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 The pathophysiological mechanisms of changes caused by PM include: increased blood viscosity, vascular reactivity, induction of a systemic inflammatory state (thrombosis), changes in cardiac autonomic control (arrhythmia, hypertension), development and progression of atherosclerosis (acute myocardial infarction) heart failure and other CVD. 676 The finer particles are more harmful to CV health given their greater ability to penetrate the airways. When inhaled, they penetrate deep into the lung tissue, inducing oxidative stress and inflammation through the release of IL-6, IL-1 β , TNF- α by macrophages. Parallel to the intense oxidative stress that begins in the lung tissue, trophic effects on vascular and cardiac cells occur, increased generation of reactive oxygen species, impairment of nitric oxide-mediated vasodilation, endothelial dysfunction and, consequently, development and/ or progression of atherosclerosis. 678 The Harvard Six Cities study, involving populations from six US cities, revealed that the risk of myocardial infarction in a city with polluted air increases by 5% compared with that of clean air. 679 In the city of São Paulo it was observed that pollution is so high that it would be the equivalent to smoking two cigarettes a day. 677 In the Brazilian Amazon, burning biomass (bush) increased mortality from CV and respiratory events among the elderly, especially from acute myocardial infarction. 680 Particles and gases released at high altitudes circulate throughout the troposphere and can be transported over long distances, with impacts on a global scale. 680 After forest fires in Canada, high concentrations (up to 30 times higher) of mostly fine PM have been recorded in the city of Baltimore, in the United States. Thus, environmental threats are not limited only to industrial gases and lead particles from motor vehicles in urban areas, but also to the PM generated by biomass burning in rural areas, and it is estimated that air pollution, a growing public health problem, will double CVD mortality by 2050. 680 The Expert Position Paper onAir Pollution andCardiovascular Disease of the European Society of Cardiology revealed that in 2010, air pollution accounted for 3.1 million of the 52.8 million deaths, for all causes and ages. The American Heart Association reports that 60,000 Americans and 6,000 Canadians die each year from short- or long-term exposure to airborne pollutants.681 Study shows that living near (50 m) high-traffic roads can increase risk sudden death. 682 Other factors related to lifestyle, eating habits, and socioeconomic variables may exacerbate the effects of exposure to pollution, such as smoking, a diet high in fats and sugars, physical inactivity, and the use of licit (alcohol) and illicit (marijuana) drugs. The key recommendations of the Environment & the Heart Campaign campaign, organized in 2015 by the European Society of Cardiology and the European Heart Network (EHN), to European policy makers to promote a healthy environment for a healthy heart were: 1) Include the air and noise pollution in the group of modifiable risk factors for CVD; 2) Include clean air and noise reduction in all areas of health policy; 3) Adopt WHO air quality limits; 4) Intensely reduce the emission of automotive gases; 5) Promote green urban planning to reduce pollution and promote physical activity; 6) Promote clean forms of energy (low emission vehicles and non-combustion renewable energy sources); 7) Guarantee funds for studies on the effects of environmental stress on the CV system; 8) Support events addressing NCD, social, economic and environmental inequalities regarding access to health. 683,684 Brian Garvey 685 from the University of Strathclyde, Scotland, in the preface to Larissa Bombardi’s study “Geography of Pesticides in Brazil and Connections with the European Union”, stated that “every sick community, every poisoned field, every polluted watercourse threatens to extinguish an alternative variety of life”. The major steps in developing an action plan for addressing CV disease risk factors, 686 are described in Figure 12.5. 12.12. Conclusion Commitment from universities, scientific societies, organized civil society, state and municipal health secretariats, state and municipal education secretariats, the ministry of health, and federal, state and municipal governments is necessary to implement population-based approaches to address CV disease risk factors. These actions should be state policies aimed at impacting the various related morbidity and mortality indicators, as well as improving the population’s quality of life. 867