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 2.8 – Fibrate doses and lipid abnormalities (mean percentages)* Drugs Dose (mg/ day) TG reduction (%) HDL-c increase (%) LDL-c reduction (%) Bezafibrate 200-600 30-60 7-11 Varying Bezafibrate retard 400 30-60 7-11 Varying Gemfibrozil 600-1200 30-60 7-11 Varying Gemfibrozil retard 500 30-60 7-11 Varying Etofibrate 500 30-60 7-11 Varying Fenofibrate 160-250 30-60 7-11 Varying Ciprofibrate 100 30-60 7-11 Varying * Effects depend on the dose used and the initial baseline TG value. HDL-c: high-density lipoprotein-cholesterol; LDL-c: low-density lipoprotein- cholesterol; TG: triglycerides. Adapted from the Updated Brazilian Guideline for Dyslipidemia and Atherosclerosis Prevention. 7 Table 3.1 – BNP screening to guide the primary prevention strategy for diabetes mellitus Study design and intervention Study population N without prior HF Hospitalizations for HF/follow-up duration Effect on hospitalization for HF Effect on major CV events* STOP-HF 42 Randomized controlled trial with BNP screening versus usual primary treatment Age > 40 years without HF but with CV disease or CV risk factors 1,374 21 / 4.2 years OR 0.48 (95% confidence interval 0.20–1.20) OR 0.60 (95% confidence interval 0.45-0.81) PONTIAC 43 Randomized controlled study, with treatment in a cardiology outpatient clinic for titration of RAAS inhibitors and beta-blockers associated with care in a DM treatment unit versus care in an isolated DM unit DM2 without known CV disease and NT-proBNP > 125 pg/mL 300 8 / 2 years HR 0.14 (95% confidence interval 0.02–1.14) HR 0.35 (95% confidence interval 0.13–0.97) BNP: brain natriuretic peptide; CV: cardiovascular; DM: diabetes mellitus; HF: heart failure; RAAS: renin-angiotensin-aldosterone system. * Major CV events, defined as unplanned hospitalizations for CV causes and deaths. 3. Diabetes and Metabolic Syndrome 3.1. Myocardial Risk Patients with DM2 have a 2 to 5 times greater risk for HF compared to non-diabetic individuals. 34 As CAD patients are excluded, the incidence of HF in the diabetic population decreases but remains significantly higher than in non-diabetic individuals. In type 1 diabetes, above 7%, each 1% increment in glycated hemoglobin (HbA1c) was associated with a 30% increase in HF risk, 35 while type 2 diabetes was associated with a 16% increase in the risk, regardless of other risk factors, including obesity, smoking, hypertension, dyslipidemia, and coronary disease. 36,37 Diabetic cardiomyopathy is characterized by myocardial fibrosis and left ventricular hypertrophy with diastolic dysfunction, initially asymptomatic, and that progresses slowly to diastolic or systolic dysfunction, followed by HF with clinical repercussion. 38 Occasionally, diabetic cardiomyopathy can manifest as arrhythmias and sudden death. Mechanisms involved in the pathophysiological process include mitochondrial dysfunction, oxidative stress, inflammation, dysfunction in the mitochondrial Ca 2+ management, activation of the renin- angiotensin-aldosterone system (RAAS) and the sympathetic nervous system (SNS), cardiac autonomic neuropathy, endoplasmic reticulum stress, microvascular dysfunction, and disorders of cardiac energy metabolism. 39-41 3.1.1. Myocardial Risk Estimate Despite the lack of an universally accepted method to estimate HF risk specifically in diabetic individuals, methods such as plasma brain natriuretic peptide (BNP), echocardiographic evaluation of diastolic dysfunction, and risk calculators such as the Health ABC Heart Failure Score and the Framingham Heart Failure Risk Score are often used to estimate the future risk for symptomatic HF. Elaborating a standardized strategy to screen and intervene in patients at HF risk might be difficult due to its different definitions, the heterogeneity of its prevalence in various populations, its inconstant duration until the development of clinic HF or left ventricular dysfunction, and the varying interventions to modify or treat risk factors. As we shall see below, the Health ABC Heart Failure Score is the mechanism with the highest sensitivity and specificity and should be recommended as the primary strategy in risk stratification of symptomatic HF. Nonetheless, BNP can be used concomitantly to reclassify individuals at high risk for HF. The evidence that supports the use of BNP in diabetic patients to predict the HF risk is based on two randomized controlled trials. As shown in Table 3.1, these programs recruited 1,674 patients without HF for randomization and identified a total of 29 subsequent events of hospitalization for HF. The combined statistical power of these studies is limited but provides the perspective for the potential benefit of screening based on biomarkers such as BNP. Diastolic dysfunction on the echocardiogram – Historically, experts disagree on recommendations for echocardiographic diagnosis of diastolic dysfunction, as 804