Updated cardiovascular prevention guideline of the Brazilian Society of Cardiology: 2019

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NT-proBNP as a predictor of death and cardiovascular events in patients with type 2 diabetes

Existing risk prediction scores based on clinical and laboratory variables have been considered inaccurate in patients with Type 2 Diabetes Mellitus (T2DM). Circulating concentrations of natriuretic peptides have been used to aid in the diagnosis and to predict outcomes in heart failure. However, there is a growing body of evidence for the use of natriuretic peptides measurements, mainly N-terminal pro-B-type natriuretic peptide (NT-proBNP), as a tool in risk stratification for individuals with T2DM. Studies have demonstrated the ability of NT-proBNP to improve outcomes prediction when incorporated into multivariate models. More recently, evidence has emerged of the discriminatory power of NT-proBNP, demonstrating, as a single variable, a similar and even superior ability to multivariate risk models for the prediction of death and cardiovascular events in individuals with T2DM. Natriuretic peptides are synthesized and released from the myocardium as a counter-regulatory response to increased cardiac wall stress, sympathetic tone, and vasoconstriction, acting on various systems and affecting different biological processes. In this article, we present a review of the accumulated knowledge about these biomarkers, underscoring the strength of the evidence of their predictive ability for fatal and non-fatal outcomes. It is likely that, by influencing the functioning of many organs, these biomarkers integrate information from different systems. Although not yet recommended by guidelines, measurement of natriuretic peptides, and particularly NT-proBNP, should be strongly considered in the risk stratification of individuals with T2DM

Brazilian guidelines on prevention of cardiovascular disease in patients with diabetes: a position statement from the Brazilian Diabetes Society (SBD), the Brazilian Cardiology Society (SBC) and the Brazilian Endocrinology and Metabolism Society (SBEM)

Abstract Background Since the first position statement on diabetes and cardiovascular prevention published in 2014 by the Brazilian Diabetes Society, the current view on primary and secondary prevention in diabetes has evolved as a result of new approaches on cardiovascular risk stratification, new cholesterol lowering drugs, and new anti-hyperglycemic drugs. Importantly, a pattern of risk heterogeneity has emerged, showing that not all diabetic patients are at high or very high risk. In fact, most younger patients who have no overt cardiovascular risk factors may be more adequately classified as being at intermediate or even low cardiovascular risk. Thus, there is a need for cardiovascular risk stratification in patients with diabetes. The present panel reviews the best current evidence and proposes a practical risk-based approach on treatment for patients with diabetes. Main body The Brazilian Diabetes Society, the Brazilian Society of Cardiology, and the Brazilian Endocrinology and Metabolism Society gathered to form an expert panel including 28 cardiologists and endocrinologists to review the best available evidence and to draft up-to-date an evidence-based guideline with practical recommendations for risk stratification and prevention of cardiovascular disease in diabetes. The guideline includes 59 recommendations covering: (1) the impact of new anti-hyperglycemic drugs and new lipid lowering drugs on cardiovascular risk; (2) a guide to statin use, including new definitions of LDL-cholesterol and in non-HDL-cholesterol targets; (3) evaluation of silent myocardial ischemia and subclinical atherosclerosis in patients with diabetes; (4) hypertension treatment; and (5) the use of antiplatelet therapy. Conclusions Diabetes is a heterogeneous disease. Although cardiovascular risk is increased in most patients, those without risk factors or evidence of sub-clinical atherosclerosis are at a lower risk. Optimal management must rely on an approach that will cover both cardiovascular disease prevention in individuals in the highest risk as well as protection from overtreatment in those at lower risk. Thus, cardiovascular prevention strategies should be individualized according to cardiovascular risk while intensification of treatment should focus on those at higher risk

Task Force of the Latin American Society of Hypertension

ABI, ankle-brachial index; ABPM, ambulatory blood pressure monitoring; ACCORD, Action to Control Cardiovascular Risk in Diabetes; ACE-I, angiotensin-converting-enzyme-inhibitors; ARB, AT1 blockers; BP, blood pressure; CARMELA, Cardiovascular Risk Factor Multiple Evaluation in Latin America; CARMEN, Community Actions for Multifactorial Reduction of Non- Communicable Diseases; CCB, calcium channel blocker; CCM, Wagner’s Chronic Care Model; CDC, Chronic Disease Center; CTA, computed tomography angiography; CV, cardiovascular; DALY, disability-adjusted life year; DPP- 4, dipeptidyl-peptidase-4; GLP-1, glucagon-like peptide 1; HBPM, home blood pressure monitoring; HOPE, Heart Outcomes Prevention Evaluation; HOT, Hypertension Optimal Treatment; HT, hypertension; LA, Latin America; LASH, Latin American Society of Hypertension; MRA, magnetic resonance angiography; NCD, noncommunicable disease; OSAS, obstructive apnea–hypopnea syndrome; PAD, peripheral artery disease; PAHO, Pan American Health Organization; RAAS, renin–angiotensin–aldosterone system; RISS, Redes Integradas de Servicios de Salud; SGLUT2, sodium–glucose cotransporter-2; SPRINT, SBP Intervention Trial; UKPDS, United Kingdom Prospective Diabetes Study; VIDA, Veracruz Initiative for Diabetes Awarenes

Update on the Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Guideline of the Brazilian Society of Cardiology-2019

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