ABC | Volume 112, Nº2, February 2019

Review Article Fontes-Carvalho et al The Year in Cardiology 2018: ABC Cardiol and RPC at a glance Arq Bras Cardiol. 2019; 112(2):193-200 Portuguese individuals. The study included a significant subset of 400 individuals that underwent 24-hour Holter monitoring and another subset of 200 individuals which had a 2-week event loop recorder to identify paroxysmal AF. Several interesting data came from this study. First, they observed a very high prevalence (9%) of AF in this elderly population, which was higher than previously reported. 28,29 Second, more than one-third (35.9%) of AF patients were not aware of having the disease, and 18.6% had paroxysmal AF, which reinforces the need for more systematic AF screening. 30 More importantly, in this “real-world” study the rates of anticoagulation were very disappointing. Although the mean CHADSVASC score was high (3.5 ± 1.2), most AF patients (56.3%) did not receive anticoagulation and only 25.8% were considered to be adequately anticoagulated. Therefore, this study highlights the enormous challenges in the diagnosis and management of AF in elderly patients and the urgent need to implement specific healthcare policies (involving patients, caregivers, doctors and health authorities) that can tackle these important problems. As previously mentioned, the treatment of atrial fibrillation is a challenge in clinical practice especially with regard to the use of oral anticoagulants, which are fundamental for the prevention of stroke. Considering the challenges imposed by this sort of treatment, Stephan et al. 31 hypothesized that mobile health support for shared decision-making may improve patients’ knowledge and optimize the decisional process. The authors developed an application (App aFib) to be used during the clinical visit, including a video about atrial fibrillation, risk calculators, explanatory graphics and information on the drugs available for treatment. In the pilot phase, 30 patients interacted with the application, which was evaluated qualitatively, and through a disease knowledge questionnaire and a decisional conflict scale. The number of correct answers in the questionnaire about the disease was significantly higher after the interaction with the application (from 4.7 ± 1.8 to 7.2 ± 1.0, p < 0.001), and the decisional conflict scale, administered after selecting the therapy with the app support, resulted in an average of 11 ± 16/100 points, indicating a low decisional conflict. Although these were initial findings, the App aFib improves patients` disease knowledge, and in the future newer studies may confirm if this finding could be translated into clinical benefit. Cardiovascular disease prevention and Epidemiology The presence of cardiovascular risk factors in childhood creates a life-long burden which increases the risk of cardiovascular disease in adulthood. 32,33 Therefore, several studies have showed the importance of evaluating risk factors and promoting healthy lifestyle across all lifespan, starting as early as in pre-school children. 34,35 In an interesting study published in 2018, Melo Rodrigues et al. 36 analyzed the prevalence and interrelation of cardiovascular risk factors in a sample of 1555 schoolchildren (6-9 years). First, they have found an enormous prevalence (29.1%) of overweight and obesity in this population, showing the magnitude of the childhood obesity epidemic. 37 The prevalence of high-normal blood pressure (4.5%) and hypertension (3.7%) was also much higher than expected. There was a strong association between anthropometric body fat indicators and blood pressure, which reinforces the need for blood pressure measurement, in obese children. However, the most important take-home message from this study is to remember that our lifestyle behaviors as adults are linked to our previous exposures during childhood 31 and, therefore, cardiovascular health promotion should involve all ages, starting from pre‑school children, and the entire family. 38 It is also known that lifestyle behaviors associated with an increased risk of cardiovascular disease are influenced by the individual’s health-related knowledge (health literacy) and by their perception of the risk of disease. 39 Therefore, improving health literacy should be viewed as an essential tool to reduce the global burden of cardiovascular disease and improve risk factor control. In an innovative article published in 2018 in Rev Port Cardiol, Andrade et al. 40 evaluated, in a large sample of 1624 portuguese individuals, the specific knowledge on cardiovascular disease, and its relationship with sociodemographic factors, health literacy and clinical history. It was striking to observe a major deficit in cardiovascular health‑related knowledge. Only around one-third of the populationwas able to estimate their risk of myocardial infarction or stroke. Interestingly, participants identified non-smoking and a healthy diet as the main behaviors for cardiovascular disease prevention and attributed a lower importance to blood pressure control. It was also observed that only a very low percentage of individuals would call the national emergency number when faced with symptoms suggestive of a possible stroke or myocardial infarction, as also demonstrated in other studies. 41 Therefore, this study clearly shows that there are important gaps in cardiovascular health‑related knowledge in the general population. All of us, both as doctors, scientific community and society, need to create increasing awareness for the importance of improving health literacy in the community. This is a new and important strategy to help prevent cardiovascular disease. It is fundamental to know about gaps in cardiovascular healthcare, and the knowledge about common problems and solutions shared by Portuguese-speaking countries (PSC) can provide us useful data regarding the similarities and differences between them, emphasizing well‑succeeded actions for fighting CVD. Nascimento et al. 1 described trends in cardiovascular disease morbidity and mortality in the PSC between 1990 and 2016, stratified by sex, and their association with the respective sociodemographic indexes (SDI) using the Global Burden of Disease (GBD) 2016 data and methodology. They observed large differences, mainly related to socioeconomic conditions, in the relative impact of CVD burden in PSC. Among CVD, ischemic heart disease was the leading cause of death in all PSC in 2016, except for Mozambique and Sao Tome and Principe, where cerebrovascular diseases have supplanted it. The most relevant attributable risk factors for CVD among all PSC are hypertension and dietary factors. Genetic factors, implicit in the cultural identity, factors inherent in the host, as well as the huge social inequality might have contributed to explain the mortality rates observed. Collaboration between the PSC might allow sharing successful experiences to confront CVD between those countries. 196