Journal Information
Vol. 36. Issue 11.
Pages 799-800 (November 2017)
Vol. 36. Issue 11.
Pages 799-800 (November 2017)
Open Access
The freedom of clinicians and the art of the impossible
A liberdade dos clínicos e a arte do impossível
Hugo Madeiraa,b
a Ex-presidente da Federação das Sociedades de Cardiologia de Língua Portuguesa, Portugal
b Centro Cardiovascular da Universidade de Lisboa, Lisboa, Portugal
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Systemic arterial hypertension, generally known nowadays simply as hypertension, is the most important and most common risk factor for death and disability from non-communicable diseases.1,2 Its prevalence in Europe ranges between 30% and 45%,3 while in the USA two-thirds of adults aged over 60 are hypertensive,4 and in south Asia and sub-Saharan Africa, prevalence rates are rising rapidly.5 A recent estimate put the worldwide prevalence of hypertension at 31%.6

The last three decades have seen the development of a large number of safe and effective drugs to treat hypertension. However, although lowering blood pressure (BP) by only 10 mmHg is known to reduce cardiovascular death and stroke by 25% and 40%, respectively, over the lifetime of these patients,7 disagreement remains concerning the target BP level to aim for in hypertensive adults in general and the elderly in particular. Furthermore, even when treated, many patients’ hypertension is uncontrolled, failing to reach the target BP levels set by the European Society of Hypertension and the European Society of Cardiology3 or those recommended on the basis of the SPRINT trial.8

Many guidelines and recommendations have been published on the diagnosis and treatment of hypertension by medical societies and other public entities, international and national, but even here there is not complete agreement. Between the target systolic BP level originally proposed in the Fifth Report of the Joint National Committee (<140 mmHg)9 and that based on the results of the SPRINT trial (<120 mmHg),8 there is a gray area of uncertainty, and although it is believed that lower BP is better for most patients, it is up to clinicians to decide.

Medical guidelines, originally recommendations suggesting approaches to difficult situations in clinical practice, used to allow clinicians the freedom to adjust therapy according to the individual characteristics of the patient. For example, in the case of hypertension, they could decide to adopt a more aggressive approach in younger individuals, even if asymptomatic, and be more conservative – accepting higher systolic BP – in older patients, on the assumption that the latter are more liable to suffer complications from antihypertensive therapy, although this is still the subject of debate.

This therapeutic flexibility is being surreptitiously eroded. Guidelines, produced on the basis of trials and studies that in at times bear little relation to real-world practice, now define what clinicians should do in every situation, or risk their performance being characterized as bad clinical practice. The change in the Portuguese term for guidelines, from Recomendações (‘Recommendations’) to Diretrizes (‘Directives’), says much about this different attitude.

It is therefore not inappropriate to recall that it is the attending physician – who knows the patient's characteristics, including cardiovascular risk, general condition, frailties and options, and taking into consideration any possible adverse effects of therapy – who will make the best decisions.

It is in this context that the guidelines for the management of hypertension in primary health care in Portuguese-speaking countries are published in this issue of the Journal,10 produced under the auspices of the Federation of Cardiology Societies of the Portuguese-Speaking Countries (FSCLP) (, which was established in 2014 with the primary aim of promoting the development of cardiology in countries and territories in which Portuguese is an official language. Before its foundation, Portuguese-Speaking Conferences on Cardiology were held in Cabo Verde in 2009 and in Mozambique in 2011. The first FSCLP Congress took place in Portugal in 2016 and the second will be held in Brazil in November 2017.

The Federation's statutes summarize the ways in which its main objective can be realized, identifying as priorities fostering research into the scientific aspects of cardiovascular disease, analyzing the social aspects of heart disease and its prevention and treatment, and encouraging closer relations between cardiologists in Portuguese-speaking communities. In short, the aim is to develop cardiology in the Portuguese-speaking world.

Producing yet more guidelines for the FSCLP and its geographic areas that do not repeat what has already been published appears an impossible task. And yet, the guidelines published here are valuable. Firstly, they paint an accurate picture of the situation in Portuguese-speaking countries, including their similarities and differences. Secondly, without being excessively detailed, they omit none of the essentials of the subject. Thirdly, and most importantly, they stress the importance of prevention and treatment of hypertension in primary health care, which is after all their purpose. Finally, they take into consideration the medical, social and economic characteristics of the geographic areas for which they are intended.

The guidelines published here10 have another and very significant merit: they are the first scientific and pedagogic work produced by the FSCLP. They set out to fulfill the aims of the FSCLP by taking an important step toward “a continuous process involving educational actions, lifestyle changes and guaranteed access to pharmacological treatment”, as stated in the document itself.

The authors of these Guidelines have managed the art of the impossible.

Conflicts of interest

The author has no conflicts of interest to declare.

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Please cite this article as: Madeira H. A liberdade dos clínicos e a arte do impossível. Rev Port Cardiol. 2017;36:799–800.

Copyright © 2017. Sociedade Portuguesa de Cardiologia
Revista Portuguesa de Cardiologia (English edition)

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