IJCS | Volume 32, Nº6, November / December 2019

580 Duarte et al. Chocolate consumption and infarction Int J Cardiovasc Sci. 2019;32(6):576-582 Original Article There was also an association between chocolate consumption and lower prevalence of smoking, but this finding only seems to be coincidental. An association between chocolate consumption and diabetes mellitus was also found. Studies suggest an inverse relationship between the prevalence of diabetes mellitus and chocolate intake. 8,30-33 Research studies have found that one of the mechanisms of this inverse relationship between chocolate and diabetes mellitus is the increased sensitivity to insulin caused by flavonoids, which helps to reduce blood glucose in the stream and can delay the onset of the disease. 34,35 An important point, reported in one of the studies analyzed, is that flavonoid consumption as a protective effect of diabetes mellitus should be recommended with caution. This is relevant because the study argues that large amounts of sugars and calories can be found in a number of cocoa products rather than high flavonoid content, which can generate a rebound effect, worsening the glycemic control of patients with type 2 diabetes mellitus. 36 Some authors believe that the beneficial effect of flavonoids also occurs in patients who already have established diabetes mellitus, reducing the risk of cardiovascular outcomes in these individuals, such as AMI. 19,20 However, it is relevant to express that patients who already have diabetes mellitus are advised not to consume sugars and, in this study, the patients interviewed already had the disease and, therefore, should eat less chocolate. Among the patients who consumed chocolate, there was a negative correlation between Syntax and the amount of chocolate consumption. The median chocolate consumption among the patients was 21.5 grams per day. There is evidence that a daily dose of 80 mg could promote beneficial vascular outcomes. 18 There is also data showing an immediate improvement in coronary flow after consumption of 45 grams of chocolate with high cocoa content. 37 The correlation between higher amount of chocolate consumption and lower complexity of coronary lesions may be justified by the anti-inflammatory properties of the flavonoids present in chocolate. 5-7 Another important mechanism is the antioxidant action of flavonoids, which helps reducing free radicals andmay result in coronary lesions of lower severity. 7,38 Also, a recent clinical trial has shown that chocolate with high cocoa content improves endothelial function (assessed through flow-mediated vasodilatation of the brachial artery) in patients with established coronary artery disease. 39 In addition to that, the beneficial effects of chocolate consumption are associated with lower mortality due to cardiovascular outcomes, which suggests lower severity of AMI in those who consume chocolate in higher amounts. 8,40 However, it was not possible to establish the exact amount of recommended consumption in order to reduce the severity of the cardiovascular outcome. It is worth noting that, although there was a negative correlation between the complexity of coronary lesions and the amount of chocolate consumed, there was no association between the amount consumed and other variables associated with severity, such as post-infarction ventricular function (LVEF) and coronary flow after primary angioplasty (TIMI frame count). Regarding the limitations of this study, the comorbidities of patients and the risk factors for cardiovascular outcomes were evaluated at a single moment, which may compromise the cause-effect relationship. Variables such as alcoholism and smoking were self-reported, which could underestimate their prevalence. Also, some risk factors such as prior coronary artery bypass grafting or kidney disease requiring dialysis were not exclusion criteria and could influence the outcomes: however, the prevalence of these variables was less than 1% (data not shown). Type I error may have occurred in some findings, such as the association between chocolate consumption and lower prevalence of smoking. It was not possible to measure the proportion of cocoa present in the chocolate consumed. Another limitation of the study was the lack of income evaluation, since there could be a bias of contamination, since higher consumers of chocolate could be those with higher incomes and greater access to health services, even though the evaluation was performed exclusively in public hospitals. Besides, most patients interviewed were from a single hospital. These biases, however, do not invalidate the data found: literature data on the subject are still scarce and this evidence justifies new research studies such as clinical trials designed with adequate power to evaluate the association between chocolate consumption in patients with ischemic heart disease and the reduction of outcomes such as mortality. Conclusion There was an inverse association between chocolate consumption and hypertension, diabetes mellitus and smoking. There was also an association between