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 time in the same region. The main sources of PM are motor vehicle emissions, tire fragmentation and reuse in asphalt production, energy industry-related combustion, ore processing, agriculture, construction and demolition activities, forest burning and volcanic eruptions, among others. 460 Thus, because of the complexity related to their composition, the particles are identified according to their diameter: coarse PM or PM10 (< 10 and ≥ 2.5 μm); Fine PM or PM2.5 (< 2.5 and ≥ 0.1 μm); Ultrathin PM or PM0.1 (< 0.1 μm). 459 Current evidence suggests that PM2.5 is the major pollutant associated with increased CVD risk for both fatal and nonfatal events. The central justification for this relationship is the increased oxidative stress and systemic inflammation promoted by the particles. These effects result in the amplification of other traditional risk factors already present and in the potential instability of coronary plaques. 461 According to the WHO, the mean daily PM2.5 concentration should be < 20 μm/m 3 , and the annual < 10 μm/m 3 . With each 10μm/m 3 increase in short-term exposure, there is a 2.5, 1 and 2.1% increase in the risks of admission or death from AMI, stroke and HF, respectively. However, as exposure tends to occur over several years, atherosclerosis becomes progressive and cumulative, and also affects regional CV mortality. Thus, recurrent events may occur even with average annual PM2.5 concentrations below the WHO targets. Other consequences possibly associated with short- and long- term pollution are venous thromboembolism, acute atrial fibrillation, hypertension, and insulin resistance. 459 The recommendations for environmental indicators and CVD risk can be seen in Table 10.2. 10.4. Vaccination for People with Heart Disease In most clinical situations, vaccination is identified as a primary prevention action. When it is transposed to heart disease, it is usually secondary prevention for decompensations that aggravate pre-existing CV disease. Several vaccines are indicated for adults, with priority to patients with NCD, such as heart disease. We will list those prescribed for adults with heart disease. There is a specific guideline published by the Brazilian Society of Cardiology regarding indications and doses of vaccines indicated for children and adolescents with heart disease. 10.4.1. Prevention of Respiratory Tract Infections in People with Heart Disease Historical reports evidence the seasonal relationship of influenza epidemics with higher mortality among the elderly and patients with NCD. Observational trials, reports, population studies and meta-analyzes have proven the Table 10.2 – Environmental indicators and cardiovascular risk Recommendation Recommendation class Level of evidence References Restrict exposure to air pollution as a non-pharmacological measure for primary and secondary prevention of cardiovascular events I B 459-461 benefits of vaccination against respiratory infections in the elderly and in patients with NCD, with a marked reduction in overall mortality, hospitalizations, myocardial infarction and stroke rates. 463-471 Venous congestion and immunosuppression present in patients with NCD who are predisposed to infections are highlighted among the pathophysiological explanations. In contrast, infections cause changes in coagulation factors, platelet aggregation, inflammatory response proteins, tumor necrosis factor and cytokines, and thus may be triggers for acute CV events. Infections also play a chronic role in decreasing cardiomyocyte contraction strength, inflammation, thrombosis, fibrin deposition, and acceleration of the atherosclerosis process and cardiac remodeling. 463,468,471 Despite all the evidence and guidelines, the rate of vaccination against respiratory infections – Influenza and pneumococcal pneumonia – are low in Brazil and worldwide. 472-474 The overall consensus is for all patients with heart disease and NCDs to be vaccinated, regardless of age; they are summarized in Chart 10.1 and Table 10.3. If the patient is over 60, the patient will be included in government campaigns according to age group. If the patient is under 60 years of age, a referral form is required along with a declaration that there is a clinical indication for vaccination. 10.4.2. Which Vaccines? Influenza Vaccine: In Brazil, it is up to the Ministry of Health to determine the composition of the vaccine according to the prevalence of circulating types and strains in recent epidemics. It is an inactivated, trivalent or tetravalent vaccine, with the latter having a greater immunization spectrum. Indications, characteristics and restrictions are common to trivalent and tetravalent. Vaccination should occur annually in the national campaign, which takes place between April and May. 475-477 Pneumococcal Vaccine: There are two types of vaccine: conjugate and polysaccharide. Among the conjugates is “Pneumo 10” which is intended to prevent serious infections in children under 2 years of age; therefore outside the scope of NCDs, with the exception of congenital heart disease. The other available type which is widely used is the “Pneumo 23”. This vaccine contains 23 pneumococcal serotypes and is indicated for those older than 60 years and those with clinical conditions which put them at risk for pneumonia, including those with NCD. Conjugate vaccines have shown better performance in clinical work, but are not always available in the public network. Referral for vaccination after confirmation of diagnosis. Recommended revaccination time is five years. 475-478 843