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 consumption pattern, and the varying alcohol concentration of these beverages. Heterogeneous results originate from the influence of the type of beverage ingested, volume consumed, lifestyle, intake pattern, and socioeconomic status of the population studied. 171-172 The INTERSALT study evaluated the consumption of 300 ml of ethanol weekly (34 g, 3 or 4 drinks/day) and found a BP increase in drinkers compared to non-drinkers. 173 Estimates indicate that excessive alcohol consumption is responsible for approximately 10-30% of AH cases. 174 The ARIC study followed 8,834 individuals for eight years and, at the end of the investigation, the patients with high alcohol consumption had a greater incidence of AH, regardless of the type of beverage, gender, or ethnicity. Moderate alcohol consumption was associated with risk of developing AH, not only in African Americans but also in the Brazilian population. 175 Approximately 6% of all-cause mortality worldwide is attributed to alcohol. 176 When ingested in a single dose, alcohol has a dose-dependent biphasic effect characterized by BP reduction, vasodilation, and increase in HR with a subsequent BP elevation. 177 In a study using the Ambulatory Blood Pressure Monitoring (ABPM) in pre-menopausal women, the group who consumed 20-300 ml of red wine/day (146-218 g of alcohol/week) showed a significant increase in BP. 178 The same situation occurred in normotensive men who ingested an average of 40 g/day of ethanol, compared to the group who did not consume alcohol for four weeks. 179 A meta-analysis with 15 RCTs, involving 2,234 participants, assessed the effects of reducing the consumption of ethanol on BP and estimated that a 2-mmHg reduction in DBP could decrease the prevalence of AH by 17%, the CAD risk by 6%, and the ischemic CVA and transient ischemic attack by 15%. 180 5.6. Weight Loss and Prevention of Arterial Hypertension Overweight is recognized as a factor related to BP elevation, and the greater the BMI, the higher risk for AH. 181 Central obesity and weight gain over time stand out as important factors for the development of AH. The Nurses’ Health Study revealed that women who gained 5.0 to 9.9 kg and those who gained more than 25 kg in 18 years of follow-up had a higher risk for AH – 1.7 and 5.2, respectively. However, estimates suggest that only 26 to 40% of AH cases are attributable to overweight, emphasizing the multifactorial nature of AH. 182 Weight loss as a non-pharmacological approach reduces BP in normotensive individuals and can prevent the development of AH. Changes in lifestyle are crucial for weight loss, focusing on the adoption of a hypocaloric diet and regular PA, with the reduction in caloric intake being more important than following specific diets. 183 Regular isolated PA, without a concomitant dietary approach rich in fruits, vegetables, grains, seeds, nuts, fish, and dairy products, and poor in meats, sugars, and alcohol in general, is not enough for a significant weight loss. 184 A meta-analysis of controlled studies with 4,184 individuals showed a reduction in SBP and DBP of 1.05 and 0.92 mmHg, respectively, for each 1 kg of weight lost. In healthy obese individuals, the combination of a low-calorie diet and BMI reduction was associated with an average decrease of 4.73/2.75 mmHg in SBP and DBP. 185 A systematic review of studies with hypertensive subjects showed that the magnitude of BP reduction with weight loss was on average 4.5/3.2 mmHg for SBP and DBP, respectively, underlining that the greater the weight loss, the higher the BP reduction. 186 The Framingham Study revealed a reduction in the risk of developing AH of 22 to 26% in individuals aged 30-49 and 50-65 years, respectively, who maintained a weight loss of 6.8 kg, in 8 years. In this context, regular PA stands as a measure of great importance in the maintenance of weight loss. 187 5.7. Low-Sodium Diet in the Prevention of Arterial Hypertension Prospective cohort studies have demonstrated that high sodium intake increases the risk of death and CV events. These studies also reported that decreasing sodium intake to below a certain value (approximately 3 g of sodium per day) further reduced BP. Paradoxically, low sodium intake was associated with an increased CV risk and risk of all-cause mortality in the general population and hypertensive individuals, suggesting a J-curve phenomenon. The mechanism of this apparent increased risk with low sodium intake is probably related to higher activity in the renin-angiotensin system under a very high restriction of salt in the diet. No epidemiological study has evidenced that very low sodium intake can be harmful. 10 On the other hand, there is evidence of a causal relationship between sodium intake and an increase in BP. Excessive sodium intake (> 5 g of sodium per day) increases BP and is associated with a higher prevalence of systolic AH with aging. 188 Many studies have shown that sodium restriction decreases BP. A meta-analysis revealed that a reduction of 1.75 g of sodium per day (4.4 g of salt/day) was associated with an average decrease of 4.2 and 2.1 mmHg in SBP and DBP, respectively, with a more pronounced effect in hypertensive individuals – 5.4 and 2.8 mmHg. The reducing effect of sodium restriction on BP is more significant in black people, older adults, and individuals with DM, MS, and chronic kidney disease (CKD). 164 In Western populations, such as the Brazilian, the usual sodium intake is estimated between 3.5 to 5.5 g/day (which corresponds to 9 to 12 g of salt per day), with marked differences among countries or even regions. 189 Sodium intake should be limited to approximately 2.0 g/day (equivalent to about 5.0 g of salt per day) in the population in general, but especially in hypertensive individuals. The effective reduction of salt is not easy, and information about which foods have high levels of salt is often scarce. It is crucial that the population pay very careful attention to the amount of salt added to meals and with foods high in salt (processed products). Reducing salt intake remains a public health priority, but it requires a combined effort between the food industry, governments, and the general population since 80% of the salt consumed originates from processed foods. The adequate consumption of fruits and vegetables enhances 815