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 Table 10.9 – Duration of secondary prophylaxis regimens for acute rheumatic fever and rheumatic heart disease Type Duration after last episode Class Level of evidence Reference ARF with carditis and residual heart disease (persistent valve disease) † 10 years or up to 40 years old (whichever is longer); Lifelong prophylaxis may be required I C 549,550 ARF with carditis but no residual heart disease (absence of persistent valve disease) † 10 years or up to 21 years old (whichever is longer) I C 549,550 FRA without carditis 5 years or up to 21 years old (whichever is longer) I C 549,550 ARF: acute rheumatic fever. † Clinical or echocardiographic evidence. Patients diagnosed with rheumatic carditis with or without valvular disease are at high risk for recurrence and presumably a progressive risk of more severe cardiac involvement at each episode. 555 These patients should receive long-term antibiotic prophylaxis until adulthood and, in selected cases, for life. Patients with persistent valvular disease should receive prophylaxis for 10 years after the last episode of RHD or until the age of 40, whichever one is longer. The severity of valvular disease and the potential for day-to-day GAS exposure should be determined, and lifetime prophylaxis should be considered in those at high risk (e.g, permanent contact with children in schools and day care centers, care for institutionalized patients, work in health facilities etc.). 550,551 In non-endemic regions, administration of benzathine penicillin G every 4 weeks is the recommended regimen for secondary prophylaxis in most situations. In higher-risk populations, administration every 3 weeks is warranted because serum antimicrobial levels may fall below protection levels before 4 weeks after the initial dose (Table 10.9). Regarding echocardiographic screening studies in high- risk populations have shown that its accuracy is arguably higher than auscultation for detection of subclinical RF, 554 and its application at the research level has grown exponentially in the last decade. Based on screening programs involving more than 100,000 patients, in 2012, the World Heart Federation (WHF) published the first evidence-based consensus standardizing the criteria for echocardiographic diagnosis of RF (borderline and definitive). 555 The concepts of subclinical (echocardiographic findings without alterations on clinical examination) and latent (a broader spectrum encompassing RHD present on echocardiography, with no known prior history of RF or RHD) were defined. 555 The population echocardiographic screening strategy has already been tested in Brazil, and its implementation has proved feasible in schools – especially the public schools in regions with low socioeconomic indices – and primary health care, with diagnostic support by telemedicine. 556,557 In addition, non-physician imaging using the WHF simplified protocol was effective, including the basic identification of changes related to RHD. 558 There was a high prevalence of subclinical RHD in low-income regions of 4.5% (4.0% borderline and 0.5% definitive). 556,557 However, despite the various cohorts involving these patients, the clinical significance and prognostic implication of these findings has not been well established so far. Recently, a score derived from large population studies in Brazil and Uganda has been proposed to stratify patients according to the risk of RHD progression, based on weights attributed to the echocardiographic variables in the WHF criteria. 559 However, it has also been shown that giving a child a diagnosis of latent RHD can potentially worsen their quality of life and create stigmas, 560 which raises important questions about the risk-benefit ratio of large screening programs. For these reasons, there is no indication for the use of echocardiographic screening outside the research field until further studies on its impact on disease progression are completed. 11. Child and Adolescence 11.1. Introduction Childhood and adolescence are the phases with the most potential for the prevention of atherosclerosis. There is robust evidence, based on analyzes of the aortas and coronary arteries, that atherosclerosis begins at fetal age. However, more recent studies show that atherosclerosis may regress in children more easily than in adults, since their lesions are less complex and fixed. CVD risk factors respect the tracking phenomenon, i.e., a child who has some risk factor will probably have the same factor in adulthood, with similar intensity. Coupled with the fact that health habits are formed in childhood and adolescence, there is a clear need and possibility to prevent atherosclerosis from an early age. 561 Therefore, we will present strategies to control the main habits and risk factors that can be controlled in this age group. (Recommendation Level IIa; level of evidence B). 11.2. Childhood and Adolescent Nutrition Nutrition is the basis of health promotion in childhood and adolescence. In addition, eating habits are mainly formed by 7 years of age, reinforcing the importance of food education from an early age. Population studies show that almost all children ingest larger amounts of poor quality fat and added sugar or lower amounts of fiber than recommended for their age. The following principles are recommended for good child growth and development to prevent atherosclerosis from childhood: 562-564 (Recommendation Level IIa; level of evidence C). 1. Exclusive breast milk up to 6 months, and introducing other foods up to 2 years old. 2. Eating fresh and whole foods from 6 months of age, starting with pureed foods and then eating the family diet, which should be as healthy as possible. 853