IJCS | Volume 33, Nº4, July and August 2020

a diagnosis of clinical atherosclerotic cardiovascular disease or diabetesmellitus, with LDL-c between 70mg/dl and 189 mg/dl and cardiovascular risk by PCE ≥ 7.5% in 10 years. 8 In 2018, a new AHA/ACC cholesterol guideline was published, proposing the categorization of cardiovascular risk and recommending the start of statin therapy for individuals at intermediate or high risk and considering those at borderline risk in certain circumstances. The use of ezetimibe and PCSK9 inhibitors was also suggested for those with severe primary hypercholesterolemia. 9 In the current edition of the International Journal of Cardiovascular Sciences, Hernandez et al., 10 have analyzed lipid-lowering regimens in Ecuadorian patients to assess whether the therapy targets of the NCEP-ATP III guidelines were achieved. Those authors carried out a retrospective analysis with 385 patients (46%men; mean age, 59.8 ± 13.2 years). They observed that 68% of the patients had a very high risk for CAD, and most of them (n=253; 95,8%) were on atorvastatin (50%), simvastatin (34,8%), and rosuvastatin (11%). Regarding the targets of the NCEP-ATP III guidelines, the authors observed that only 24 individuals (19%) with high cardiovascular risk reached LDL-c <100 mg/dl, while 30 individuals (11%) with very high risk reached LDL-c <70 mg/dl. The results were also analyzed based on the 2013 ACC/AHA guidelines, and only 10.7% of the patients receiving high- intensity statins reached the target of a 50% reduction in LDL cholesterol. Few studies have described the impact of guidelines on clinical practice. Yu et al., 11 have assessed the achievement of statin-use goals, as well as LDL-c levels before and after the 2013 ACC/AHA guidelines in 1938 patients with CAD. Those authors have reported that the proportion of patients achieving LDL-c goals ranged from 51% to 56% for the 70-mg/dl target and from 77% to 85% for the 100-mg/dl target, remaining unchanged in the comparison cohorts. 10 The authors have attributed those results to the prescription of low doses of drugs and to therapies aimed at isolated lipid fractions. Other factors, however, must be considered, such as the knowledge of healthcare professionals about the guidelines and adherence to the treatment proposed, which includes both drug therapy and changes in lifestyle. In this sense, the guidelines are consistent in recommending to all individuals, regardless of their level of risk, changes in lifestyle, such as the following: adoption of a healthy eating pattern, which emphasizes the intake of fruits, vegetables, whole grains and healthy sources of protein, and limits the consumption of ultra-processed foods; maintenance of body weight; regular physical exercise; and smoking cessation. Those measures are the basis of any intervention to reduce the risk of CVD. 6,8,9,11 Considering the multifactorial nature of CVDs, it is necessary to implement a multidisciplinary approach to the set of risk factors responsible for their occurrence, morbidity, and mortality, with guidelines that contemplate these premises. This relates directly to the success of the proposed recommendations. Thus, the successful treatment of dyslipidemias will not only depend on the degree of cardiovascular risk and lipid profile, as assessed by the authors. It also depends on interventions that promote greater knowledge about the recommendations among all involved with the care, as well as on a more comprehensive scope of non- pharmacological population measures, which will have direct implications for cardiovascular outcome. 12,13 1. GBD 2017 Disease and Injury Incidence and Prevalence Collaborators. Global, regional, and national incidence, prevalence, and years lived with disability for 354 diseases and injuries for 195 countries and territories, 1990-2017: a systematic analysis for the Global Burden of Disease Study 2017. Lancet. 2018;392(10159):1789-858. doi: 10.1016/ S0140-6736(18)32279-7. Epub 2018 Nov 8. Erratum in: Lancet. 2019 Jun 22;393(10190): e44. 2. Kopin L, Lowenstein C. Dyslipidemia. Ann Intern Med.2017; 167(11):ITC81-ITC96. 3. Andersson C, Lyass A, Vasan RS, Massaro JM, D’Agostino RB Sr, Robins SJ. Long-term risk of cardiovascular events across a spectrum of adverse major plasma lipid combinations in the Framingham Heart Study. Am Heart J. 2014;168(6):878-83 e1. 4. Lu Y, Cheng Z, Zhao Y, Chang X, Chan C, Bai Y, Cheng N. Efficacy and safety of long-term treatment with statins for coronary heart disease: A Bayesian network meta-analysis. Atherosclerosis.2016 Nov;254:215-27. doi: 10.1016/j.atherosclerosis.2016.10.025 5. Yebyo HG, Aschmann HE, Kaufmann M, Puhan MA. Comparative effectiveness and safety of statins as a class and of specific statins for primary prevention of cardiovascular disease: A systematic review, meta-analysis, and network meta-analysis of randomized trials with 94,283 participants. Am Heart J. 2019 Apr; 210:18-28. doi: 10.1016/j. ahj.2018.12.007. 6. Grundy SM, Cleeman JI, Bairey Merz CN, Brewer Jr B, Clark LT, Hunninghake DB, for the Coordinating Committee of the National Cholesterol Education Program Endorsed by the National Heart, Lung, References 378 Aranha & Oliveira Improving adherence to cardiovascular guidelines Int J Cardiovasc Sci. 2020; 33(4):377-379 Editorial