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Abstract(s)
Introdução: existe evidência de que os valores de pressão arterial no período noturno
são melhores preditores dos outcomes clínicos do que os valores tensionais no período
diurno, sendo que doentes com perfil tensional non-dipper ou riser (padrão prevalente na
doença renal crónica) apresentam maior risco cardiovascular e de desenvolver lesão de
órgão-alvo. Assim, pressupõe-se que utilizando um tratamento eficaz e seguro, tendo em
conta o ritmo circadiano tensional e os valores de tensão arterial noturna num indivíduo
com doença renal crónica hipertenso, os perfis tensionais de maior risco possam ser
revertidos através da administração de anti-hipertensores ao deitar (cronoterapia).
Objetivos: avaliar qual o benefício da administração ao deitar de anti-hipertensores no
controlo da pressão arterial, na alteração do perfil tensional e na diminuição do risco
cardiovascular comparativamente à administração de anti-hipertensores fora do período
noturno, no doente renal crónico hipertenso sem terapêutica renal de substituição, e
verificar se essa evidência está representada nas atuais guidelines sobre o tema.
Métodos: foi feita pesquisa de meta-análises, revisões sistemáticas, ensaios clínicos e
guidelines publicados nas línguas inglesa, portuguesa e espanhola, sem restrição na data
da publicação. Utilizou-se a escala “Strength of Recommendation Taxonomy” para
avaliação dos níveis de evidência e da força de recomendação.
Resultados: obtiveram-se 52 artigos científicos na pesquisa inicial, dos quais seis
cumpriram os critérios de inclusão (uma meta-análise, uma revisão sistemática e quatro
ensaios clínicos). Da pesquisa de guidelines resultaram seis documentos. Os resultados
indicam que, embora a eficácia na redução dos valores de pressão arterial diurna e nas
24h com a administração de fármacos anti-hipertensores ao deitar seja similar à da
administração matinal, a cronoterapia transformou perfis non-dipper/riser em dipper,
reduziu significativamente os valores de tensão arterial no período noturno, e mostrou
uma redução do risco cardiovascular. Apenas duas guidelines fazem referência à
cronoterapia, sem uma recomendação específica.
Discussão: a cronoterapia pode beneficiar o doente renal crónico hipertenso pela
redução da pressão arterial noturna e controlo dos perfis tensionais de maior risco, já que
tem em conta o ritmo circadiano e otimiza a farmacodinâmica e farmacocinética da
terapêutica, reduzindo o risco cardiovascular sem um custo adicional para o paciente ou
para o Serviço Nacional de Saúde. Conclusão: A administração de anti-hipertensores ao deitar poderá ser aconselhada no
doente renal crónico com hipertensão para diminuir a tensão arterial noturna e reduzir o
risco cardiovascular associado (Força de Recomendação B), facto que poderá sugerir uma
atualização das guidelines atuais.
Introduction: there is some evidence that blood pressure values at night are better predictors of clinical outcomes than daytime blood pressure values, and that patients with a non-dipper or riser blood pressure profile (a prevalent pattern in chronic kidney disease) have a higher cardiovascular risk and risk of developing a harmful target organ alterations. Thus, it is assumed that by using an effective and safe treatment, considering the circadian rhythm and nocturnal blood pressure values in a hypertensive individual with chronic kidney disease, the higher-risk tension profiles can be reversed through the administration of antihypertensive drugs at bedtime (chronotherapy). Objectives: what are the benefits of bedtime administration of antihypertensive drugs in blood pressure control, in the effectiveness of reversing pressure profiles and in reducing cardiovascular risk compared to administration of all antihypertensive drugs outside the nighttime period, in hypertensive patients with chronic kidney disease without renal replacement therapy and ascertain if that evidence is represented in the current guidelines about the topic. Methods: research of meta-analysis, systematic reviews, clinical trials and guidelines available in English, Portuguese and Spanish without limiting the time of the publication was done. The “Strength of Recommendation Taxonomy” was used to assess the levels of evidence and of the strengths of recommendation. Results: a total of 52 scientific articles were found in the initial research, six of which met the inclusion criteria (one meta-analysis, one systematic review and four clinical trials). The guidelines search resulted in six clinical guidelines that were included in this review. The results show that, although the bedtime administration of antihypertensive drugs showed a similar daytime and 24-hour blood pressure reduction as the morning administration of these drugs, chronotherapy transformed nighttime blood pressure profiles from non-dipper/riser to dipper and significantly reduced the cardiovascular risk. Only two guidelines mentioned chronotherapy treatment, without any particular recommendation. Discussion: chronotherapy can benefit these patients by reducing nighttime blood pressure and controlling higher-risk blood pressure profile, as it considers the circadian rhythm and optimizes the pharmacodynamics and pharmacokinetics of these drugs, reducing cardiovascular risk with no additional cost to the patient or the National Health Service. Conclusion: the administration of antihypertensive drugs at bedtime may be encouraged in hypertensive patients with chronic kidney disease to decrease nighttime blood pressure and reduce the associated cardiovascular risk (strength of recommendation B), which may suggest an update of the current guidelines.
Introduction: there is some evidence that blood pressure values at night are better predictors of clinical outcomes than daytime blood pressure values, and that patients with a non-dipper or riser blood pressure profile (a prevalent pattern in chronic kidney disease) have a higher cardiovascular risk and risk of developing a harmful target organ alterations. Thus, it is assumed that by using an effective and safe treatment, considering the circadian rhythm and nocturnal blood pressure values in a hypertensive individual with chronic kidney disease, the higher-risk tension profiles can be reversed through the administration of antihypertensive drugs at bedtime (chronotherapy). Objectives: what are the benefits of bedtime administration of antihypertensive drugs in blood pressure control, in the effectiveness of reversing pressure profiles and in reducing cardiovascular risk compared to administration of all antihypertensive drugs outside the nighttime period, in hypertensive patients with chronic kidney disease without renal replacement therapy and ascertain if that evidence is represented in the current guidelines about the topic. Methods: research of meta-analysis, systematic reviews, clinical trials and guidelines available in English, Portuguese and Spanish without limiting the time of the publication was done. The “Strength of Recommendation Taxonomy” was used to assess the levels of evidence and of the strengths of recommendation. Results: a total of 52 scientific articles were found in the initial research, six of which met the inclusion criteria (one meta-analysis, one systematic review and four clinical trials). The guidelines search resulted in six clinical guidelines that were included in this review. The results show that, although the bedtime administration of antihypertensive drugs showed a similar daytime and 24-hour blood pressure reduction as the morning administration of these drugs, chronotherapy transformed nighttime blood pressure profiles from non-dipper/riser to dipper and significantly reduced the cardiovascular risk. Only two guidelines mentioned chronotherapy treatment, without any particular recommendation. Discussion: chronotherapy can benefit these patients by reducing nighttime blood pressure and controlling higher-risk blood pressure profile, as it considers the circadian rhythm and optimizes the pharmacodynamics and pharmacokinetics of these drugs, reducing cardiovascular risk with no additional cost to the patient or the National Health Service. Conclusion: the administration of antihypertensive drugs at bedtime may be encouraged in hypertensive patients with chronic kidney disease to decrease nighttime blood pressure and reduce the associated cardiovascular risk (strength of recommendation B), which may suggest an update of the current guidelines.
Description
Keywords
Anti-Hipertensores Cronoterapia Doença Renal Crónica Hipertensão Arterial Morbimortalidade Cardiovascular