ELIZABETH SILAID MUXFELDT
@ufrj.br
Universidade Federal do Rio de Janeiro - Internal Medicine
Universidade Federal do Rio de Janeiro
EDUCATION
Medicine Course - Universidade Federal do Rio de Janeiro
RESEARCH INTERESTS
Hypertension
Ambulatory Blood Pressure Monitoring
Cardiovascular risk
Scopus Publications
Scopus Publications
Paula Rocha, Julia Barroso, Fernanda Carlos, Elizabeth Muxfeldt, Monica Gadelha, and Leandro Kasuki
Springer Science and Business Media LLC
Aletta E Schutte, Tazeen H Jafar, Neil R Poulter, Albertino Damasceno, Nadia A Khan, Peter M Nilsson, Jafar Alsaid, Dinesh Neupane, Kazuomi Kario, Hind Beheiry,et al.
Oxford University Press (OUP)
Abstract Abstract Raised blood pressure (BP) is the leading cause of preventable death in the world. Yet, its global prevalence is increasing, and it remains poorly detected, treated, and controlled in both high- and low-resource settings. From the perspective of members of the International Society of Hypertension based in all regions, we reflect on the past, present, and future of hypertension care, highlighting key challenges and opportunities, which are often region-specific. We report that most countries failed to show sufficient improvements in BP control rates over the past three decades, with greater improvements mainly seen in some high-income countries, also reflected in substantial reductions in the burden of cardiovascular disease and deaths. Globally, there are significant inequities and disparities based on resources, sociodemographic environment, and race with subsequent disproportionate hypertension-related outcomes. Additional unique challenges in specific regions include conflict, wars, migration, unemployment, rapid urbanization, extremely limited funding, pollution, COVID-19-related restrictions and inequalities, obesity, and excessive salt and alcohol intake. Immediate action is needed to address suboptimal hypertension care and related disparities on a global scale. We propose a Global Hypertension Care Taskforce including multiple stakeholders and societies to identify and implement actions in reducing inequities, addressing social, commercial, and environmental determinants, and strengthening health systems implement a well-designed customized quality-of-care improvement framework.
Thalyta Georgia Vieira Borges, Carla Rocha Muniz, Flavia Rodrigues Ferreira, Mariana Pinheiro Brendim, and Elizabeth Silaid Muxfeldt
Springer Science and Business Media LLC
Christian Nejm Roderjan, Aline de Hollanda Cavalcanti, Arthur Fernandes Cortez, Bernardo Chedier, Fernanda Oliveira de Carvalho Carlos, Fabio de Souza, and Elizabeth Silaid Muxfeldt
Springer Science and Business Media LLC
Elizabeth S. Muxfeldt, Rafael B. Azevedo, Débora C.R. Wandermurem, Flávia C.F. Libório, Maíra K. Machado, Natália M. Ushijima, Ramon S. Narde, and Inah Maria D. Pecly
Bentham Science Publishers Ltd.
Background: Cardiovascular (CV) risk factors, particularly cardiometabolic, seem to be associated with heightened severity and increased morbimortality in patients infected with the novel Coronavirus disease-2019 (COVID-19). Methods: A thorough scoping review was conducted to elucidate and summarize the latest evidence for the effects of adverse cardiac metabolic profiles on the severity, morbidity, and prognosis of COVID-19 infection. Results: The pathophysiology of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is complex, being characterized by viral-induced immune dysregulation and hypercytokinemia, particularly in patients with critical disease, evolving with profound endothelial dysfunction, systemic inflammation, and prothrombotic state. Moreover, cardiovascular comorbidities such as diabetes are the most prevalent amongst individuals requiring hospitalization, raising concerns towards the clinical evolution and prognosis of these patients. The chronic proinflammatory state observed in patients with cardiovascular risk factors may contribute to the immune dysregulation mediated by SARS-CoV-2, favoring more adverse clinical outcomes and increased severity. Cardiometabolism is defined as a combination of interrelated risk factors and metabolic dysfunctions such as dyslipidemia, insulin resistance, impaired glucose tolerance, and central adiposity, which increase the likelihood of vascular events, being imperative to specifically analyze its clinical association with COVID-19 outcomes. Conclusion: DM and obesity appears to be important risk factors for severe COVID-19. The chronic proinflammatory state observed in patients with excess visceral adipose tissue (VAT) possibly augments COVID-19 immune hyperactivity leading to more adverse clinical outcomes in these patients.
Mariana Pinheiro Brendim, Carla Rocha Muniz, Thalýta Georgia Vieira Borges, Flávia Rodrigues Ferreira, and Elizabeth Silaid Muxfeldt
Elsevier BV
George Stergiou, Mattias Brunström, Thomas MacDonald, Konstantinos G. Kyriakoulis, Michael Bursztyn, Nadia Khan, George Bakris, Anastasios Kollias, Ariadni Menti, Paul Muntner,et al.
Ovid Technologies (Wolters Kluwer Health)
Antihypertensive drug therapy is one of the most efficient medical interventions for preventing disability and death globally. Most of the evidence supporting its benefits has been derived from outcome trials with morning dosing of medications. Accumulating evidence suggests an adverse prognosis associated with night-time hypertension, nondipping blood pressure (BP) profile and morning BP surge, with increased incidence of cardiovascular events during the first few morning hours. These observations provide justification for complete 24-h BP control as being the primary goal of antihypertensive treatment. Bedtime administration of antihypertensive drugs has also been proposed as a potentially more effective treatment strategy than morning administration. This Position Paper by the International Society of Hypertension reviewed the published evidence on the clinical relevance of the diurnal variation in BP and the timing of antihypertensive drug treatment, aiming to provide consensus recommendations for clinical practice. Eight published outcome hypertension studies involved bedtime dosing of antihypertensive drugs, and all had major methodological and/or other flaws and a high risk of bias in testing the impact of bedtime compared to morning treatment. Three ongoing, well designed, prospective, randomized controlled outcome trials are expected to provide high-quality data on the efficacy and safety of evening or bedtime versus morning drug dosing. Until that information is available, preferred use of bedtime drug dosing of antihypertensive drugs should not be routinely recommended in clinical practice. Complete 24-h control of BP should be targeted using readily available, long-acting antihypertensive medications as monotherapy or combinations administered in a single morning dose. Video Abstract Video Abstract1VV1Stergiou
Flavia Rodrigues Ferreira, Thalyta Georgia Vieira Borges, Carla Rocha Muniz, Mariana Pinheiro Brendim, and Elizabeth Silaid Muxfeldt
Springer Science and Business Media LLC
Bernardo Chedier, Christian N. Roderjan, Aline H. Cavalcanti, Fabio de Souza, and Elizabeth S. Muxfeldt
Ovid Technologies (Wolters Kluwer Health)
Background: Refractory hypertension (RfHT) and obstructive sleep apnea (OSA) share common pathophysiological mechanisms and probably are intrinsically associated, but their prevalence, clinical profile, and polysomnography (PSG) pattern remain misunderstood. Objective: To describe OSA prevalence and PSG pattern of patients with RfHT in a large cohort of resistant hypertension (RHT). Methods: This is a cross-sectional study involving 418 RHT patients (30.9% male; mean age of 62.5 ± 9.9 years) who were submitted to full-night PSG. RfHT was defined as uncontrolled ambulatory blood pressure monitoring using five or more antihypertensive drugs, including spironolactone. Bivariate analysis compared RHT and RfHT and multivariate analysis was performed to assess the independent correlates of OSA. Results: A total of 90 patients (21.5%) were diagnosed with RfHT (26.7% male; mean age of 58.5 ± 8.3 years). In comparison with resistant ones, RfHT patients were younger, with higher smoking and previous cardiovascular diseases prevalence, especially stroke. There was no difference regarding anthropometric measures. OSA prevalence (80.0 vs. 82.9%) and moderate/severe OSA (51.1 vs. 57.0%) were similar in both groups as well as apnea–hypopnea index. In its turn, refractory hypertensive patients presented better sleep efficiency (78 vs. 71%), with higher total sleep time (315 vs. 281 min) and lower sleep latency (11 vs. 17 min). There was no difference regarding rapid eye movement sleep, oxygen saturation, microarousals index, and periodic limb movement. Conclusion: In this large RHT cohort, resistant and refractory hypertensive patients have similar OSA prevalence, although refractory ones, which by definition use spironolactone, are younger and apparently have a better sleep pattern.
Cibele Isaac Saad Rodrigues, Rafael Bellotti Azevedo, and Elizabeth Silaid Muxfeldt
FapUNIFESP (SciELO)
A. Cortez and E. Muxfeldt
Elsevier BV
Inah Maria D. Pecly, Rafael B. Azevedo, Elizabeth S. Muxfeldt, Bruna G. Botelho, Gabriela G. Albuquerque, Pedro Henrique P. Diniz, Rodrigo Silva, and Cibele I. S. Rodrigues
FapUNIFESP (SciELO)
Abstract Acute kidney injury (AKI) in hospitalized patients with COVID-19 is associated with higher mortality and a worse prognosis. Nevertheless, most patients with COVID-19 have mild symptoms, and about 5% can develop more severe symptoms and involve hypovolemia and multiple organ dysfunction syndrome. In a pathophysiological perspective, severe SARS-CoV-2 infection is characterized by numerous dependent pathways triggered by hypercytokinemia, especially IL-6 and TNF-alpha, leading to systemic inflammation, hypercoagulability, and multiple organ dysfunction. Systemic endotheliitis and direct viral tropism to proximal renal tubular cells and podocytes are important pathophysiological mechanisms leading to kidney injury in patients with more critical infection, with a clinical presentation ranging from proteinuria and/or glomerular hematuria to fulminant AKI requiring renal replacement therapies. Glomerulonephritis, rhabdomyolysis, and nephrotoxic drugs are also associated with kidney damage in patients with COVID-19. Thus, AKI and proteinuria are independent risk factors for mortality in patients with SARS-CoV-2 infection. We provide a comprehensive review of the literature emphasizing the impact of acute kidney involvement in the evolutive prognosis and mortality of patients with COVID-19.
Bernardo Chedier, Arthur Fernandes Cortez, Christian Nejm Roderjan, Aline de Hollanda Cavalcanti, Fernanda Oliveira de Carvalho Carlos, Bruno Dussoni Moreira dos Santos, and Elizabeth Silaid Muxfeldt
Springer Science and Business Media LLC
Inah Maria D. Pecly, Rafael B. Azevedo, Elizabeth S. Muxfeldt, Bruna G. Botelho, Gabriela G. Albuquerque, Pedro Henrique P. Diniz, Rodrigo Silva, and Cibele I. S. Rodrigues
FapUNIFESP (SciELO)
Abstract Kidney impairment in hospitalized patients with SARS-CoV-2 infection is associated with increased in-hospital mortality and worse clinical evolution, raising concerns towards patients with chronic kidney disease (CKD). From a pathophysiological perspective, COVID-19 is characterized by an overproduction of inflammatory cytokines (IL-6, TNF-alpha), causing systemic inflammation and hypercoagulability, and multiple organ dysfunction syndrome. Emerging data postulate that CKD under conservative treatment or renal replacement therapy (RRT) is an important risk factor for disease severity and higher in-hospital mortality amongst patients with COVID-19. Regarding RAAS blockers therapy during the pandemic, the initial assumption of a potential increase and deleterious impact in infectivity, disease severity, and mortality was not evidenced in medical literature. Moreover, the challenge of implementing social distancing in patients requiring dialysis during the pandemic prompted national and international societies to publish recommendations regarding the adoption of safety measures to reduce transmission risk and optimize dialysis treatment during the COVID-19 pandemic. Current data convey that kidney transplant recipients are more vulnerable to more severe infection. Thus, we provide a comprehensive review of the clinical outcomes and prognosis of patients with CKD under conservative treatment and dialysis, and kidney transplant recipients and COVID-19 infection.
Elizabeth Silaid Muxfeldt and Bernardo Chedier
Springer Science and Business Media LLC
Elizabeth Silaid Muxfeldt
Sociedade Brasileira de Cardiologia
Subjective self-report questionnaires show higher adherence than more objective methods. 7 The main variables associated with poor adherence among patients with resistant hypertension are female sex, physical inactivity, depressive symptoms, and history of coronary disease. 8 Barletta et al. assessed 181 women with hypertension, 60.8% of whom were diagnosed with apparent resistant hypertension. The study found that 44.2% of patients had appropriate blood pressure control based on office measurement. Adherence was evaluated using the 8-item Morisky Medication Adherence Scale (MMAS-8), which showed that 13.8% had low adherence, 42.0%, moderate adherence, and 44.2%, high adherence. The variable independently related to low adherence was depression. 9 A systematic review and meta-analysis including 28 studies that also evaluated adherence using MMAS-8 found a 45% prevalence of non-adherence, with a risk 1.3 times higher among men. 10 This high rate of blood pressure control associated with moderate/high adherence (higher than 80%) is probably due to the follow-up of patients in a specialized hypertension care clinic. It is also the result of a subjective evaluation method
Tomás de Souza Mello, Mariana Stutz Klen, Rafael Bellotti Azevedo, Fernanda Costa Barradas, Luiza Araújo Nogueira, Natália Rossilho Moyses Ushijima, Rafael Barbosa da Silva Bica, and Elizabeth Silaid Muxfeldt
Sociedade Brasileira de Cardiologia
Abstract Background Although cardiovascular disease is a major cause of death among women, cardiovascular risk assessment in young women is frequently postponed due to a number of factors. Objectives To assess cardiovascular risk of young adult women living in one of Rio de Janeiro’s Family Health Strategy geographical units in the city’s central area. Materials and Methods populational, cross-sectional study with adults between 20 and 50 years old. Sociodemographic characteristics such as educational level and employment status were recorded. Anthropometric measurements, traditional cardiovascular risk factors, gynecological and gestational history, and selected laboratory exams were assessed. The bivariate analysis compared the baseline characteristics of the population between genders and the prevalence of cardiovascular risk factors in women according to educational level and occupation status, using non-paired Student’s t-test for normal continuous variables, Mann-Whitney test for asymmetrical continuous variables, and chi-square test for categorical variables. A significance level of 5% (p < 0.05) was adopted. Results A total of 710 individuals were enrolled. In women, who comprised 59.7% of our sample, central obesity and a sedentary lifestyle were more prevalent, whereas smoking and hypertension were less observed. However, women with lower educational status had a higher prevalence of smoking and hypertension. In hypertensive women, factors such as early menopause, higher prevalence of hypertensive disorders of pregnancy and higher number of pregnancies were noticed. Conclusion An adverse cardiovascular risk profile in our population of young women was particularly influenced by central obesity, sedentary lifestyle, hypertensive disorders of pregnancy and lower educational status.
Rafael Bellotti Azevedo, Bruna Gopp Botelho, João Victor Gonçalves de Hollanda, Leonardo Villa Leão Ferreira, Letícia Zarur Junqueira de Andrade, Stephanie Si Min Lilienwald Oei, Tomás de Souza Mello, and Elizabeth Silaid Muxfeldt
Sociedade Brasileira de Cardiologia
Abstract Acute cardiac injury is associated with higher mortality in patients with the novel coronavirus disease-2019 (COVID-19) and the exact etiology can be challenging to diagnose in the emergency setting during the pandemic. From a pathophysiological perspective, SARS-CoV-2 infection is characterized by an overproduction of inflammatory cytokines (IL-6, TNF-alpha) that leads to systemic inflammation and consequent increased risk of acute myocardial infarction (AMI) caused by atheromatous plaque rupture and significant myocardial oxygen supply-demand imbalance. Moreover, SARS-CoV-2 tropism to the renin-angiotensin-aldosterone system through the ACE2 receptor induces myocarditis that may rapidly progress to left ventricular dysfunction and hemodynamic instability. Myocardial inflammation with pericardial involvement, i.e. , myopericarditis, can progress to cardiac tamponade and obstructive shock. These cardiovascular complications, which are associated with a worse prognosis and higher mortality, can be associated with clinical manifestations, electrocardiographic changes, and troponin values similar to AMI. Thus, the diagnosis and treatment of patients with acute chest pain and dyspnea admitted to the emergency department is a significant challenge during the COVID-19 pandemic. Here, we provide a review of the literature focusing on a practical approach to acute coronary syndrome patients with confirmed or suspected COVID-19.
Lutgarde Thijs, Kei Asayama, Gladys E. Maestre, Tine W. Hansen, Luk Buyse, Dong-Mei Wei, Jesus D. Melgarejo, Jana Brguljan-Hitij, Hao-Min Cheng, Fabio de Souza,et al.
Informa UK Limited
Abstract Background Hypertension and diabetes cause chronic kidney disease (CKD) and diastolic left ventricular dysfunction (DVD) as forerunners of disability and death. Home blood pressure telemonitoring (HTM) and urinary peptidomic profiling (UPP) are technologies enabling prevention. Methods UPRIGHT-HTM (Urinary Proteomics Combined with Home Blood Pressure Telemonitoring for Health Care Reform [NCT04299529]) is an investigator-initiated 5-year clinical trial with patient-centred design, which will randomise 1148 patients to be recruited in Europe, sub-Saharan Africa and South America. During the whole study, HTM data will be collected and freely accessible for patients and caregivers. The UPP, measured at enrolment only, will be communicated early during follow-up to 50% of patients and their caregivers (intervention), but only at trial closure in 50% (control). The hypothesis is that early knowledge of the UPP risk profile will lead to more rigorous risk factor management and result in benefit. Eligible patients, aged 55–75 years old, are asymptomatic, but have ≥5 CKD- or DVD-related risk factors, preferably including hypertension, type-2 diabetes, or both. The primary endpoint is a composite of new-onset intermediate and hard cardiovascular and renal outcomes. Demonstrating that combining UPP with HTM is feasible in a multicultural context and defining the molecular signatures of early CKD and DVD are secondary endpoints. Expected outcomes The expected outcome is that application of UPP on top of HTM will be superior to HTM alone in the prevention of CKD and DVD and associated complications and that UPP allows shifting emphasis from treating to preventing disease, thereby empowering patients.
Weimar Kunz Sebba Barroso, Cibele Isaac Saad Rodrigues, Luiz Aparecido Bortolotto, Marco Antônio Mota-Gomes, Andréa Araujo Brandão, Audes Diógenes de Magalhães Feitosa, Carlos Alberto Machado, Carlos Eduardo Poli-de-Figueiredo, Celso Amodeo, Décio Mion,et al.
Arquivos brasileiros de cardiologia Sociedade Brasileira de Cardiologia
Rafael Bellotti Azevedo, Bruna Gopp Botelho, João Victor Gonçalves de Hollanda, Leonardo Villa Leão Ferreira, Letícia Zarur Junqueira de Andrade, Stephanie Si Min Lilienwald Oei, Tomás de Souza Mello, and Elizabeth Silaid Muxfeldt
Springer Science and Business Media LLC
Claudia R. L. Cardoso, Christian N. Roderjan, Aline H. Cavalcanti, Arthur F. Cortez, Elizabeth S. Muxfeldt, and Gil F. Salles
Wiley
Resistant hypertension (RHT) is associated with obstructive sleep apnea (OSA) and increased aortic stiffness, measured by carotid‐femoral pulse wave velocity (cf‐PWV). We aimed to evaluate in a randomized controlled trial, the effect of Continuous positive airway pressure (CPAP) treatment on cf‐PWV in comparison with a control group in patients with RHT and moderate‐severe OSA. One‐hundred and sixteen patients were randomized to 6‐month CPAP treatment (56 patients) or no therapy (60 patients), while keeping their antihypertensive treatment unchanged. Carotid‐femoral pulse wave velocity was performed at the beginning and end of the 6‐month period. Intention‐to‐treat intergroup differences in cf‐PWV changes were assessed by a generalized mixed‐effects model with the allocation group as a fixed factor and adjusted for age, sex, changes in mean arterial pressure and the baseline cf‐PWV values. Subgroup sensitivity analyses were performed, excluding patients with low CPAP adherence and low cf‐PWV at baseline. CPAP and control groups had similar clinic‐laboratorial characteristics. Patients had a mean cf‐PWV of 9.4 ± 1.6 m/s and 33% presented cf‐PWV > 10 m/s. During treatment, the control group had a mean increase in cf‐PWV of +0.43 m/s (95% confidence interval [CI], +0.14 to +0.73 m/s; p = .005), whereas the CPAP group had a mean increase of +0.03 m/s (95% CI, −0.33 to +0.39 m/s; p = .87), resulting in a mean difference in changes between CPAP and control of −0.40 m/s (95% CI, −0.82 to +0.02 m/s; p = .059). Subgroup analyses did not change the results. In conclusion, a 6‐month CPAP treatment did not reduce aortic stiffness, measured by cf‐PWV, in patients with RHT and moderate/severe OSA, but treatment may prevent its progression, in contrast to no‐CPAP therapy.
Juan Carlos Yugar-Toledo, Heitor Moreno Júnior, Miguel Gus, Guido Bernardo Aranha Rosito, Luiz César Nazário Scala, Elizabeth Silaid Muxfeldt, Alexandre Alessi, Andrea Araújo Brandão, Osni Moreira Filho, Audes Diógenes de Magalhães Feitosa,et al.
Sociedade Brasileira de Cardiologia
Autores do Posicionamento: Juan Carlos Yugar-Toledo,1 Heitor Moreno Júnior,2 Miguel Gus,3 Guido Bernardo Aranha Rosito,4 Luiz César Nazário Scala,5 Elizabeth Silaid Muxfeldt,6 Alexandre Alessi,7 Andrea Araújo Brandão,8 Osni Moreira Filho,9 Audes Diógenes de Magalhães Feitosa,10 Oswaldo Passarelli Júnior,11 Dilma do Socorro Moraes de Souza,12 Celso Amodeo,11 Weimar Kunz Sebba Barroso,13 Marco Antônio Mota Gomes,14 Annelise Machado Gomes de Paiva,14 Eduardo Costa Duarte Barbosa,15 Roberto Dischinger Miranda,16 José Fernando Vilela-Martin,1 Wilson Nadruz Júnior,2 Cibele Isaac Saad Rodrigues,17 Luciano Ferreira Drager,18 Luiz Aparecido Bortolotto,18 Fernanda Marciano Consolim-Colombo,18 Márcio Gonçalves de Sousa,11 Flávio Antonio de Oliveira Borelli,11 Sérgio Emanuel Kaiser,8 Gil Fernando Salles,6 Maria de Fátima de Azevedo,19 Lucélia Batista Neves Cunha Magalhães,20 Rui Manoel dos Santos Póvoa,16 Marcus Vinícius Bolívar Malachias,21 Armando da Rocha Nogueira,22 Paulo César Brandão Veiga Jardim,23,24 Thiago de Souza Veiga Jardim23
Elizabeth Silaid Muxfeldt, Bernardo Chedier, and Cibele Isaac Saad Rodrigues
FapUNIFESP (SciELO)
Abstract Refractory hypertension (RfH) is an extreme phenotype of resistant hypertension (RH), being considered an uncontrolled blood pressure besides the use of 5 or more antihypertensive medications, including a long-acting thiazide diuretic and a mineralocorticoid antagonist. RH is common, with 10-20% of the general hypertensives, and its associated with renin angiotensin aldosterone system hyperactivity and excess fluid retention. RfH comprises 5-8% of the RH and seems to be influenced by increased sympathetic activity. RH patients are older and more obese than general hypertensives. It is strongly associated with diabetes, obstructive sleep apnea, and hyperaldosteronism status. RfH is more frequent in women, younger patients and Afro-americans compared to RFs. Both are associated with increased albuminuria, left ventricular hypertrophy, chronic kidney diseases, stroke, and cardiovascular diseases. The magnitude of the white-coat effect seems to be higher among RH patients. Intensification of diuretic therapy is indicated in RH, while in RfH, therapy failure imposes new treatment alternatives such as the use of sympatholytic therapies. In conclusion, both RH and RfH constitute challenges in clinical practice and should be addressed as distinct clinical entities by trained professionals who are capable to identify comorbidities and provide specific, diversified, and individualized treatment.
Elizabeth Silaid Muxfeldt
Ovid Technologies (Wolters Kluwer Health)
Resistant hypertension (RHT) is defined as an uncontrolled office blood pressure (BP) despite the use of ≥3 antihypertensive drugs, preferably including a diuretic (Calhoun et al). This clinical condition presents high cardiovascular morbidity and mortality. Recently described, refractory hypertension (RfHT) is considered an extreme phenotype of RHT and its definition has been in development for the last few years. Presently, it is defined as a failure to control office BP in spite of the use of ≥5 drugs, including a long-acting thiazide-like diuretic and a mineralocorticoid receptor blocker. Although these 2 entities are seen as a continuum of the same process, some studies suggested 2 distinct conditions, probably with different pathophysiological mechanisms. RHT seems to be more related to excess volume, characterized by renin-angiotensin-aldosterone system hyperactivity with a remarkable magnitude of the hyperaldosteronism status. However, RfHT, defined as a failure of intensive diuretic therapy, may be less volume-dependent, with a high sympathetic activity. A growing body of literature has described different epidemiological, pathophysiological, and clinical characteristics in these 2 entities, showing that patients with RfHT are younger and more obese, with a higher prevalence of diabetes mellitus, metabolic syndrome, and asymptomatic organ damage (left ventricular hypertrophy and moderately increased albuminuria). However, until now, there has been no study discussing specifically the prevalence of obstructive sleep apnea (OSA) in this group of patients. OSA is defined as a recurrent partial or complete superior airway obstruction during sleep, causing intermittent hypoxemia, multiple arousals and, consequently, increased renin-angiotensin-aldosterone and sympathetic system activity. It has been well demonstrated that OSA is a risk factor for cardiovascular diseases strongly associated with RHT. OSA is present in 82% of patients with RHT, whereas moderate and severe apnea is present in more than half of these patients. Although it is considered a principal cause of RHT, it is not clear whether OSA is a cause or a consequence of antihypertensive treatment resistance, or if, in reality, this robust association is because of the presence of common risk factors, such as obesity, old age, hyperaldosteronism status, and sympathetic hyperactivity, in both situations. In the current edition of Hypertension, Martínez-García et al are one of the first authors to evaluate specifically the relationship between RfHT and OSA, adding important information to previous studies. Using the strength of the HIPARCO randomized clinical trial (Effect of Continuous Positive Airway Pressure [CPAP] Treatment in the Control of Refractory Hypertension), the authors prospectively evaluated 194 patients from HIPARCO aged 18 to 75 diagnosed with RHT and added 35 RHT patients without OSA. One remarkable aspect of the study was the definition of antihypertensive treatment failure based on ambulatory blood pressure monitoring. Although we know that ambulatory blood pressure monitoring is mandatory in those patients, because of a high magnitude of white coat phenomenon, both RHT and RfHT have been defined, until now, as uncontrolled office BP. In this study, the investigators refined the diagnosis of RfHT, considering patients with 24-hour ambulatory BP ≥130×80 mm Hg, while using ≥5 antihypertensive drugs as refractory. This makes sense, because, in clinical practice, the real BP control of resistant hypertensives is evaluated by ambulatory blood pressure monitoring during the follow-up. Therefore, it is reasonable to assume that those patients already had ambulatory BP regularly evaluated. As a result, a patient who is already using 5 drugs, with office BP ≥140×90 mm Hg, but with controlled ambulatory BP, will not be diagnosed as RfHT; instead, the diagnosis will be white coat RHT. Despite this, investigators found a high prevalence of RfHT patients among RHT patients (up to 18.3%). Previous studies that considered as refractory only patients using chlorthalidone and spironolactone found a prevalence range between 2% and 9.5%. The main objective of the Martínez-García et al study was to compare RHT and RfHT patients in relation to the presence and severity of OSA and the prevalence of OSA syndrome, considered as apnea-hypopnea index ≥5 per hour added to Epworth scale score of >10. The results showed an impressive prevalence of OSA: 100% among RfHT patients and 89.3% among RHT patients. Comparing refractory and resistant hypertensives, moderate apnea was found in 95.2% and 81.8% of patients, whereas severe apnea was found in 64.3% and 48.6% of patients, respectively. OSA syndrome was also significantly higher in RfHT patients (52.4% versus 33.7%). The opinions expressed in this article are not necessarily those of the editors or of the American Heart Association. From the Department of Internal Medicine, University Hospital Clementino Fraga Filho, School of Medicine, Universidade Federal do Rio de Janeiro, Brazil. Correspondence to Elizabeth Silaid Muxfeldt, Department of Internal Medicine, Universidade Federal do Rio de Janeiro, Rua Homem de Melo, 150/102 Tijuca, Rio de Janeiro 20510-180, Brazil. Email bethmux@ globo.com Prevalence of Obstructive Sleep Apnea in Refractory Hypertension