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 Mineralocorticoid antagonists – Patients with and without DM2 showed a reduction in mortality, with the use of both spironolactone (RALES trial) 65 and eplerenone (EMPHASIS- HF). 66 We underline the risk for hyperkalemia, which might particularly affect patients with renal function deterioration and already using ACEI or ARB. Beta-blockers – In patients with DM and HF, the use of metoprolol succinate (MERIT-HF), bisoprolol (CIBIS II), and carvedilol (COPERNICUS) is recommended. They presented equal efficiency in patients with and without DM. A meta- analysis that included six trials indicated a reduction in all-cause mortality among patients with DM2, as well as in non-diabetic individuals. 67 Nitrates and Hydralazine – Approximately 40% of the patients randomized in the A-HeFT trial had DM2. In this subpopulation, the combination of a fixed dose of hydralazine and nitrate significantly reduced all-cause mortality. 68 Ivabradine – Its use decreasedmortality and hospitalizations in patients with and without DM2 in the SHIFT study, which involved 6,558 patients. 69 The sacubitril-valsartan combination is not well established yet in patients with preserved ejection fraction or at high risk for HF; even for patients with reduced ejection fraction, there is no specific study or subanalysis focused on the diabetic population. 3.2. Atherosclerotic Risk 3.2.1. Metabolic Syndrome, Diabetes Mellitus, and the Continuous Corollary of Coronary Artery Disease MS and the DM comprise a spectrum of multisystemic diseases, particularly in the vascular endothelium, that contribute dramatically to the progression of pathophysiological substrates of CAD. Robust evidence suggests that CV risk increases even in stages that precede the clinical diagnosis of DM in 10 to 20 years, based on current criteria. As MS is one of the main risk factors for DM, considering it within a continuum of metabolic changes related to coronary atherothrombosis is reasonable. 70,71 In fact, estimates indicate that glucose metabolic changes precede the diagnosis of diabetes in 4 to 12 years 72 (Figure 3.2). While in early stages the overproduction of insulin can compensate its resistance, after a certain point, the pancreatic functional reserve is exhausted, and the production of insulin Figure 3.1 – Health ABC Heart Failure Score. Age Age Score ≤ 71 -1 72-75 0 76-78 1 ≥ 79 2 Coronary artery disease Status Score No 0 Possible 2 Diagnosed 5 Left ventricular hypertrophy Status Score No 0 Yes 2 Systolic BP mmHg Score ≤ 90 -4 95-100 -3 105-115 -2 120-125 -1 130-140 0 145-150 1 155-165 2 170-175 3 180-190 4 195-200 5 > 200 6 Heart rate bpm Score ≤ 50 -2 55-60 -1 65-70 0 75-80 1 85-90 2 ≥ 95 3 Smoking Status Score No 0 Former 1 Present 4 Albumin g/dL Score ≥ 4.8 -3 4.5-4.7 -2 4.2-4.4 -1 3.9-4.1 0 3.6-3.8 1 3.3-3.5 2 ≤ 3.2 3 Creatinine mg/dL Score ≤ 0.7 -2 0.8-0.9 -1 1.0-1.1 0 1.2-1.4 1 1.5-1.8 2 1.9-2.3 3 > 2.3 6 SBP-nearest 5 mmHg HR-nearest 5 bpm Glucose-nearest 5 mg/dL Fasting blood glucose mg/dL Score ≤ 80 -1 85-125 0 130-170 1 175-220 2 225-265 3 ≥ 270 5 Health ABC Risk Score HF risk HF risk in 5 years ≤ 2 points Low < 5% 3-5 points Moderate 5-10% 6-9 points High 10-20% ≥ 10 points Very High > 20% 806