability of thiazide diuretics to promote diuresis diminishes with impaired renal function. The use of an appropriate drug combination that provides synergistic effect on BP could minimize the number of medications needed to control hypertension. Assessment of hemodynamic variables is also helpful in deciding appropriate drug combination. For example, the use of BBs and a central sympatholytic drug generally yields minimal incremental benefit and is prohibited in patients with bradycardia or heart block. These patients should be treated with vasodilators such as DHP CCBs, ACEIs, ARBs, or hydralazine (Figure 2–2). Patients with elevated resting heart rate are more likely to derive large BP reduction with BBs, diltiazem, or verapamil because elevated heart rate is usually a good indicator for hyperkinetic circulation in hypertensive patients. Addition of spironolactone should also be considered in patients with resistant hypertension despite adjustment of medications, as mentioned earlier. An increasing body of evidence suggests that low-dose spironolactone between 12.5 and 25 mg/day, which is not likely to produce a major diuretic effect, causes a dramatic fall in BP on average of 25/12 mm Hg, when used as add-on therapy in patients with uncontrolled hypertension. Antihypertensive effect of spironolactone is observed even in patients with essential hypertension without an elevated aldosterone-to-renin ratio. Combination of DHP and non-DHP CCBs appears to have additive effects on peripheral vasodilation and BP, possibly due to binding to different sites of the receptors, and should also be considered in these patients. In contrast, addition of an ARB to ACEI has modest effects on BP, on average of only 5/3 mm Hg. The addition of long-acting nitrates may be considered in patients with isolated systolic hypertension who are refractory to treatment because it has been shown to be beneficial in one small study."

Abraços,