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 Table 1.1 – Recommendations for cardiovascular risk stratification Recommendation Recommendation grade Level of evidence Reference Routine evaluation of cardiovascular risk factors in adults aged 40 to 75 years, according to GRS for 10 years (Charts 1.5, 1.6, 1.7, 1.8; Figure 1.1) I B 2,9,10 Routine evaluation of cardiovascular risk factors in adults aged 20 to 39 years, according to GRS for each 4 to 6 years (Charts 1.5, 1.6, 1.7, 1.8; Figure 1.1) IIa B 2,9,10 For adults with borderline (5 to < 7.5%/10 years) or moderate (≥ 7.5 to < 20%/10 years) risk, including aggravating factors is recommended to guide therapeutic decisions IIa B 2,9,10 Adults with borderline (5 to < 7.5%/10 years) or moderate risk (≥ 7.5 to < 20%/10 years) can have their calcium score assessed to guide therapeutic decisions IIa B 2,9,10 The risk to life or for 30 years can be considered in adults aged 20 to 59 years with an estimated risk < 7.5%/10 years IIb B 2,9,10 GRS: global risk score. 2. Dyslipidemia 2.1. Introduction Dyslipidemias represent an important CV risk factor, with low-density lipoprotein cholesterol (LDL-c) as the most relevant modifiable risk factor for CAD. 11 Genetic 12 and clinical studies with statins and other lipid-lowering drugs provide ample evidence that lower LDL-c levels are associated with the proportional decrease in CV outcomes, including myocardial infarction, CVA, and CV death. 13,14 The 2017 Updated Brazilian Guideline for Dyslipidemia incorporated some changes in the approach of dyslipidemias compared to the previous version. 7 One of the changes was that fasting was no longer mandatory for total cholesterol (TC) and high-density lipoprotein cholesterol (HDL-c) tests, provided that the laboratory specifies the situation in the report, without fasting or with 12-hour fasting. As for triglycerides (TG), it might increase in the absence of fasting. In hypertriglyceridemia, particularly with a value > 440 mg/dL, a new collection after 12-hour fasting is crucial. 15 Apolipoprotein (ApoA1 and ApoB) levels can be determined in a sample without prior fasting, and moderately high TG levels do not influence immunochemical methods. The analytical performance of this methodology is good, and the levels can be measured in automated platforms with an immunoturbidimetry or nephelometry profile. There is evidence of an independent association between elevated lipoprotein (a) [Lp(a)] and CVD risk in the general population, 16 not only for the lipid content of Lp(a) but also for its prothrombotic and proinflammatory properties. The gold standard for quantification of plasma concentrations is the measurement of Apo(a) mass by turbidimetry, nephelometry, or chemiluminescence, using isoform-insensitive assays, which Figure 1.1 – Cardiovascular risk stratification. CKD: chronic kidney disease (glomerular filtration rate < 60 ml/min/m 2 , non-dialysis); GRS: global risk score; RS: risk stratifiers; SAD: subclinical atherosclerotic disease. GRS < 5% in men or women Low risk GRS from 5 to < 20% in men GRS from 5 to < 10% in women Diabetic patients without SAD or RS Moderate risk GRS > 20% in men GRS > 10% in women Subclinical atherosclerosis Abdominal aortic aneurysm CKD High LDL High risk Significant atherosclerosis (> 50% obstruction) With or without clinical symptoms coronary cerebrovascular peripheral vascular Very high risk 799