ABC | Volume 110, Nº3, March 2018

Editorial Oliveira & Ferreira Yellow fever and cardiovascular disease Arq Bras Cardiol. 2018; 110(3):207-210 Table 1 – Clinical spectrum of dengue, chikungunya and zika Arboviral disease Clinical presentation Mild forms Severe forms Dengue High fever, myalgia, joint pain, nauseas, vomiting, skin rash, hemorrhagic manifestations, low platelet count Organ failure (respiratory, heart, hepatic, hematologic, central nervous system), refractory shock and death Chikungunya The aforementioned manifestations + symmetrical pain in small and large joints, except for hemorrhagic syndrome Nephritis, meningoencephalitis, Guillain–Barré syndrome and flaccid paralysis Zika Milder aforementioned manifestations, conjunctivitis Neurological complications, such as microcephaly (newborn infants), Guillain–Barré syndrome, hearing loss Table 2 – Clinical spectrum of yellow fever and respective treatment site 14 Form Signs and symptoms Laboratory changes Treatment site Mild / Moderate Fever, headache, myalgia, nauseas, absent/ mild jaundice Low platelet count, moderate elevation of transaminases, normal or mildly elevated bilirubin levels Outpatient clinic / hospital (ward) Severe All aforementioned, jaundice, severe hemorrhages, oliguria, reduced level of consciousness Severe low platelet count, increased creatinine, significant elevation of transaminases Hospital (ward / intensive care unit) Malignant All classic symptoms of the severe form intensified All aforementioned, disseminated intravascular coagulation Hospital (intensive care unit) drug‑eluting stents with everolimus or zotarolimus has allowed for shorter periods of dual antiplatelet therapy with the same safety level. Considering that low platelet count is one of the most important characteristics of all viral hemorrhagic fevers, those recommendations could also serve as a model for new recommendations for YF. 16 Thus, the consideration of validated tools to assess the risks for hemorrhage and thrombosis after coronary stent implantation is a promising strategy. An example is the PRECISE-DAPT score, which uses hemoglobin, leukocyte count, age, creatinine clearance and history of bleeding as variables to estimate that risk. Scores < 25 are predictors of a low risk of bleeding and could identify patients who benefit from longer periods of dual antiplatelet therapy (6‑12 months). However, scores ≥ 25 are associatedwith high rates of bleeding, indicating a shorter period of dual antiplatelet therapy (3-6 months). 17 The 2017 European Society of Cardiology guideline considers that score in some of its recommendations and raises the possibility of only 1 month of dual antiplatelet therapy for patients at high risk for bleeding (PRECISE‑DAPT ≥25), who might not tolerate 3 months of use. Those recommendations and that score application do not depend on the type of stent implanted. 17 Although the incorporation of that strategy into the management of patients with YF has been neither studied nor validated, it provides additional enhancement to isolated platelet count to estimate the risk for thrombosis and bleeding after percutaneous coronary interventions. Such assessment would be of fundamental importance to define the management, mainly because the modifiable variables used in the PRECISE-DAPT score can be affected by YF. Figure 1 shows an algorithm for the antiplatelet management of patients with coronary stents implanted within less than 12 months from the YF infection. It is worth noting that in the presence of active bleeding or significant blood dyscrasia secondary to hepatic failure (INR > 1.5 or clotting time > 20 minutes), antiplatelet therapy should be suspended independently of any other criterion. Similarly, the suspension of antiplatelet drugs in patients with CAD without stents, or who had undergone percutaneous coronary interventions more than 12 months before, is recommended, even in moderate cases without significantly low platelet count, because the short-term thrombotic risk of those patients is lower. In addition, oral anticoagulants should be avoided in moderate severity cases, and in-hospital parenteral anticoagulation can be considered for patients with mechanical valve prostheses without active bleeding, evidence of liver dysfunction or other criteria of greater severity. Patients with heart failure constitute another group whose management might require differentiated approaches in the context of YF. Support therapy in patients with moderate to severe forms of disease depends mainly on the maintenance of an appropriate hemodynamic status through oral or venous hydration, occasional transfusions of blood derivatives and even the use of vasoactive amines. In this scenario, the hemodynamic balance should be constantly reassessed and carefully adjusted, with eventual invasive monitoring in more extreme situations, because those patients are very sensitive to small variations in blood volume. In addition, the maintenance of drugs often used in the chronic treatment of heart failure, such as diuretics, angiotensin-converting enzyme (ACE) inhibitors and beta‑blockers, might hinder the clinical management. Thus, in situations of moderate severity, with neither bleeding nor hemodynamic, renal or respiratory impairment, we suggest maintaining only beta-blockers, preferably at their usual dose. However, they should be avoided in severe cases, with a higher 208