Identify high-risk patients early, treat them hard
Em resposta ao avanço das doenças cardiovasculares no Brasil, a comunidade médica revisou profundamente suas diretrizes para o manejo das dislipidemias, adotando metas mais rigorosas e intervenções mais precoces. O novo marco, apresentado em São Paulo em junho de 2025, reflete uma mudança filosófica fundamental: não esperar que o risco se manifeste em sintomas, mas agir com precisão e intensidade antes que o dano se instale. Para pacientes de alto risco — hipertensos, diabéticos, portadores de doença renal crônica — a ciência agora exige mais, e a medicina brasileira responde à altura.
- A crescente carga de doenças ateroscleróticas no Brasil tornou insustentável a abordagem conservadora anterior, pressionando especialistas a elevar os padrões de controle lipídico.
- As novas metas exigem reduções de LDL superiores a 50% em pacientes de alto risco, criando um desafio real de adesão terapêutica e capacitação clínica em larga escala.
- A intolerância às estatinas, frequentemente relatada mas raramente confirmada em estudos controlados, emerge como um obstáculo clínico que precisa ser sistematicamente reavaliado antes de se abandonar a terapia de primeira linha.
- Ferramentas de imagem — como ultrassom carotídeo e tomografia coronariana — e marcadores como o colesterol não-HDL ampliam a capacidade de estratificar riscos com maior precisão individual.
- O novo framework posiciona o Brasil em alinhamento com as tendências globais de medicina personalizada, substituindo protocolos uniformes por decisões calibradas ao perfil de risco de cada paciente.
A Associação Médica Brasileira apresentou, durante o Quarto Congresso Brasileiro de Medicina Geral realizado em São Paulo no início de junho, diretrizes atualizadas para o tratamento das dislipidemias. O documento representa uma virada significativa: em vez de aguardar sintomas ou trabalhar com metas conservadoras, a nova abordagem exige identificação precoce e tratamento intensivo para pacientes em alto risco cardiovascular — especialmente aqueles com hipertensão, diabetes ou doença renal crônica.
Liderada por especialistas como Dr. Bento José Bezerra Neto e Dr. Álvaro Avezum Júnior, a discussão central foi clara: metas antigas deixaram pacientes vulneráveis por tempo demais. As novas diretrizes estabelecem reduções de LDL superiores a 50% para os casos de maior risco, exigindo intervenções mais precoces e mais robustas. Dr. Márcio Hiroshi Miname reforçou que a correta estratificação do risco é o alicerce de tudo — ela define a intensidade do tratamento, a escolha dos medicamentos e a frequência do acompanhamento.
As estatinas permanecem no centro do arsenal terapêutico, respaldadas por décadas de evidências que demonstram redução significativa de infartos, derrames e tromboses. Dr. Fernando Cesena defendeu seu papel insubstituível, enquanto Dr. Remo Furtado alertou que a intolerância a esses medicamentos é frequentemente superestimada: muitos pacientes que acreditam não tolerá-los conseguem usá-los com sucesso quando reavaliados criteriosamente. Causas tratáveis — como hipotireoidismo não diagnosticado ou consumo excessivo de álcool — podem mimetizar efeitos adversos e devem ser descartadas antes de se abandonar a terapia.
Além dos alvos lipídicos tradicionais, as diretrizes incorporam novos instrumentos de avaliação: exames de imagem das artérias carótidas e coronárias ganham protagonismo na identificação dos pacientes que mais se beneficiam do tratamento intensivo, e o colesterol não-HDL passa a ser enfatizado como marcador complementar ao LDL. O resultado é um modelo mais individualizado e baseado em evidências — uma resposta deliberada e estruturada ao peso crescente das doenças cardiovasculares na saúde pública brasileira.
Brazil's medical establishment has tightened its approach to managing abnormal cholesterol levels, releasing updated guidelines that demand more aggressive intervention and earlier treatment for patients at serious cardiovascular risk. The new framework, unveiled at the Fourth Brazilian Congress of General Medicine in São Paulo in early June, represents a significant shift toward intensive lipid control and represents the medical community's response to rising rates of atherosclerotic disease across the country.
The guidelines emerged from a panel discussion led by Dr. Bento José Bezerra Neto, a prominent physician from Pernambuco, and Dr. Álvaro Avezum Júnior, who coordinates research and innovation for Brazil's cardiology society. Their central argument was straightforward: waiting for symptoms or using conservative targets has left too many patients vulnerable. The updated approach calls for identifying high-risk patients earlier—those with hypertension, diabetes, or chronic kidney disease—and treating them with substantially more force. For these individuals, the new targets call for LDL-cholesterol reductions exceeding 50 percent, a considerably more ambitious goal than previous guidance.
Dr. Márcio Hiroshi Miname, who works in the lipid clinic at São Paulo's premier cardiac institute, emphasized that precise risk assessment is now the foundation of treatment decisions. The ability to correctly classify a patient's cardiovascular danger determines everything that follows—the intensity of therapy, the choice of medications, the frequency of monitoring. This precision matters because it prevents both under-treatment of truly vulnerable patients and unnecessary escalation for those at lower risk.
Statins—the cholesterol-lowering drugs that have dominated cardiovascular prevention for decades—remain the cornerstone of therapy. Dr. Fernando Henpin Yue Cesena, a cardiologist at São Paulo's Dante Pazzanese Institute, defended their central role by pointing to decades of evidence: statins reduce heart attacks, strokes, and blood clots at rates that far outweigh their side effects. Yet he acknowledged that some patients struggle with statin therapy, experiencing muscle pain or other adverse effects that make compliance difficult or impossible.
This is where the guidelines address a persistent clinical problem: statin intolerance is widely reported by patients but often cannot be confirmed in controlled studies. Dr. Remo Holanda de Mendonça Furtado, a clinical researcher at the University of São Paulo, argued that the condition is frequently overestimated, with many patients who believe they cannot tolerate statins actually able to use them successfully when retested carefully. He pointed to treatable causes—untreated thyroid disease, excessive alcohol consumption—that can mimic statin side effects and should be ruled out before abandoning the drugs. For patients with genuine intolerance, newer therapeutic options now exist.
The updated guidelines also expand the toolkit for assessing risk beyond simple cholesterol numbers. Imaging studies—ultrasound of the carotid arteries, CT scans of the coronary arteries—now play a larger role in determining who needs the most aggressive treatment. Non-HDL cholesterol, a measure that captures all the harmful cholesterol particles in the bloodstream, receives new emphasis as a complementary marker alongside the traditional LDL target.
What emerges from these changes is a more individualized, evidence-based approach to a common problem. Rather than applying the same treatment to all patients with high cholesterol, physicians now have clearer guidance on stratifying risk and matching intensity to danger. The framework integrates scientific evidence with practical clinical experience, acknowledging both what works and where real-world obstacles—like genuine statin intolerance or patient adherence challenges—require flexibility and alternative strategies. For Brazil's healthcare system, managing a population increasingly burdened by heart disease and stroke, these updated targets represent a deliberate escalation in the fight against atherosclerotic disease.
Notable Quotes
The updated approach reinforces the importance of earlier and more intensive strategies for controlling cardiovascular risk, given the rising burden of atherosclerotic disease in the population— Dr. Bento José Bezerra Neto, president of the Pernambuco Medical Association
Statin intolerance is frequently overestimated, with most cases not confirmed in controlled studies— Dr. Remo Holanda de Mendonça Furtado, clinical researcher at University of São Paulo
The Hearth Conversation Another angle on the story
Why did Brazil's medical association feel compelled to update these guidelines now, in 2025?
The burden of atherosclerotic disease—heart attacks, strokes, blocked arteries—has been rising in Brazil. The old targets weren't aggressive enough to protect the people who needed it most. They wanted to align practice with what the evidence actually shows works.
So they're saying doctors have been too cautious?
In a sense, yes. For high-risk patients—people with diabetes, kidney disease, hypertension—waiting for symptoms or using modest cholesterol targets leaves them exposed. The new guidelines say: identify these patients early, treat them hard.
What about statins? Are they pushing more people onto these drugs?
They're defending statins as essential, but they're also acknowledging a real problem: many patients report side effects that make the drugs unbearable. The guidelines say that intolerance is often overstated—sometimes it's actually thyroid disease or alcohol use mimicking statin problems. But for people with genuine intolerance, there are now alternatives.
What's the practical change a doctor would notice?
More precise risk stratification. Instead of one-size-fits-all targets, you're now classifying patients into risk categories and matching treatment intensity to that category. High-risk patients get pushed toward 50 percent reductions in LDL. You're also using imaging—carotid ultrasounds, coronary CT scans—to refine who really needs aggressive therapy.
Does this mean more medication, more cost?
Potentially, yes. But the argument is that preventing a heart attack or stroke in a high-risk patient justifies the investment. The guidelines also emphasize non-drug strategies—diet, exercise, weight loss—so it's not purely pharmaceutical.
Who benefits most from these changes?
Patients at highest risk—those with multiple conditions, those who've already had a cardiovascular event. They get clearer targets and more aggressive support. But the guidelines also protect lower-risk patients from unnecessary treatment by improving the precision of risk assessment.