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 hypertension and / or diabetes and also with aging, it may reach a prevalence of over 68% in these populations and also be related to therapy with CV action drugs that contribute to the occurrence of ED. 542-544 ED is currently recognized as being of vascular etiology in most men, with endothelial dysfunction as the common denominator. ED often precedes CVD and is often present in men with known CVD, leading to the concept that a man with ED and no CVD symptoms is a patient with CVD until proven otherwise, and a man with known CVD should be routinely asked about your erectile dysfunction. ED also has a significant negative impact on the patient and partner (one man’s problem but a couple’s concern), thus emphasizing the need to approach ED as early as possible. 545 A meta-analysis of 20 prospective cohort studies involving 36,744 participants suggested that erectile dysfunction significantly increases the risk of ischemic heart disease, stroke and all-cause mortality and concluded that it could play a role in quantifying CV risk based on traditional risk factors. 546 Another population-based study of 95,038 men aged 45 and over showed that CVD risk is related to the severity of erectile dysfunction in men with and without established CVD, with a relative risk (respectively) of 1.6 and 1.7 for the development of ischemic heart disease. 547 All men with erectile dysfunction should be considered potential candidates for primary prevention, CV risk stratification and treated according to their risk estimates. Recommendations for autoimmune diseases and CV risk are listed in Table 10.7. 10.10. Prevention of Rheumatic Heart Disease Rheumatic heart disease (RHD) is the cardiac consequence of acute rheumatic fever (ARF), an inflammatory disease caused by streptococcal pharyngitis. Its prevalence is closely related to unfavorable sanitary conditions, agglomerations and inadequate access to health systems. 548 Over the last decades there has been a significant reduction in prevalence and mortality from RHD worldwide (with a reduction in standardized global mortality of 47, 8% from 1990 to 2015 2 ), markedly in developed countries, and even near eradication in some regions. However, the burden of disease remains high in underdeveloped countries and even in poor regions of developed countries. 548 In 2015, the highest age-standardized mortality rates for RHD prevalence were observed in Oceania, South Asia, and central sub-Saharan Africa, but there is clearly an underestimation of data from Brazil and Latin America, partly due to the scarcity of primary data. It is estimated that in 2015 there were 33.4 million cases and approximately 10.5 million disability-adjusted life years (DALY) attributable to RHD worldwide. 549 The principal determinant of RF is the admittedly repeated infection with group A beta-hemolytic streptococci (GAS), and some theories attempt to explain the pathophysiology involved in susceptibility to damage, which affects only 6% of individuals exposed to GAS: a) an antigenic similarity between agent structures (M protein surface and GlcNAc epitope) and molecules in host tissues, triggering an exaggerated immune response, and b) generation of a “neo- antigen” through contact between GAS and collagen matrix subendothelial, with consequent binding between M proteins and CB3 region of collagen type IV, inducing an autoimmune response against collagen. 548 Thus, primary prevention of RF requires early identification and appropriate therapy for GAS pharyngitis. When selecting a treatment regimen, consideration should be given to the bacteriological and clinical efficacy, ease of adherence to the recommended regimen (ie: dosing frequency, duration of therapy and acceptability), cost, spectrum of activity of the selected agent and potential adverse effects. In this context, intramuscular benzathine penicillin G, oral potassium penicillin V and oral amoxicillin are the recommended antimicrobial agents for the treatment of GAS pharyngitis in people without penicillin allergy (Table 10.8). GAS resistance to penicillin has never been documented, and penicillin potentially prevents primary attacks of RF even when started nine days after the onset of infection. 550,551 In recent decades, the long asymptomatic period of RHD and the possibility of early interventions in the subclinical phase have led to the increased role of echocardiography in disease management, with the development of population screening studies and the publication of the 2015 revised Jones criteria. 552 In addition to the incorporation of detected subclinical carditis on echocardiography, patients were stratified according to population risk for RHD, 552-554 with different criteria for endemic and non-endemic regions (Chart 10.4). Once RHD is diagnosed, prevention strategies should focus on preventing recurrences that are associated with worsening or developing RHD. A GAS infection does not necessarily have to be symptomatic to trigger a recurrence, and RHD can recur even when a symptomatic infection is correctly treated. Therefore, prevention requires continuous antimicrobial prophylaxis rather than simply recognizing and treating acute episodes of pharyngitis. 548 Therefore, continuous prophylaxis is recommended in patients with well-documented history of RHD and in those with evidence of RHD. Prophylaxis should be started as soon as RHD or RF is diagnosed. In order to eradicate GAS in the oropharynx, a complete penicillin cycle should be given to patients with RHD, even for those with a negative oropharyngeal culture. 548,550,551 Table 10.7 – Autoimmune Diseases and Cardiovascular Risk Recommendation Class Level of evidence Reference All men with erectile dysfunction should be submitted to cardiovascular risk stratification and treated according to the observed risk estimate IIa C 9,546,547 851