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 2.5 – Intensity of the lipid-lowering treatment Low Moderate High Expected LDL-c reduction with daily dose, % < 30 30-50 ≥ 50 Examples, daily doses in mg Lovastatin 20 Simvastatin 10 Pravastatin 10-20 Fluvastatin 20-40 Pitavastatin 1 Lovastatin 40 Simvastatin 20-40 Pravastatin 40-80 Fluvastatin 80 Pitavastatin 2-4 Atorvastatin 10-20 Rosuvastatin 5-10 Atorvastatin 40-80 Rosuvastatin 20-40 Simvastatin 40/ Ezetimibe 10 Note: the use of Ezetimibe alone reduces LDL-c in 18-20%. LDL-c: low-density lipoprotein-cholesterol. Adapted from the Updated Brazilian Guideline for Dyslipidemia and Atherosclerosis Prevention. 7 Chart 2.1 – Recommendations for blood lipid management, recommendation grade, and level of evidence Recommendation Recommendation grade Level of evidence Reference Individuals at very high CV risk: LDL-c should be reduced to < 50 mg/dL and non-HDL-c to < 80 mg/dL I B 7 Individuals at high CV risk: LDL-c should be reduced to < 70 mg/dL and non-HDL-c to < 100 mg/dL I A 7 Individuals at high and very high CV risk: whenever possible and tolerated, give preference to high-intensity statins or Ezetimibe associated with statin (Simvastatin 40 mg or another statin at least as potent) I A 7 Individuals at moderate CV risk: LDL-c should be reduced to < 100 mg/dL and non-HDL-c to < 130 mg/dL I A 7 Individuals at moderate CV risk: whenever possible and tolerated, give preference to statins of at least moderate intensity I A 7 Individuals at low CV risk: the LDL-c target should be < 130 mg/dL and non-HDL-c < 160 mg/dL I A 7 Drug therapy to increase HDL-c levels is not recommended III A 7 Individuals with TG levels > 500 mg/dL should receive appropriate therapy to reduce the risk for pancreatitis I A 7 Individuals with TG levels between 150 and 499 mg/dL should receive therapy based on CV risk and associated conditions IIa B 7 CV: cardiovascular; HDL-c: high-density lipoprotein cholesterol; LDL-c: low-density lipoprotein cholesterol; TG: triglycerides. The reassessment period after the drug treatment must be of at least a month. Adapted from the Updated Brazilian Guideline for Dyslipidemia and Atherosclerosis Prevention. 7 mortality, coronary ischemic events, need for revascularization, and CVA. LDL-c reduction varies among statins, a difference closely related to the initial dose, as shown in Table 2.5. Chart 2.1 presents the recommendations for lipid management and the evidence that supports such recommendations. Side effects are rare in statin treatment, but among them, muscular effects are the most common and can occur weeks or years after the start of treatment. They range from myalgia, with or without elevation of creatine kinase (CK), to rhabdomyolysis. CK levels should be evaluated at the start of treatment or when the dose needs to be increased, in case of muscle symptoms (pain, tenderness, stiffness, cramps, weakness, and localized or generalized fatigue), and when introducing drugs that might interact with statin (Recommendation Grade: IIa, Level of Evidence: B). The baseline evaluation of liver enzymes alanine aminotransferase (ALT) and aspartate aminotransferase (AST) must be performed before the beginning of statin therapy. During the treatment, the liver function should be assessed in case of signs or symptoms suggesting hepatotoxicity (fatigue or weakness, loss of appetite, abdominal pain, dark urine, or jaundice) (Recommendation Grade: IIa, Level of Evidence: B). 7 Repeated analyses of enzyme samples in asymptomatic patients lead to additional costs with no benefit to patients. Table 2.6 describes the indications for the association of other lipid-lowering drugs. 2.2.3. Drug Treatment Focused on Hypertriglyceridemia Hypertriglyceridemia is an independent risk factor for CVD, particularly for CAD. 21 However, it is not clear if hypertriglyceridemia causes atherosclerosis, since TG does not tend to accumulate in arterial walls, or if the abnormalities 802