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 Based on the non-automated measurement taken in the doctor’s office, the recommended BP target is <130/80mmHg for individuals with stages 1 and 2 hypertension at low and moderate CV risk, and those with stage 3 hypertension at low, moderate, and high CV risk. 146 This recommendation is based on meta-analyses of randomized studies, 193,194 which demonstrated the superiority of this BP target compared to values above 150/90 mmHg. Decreasing this target to 130/80 mmHg seems to be safe in this lower-risk population, as observational 195 and some randomized studies corroborate, 194,196 although the additional benefit is relatively small and counterbalanced by the risk for symptomatic hypotension and adverse effects of drugs. On the other hand, individuals with stages 1 and 2 hypertension at high or very high CV risk or with three or more risk factors, and/or MS, and/or target-organ damage should have BP levels < 130/80 mmHg. 146 In the SPRINT study, 197 among the 9,361 non-diabetic individuals at high CV risk (median of 24.8% in 10 years), 39% met the criteria for MS. The study population was randomized for a more (< 120 mmHg) and less intense (< 140 mmHg) reduction in SBP – automated BP measurement (on average, 10 mmHg lower than the SBP measured at the doctor’s office with a non-automated method). Among patients with MS, the reduction in the primary outcome – comprising acute coronary syndromes, CVA, HF, or CV death – was similar to that of patients without MS after 3.26 years of follow-up. The most intense SBP treatment arm presented a decrease of 25% in the risk of primary outcome compared to that with less intense reduction (HR 0.75; 95% confidence interval: 0.57-0.96; p < 0.001). 198,199 Among patients with coronary disease, the recommended BP target should be between 130 x 80 and 120 x 70 mmHg, particularly avoiding a DBP below 60 mmHg due to the risk for coronary hypoperfusion, myocardial damage, and CV events. 146 A J curve has been consistently identified in this population, with SBP < 120 mmHg and DBP < 70 mmHg being associated with higher mortality. 200 6. Vitamins and Omega-3 Fatty Acids 6.1. Introduction Several observational studies have found a strong association between the consumption of grains, fruits, and vegetables – foods rich in vitamins and minerals – and low CV mortality 201 and lower risk for myocardial infarction. 202 Given this strong evidence, numerous intervention studies have tested the impact of supplementation with micronutrients (vitamins) and certain fatty acids (omega-3 series) on primary and secondary prevention of CV events. From a practical point of view, most of these studies showed no clinical benefit related to supplementation in the doses studied and in the face of the drug therapies used to prevent CV. Tables 6.1. to 6.3 summarize the recommendations for and against the use of these supplements. 6.2. Carotenoids Carotenoids are a class with over 600 compounds, responsible for the yellow, red, and orange pigments in plants, with α -carotene, β -carotene, β -cryptoxanthin, lycopene, lutein, and zeaxanthin being the most commonly found in food. Known primarily as precursors of vitamin A, carotenoids are also essential suppressors of free radicals and act as potent antioxidants. 203 The evidence for the role of carotenoids in CVD originated from studies showing that increased consumption of fruits and vegetables was associated with a lower risk for CVD. 204 A series of retrospective and prospective longitudinal studies identified an inverse association between carotenoid intake and risk for CVD. 204 However, the effect of carotenoids is complex and probably does not result from a single isolated compound. In contrast, prospective randomized studies showed no benefit of carotenoid supplementation for CVD. 204,205 Corroborating this information, a cross-sectional analysis, consisting of 894 members of the cohort study Kardiovize, revealed that the consumption of foods containing vitamins (carotene, zinc, selenium, and vitamins A and C) was associated with a reduction in the intimal thickening of the Table 6.1 – Summary of the recommendations for the non-consumption of vitamin supplements to prevent cardiovascular diseases Recommendations Description Recommendation grade Level of evidence References Vitamin A or beta-carotene There is no evidence of the benefit of vitamin A or beta-carotene supplementation for primary or secondary prevention of CVD III A 204,205 Vitamin B and folic acid supplements They are not effective in preventing primary or secondary CVD III A 164,208 Vitamin D Vitamin D supplementation is not recommended to prevent CVD in people with normal blood levels for this vitamin. Similarly, there is no evidence that its supplementation in individuals with deficiency will prevent CVD III A 215,216,217 Vitamin E Vitamin E supplementation is not recommended to prevent CVD III A 205,208 Vitamin K In the same way, there is no evidence that vitamin K supplementation, in its different forms, can prevent CVD IIa C 219,220 CVD: cardiovascular disease. 817