ABC | Volume 113, Nº4, October 2019

Updated Updated Cardiovascular Prevention Guideline of the Brazilian Society Of Cardiology – 2019 Arq Bras Cardiol. 2019; 113(4):787-891 Chart 1.1 – Individuals with very high cardiovascular risk according to the Department of Atherosclerosis of the Brazilian Society of Cardiology 7 Significant atherosclerosis (≥ 50% obstruction) with or without clinical events in the following territories • Coronary • Cerebrovascular • Peripheral vascular Chart 1.2 – Individuals with high cardiovascular risk according to the Department of Atherosclerosis of the Brazilian Society of Cardiology 7 • Men with overall risk score > 20% • Women with overall risk score > 10% • Subclinical atherosclerosis documented by: - Carotid ultrasound with the presence of plaque - ABI < 0.9 - CACS > 100 Agatston U - Atherosclerotic plaques in coronary computed tomography angiography • Abdominal aortic aneurysm • CKD defined by Glomerular Filtration Rate < 60 mL/min in the non-dialysis stage • Patients with LDL-c ≥ 190 mg/dL • Type 1 or 2 diabetes, with LDL-c between 70 and 189 mg/dL, and presence of RS* or SAD** ABI: Ankle-Brachial Index; CACS: Coronary Artery Calcium Score; CKD: chronic kidney disease; LDL-c: low-density lipoprotein-cholesterol; RS: Risk Stratifiers; SAD: Subclinical Atherosclerotic Disease. * Age ≥ 48 years in men and ≥ 54 years in women; time to diabetes diagnosis > 10 years; family history of premature CVD (< 55 years for men and < 65 years for women) in first degree relative; smoking (at least one cigarette in the previous month); systemic arterial hypertension; metabolic syndrome, according to the International Diabetes Federation; albuminuria > 30 mg/g creatinine and/or retinopathy; glomerular filtration rate < 60 mL/min. ** Carotid ultrasound with presence of plaque > 1.5 mm; ABI < 0.9; coronary calcium score > 10 Agatston units; atherosclerotic plaques in coronary computed tomography angiography; LDL-c between 70 and 189 mg/dL, with overall risk score > 20% for males and > 10% for females. Chart 1.3 – Moderate Risk according to the Department of Atherosclerosis of the Brazilian Society of Cardiology • Male patients with GRS from 5 to 20% • Female patients with GRS from 5 to 10% • Diabetic patients without RS* or SAD** factors GRS: overall risk score; RS: risk stratifiers; SAD: subclinical atherosclerotic disease. *Age ≥ 48 years in men and ≥ 54 years in women; time to diabetes diagnosis > 10 years; family history of premature CVD (< 55 years for men and < 65 years for women) in first degree relative; smoking (at least one cigarette in the previous month); systemic arterial hypertension (SAH); metabolic syndrome, according to the International Diabetes Federation; albuminuria > 30 mg/g creatinine and/or retinopathy; glomerular filtration rate < 60 mL/min. ** Carotid ultrasound with presence of plaque > 1.5 mm; ABI < 0.9; coronary calcium score > 10 Agatston units; atherosclerotic plaques in coronary computed tomography angiography; LDL-c between 70 and 189 mg/dL, with ORS > 20% for males and > 10% for females. Strategies for primary or secondary prevention of the disease are proposed based on the characterization of CV risk. 1.2. Very High Risk Individuals who have a significant atherosclerotic disease (coronary, cerebrovascular, or peripheral vascular) with or without clinical events belong to this category (Chart 1.1). 1.3. High Risk Patients in primary prevention who present ORS > 20% (men) or > 10% (women) or aggravating risk conditions based on clinical data or subclinical atherosclerosis (Chart 1.2). 1.4. Moderate Risk The estimated risk for atherosclerotic disease results from the sum of the risk associated with each risk factor and the powering caused by synergisms between some of these factors. Given the complexity of these interactions, intuitive risk allocation often leads to under- or overestimation of higher or lower risk cases, respectively. Among the algorithms created to stratify CV risk, the last Updated Brazilian Guideline for Dyslipidemia and Atherosclerosis Prevention recommends the use of ORS, which estimates the risk for myocardial infarction, cerebrovascular accident (CVA), HF – fatal or non-fatal –, or peripheral vascular insufficiency in 10 years. Based on this score, individuals with GRS ranging from 5 to 20% (males) and 5 to 10% (females) are classified as moderate risk. Patients with diabetes mellitus (DM) without SAD criteria or RS are also considered at moderate risk. Many middle-aged individuals belong to this risk category (Chart 1.3). Part of the latest recommendations leans towards inflammatory conditions and the use of coronary calcium to restratify patients at moderate risk. 8 1.5. Low Risk Any estimated CV risk based on findings of observational studies inevitably has limitations related to calibration and discriminatory power: the attempt to allocate a certain risk percentage to each patient collides with individual aspects, not covered by risk prediction equations. The idea of restoring the concept of aggravating risk – understood as individual phenotypic expressions causally related to greater chances of a CV outcome – to improve somewhat the individualization of the algorithms created from large population samples has been gaining strength. 8 However, in the low-risk population stratum, an aggravating risk in those with less than 5% chance of having a CV outcome in 10 years 6,8 would hardly have a decisive influence in this relatively short time interval. On the other hand, as age is one of the most important determinants of risk for CV events, a man aged 62 years, without SAD, normotensive, non-smoker, non-diabetic, and with optimal levels of serum lipids would already be classified by ORS as moderate risk, even without any aggravating factor. 6 796