Risco Cardiovascular e Elegibilidade Para Estatina na Prevenção Primária: Comparação Entre a Diretriz Brasileira e a Diretriz da AHA/ACC / Cardiovascular Risk and Statin Eligibility in Primary Prevention: A Comparison between the Brazilian and the AHA/ACC Guidelines

Resumo Fundamento Diferenças entre as versões atualizadas da Diretriz Brasileira de Dislipidemias e da Diretriz de Colesterol da American Heart Association (AHA)/American College of Cardiology (ACC) quanto à estratificação de risco cardiovascular e à elegibilidade para a terapia com estatina não são conhecidas. Objetivos Comparar a categorização de risco cardiovascular e a elegibilidade à terapia com estatina estabelecidas segundo a diretriz brasileira ou a diretriz da AHA/ACC em pacientes em prevenção primária. Métodos Nós avaliamos retrospectivamente indivíduos com idade entre 40 e 74 anos sem condições de alto risco, com LDL-c 70 -< 190 mg/dL, sem tratamento com agentes hipolipemiantes, e que passaram por avaliação clínica de rotina. O risco cardiovascular foi estratificado de acordo com a diretriz brasileira e a da AHA/ACC. Os indivíduos foram considerados elegíveis para estatina se os níveis de LDL-c estivessem no mínimo 30 mg/dL acima da meta para o risco cardiovascular (diretriz brasileira) ou se o risco em 10 anos para doença cardiovascular aterosclerótica fosse ≥ 7,5% (diretriz da AHA/ACC). Um valor de p < 0,05 foi considerado estatisticamente significativo. Resultados A amostra do estudo consistiu 18525 indivíduos (69% homens, idade 48 ± 6 anos). Entre os indivíduos considerados de risco intermediário ou alto segundo a diretriz brasileira, mais de 80% seriam classificados em uma categoria de risco mais baixo segundo a diretriz da AHA/ACC. Entre os homens, 45% e 16% seriam considerados elegíveis para a terapia com estatina segundo as diretrizes brasileira e da AHA/ACC, respectivamente (p < 0,001). Entre as mulheres, as respectivas proporções seriam 16% e 1% (p < 0,001). Oitenta e dois porcento das mulheres e 57% dos homens elegíveis para estatina com base no critério da diretriz brasileira não seriam considerados elegíveis para estatina segundo o critério da AHA/ACC. Conclusões Em comparação à diretriz da AHA/ACC, a diretriz brasileira classifica uma maior proporção dos pacientes em prevenção primária em categorias de risco mais alto e aumenta substancialmente a elegibilidade para estatina. (Arq Bras Cardiol. 2020; 115(3):440-449)

Abstract Background Differences between the updated versions of the Brazilian Guideline on Dyslipidemias and the American Heart Association (AHA)/American College of Cardiology (ACC) Cholesterol Guideline regarding cardiovascular risk stratification and statin eligibility are unknown. Objectives To compare cardiovascular risk categorization and statin eligibility based on the Brazilian guideline with those based on the AHA/ACC guideline in primary prevention patients. Methods We retrospectively analyzed individuals aged 40-74 years without high-risk conditions, with LDL-c 70 to < 190 mg/dL, not on lipid-lowering drugs, who underwent routine clinical assessment. Cardiovascular risk was stratified according to the Brazilian and the AHA/ACC guidelines. Subjects were considered eligible for statin therapy if LDL-c was at least 30 mg/dL above the target for the cardiovascular risk (Brazilian guideline) or the 10-year atherosclerotic cardiovascular disease risk was ≥7.5% (AHA/ACC guideline). A p-value < 0.05 was considered statistically significant. Results The study sample consisted of 18,525 subjects (69% male, age 48 ± 6 years). Among subjects considered at intermediate or high risk by the Brazilian guideline, over 80% would be in a lower risk category by the AHA/ACC guideline. Among men, 45% and 16% would be statin eligible by the Brazilian and the AHA/ACC guidelines criteria, respectively (p < 0.001). Among women, the respective proportions would be 16% and 1% (p < 0.001). Eighty-two percent of women and 57% of men eligible for statins based on the Brazilian guideline criterion would not be eligible according to the AHA/ACC guideline criterion. Conclusions Compared with the AHA/ACC guideline, the Brazilian guideline classifies a larger proportion of primary prevention patients into higher-risk categories and substantially increases statin eligibility. (Arq Bras Cardiol. 2020; 115(3):440-449)

2017 American College of Cardiology/American Heart Association Clinical Guideline-based Prevalence of Hypertension in a semi-urban community in Nigeria: Public Health Perspective / Guía clínica de 2017 sobre prevalencia de hipertensión del American College of Cardiology/American Heart Association en una comunidad semi-urbana de Nigeria: Perspectiva de Salud Pública

Abstract Background: Evidence from previous studies has consistently revealed that patients develop target organ damage even with seemingly normal blood pressure thus informing the development of a new treatment guideline in 2017. The prevalence of hypertension in Nigeria ranges from 8-45%, however this is expected to change due to the new guideline. Thus, this study sought to estimate the prevalence of hypertension based on 2017 ACC/AHA clinical guidelines, and determine its associated factors. Methods: In this cross-sectional study a total of 296 participants were recruited with a simple random technique using a table of random numbers. Blood pressure, weight and height were measured and data was analysed with SPSS version 22. The primary outcome measures included proportion of respondents with hypertension based on AHA guideline and JNC 7 classifications, as well as the association between hypertension and BMI, age, sex and marital status. Results: The mean age of study participants was 38.71years, and male to female ratio was 2:3. Overall prevalence of hypertension was 63.5% and 22.6% based on the new guideline and JNC 7 classification respectively; higher risk of hypertension was significantly associated with the AHA guideline (p< 0.001). Association between body mass index, marital status (currently married/not married), sex, age group (≥40 vs. < 40years) and systolic as well as diastolic hypertension was significant (p< 0.001). Females were more than twice as likely to be hypertensive as males [OR: 2.51 (1.54 - 4.10)]. Age and weight were the only significant predictors of abnormal blood pressure, diastolic and systolic hypertension. Conclusion: Prevalence of hypertension based on the new guideline is staggeringly high and portends a huge public health problem. This conundrum requires immediate intervention in order to forestall the damaging effects of hypertension on vital body organs and for participants to lead a healthy life.

Resumen Antecedentes: La evidencia de los estudios previos ha revelado, consistentemente, que los pacientes desarrollan daños en los órganos diana aun cuando su presión arterial es aparentemente normal, lo cual ha impulsado el desarrollo de una nueva guía de tratamiento en 2017. La prevalencia de la hipertensión en Nigeria oscila del 8 al 45%, aunque está previsto que cambie, debido a esta nueva guía. En nuestro estudio calculamos la prevalencia de la hipertensión, basada en la guía clínica de ACC/AHA de 2017, y determinamos sus factores asociados. Métodos: En este estudio transversal reunimos a un total de 296 participantes mediante una técnica aleatoria simple, utilizando una tabla de números aleatorios. Medimos la presión arterial, el peso y la altura, y analizamos los datos con SPSS versión 22. Las medidas del resultado primario incluyeron la proporción de respondedores hipertensos, basándonos en la guía AHA y en la clasificación JNC 7, así como en la asociación entre hipertensión e IMC, edad, sexo y estado civil. Resultados: La edad media de los participantes del estudio fue de 38,71 años, siendo el ratio varón:mujer de 2:3. La prevalencia global de la hipertensión fue del 63,5% y del 22,6%, sobre la base de la nueva guía y la clasificación JNC 7, respectivamente. El mayor riesgo de hipertensión se asoció significativamente a la guía AHA (p< 0,001). La asociación entre índice de masa corporal, estado civil (actualmente casados/solteros), sexo, grupo de edad (≥40 vs. < 40 años), e hipertensión sistólica y diastólica fue significativa (p< 0,001). Las mujeres superaron en más del doble a los varones, en cuanto a la probabilidad de padecer hipertensión [OR: 2,51 (1,54 - 4,1)]. La edad y el peso constituyeron los únicos factores predictivos significativos de presión arterial anormal e hipertensión diastólica y sistólica. Conclusión: La prevalencia de la hipertensión basada en una nueva guía es asombrosamente elevada, presagiando un gran problema de salud pública. Este interrogante requiere una intervención inmediata, a fin de prevenir los efectos dañinos de la hipertensión en los órganos vitales, y animar a los participantes a llevar una vida sana.

¿Qué representa cambiar el umbral diagnóstico de la hipertensión arterial? Guías ACC/AHA 2017 y su aplicación en Perú / Changes in the prevalence of hypertension in Peru using the new guideline of the American College of Cardiology

Introduction and Objective: There is little evidence in Latin America about the impact of the ACC/AHA 2017 guideline. Taking as reference the JNC 7 guideline, the objective of our study is to estimate changes in the prevalence of arterial hypertension (HBP) according to socio-demographic characteristics and geographic regions, applying the criteria of the new ACC / AHA guide 2017. Methods: Cross-sectional study of the Demographic and Family Health Survey conducted in Peru in 2017. Standardized weighted hypertension prevalence's were estimated for the WHO population according to both guidelines, and absolute differences with 95% CI. Results: We included 30,682 people aged 18 years and over, with an average age of 42.3 years, 51.1% women. The standardized prevalence of HBP for 2017 according to JNC 7 was 14.4% (95% CI: 13.8-15.1) and according to ACC / AHA 2017 it was 32.9% (95% CI: 32.0-33.7), so the prevalence increase is 18.5 percentage points, being higher in males than females (24.2 vs 12.9 respectively). In people with obesity and / or who consume tobacco, the increases were higher (24.3 and 24.1 percentage points respectively). In the regions of Tacna, Ica and Metropolitan Lima, the increase, in comparison with the JNC 7 guidelines, overcome the national average (22.4, 20.7 and 20.4, percentage points, respectively). Conclusions: Considering the context of a Latin American country and knowing the epidemiology of hypertension in Peru, the potential adoption of the ACC/AHA 2017 guidelines for the prevention, detection, evaluation, and management of hypertension should be accompanied by an evaluation of the impact at the individual, system and social level.

Comparison of the ACC/AHA and Framingham algorithms to assess cardiovascular risk in HIV-infected patients

ABSTRACT The aim of this study was to compare the predictions of Framingham cardiovascular (CV) risk score (FRS) and the American College of Cardiology/American Heart Association (ACC/AHA) risk score in an HIV outpatient clinic in the city of Vitoria, Espirito Santo, Brazil. In a cross-sectional study 341 HIV infected patients over 40 years old consecutively recruited were interviewed. Cohen's kappa coefficient was used to assess agreement between the two algorithms. 61.3% were stratified as low risk by Framingham score, compared with 54% by ACC/AHA score (Spearman correlation 0.845; p < 0.000). Only 26.1% were classified as cardiovascular high risk by Framingham compared to 46% by ACC/AHA score (Kappa = 0.745; p < 0.039). Only one out of eight patients had cardiovascular high risk by Framingham at the time of a myocardial infarction event registered up to five years before the study period. Both cardiovascular risk scores but especially Framingham underestimated high-risk patients in this HIV-infected population.

Cardiovascular Risk Stratification and Statin Eligibility Based on the Brazilian vs. North American Guidelines on Blood Cholesterol Management / Estratificação de Risco Cardiovascular e Elegibilidade para Estatina com Base na Diretriz Brasileira vs. Norte-Americana para Manejo do Colesterol

Abstract Background: The best way to select individuals for lipid-lowering treatment in the population is controversial. Objective: In healthy individuals in primary prevention: to assess the relationship between cardiovascular risk categorized according to the V Brazilian Guideline on Dyslipidemia and the risk calculated by the pooled cohort equations (PCE); to compare the proportion of individuals eligible for statins, according to different criteria. Methods: In individuals aged 40-75 years consecutively submitted to routine health assessment at one single center, four criteria of eligibility for statin were defined: BR-1, BR-2 (LDL-c above or at least 30 mg/dL above the goal recommended by the Brazilian Guideline, respectively), USA-1 and USA-2 (10-year risk estimated by the PCE ≥ 5.0% or ≥ 7.5%, respectively). Results: The final sample consisted of 13,947 individuals (48 ± 6 years, 71% men). Most individuals at intermediate or high risk based on the V Brazilian Guideline had a low risk calculated by the PCE, and more than 70% of those who were considered at high risk had this categorization because of the presence of aggravating factors. Among women, 24%, 17%, 4% and 2% were eligible for statin use according to the BR-1, BR-2, USA-1 and USA-2 criteria, respectively (p < 0.01). The respective figures for men were 75%, 58%, 31% and 17% (p < 0.01). Eighty-five percent of women and 60% of men who were eligible for statin based on the BR-1 criterion would not be candidates for statin based on the USA-1 criterion. Conclusions: As compared to the North American Guideline, the V Brazilian Guideline considers a substantially higher proportion of the population as eligible for statin use in primary prevention. This results from discrepancies between the risk stratified by the Brazilian Guideline and that calculated by the PCE, particularly because of the risk reclassification based on aggravating factors.

Resumo Fundamento: Existe controvérsia sobre a melhor forma de selecionar indivíduos para tratamento hipolipemiante na população. Objetivos: Em indivíduos saudáveis em prevenção primária: avaliar a relação entre o risco cardiovascular segundo a V Diretriz Brasileira de Dislipidemias e o risco calculado pelas pooled cohort equations (PCE); comparar a proporção de indivíduos elegíveis para estatinas, de acordo com diferentes critérios. Métodos: Em indivíduos de 40 a 75 anos submetidos consecutivamente a avaliação rotineira de saúde em um único centro, quatro critérios de elegibilidade para estatina foram definidos: BR-1, BR-2 (LDL-c acima ou pelo menos 30 mg/dL acima da meta preconizada pela diretriz brasileira, respectivamente), EUA-1 e EUA-2 (risco estimado pelas PCE em 10 anos ≥ 5,0% ou ≥ 7,5%, respectivamente). Resultados: Foram estudados 13.947 indivíduos (48 ± 6 anos, 71% homens). A maioria dos indivíduos de risco intermediário ou alto pela V Diretriz apresentou risco calculado pelas PCE baixo e mais de 70% daqueles considerados de alto risco o foram devido à presença de fator agravante. Foram elegíveis para estatina 24%, 17%, 4% e 2% das mulheres pelos critérios BR-1, BR-2, EUA-1 e EUA-2, respectivamente (p < 0,01). Os respectivos valores para os homens foram 75%, 58%, 31% e 17% (p < 0,01). Oitenta e cinco por cento das mulheres e 60% dos homens elegíveis para estatina pelo critério BR-1 não seriam candidatos pelo critério EUA-1. Conclusões: Comparada à diretriz norte-americana, a V Diretriz Brasileira considera uma proporção substancialmente maior da população como elegível para estatina em prevenção primária. Isso se relaciona com discrepâncias entre o risco estratificado pela diretriz brasileira e o calculado pelas PCE, particularmente devido à reclassificação de risco baseada em fatores agravantes.

Superioridad del nuevo puntaje de riesgo ACC/AHA 2013 por sobre el puntaje de Framingham, en la predicción de riesgo de mortalidad cardiovascular en Santiago / Evaluation the American College of Cardiology and American Heart Association Predictive score for cardiovascular diseases

Background: Recently, the American College of Cardiology and American Heart Association (ACC/AHA) proposed a new cardiovascular risk (CV) score. Aim: To evaluate the new risk score (ACC/AHA 2013) in a Chilean population. Material and Methods: Between 2002 and 2014, body mass index (BMI), waist circumference, blood pressure, lipid profile and fasting blood glucose levels were measured and a survey about CV risk factors was responded by 3,284 subjects aged 40 to 79 years (38% females), living in urban Santiago. ACC/AHA 2013, FRAM and Chilean FRAM scores were calculated. All-cause mortality was determined in July 2014 by consulting the Death Registry of the Chilean Identification Service, with an average follow up of 7 ± 3 years. Results: The prevalence of risk factors were 78% for dyslipidemia, 37% for hypertension, 20% for smoking, 7% for diabetes, 20% for obesity and 54% for physical inactivity. The mean FRAM, Chilean FRAM and ACC/AHA scores were 8, 3 and 9%, respectively. During follow-up, 94 participants died and 34 deaths were of cardiovascular cause. Participants who died had a higher prevalence of hypertension (p < 0.01) and diabetes (p < 0. 01) and tended to be older (p = 0.06). The FRAM score for 10 years for deceased and surviving patients was 12 and 8%, respectively (p = NS). The figures for the Chilean FRAM were 5 and 2%, respectively (p = 0.09). The figures for the ACC/AHA 2013 score were 33 and 9%, respectively (p = 0.04). According to receiver operating characteristic curves, ACC/AHA 2013 had a higher area under de curve for CV mortality than FRAM and Chilean FRAM. Conclusions: The new ACC/AHA 2013 score, is better than traditional FRAM and Chilean FRAM scores in predicting cardiovascular mortality in a low risk population.

Brazilian Cardiorespiratory Fitness Classification Based on Maximum Oxygen Consumption / Classificação Nacional da Aptidão Cardiorrespiratória pelo Consumo Máximo de Oxigênio

Abstract Background: Cardiopulmonary exercise test (CPET) is the most complete tool available to assess functional aerobic capacity (FAC). Maximum oxygen consumption (VO2 max), an important biomarker, reflects the real FAC. Objective: To develop a cardiorespiratory fitness (CRF) classification based on VO2 max in a Brazilian sample of healthy and physically active individuals of both sexes. Methods: We selected 2837 CEPT from 2837 individuals aged 15 to 74 years, distributed as follows: G1 (15 to 24); G2 (25 to 34); G3 (35 to 44); G4 (45 to 54); G5 (55 to 64) and G6 (65 to 74). Good CRF was the mean VO2 max obtained for each group, generating the following subclassification: Very Low (VL): VO2 < 50% of the mean; Low (L): 50% - 80%; Fair (F): 80% - 95%; Good (G): 95% -105%; Excellent (E) > 105%. Results: Men VL < 50% L 50-80% F 80-95% G 95-105% E > 105% G1 < 25.30 25.30-40.48 40.49-48.07 48.08-53.13 > 53.13 G2 < 23.70 23.70-37.92 37.93-45.03 45.04-49.77 > 49.77 G3 < 22.70 22.70-36.32 36.33-43.13 43.14-47.67 > 47.67 G4 < 20.25 20.25-32.40 32.41-38.47 38.48-42.52 > 42.52 G5 < 17.54 17.65-28.24 28.25-33.53 33.54-37.06 > 37.06 G6 < 15 15.00-24.00 24.01-28.50 28.51-31.50 > 31.50 Women G1 < 19.45 19.45-31.12 31.13-36.95 36.96-40.84 > 40.85 G2 < 19.05 19.05-30.48 30.49-36.19 36.20-40.00 > 40.01 G3 < 17.45 17.45-27.92 27.93-33.15 33.16-34.08 > 34.09 G4 < 15.55 15.55-24.88 24.89-29.54 29.55-32.65 > 32.66 G5 < 14.30 14.30-22.88 22.89-27.17 27.18-30.03 > 30.04 G6 < 12.55 12.55-20.08 20.09-23.84 23.85-26.35 > 26.36 Conclusions: This chart stratifies VO2 max measured on a treadmill in a robust Brazilian sample and can be used as an alternative for the real functional evaluation of physically and healthy individuals stratified by age and sex.

Resumo Fundamento: O teste cardiopulmonar de exercício (TCPE) é a ferramenta disponível mais completa na avaliação da capacidade aeróbica funcional (CF) do indivíduo. O consumo máximo de oxigênio (VO2 max), importante marcador biológico, reflete a real CF. Objetivo: Elaborar uma classificação de aptidão cardiorrespiratória (ACR) baseada no VO2 max em uma amostra nacional de sujeitos saudáveis e ativos de ambos os sexos. Métodos: Selecionamos 2837 TCPE de indivíduos entre 15 e 74 anos, assim distribuídos: G1 (15 a 24); G2 (25 a 34); G3 (35 a 44); G4 (45 a 54); G5 (55 a 64) e G6 (65 a 74). A ACR boa foi a média do VO2 max obtido em cada grupo, gerando as seguintes subclassificações: Muito Fraca (MF) VO2 < 50% da média; Fraca (F): 50%-80%; Regular (R): 80%-95%; Boa (B): 95%-105%; e Excelente (E) > 105%. Resultados: Homens MF < 50% F 50-80% R 80-95% B 95-105% E > 105% G1 < 25,30 25,30-40,48 40,49-48,07 48,08-53,13 > 53,13 G2 < 23,70 23,70-37,92 37,93-45,03 45,04-49,77 > 49,77 G3 < 22,70 22,70-36,32 36,33-43,13 43,14-47,67 > 47,67 G4 < 20,25 20,25-32,40 32,41-38,47 38,48-42,52 > 42,52 G5 < 17,54 17,65-28,24 28,25-33,53 33,54-37,06 > 37,06 G6 < 15 15,00-24,00 24,01-28,50 28,51-31,50 > 31,50 Mulheres G1 < 19,45 19,45-31,12 31,13-36,95 36,96-40,84 > 40,85 G2 < 19,05 19,05-30,48 30,49-36,19 36,20-40,00 > 40,01 G3 < 17,45 17,45-27,92 27,93-33,15 33,16-34,08 > 34,09 G4 < 15,55 15,55-24,88 24,89-29,54 29,55-32,65 > 32,66 G5 < 14,30 14,30-22,88 22,89-27,17 27,18-30,03 > 30,04 G6 < 12,55 12,55-20,08 20,09-23,84 23,85-26,35 > 26,36 Conclusão: A presente tabela estratifica o VO2 max aferido em esteira em uma robusta amostra nacional e pode ser utilizada como opção para a real avaliação funcional de indivíduos ativos e saudáveis de acordo com sexo e faixa etária.