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 Chart 10.1 – Main priority indications for influenza vaccination and pneumococcal vaccine System Syndromes, diseases or clinical situations Cardiovascular Stroke Congenital heart disease Valvular heart disease Coronary Artery Disease (Angina pectoris, Myocardial Infarction) Pulmonary hypertension Systemic hypertension if target organ injury Heart failure and cardiomyopathies Respiratory Asthma Bronchiectasis Bronchopulmonary dysplasia Interstitial lung disease Chronic Obstructive Pulmonary Disease (COPD) Cystic fibrosis Endocrine Diabetes mellitus Grade 3 Obesity Gastrointestinal Cirrhotics Chronic liver disease Other Chronic kidney disease (stages 3,4 and 5) Down Syndrome Solid organ transplant Over 60 years old, even if healthy Source: Martins WA. 477 Table 10.3 – Indication of vaccination in heart disease Recommendation Recommendation class Level of evidence References Vaccine heart disease patients against influenza to reduce morbidity and mortality I B 463-471 Vaccine heart disease patients against pneumococcus to reduce morbidity and mortality I C 475,476,478 Vaccine heart disease patients with other vaccines recommended for adults (Hepatitis, Triple Viral, Diphtheria and Tetanus) I C 475-477 Yellow fever vaccine for people over 60 years old, with or without heart disease, at high risk of exposure to the disease against Yellow Fever IIa C 475-477,479 Yellow fever vaccine for people older than 60 years, with or without heart against at low risk of exposure to the disease III C 475-477,479 Other vaccines indicated for adolescents and adults with NCDs: The other vaccines indicated for adults should not be neglected for those with heart disease. Among them is the Hepatitis B vaccine, for which three doses are recommended in patients up to 49 years of age, depending on the previous vaccination situation. Regarding the triple virus, two doses up to 29 years of age and one dose over 30 years are indicated, with an age limit of 49 years. Older people and patients with heart disease are susceptible to falls and injuries, and therefore the double vaccine is recommended, DT (Diphtheria and Tetanus), with a booster vaccine every 10 years. 475-477 Yellow Fever: There is limited evidence regarding the safety of the yellow fever vaccination in heart disease patients and those over 60 years of age. There are two prospective studies and one report suggesting that serious adverse effects are rare in this age group, but much more frequent than in young people. There is limited data available on the relationship between the risk of adverse effects and the presence of previous CVD disease; interaction with CVD drugs; and the use of the fractional doses currently adopted in Brazil. Therefore, vaccination is recommended for those at risk of exposure to the disease, such as the elderly and heart disease patients. The vaccine should be given as a single dose without the need for a booster vaccine. 475-477,479 Vaccination Precautions: The use of platelet antiaggregants is not an impediment to the use of intramuscular vaccines, thus there is no need for suspension. Subcutaneous vaccination can be performed in patients taking warfarin anticoagulation or direct anticoagulants. There are no reports of clinically significant interactions of vaccination in patients using antihypertensives, anti-ischemics, statins, fibrate, warfarin or digoxin. 475,476,480,481 10.5. Lower Extremity Peripheral Artery Disease 10.5.1. Context The evolution of atheromatous plaque and its association with the various CVD risk factors is widely described in the literature. It is also recognized that the atherosclerotic phenomenon can occur in different vascular beds, of larger or smaller caliber. The term peripheral arterial disease (PAD) has been used to characterize atherosclerotic disease that affects several peripheral (non-coronary) vascular beds. In this context, the current PAD guidelines deal with the theme in different ways. While the European directive, 482 has chosen to analyze PAD in various vascular territories (i.e., carotid, subclavian, mesenteric, renal, and lower limb arteries), the current American document, 483 as well as the Society for Vascular directive Surgery, 484 deals exclusively with lower extremity PAD. 844