Joäo Fernando Monteiro Ferreira

Mild chronic kidney dysfunction and treatment strategies for stable coronary artery disease

OBJECTIVE Our objective was to evaluate the association of chronic kidney dysfunction in patients with multivessel chronic coronary artery disease, preserved left ventricular function, and the possible interaction between received treatment and cardiovascular events. METHODS The glomerular filtration rate was determined at baseline on 611 patients who were randomized into three treatment groups: medical treatment, percutaneous coronary intervention, and coronary artery bypass surgery. Incidence of myocardial infarction, angina requiring a new revascularization procedure, and death were analyzed during 5 years in each group. RESULTS Of 611 patients, 112 (18%) were classified as having normal renal function, 349 (57%) were classified as having mild dysfunction, and 150 (25%) were classified as having moderate dysfunction. There were significant differences among the cumulative overall mortality curves among the three renal function groups. Death was observed more frequently in the moderate dysfunction group than the other two groups (P < .001). Interestingly, in patients with mild chronic kidney dysfunction, we observed that coronary artery bypass treatment presented a statistically higher percentage of event-free survival and lower percentage of mortality than did percutaneous coronary intervention or medical treatment CONCLUSIONS Our results confirm that coronary artery disease accompanied by chronic kidney dysfunction has a worse prognosis, regardless of the therapeutic strategy for coronary artery disease, when renal function is at least mildly impaired. Additionally, our data suggest that the different treatment strategies available for stable coronary artery disease may have differential beneficial effects according to the range of glomerular filtration rate strata.

Impact of metabolic syndrome on the outcome of patients with stable coronary artery disease: 2-year follow-up of the MASS II study.

ObjectiveWe characterized the impact of the metabolic syndrome (MetS) and its components on cardiovascular adverse events in patients with symptomatic chronic multivessel coronary artery disease, which have been followed prospectively for 2 years. MethodsPatients enrolled in the MASS II study were evaluated for each component of the MetS, as well as the full syndrome. ResultsThe criteria for MetS were fulfilled in 52% of patients. The presence of MetS (P<0.05), glucose intolerance (P=0.007), and diabetes (P=0.04) was associated with an increased mortality in our studied population. Moreover, despite a clear tendency for each of its components to increase the mortality risk, only the presence of the MetS significantly increased the risk of mortality among nondiabetic study participants in a multivariate model (P=0.03, relative risk 3.5, 95% confidence interval 1.1–6). Finally, MetS was still associated with increased mortality even after adjustment for diabetes status. These results indicate a strong and consistent relationship of the MetS with mortality in patients with stable coronary artery disease. ConclusionAlthough glucose homeostasis seems to be the major force driving the increased risk of MetS, the operational diagnosis of MetS still has information for stratifying patients when diabetes information is taken into account.

Cardiovascular health of the brazilian male: the view of the Brazilian Society of Cardiology

Correspondencia: Antonio Carlos Palandri Chagas• Avenida Marechal Câmara, 160/330, Centro 20020-907, Rio de Janeiro, RJ Brasil E-mail: acchagas@cardiol.br Articulo recibido el 08/12/09; revisado recibido el 08/12/09; aceptado el 08/12/09. La comprension de los mecanismos de la enfermedad ha llevado la medicina a desarrollar intensamente nuevas estrategias terapeuticas en las ultimas decadas, estrategias basadas principalmente en intervencion. Sin embargo, estas indiscutibles conquistas en mortalidad y calidad de vida no llegan a promover la curacion o remision completa de los sintomas de la enfermedad, y se acompanan de significativo aumento de los costes de la salud, lo que convierte en universal el problema del financiamiento de la salud, que alcanza incluso a los paises mas ricos. Estas cuestiones mueven de forma intensa la medicina del siglo XXI hacia la busqueda de una nueva estrategia de encarar el padecimiento del varon, y volver a tener como enfoque principal la prevencion de las enfermedades, en lugar de aguardarlas y tratarlas tras su instalacion. Este camino esta volviendose irreversible, como puede se ejemplifica por conferencia impartida por el profesor Eugene Braunwald, en el ultimo congreso europeo de cardiologia, en la ciudad de Barcelona. Dr. Braunwald participo en el simposio “Futuro de la cardiologia como especialidad” y impartio la conferencia “Cardiologia como profesion en 2020 y ademas”, en la que enfoco su presentacion en los aspectos de la prevencion como el mejor camino para el abordaje de enfermedad cardiovascular, y actitud prioritaria de los cardiologos en el proximo siglo.The comprehension of the mechanisms of disease has led Medicine to intensely develop new therapeutic strategies in the last decades, strategies based mainly on intervention. However, these indisputable achievements in mortality and quality of life have not promoted the cure or complete remission of the disease symptoms and have been accompanied by a significant increase in healthcare costs that affect even the wealthier countries. These questions are setting the Medicine of the XXI century in motion toward the search for a new strategy to face Man’s sickness and again have as the main focus the prevention of diseases, instead of waiting for the diseases to appear and treat them after they have set in. This path is becoming irreversible, as demonstrated by a lecture given by Professor Eugene Braunwald, at the last European Congress of Cardiology in the city of Barcelona, Spain. Dr. Braunwald participated in the symposium “Future of Cardiology as a Medical Specialty” and presented the lecture “Cardiology as a Profession in 2020 and beyond” and focused his presentation on the aspects of prevention as the best way to approach cardiovascular disease and the cardiologists’ high priority in the next century. The concept of prevention is not new and it is currently being used in our country. The Ministry and State Secretaries of Health have already developed several programs of health promotion that currently reach children and adolescents, women and the elderly. However, some questions have arisen: for which diseases should prevention be prioritized and which population should be the focus?Brazil is rapidly going through a demographic transition, in which the mean age of the population is older. In 2000, approximately 15% of the population (27 million people) was 50 years or older. This percentage should increase to 42% (96 million people) in 2050. The mean age of the Brazilian individual, which in 2000 was 26 years, will be 44 years in 2050. As the population ages, the non-transmissible diseases will result in a burden to the Public Health System, considering that the cost of these diseases already represents half the costs of all hospital admissions in Brazil. These diseases are already responsible for a large and increasing part of the disease burden in Brazil, reaching a percentage of 66%, compared to 24% of transmissible diseases and 10% of wounds. The change in this profile, with a higher burden of non-transmissible diseases is due to the urbanization, improvement in healthcare quality, changes in life style, specific policies and globalization itself, expanding and disseminating technical-scientific knowledge. This burden of non-transmissible diseases is not necessarily an inevitable result of a modern society, but of a harm that can be prevented. For most of these diseases (coronary diseases, strokes, diabetes and several types of cancer), the main cause is not found in genetics, but in modifiable environmental and behavioral risk factors. Among the non-transmissible diseases, the main focus is on the cardiovascular diseases, due to their current morbimortality rate as well as the somber perspectives for the following years. The World Health Organization, in a study that projects a worldwide increase in the morbimortality of cardiovascular diseases, having as basis for this analysis the year 2040, elevates us to the tragic condition of world champions, by estimating that Brazil will reach an incremental rate of 250% when compared to China (200%) and India (180%)

Saúde cardiovascular do homem brasileiro: visão da Sociedade Brasileira de Cardiologia

Correspondencia: Antonio Carlos Palandri Chagas• Avenida Marechal Câmara, 160/330, Centro 20020-907, Rio de Janeiro, RJ Brasil E-mail: acchagas@cardiol.br Articulo recibido el 08/12/09; revisado recibido el 08/12/09; aceptado el 08/12/09. La comprension de los mecanismos de la enfermedad ha llevado la medicina a desarrollar intensamente nuevas estrategias terapeuticas en las ultimas decadas, estrategias basadas principalmente en intervencion. Sin embargo, estas indiscutibles conquistas en mortalidad y calidad de vida no llegan a promover la curacion o remision completa de los sintomas de la enfermedad, y se acompanan de significativo aumento de los costes de la salud, lo que convierte en universal el problema del financiamiento de la salud, que alcanza incluso a los paises mas ricos. Estas cuestiones mueven de forma intensa la medicina del siglo XXI hacia la busqueda de una nueva estrategia de encarar el padecimiento del varon, y volver a tener como enfoque principal la prevencion de las enfermedades, en lugar de aguardarlas y tratarlas tras su instalacion. Este camino esta volviendose irreversible, como puede se ejemplifica por conferencia impartida por el profesor Eugene Braunwald, en el ultimo congreso europeo de cardiologia, en la ciudad de Barcelona. Dr. Braunwald participo en el simposio “Futuro de la cardiologia como especialidad” y impartio la conferencia “Cardiologia como profesion en 2020 y ademas”, en la que enfoco su presentacion en los aspectos de la prevencion como el mejor camino para el abordaje de enfermedad cardiovascular, y actitud prioritaria de los cardiologos en el proximo siglo.The comprehension of the mechanisms of disease has led Medicine to intensely develop new therapeutic strategies in the last decades, strategies based mainly on intervention. However, these indisputable achievements in mortality and quality of life have not promoted the cure or complete remission of the disease symptoms and have been accompanied by a significant increase in healthcare costs that affect even the wealthier countries. These questions are setting the Medicine of the XXI century in motion toward the search for a new strategy to face Man’s sickness and again have as the main focus the prevention of diseases, instead of waiting for the diseases to appear and treat them after they have set in. This path is becoming irreversible, as demonstrated by a lecture given by Professor Eugene Braunwald, at the last European Congress of Cardiology in the city of Barcelona, Spain. Dr. Braunwald participated in the symposium “Future of Cardiology as a Medical Specialty” and presented the lecture “Cardiology as a Profession in 2020 and beyond” and focused his presentation on the aspects of prevention as the best way to approach cardiovascular disease and the cardiologists’ high priority in the next century. The concept of prevention is not new and it is currently being used in our country. The Ministry and State Secretaries of Health have already developed several programs of health promotion that currently reach children and adolescents, women and the elderly. However, some questions have arisen: for which diseases should prevention be prioritized and which population should be the focus?Brazil is rapidly going through a demographic transition, in which the mean age of the population is older. In 2000, approximately 15% of the population (27 million people) was 50 years or older. This percentage should increase to 42% (96 million people) in 2050. The mean age of the Brazilian individual, which in 2000 was 26 years, will be 44 years in 2050. As the population ages, the non-transmissible diseases will result in a burden to the Public Health System, considering that the cost of these diseases already represents half the costs of all hospital admissions in Brazil. These diseases are already responsible for a large and increasing part of the disease burden in Brazil, reaching a percentage of 66%, compared to 24% of transmissible diseases and 10% of wounds. The change in this profile, with a higher burden of non-transmissible diseases is due to the urbanization, improvement in healthcare quality, changes in life style, specific policies and globalization itself, expanding and disseminating technical-scientific knowledge. This burden of non-transmissible diseases is not necessarily an inevitable result of a modern society, but of a harm that can be prevented. For most of these diseases (coronary diseases, strokes, diabetes and several types of cancer), the main cause is not found in genetics, but in modifiable environmental and behavioral risk factors. Among the non-transmissible diseases, the main focus is on the cardiovascular diseases, due to their current morbimortality rate as well as the somber perspectives for the following years. The World Health Organization, in a study that projects a worldwide increase in the morbimortality of cardiovascular diseases, having as basis for this analysis the year 2040, elevates us to the tragic condition of world champions, by estimating that Brazil will reach an incremental rate of 250% when compared to China (200%) and India (180%)

Combination of amlodipine and enalapril in hypertensive patients with coronary disease

FUNDAMENTO: Pacientes (pts) com doenca coronariana (DAC) estavel podem se beneficiar de menor pressao arterial (PA), conforme estudos recentes. OBJETIVO: Avaliar a eficacia e a tolerabilidade da combinacao fixa anlodipino + enalaprila, comparada a anlodipino na normalizacao da PA diastolica (PAD) ( 90 e 110 mmHg durante o wash-out de quatro semanas, em uso so de atenolol. Apos wash-out randomizamos para combinacao (A) ou anlodipino (B) e seguimos de quatro em quatro semanas ate 98 dias. As doses (mg) iniciais foram, respectivamente: A- 2,5/10 e B- 2,5, sendo incrementadas se PAD> 85mmHg, nas visitas. Estatistica com χ2, Fischer e analise de variância, para p< 0,05. RESULTADOS:de 110 pts selecionados, randomizamos 72 (A= 32, B= 40). As reducoes da PAD e da PA sistolica (PAS) foram intensas (p< 0,01), mas sem diferencas entre os grupos em mmHg: PAS, A (127,7 ± 13,4) e B (125,3 ± 12,6) (p= 0,45) e PAD, A (74,5 ± 6,7 mmHg) e B (75,5 ± 6,7 mmHg) (p= 0,32). Houve menos edema de membros inferiores no A (7,1% vs 30,6%, p=0,02) no 98o dia. CONCLUSAO: A combinacao fixa de enalaprila com anlodipino, tal qual anlodipino isolado, em pts com DAC e HAS estagios I e II foi eficaz na normalizacao da pressao, adicionando bloqueio ao sistema renina-angiotensina.BACKGROUND Patients (pts) with stable coronary artery disease (CAD) can benefit from a decrease in the blood pressure (BP), according to recent studies. OBJECTIVE To evaluate the efficacy and tolerability of the fixed combination: amlodipine + enalapril, when compared to amlodipine in the normalization of the diastolic arterial pressure (DAP) (<85 mmHg), in pts with CAD and systemic arterial hypertension (SAH). METHODS Double-blind and randomized study, with two groups of pts with DAP > or =90 and <110 mmHg and CAD. Patients with left ventricular ejection fraction (LVEF) < 40%, symptoms of heart failure or angina class III and IV, severe diseases and DAP > or =110 mmHg during the four-week wash-out with atenolol treatment alone, were excluded. After the wash-out, pts were randomly distributed for the use of the combination (A) or amlodipine (B) and were followed every four weeks up to 98 days. The initial doses (in mg) were, respectively: A- 2.5/10 and B- 2.5; the doses were increased when DAP > 85mmHg, at the visits. Statistical analysis was carried out with chi2, Fischer and analysis of variance, for p< 0.05. RESULTS Of the 110 selected pts, 72 (A= 32, B= 40) were randomized. The decreases in DAP and systolic arterial pressure (SAP) were significant (p< 0.01), but with no difference between the groups in mmHg: SAP, A (127.7 +/- 13.4) and B (125.3 +/- 12.6) (p= 0.45) and DAP, A (74.5 +/- 6.7 mmHg) and B (75.5 +/- 6.7 mmHg) (p= 0.32). Group A presented a lower incidence of lower-limb edema: (7.1% vs 30.6%, p=0.02) on the 98th day of follow-up. CONCLUSION The fixed combination of enalapril and amlodipine, as well as isolated amlodipine, was effective in the normalization of BP in pts with CAD and SAH stages I and II, adding blockage of the renin-angiotensin system.

Combinação de anlodipino e enalaprila em pacientes hipertensos com doença coronariana

FUNDAMENTO: Pacientes (pts) com doenca coronariana (DAC) estavel podem se beneficiar de menor pressao arterial (PA), conforme estudos recentes. OBJETIVO: Avaliar a eficacia e a tolerabilidade da combinacao fixa anlodipino + enalaprila, comparada a anlodipino na normalizacao da PA diastolica (PAD) ( 90 e 110 mmHg durante o wash-out de quatro semanas, em uso so de atenolol. Apos wash-out randomizamos para combinacao (A) ou anlodipino (B) e seguimos de quatro em quatro semanas ate 98 dias. As doses (mg) iniciais foram, respectivamente: A- 2,5/10 e B- 2,5, sendo incrementadas se PAD> 85mmHg, nas visitas. Estatistica com χ2, Fischer e analise de variância, para p< 0,05. RESULTADOS:de 110 pts selecionados, randomizamos 72 (A= 32, B= 40). As reducoes da PAD e da PA sistolica (PAS) foram intensas (p< 0,01), mas sem diferencas entre os grupos em mmHg: PAS, A (127,7 ± 13,4) e B (125,3 ± 12,6) (p= 0,45) e PAD, A (74,5 ± 6,7 mmHg) e B (75,5 ± 6,7 mmHg) (p= 0,32). Houve menos edema de membros inferiores no A (7,1% vs 30,6%, p=0,02) no 98o dia. CONCLUSAO: A combinacao fixa de enalaprila com anlodipino, tal qual anlodipino isolado, em pts com DAC e HAS estagios I e II foi eficaz na normalizacao da pressao, adicionando bloqueio ao sistema renina-angiotensina.BACKGROUND Patients (pts) with stable coronary artery disease (CAD) can benefit from a decrease in the blood pressure (BP), according to recent studies. OBJECTIVE To evaluate the efficacy and tolerability of the fixed combination: amlodipine + enalapril, when compared to amlodipine in the normalization of the diastolic arterial pressure (DAP) (<85 mmHg), in pts with CAD and systemic arterial hypertension (SAH). METHODS Double-blind and randomized study, with two groups of pts with DAP > or =90 and <110 mmHg and CAD. Patients with left ventricular ejection fraction (LVEF) < 40%, symptoms of heart failure or angina class III and IV, severe diseases and DAP > or =110 mmHg during the four-week wash-out with atenolol treatment alone, were excluded. After the wash-out, pts were randomly distributed for the use of the combination (A) or amlodipine (B) and were followed every four weeks up to 98 days. The initial doses (in mg) were, respectively: A- 2.5/10 and B- 2.5; the doses were increased when DAP > 85mmHg, at the visits. Statistical analysis was carried out with chi2, Fischer and analysis of variance, for p< 0.05. RESULTS Of the 110 selected pts, 72 (A= 32, B= 40) were randomized. The decreases in DAP and systolic arterial pressure (SAP) were significant (p< 0.01), but with no difference between the groups in mmHg: SAP, A (127.7 +/- 13.4) and B (125.3 +/- 12.6) (p= 0.45) and DAP, A (74.5 +/- 6.7 mmHg) and B (75.5 +/- 6.7 mmHg) (p= 0.32). Group A presented a lower incidence of lower-limb edema: (7.1% vs 30.6%, p=0.02) on the 98th day of follow-up. CONCLUSION The fixed combination of enalapril and amlodipine, as well as isolated amlodipine, was effective in the normalization of BP in pts with CAD and SAH stages I and II, adding blockage of the renin-angiotensin system.

Isquemia silenciosa na doença coronariana estável em vigência de tratamento medicamentoso

BACKGROUND Few data are available on the behavior of myocardial ischemia during daily activities in patients with coronary artery disease receiving antianginal drug therapy. OBJECTIVE To study the mechanism generating myocardial ischemia by evaluating blood pressure and heart rate changes in patients with stable atherosclerotic disease receiving drug therapy and with evidence of myocardial ischemia. METHODS Fifty non-hospitalized patients (40 males) underwent 24-hour electrocardiographic monitoring synchronized with blood pressured monitoring. RESULTS Thirty five episodes of myocardial ischemia were detected in 17 patients, with a total duration of 146.3 minutes; angina was reported in five cases. Twenty nine episodes (100.3 minutes) occurred during wakefulness, with 11 episodes (35.3 + 3.7 min) in the period from 11 a.m. to 3 p.m. Blood pressure and heart rate evaluation in the three ten-minute intervals following the ischemic episodes showed a statistically significant difference (p< 0.05), unlike that shown for the three intervals preceding the episodes. However, during the ischemic episode, a higher than 10-mmHg elevation in blood pressure and 5 beats per minute in heart rate were observed when compared with the time interval between 20 and 10 minutes before the episode. The mean heart rate at the onset of ischemia during the exercise test performed before the study was 118.2 + 14.0, and 81.1 + 20.8 beats per minute on the 24-hour electrocardiogram (p < 0.001). CONCLUSION The incidence of silent myocardial ischemia is high in stable coronary artery disease and is related to alterations in blood pressure and heart rate, with different thresholds for ischemia for the same patient.

Executive Summary of the Guidelines on Stable Coronary Disease

Diagnosis of symptomatic patients The approach proposed by Diamond and Forrester2,3 (Table 1): Level of recommendation I, evidence level B was considered for diagnosis. For the assessment of cardiovascular risk, the Brazilian Guidelines for Atherosclerosis Prevention and the V Brazilian Guidelines on Dyslipidemia and Atherosclerosis Prevention were used4,5. (Level of recommendation IIa, evidence level B).

Combinación de amlodipino y enalapril en pacientes hipertensos con enfermedad coronaria

FUNDAMENTO: Pacientes (pts) com doenca coronariana (DAC) estavel podem se beneficiar de menor pressao arterial (PA), conforme estudos recentes. OBJETIVO: Avaliar a eficacia e a tolerabilidade da combinacao fixa anlodipino + enalaprila, comparada a anlodipino na normalizacao da PA diastolica (PAD) ( 90 e 110 mmHg durante o wash-out de quatro semanas, em uso so de atenolol. Apos wash-out randomizamos para combinacao (A) ou anlodipino (B) e seguimos de quatro em quatro semanas ate 98 dias. As doses (mg) iniciais foram, respectivamente: A- 2,5/10 e B- 2,5, sendo incrementadas se PAD> 85mmHg, nas visitas. Estatistica com χ2, Fischer e analise de variância, para p< 0,05. RESULTADOS:de 110 pts selecionados, randomizamos 72 (A= 32, B= 40). As reducoes da PAD e da PA sistolica (PAS) foram intensas (p< 0,01), mas sem diferencas entre os grupos em mmHg: PAS, A (127,7 ± 13,4) e B (125,3 ± 12,6) (p= 0,45) e PAD, A (74,5 ± 6,7 mmHg) e B (75,5 ± 6,7 mmHg) (p= 0,32). Houve menos edema de membros inferiores no A (7,1% vs 30,6%, p=0,02) no 98o dia. CONCLUSAO: A combinacao fixa de enalaprila com anlodipino, tal qual anlodipino isolado, em pts com DAC e HAS estagios I e II foi eficaz na normalizacao da pressao, adicionando bloqueio ao sistema renina-angiotensina.BACKGROUND Patients (pts) with stable coronary artery disease (CAD) can benefit from a decrease in the blood pressure (BP), according to recent studies. OBJECTIVE To evaluate the efficacy and tolerability of the fixed combination: amlodipine + enalapril, when compared to amlodipine in the normalization of the diastolic arterial pressure (DAP) (<85 mmHg), in pts with CAD and systemic arterial hypertension (SAH). METHODS Double-blind and randomized study, with two groups of pts with DAP > or =90 and <110 mmHg and CAD. Patients with left ventricular ejection fraction (LVEF) < 40%, symptoms of heart failure or angina class III and IV, severe diseases and DAP > or =110 mmHg during the four-week wash-out with atenolol treatment alone, were excluded. After the wash-out, pts were randomly distributed for the use of the combination (A) or amlodipine (B) and were followed every four weeks up to 98 days. The initial doses (in mg) were, respectively: A- 2.5/10 and B- 2.5; the doses were increased when DAP > 85mmHg, at the visits. Statistical analysis was carried out with chi2, Fischer and analysis of variance, for p< 0.05. RESULTS Of the 110 selected pts, 72 (A= 32, B= 40) were randomized. The decreases in DAP and systolic arterial pressure (SAP) were significant (p< 0.01), but with no difference between the groups in mmHg: SAP, A (127.7 +/- 13.4) and B (125.3 +/- 12.6) (p= 0.45) and DAP, A (74.5 +/- 6.7 mmHg) and B (75.5 +/- 6.7 mmHg) (p= 0.32). Group A presented a lower incidence of lower-limb edema: (7.1% vs 30.6%, p=0.02) on the 98th day of follow-up. CONCLUSION The fixed combination of enalapril and amlodipine, as well as isolated amlodipine, was effective in the normalization of BP in pts with CAD and SAH stages I and II, adding blockage of the renin-angiotensin system.

Salud cardiovascular del varón brasileño: una mirada de la Sociedad Brasileña de Cardiología

Correspondencia: Antonio Carlos Palandri Chagas• Avenida Marechal Câmara, 160/330, Centro 20020-907, Rio de Janeiro, RJ Brasil E-mail: acchagas@cardiol.br Articulo recibido el 08/12/09; revisado recibido el 08/12/09; aceptado el 08/12/09. La comprension de los mecanismos de la enfermedad ha llevado la medicina a desarrollar intensamente nuevas estrategias terapeuticas en las ultimas decadas, estrategias basadas principalmente en intervencion. Sin embargo, estas indiscutibles conquistas en mortalidad y calidad de vida no llegan a promover la curacion o remision completa de los sintomas de la enfermedad, y se acompanan de significativo aumento de los costes de la salud, lo que convierte en universal el problema del financiamiento de la salud, que alcanza incluso a los paises mas ricos. Estas cuestiones mueven de forma intensa la medicina del siglo XXI hacia la busqueda de una nueva estrategia de encarar el padecimiento del varon, y volver a tener como enfoque principal la prevencion de las enfermedades, en lugar de aguardarlas y tratarlas tras su instalacion. Este camino esta volviendose irreversible, como puede se ejemplifica por conferencia impartida por el profesor Eugene Braunwald, en el ultimo congreso europeo de cardiologia, en la ciudad de Barcelona. Dr. Braunwald participo en el simposio “Futuro de la cardiologia como especialidad” y impartio la conferencia “Cardiologia como profesion en 2020 y ademas”, en la que enfoco su presentacion en los aspectos de la prevencion como el mejor camino para el abordaje de enfermedad cardiovascular, y actitud prioritaria de los cardiologos en el proximo siglo.The comprehension of the mechanisms of disease has led Medicine to intensely develop new therapeutic strategies in the last decades, strategies based mainly on intervention. However, these indisputable achievements in mortality and quality of life have not promoted the cure or complete remission of the disease symptoms and have been accompanied by a significant increase in healthcare costs that affect even the wealthier countries. These questions are setting the Medicine of the XXI century in motion toward the search for a new strategy to face Man’s sickness and again have as the main focus the prevention of diseases, instead of waiting for the diseases to appear and treat them after they have set in. This path is becoming irreversible, as demonstrated by a lecture given by Professor Eugene Braunwald, at the last European Congress of Cardiology in the city of Barcelona, Spain. Dr. Braunwald participated in the symposium “Future of Cardiology as a Medical Specialty” and presented the lecture “Cardiology as a Profession in 2020 and beyond” and focused his presentation on the aspects of prevention as the best way to approach cardiovascular disease and the cardiologists’ high priority in the next century. The concept of prevention is not new and it is currently being used in our country. The Ministry and State Secretaries of Health have already developed several programs of health promotion that currently reach children and adolescents, women and the elderly. However, some questions have arisen: for which diseases should prevention be prioritized and which population should be the focus?Brazil is rapidly going through a demographic transition, in which the mean age of the population is older. In 2000, approximately 15% of the population (27 million people) was 50 years or older. This percentage should increase to 42% (96 million people) in 2050. The mean age of the Brazilian individual, which in 2000 was 26 years, will be 44 years in 2050. As the population ages, the non-transmissible diseases will result in a burden to the Public Health System, considering that the cost of these diseases already represents half the costs of all hospital admissions in Brazil. These diseases are already responsible for a large and increasing part of the disease burden in Brazil, reaching a percentage of 66%, compared to 24% of transmissible diseases and 10% of wounds. The change in this profile, with a higher burden of non-transmissible diseases is due to the urbanization, improvement in healthcare quality, changes in life style, specific policies and globalization itself, expanding and disseminating technical-scientific knowledge. This burden of non-transmissible diseases is not necessarily an inevitable result of a modern society, but of a harm that can be prevented. For most of these diseases (coronary diseases, strokes, diabetes and several types of cancer), the main cause is not found in genetics, but in modifiable environmental and behavioral risk factors. Among the non-transmissible diseases, the main focus is on the cardiovascular diseases, due to their current morbimortality rate as well as the somber perspectives for the following years. The World Health Organization, in a study that projects a worldwide increase in the morbimortality of cardiovascular diseases, having as basis for this analysis the year 2040, elevates us to the tragic condition of world champions, by estimating that Brazil will reach an incremental rate of 250% when compared to China (200%) and India (180%)