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 Finally, regarding the use of antiplatelet agents in primary prevention, the evidence regarding its benefit is not robust enough to indicate its routine use considering CKD alone. In a meta-analysis of more than 50 studies and more than 27,000 patients, the use of ASA reduced the risk of infarction without, however, reducing overall mortality, CV mortality or stroke, with increased numbers of major and minor bleeds. 527 Thus, the use of antiplatelet agents should be assessed according to the overall risk and decision-making should be made on an individual basis when considering their use solely for CKD. Recommendations for CKD and CV risk can be seen in Table 10.5. 10.8. Obstructive Sleep Apnea In recent years, much has been debated about obstructive sleep apnea (OSA) as a CV risk factor and, in 2018, the Brazilian Society of Cardiology published a position on this clinical condition and its implications on CV risk. 528 OSA is characterized by the temporary narrowing or occlusion of the upper airway during sleep, 529 which in turn activates the sympathetic nervous system and triggers a chain of events involving elevation of blood pressure, release of inflammatory mediators, oxidative stress, endothelial dysfunction, reduced insulin sensitivity and activation of the renin-angiotensin- aldosterone system. 528-530 Despite the short duration of events, prolonged repetitive exposure to periods of hypoventilation and hypoxemia can lead to chronic changes in metabolism and circulatory system leading to consequences such as systemic arterial hypertension, pulmonary hypertension, arrhythmias, coronary disease, stroke, heart failure, diabetes, dyslipidemia, and increased mortality CV. 528-533 The prevalence of OSA has increased in recent years 528,529 and some series have reported apnea-hypopnea index equal to or greater than 5 events per hour in 34% of men and 17% of women aged 30 to 70. 534 In CVD patients The prevalence of OSA is higher when compared to patients of the same age and sex in the general population, regardless of body mass index. 529 Among CVD, hypertension, coronary artery disease, stroke and heart failure with reduced ejection fraction, with reports of associated prevalence of OSA of up to 83%, 58%, 91% and 53%, respectively. 528,529 The treatment of OSA is mainly based on the use of continuous positive airway pressure (CPAP). There is evidence that this treatment modality has beneficial effects on blood pressure control, 535 but evidence regarding rigid outcomes such as total and CV mortality is not as robust, 528-530 with data on primary prevention from observational studies. 531,536 In a recent systematic and meta-analysis review, no reduction in major CV events including vascular death or all-cause death was observed. 537 It is worth mentioning that in 60% of the studies evaluated CV disease (secondary prevention) was documented and in such cases, with patients undergoing optimal clinical treatment, CPAP treatment may have little additional effect than current treatment when assessing total mortality and CV outcomes, 530,537 despite the benefits of blood pressure control and improvement of extra-cardiac symptoms. 530 Finally, CV prevention strategies in OSA patients should consider the higher morbidity and mortality attributed to this condition, emphasizing the control of other associated risk factors and respecting specific treatment indications according to this Society’s position on group 11 of AOS. 528 Recommendations for obstructive sleep apnea (OSA) and CV risk are shown in Table 10.6. 10.9. Erectile Dysfunction Erectile dysfunction (ED) is the recurrent inability to obtain and maintain an erection that allows for satisfactory sexual activity. ED is not a disease but a symptomatic manifestation of isolated or associated pathologies. 538 It has a prevalence of just over 50% in men over 40 years of age in the USA and Brazil. Studies have shown a prevalence between 43 and 46% in the same age range. 538-541 The causes of ED can be classified as psychological, organic or a combination of both. Organic factors include vascular, endocrine, neurological, drug-related causes, and urological interventions. Vascular etiology is the most common cause of erectile dysfunction. Arterial traumatic disease, atherosclerosis and SAH are among the main causes of vascular ED. Increasing the prevalence in patients with Table 10.5 – Chronic Kidney Disease (CKD) and cardiovascular risk Recommendation Recommended class Level of evidence Reference Cardiovascular prevention measures in patients with CKD should be individualized and consider the eGFR, the presence of other associated diseases and the overall cardiovascular risk I C 525-527 CKD: chronic kidney disease; eGFR: estimated glomerular filtration rate. Table 10.6 – Obstructive sleep apnea and cardiovascular risk Recommendation Recommended class Level of evidence References Measures for cardiovascular prevention in patients with obstructive sleep apnea should be individualized and consider the presence of other associated diseases, the overall cardiovascular risk and indications for treating the disease itself I C 528,530,537 850