Estrategias de tratamiento inicial de la hipertensión arterial: posicionamiento de sociedades científicas en Paraguay
Palabras clave:
hipertensión, terapia de modalidad combinada, agentes antihipertensivos, consenso, Paraguay
Resumen
Introducción: la hipertensión arterial es la principal causa prevenible de enfermedad cardiovascular y muerte prematura a nivel global. En Paraguay, afecta a más del 38,6% de la población adulta, con tasas de control subóptimas a pesar de la disponibilidad de múltiples terapias.
Objetivo: emitir una postura institucional basada en la evidencia disponible, que respalde el uso de terapia combinada como estrategia inicial en el tratamiento farmacológico de la hipertensión arterial en Paraguay.
Métodos: se conformó un grupo multidisciplinario de expertos. Se revisaron guías internacionales (ESC/ESH, ACC/AHA, ISH, LASH) y datos epidemiológicos nacionales y regionales. Se aplicó la técnica Delphi modificada para consensuar las recomendaciones.
Resultados: la evidencia demuestra que la terapia combinada inicial, especialmente en formulaciones a dosis fija, mejora el control tensional, reduce eventos cardiovasculares y favorece la adherencia terapéutica. Se identificaron subgrupos específicos en los que puede considerarse monoterapia.
Conclusión: las distintas sociedades científicas nacionales recomiendan el uso de combinaciones farmacológicas desde el inicio en la mayoría de los pacientes con hipertensión arterial, promoviendo su implementación como estándar clínico nacional.
Citas
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21. Ordunez P, Martinez R, Niebylski ML, Campbell NR. Hypertension prevention and control in Latin America and the Caribbean. J Clin Hypertens (Greenwich) [Internet]. 2015 [cited 2024 Mar 17];17(7):499-502. Available from: https://pubmed.ncbi.nlm.nih.gov/25727743/
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2. Ordunez P, Campbell NRC, Giraldo Arcila GP, Angell SY, Lombardi C, Brettler JW, et al. HEARTS en las Américas: innovaciones para mejorar el manejo de la hipertensión y del riesgo cardiovascular en la atención primaria. Rev Panam Salud Pública. 17 de octubre de 2022;46:e197. . https://doi.org/10.26633/RPSP.2022.197 Available from: https://iris.paho.org/bitstream/handle/10665.2/56528/v46e1972022.pdf?sequence=1&isAllowed=y
3. Barroso WKS, Rodrigues CIS, Bortolotto LA, Mota-Gomes MA, Brandão AA, Feitosa ADM, et al. Brazilian Guidelines of Hypertension - 2020. Arq Bras Cardiol. 2021 Mar;116(3):516-658. doi: 10.36660/abc.20201238 Available from: https://pubmed.ncbi.nlm.nih.gov/33909761/
4. Ministerio de Salud Pública y Bienestar Social. Encuesta nacional factores de riesgo 2011. Primera encuesta nacional de factores de riesgo de enfermedades no transmisibles. [Internet] Asunción: MSPBS; 2012. [citado 17 Mar 2024]. Disponible en: https://dvent.mspbs.gov.py/encuesta-nacional-factores-de-riesgo-2011/
5. Organización Panamericana de la Salud. Organización Mundial de la Salud. Indicadores básicos 2023. [Internet] Washington D.C: OPS-OMS; 2023. [citado 17 Mar 2024]. Disponible en: https://www.paho.org/es/evidencia-e-inteligencia-para-accion-salud/indicadores-basicos-2023
6. López-Jaramillo P, Coca A, Sánchez R, Zanchetti A; Latin American Society of Hypertension. Hypertension Guidelines: Is It Time to Reappraise Blood Pressure Thresholds and Targets? Position Statement of the Latin American Society of Hypertension. Hypertension. 2016 Aug;68(2):257-62. doi: 10.1161/HYPERTENSIONAHA.116.07738. Available from: https://pubmed.ncbi.nlm.nih.gov/27296997
7. Abreu AP. Hypertension in Latin America and the Caribbean: an analysis of recent progress and remaining challenges. J Bras Nefrol. 2025 Jul-Sep;47(3):e20240245. doi: 10.1590/2175-8239-JBN-2024-0245en. doi: 10.1590/2175-8239-JBN-2024-0245en. Available from: https://pmc.ncbi.nlm.nih.gov/articles/PMC12227124/
8. Whelton PK, Carey RM, Aronow WS, Casey Jr DE, Collins KJ, Himmelfarb ChD, et al. 2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA guideline for the prevention, detection, evaluation, and management of high blood pressure in adults: Executive summary: A report of the American College of Cardiology/American Heart Association task force on clinical practice guidelines. Hypertension [Internet]. 2018 [cited 2024 Mar 17];71(6):1269-1324. Available from: https://pubmed.ncbi.nlm.nih.gov/29133354/
9. Williams B, Mancia G, Spiering W, Agabiti Rosei E, Azizi M, Burnier M, et al. 2018 ESC/ESH guidelines for the management of arterial hypertension. Eur Heart J [Internet]. 2018 [cited 2024 Mar 17];39(33):3021–104. Available from: https://pubmed.ncbi.nlm.nih.gov/30165516/
10. Unger T, Borghi C, Charchar F, Khan NA, Poulter NR, Prabhakaran D, et al. 2020 International Society of Hypertension global hypertension practice guidelines. Hypertension [Internet]. 2020 [cited 2024 Mar 17];75(6):1334–57. Available from: https://pubmed.ncbi.nlm.nih.gov/32370572/
11. Murphy MK, Black NA, Lamping DL, McKee CM, Sanderson CF, Askham J, Marteau T, et al. Consensus development methods, and their use in clinical guideline development. Health Technol Assess [Internet]. 1998 [cited 2024 Mar 17];2(3):i-iv, 1–88. Available from: https://pubmed.ncbi.nlm.nih.gov/9561895/
12. Fitch K, Bernstein SJ, Aguilar MD, Burnand B, Ramon LaCalle JR, Lazaro P, et al. The RAND/UCLA appropriateness method user’s manual. [Internet] Santa Monica, CA: RAND Corporation; 2001. [cited 2024 Mar 17]. Available from: https://www.rand.org/pubs/monograph_reports/MR1269.html
13. Organización Panamericana de la Salud. Salud en las Américas 2022: Panorama de la región de las Américas en el contexto de la pandemia de COVID-19. [Internet] Washington, D.C.: OPS; 2022. [citado 17 Mar 2024]. Disponible en: https://iris.paho.org/handle/10665.2/56471
14. Sánchez R (Chair), Coca A (Co-Chair), de Salazar DIM, Alcocer L, Aristizabal D, Barbosa E, et al; LASH Guidelines Task Force Steering and Writing Committee. 2024 Latin American Society of Hypertension guidelines on the management of arterial hypertension and related comorbidities in Latin America. J Hypertens. 2025 Jan 1;43(1):1-34. doi: 10.1097/HJH.0000000000003899. Available from: https://pubmed.ncbi.nlm.nih.gov/39466069/
15. Mancia G, Kreutz R, Brunström M, Burnier M, Grassi G, Januszewicz A, et al. 2023 ESH guidelines for the management of arterial hypertension The Task Force for the management of arterial hypertension of the European Society of Hypertension: Endorsed by the International Society of Hypertension (ISH) and the European Renal Association (ERA). J Hypertens [Internet]. 2023 [cited 2024 Mar 17];41(12):1874–2071. Available from: https://pubmed.ncbi.nlm.nih.gov/37345492/
16. Wright Jr JT, Williamson JD, Whelton PK, Snyder JK, Sink KM, Rocco MV, et al. A randomized trial of intensive versus standard blood-pressure control. N Engl J Med [Internet]. 2015 [cited 2024 Mar 17]; 373(22):2103–16. Available from: https://www.nejm.org/doi/full/10.1056/NEJMoa1511939
17. Law MR, Morris JK, Wald NJ. Use of blood pressure lowering drugs in the prevention of cardiovascular disease: meta-analysis of 147 randomized trials in the context of expectations from prospective epidemiological studies. BMJ [Internet]. 2009 [cited 2024 Mar 17]; 338: b1665. Available from: https://pubmed.ncbi.nlm.nih.gov/19454737/
18. Turnbull F, Neal B, Ninomiya T, Algert C, Arima H, Barzi F, et al. Effects of different regimens to lower blood pressure on major cardiovascular events in older and younger adults: meta-analysis of randomised trials. BMJ [Internet]. 2008 [cited 2024 Mar 17];336(7653):1121–3. Available from: https://pubmed.ncbi.nlm.nih.gov/18480116/
19. National Institute for Health and Care Excellence (NICE). Hypertension in adults: diagnosis and management [Internet]. Londres: NICE; 2023. [cited 2024 Mar 17]. Available from: https://www.nice.org.uk/guidance/ng136
20. Ministerio de Salud Pública y Bienestar Social, Dirección General de Vigilancia de la Salud. Dirección de Vigilancia de Enfermedades No Transmisibles. Segunda encuesta nacional sobre factores de riesgo de enfermedades no transmisibles – Paraguay 2023 [Internet]. Asunción: Dirección General de Vigilancia de la Salud. Dirección de Vigilancia de Enfermedades No Transmisibles; 2023. [citado 17 Mar 2024]. Disponible en: https://dvent.mspbs.gov.py/ii-encuesta-nacional-sobre-factores-de-riesgo-de-enfermedades-no-transmisibles-paraguay-2023/
21. Ordunez P, Martinez R, Niebylski ML, Campbell NR. Hypertension prevention and control in Latin America and the Caribbean. J Clin Hypertens (Greenwich) [Internet]. 2015 [cited 2024 Mar 17];17(7):499-502. Available from: https://pubmed.ncbi.nlm.nih.gov/25727743/
22. Mancia G, Rea F, Corrao G, Grassi G. Two-drug combinations as first-step antihypertensive treatment. Circ Res [Internet]. 2019 [cited 2024 Mar 17];124(7):1113-23. Available from: https://pubmed.ncbi.nlm.nih.gov/30920930/
23. N de Cates A, Farr MRB, Wright N, Jarvis MC, Rees K, Ebrahim S, Huffman MD. Fixed-dose combination therapy for the prevention of cardiovascular disease. Cochrane Database Syst Rev [Internet]. 2014 [cited 2024 Mar 17];4(4): CD009868. Available from: https://pubmed.ncbi.nlm.nih.gov/24737108/
24. Gupta AK, Arshad S, Poulter NR. Compliance, safety, and effectiveness of fixed-dose combinations of antihypertensive agents: a meta-analysis. Hypertension [Internet]. 2010 [cited 2024 Mar 17];55(2):399-407. Available from: https://pubmed.ncbi.nlm.nih.gov/20026768/
25. Kostova D, Spencer G, Moran AE, Cobb LK, Husain MJ, Datta BK, Matsushita K, Nugent R. The cost-effectiveness of hypertension management in low-income and middle-income countries: a review. BMJ Glob Health [Internet]. 2020 [cited 2024 Mar 17];5(9):e002213. Available from: https://pmc.ncbi.nlm.nih.gov/articles/PMC7484861/
