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 distribution, wealth and education. These indicators act as interdependent risk factors for disease occurrence. Relationships between mortality rates and socioeconomic level have already been evidenced in Brazil and other countries, showing an inverse relationship, i.e., low socioeconomic levels are related to high mortality rates. These relationships between reductions in mortality rates, in particular deaths from diseases of the circulatory system (DCS), and improvement in socioeconomic indicators are highly correlated. Several prospective studies have shown that low socioeconomic status, defined as low educational level, low income, low status employment, or living in poorer residential areas, have contributed to the increase in all causes of death, as well as the risk of death from CVD. 9,442-446 Low socioeconomic status, when defined as an independent CV risk factor, has been shown to confer an increased risk for CVD; with RR mortality between 1.3 and 2.0. 445,447 The time periods in which there was a reduction in mortality rates due to diseases of the circulatory system were preceded by periods with improvement in socioeconomic indicators. In Brazil, between the 1930s and 1980s, there was great economic growth that, despite the concentration of income, enabled educational, sanitary, economic and infrastructure improvements, reducing infectious diseases and inflammatory processes. In developed countries, the decline in CVD mortality began a little over a decade after the end of World War II, which followed the great depression of the early 1930s and the 1918 influenza pandemic. The same decline began just over 40 years after the beginning of the period of economic growth. Exposure to infectious agents and other unhealthy conditions in the early years of life may make individuals more susceptible to the development of atherothrombogenesis. It is also possible that the reduction in exposure to infectious diseases in the early stages of life is related to the observed decline in adult CV mortality. 442,446,448-452 Strong correlations have been shown between the Human Development Index, falling child mortality, rising per capita gross domestic product (GDP) and the increasing education levels; with the reduction in mortality from diseases of the circulatory system in adults, from 1980, in some Brazilian states and municipalities, showing that the improvement in socioeconomic indicators preceded the reduction of CV deaths. The great increase in education over the last decades, which practically doubled in the states of Rio de Janeiro, São Paulo and Rio Grande do Sul, had a great impact on mortality, and is related to the reduction of more than 100 deaths from CVD with a one-year increase in average years of study in adults. Comprehensive measures to improve socioeconomic indicators should be part of the paradigm for CV disease control. These relationships show the importance of improving the living conditions of the population in order to reduce CV mortality. 442,446,448,449,453,454 The assessment of social factors in patients and people with CV risk factors is essential as a means to stratify future preventive efforts with individual’s risk profile. Recommendations for socioeconomic indicators and CV risk are listed in Table 10.1. 10.3. Environmental Factors and Cardiovascular Risk Atherosclerosis has a complex and multifactorial pathophysiology, depending on the integration of several factors inherent to the individual, acquired or not, with the environment in which he is inserted. The impact of environmental factors on the epidemiology of CV disease has been increasingly studied and recognized, especially in relation to the possibility of adopting preventive strategies. In this context, in addition to the influence of socioeconomic factors such as income and education, the characteristics of the individual’s own habitat and lifestyle are also considered. Thus, the natural and social environments are two different types that potentially influence CV disease. 455 The natural environment is determined by specificites of the place where the individual resides such as altitude and latitude, density of wooded areas, seasons, exposure to sunlight and atmospheric temperature. A study by Massa et al., 456 in the city of São Paulo in 2010, suggested an inverse relationship between green area density and CV risk, regardless of income. 456 In addition, CVD lethality appears to be higher in winter months, while in some places there is an increase of up to 53% in the incidence of AMI. 457 This increase occurs similarly in young adults (< 55 years) and in elderly (> 75 years) individuals, and may be a consequence of both hemodynamic variations. (e.g., elevated BP), as well as the higher incidence of respiratory infections at this time (e.g., influenza), which are known to increase the risk of heart attack. 455 However, elevated temperatures are also associated with a higher CVD risk, especially when there is an abrupt variation in temperature. 458 The social environment is related to the artificial forms of housing and the characteristic of daily life in modern society, especially in the urban environment. Population, noise level, violence, access to clean water, sanitation and air pollution may limit health promotion and promote the development of infectious and chronic diseases. In this context, air pollution was established as the most important modifiable environmental determinant of CVD risk, consisting of a complex mixture of gaseous particles and components. 459 Among such pollutants, particulate matter (PM) is the element that is most relevant to health, which is formed by substances whose size and types of particles vary over Table 10.1 – Socioeconomic indicators and cardiovascular risk Recommendation Recommendation Class Level of Evidence References Socioeconomic indicators should be investigated in the clinical assessment and considered in the patient approach to improve the quality of life and prognosis of circulatory system diseases. IIb B 483,484,486,488 842