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 On the other hand, with the advent of new drugs that allow effective glycemic control associated with weight loss and minimal risk for hypoglycemia, the paradigm of glycemic control regarding CVD was broken. In a recent meta-analysis, GLP-1 analogs consistently reduced the incidence of CV deaths and non-fatal infarction by 14 and 18%, respectively. 109 Data from the studies LEADER (liraglutide), 110 SUSTAIN-6 (semaglutide), 55 HARMONY (albiglutide), 111 and REWIND (dulaglutide) demonstrated safety and efficacy among diabetic patients in secondary prevention and patients in primary prevention at high or very high CV risk. Chart 3.1 presents the recommendations for DM and MS management. 4. Obesity and Overweight 4.1. Introduction In the past decades, Brazil underwent a process called nutritional transition 112 – a concept related to secular changes in dietary patterns and nutritional status – and important modifications regarding food intake and PA patterns, as a consequence of economic, social, demographic, and health transformations. 113 Obesity and overweight are complex and chronic conditions, whose prevalence has grown inexorably in the last 4 to 5 decades. 114 Between 1980 and 2013, the Chart 3.1 – Recommendations for diabetes mellitus and metabolic syndrome management Recommendation Recommendation grade Level of evidence Reference The Health ABC Heart Failure Score should be recommended for patients with MS or DM as a primary strategy in the risk stratification of HF I B 52-54 BNP values ≥ 50 pg/mL or NT-proBNP ≥ 125 pg/mL must be used together to reclassify individuals at moderate risk for HF into high risk Individuals at high and very high risk should receive an intensive primary prevention approach IIa A 52-54 Echocardiographic diagnosis of diastolic dysfunction in patients with DM or MS without clinical symptoms of HF should suggest an increased risk for the development of HF. However, the data available are not enough to recommend its routine use to estimate the future risk for symptomatic HF IIA B 50,51 The use of an SGLT2 inhibitor is recommended for patients with DM or MS without clinical symptoms of HF, but at high or very high risk for HF, based on the Health ABC Heart Failure Score and BNP levels I B 57,58 Prescribing rosiglitazone, pioglitazone, or saxagliptin is contraindicated for patients with DM or MS without clinical symptoms of HF, but at high or very high risk for HF, based on the Health ABC Heart Failure Score and BNP levels III A 59-61 Strategies for weight control, PA, dietary guidance, and quitting smoking should be offered to all patients with glucose intolerance, MS, or DM, so as to mitigate the progression of CAD 1 A 75-77 Stratifying the risk for coronary events with anatomical or functional methods is not recommended for asymptomatic patients with MS or DM III A 78-84 Using CACS is recommended for patients with DM or MS and at moderate CV risk (ORS 5 – 20%). When CACS = 0, the recommendation is usually not to start statin treatment I B 89-94 CACS should not be requested for patients with DM or MS and at low (ORS < 5%) or very high (> 20% in 10 years) CV risk III B 14,95-97 In primary prevention, patients with DM or MS referred to statin therapy should receive highly potent doses of these medicines and/or ezetimibe, with an LDL-c target < 70 mg/dL Alternatively, in individuals with DM or MS and at high or very high risk, the LDL-c target should be < 50 mg/dL I I A B 14,95-97 In primary prevention for patients with familial hypercholesterolemia, with or without DM or MS, the LDL-c target should be < 50 mg/dL, with an indication for a highly potent statin, ezetimibe, and PCSK9 inhibitors until the target is reached I A 14,95-97 Using ASA is not recommended as a primary prevention strategy for patients with MS or DM, regardless of CV risk III A 103,104 The introduction of a GLP-1 analog is recommended for diabetic patients with or without a history of CV disease, but at high or very high risk for ASCVD I A 55,108-111 ASCVD: atherosclerotic cardiovascular disease; BNP: brain natriuretic peptide; CACS: coronary artery calcium score; CAD: coronary artery disease; CV: cardiovascular; DM: diabetes mellitus; GLP1: glucagon-like peptide-1; HF: heart failure; LDL-c: low-density lipoprotein-cholesterol; MS: metabolic syndrome; ORS: overall risk score; SGLT2: sodium-glucose 2 cotransporter. 810