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 2.1 – Reference values, according to the evaluation of cardiovascular risk estimated for adults over 20 years of age Lipids With fasting (mg/dL) Without fasting (mg/dL) Risk category Total cholesterol < 190 < 190 Desired HDL-c > 40 > 40 Desired Triglycerides < 150 < 175 Desired LDL-c* < 130 < 130 Low < 100 < 100 Moderate < 70 < 70 High < 50 < 50 Very high Non-HDL-c < 160 < 160 Low < 130 < 130 Moderate < 100 < 100 High < 80 < 80 Very high HDL-c: high-density lipoprotein-cholesterol; LDL-c: low-density lipoprotein- cholesterol. * LDL-c values calculated by the Martin formula. 7,15 Adapted from the Updated Guideline for Dyslipidemia and Atherosclerosis Prevention. 7 Table 2.2 – LDL-c and non-HDL-c percentage reduction and absolute therapeutic targets in patients who use and do not use lipid- lowering drugs Risk Without lipid- lowering drugs With lipid-lowering drugs Reduction (%) LDL-c target (mg/dL) Non-HDL-c target (mg/dL) Very high > 50 < 50 < 80 High > 50 < 70 < 100 Moderate 30-50 < 100 < 130 Low > 30 < 130 < 160 LDL-c: low-density lipoprotein-cholesterol; non-HDL-c: non-high-density lipoprotein-cholesterol. Adapted from the Updated Brazilian Guideline for Dyslipidemia and Atherosclerosis Prevention. 7 are little affected by the heterogeneity in Apo(a) isoforms. It does not require fasting and provides accurate data. Its analysis is not recommended for routine assessment of CVD risk in the general population, but it should be determined in the risk stratification of individuals with a family history of premature atherosclerotic disease and familial hypercholesterolemia (FH). 7 Lp(a) values above 50 mg/dL, equivalent to 80%, are considered high; if the result is in nmol/L, it should be multiplied by 2.5, with Lp(a) values above 125 nmol/L classified as high. 7 Table 2.1 reports the reference values of the lipid profile with and without fasting, according to the evaluation of CV risk in adults. The primary (LDL-c) and secondary (non-high-density lipoprotein cholesterol – non-HDL-c) therapeutic targets for lipid control are established following the risk stratification of patients (discussed in Chapter 1). This stratification considers the presence or absence of clinical or subclinical atherosclerotic disease, the presence of diabetes, and the GRS, with subsequent risk classification into four possible categories: low (< 5%), moderate (5-10% in women and 5-20% in men), high (> 10% in women and > 20% in men), and very high (clinical atherosclerotic cardiovascular disease, > 30%) risk. Chapter 1 presents the complete risk stratification. Specific targets for each category were defined in accordance with Table 2.1. 7 The Updated Brazilian Guideline for Dyslipidemia and Atherosclerosis Prevention 7 also included a change in CV risk stratification for individuals already using statins. Considering the imprecision of risk calculation in these patients, the guideline proposes using a correction factor for TC to estimate the risk score in this context, derived from studies that compared the efficacy of different statins in the doses used and that allowed an average LDL-c reduction of ~ 30% with the treatment. 17 This situation applies to most patients who take moderate doses of statins. Given the average TC reduction of 30% with statins, patients who use these medicines should have their TC multiplied by 1.43. 17 Moreover, in the initial approach, the target for individuals who are not on lipid-lowering treatment should be decreasing the percentage of LDL-c and non-HDL-c. For those already on lipid-lowering therapy, the recent guideline also established a reduction in absolute LDL-c and non-HDL-c values with the treatment, as shown in Table 2.2. 2.1.1. Familial Hypercholesterolemia FH is a genetic condition characterized by very high LDL-c levels and, therefore, increased risk for premature atherosclerotic disease, especially of a coronary event. However, despite its importance, this condition is still underdiagnosed and undertreated. 18,19 This version of the guideline reinforces that greatly increased cholesterol values could indicate FH, after excluding secondary dyslipidemias. Adult individuals with TC values ≥ 310 mg/dL or children and adolescents with levels ≥ 230 mg/dL should be evaluated for this possibility. Among the clinical scores available for FH, we highlight the Dutch Lipid Clinic Network score, used in our field, and presented in Table 2.3. In addition to clinical scores, the genetic test for FH is a very useful, but not mandatory, tool to confirm suspected cases and screen relatives of established index cases. 2.2. Dyslipidemia Treatment 2.2.1. Non-Pharmacological Therapy Nutritional therapy, weight loss, and the practice of physical activity should be recommended for all patients. Table 2.4 describes the dietary recommendations for the treatment. 2.2.2. Drug Treatment Focused on Hypercholesterolemia Statins are the first treatment choice for hypercholesterolemia, due to the evidence showing that their use decreases all-cause 800