I Cardiovascular Prevention Guideline of the Brazilian Society of Cardiology - Executive Summary

Atherosclerotic coronary artery, cerebrovascular or obstructive peripheral diseases with clinical manifestations (cardiovascular events) and still in the subclinical form, documented by use of diagnostic methodology; Arterial revascularization procedures;Type 1 and type 2 diabetes mellitus;Chronic kidney disease.

# Introduction
Brazil currently faces a major health challenge: the pandemic scenario of cardiovascular morbidity and mortality. According to Brazilian Health Ministry data, 326,000 deaths due to cardiovascular diseases (CVD) occurred in 2010, corresponding to approximately 1,000 deaths/day, 200,000 deaths due exclusively to ischemic heart and cerebrovascular diseases, reflecting a gloomy scenario far from the minimally acceptable control.
This current scenario can be attributed to many reasons, such as the insufficiency and inadequacy of public health policies for CVD prevention, leading to the well-known lack of infrastructure in primary health care, hindering the fight against preventable affections, mainly in the neediest areas.
In addition, it is worth mentioning the well-known sociocultural factors, such as the excessive consumption of high-caloric foods in association with physical inactivity, and, consequently, the development of obesity and diabetes, and excessive salt intake. Those factors contribute to the development of arterial hypertension, being decisive to the high prevalence of CVD and no opportunity to provide instructions on lifestyle changes.
The medical societies, in partnership with governments and universities, have endeavored to elaborate valuable documents containing strategic plans of CVD prevention and fight. However, simple and objective guidelines, which can be easily accessed and managed by health care personnel, are required to implement that which has been long discussed by specialists and scientists, although with modest results.
For the first time, guidelines and consensus documents, most of which already published in several other guidelines of specialties, have been gathered in a single document to provide the clinician with easy access to the recommendations for primary and secondary CVD prevention. For that, the Brazilian Society of Cardiology (SBC) has gathered specialized physicians with large experience in preventive actions to elaborate the present document.
Chapter 1 presents the cardiovascular risk stratification for atherosclerosis prevention and treatment. In this chapter, the authors discuss questions such as acute coronary event as the first manifestation of atherosclerotic disease in at least half of the individuals with that complication. Thus, the identification of predisposed asymptomatic individuals is crucial to the effective prevention with correct definition of therapeutic goals, especially the criteria to identify high-risk patients . The authors discuss the so-called risk scores, through which the overall risk is calculated, enabling the clinician to quantify and qualify the patients' individual risk, for both women [fig_ref] Table 2 -: Scoring according to overall risk for women HDL-C [/fig_ref] and men [fig_ref] Table 4 -: Scoring according to overall risk for men [/fig_ref]. The combination of those different scores allow the clinician to better estimate the risk, stratifying it gradually: presence of significant atherosclerotic disease or its equivalents; calculation of risk score; aggravating factors (Chart 1) and risk stratification based on lifespan. The authors propose a simplified algorithm for cardiovascular risk stratification, which is exemplified in . The recommendations listed as class I and level of evidence A are few, because the other recommendations still require more comprehensive studies with long-term follow-up [fig_ref] Table 6 -: Classification of recommendation and level of evidence for risk stratification in cardiovascular... [/fig_ref].
Chapter 2 approaches tobacco smoking, the major avoidable risk factor. It is known that 50% of the deaths of smokers, most of which caused by CVD, could be prevented with smoking cessation. In this chapter, the authors discuss preventive measures for tobacco use. Data from the Surveillance of Risk Factors and Protection Against Chronic Diseases via Telephone Inquiry (VIGITEL, in Portuguese), disclosed on April 2012, revealed advances in tobacco use control in Brazil, with 14.8% of smokers older than 18 years. They also approached the primordial prevention of tobacco use, enumerating factors that contribute to smoking initiation and proposing practical strategies for its combat. In addition, the authors discuss techniques to treat the psychological dependence of smokers with general and specific behavioral approaches. Furthermore, this chapter presents instruments to help to assess and understand the patient's profile by using universally accepted scales, such as Prochaska and Di Clemente's and Fagerstrom's. Finally, the authors approach, in a practical way, pharmacological treatment strategies of tobacco use, such as nicotine replacement with bupropion and varenicline, in addition to second-line drugs (nortriptyline), with their possible associations. [fig_ref] Table 7 -: Classification of recommendation and level of evidence for the treatment of smoking... [/fig_ref] summarizes the classification of recommendation and level of evidence of those strategies.
Chapter 3 discusses the real benefits of primary and secondary CVD prevention, with evident confirmation of diet, supplements and vitamins, aiming at helping the clinician to guide the community in choosing and consuming those products. In addition to supplements, omega-3 fatty acids, vitamins B, C, D and E, folates, alpha-linolenic acids and carotenoids were assessed [fig_ref] Table 8 -: Summary of the recommendations for not using vitamin supplements to prevent cardiovascular... [/fig_ref] Chapter 4 approaches obesity, overweight and nutrition transition, as well as the consequences for cardiovascular morbidity and mortality of their association with arterial hypertension, dyslipidemias, type 2 diabetes, osteoarthritides and cancer. Tables 9 and 10 list the classification of recommendation and levels of evidence for primary and secondary prevention.
Chapter 5 summarizes the recommendations for systemic arterial hypertension (SAH), emphasizing its importance for the development of several pathologies, such as coronary artery disease, heart failure, cerebrovascular disease and chronic kidney disease. [fig_ref] Table 11 -: Routine initial assessment of the hypertensive patient [/fig_ref] shows the routine initial assessment of hypertensive patients, and [fig_ref] Table 2 -: Scoring according to overall risk for women HDL-C [/fig_ref] , its complementary assessment. Therapeutic decision should consider the patient's additional risk. [fig_ref] Table 3 -: Overall cardiovascular risk in 10 years for women [/fig_ref] shows nonpharmacological measures, which are listed according to their recommendation class and level of evidence. shows the algorithm of pharmacological treatment based on the patients' hypertension stages. Monotherapy can be initiated with any drug class, but SAH control is only achieved in one-third of the cases with that strategy. Chart 2 shows the goals to be met according to patients' characteristics.
Chapter 6 was aimed at discussing dyslipidemias, in an attempt to, after stratifying the individual risk, establish the therapeutic goals according to the overall risk level (low, intermediate or high). Specific goals are listed for high-and intermediate-risk patients. Patients at low cardiovascular risk should have their goals individualized at their clinician's discretion and according to lipid reference values. [fig_ref] Table 4 -: Scoring according to overall risk for men [/fig_ref] presents strategies for lifestyle changes. [fig_ref] Table 5 -: Overall cardiovascular risk in 10 years for men [/fig_ref] lists the pharmacological alternatives based on their recommendation class and level of evidence.
Chapter 7 discusses diabetes, emphasizing its high prevalence in the adult population, up to 13.5% in some municipalities, which could represent a current population of 17 million individuals with diabetes. Those numbers are increasing due to factors such as population growth and aging, and increasing urbanization, sedentary lifestyle and obesity. This important chapter discusses essential measures for prevention, such as lifestyle changes [fig_ref] Table 6 -: Classification of recommendation and level of evidence for risk stratification in cardiovascular... [/fig_ref].

## Special article

## Simao et al. cardiovascular prevention guideline
Arq Bras Cardiol. 2014; 102(5):420-431

## Chart 1 -aggravating risk factors
- Family history of early coronary artery disease (male first-degree relative < 55 years-old or female first-degree relative < 65 years-old); - Criteria of metabolic syndrome according to the International Diabetes Federation; - Microalbuminuria (30-300 mg/min) or macroalbuminuria (>300 mg/min); - Left ventricular hypertrophy; - 
High-sensitivity C-reactive protein > 3 mg/L; - Evidence of subclinical atherosclerotic disease: carotid stenosis/thickening > 1mm coronary calcium score > 100 or > 75 th percentile for age or sex ankle-brachial test < 0.9 Chapter 8 provides a review on metabolic syndrome. There are several versions of the metabolic syndrome definition, and this guideline adopted the joint position paper of several international organizations on the topic. The authors discuss the epidemiological aspects of its prevalence, approaching different population groups, and aspects related to cardiovascular and metabolic risks, in addition to metabolic syndrome risk factors. [fig_ref] Table 7 -: Classification of recommendation and level of evidence for the treatment of smoking... [/fig_ref] shows the recommendation class and level of evidence of interventions in metabolic syndrome.

## Special article

## Simao et al. cardiovascular prevention guideline
Arq Bras Cardiol. 2014; 102(5):420-431 Chapter 9 discusses the role played by physical activity, physical exercise and sports in CVD prevention. Physically active individuals tend to be healthier and have better quality of life and longer life expectancy. [fig_ref] Table 8 -: Summary of the recommendations for not using vitamin supplements to prevent cardiovascular... [/fig_ref] lists the recommended physical exercise levels. In addition, the risks of physical activity are approached, as well as the basic principles for exercise prescription and strategies to encourage referral, implementation and adherence.
Chapter 10 discusses psychosocial factors in CVD prevention. Beginning with the definition of the concept, the chapter discusses the psychosocial conditions frequently associated with cardiovascular risk, such as low socioeconomic status, lack of social support, stress at work place and family life, depression, anxiety, hostility and type D personality. In addition, it assesses the recommendation class and level of evidence of approaching the psychosocial factors in [fig_ref] Table 9 -: Summary of the recommendations for obesity and overweight in cardiovascular disease primary... [/fig_ref] and for adherence [fig_ref] Table 2 -: Scoring according to overall risk for women HDL-C [/fig_ref] by using cognitive-behavioral methods and indicating the 'ten strategic steps' to improve counseling for behavioral changes. Interventions on depression, anxiety and distress are also proposed as potential tools for adherence to preventive strategies (Chart 3), which can also be improved with the simple measures.
Chapter 11 approaches dyslipidemia, obesity and SAH in childhood and adolescence. Brazilian population studies have shown a 10%-35% prevalence of dyslipidemia in children and adolescents. [fig_ref] Table 2 -: Scoring according to overall risk for women HDL-C [/fig_ref] shows the reference values for lipids and lipoproteins in those age groups. recommendation for primary SAH in children and adolescents. Pharmacological treatment is indicated for individuals with symptomatic hypertension, secondary hypertension, SAH target-organ lesion, types 1 and 2 diabetes mellitus, and persistent SAH despite the adoption of nonpharmacological measures, a situation in which such measures are an adjunct to the pharmacological treatment.
The diagnosis of obesity or overweight in children is clinical, and should be established via history and physical exam, followed by comparison of anthropometric data with population parameters, by using curves of body mass index (BMI) for age. Prevention comprises adequate nutrition during pregnancy, breastfeeding encouragement, identification of familial risk factors, careful child's growth and development follow-up, habit

## Special article

## Simao et al. cardiovascular prevention guideline
Arq Bras Cardiol. 2014; 102(5):420-431 changes, especially the adoption of a healthy diet and global increase in physical activity. It is important to involve the child's entire family, parents, teachers and health care professionals, in addition to count on a multidisciplinary team.
The systematic analysis of studies on the effectiveness of interventions to promote physical activity in the pediatric age group (more particularly adolescents) has shown better results when the actions associate school, family and community, and when the educational actions involve environmental and health policies. [fig_ref] Table 2 -: Scoring according to overall risk for women HDL-C [/fig_ref] shows the recommendations and their levels of evidence to prevent CVD in children and adolescents.
Chapter 12 discusses topics related to legislation and prevention of CVD risk factors. The authors approach specific sanitary laws, discussing their effective role in health promotion and prevention, by creating healthy environments, in addition to emphasizing the importance of surveillance, prevention, health care, rehabilitation and health promotion
Chapter 13 discusses specific aspects of prevention of CVD associated with autoimmune diseases, influenza, chronic kidney disease, obstructive arterial disease, socioeconomic factors, obstructive sleep apnea, erectile dysfunction and periodontitis [fig_ref] Table 2 -: Scoring according to overall risk for women HDL-C [/fig_ref].
We provide the medical class with a guideline that gathers, in one single publication, compiled and updated essential prevention topics to be used as a reference in CVD prevention.

# Author contributions

## Potential conflict of interest
The author Harry Correa Filho declares have conflict with the companies: Pfizer, Astra Zeneca.

# Sources of funding
There were no external funding sources for this study.

## Study association
This study is not associated with any thesis or dissertation work.

## Dietary fat
Fat ingestion by infants should not be restricted without medical indication I C From the 12th to the 24th month, transition to family meals with fat corresponding to 30% of the total caloric ingestion, 8%-10% of which of saturated fat I B
From 2 to 21 years of age, fat should correspond to 25%-30% of the total caloric ingestion, 8%-10% of which of saturated fat I A Avoid trans fat I B
Cholesterol < 300 mg/dL I A

## Others
From 2 to 21 years of age, encourage fiber ingestion, limit sodium ingestion and encourage healthy life habits: family meals, breakfast, limit fast snacks I B

## Physical activity
Parents should create an environment that promotes physical activity and limit sedentary activities, and be role models I C
[table] Table 2 -: Scoring according to overall risk for women HDL-C: high-density lipoprotein cholesterol; TC: total cholesterol; SBP: systolic blood pressure [/table]
[table] Table 3 -: Overall cardiovascular risk in 10 years for women [/table]
[table] Table 4 -: Scoring according to overall risk for men [/table]
[table] Table 5 -: Overall cardiovascular risk in 10 years for men [/table]
[table] Table 6 -: Classification of recommendation and level of evidence for risk stratification in cardiovascular prevention [/table]
[table] Table 7 -: Classification of recommendation and level of evidence for the treatment of smoking in cardiovascular prevention [/table]
[table] Table 8 -: Summary of the recommendations for not using vitamin supplements to prevent cardiovascular disease (CVD) and recommendations for the consumption of products rich in omega-3 fatty acidsThere is no evidence that supplementation of vitamin A or beta-carotene is beneficial to the primary or secondary prevention of CVD III A Supplementations of vitamin B and folic acid are not effective to the primary or secondary prevention of CVD III A  There is no evidence that supplementation of vitamin C is beneficial to CVD prevention, progression or mortality II A  Supplementation of vitamin D is not recommended to CVD prevention in individuals with normal serum levels of that vitamin. Likewise, there is no evidence that supplementation in individuals with deficiency of that vitamin will prevent CVD. III C  Marine omega-3 supplementation (2-4g/day) or even at higher doses should be recommended for severe hypertriglyceridemia (>500mg/dL), at risk for pancreatitis, refractory to nonpharmacological measures and drug treatment I A  At least two fish-based meals per week, as part of a healthy diet, are recommended to reduce the cardiovascular risk. That is particularly recommended for high-risk individuals, such as those with previous myocardial infarction. I B  Supplementation of eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA) is not recommendedfor individuals at risk for cardiovascular disease undergoing evidence-based preventive treatment. III A The consumption of polyunsaturated omega-3 fatty acids of vegetable origin, as part of a healthy diet, should be recommended to reduce the cardiovascular risk, although the real benefit of that recommendation is arguable and the evidence is inconclusive. IIb B Alpha-linolenic acid (ALA) supplementation is not recommended for cardiovascular disease prevention. III B [/table]
[table] Table 9 -: Summary of the recommendations for obesity and overweight in cardiovascular disease primary prevention [/table]
[table] Table 10 -: Summary of the recommendations for obesity and overweight in cardiovascular disease secondary prevention [/table]
[table] Table 11 -: Routine initial assessment of the hypertensive patient [/table]
[table] Table 12 -: Complementary assessment of hypertensive patients [/table]
[table] Table 22: shows the classification of SAH for children and adolescents. Changes in lifestyle are the initial therapeutic [/table]
[table] Table 13 -: Nonpharmacological treatment of hypertensive patients CombinationsTwo antihypertensive drugs of different classes and at low dosesInadequate response or intolerable adverse events [/table]
[table] Table 14 -: Recommendations for the nonpharmacological treatment of dyslipidemia in cardiovascular prevention [/table]
[table] Table 15 -: Recommendations for the pharmacological treatment of dyslipidemia [/table]
[table] Table 16 -: Dietary and physical activity interventions in diabetes mellitus (DM) to prevent cardiovascular disease [/table]
[table] Table 18 -: Recommended exercise levels for health promotion and maintenance [/table]
[table] Table 19 -: Classification of recommendation and level of evidence in approaching psychosocial factors in primary prevention [/table]
[table] Table 20 -: Classification of recommendation and level of evidence of adherence to strategy in cardiovascular prevention, lifestyle and medication [/table]
[table] Table 21 -: Reference values for lipids and lipoproteins in children and adolescents [/table]
[table] Table 23 -: Classification of recommendation and level of evidence for the presence of cardiovascular diseases (CVD) in children and adolescents Obesity screening by use of BMI in children  6 years, providing or indicating intensive behavioral interventions directed to achieving a healthy weight  Ask about early CAD family history to identify children at risk  In the presence of positive family history, assess all family members, especially the parents I B  In children aged > 2 years with BMI  85 th percentile: Reinforce preventive instructions (see below) Identify complications and RF: SBP, gallbladder disease symptoms, diabetes, sleep apnea, hypothyroidism, orthopedic disorders, lipid profile I C  In children aged > 2 years with BMI  85 th -94 th percentile,all measures above plus: control of weight gain and fat ingestion, focusing on nutrition and development treatment of RF and complications multidisciplinary approach of moderate to high intensity measure aspartate aminotransferase (AST), alanine aminotransferase (ALT) and blood sugar in children  10 years of age From the 12th to the 24th month, transition to non-aromatic low-fat milk (2% or skim) I B From 2 to 21 years of age, non-aromatic skim milk should be the major beverage I A Avoid sugar beverages, encourage water ingestion I B [/table]
[table] Table 24 -: Recommendation for approaching special conditions in cardiovascular disease prevention In the context of preventing cardiovascular events, the benefit of using more strict therapeutic targets, especially due to the presence of autoimmune diseases, is uncertain.IIb C  Annual influenza vaccination for patients with established coronary artery or cerebrovascular disease, regardless of age I B  Annual influenza vaccination for patients at high risk for coronary events, but with no cardiovascular disease, regardless of age. IIa C  Patients with chronic kidney disease should be considered at very high risk for cardiovascular risk factors, requiring the assessment of glomerular filtration rate reduction and presence of co-morbidities. I C  Patients with obstructive arterial disease should be considered at very high risk, similarly to that of manifest coronary artery disease, for approaching cardiovascular risk factors. I C  Socioeconomic indicators should be investigated in clinical assessment and considered when approaching a patient, to improve quality of life and the prognosis of cardiovascular diseases. IIa B  All patients with obstructive sleep apnea should be considered as potential candidates to primary prevention, undergo cardiovascular risk stratification and be treated according to estimated risk. IIa A  All men with erectile dysfunction should be considered as potential candidates to primary prevention, undergo cardiovascular risk stratification and be treated according to estimated risk. IIa B  Patients with periodontitis should be considered for cardiovascular risk stratification and intensive local treatment. IIa B [/table]