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 iii. diabetes: adjusted risk of 3.01; and iv. CLI: adjusted risk of 5.96. 497 10.5.3. Summary of Anatomical Location of Atherosclerotic Lesions of Lower Extremity Peripheral Artery Disease The classic document from the Inter-Society Consensus for the Management of Peripheral Arterial Disease (TASC II) has been updated to include infrapopliteal segment lesions in the anatomical classification of lower extremity PAD. 498,499 The location of lower extremity PAD according to the affected arterial territory has been harmonized by the recent Peripheral Academic Research Consortium (PARC) document (Chart 10.2). 500 10.5.4. Preventive Management of Lower Extremity Peripheral Artery Disease Several aspects of the preventive approach to lower extremity PAD risk factors are equally applicable, both regarding the asymptomatic and symptomatic (intermittent claudication) form of the disease. 484 The items listed below and, in particular, Chart 10.3 summarize the risk factors and proposed treatment approaches (including recommendation class / level of evidence) according to the latest international guidelines for lower extremity PAD: i. Smoking cessation is recommended for people with lower extremity PAD. 482-484 ii. Physical Exercise: In patients with claudication due to lower extremity PAD, a supervised exercise program is recommended to improve functional performance and quality of life. 482-484 The comprehensive review by Olin et al., 501 highlights that the methodology of supervised exercise, either home or community-based, has improved considerably over the past decade. iii. Antiplatelet: Despite the small sample size (n = 366), the CLIPS study showed the benefit of ASA in preventing 52% of vascular events such as AMI, stroke, pulmonary embolism, and CLI. 502 The CAPRIE lower extremity PAD subgroup analysis, which compared clopidogrel 75mg / day and acetylsalicylic acid in the secondary prevention, showed positive results in reducing CVD death, AMI and stroke by 24% in symptomatic lower extremity PAD. 502 The EUCLID study compared ticagrelor and clopidogrel in 13,885 symptomatic lower extremity PAD patients. There was no significant difference between drugs in preventing CVD, AMI, or stroke. 502 The presence of increased bleeding (TIMI score) was infrequent (0.94/100-patient years) and Chart 10.2 – Lower extremity PAD location according to PARC 500 Aortoiliac segment: infrarenal abdominal aorta; common iliac arteries; internal iliac artery, external iliac artery. Distal limit is the pelvic ring or inguinal ligament. Femoropopliteal: common femoral artery; deep femoral artery; superficial femoral artery; segment 1 - above the knee popliteal artery, from the Hunter canal to the proximal edge of the patella; segment 2 - from the proximal portion of the patella to the center of the knee joint space; segment 3 - below the popliteal knee artery, from the center of the knee joint space to the origin of the anterior tibial artery (distal limit). Tibiopedal: tibioperoneal trunk (origin of the anterior and below tibial artery until the bifurcation of the posterior and peroneal tibial arteries); anterior tibial, posterior tibial, peroneal, dorsalis pedis, arterial plantar arch and minor arteries of the feet. similar in randomized patients on ticagrelor and clopidogrel (p = 0.49) . 503 iv. Anticoagulants: The recent COMPASS study evaluated the cumulative risk of new outcomes one year after the occurrence of a major lower limb adverse event (MALE). The cumulative incidence 1 year after hospitalization due to MALE was 95.4%, vascular amputation was 22.9%, the risk of death was 8.7% and major CV events reached 3.8%. In this study, rivaroxaban (direct selective coagulation factor Xa inhibitor) at a dose of 2.5 mg twice daily associated with ASA reduced the incidence of MALE by 43% (p = 0.01), decreased vascular amputations by 58 % (p = 0.01), restricted peripheral vascular interventions by 24% (p = 0.03) and decreased all peripheral vascular outcomes by 24% (p = 0.02) compared to AAS monotherapy. 504 v. At present, this analysis of patients with lower extremity PAD from the COMPASS study is not characterized as a recommended treatment, but it has been relevant as a hypothesis and has reinforced the importance of further investigation on the possible role of new oral anticoagulants in the prevention of vascular events in symptomatic lower extremity PAD. vi. Antihypertensives: In hypertensive patients with lower extremity PAD, strict BP control below 140/90 mmHg with first-choice drugs is recommended. vii.Renin-angiotensin inhibitor drugs, such as ACE inhibitors or ARBs, when tolerated, are recommended to control BP in lower extremity PAD. 482,483 viii. Hypolipidemics: Management of hypercholesterolaemia in patients with lower extremity PAD aims to keep LDL-cholesterol below 70 mg/dL or reduce it by 50% if baseline levels are between 70-135 mg / dL. 482 Statin prescription is broadly recommended in current international guidelines. 482-484 Statins reduce the risk of CVD and lower limb ischemic events in patients with lower extremity PAD. 482,483 ix. The FOURIER study tested evolocumab (PCSK-9 inhibitor monoclonal antibody) in patients aged 40 to 85 years with a history of clinically evident atherosclerotic CVD disease. In this trial, 13.5% of patients in the evolocumab group and 12.9% in the placebo group had symptomatic lower extremity PAD (13.2% of all participants). 98 In the subgroup analysis of patients with lower extremity PAD claudication, evolocumab reduced the primary combination of outcomes by 21% (p = 0.0098). 505 Additional information on 846