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 carotids in women. 206 In this research, the authors developed a “dietary antioxidant index” to categorize the foods, excluding individuals who used antioxidant supplements. Therefore, the use of supplements only with carotenoids, β -carotene, or similar compounds is not recommended. Instead, efforts should be directed toward increasing the consumption of fruits and vegetables rich in these nutrients. 6.3. Vitamin E Vitamin E is the main fat-soluble antioxidant in the human body and is present in a complex of four isomers ( α -, β -, γ -, and δ -tocopherol). The interest in the potential benefit of vitamin E for risk of CVD was related to its antioxidant capacity and the possibility of modifying oxidized low-density lipoprotein (Ox-LDL), particularly involved in atherogenesis. 207 However, prospective randomized studies, such as the ATBC, CHAOS, GISSI, and HOPE, showed no benefit of vitamin E supplementation for CVD. 205,208 The effect of supplementation with vitamin E and vitamin C on alternate days for eight years on 14,641 individuals did not reduce the incidence of myocardial infarction, CVA, and CV mortality, in addition to being associated with an increased incidence of hemorrhagic CVA. 209 Despite the solid molecular basis theory of oxidative stress and its role in atherosclerosis, these clinical trials do not corroborate the use of vitamin E supplementation to prevent CVD. On the other hand, consuming foods containing vitamins E, A, and C was associated with a lower risk for adverse CV outcomes, as demonstrated in the Hong Kong Cardiovascular Risk Factor Prevalence Study (CRISPS), a longitudinal study comprising 875 participants. 210 Thus, the consumption of foods with vitamin E has proven to be more effective and safe, and vitamin E supplementation is not recommended to prevent CVD. 6.4. Vitamin D Vitamin D is an important precursor of the steroid hormone calcitriol, which is crucial for mineral and bone metabolism. In addition, it has other functions and supplementation with this vitamin to prevent and treat a wide range of diseases has increased considerably in the past decade. 211 Its two main forms are vitamin D2 (ergocalciferol) and D3 (cholecalciferol). Vitamin D3 can be synthesized by human skin cells after exposure to UV-B radiation from sunlight. In the absence of sunlight, the intake of vitamin D is crucial. Vitamin D and dietary supplements are absorbed by the intestine and then converted into 25-hydroxyvitamin D3 [25(OH)D] in the liver, and 1.25 dihydroxyvitamin D3 [1.25(OH)2D3], the active form of vitamin D, in the kidney. Zittermann et al. 212 summarized the underlying mechanisms for the potential role of vitamin D in preventing coronary disease. They include inhibiting the proliferation of vascular smooth muscle, suppressing vascular calcification, down-regulating pro-inflammatory cytokines, up-regulating anti-inflammatory cytokines, and acting as a negative Table 6.2 – Recommendations for the consumption of and/or supplementation with products rich in omega-3 fatty acids Recommendation Recommendation grade Level of evidence References Supplementation with 2-4 grams of marine omega-3 per day or even higher doses should be recommended for severe hypertriglyceridemia (>500 mg/dL in the absence of familial chylomicronemia), with risk for pancreatitis, refractory to non-pharmacological measures and drug treatment I A 235 At least two fish meals per week should be recommended as part of a healthy diet to decrease the CV risk. This recommendation is particularly aimed at individuals at high risk, such as those who already had myocardial infarction I B 32 Omega-3 supplementation (EPA) at a dose of 4 g per day can be administered to patients in secondary prevention who use statins and have TG between 150-499 mg/dL II B 227 Omega-3 supplementation at a dose of 1 g/day (EPA+DHA) can be administered to patients with HF functional class II to IV II B 235 Supplementation with EPA+DHA is not recommended for individuals in primary prevention, whether or not they are on preventive treatments based on evidence III A 231 CV: cardiovascular; DHA: docosahexaenoic acid; EPA: eicosapentaenoic acid; HF: heart failure; TG: triglycerides. Table 6.3 – Recommendation for the consumption of foods rich in omega-3 fatty acids of plant origin Indication Class Level of evidence References Stimulating the consumption of omega-3 polyunsaturated fatty acids of plant origin as part of a healthy diet can be recommended to reduce the CV risk, although the real benefit of this recommendation is debatable, and the evidence is inconclusive IIb B 238 ALA supplementation is not recommended to prevent CVD III B ALA: alpha-linolenic acid; CV: cardiovascular; CVD: cardiovascular disease. 818