Linha de Cuidado do Adulto com Hipertensão Arterial Sistêmica

Objectives

The guideline establishes an integrated care pathway for adults with chronic systemic arterial hypertension and hypertensive crisis within Brazil’s Health-Care Network, aiming to expand access, improve care quality and organise safe, person-centred journeys across levels of care.[1]It seeks to prevent hypertension and complications, achieve early diagnosis and sustained control, reduce cardiovascular and renal outcomes, and strengthen secondary prevention, self-care and treatment adherence.[2][3][4]

• Centre care on individual needs through diagnostic assessment, confirmation, referral or transfer, therapeutic planning, continuous treatment and secondary prevention.[1][5]
• Identify hypertension, secondary causes, cardiovascular risk factors, associated disease and target-organ damage, including renal, cardiac, neurological and ophthalmic complications.[6][7][8]
• Promote healthier diets, reduced salt and alcohol consumption, smoking cessation, weight management and regular physical activity as core measures for cardiovascular-risk reduction.[9][10]
• Combine non-pharmacological and pharmacological treatment, escalating medicines when blood pressure remains uncontrolled, treatment is not tolerated or adherence is inadequate.[11][12]
• Manage hypertensive crisis according to the presence of acute target-organ injury, prioritising safe blood-pressure reduction, prevention of deterioration and timely intensive or emergency care where required.[13][14]
• Support differentiated management for people with diabetes, chronic kidney disease, coronary disease, pregnancy, resistant hypertension and suspected secondary hypertension.[8][15][16]

Implementation

Implementation is based on a multidirectional, regionally coordinated care pathway in which primary health-care units manage care flows, coordinate the Health-Care Network and retain the patient’s link with the originating service.[1][5]Care is delivered across homes, primary-care units, emergency care units and hospital emergency departments, with the Mobile Emergency Care Service providing assessment or transfer according to local regulation.[1][17]The Ministry of Health, Secretariat for Primary Health Care, Department of Family Health and Institute for Health Technology Assessment are identified in the publication and its organisation, alongside consultation involving health secretariats, professional societies and the Pan American Health Organization.[18][19]

• Organise regional referral arrangements through intermunicipal agreements, regulation centres, emergency regulation, specialist waiting-list and hospital-bed management, counter-referral, laboratory and imaging agreements, pharmaceutical assistance and communication between care points.[5]
• Provide chronic hypertension care in primary care through at least a doctor and nurse, supported where locally available by multidisciplinary professionals and access to necessary laboratory, imaging and specialist services.[2][20]
• Screen adults aged 18 years or over attending primary care when no blood-pressure record exists from the previous two years, and use nursing reception, clinical and family history, physical examination and laboratory assessment in initial evaluation.[21][6]
• Measure blood pressure using validated, appropriately sized equipment, initially in both arms and with repeated readings; use the higher-reading arm subsequently, record exact values and validate or calibrate equipment before use, annually and after alteration.[22][23][20]
• Use ambulatory or home blood-pressure monitoring where appropriate, particularly for suspected white-coat or masked hypertension, borderline readings, high cardiovascular risk, and persistent elevation despite optimised treatment.[24][25][26]
• Stratify cardiovascular risk using blood-pressure stage, risk factors, target-organ damage, cardiovascular disease, chronic kidney disease and diabetes, supported by electrocardiography, renal-function testing, urinalysis, glucose, lipid and other indicated investigations.[27][3]
• Deliver person-centred adherence support through jointly agreed therapeutic plans, motivational interviewing, education, group interventions, family involvement and multidisciplinary care.[28][29]
• Coordinate nursing and medical follow-up, including intercalated consultations where possible, weekly recording of blood-pressure results during treatment initiation, change or uncontrolled elevation, and medical reassessment within 30 days in these circumstances.[30]
• Refer patients with severe, resistant or suspected secondary hypertension, progressive renal impairment, suspected cardiac target-organ damage, endocrine causes or sleep apnoea through appropriate cardiology, nephrology, endocrinology, respiratory or otorhinolaryngology pathways.[8]
• Use Ministry of Health referral protocols and Telehealth Brazil Networks to support clinical queries, referral qualification and continuity of care.[5][11]
• Provide urgent-care capacity for hypertensive crisis, including intravenous medicines, monitoring, investigations and urgent transport when acute target-organ injury is suspected or confirmed.[2][31]Patients with acute injury require intensive intervention and emergency transfer, whereas those without acute injury generally receive gradual oral-treatment adjustment and early outpatient review.[13][32]
• Prepare discharge documentation with diagnosis, clinical information, test results, prescriptions, specialist or multidisciplinary requirements, self-care advice and referral to the reference primary-care unit within seven days.[33][34]
• Supply medicines through Brazil’s National List of Essential Medicines and the Unified Health System, while municipalities or municipal consortia may acquire some non-listed medicines through regional contracting arrangements.[35][36]

Monitoring & Evaluation

Monitoring is primarily clinical and pathway-based rather than a formal programme performance framework. It covers accurate blood-pressure measurement, diagnostic confirmation, risk stratification, treatment follow-up, emergency monitoring, referral and post-discharge review. No consolidated indicator set, routine reporting system, audit cycle, surveillance governance structure or named accountability body is specified in the supplied extracts.[5][20][37]

• Measure blood pressure using validated, calibrated equipment, initially in both arms with repeated readings, record exact non-rounded values and use the arm with the higher reading for subsequent measurements.[20][38][39]
• Calibrate equipment before initial use, annually and after repairs or other alterations; annual equipment checks are linked to guidance from Brazil’s National Institute of Metrology, Quality and Technology.[20][25]
• Screen adults attending primary care when no blood-pressure measurement has been recorded in the preceding two years, and measure blood pressure at least every two years for adults aged 18 years or over.[21][40]
• Confirm hypertension through at least two measurements per consultation over at least two consultations, preferably across two to three visits; permit single-visit diagnosis where blood pressure is at least 180/110 mmHg and cardiovascular disease is present.[20][24][6]
• Use ambulatory or home blood-pressure monitoring where indicated, including for suspected white-coat or masked hypertension and persistent elevated clinic readings despite optimised treatment.[7][25][26]
• Assess cardiovascular risk, target-organ damage and associated disease through clinical review, laboratory testing, electrocardiography and complementary tests selected according to clinical indication.[22][27][3]
• Monitor treatment adherence, lifestyle measures, blood-pressure control and cardiovascular risk during primary-care follow-up; record weekly blood-pressure results, dates and times after treatment initiation or change, or when pressure is elevated, until first medical reassessment.[28][30]
• Schedule medical reassessment within 30 days when treatment is initiated or changed or pressure is elevated; use control and cardiovascular risk to determine consultation frequency, including monthly intercalated consultations until control for uncontrolled hypertension.[30]
• Use referral, regulation and counter-referral arrangements to maintain continuity and coordination between primary, specialist, emergency and hospital care.[5]
• Monitor hypertensive crises through repeated bilateral blood-pressure readings, heart rate, oxygen saturation, consciousness, capillary glucose, electrocardiography and, where required, continuous cardiac monitoring and laboratory or imaging investigation.[41][32][14]
• Apply staged emergency blood-pressure targets, including a reduction of no more than 25% in the first hour, approximately 160/100–110 mmHg within two to six hours and 135/85 mmHg within 24 to 48 hours for acute target-organ injury.[42][43][14]
• Reassess blood pressure after three to six hours following restart of usual antihypertensive medicine, and arrange primary-care review within seven days after discharge for secondary prevention and self-care support.[44][33][34]
• Record periodic Glasgow Coma Scale and pupillary assessments where neurological monitoring is required, to identify improvement or deterioration.[26][45]

Costing & Financing

No explicit costs, prices, budgets, expenditure allocations, financing sources, funding gaps, resource-mobilisation strategy or economic assumptions are specified in the supplied extracts.[18][2][37]

• Identify resource requirements for hypertension care, including trained primary-care and multidisciplinary staff, validated measurement equipment, laboratory and imaging access, medicines, urgent transport, emergency capacity and specialist referral services, without quantifying their cost.[2][20][46]
• Provide medicines and supplies through Brazil’s Unified Health System in line with the National List of Essential Medicines, while recognising that availability of medicines not included in that list may vary locally.[47][4][48]
• Assign municipalities or municipal consortia responsibility for acquiring some medicines outside the national list through regional contracting arrangements, without stating financial allocations or procurement values.[35][36]
• Note that clonidine, esmolol and metoprolol may not be included in the National List of Essential Medicines for the Unified Health System; this concerns potential local availability rather than a quantified funding commitment.[49][13][32]