ABC | Volume 114, Nº2, February 2020

Update Update of the Brazilian Guideline on Nuclear Cardiology – 2020 Arq Bras Cardiol. 2020; 114(2):325-429 and major adverse events in stable chest pain patients or asymptomatic patients, such as Framingham Risk Score (FRS), PROCAM, SCORE, Diamond Forrester, 125 or Global Risk; 126 the estimated prevalence (EP) of the disease is observed to be significantly higher than the observed prevalence (OP), when coronary angio-CT is used to characterize luminal obstruction, ≥ 50% and ≥ 70%, respectively. In this situation, an international multicenter study (CONFIRM) 127 of 14,048 consecutive patients with clinical suspicion of coronary obstructive atherosclerosis who underwent angio-CT showed that, in all age and sex categories, guidelines for calculating probability overestimated prevalence in the general population (51% EP × 18% OP for lesions ≥ 50% and 42% EP × 10% OP for obstructions ≥ 70%, p < 0.001), directed by accentuated differences between patients with typical angina (86% EP × 29% OP for lesions ≥ 50%) and atypical angina (47% EP × 15% OP for lesions > 50%). Considering this information to be true, more evidence has arisen within the literature in the search for newmarkers which might aggregate value and assist in more objective and realistic restratification of cardiovascular risk, with specific guidelines 128 dealing with critical questions regarding, for instance, what types of evidence will contribute to risk assessment or reclassification when new markers are added to traditional scores, with emphasis on functional capacity and CS (Table 23). 6.1. The Application of Bayes’ Theorem to Analysis of Myocardial Perfusion Images with Radiopharmaceuticals Even when isolated analysis of images is used to describe perfusion findings, interpret data, and write reports, medical comments and conclusions should be the result of the Table 20 – Recommendations for cardiovascular risk assessment, considering the presence or absence of known risk factors. European Guidelines on cardiovascular disease prevention in clinical practice 119 Recommendations Class of recommendation Level of evidence CV risk assessment in individuals with family history of premature CV disease, family history of dyslipidemia, major risk factors (smoking, HBP, DM, raised lipid levels), or specific comorbidities that increase CV risk. I C Repeat risk assessment every 5 years; repeat more often in individuals with risks close to levels which treatment is mandatory I C Consider CV risk assessment in men > age 40 and women > age 50 or post-menopausal with no known risk factors IIb C CV risk assessment in men < age 40 and women < age 50 with no known risk factors is not recommended III C C: level of evidence based on consensus of expert opinion and/or small studies, registries, or retrospective studies; CV: cardiovascular; DM: diabetes mellitus; HBP: High blood pressure; I, IIb, and III: class of recommendation. Table 21 – Percent probability of obstructive coronary artery disease, considering the presence of chest pain, sex, and age. Adapted from Diamond GA, Forrester JS and the Brazilian Cardiology Society’s Third Guidelines on Exercise Testing 117,118 Age Non-anginal chest pain Atypical angina Typical angina Men Women Men Women Women Men 30-39 4 2 34 12 76 26 40-49 13 3 51 22 87 55 50-59 20 7 65 31 93 73 60-69 27 14 72 51 94 86 Table 22 – Percent probability of obstructive coronary artery disease, considering the presence of chest pain, sex, and age. Comparison between LR and HR patients. Adapted from Gibbons RJ et al. and the Brazilian Cardiology Society’s Third Guidelines on Exercise Testing 117,119 Age Non-anginal chest pain Atypical angina Typical angina Men Women Men Women Men Women LR HR LR HR LR HR LR HR LR HR LR HR 35 3 35 1 19 8 59 2 39 30 86 10 78 45 9 47 2 22 21 70 5 43 51 92 20 79 55 23 59 4 25 45 79 10 47 80 95 38 82 65 49 69 9 29 71 86 20 51 93 97 56 84 CAD: coronary artery disease; HR: high risk (smoking, diabetes, or dyslipidemia); LR: low risk (without smoking, diabetes, or dyslipidemia). 349