FUNDAMENTO: Dados de atendimento ambulatorial ao paciente de alto risco cardiovascular no Brasil são insuficientes. OBJETIVO: Descrever o perfil e documentar a prática clínica do atendimento ambulatorial de pacientes de alto risco cardiovascular no Brasil, no que diz respeito à prescrição de terapias baseadas em evidências. MÉTODOS: Registro prospectivo que documentou a prática clínica ambulatorial de indivíduos de alto risco cardiovascular, que foi definido como a presença de um dos seguintes fatores: doença arterial coronariana, cerebrovascular e vascular periférica; diabetes; ou aqueles com pelo menos três dos seguintes fatores: hipertensão arterial, tabagismo, dislipidemia, maiores 70 anos, histórico familiar de doença arterial coronariana, nefropatia crônica ou doença carotídea assintomática. Foram avaliadas características basais e a taxa de prescrição das intervenções medicamentosas e não medicamentosas. RESULTADOS: Foram incluídos 2.364 pacientes consecutivos, sendo 52,2% do gênero masculino, idade média de 66,0 anos (± 10,1). Dentre os pacientes incluídos, 78,3% utilizavam antiplaquetários, 77,0% estatinas e, dos pacientes com história de infarto do miocárdio, 58,0% receberam betabloqueadores. O uso concomitante destas três classes foi de 34%. Não atingiram as metas preconizadas pelas diretrizes 50,9% dos hipertensos, 67% dos diabéticos e 25,7% dos dislipidêmicos. Os principais preditores de prescrição de terapias com benefício comprovado foram centro com cardiologista e histórico de doença arterial coronariana. CONCLUSÃO: Este registro nacional e representativo identificou hiatos importantes na incorporação de terapias com benefício comprovado, oferecendo um panorama real dos pacientes de alto risco cardiovascular.
IHospital do Coração, São Paulo, SP
IISociedade Brasileira de Cardiologia, Rio de Janeiro, RJ
IIIInstituto Dante Pazzanese de Cardiologia, São Paulo, SP
IVUnidades de Hemodinâmica e Intervenção Cardiovascular Rede D'Or / São Luiz - Recife, São Paulo e Santo André
VHospital de Base, São José do Rio Preto, SP
VICentro de Pesquisa Clínica das Disciplinas de Clínica Médica e Cardiologia da UNIFESP, São Paulo, SP
VIIHospital Lifecenter, Belo Horizonte, MG
VIIISociedade Hospitalar Angelina Caron, Campina Grande do Sul, PR
IXAmbulatório Médico de Especialidades Maria Zélia, São Paulo, SP
XHospital da Bahia, Salvador, BA - Brasil
A projeção do estudo
Diversos ensaios clínicos randomizados de grande porte e revisões sistemáticas demonstraram que, em pacientes de alto risco cardiovascular, o benefício de fármacos, como as estatinas, estende-se mesmo a pacientes com níveis de colesterol normais5; os antiplaquetários são capazes de reduzir eventos cardiovasculares maiores, mesmo em indivíduos sem manifestações clínicas de aterosclerose6, e diversos anti-hipertensivos, particularmente os inibidores da enzima conversora de angiotensina (IECA), apresentam potencial para redução de eventos cardiovasculares, mesmo em pacientes sem critérios diagnósticos de hipertensão arterial sistêmica7. Adicionalmente, intervenções não farmacológicas, como dietas cardioprotetoras, cessação do tabagismo e atividade física regular, apesar dos dados serem menos robustos do que de estudos com terapia farmacológicas, também estão associadas à redução de desfechos clinicamente relevantes8-22.
Dada a importância da utilização de terapias baseadas em evidência para redução de risco cardiovascular, é fundamental avaliar a prática clínica diária. Registros internacionais vêm demonstrando importantes hiatos na incorporação de recomendações de diretrizes no mundo real . Até o momento, nenhum registro totalmente brasileiro documentou a prática clínica em relação ao atendimento de indivíduos de alto risco cardiovascular em uma amostra representativa e ampla, o qual contemplasse tanto centros públicos quanto privados de todas as regiões do Brasil. Assim, o objetivo deste estudo foi documentar a prática clínica vigente por meio dos padrões de prescrição das intervenções baseadas em evidência em pacientes de alto risco cardiovascular no Brasil.
A metodologia completa do REACT já foi previamente publicada23. De forma sucinta, trata-se de um estudo observacional transversal do tipo registro, prospectivo, com seguimento longitudinal de pacientes e avaliação cega dos desfechos. Esse projeto foi planejado e coordenado pela Sociedade Brasileira de Cardiologia (SBC), contando com a participação de centros públicos e privados de todas as regiões brasileiras e respeitando a distribuição populacional de acordo com os dados do Instituto Brasileiro de Geografia e Estatística (IBGE). Foram convidados a participar centros públicos e privados, universitários e não universitários, tanto de capitais quanto de cidades do interior, desde que preenchessem os requisitos mínimos de Boas Práticas de Pesquisa Clínica.
Foram incluídos indivíduos consecutivos de ambos os gêneros, maiores de 45 anos, portadores de pelo menos um dos critérios para enquadramento no alto risco cardiovascular: doença arterial coronariana (DAC), doença cerebrovascular, doença vascular periférica e diabetes melito. Além disso, também foram incluídos pacientes com pelo menos três fatores de risco para aterosclerose: hipertensão arterial, tabagismo, dislipidemia, idade acima de 70 anos, histórico familiar de DAC, nefropatia crônica ou doença carotídea assintomática. Todos os pacientes incluídos estavam em seguimento ambulatorial.
Foram excluídos os pacientes com condições psiquiátricas ou neurocognitivas que impedissem a obtenção de dados clínicos fidedignos (definida pelo julgamento clínicos dos investigadores), assim como pacientes com neoplasias de evolução clínica desfavorável.
O desfecho primário referente à presente análise foi a proporção de pacientes em uso de terapias baseadas em evidência (definidas como uso concomitante de antiplaquetários, estatinas e IECA) durante visita de
Demais desfechos incluíram: proporção de pacientes que recebeu orientações quanto a medidas de modificação de estilo de vida (cessação do tabagismo, prática de atividade física e orientações nutricionais) e proporção de pacientes que recebeu cada uma das seguintes medicações individualmente, durante visita de
Adicionalmente, foi calculada a taxa de pacientes hipertensos e dislipidêmicos com níveis controlados dentro das metas terapêuticas preconizadas, conforme as recomendações da SBC.
Os centros foram treinados, no que diz respeito aos procedimentos do estudo e sistema eletrônico, de maneira presencial ou por telefone, pela equipe de coordenação. O controle de qualidade dos dados foi realizado por diversas estratégias, como utilização de sistema de captura eletrônica de dados, checagem estatística central das variáveis coletadas, envios periódicos de relatórios contendo
Por fim, foram realizadas reuniões semestrais presenciais, com o objetivo de atualizar o
A fim de detectar uma proporção de 40% para a ocorrência do desfecho primário, considerando-se erro amostral de 2%, um alfa bicaudal de 5% e um poder estatístico de 90%, foi necessária, então, a inclusão de, pelo menos, 2.305 pacientes.
As variáveis quantitativas foram descritas por média e desvio-padrão, e variáveis qualitativas foram apresentadas por frequências absolutas e relativas. Os desfechos primários e secundários foram descritos por estimativas ponderadas pelo número de pacientes de cada centro, que variou de 3 a 213. A avaliação da associação entre uso concomitante de antiplaquetários, IECA e estatina e fatores como gênero, idade, região, especialidade e tipo de centro foi feita por meio de um modelo de regressão logística múltipla. Os resultados do ajuste do modelo foram apresentados por razões de chances (OR) e respectivos intervalos de confiança (IC) de nível 95%. Todas as análises foram feitas com o auxílio dos programas estatísticos
O protocolo foi aprovado pelo Comitê de Ética em Pesquisa (CEP) do Hospital do Coração de São Paulo, na cidade de São Paulo (SP), em 22 de junho de 2010, sob o número de registro 118/2010 e, na sequência, cada centro participante também teve sua aprovação em seu CEP local. Todos os pacientes assinaram Termo de Consentimento Livre e Esclarecido, e o estudo clínico foi conduzido de acordo com os princípios da revisão atual da Declaração de Helsinque e das Diretrizes de Boas Práticas Clínicas, em sua versão mais recente, bem como da Resolução 196/96.
Um total de 2.403 pacientes foi incluído em 45 centros no período de julho de 2010 a dezembro de 2011, sendo que, nesta análise, foram contemplados apenas os pacientes com dados completos de
O perfil de atendimento assistencial desses pacientes foi predominantemente de estabelecimentos mistos (40,5%), seguido de Saúde Suplementar (31%) e, por fim, 28,6% foram provenientes do Sistema Único de Saúde (SUS), conforme
A
A
Dos 2.364 pacientes analisados, 78,3% receberam antiplaquetários, 77,0% estatinas e 53,0% IECA. Dentre os 681 pacientes com história de infarto, 79,4 % receberam betabloqueadores (
O uso conjunto de antiplaquetários, estatinas e IECA foi observado em 34% dos pacientes, havendo maior frequência de uso (40,1%) nos 1.249 pacientes portadores de DAC em relação a outras categorias de alto risco cardiovascular (
Em relação ao cumprimento de metas determinadas por diretrizes da SBC, observou-se que, em 51,2% dos 1.328 pacientes diabéticos, a glicemia estava acima dos valores recomendados. Já em relação ao controle da hipertensão arterial sistêmica, 50,9% dos 2.180 pacientes hipertensos estavam com a pressão arterial em níveis superiores a uma pressão arterial usual de 140/90 mmHg. Finalmente, em relação a metas lipídicas recomendadas para o paciente de alto risco cardiovascular, em torno de 20% a 30% da amostra apresentava níveis de LDL
Efetivou-se regressão logística multivariada para avaliação de fatores independentes associados à maior probabilidade de prescrição de terapias baseadas em evidências (definida para esta análise como uso conjunto de aspirina, estatinas e IECA). Nesse sentido, dentre os fatores preditores independentes, destacam-se o atendimento realizado por cardiologista (OR = 1,42; IC95% = 1,10 - 1,82) e o diagnóstico de DAC (OR = 1,91; IC95% = 1,59 - 2,30) (
O estudo REACT representa o maior e mais recente registro nacional, coordenado por uma sociedade médica e envolvendo pacientes de alto risco cardiovascular atendidos em ambiente ambulatorial de todas as regiões do país. O principal achado desse estudo referiu-se ao fato de que o controle de fatores de risco (de acordo com metas de diretrizes para LDL, pressão arterial e glicemia) é abaixo do esperado e de que existem oportunidades para melhoria de prática clínica, com destaque para melhoria em relação à prescrição de intervenções baseadas em evidência, principalmente no uso conjunto de antiplaquetários estatinas e IECA. Dentre os fatores associados de forma independente à prescrição de terapias baseadas em evidência, destacam-se o atendimento por cardiologistas e o diagnóstico de DAC.
Os achados da presente análise demonstraram que pacientes de alto risco cardiovascular atendidos em centros de excelência brasileiros possuem padrão demográfico e recebem condutas semelhantes àquelas observadas em registros recentes realizados na América do Norte e na Europa Ocidental. Nesse sentido, os fatores de risco mais prevalentes na população brasileira foram hipertensão arterial e dislipidemia, o que condiz com a literatura. O estudo multicêntrico REACH, por exemplo, reportou prevalência da hipertensão arterial sistêmica e dislipidemia de 81,3% e 70,4%, respectivamente, semelhante ao encontrado neste registro, bem como em publicações semelhantes24.
O adequado controle do diabetes melito no estudo REACT foi insatisfatório, uma vez que somente 23% dos diabéticos mantiveram níveis de hemoglobina glicada < 7%, apesar desses pacientes possuírem maior risco cardiovascular do que os não diabéticos25. A IV Diretriz Brasileira Sobre Dislipidemias e Prevenção da Aterosclerose da Sociedade Brasileira de Cardiologia26 recomendou, nos indivíduos de alto risco, o início simultâneo das medidas não farmacológicas e tratamento com hipolipemiantes. O estudo REACT demonstrou que 88% dos pacientes foram orientados quanto à dieta cardioprotetora e 77% estavam em uso de hipolipemiante, no entanto, a minoria dos pacientes dislipidêmicos em prevenção secundária, diabéticos, portadores de DAC, DCV ou DAP atingiu níveis < 100 mg/dL de LDL colesterol. O estudo L-TAP 2, que avaliou cerca de 10 mil pacientes em nove países com dislipidemia em uso de estatina, entre 2006 e 2007, constatou que 73% tinham atingido seus objetivos de colesterol LDL, tal como definido pelas diretrizes nacionais, com maior controle pelos pacientes de baixo risco (86%) do que por aqueles de alto risco (67%)26.
Recentes pesquisas internacionais e nacionais evidenciaram um hiato entre as diretrizes e a práticas clínica, particularmente para esses pacientes com maior risco para o desenvolvimento de eventos cardiovasculares. Dados do estudo PREMISE27, realizado pela Organização Mundial da Saúde (OMS) em 2005 e que incluiu 10 mil pacientes em países em desenvolvimento (sendo mil pacientes no Brasil), demonstraram que apenas cerca de 30% dos pacientes de alto risco cardiovascular com indicação estavam tomando estatinas e IECA e que apenas 80% recebiam antiplaquetários. Esses dados são consistentes aos achados do REACT, visto que antiplaquetários, estatinas e IECA tiveram taxas de prescrição de 78,3%, 72,6% e 53,0%, respectivamente. O estudo REACT agrega informações adicionais aos achados do PREMISE27, visto que esse último, no Brasil, foi conduzido unicamente na região Sul. Outros estudos observacionais também demonstraram achados consistentes com o estudo REACT no que se refere à prescrição a terapias baseadas em evidência no mundo real. Assim, no estudo REACH24, de 31.195 pacientes analisados, 72,6% usavam estatina, 43,3% estavam em uso de IECA e 69% de antiplaquetários. Por ter incluído um maior número de centros brasileiros, contemplados centros não universitários e centros de cidades do interior, o estudo REACT agregou informações adicionais importantes em relação aos achados do REACH. Em comunidades de países em desenvolvimento, os hiatos são ainda mais significativos. O estudo PURE, que incluiu 153.662 pacientes, em 18 países (desenvolvidos e subdesenvolvidos), com idades entre 35 e 75 anos, residentes em área urbana e rural, entre janeiro de 2003 e dezembro de 2009, encontrou números ainda mais preocupantes. Na população com DAC, apenas 25,8% usavam antiplaquetários e 16,7% estatina. Quando se avaliaram somente os países desenvolvidos, essas taxas subiram para 64,1% e 70,9%, respectivamente28.
Dentre os fatores associados de forma independente com prescrição de terapias baseadas em evidência, destacam-se o atendimento por cardiologistas e o diagnóstico de DAC. Os achados do presente estudo são consistentes com recente estudo transversal, conduzido em dez países europeus e que analisou indicadores de qualidade em 8.928 pacientes, demonstrando que o controle dos fatores de risco foi melhor no grupo com doença coronariana conhecida quando comparado àqueles com alto risco e sem doença cardiovascular, tanto para as taxas de pressão arterial não controlada (34,2
As principais forças do estudo REACT devem-se ao fato de que ele representa o maior e mais recente registro nacional para documentar o atendimento de pacientes de alto risco cardiovascular, seu caráter suprainstitucional (uma vez que foi conduzido pela SBC), a participação de centros de todas as regiões brasileiras, incluindo hospitais públicos (universitários e não universitários), privados e mistos, tanto de capitais e de grandes centros urbanos, quanto de cidades do interior. Esse último aspecto representa um diferencial do REACT em relação a registros internacionais com participação de centros brasileiros, os quais são, geralmente, conduzidos apenas em grandes centros universitários, com tradição acadêmica. Adicionalmente, utilizou-se metodologia robusta, no que tange ao delineamento de estudos observacionais do tipo registro, a saber: minimização do viés de seleção pela inclusão de amostra consecutiva de pacientes, controle adequado do erro aleatório por meio de tamanho amostral satisfatório e por métodos estatísticos robustos, minimização do viés de aferição por adjudicação central dos desfechos e, finalmente, o emprego de várias estratégias validadas para o controle de qualidade dos dados e prevenção de fraudes (sistema de captura eletrônica de dados, checagem estatística central de consistência, bem como monitorias dos centros locais e à distância).
Por outro lado, existem limitações que merecem destaque. Vale ressaltar que, a despeito de terem sido incluídas unidades de atenção básica e centros de outras especialidades, a maior parte dos centros incluídos era de cardiologia. Assim, potencialmente, a inclusão de um maior número de pacientes de Unidades Básicas de Saúde e de comunidades com menos acesso a serviços especializados poderiam revelar ainda maiores hiatos na incorporação de terapias baseadas em evidência e no controle satisfatório de fatores de risco, de acordo com metas de diretrizes. Entretanto, do ponto vista qualitativo (ou seja, presença de hiatos na incorporação de evidências), os resultados permaneceriam semelhantes, mesmo com a inclusão desses centros. Adicionalmente, apesar de termos procurado respeitar a distribuição geográfica populacional do último senso do IBGE, o número de centros das regiões Norte, Nordeste e Centro-Oeste foi menor do que a representatividade de centros das regiões Sul e Sudeste. Finalmente, na presente análise foram apresentados apenas dados de
As metas de controle dos fatores de risco cardiovascular, prescrições de medicamentos e recomendações de mudança de estilo de vida, para pacientes de alto risco cardiovascular no Brasil, estiveram fora do recomendado pelas diretrizes brasileiras. Dado o exposto e com base nos resultados do REACT, há a necessidade de desenvolver Programas de Melhoria de Prática Clínica sob a coordenação da SBC, incluindo pesquisa (estudos randomizados em
Apesar da análise não ter incluído apenas os pacientes elegíveis para a intervenção farmacológica, se considerarmos que a taxa de contraindicação à terapia antiplaquetária, estatinas e IECA está abaixo de 5%, uma taxa ótima de prescrição estaria em torno de 95%. Dessa forma, os resultados do REACT mostraram que a prescrição das medicações cardiovascular encontra-se abaixo do esperado.
Finalmente, existe a necessidade de conduzir estudos semelhantes em pacientes na comunidade com menos acesso a serviços especializados, onde são esperados maiores hiatos na incorporação de terapias com benefício comprovado.
Os autores expressam seus sinceros agradecimentos aos seguintes colaboradores: Rodolfo Vieira (SBC), William Duraes (SBC), Eliana Vieira Santucci (SBC), Eliana Vieira Santucci (IEP/HCor) e Luis Paulo Duprat (IEP/HCor)
A SBC expressa seu agradecimento ao apoio irrestrito recebido da EMS®.
Hospital de Base (São José do Rio Preto, SP): José Fernando Vilela Martin (213); Centro de Pesquisa Clínica das Disciplinas de Clínica Médica e Cardiologia da UNIFESP (São Paulo,SP): Renato Delascio Lopes (174); Hospital Lifecenter (Belo Horizonte, MG): Estevão Lanna Figueiredo (166); Instituto Dante Pazzanese de Cardiologia - Ambulatório de Nutrição Clínica (São Paulo, SP): Daniel Magnoni (165); Sociedade Hospitalar Angelina Caron (Campina Grande do Sul, PR): Dalton Bertolim Precoma (131); Ambulatório Médico de Especialidades Maria Zélia (São Paulo,SP): Carlos Alberto Machado (127); Instituto Nacional de Cardiologia (Rio de Janeiro,RJ): Antônio Luiz Brasileiro (114); Hospital de Clínicas de Porto Alegre - Centro de Hipertensão Arterial Sistêmica (Porto Alegre,RS): Leila Beltrami Moreira (107); Hospital Vera Cruz (Belo Horizonte,MG): Fernando Carvalho Neuesnchwander (96); Hospital Escola Álvaro Alvim (Campos dos Goytacazes,RJ): Felipe Montes Pena (93); Hospital de Clínicas de Porto Alegre - Centro de Diabetes (Porto Alegre,RS): Beatriz D'Agord Schaan (89); Hospital de Clínicas de Porto Alegre - Centro de Unidade Básica de Saúde (Porto Alegre,RS): Erno Harzheim (89); Hospitais da Rede D'Or (Rio de Janeiro,RJ): João Luiz Fernando Petriz (60); Hospital de Terapia Intensiva (Teresina,PI): Paulo Márcio Sousa Nunes (59); Real Hospital Português (Recife,PE): Sérgio Montenegro (57); Instituto Dante Pazzanese de Cardiologia (São Paulo,SP): Áurea Chaves (50); Grupo Hospitalar Conceição (Porto Alegre,RS): Elizabete Rosa (47); Instituto de Cardiologia - Fundação Universitária de Cardiologia (Porto Alegre, RS): José Luis da Costa Vieira (43); Hospital de Clínicas Gaspar Vianna (Belém,PA): Claudia Hanna Diniz (43); Hospital São Lucas da PUCRS (Porto Alegre,RS): Luiz Carlos Bodanese (42); Hospital das Clínicas FMUSP (São Paulo,SP): Décio Mion (41); Santa Casa de Porto Alegre (Porto Alegre,RS): Paulo Ernesto Leães (35); Hospital da Cidade (Salvador,BA): Marcelo Silveira Teixeira (34); Instituto Rodolfo Neirotti de Gerenciamento e Pesquisa Ltda - Hospital do Coração (Aracaju,SE): Thiago do Nascimento (31); Hospital Universitário do Maranhão - HUUFMA (São Luiz,MA): José Albuquerque Neto (28); Hospital Pro Cardíaco (Rio de Janeiro,RJ): Luiz Antonio de Almeida Campos (21); Hospital do Coração do Brasil (Brasília,DF): Alberto Gomes Taques Fonseca (21); Hospital Universitário Francisca Mendes (Manaus,AM): Mariano Terrazas (20); Hospital das Clínicas de Botucatu (Botucatu,SP); Ana Lúcia Cogni (19); Hospital Nossa Senhora Auxiliadora (Caratinga,MG): Valéria Nunes (19); Instituto de Cardiologia do Distrito Federal (Brasília,DF): Juliana Ascensão de Souza (19); Instituto do Coração de São Paulo (São Paulo,SP): Luiz Antônio Machado César (18); Ambulatório Médio de Especialidades de São José dos Campos (São José dos Campos,SP): Gustavo André Costa de Sá (17); Hospital do Coração - Clínica Médica (São Paulo,SP): Abrão Cury Junior (16); Hospital do Coração (São Paulo,SP): Otavio Berwanger (16); Secretaria de Saúde de Pomerode (Pomerode,SC): Edson Tafner (15); São Bernardo Apart Hospital (Colatina,ES): João Miguel Malta Dantas (14); Hospital Moinhos de Vento (Porto Alegre,RS); Eduardo Costa Barbosa (11); Hospital do Coração do Cariri (Barbalha,CE): Francisco Carleial Feijó de Sá (11); Centro Cardiológico da Paraíba - Centrocor (João Pessoa;PB): Lenine Ângelo Silva (10); Hospital São Vicente de Paulo (Guarapuava,PR): Stefan Wolanski Negrão (8); Hospital Santa Isabel (Blumenau,SC): Sérgio Luiz Zimmermann (5); Hospital e Pronto Socorro João Paulo II (Porto Velho;RO): Sérgio Paulo Mello (5); Hospital Costantini (Curitiba,PR): Constantino R. Costantini (3); Hospital do Coração de Poços de Caldas (Poços de Caldas,MG): Ricardo Reinaldo Bergo (1).
Concepção e desenho da pesquisa, Análise e interpretação dos dados, Análise estatística, Obtenção de financiamento e Revisão crítica do manuscrito quanto ao conteúdo intelectual: Berwanger O, Piva e Mattos LA, Guimarães JI, Andrade JP; Obtenção de dados: Martin JFV, Lopes RD, Figueiredo EL, Magnoni D, Precoma DB, Machado CA; Redação do manuscrito: Berwanger O, Piva e Mattos LA, Martin JFV, Lopes RD, Figueiredo EL, Magnoni D, Precoma DB, Machado CA, Guimarães JI, Andrade JP.
Declaro não haver conflito de interesses pertinentes.
O presente estudo foi financiado pela Sociedade Brasileira de Cardiologia.
Não há vinculação deste estudo a programas de pós-graduação.
1. World Health Organization (WHO). The World Health Report 2005: health systems: improving performance. Geneva: WHO; 2005.
2. Ministério da Saúde. Datasus: indicadores de saúde. [Acesso em 2010 mar 9]. Disponível em:
3. Lloyd Jones D, Adams R, Carnethon M, de Simone G, Ferguson B, Flegal K, et al; American Heart Association Statistical Update. Heart Disease and Stroke Statistics_2009 Update: a report from the American Heart Association Statistics Committee and Stroke Statistics Subcommittee. Circulation. 2009;119(3):e21-e181.
4. Murray CJL, Lopez AD. The global burden of disease: a comprehensive assessment of mortality and disability from disease, injuries and risk factors in 1990 and projected to 2020. Cambridge: Harvard University Press; 1996.
5. Avezum A, Guimarães HP, Berwanger O, Bautista L, Franzosi MG, Commerford P, et al. Aspectos epidemiológicos: educação continuada em pós-infarto do miocárdio. Rev Soc Cardiol Estado de São Paulo. 2004;14(6):1-16.
6. Yusuf S, Hawken S, Ounpuu S, Bautista L, Franzosi MG, Commerford P, et al; INTERHEART Study Investigators. Obesity and the risk of myocardial infarction in 27,000 participants from 52 countries: a case-control study. Lancet. 2005;366(9497):1640-9.
7. Yusuf S, Sleight P, Pogue J, Bosch J, Davies R, Dagenais G. Effects of an angiotensin-converting enzyme inhibitor, ramipril, on cardiovascular events in high-risk patients. The Heart Outcomes Prevention Evaluation Study Investigators. N Engl J Med. 2000;342(3):145-53. Erratum in: N Engl J Med 2000;342(10):748. 2000;342(18):1376.
8. Grundy SM, Brewer HB Jr, Cleeman JI, Smith SC Jr, Lenfant C; American Heart Association; National Heart, Lung, and Blood Institute. Definition of metabolic syndrome: report of the National Heart, Lung, and Blood Institute/American Heart Association conference on scientific issues related to definition. Circulation. 2004;109(3):433-8.
9. Girman CJ, Rhodes T, Mercuri M, Pyörälä K, Kjekshus J, Pedersen TR, et al; 4S Group and the AFCAPS/TexCAPS Research Group. The metabolic syndrome and risk of major coronary events in the Scandinavian Simvastatin Survival Study (4S) and the Air Force/Texas Coronary Atherosclerosis Prevention Study (AFCAPS/TexCAPS). Am J Cardiol. 2004;93(2):136-41.
10. Wilson PW, D'Agostino RB, Levy D, Belanger AM, Silbershatz H, Kannel WB. Prediction of coronary heart disease using risk factor categories. Circulation. 1998;97(18):1837-47.
11. Kannel WB. Hypertension as a risk factor for cardiac events: epidemiologic results of long-term studies. J Cardiovasc Pharmacol. 1993;21(Suppl 2):S27-37.
12. Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults. Executive Summary of The Third Report of The National Cholesterol Education Program (NCEP) Expert Panel on Detection, Evaluation, And Treatment of High Blood Cholesterol In Adults (Adult Treatment Panel III). JAMA. 2001;285(19):2486-97.
13. Balady GJ, Williams MA, Ades PA, Bittner V, Comoss P, Foody JM, et al; American Heart Association Exercise, Cardiac Rehabilitation, and Prevention Committee, the Council on Clinical Cardiology; American Heart Association Council on Cardiovascular Nursing; American Heart Association Council on Epidemiology and Prevention; American Heart Association Council on Nutrition, Physical Activity, and Metabolism; American Association of Cardiovascular and Pulmonary Rehabilitation. Core components of cardiac rehabilitation/secondary prevention programs: 2007 update: a scientific statement from the American Heart Association Exercise, Cardiac Rehabilitation, and Prevention Committee, the Council on Clinical Cardiology; the Councils on Cardiovascular Nursing, Epidemiology and Prevention, and Nutrition, Physical Activity, and Metabolism; and the American Association of Cardiovascular and Pulmonary Rehabilitation. Circulation. 2007;115(20):2675-82.
14. Smith SC Jr, Allen J, Blair SN, Bonow RO, Brass LM, Fonarow GC, et al; AHA; ACC; National Heart, Lung, and Blood Institute. AHA/ACC guidelines for secondary prevention for patients with coronary and other atherosclerotic vascular disease: 2006 update endorsed by the National Heart, Lung, and Blood Institute. J Am Coll Cardiol. 2006;47(10):2130-9.
15. Cannon CP, Braunwald E, McCabe CH, Rader DJ, Rouleau JL, Belder R, et al; Pravastatin or Atorvastatin Evaluation and Infection Therapy-Thrombolysis in Myocardial Infarction 22 Investigators. Intensive versus moderate lipid lowering with statins after acute coronary syndromes. N Engl J Med. 2004;350(15):1495-504.
16. Baigent C, Keech A, Kearney PM, Blackwell L, Buck G, Pollicino C, et al; Cholesterol Treatment Trialists' (CTT) Collaborators. Efficacy and safety of cholesterol-lowering treatment: prospective meta-analysis of data from 90,056 participants in 14 randomised trials of statins. Lancet. 2005;366(9493):1267-78. Erratum in: Lancet. 2005;366(9494):1358.
17. Thompson PD, Buchner D, Pina IL, Balady GJ, Williams MA, Marcus BH, et al., American Heart Association Council on Clinical Cardiology Subcommittee on Exercise, Rehabilitation, and Prevention; American Heart Association Council on Nutrition, Physical Activity, and Metabolism Subcommittee on Physical Activity. Exercise and physical activity in the prevention and treatment of atherosclerotic cardiovascular disease: a statement from the Council on Clinical Cardiology (Subcommittee on Exercise, Rehabilitation, and Prevention) and the Council on Nutrition, Physical Activity, and Metabolism (Subcommittee on Physical Activity). Circulation. 2003;107(24):3109-16.
18. Sacks FM, Pfeffer MA, Moye LA, Rouleau JL, Rutherford JD, Cole TG, et al. The effect of pravastatin on coronary events after myocardial infarction in patients with average cholesterol levels. Cholesterol and Recurrent Events Trial investigators. N Engl J Med. 1996;335(14):1001-9.
19. Downs JR, Clearfield M, Weis S, Whitney E, Shapiro DR, Beere PA, et al. Primary prevention of acute coronary events with lovastatin in men and women with average cholesterol levels: results of AFCAPS/TexCAPS. Air Force/Texas Coronary Atherosclerosis Prevention Study. JAMA. 1998;279(20):1615-22.
20. Prevention of cardiovascular events and death with pravastatin in patients with coronary heart disease and a broad range of initial cholesterol levels. The Long-Term Intervention with Pravastatin in Ischaemic Disease (LIPID) Study Group. N Engl J Med. 1998;339(19):1349-57.
21. Iestra JA, Kromhout D, van der Schouw YT, Grobbee DE, Boshuizen HC, van Staveren WA. Effect size estimates of lifestyle and dietary changes on all-cause mortality in coronary artery disease patients: a systematic review. Circulation. 2005;112(6):924-34.
22. de Lorgeril M, Salen P, Martin JL, Monjaud I, Delaye J, Mamelle N. Mediterranean diet, traditional risk factors, and the rate of cardiovascular complications after myocardial infarction: final report of the Lyon Diet Heart Study. Circulation. 1999;99(6):779-85.
23. Mattos LA. Racionalidade e métodos: registro da prática clínica em pacientes de alto risco cardiovascular. Arq Bras Cardiol. 2011;97(1):3-7.
24. Bhatt DL, Eagle KA, Ohman EM, Hirsch AT, Goto S, Mahoney EM, et al; REACH Registry Investigators. Comparative determinants of 4-year cardiovascular event rates in stable outpatients at risk of or with atherothrombosis. JAMA. 2010;304(12):1350-7.
25. Yusuf S, Islam S, Chow CK, Rangarajan S, Dagenais G, Diaz R, et al; Prospective Urban Rural Epidemiology (PURE) Study Investigators. Use of secondary prevention drugs for cardiovascular disease in the community in high-income, middle-income, and low-income countries (the PURE Study): a prospective epidemiological survey. Lancet. 2011;378(9798):1231-43.
26. Haffner SM, Lehto S, Rönnemaa T, Pyörälä K, Laakso M. Mortality from coronary heart disease in subjects with type 2 diabetes and nondiabetetic subjects with and without prior myocardial infarction. N Engl J Med. 1998;339(4):229-34.
27. Sposito AC, Caramelli B, Fonseca FA, Bertolami MC, Afiune Neto A, Souza AD, et al; Sociedade Brasileira de Cardiologia. IV Diretriz brasileira sobre dislipidemias e prevenção da aterosclerose. Arq Bras Cardiol. 2007;88(supl 1):1-18.
28. WHO study on prevention of REcurrences of myocardial infarction. [Acesso em 2010 out 10]. Disponível em
29. Ludt S, Wensing M, Campbell SM, Ose D, van Lieshout J, Rochon J, et al. The challenge of cardiovascular prevention in primary care: implications of a European observational study in 8928 patients at different risk levels. Eur J Prev Cardiol. 2012 Sept 21. [Epub ahead of print] .
Otávio Berwanger Instituto de Ensino e Pesquisa - HCor Rua Abilio Soares, 250, 12º andar, Paraíso CEP 04005-000, São Paulo, SP - Brasil E-mail:
Artigo recebido em 11/01/13, revisado em 11/01/13; aceito em 18/02/13.
BACKGROUND: Data on outpatient care provided to patients at high cardiovascular risk in Brazil are insufficient. OBJECTIVE: To describe the profile and document the clinical practice of outpatient care in patients at high cardiovascular risk in Brazil, regarding the prescription of evidence-based therapies. METHODS: Prospective registry that documented the ambulatory clinical practice in individuals at high cardiovascular risk, which was defined as the presence of the following factors: coronary artery disease, cerebrovascular and peripheral vascular diseases, diabetes, or those with at least three of the following factors: hypertension, smoking, dyslipidemia, age > 70 years, family history of coronary artery disease, chronic kidney disease or asymptomatic carotid artery disease. Basal characteristics were assessed and the rate of prescription of pharmacological and non-pharmacological interventions was analyzed. RESULTS: A total of 2364 consecutive patients were included, of which 52.2% were males, with a mean age of 66.0 years (± 10.1). Of these, 78.3% used antiplatelet agents, 77.0% used statins and of patients with a history of myocardial infarction, 58.0% received beta-blockers. Concomitant use of these three classes of drugs was 34%; 50.9% of hypertensive, 67% of diabetic and 25.7% of dyslipidemic patients did not achieve the goals recommended by guidelines. The main predictors of prescription therapies with proven benefit were centers with a cardiologist and history of coronary artery disease. CONCLUSION: This national and representative registry identified important gaps in the incorporation of therapies with proven benefit, offering a realistic outlook of patients at high cardiovascular risk.
IHospital do Coração, São Paulo, SP
IISociedade Brasileira de Cardiologia, Rio de Janeiro, RJ
IIIInstituto Dante Pazzanese de Cardiologia, São Paulo, SP
IVUnidades de Hemodinâmica e Intervenção Cardiovascular Rede D'Or / São Luiz - Recife, São Paulo e Santo André
VHospital de Base, São José do Rio Preto, SP
VICentro de Pesquisa Clínica das Disciplinas de Clínica Médica e Cardiologia da UNIFESP, São Paulo, SP
VIIHospital Lifecenter, Belo Horizonte, MG
VIIISociedade Hospitalar Angelina Caron, Campina Grande do Sul, PR
IXAmbulatório Médico de Especialidades Maria Zélia, São Paulo, SP
XHospital da Bahia, Salvador, BA - Brasil
The projection of the Global Burden of Diseases study1 for 2020 indicates that cardiovascular diseases remain the leading cause of death and disability, particularly in developing countries. In Brazil, the incidence has been increasing over the years and, in parallel, the expenses devoted to treatment have been progressively increasing, both in the setting of public assistance, as well as private health care2-4.
Several large randomized trials and systematic reviews have shown that in patients with high cardiovascular risk, the benefit of drugs such as statins extends even to patients with normal cholesterol levels5; antiplatelets are capable of reducing major cardiovascular events, even in individuals with no clinical manifestations of atherosclerosis6 and many antihypertensive drugs, mainly angiotensin-converting enzyme inhibitors (ACEI), have the potential to reduce cardiovascular events, even in patients with no diagnostic criteria for systemic arterial hypertension7. Additionally, non-pharmacological interventions, such as cardioprotective diets, smoking cessation and regular physical activity, although the data are less robust than those in studies with pharmacological therapies, are also associated with a reduction in clinically relevant outcomes8-22.
In view of the importance of using evidence-based therapies for cardiovascular risk reduction, it is essential to assess daily clinical practice. International registries have shown significant gaps in the incorporation of guideline recommendations into the real world. To date, no registry has fully documented Brazilian clinical practice in relation to the care of individuals at high cardiovascular risk in a large and representative sample, which contemplated both public and private centers from all regions of Brazil. Thus, the objective of this study was to document the current clinical practice through patterns of prescription of evidence-based interventions in patients at high cardiovascular risk in Brazil.
The complete methodology of REACT has been previously published23. Briefly, this is a cross-sectional observational and prospective registry with longitudinal follow-up of patients, with blinded assessment of outcomes. This project was conceived and coordinated by the Brazilian Cardiology Society (SBC), with the participation of public and private centers from all regions of Brazil, respecting the distribution of population according to data from the Brazilian Institute of Geography and Statistics (Instituto Brasileiro de Geografia e Estatística - IBGE). Public and private centers, university and non-university ones, were invited to participate in the study, from both large cities and small towns, which met the minimum requirements of Good Clinical Research Practice.
We included consecutive individuals of both genders, aged 45 years and older that met at least one of the criteria for high cardiovascular risk classification: coronary artery disease (CAD), cerebrovascular disease (CVD), peripheral vascular disease and diabetes mellitus. It also included patients with at least three risk factors for atherosclerosis: hypertension, smoking, dyslipidemia, age > 70 years, family history of CAD, chronic kidney disease or asymptomatic carotid artery disease. All included patients were outpatients.
We excluded patients with neurocognitive or psychiatric conditions that prevented obtaining reliable clinical data (defined by the investigators' clinical decisions), as well as patients with tumors of unfavorable clinical course.
The primary outcome referring to this analysis was the proportion of patients using evidence-based therapies (defined as concurrent use of antiplatelet agents, statins and ACE inhibitors) during the baseline consultation of the REACT study, considering a minimum prescription rate of 90%.
Other outcomes included: the proportion of patients who received recommendations regarding measures of lifestyle changes (smoking cessation, physical activity and nutrition guidelines) and proportion of patients who received each of the following medications individually during the baseline consultation: statins, antiplatelet agents, ACE inhibitors, beta-blockers (analysis restricted to patients with a history of myocardial infarction) and thiazide diuretics (in hypertensive patients).
Additionally, we calculated the rate of hypertensive and dyslipidemic patients with controlled levels within the recommended therapeutic goals, as recommended by SBC.
The participating centers were trained regarding the study procedures and electronic systems, either in person or by phone, by the coordination team. Data quality control was performed through different strategies, such as use of electronic data capture system, central statistical monitoring of collected variables, sporadic sending of reports containing the status of patients at participating centers and direct check of 10% of the records in five centers with higher recruitment. Additionally 20% of the medical records from 20% of the remaining centers were checked after being chosen randomly within each national demographic region.
Finally, biannual meetings were held in order to update their status and discuss, among participating researchers, relevant points of the registry.
In order to detect a proportion of 40% for the occurrence of the primary outcome, considering a sampling error of 2%, a two-sided alpha of 5% and a statistical power of 90% were required, thus resulting in the inclusion of at least 2,305 patients.
Quantitative variables were expressed as mean and standard deviation, whereas qualitative variables were expressed as absolute and relative frequencies. The primary and secondary outcomes were described by estimates weighted by the number of patients at each center, which ranged from 3 to 213. The assessment of the association between concomitant use of antiplatelet agents, statins and ACE inhibitors and factors such as gender, age, region, specialty and type of center was performed using a multiple logistic regression model. The results of model adjustment were shown as odds ratios (OR) and 95% confidence intervals (95%CI). All analyses were performed with the statistical software Statistical Package for Social Science (SPSS), release 16.0 (SPSS Inc., Chicago, IL, USA) and R 2.13 (R Development Core Team, 2011,
The protocol was approved by the Research Ethics Committee (REC) of Hospital do Coração de São Paulo, in São Paulo (SP), on June 22, 2010 under registration number 118/2010 and subsequently, each participating center also had its local approval. All patients signed a free and informed consent form, and the trial was carried out according to the principles of the current review of the Declaration of Helsinki and Good Clinical Practice Guidelines, in its latest version, as well as Edict 196/96.
A total of 2,403 patients were enrolled at 45 centers between July 2010 and December 2011 and this analysis included only patients with complete baseline data, totaling 2,364 patients. Of this sample, 60.3% were from the Southeast, 26.1% from the South, 9.3% from the Northeast, 2.7% from the North and 1.6% from the Midwest.
The care profile of these patients showed a predominance of mixed institutions (40.5%), followed by Supplemental Health Institutions (31%) and, finally, 28.6% that belonged to the Brazilian Unified Health System (SUS), as shown in
Of the 2,364 patients analyzed, 78.3% received antiplatelet agents, 77.0% statins and 53.0% ACE inhibitors. Among the 681 patients with a history of myocardial infarction, 79.4% received beta-blockers (
The combined use of antiplatelet agents, statins and ACE inhibitors was observed in 34% of patients, with a higher frequency of use (40.1%) in 1,249 patients with CAD, when compared to other categories of high cardiovascular risk (
Regarding the attainment of goals determined by SBC guidelines, we observed that in 51.2% of 1,328 diabetic patients, blood glucose levels were higher than the recommended ones. In relation to hypertension control, 50.9% of 2,180 patients were hypertensive, with blood pressure levels higher than a usual blood pressure of 140/90 mmHg. Finally, regarding lipid goals recommended for patients at high cardiovascular risk, about 20% to 30% of the sample had LDL levels
A multivariate logistic regression was performed to assess independent factors associated with increased likelihood of prescription of evidence-based therapies (defined for this analysis as the combined use of aspirin, statins and ACE inhibitors). Accordingly, among the independent predictors, we highlight the service performed by a cardiologist (OR=1.42, 95% CI: 1.10 - 1.82) and CAD diagnosis (OR=1.91, 95% CI: = 1.59 - 2.30) (
The REACT study represents the largest and most recent national registry, coordinated by a medical society and involving patients at high cardiovascular risk treated in an outpatient setting, from all regions of the country. The main finding of this study refers to the fact that risk factor control (according to guideline goals for LDL, blood pressure and blood glucose levels) is lower than the expected and that there are opportunities for improvement in clinical practice, especially concerning the prescription of evidence-based interventions and mainly the combined use of statins, antiplatelets and ACEI. Among the factors independently associated with the prescription of evidence-based therapies, we highlight treatment by cardiologists and CAD diagnosis.
The findings of this study showed that patients at high cardiovascular risk treated at Brazilian centers of excellence have a demographic pattern and are receive treatment similar to those seen in recent registries carried out in North America and Western Europe. In this sense, the most prevalent risk factors in the Brazilian population were hypertension and dyslipidemia, which is consistent with literature. The multicenter REACH study, for instance, reported a prevalence of hypertension and dyslipidemia of 81.3% and 70.4%, respectively, similar to that found in this registry, as well as in similar publications24.
The adequate control of diabetes mellitus in the REACT study was unsatisfactory, as only 23% of diabetics maintained levels of glycated hemoglobin < 7%, even though these patients have greater cardiovascular risk than non-diabetic ones25. The IV Brazilian Guidelines on Dyslipidemia and Atherosclerosis Prevention of the Brazilian Society of Cardiology26 recommends, for high-risk individuals, the simultaneous start of nonpharmacological measures and treatment with lipid-lowering drugs. The REACT study showed that 88% of patients were instructed on cardioprotective diets and 77% were taking lipid-lowering drugs; however, a minority of dyslipidemic patients undergoing secondary prevention, diabetics, patients with CAD, CVD, or PAD reached levels <100 mg/dL of LDL cholesterol. The L-TAP 2 study, which assessed between 2006 and 2007 approximately 10,000 patients from nine countries with dyslipidemia who used statins, found that 73% had achieved their goals of LDL cholesterol, as defined by national guidelines, with greater control found among low-risk patients (86%), when compared to those at high risk (67%)26.
Recent international and national studies have shown a gap between guidelines and clinical practice, particularly for those patients at higher risk for the development of cardiovascular events. Data from the PREMISE study27, carried out by the World Health Organization (WHO) in 2005, which included 10,000 patients in developing countries (one thousand patients from Brazil) showed that only about 30% of patients with high cardiovascular risk who had indication for drug therapy were taking statins and ACE inhibitors and only 80% received antiplatelet agents. These findings are consistent with those from the REACT study, considering that antiplatelet agents, statins and ACE inhibitor prescription rates were 78.3%, 72.6% and 53.0%, respectively. The REACT adds additional information to the findings of the PREMISE study27 as the latter, in Brazil, was carried out exclusively in the South region. Other observational studies have also demonstrated findings consistent with those from the REACT study in relation to the prescription of evidence-based therapies in the real world. Thus, in the REACH study24 of 31,195 patients assessed, 72.6% were using statins, 43.3% used ACEI and 69% used antiplatelets. As it included a larger number of Brazilian centers, including non-university centers and centers located in small towns, the REACT study added additional important information regarding the findings of the REACH study. In communities located in developing countries, the gaps are even more significant. The PURE study, which included 153,662 patients from 18 countries (both developed and developing ones), aged between 35 and 75 years, living in urban and rural areas, between January 2003 and December 2009, found even more disturbing numbers. Among the population with CAD, only 25.8% used antiplatelets and 16.7% used statins. When we evaluated only the developed countries, these rates increased to 64.1% and 70.9%, respectively28.
Among the factors independently associated with prescription of evidence-based therapies, treatment by cardiologists and diagnosis of CAD are highlighted. The findings of the present study are consistent with recent cross-sectional study carried out in ten European countries that analyzed quality indicators in 8928 patients, showing that risk factor control was better in the group with known coronary artery disease, when compared to those with high risk and no cardiovascular disease, for both rates of uncontrolled blood pressure (34.2 vs. 49.3%, p < 0.001) and uncontrolled cholesterol (32.4
The main strengths of the REACT study are the fact that it represents the largest and most recent national registry that documents care of patients at high cardiovascular risk, its supra-institutional characteristic (as it was carried out by SBC), the participation of centers from all Brazilian regions, including public (university and non-university), private and mixed hospitals, both from capital and large cities, as well as from smaller towns. The latter aspect represents a differential of the REACT study in relation to international registries with the participation of Brazilian centers, which are usually carried out in large university centers only, which have academic tradition. Additionally, robust methodology was used regarding the observational study design of the registry type, namely: minimization of selection bias by including a consecutive sample of patients, adequate control of random error through satisfactory sample size and robust statistical methods, minimizing measurement bias by central adjudication of outcomes, and finally, the use of several strategies validated for data quality control and fraud prevention system (electronic capture of data, central statistical consistency checking, as well as local and at-distance monitoring centers).
On the other hand there are limitations that must be mentioned. It is noteworthy that, although it included primary care center units and other specialty centers, most centers included were specialized in Cardiology. Thus, potentially, the inclusion of a greater number of patients from Basic Health Units and communities with less access to specialized services could disclose an even greater gap in the incorporation of evidence-based therapies and satisfactory control of risk factors, according to guideline targets. However, from a qualitative point of view (i.e., presence of gaps in the incorporation of evidence), the results would remain similar, even with the inclusion of those centers.
Additionally, although we have tried to respect the geographical distribution of the population according to the last census of the Brazilian Institute of Geography and Statistics (IBGE), the number of centers in the North, Northeast and Midwest was lower than the representativeness of centers in the South and Southeast regions. Finally, this analysis shows baseline data only, with no description of longitudinal follow-up of patients that might allow measurement of the incidence and predictors of cardiovascular events. Regarding this latter point, it is important to mention that new analyses of the REACT study, regarding the longitudinal follow-up, are in progress and will probably bring relevant information on the incidence of clinically relevant outcomes in this population.
The goals of cardiovascular risk factor control, drug prescriptions and recommendations for lifestyle change for patients at high cardiovascular risk in Brazil, were outside of those recommended by the Brazilian guidelines. Given the abovementioned facts and based on the results of the REACT study, it is necessary to develop Clinical Practice Improvement Programs under the coordination of the SBC, including research (cluster randomized trials) and professional training, also involving non-specialists.
Although the analysis did not include only patients eligible for pharmacologic intervention, considering that the rate of contraindication to antiplatelet therapy, statins and ACE inhibitors is below 5%, an optimal rate of prescription would be around 95%. Thus, the REACT results showed that the prescription of cardiovascular drugs is lower than the expected.
Finally, it is necessary to carry out similar studies in patients in the community with less access to specialists' services, where larger gaps are expected regarding the incorporation of therapies with proven benefit.
Conception and design of the research, Analysis and interpretation of the data, Statistical analysis, Obtaining funding and Critical revision of the manuscript for intellectual content: Berwanger O, Piva e Mattos LA, Guimarães JI, Andrade JP; Acquisition of data: Martin JFV, Lopes RD, Figueiredo EL, Magnoni D, Precoma DB, Machado CA; Writing of the manuscript: Berwanger O, Piva e Mattos LA, Martin JFV, Lopes RD, Figueiredo EL, Magnoni D, Precoma DB, Machado CA, Guimarães JI, Andrade JP.
No potential conflict of interest relevant to this article was reported.
This study was funded by Sociedade Brasileira de Cardiologia.
This study is not associated with any post-graduation program.
1. World Health Organization (WHO). The World Health Report 2005: health systems: improving performance. Geneva: WHO; 2005.
2. Ministério da Saúde. Datasus: indicadores de saúde. [Acesso em 2010 mar 9]. Disponível em:
3. Lloyd Jones D, Adams R, Carnethon M, de Simone G, Ferguson B, Flegal K, et al; American Heart Association Statistical Update. Heart Disease and Stroke Statistics_2009 Update: a report from the American Heart Association Statistics Committee and Stroke Statistics Subcommittee. Circulation. 2009;119(3):e21-e181.
4. Murray CJL, Lopez AD. The global burden of disease: a comprehensive assessment of mortality and disability from disease, injuries and risk factors in 1990 and projected to 2020. Cambridge: Harvard University Press; 1996.
5. Avezum A, Guimarães HP, Berwanger O, Bautista L, Franzosi MG, Commerford P, et al. Aspectos epidemiológicos: educação continuada em pós-infarto do miocárdio. Rev Soc Cardiol Estado de São Paulo. 2004;14(6):1-16.
6. Yusuf S, Hawken S, Ounpuu S, Bautista L, Franzosi MG, Commerford P, et al; INTERHEART Study Investigators. Obesity and the risk of myocardial infarction in 27,000 participants from 52 countries: a case-control study. Lancet. 2005;366(9497):1640-9.
7. Yusuf S, Sleight P, Pogue J, Bosch J, Davies R, Dagenais G. Effects of an angiotensin-converting enzyme inhibitor, ramipril, on cardiovascular events in high-risk patients. The Heart Outcomes Prevention Evaluation Study Investigators. N Engl J Med. 2000;342(3):145-53. Erratum in: N Engl J Med 2000;342(10):748. 2000;342(18):1376.
8. Grundy SM, Brewer HB Jr, Cleeman JI, Smith SC Jr, Lenfant C; American Heart Association; National Heart, Lung, and Blood Institute. Definition of metabolic syndrome: report of the National Heart, Lung, and Blood Institute/American Heart Association conference on scientific issues related to definition. Circulation. 2004;109(3):433-8.
9. Girman CJ, Rhodes T, Mercuri M, Pyörälä K, Kjekshus J, Pedersen TR, et al; 4S Group and the AFCAPS/TexCAPS Research Group. The metabolic syndrome and risk of major coronary events in the Scandinavian Simvastatin Survival Study (4S) and the Air Force/Texas Coronary Atherosclerosis Prevention Study (AFCAPS/TexCAPS). Am J Cardiol. 2004;93(2):136-41.
10. Wilson PW, D'Agostino RB, Levy D, Belanger AM, Silbershatz H, Kannel WB. Prediction of coronary heart disease using risk factor categories. Circulation. 1998;97(18):1837-47.
11. Kannel WB. Hypertension as a risk factor for cardiac events: epidemiologic results of long-term studies. J Cardiovasc Pharmacol. 1993;21(Suppl 2):S27-37.
12. Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults. Executive Summary of The Third Report of The National Cholesterol Education Program (NCEP) Expert Panel on Detection, Evaluation, And Treatment of High Blood Cholesterol In Adults (Adult Treatment Panel III). JAMA. 2001;285(19):2486-97.
13. Balady GJ, Williams MA, Ades PA, Bittner V, Comoss P, Foody JM, et al; American Heart Association Exercise, Cardiac Rehabilitation, and Prevention Committee, the Council on Clinical Cardiology; American Heart Association Council on Cardiovascular Nursing; American Heart Association Council on Epidemiology and Prevention; American Heart Association Council on Nutrition, Physical Activity, and Metabolism; American Association of Cardiovascular and Pulmonary Rehabilitation. Core components of cardiac rehabilitation/secondary prevention programs: 2007 update: a scientific statement from the American Heart Association Exercise, Cardiac Rehabilitation, and Prevention Committee, the Council on Clinical Cardiology; the Councils on Cardiovascular Nursing, Epidemiology and Prevention, and Nutrition, Physical Activity, and Metabolism; and the American Association of Cardiovascular and Pulmonary Rehabilitation. Circulation. 2007;115(20):2675-82.
14. Smith SC Jr, Allen J, Blair SN, Bonow RO, Brass LM, Fonarow GC, et al; AHA; ACC; National Heart, Lung, and Blood Institute. AHA/ACC guidelines for secondary prevention for patients with coronary and other atherosclerotic vascular disease: 2006 update endorsed by the National Heart, Lung, and Blood Institute. J Am Coll Cardiol. 2006;47(10):2130-9.
15. Cannon CP, Braunwald E, McCabe CH, Rader DJ, Rouleau JL, Belder R, et al; Pravastatin or Atorvastatin Evaluation and Infection Therapy-Thrombolysis in Myocardial Infarction 22 Investigators. Intensive versus moderate lipid lowering with statins after acute coronary syndromes. N Engl J Med. 2004;350(15):1495-504.
16. Baigent C, Keech A, Kearney PM, Blackwell L, Buck G, Pollicino C, et al; Cholesterol Treatment Trialists' (CTT) Collaborators. Efficacy and safety of cholesterol-lowering treatment: prospective meta-analysis of data from 90,056 participants in 14 randomised trials of statins. Lancet. 2005;366(9493):1267-78. Erratum in: Lancet. 2005;366(9494):1358.
17. Thompson PD, Buchner D, Pina IL, Balady GJ, Williams MA, Marcus BH, et al., American Heart Association Council on Clinical Cardiology Subcommittee on Exercise, Rehabilitation, and Prevention; American Heart Association Council on Nutrition, Physical Activity, and Metabolism Subcommittee on Physical Activity. Exercise and physical activity in the prevention and treatment of atherosclerotic cardiovascular disease: a statement from the Council on Clinical Cardiology (Subcommittee on Exercise, Rehabilitation, and Prevention) and the Council on Nutrition, Physical Activity, and Metabolism (Subcommittee on Physical Activity). Circulation. 2003;107(24):3109-16.
18. Sacks FM, Pfeffer MA, Moye LA, Rouleau JL, Rutherford JD, Cole TG, et al. The effect of pravastatin on coronary events after myocardial infarction in patients with average cholesterol levels. Cholesterol and Recurrent Events Trial investigators. N Engl J Med. 1996;335(14):1001-9.
19. Downs JR, Clearfield M, Weis S, Whitney E, Shapiro DR, Beere PA, et al. Primary prevention of acute coronary events with lovastatin in men and women with average cholesterol levels: results of AFCAPS/TexCAPS. Air Force/Texas Coronary Atherosclerosis Prevention Study. JAMA. 1998;279(20):1615-22.
20. Prevention of cardiovascular events and death with pravastatin in patients with coronary heart disease and a broad range of initial cholesterol levels. The Long-Term Intervention with Pravastatin in Ischaemic Disease (LIPID) Study Group. N Engl J Med. 1998;339(19):1349-57.
21. Iestra JA, Kromhout D, van der Schouw YT, Grobbee DE, Boshuizen HC, van Staveren WA. Effect size estimates of lifestyle and dietary changes on all-cause mortality in coronary artery disease patients: a systematic review. Circulation. 2005;112(6):924-34.
22. de Lorgeril M, Salen P, Martin JL, Monjaud I, Delaye J, Mamelle N. Mediterranean diet, traditional risk factors, and the rate of cardiovascular complications after myocardial infarction: final report of the Lyon Diet Heart Study. Circulation. 1999;99(6):779-85.
23. Mattos LA. Racionalidade e métodos: registro da prática clínica em pacientes de alto risco cardiovascular. Arq Bras Cardiol. 2011;97(1):3-7.
24. Bhatt DL, Eagle KA, Ohman EM, Hirsch AT, Goto S, Mahoney EM, et al; REACH Registry Investigators. Comparative determinants of 4-year cardiovascular event rates in stable outpatients at risk of or with atherothrombosis. JAMA. 2010;304(12):1350-7.
25. Yusuf S, Islam S, Chow CK, Rangarajan S, Dagenais G, Diaz R, et al; Prospective Urban Rural Epidemiology (PURE) Study Investigators. Use of secondary prevention drugs for cardiovascular disease in the community in high-income, middle-income, and low-income countries (the PURE Study): a prospective epidemiological survey. Lancet. 2011;378(9798):1231-43.
26. Haffner SM, Lehto S, Rönnemaa T, Pyörälä K, Laakso M. Mortality from coronary heart disease in subjects with type 2 diabetes and nondiabetetic subjects with and without prior myocardial infarction. N Engl J Med. 1998;339(4):229-34.
27. Sposito AC, Caramelli B, Fonseca FA, Bertolami MC, Afiune Neto A, Souza AD, et al; Sociedade Brasileira de Cardiologia. IV Diretriz brasileira sobre dislipidemias e prevenção da aterosclerose. Arq Bras Cardiol. 2007;88(supl 1):1-18.
28. WHO study on prevention of REcurrences of myocardial infarction. [Acesso em 2010 out 10]. Disponível em
29. Ludt S, Wensing M, Campbell SM, Ose D, van Lieshout J, Rochon J, et al. The challenge of cardiovascular prevention in primary care: implications of a European observational study in 8928 patients at different risk levels. Eur J Prev Cardiol. 2012 Sept 21. [Epub ahead of print]
Otávio Berwanger Instituto de Ensino e Pesquisa – HCor Rua Abilio Soares, 250, 12º andar, ParaÃso Postal Code 04005-000, São Paulo, SP - Brazil E-mail:
Manuscript received January 11, 2013, revised manuscript January 11, 2013; accepted February 18, 2013.