Hypertension is a major cause of morbidity and mortality in communities of African ancestry. The most appropriate method of predicting the risk for blood pressure (BP)-related cardiovascular events is through 24-hour ambulatory BP (ABP) monitoring. Although the cost of monitors precludes the use of 24-hour BP measurement in groups of African descent in Africa, the extent to which BP-related cardiovascular risk may be underestimated by nurse-derived clinic BP measurements, and the current method of BP-related risk assessment in these communities, is uncertain. In this regard, nursederived BP measurement is thought to be superior to other forms of in-office BP measurement. Ambulatory 24-hour, day and night BP (SpaceLabs, model 90207) and nursederived clinic BP (CBP) (mean of 5 values) control rates were determined in 689 randomly selected participants (>16 years) of African ancestry in South Africa. Of the participants 45.7% were hypertensive and 22.6% were receiving antihypertensive medication. More participants had uncontrolled BP at night (34.0%) than during the day (22.6%, p<0.0001). However, uncontrolled CBP was noted in 37.2% of participants, while a much lower proportion had uncontrolled ABP (24.1%)(p<0.0001). These differences were accounted for by a high prevalence of isolated increases in CBP (whitecoat effects)(39.4%). Thus, in communities of African descent, despite a worse BP control at night than during the day, a high prevalence of white-coat effects translates into a striking underestimation of BP control when employing CBP rather than ABP measurements. Nurse-derived BP measurements are often as closely associated with organ damage as ABP. However, the extent to which relationships between nurse-derived BP measurements and organ damage reflect a white-coat effect (isolated increase in inoffice BP) as opposed to the adverse effects of BP per se are unknown. In 750 participants from a community sample, target organ changes were determined from carotid-femoral pulse wave velocity (PWV) (applanation tonometry and SphygmoCor software) (n=662) and left ventricular mass indexed to height2.7 (LVMI) (echocardiography)(n=463). Nurse-derived CBP was associated with organ changes independent of 24-hour BP (LVMI; partial r=0.15, p<0.005, PWV; partial r=0.21, p<0.0001) and day BP. However, in both unadjusted (p<0.0001 for both) and multivariate adjusted models (including adjustments for 24-hour BP)(LVMI; partial r=0.14, p<0.01, PWV; partial r=0.21, p<0.0001) nurse office-day SBP (an index of isolated increases in in-office BP) was associated with target organ changes independent of ambulatory BP and additional confounders. Thus, nurse-elicited whitecoat effects account for a significant proportion of the relationship between nursederived CBP and target organ changes independent of ambulatory BP. Therefore, high quality nurse-derived BP measurements do not approximate the impact of BP effects per se on cardiovascular damage. In 750 participants from a community sample I evaluated whether nurse officeday BP is inversely related to day-night BP (BP dipping) and whether this relationship may in-part explain the independent association between office-day BP and organ damage. Nurse office-day systolic BP (SBP) was correlated with % night/day SBP (r=0.22, p<0.0001) and night SBP (r=0.14, p=0.0001). Although unadjusted and multivariate adjusted (including for day SBP) nurse office-day SBP was associated with LVMI (partial r=0.15, p<0.01) and PWV (partial r=0.22, p<0.0001), neither day-night SBP (LVMI; partial r=-0.01, p=0.88, PWV: partial r=-0.04, p=0.30) nor % night/day SBP (LVMI; partial r=0.01, p=0.91, PWV: partial r=0.04, p=0.37) were independently related to target organ changes. Moreover, the relationships between nurse office-day SBP and target organ changes persisted with adjustments for either day-night SBP (p<0.05- p<0.0001) or night SBP (p<0.01-p=0.0001). Thus, although nurse office-day SBP, an index of an alerting response, is independently associated with an atttenuation of nocturnal decreases in SBP, neither a decreased BP dipping, nor nocturnal BP explain the independent relationship between nurse office-day SBP and target organ changes. Whether nurse office-day BP is affected by antihypertensive therapy, is uncertain. In the present study the effect of antihypertensive therapy on nurse office-day BP was assessed in 173 patients whom, off treatment, had a daytime diastolic BP ranging from 90 to 114 mm Hg. Over the treatment period marked decreases in BP occurred (p<0.0001). However, neither nurse office-day systolic (baseline=16.5±15.8 mm Hg, 4 months=15.3±18.9 mm Hg, p=0.49), nor diastolic (baseline=0.9±9.3 mm Hg, 4 months=4.3±10.7 mm Hg, p<0.005) BP decreased significantly from baseline. Thus, despite producing marked decreases in nurse-derived in-office and out-of-office ambulatory BP, antihypertensive therapy produces no change in nurse-elicited isolated increases in in-office BP (white coat-effects) in a group of African descent. In conclusion, the results of the present thesis indicate that in an urban, developing community of African descent, as compared to 24-hour BP measurements, nurse-derived BP measurements elicit a significant in-office increase in BP which translates into a marked underestimation of BP control at a community level; is strongly associated with organ damage through effects that cannot be attributed to 24-hour BP or to relationships with an attenuated decline in nocturnal BP; and which cannot be treated with antihypertensive therapy. Further work is required to assess the most cost-effective approach to excluding nurse-elicited isolated increases in in-office BP before initiating antihypertensive therapy to groups of African descent.

No description available.

BACKGROUND Worldwide, hypertension is the third leading risk factor contributing to death, surpassed only by malnutrition and smoking. 1 Hypertension is common and treatable and because uncontrolled hypertension has serious consequences, preventive measures and control of blood pressure should be a high priority. A healthy lifestyle remains the cornerstone of the management of blood pressure (BP) for all severities of hypertension. It is possible to prevent the development of hypertension and to lower blood pressure levels by simply adopting a healthy lifestyle. 2 Health care workers can assess and contribute to the management of hypertension with exercise adequately if the patient is educated and convinced that lifestyle changes are essential and indeed the most cost effective method of obviating cardiovascular disease. METHODS Patients with hypertension (N=110) were identified from a cohort of patients attending the outpatients department of Carletonville Hospital, a district hospital situated in the mining town of Carletonville, South Africa, and were then invited to participate in the study. A crosssectional descriptive study design was used to determine the knowledge and attitudes of these patients with respect to the importance of lifestyle modification in the management of hypertension. This was achieved by administering a questionnaire. Descriptive and inferential statistical methods were employed to analyze the data. RESULTS The largest number of respondents fell in the 50-59 year old age groups (28%). Females (62%) made up a significant majority of the study population. The population breakdown included the following: Black respondents were 75%, while 24 % were white and 1% coloured. Body Mass Index was more than 25 in 81% of the respondents and 84% of the population had schooling levels below high school. Fifty seven percent (57%) of the respondents ate fried foods regularly, 70 % cooked with salt, 18% add salt to their food, while 14% ate red meat regularly and 26 % consumed alcohol, with 6 % having more than 3 beers/day. The majority of participants led sedentary lifestyles according to the physical activity score, with 74% having little or no activity. At the time of the study 69% had blood pressure (BP) levels above 140/90 mmHg with only 42% knowing what their normal BP should be. Seventy seven percent (77%) believed that exercise lowers BP, and only 30% reported having received such advice from a medical professional. Ninety five percent (95%) believed that a balanced diet is important in controlling hypertension and fifty one percent (51%) reported having being advised by a medical professional about a balanced diet. Ninety four percent (94%) knew that adding salt to food affects BP and sixty nine percent (69%) reported having being told by a medical professional about the effects of excessive salt intake in their diets. Eighty percent (80%) believed that alcohol affects blood pressure and forty four percent (44%) reported having received such information from a medical professional. Seventy five percent (75%) believed that smoking affects BP and thirty six percent (36%) got this information from a medical professional. DISCUSSION The results indicate that respondents reported having received advice about lifestyle modification from medical professionals. The advice varied between areas of lifestyle change, which included education on diet, alcohol, smoking and exercise. The most frequently given advice was on diet and salt intake, with exercise being the least often information provided to the patients by medical professionals. Reduced salt intake advice was the most frequently reported (69%), followed by a balanced diet (51%), reduced alcohol intake (44%), not smoking (35%) and benefits of exercise (30%).Despite this most of the respondents were leading sedentary lifestyles, were overweight (BMI>25) and had BP`s greater than 140/90 mmHg . The reasons provided for not exercising varied from “not being used to it”, “no- time” to “body pain”. Twenty one percent (21%) were not on a proper diet due to financial reasons, 16% stated lack of information as the reason and 9% just found unhealthy food to be very tempting. CONCLUSION The results of this study suggest that although patients do receive advice on lifestyle modification, it is not effective in changing patient behavior, and may therefore be inadequate and not emphasized enough and also not all patients are advised by medical professionals about lifestyle change. The reason for this is not known. Greeff (2006) in his study emphasized that building a trusting relationship between the healthcare worker and the patient is one of the most important aspects when motivating patients. 2

Hypertensive left ventricular hypertrophy (LVH) increases the risk for the development of heart failure with systolic chamber dysfunction. However, the exact mechanisms and hence best therapeutic approach to prevent this transition process is uncertain. One potential mechanism is through excessive β-adrenergic receptor (-AR) activation, but the risks of β-AR blocker therapy may outweigh the benefits. Since activation of -AR augments function of the renin-angiotensin-aldosterone system, I therefore explored whether mineralocorticoid receptor (MR) blockade prevents the transition from hypertensive LVH to systolic chamber decompensation produced by excessive β-AR activation, and the mechanisms thereof. The role of hypertensive LVH as a predisposing factor to systolic chamber decompensation post-myocardial infarction (MI) is controversial. In the present thesis I therefore also evaluated this question. The effect of spironolactone (SPIRO, 80 mg.kg-1.day-1), an MR blocker, on LV chamber remodelling and function was evaluated in spontaneously hypertensive rats (SHR) in whom decompensation was induced by administering a low dose of the -AR agonist, isoproterenol (ISO) for 4.5 months. ISO administration resulted in an increased urinary aldosterone excretion and LV cavity dimensions, a right shift in LV diastolic pressure-volume relations, and a decreased LV relative wall thickness without further enhancing an increased myocardial norepinephrine (NE) release in SHR. ISO reduced LV systolic chamber function (decreased LV endocardial fractional shortening and the slope of the LV systolic pressure- volume relationship) without modifying intrinsic myocardial systolic function (as assessed from LV midwall fractional shortening and the slope of systolic stress-strain relationship). SPIRO abolished ISO-induced chamber dilatation, wall thinning and systolic dysfunction, but failed to modify blood pressure, volume preloads, intrinsic myocardial systolic function, or myocardial NE release. These results suggest that MR activation, through load-independent effects, may be critical in mediating the transition from compensated hypertensive LVH to dilatation and LV systolic chamber dysfunction. In SHR, ISO increased myocardial matrix metalloproteinase (MMP)-2 activity (zymography) after only 4-5 days of administration, a change that was associated with MMP-2, but not TIMP expression. The increased MMP-2 activity persisted until 4.5 months of the study and these changes were prevented by SPIRO. At 4.5 months, ISO resulted in increased non-cross-linked, but not cross-linked myocardial collagen concentrations in SHR, an effect that was abolished by SPIRO. Although at 4.5 months ISO administration was not associated with an increased cardiomyocyte apoptosis (TUNEL), an early (4-5 days) ISO-induced apoptotic effect was noted, which was prevented by SPIRO. Neither ISO nor SPIRO influenced cardiomyocyte length (image analysis and flow cytometry) in SHR. Thus MR blockade may prevent the adverse effects of β-AR activation in hypertensive LVH through alterations in the cardiac interstitium and cardiomyocyte apoptosis. Six-to-seven months after ligation of the left anterior descending coronary artery, LV myocardial systolic function as assessed from % shortening of the non-infarcted lateral wall segmental length determined over a range of filling pressures (ultrasonic transducers placed in the lateral wall in anaesthetized, open-chest, ventilated rats) and % thickening of the posterior wall (echocardiography) was reduced in infarcted SHR (SHR-MI) (p<0.05), but not in normotensive Wistar Kyoto (WKY-MI) animals as compared to corresponding controls (SHR-Sham, WKY-Sham). This change in regional myocardial function in SHR-MI, but not in WKY- MI, occurred despite a similar degree of LV dilatation in SHR-MI and WKY-MI rats and a lack of difference in LV relative wall thinning, LV wall stress, apoptosis (TUNEL) or necrosis (pathological score) between SHR-MI and WKY-MI rats. Although the change in regional myocardial function in the SHR-MI group was not associated with a greater reduction in resting global LV chamber systolic function (endocardial fractional shortening-FSend and end-systolic elastance [LV Ees] determined in the absence of an adrenergic stimulus), in the presence of an ISO challenge a reduction in LV Ees in SHR-MI compared to WKY-MI and SHR and WKY-Sham rats was noted (p<0.04). These data suggest that with chronic MI, the hypertensive heart is susceptible to development of viable tissue myocardial dysfunction, a change which cannot be attributed to excessive chamber dilatation, apoptosis or necrosis, but which in-turn, contributes toward a reduced cardiac adrenergic-inotropic reserve. The present thesis therefore suggests that MR blockade may prevent the transition from hypertensive LVH to systolic chamber decompensation, and that pre-existing hypertensive LVH increases the susceptibility to a depressed LV regional myocardial systolic function in the non-infarcted LV myocardium subsequent to MI, an effect that translates into a reduced inotropic reserve.

No description available.

INTRODUÇÃO: Não se sabe se o ajuste da terapia anti-hipertensiva baseado na Monitorização Residencial da Pressão Arterial (MRPA) pode melhorar o controle da pressão arterial em pacientes em hemodiálise. OBJETIVOS: Comparar a redução da pressão arterial (PA) e do índice de massa ventricular esquerda (IMVE) obtido com o uso da MRPA em relação às medidas da PA pré-diálise em pacientes em hemodiálise. MÉTODOS: Pacientes hipertensos em hemodiálise foram randomizados para ter a terapia anti-hipertensiva ajustada em dois grupos: controle, baseado na PA pré-diálise, e intervenção, baseada na MRPA. Antes e após 06 meses de acompanhamento, os pacientes realizaram Monitorização Ambulatorial da Pressão Arterial (MAPA) por 24 horas, MRPA durante uma semana e ecocardiograma transtorácico. RESULTADOS: 34 e 31 pacientes completaram o estudo no grupo intervenção e controle, respectivamente. As pressões arteriais sistólica (PAS) e diastólica (PAD) no período interdialítico pela MAPA foram significativamente menores no grupo intervenção em relação ao grupo controle no final do estudo (média 24 horas: 135 ± 13mmHg / 76 ± 7mmHg versus 147 ± 15mmHg / 79 ± 8mmHg, respectivamente - p<0,05). Na análise da MRPA, o grupo intervenção apresentou redução significativa somente para a PAS em comparação ao grupo controle (média semanal: 144 ± 21mmHg versus 154 ± 22 mmHg, respectivamente - p<0,05). Não houve diferenças entre os grupos intervenção e controle em relação ao IMVE ao final do estudo (108 ± 35 g/m2 versus 110 ±33 g/m2, respectivamente - p>0,05). CONCLUSÕES: O uso sistemático da MRPA no ajuste da terapia anti-hipertensiva em pacientes em hemodiálise propiciou maior controle da PA no período interdialítico em comparação às medidas da PA pré-diálise. A MRPA pode ser usada como um instrumento adjuvante útil no controle da pressão arterial em pacientes em hemodiálise / INTRODUCTION: It is not known whether the adjustment of the antihypertensive therapy based on Home Blood Pressure Monitoring (HBPM) can improve blood pressure (BP) control in hemodialysis patients. OBJECTIVES: To compare the reduction in BP and in the left ventricular mass index (LVMI) obtained with the use of HBPM in relation to that achieved with predialysis BP measurements in hemodialysis patients. METHODS: Hypertensive patients on hemodialysis were randomized to have the antihypertensive therapy adjusted according two groups: control, based on the predialysis BP measurements, and intervention, based on HBPM. Before and after 06 months of follow-up, patients were submitted to Ambulatory Blood Pressure Monitoring (ABPM) for 24 hours, HBPM during one week and transthoracic echocardiogram. RESULTS: 34 and 31 patients completed the study in the intervention and control groups, respectively. The systolic (SBP) and diastolic (DBP) blood pressure in the interdialytic period by ABPM were significantly lower in the intervention group compared with the control group at the end of the study (mean 24-hours BP: 135 ± 13 mm Hg / 76 ± 7 mmHg versus 147 ± 15 mm Hg / 79 ± 8 mmHg, respectively - p <0.05). When the interdialytic BP was analysed by HBPM, the intervention group showed significant reduction only for the PAS in comparison with control group (mean weekly BP: 144 ± 21 mm Hg versus 154 ± 22 mm Hg, respectively - p <0.05). There were no differences between intervention and control groups in relation to LVMI at the end of the study (108 ± 36 g/m2 versus 110 ± 33 g/m2, respectively - p> 0.05). CONCLUSIONS: The systematic use of HBPM in the adjustment of antihypertensive therapy in patients on hemodialysis has led to better control of BP during interdialytic period compared to that achieved with the predialysis BP measurements. The HBPM can be used as a useful adjunct instrument to control blood pressure in hemodialysis patients

INTRODUÇÃO: A hipertensão é um importante problema de saúde pública e os estudos de Custo-Efetividade (C/E) do tratamento antihipertensivo são raros no Brasil. OBJETIVO: Realizar análise farmacoeconômica retrospectiva do tipo C/E do tratamento medicamentoso em hipertensos. MATERIAL E MÉTODOS: Foi analisado o custo (C) dos medicamentos anti-hipertensivos, do número de visitas médicas não programadas e do tratamento dos efeitos adversos e a efetividade (E) medida pela redução média da pressão arterial em mm Hg ao término de estudo sobre eficácia do tratamento Tradicional iniciado com hidroclorotiazida e atenolol comparado ao tratamento Atual iniciado com losartan e anlodipino, administrados aleatoriamente durante 12 meses a hipertensos sem outras doenças concomitantes pertencentes ao estágios 1 e 2 (grupo HT1-2 = 140 menor ou igual PAS < 180 e 90 menor ou igual PAD < 110 mm Hg) e ao estágio 3 (grupo HT3 = PAS > 180 e PAD > 110 mm Hg). RESULTADOS: A razão C/E (R$/mm Hg) no grupo HT1-2 (n = 231) para PAS/PAD dos tratamentos Atual e Tradicional foi de 112,52 ± 395,28 / 181,26 ± 358,91 e 43,05 ± 50,73 / 80,51 ± 108,31 (p < 0,05) ao passo que no grupo HT3 (n = 132) foi de 115,12 ± 254,87 / 108,14 ± 82,56 e 218,59 ± 891,93 / 173,97 ± 447,23 (p > 0,05). CONCLUSÃO: O tratamento Tradicional foi custo-efetivo em relação ao Atual nos hipertensos estágios 1 e 2. Por outro lado, nos hipertensos estágio 3 não houve diferença na razão C/E entre os tratamentos. Estes resultados foram confirmados quando foi utilizado o menor preço de aquisição dos medicamentos e quando foram considerados somente os pacientes que atingiram o controle da pressão arterial ao final do estudo. / INTRODUCTION: Hypertension is an important public health problem and Cost-Effectiveness (C/E) studies of antihypertensive drug treatment are uncommon in Brazil. OBJECTIVE: To perform a cost-effectiveness (C/E) ratio retrospective pharmacoeconomic analysis of drug treatment in hypertensive patients. MATERIAL AND METHODS: Antihypertensive medication cost (C) was analysed, along with the number of non-scheduled medical visits, treatment of adverse effects, and effectiveness (E) based on the average reduction of arterial blood pressure measured in mm Hg at the end of the study comparing the efficacy of a Traditional Treatment with hydrochlorothiazide and atenolol versus Current Treatment using losartan and amlodipine, administered at random for 12 months to hypertensive patients with no other simultaneous diseases and presenting disease stage 1 and 2 (HT1-2 Group = 140 < or = SBP < 180 and < or = 90 DBP < 110mmHg) and stage 3 (HT3 Group = SBP maior or = 180 and DBP > or = 110mmHg). RESULTS: The C/E ratio (R$/mmHg) in the HT1-2 Group (n=231), based on SBP/DBP, for Current and Traditional Treatments was 112.52 ± 395.28 / 181.26 ± 358.91 and 43.05 ± 50.73 / 80.51 ± 18.31 (p < 0.05), while in the HT3 Group (n=132), 115.12 ± 254.87 / 108.14 ± 82.56 and 218.59 ± 891.93 / 173.97 ± 447.23 (p>0.05). CONCLUSION: Traditional treatment was more cost-effective compared to the Current therapy in hypertensive patients with disease stages 1 and 2. On the other hand, in hypertensive patients with disease stage 3 there was no difference in C/E ratio between the treatment regimens. These results were confirmed by using the lowest purchase price of medication and by considering only patients that reached control of their blood pressures at the end of the study.

A adesão ao tratamento representa um problema de âmbito mundial por piorar os resultados terapêuticos, em especial de doenças crônicas, e aumentar os custos dos sistemas de saúde. Pouco se conhece sobre a magnitude da não-adesão ao tratamento com medicamentos antihipertensivos, em particular no contexto da atenção primária no Brasil. O objetivo desta tese é estudar a prevalência e fatores associados à não-adesão ao tratamento anti-hipertensivo de pessoas com HAS atendidas no PSF de Blumenau, SC. Trata-se de um estudo epidemiológico observacional, transversal, com amostra aleatória estratificada, de 595 pessoas usuárias de serviços de saúde da familia de Blumenau, SC. A não-adesão foi medida com questionário previamente validado (QAM-Q). Foram coletadas variáveis socioeconômicas, relativas aos serviços de saúde, das pessoas (características demográficas, biológicas e comportamentais) e do tratamento com medicamentos, em visita domiciliar, com instrumento padronizado e entrevistadores treinados. Procedeu-se análise descritiva com intervalo de 95% de confiança para caracterização da amostra. Na análise univariada, utilizou-se o odds ratio como medida de efeito, sendo incluídas na análise multivariada as variáveis com p<0,10. Para o ajuste para variáveis de confusão, foi utilizado um modelo de regressão logística não condicional hierarquizado por blocos de variáveis, com nível de significância de p<0,05. As características predominantes das pessoas com HAS foram: sexo feminino (70,4%) e com idade média de 60,6 anos, brancas (80,7%), casadas (63,6%), com ate 4 anos de estudo (64,3%), sem trabalhar (75,5%). 13,1% relataram ser tabagistas e 23,7% consumiam álcool. O tempo médio de uso de medicamentos foi de 127,9 meses, em média 1,9 medicamentos, sendo a monoterapia com IECA o esquema mais freqüente (19,1%) e 20,1% relataram reações adversas. As principais doenças associadas foram diabetes mellitus (44,8%) e dislipidemias (24,7%), sendo que em 44,8% detectou-se a presença de transtorno mental comum. A maioria se mostrou satisfeita com os serviços. A prevalência de não adesão foi de 53% e 69,3% tinham PA 140x90mmHg. No bloco das variáveis socioeconômicas, pessoas de classes econômicas C/D/E (OR=1,7; IC95% 1,1-2,4) , trabalhadores (OR=1,6; IC95% 1,1-2,4), em especial não qualificados (OR=3,2; IC95% 1,8-5,8) apresentam maiores risco de não adesão. Dentre as variáveis relativas aos serviços de saúde, precisar comprar seus medicamentos (OR 4,5; IC95% 1,4-14,0) e mais que 6 meses desde a última consulta (OR=1,6; IC95% 1,0-2,5) se mostraram associadas à não-adesão. Quanto às características das pessoas e do tratamento com medicamentos, interromper previamente o tratamento (OR=1,8; IC95% 1,2-2,7), fazer tratamento há menos de 3 anos (OR=1,3; IC95% 1,2-2,7) e presença de transtorno mental comum (OR=2,1 IC95% 1,4-2,9) também se mostraram fatores de risco para não-adesão aos anti-hipertensivos. O estudo dos determinantes da não-adesão, articulados num modelo hierarquizado que ordenou as variáveis em blocos, permitiu ressaltar a importância dos fatores socioeconômicos na não-adesão. Utilizar uma abordagem teórica e optar por ajustar os resultados num modelo logístico hierarquizado, permitiu uma melhor discriminação das variáveis socioeconômicas e destacou que as desigualdades sociais podem se mostrar diretamente associadas à não-adesão, ou mediadas por fatores dos serviços e das pessoas / Adherence to treatment represents a worldwide problem, due to the outcome chronic diseases, increasing in mortality and health systems costs. In Brazil, the magnitude of non-adherence to antihypertensives is not well-known. This thesis aims to find out the prevalence and risk factors associated to non-adherence to antihypertensive treatment among people with hypertension assisted by family health program in Blumenau, SC. Its a sectional epidemiological study with 595 persons provided by stratified sample procedure. Users of family health services were visited at home and a tested questionnaire (QAM-Q) was used to measure non-adherence and other variables (related to social, economical, demographics, health assistance and medicines) in an private interview. Descriptive analysis was presented with 95% confidence interval, and odds ratio was calculated to measure association. Variables with p-value <0.10 were included in mulvariated analysis. Non-conditional logistic regression model with a hierarchical approach was used to fit odds ratio for confounding, with a p-value <0.05. Most of people are females (70.4%) average age between 60.6 years, whites (80.7%), married (63.6%), studied 4 years or less (64.3%), unemployed (75.5%). 13.1% are smokers and 23.7% drink alcohol beverages. The average time of medicine use was of 127.9 months, on average 1,9 medicines. Monotherapy with IECA is the most frequent scheme (19.1%) and 20.1% told adverse reactions. Diabetes mellitus (44.8%) and lipid disorders (24.7%) were the most frequent associated disease and common mental disorders present in 44.8% of people. The majority of people seemed satisfied with the health services. The prevalence of nonadherence to antihypertensives was 53% and 69.3% have blood pressure higher than 140x90mmHg. People of C/D/E classes(OR=1.7; IC95% 1.1-2.4), employed workers (OR=1.6; IC95% 1.1-2.4), specially unqualified ones (OR=3.2; IC95% 1.8-5.8), are in conditions associated with non-adherence. Among the variables related to health services, the need to buy medicines (OR 4.5; IC95% 1.4-14.0) and more than 6 month since last appointment (OR=1.6; IC95% 1.0-2.5) are also associated to non-adherence. Previously stopping the treatment (OR=1.8; IC95% 1.2-2.7), to have treated less than 3 years (OR=1.3; IC95% 1.2-2.7) and the presence of common mental disorders (OR=2.1 IC95% 1.4-2.9) represent people and treatment characteristics associated to antihypertensives nonadherence. The study of determinants of non-adherence, articulated in an theoretic hierarchical model, which ordinate the variables in blocks, allowed to highlight the importance of socioeconomic factors to explain non-adherence. A better discrimination of socioeconomic variables was obtained using a theoretical approach and hierarchical logistic model. It shows that social inequalities can be directly associated to non-adherence or mediated through factors of services and people

A adesão ao tratamento representa um problema de âmbito mundial por piorar os resultados terapêuticos, em especial de doenças crônicas, e aumentar os custos dos sistemas de saúde. Pouco se conhece sobre a magnitude da não-adesão ao tratamento com medicamentos antihipertensivos, em particular no contexto da atenção primária no Brasil. O objetivo desta tese é estudar a prevalência e fatores associados à não-adesão ao tratamento anti-hipertensivo de pessoas com HAS atendidas no PSF de Blumenau, SC. Trata-se de um estudo epidemiológico observacional, transversal, com amostra aleatória estratificada, de 595 pessoas usuárias de serviços de saúde da familia de Blumenau, SC. A não-adesão foi medida com questionário previamente validado (QAM-Q). Foram coletadas variáveis socioeconômicas, relativas aos serviços de saúde, das pessoas (características demográficas, biológicas e comportamentais) e do tratamento com medicamentos, em visita domiciliar, com instrumento padronizado e entrevistadores treinados. Procedeu-se análise descritiva com intervalo de 95% de confiança para caracterização da amostra. Na análise univariada, utilizou-se o odds ratio como medida de efeito, sendo incluídas na análise multivariada as variáveis com p<0,10. Para o ajuste para variáveis de confusão, foi utilizado um modelo de regressão logística não condicional hierarquizado por blocos de variáveis, com nível de significância de p<0,05. As características predominantes das pessoas com HAS foram: sexo feminino (70,4%) e com idade média de 60,6 anos, brancas (80,7%), casadas (63,6%), com ate 4 anos de estudo (64,3%), sem trabalhar (75,5%). 13,1% relataram ser tabagistas e 23,7% consumiam álcool. O tempo médio de uso de medicamentos foi de 127,9 meses, em média 1,9 medicamentos, sendo a monoterapia com IECA o esquema mais freqüente (19,1%) e 20,1% relataram reações adversas. As principais doenças associadas foram diabetes mellitus (44,8%) e dislipidemias (24,7%), sendo que em 44,8% detectou-se a presença de transtorno mental comum. A maioria se mostrou satisfeita com os serviços. A prevalência de não adesão foi de 53% e 69,3% tinham PA 140x90mmHg. No bloco das variáveis socioeconômicas, pessoas de classes econômicas C/D/E (OR=1,7; IC95% 1,1-2,4) , trabalhadores (OR=1,6; IC95% 1,1-2,4), em especial não qualificados (OR=3,2; IC95% 1,8-5,8) apresentam maiores risco de não adesão. Dentre as variáveis relativas aos serviços de saúde, precisar comprar seus medicamentos (OR 4,5; IC95% 1,4-14,0) e mais que 6 meses desde a última consulta (OR=1,6; IC95% 1,0-2,5) se mostraram associadas à não-adesão. Quanto às características das pessoas e do tratamento com medicamentos, interromper previamente o tratamento (OR=1,8; IC95% 1,2-2,7), fazer tratamento há menos de 3 anos (OR=1,3; IC95% 1,2-2,7) e presença de transtorno mental comum (OR=2,1 IC95% 1,4-2,9) também se mostraram fatores de risco para não-adesão aos anti-hipertensivos. O estudo dos determinantes da não-adesão, articulados num modelo hierarquizado que ordenou as variáveis em blocos, permitiu ressaltar a importância dos fatores socioeconômicos na não-adesão. Utilizar uma abordagem teórica e optar por ajustar os resultados num modelo logístico hierarquizado, permitiu uma melhor discriminação das variáveis socioeconômicas e destacou que as desigualdades sociais podem se mostrar diretamente associadas à não-adesão, ou mediadas por fatores dos serviços e das pessoas / Adherence to treatment represents a worldwide problem, due to the outcome chronic diseases, increasing in mortality and health systems costs. In Brazil, the magnitude of non-adherence to antihypertensives is not well-known. This thesis aims to find out the prevalence and risk factors associated to non-adherence to antihypertensive treatment among people with hypertension assisted by family health program in Blumenau, SC. Its a sectional epidemiological study with 595 persons provided by stratified sample procedure. Users of family health services were visited at home and a tested questionnaire (QAM-Q) was used to measure non-adherence and other variables (related to social, economical, demographics, health assistance and medicines) in an private interview. Descriptive analysis was presented with 95% confidence interval, and odds ratio was calculated to measure association. Variables with p-value <0.10 were included in mulvariated analysis. Non-conditional logistic regression model with a hierarchical approach was used to fit odds ratio for confounding, with a p-value <0.05. Most of people are females (70.4%) average age between 60.6 years, whites (80.7%), married (63.6%), studied 4 years or less (64.3%), unemployed (75.5%). 13.1% are smokers and 23.7% drink alcohol beverages. The average time of medicine use was of 127.9 months, on average 1,9 medicines. Monotherapy with IECA is the most frequent scheme (19.1%) and 20.1% told adverse reactions. Diabetes mellitus (44.8%) and lipid disorders (24.7%) were the most frequent associated disease and common mental disorders present in 44.8% of people. The majority of people seemed satisfied with the health services. The prevalence of nonadherence to antihypertensives was 53% and 69.3% have blood pressure higher than 140x90mmHg. People of C/D/E classes(OR=1.7; IC95% 1.1-2.4), employed workers (OR=1.6; IC95% 1.1-2.4), specially unqualified ones (OR=3.2; IC95% 1.8-5.8), are in conditions associated with non-adherence. Among the variables related to health services, the need to buy medicines (OR 4.5; IC95% 1.4-14.0) and more than 6 month since last appointment (OR=1.6; IC95% 1.0-2.5) are also associated to non-adherence. Previously stopping the treatment (OR=1.8; IC95% 1.2-2.7), to have treated less than 3 years (OR=1.3; IC95% 1.2-2.7) and the presence of common mental disorders (OR=2.1 IC95% 1.4-2.9) represent people and treatment characteristics associated to antihypertensives nonadherence. The study of determinants of non-adherence, articulated in an theoretic hierarchical model, which ordinate the variables in blocks, allowed to highlight the importance of socioeconomic factors to explain non-adherence. A better discrimination of socioeconomic variables was obtained using a theoretical approach and hierarchical logistic model. It shows that social inequalities can be directly associated to non-adherence or mediated through factors of services and people

INTRODUÇÃO: A hipertensão é um importante problema de saúde pública e os estudos de Custo-Efetividade (C/E) do tratamento antihipertensivo são raros no Brasil. OBJETIVO: Realizar análise farmacoeconômica retrospectiva do tipo C/E do tratamento medicamentoso em hipertensos. MATERIAL E MÉTODOS: Foi analisado o custo (C) dos medicamentos anti-hipertensivos, do número de visitas médicas não programadas e do tratamento dos efeitos adversos e a efetividade (E) medida pela redução média da pressão arterial em mm Hg ao término de estudo sobre eficácia do tratamento Tradicional iniciado com hidroclorotiazida e atenolol comparado ao tratamento Atual iniciado com losartan e anlodipino, administrados aleatoriamente durante 12 meses a hipertensos sem outras doenças concomitantes pertencentes ao estágios 1 e 2 (grupo HT1-2 = 140 menor ou igual PAS < 180 e 90 menor ou igual PAD < 110 mm Hg) e ao estágio 3 (grupo HT3 = PAS > 180 e PAD > 110 mm Hg). RESULTADOS: A razão C/E (R$/mm Hg) no grupo HT1-2 (n = 231) para PAS/PAD dos tratamentos Atual e Tradicional foi de 112,52 ± 395,28 / 181,26 ± 358,91 e 43,05 ± 50,73 / 80,51 ± 108,31 (p < 0,05) ao passo que no grupo HT3 (n = 132) foi de 115,12 ± 254,87 / 108,14 ± 82,56 e 218,59 ± 891,93 / 173,97 ± 447,23 (p > 0,05). CONCLUSÃO: O tratamento Tradicional foi custo-efetivo em relação ao Atual nos hipertensos estágios 1 e 2. Por outro lado, nos hipertensos estágio 3 não houve diferença na razão C/E entre os tratamentos. Estes resultados foram confirmados quando foi utilizado o menor preço de aquisição dos medicamentos e quando foram considerados somente os pacientes que atingiram o controle da pressão arterial ao final do estudo. / INTRODUCTION: Hypertension is an important public health problem and Cost-Effectiveness (C/E) studies of antihypertensive drug treatment are uncommon in Brazil. OBJECTIVE: To perform a cost-effectiveness (C/E) ratio retrospective pharmacoeconomic analysis of drug treatment in hypertensive patients. MATERIAL AND METHODS: Antihypertensive medication cost (C) was analysed, along with the number of non-scheduled medical visits, treatment of adverse effects, and effectiveness (E) based on the average reduction of arterial blood pressure measured in mm Hg at the end of the study comparing the efficacy of a Traditional Treatment with hydrochlorothiazide and atenolol versus Current Treatment using losartan and amlodipine, administered at random for 12 months to hypertensive patients with no other simultaneous diseases and presenting disease stage 1 and 2 (HT1-2 Group = 140 < or = SBP < 180 and < or = 90 DBP < 110mmHg) and stage 3 (HT3 Group = SBP maior or = 180 and DBP > or = 110mmHg). RESULTS: The C/E ratio (R$/mmHg) in the HT1-2 Group (n=231), based on SBP/DBP, for Current and Traditional Treatments was 112.52 ± 395.28 / 181.26 ± 358.91 and 43.05 ± 50.73 / 80.51 ± 18.31 (p < 0.05), while in the HT3 Group (n=132), 115.12 ± 254.87 / 108.14 ± 82.56 and 218.59 ± 891.93 / 173.97 ± 447.23 (p>0.05). CONCLUSION: Traditional treatment was more cost-effective compared to the Current therapy in hypertensive patients with disease stages 1 and 2. On the other hand, in hypertensive patients with disease stage 3 there was no difference in C/E ratio between the treatment regimens. These results were confirmed by using the lowest purchase price of medication and by considering only patients that reached control of their blood pressures at the end of the study.