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

BackgroundSince 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 bodyThe 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.ConclusionsDiabetes 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.

Portuguese-Brazilian evidence-based guideline on the management of hyperglycemia in type 2 diabetes mellitus

“…The level of evidence was determined using the same criteria in Table 1B. Specific criteria for atherosclerotic cardiovascular disease (ASCVD) are shown in Table 2 [1]. The panel chose to classify therapeutic options into two groups of glucoselowering agents: antidiabetics with proven CV or renal benefit (AD1) and general glucose-lowering agents (AD).…”

“…The guideline-building process was conducted as described elsewhere [1]. In brief, a preliminary manuscript outlining grades of recommendation and levels of evidence was drafted.…”

High Intensity Hypolipidemic Therapy and Decreased Level of Low Density Lipoproteides Cholesterol: Is the Approach Justified? Point of View

“…В 2017г Коллегия эндокринологов и Ассоциация клинических эндокринологов США предложили вве-сти более жесткий целевой уровень ХС ЛНП <1,5 ммоль/л (55 мг/дл) для пациентов с крайне высо-ким ССР -прогрессирующим атеросклеротическим ССЗ, НС, при его сочетании с СД 2 типа, ХБП 3-4 стадии, и/или гетерозиготной семейной ГХС, или с отягощенным семейным анамнезом [19]. В июле 2017г три бразильских сообщества (кардиологов, диа-бетологов, эндокринологов) предложили ввести для больных СД в сочетании с очень высоким ССР целе-вой уровень ХС ЛНП <1,3 ммоль (50 мг/дл) [20].…”

Custo-efetividade da empagliflozina em pacientes com diabetes mellitus do tipo 2 com alto risco cardiovascular na perspectiva da saúde suplementar

“…O estudo mostrou ainda redução de eventos associados a doença renal e ICC. A partir desses resultados, os benefícios da empagliflozina foram reconhecidos, e as sociedades brasileiras de diabetes, cardiologia e endocrinologia e metabolismo já recomendam o seu uso em pacientes com DM2 na presença de doença aterosclerótica e com eventos cardiovasculares prévios (risco muito alto) (Bertoluci et al, 2017). Além desses benefícios, em um estudo anterior de nosso grupo, mostrou--se que a empagliflozina tinha uma relação de custo-efetividade favorável no contexto do SUS (Santoni et al, 2018).…”