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 Antihypertensives Optimized antihypertensive therapy is recommended for all patients with claudication and after endovascular or open surgical procedure I-A Antihypertensive therapy recommended in hypertensive patients to reduce the risk of AMI, stroke, heart failure and CV death inLower extremity PAD I-A Use of ACE inhibitors or ARB may be effective in reducing risk of CV events in Lower extremity PAD IIa In hypertensive patients with Lower extremity PAD it is recommended to maintain BP < 140/90 mmHg I-A The use of ACE inhibitors or ARB is considered a drug of choice in patients with Lower extremity PAD and hypertension IIa-B Diabetes, glycemic control and hypoglycemic drugs Hemoglobin A1C target < 7.0% in lameness if it can be achieved without hypoglycaemia I-B Recommended optimized glycemic control for all patients with claudication and after endovascular or open surgical procedure I-A Optimized glycemic control may be beneficial in patients with critical lower extremity ischemia to reduce limb outcomes IIa-B Strict glycemic control in diabetic patients with Lower extremity PAD I-C ABI*: Ankle-Brachial Index; ACEI: angiotensin-converting enzyme inhibitors; AMI: acute myocardial infarction; ARB: angiotensin receptor blocker; CV: cardiovascular; CVI: Stroke; Lower extremity PAD: lower extremity peripheral arterial disease. be individualized, with constant reassessments throughout the disease evolution of the potential risks and benefits of treatment. Recommendations for autoimmune diseases and CV risk are shown in Table 10.4. 10.7. Chronic Kidney Disease The overall prevalence of CKD is estimated at 11-13%, 517 and in Brazil, despite inconsistent data, it is estimated that between three and six million people have the disease. 518 The relationship between CKD and CVD is complex, dynamic and multifactorial. In addition to both sharing risk factors such as systemic arterial hypertension, diabetes and advanced age, there is a higher prevalence of traditional CVD risk factors in patients with CKD. 519,520 In a study by Foley et al., 519 with more than 15,000 patients, 83.6% of those with estimated glomerular filtration rate (eGFR) < 60 ml/min/1.73 m 2 and 100% of those with GFR-e < 30 ml/min/1.73 m 2 had at least two risk factors for CVD. 519 Furthermore, the loss of renal function itself causes changes that can accelerate CVD, such as arterial stiffness and anemia contributing to left ventricular hypertrophy, endothelial dysfunction disease, chronic inflammation, vitamin D deficiency, oxidative stress, and activation of the renin-angiotensin system. 520-523 The result of this interaction is that CVD is the leading cause of death in patients with CKD. 521 In a meta-analysis by van der Velde et al., 524 evaluating cohorts of patients with hypertension, diabetes or CV disease, they observed an increase in all causes of mortality with eGFR reduction, and rates of 60, 45 and 15 ml/min/1.73m 2 presented a hazard ratio of 1.03, 1.38 and Table 10.4 – Autoimmune Diseases and Cardiovascular Risk Recommendation Recommendation Class Level of evidence References In the context of preventing cardiovascular events, the benefit of using stricter therapeutic targets specifically due to the presence of autoimmune diseases is uncertain IIb C 513,514,516 3.11, respectively, when compared to patients with eGFR 95 ml/min/1.73 m 2 . In addition, the presence of albuminuria, even when borderline, was also associated with higher mortality in this same study, and urinary albumin-creatinine ratios of 10 mg/g, 30 mg/g and 300 mg/g presented a hazard ratio of 1.08, 1.38 and 2.16 when compared to the ratio of 5 mg/g. 524 Currently, CKD 525 and albuminuria are considered independent predictors of CV 522-526 events and thus, CV prevention plays a key role in the management of CKD patients. Overall, the risk assessment should be individualized and CKD should be interpreted in the context of the overall risk assessment according to each clinical setting, and is considered a high risk CV marker. 7,525 Given the various clinical scenarios related to CKD, it is worth mentioning systemic arterial hypertension, dyslipidemia and the use of antiplatelet agents in primary prevention. With regard to systemic arterial hypertension, risk stratification and treatment to prevent events and additional loss of renal function should follow the guidelines published by this Society. 146 It is noteworthy that in this case, CKD is used in the additional risk stratification according to eGFR and urinary albumin-creatinine ratio, and can be interpreted as target organ damage (eGFR 30-60 ml/min/1.73 m 2 or urinary albumin-creatinine 30-300 mg/g) or as an established disease (eGFR < 30 ml/min / 1.73 m 2 or urinary albumin-creatinine > 300 mg/g). Similarly, the approach to dyslipidemia in CKD patients should follow the stratification and treatment model proposed in this Society’s specific guideline. 7 In this case, CKD (eGFR < 60 ml/min/1.73 m 2 ) is considered as a high-risk CV marker for proposed goals and treatments. 7 849