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    "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Atherosclerosis is a progressive disease caused by thickening and cumulative hardening of the arterial walls&#44; mainly due to cholesterol deposits&#46; This pathological process is associated with several risk factors&#44; including dyslipidemia&#44; hypertension&#44; obesity&#44; smoking&#44; diabetes and some genetic abnormalities&#46; The starting point in atherogenesis is the deposition of low-density lipoprotein cholesterol &#40;LDL-C&#41; and cholesterol-rich apolipoprotein B within the arterial wall&#44; and therefore high LDL-C levels are the most important direct risk factor in atherosclerosis&#46;<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">1</span></a> Prevention of ischemic atherothrombotic disease centers on promoting healthy lifestyles and&#44; at the individual level&#44; by combating unhealthy conditions and reducing the impact of direct and indirect cardiovascular risk factors&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">Atherosclerosis can affect arteries in any part of the body and is the cause of important diseases such as myocardial infarction&#44; ischemic stroke and peripheral arterial disease&#46; Ischemic heart disease and stroke are the leading causes of death worldwide &#40;accounting for 15 million deaths per year&#41; and have been for the past 15 years&#46;<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">2</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">With the latest advances in invasive medicine and new drugs&#44; more individuals survive the first ischemic event&#44; but they are at high risk for recurrence&#46; In patients who have had a myocardial infarction and survived&#44; daily aspirin decreases the chance of recurrence of an atherosclerotic event within five years by 25&#37;&#44; beta-blockers by 25&#37;&#44; angiotensin-converting enzyme inhibitors by 25&#37; and statins by more than 40&#37;&#46; So&#44; hypothetically&#44; if a person could only take one medication after a myocardial infarction &#40;which of course is not desirable&#41;&#44; the most effective would be a statin&#46;<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">3</span></a> There is strong evidence that lowering blood cholesterol levels using low-cost statins or ezetimibe is cost-effective for secondary and even primary prevention&#46; An effective statin regimen for about five years in 10<span class="elsevierStyleHsp" style=""></span>000 patients would typically prevent major vascular events in about 1000 &#40;10&#37;&#41; patients at high risk of clinical events and in 500 patients &#40;5&#37; absolute benefit&#41; who are at high risk but without events &#40;primary prevention&#41;&#46; The evidence indicates that generic statin-based treatments are cost-effective for people at least down to 1&#37; annual total cardiovascular risk and could be cost-effective at even lower risk&#46;<a class="elsevierStyleCrossRefs" href="#bib0070"><span class="elsevierStyleSup">4&#44;5</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">The article by Costa et al&#46; published in this issue of the <span class="elsevierStyleItalic">Journal</span><a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">6</span></a> gives an estimate of the costs of atherosclerosis in Portugal&#44; based on a prevalence approach&#44; and using national epidemiological sources&#46; These costs were estimated at 1&#46;9 billion euros per year &#40;11&#37; of all health expenditure&#41;&#44; including direct &#40;58&#37;&#41; and indirect &#40;42&#37;&#41; costs&#46; Surprisingly &#40;or perhaps not&#41;&#44; most of the direct costs were related to primary health care &#40;55&#37;&#41; rather than hospitalizations &#40;18&#37;&#41;&#44; which include surgical and percutaneous procedures that are often necessary&#44; such as angioplasty&#44; revascularization surgery&#44; thrombectomy and defibrillator implantation&#46; In recent years there has been wider use of new drugs&#44; leading to longer survival of patients with atherothrombotic disease&#44; although at the expense of increasing the number of so-called mandatory drugs&#44; which have a clear influence on prognosis&#46; Regarding indirect costs&#44; it was not surprising that the largest slice &#40;91&#37;&#41; was due to absenteeism in the workplace&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">Estimating the costs related to atherosclerosis in a country like Portugal necessitates estimation of the costs of all these diseases and their risk factors&#46; From a methodological point of view&#44; this calculation is very difficult and the result will be probably less than the actual figure&#44; as it is practically impossible to predict all the consequences of an entity such as atherosclerosis&#46; Examples of other diseases not directly accounted for in this study and strongly associated with atherosclerotic processes are some forms of dementia and kidney failure&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">Regardless of the methodology used in this and similar studies&#44;<a class="elsevierStyleCrossRefs" href="#bib0085"><span class="elsevierStyleSup">7&#44;8</span></a> the same conclusion is always reached &#8211; variables are missing and the costs related to atherosclerosis are probably even higher than those presented&#46; All of this leads to the main question&#58; can these costs be reduced&#63; Probably yes&#44; if more money is spent on prevention measures&#44; in order to avoid symptomatic atherosclerosis&#44; which is more expensive&#46; We also need to increase the use of available cost-effectiveness analyses of drugs and hospital interventions&#46; Finally&#44; it is still necessary to educate doctors&#44; institutions and government decision-makers&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">The value of new antiatherosclerotic drugs and hospital interventions is maximized when they are used in the right way in clinical practice&#46; Clinical trials conducted during drug development help predict the real value of a specific therapy&#46; Regulatory approval is an indication of value&#44; which is complemented by an assessment of clinical value for decisions about reimbursement&#44; using the methodology of health technology assessment&#46; Formal cost-effectiveness studies are an important part of this methodology&#44; to guide decisions on health care spending&#46; For instance&#44; incremental cost-effectiveness ratios&#44; quality-adjusted life-years and life expectancy are valuable parameters for assessing the usefulness of a given therapeutic intervention&#44; and so all physicians should be familiar with these tools&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">According to the American Heart Association&#39;s Heart Disease and Stroke Statistics 2020 Update&#44;<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">9</span></a> the mean annual direct and indirect cost in the USA of cardiovascular disease and stroke&#44; caused primarily by atherosclerosis&#44; was estimated at &#36;351&#46;3 billion &#40;&#36;1048 per capita&#41;&#46; The same report estimates that by 2035&#44; total projected costs &#40;direct and indirect&#41; will increase markedly for older patients&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">The aging of the population&#44; which is not only occurring in the USA&#44; will increase this health expenditure&#44; particularly direct costs related to outpatient care and hospital interventions that individuals can expect throughout their adult life&#46; Life expectancy for Portuguese adults is currently 80&#46;8 years &#40;77&#46;8 for men and 83&#46;4 for women&#41;&#44; and this is expected to increase in the coming years&#46;<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">10</span></a></p><p id="par0050" class="elsevierStylePara elsevierViewall">To deal with this situation&#44; a new culture of education and responsibility for physicians&#44; hospitals&#44; universities and government entities is needed&#44; to achieve effective reductions in costs related not only to atherosclerosis&#44; but also to other areas of health care&#46;</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Conflicts of interest</span><p id="par0055" class="elsevierStylePara elsevierViewall">The author has no conflicts of interest to declare&#46;</p></span></span>"
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Atherothrombotic ischemic disease: The price is too high to ignore
Doença isquémica aterotrombótica: o preço é demasiadamente elevado para ser ignorado
Marco Costa
Cardiovascular Intervention Unit, Cardiology Department, Centro Hospitalar e Universitário de Coimbra, Coimbra, Portugal
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    "titulo" => "Atherothrombotic ischemic disease&#58; The price is too high to ignore"
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    "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Atherosclerosis is a progressive disease caused by thickening and cumulative hardening of the arterial walls&#44; mainly due to cholesterol deposits&#46; This pathological process is associated with several risk factors&#44; including dyslipidemia&#44; hypertension&#44; obesity&#44; smoking&#44; diabetes and some genetic abnormalities&#46; The starting point in atherogenesis is the deposition of low-density lipoprotein cholesterol &#40;LDL-C&#41; and cholesterol-rich apolipoprotein B within the arterial wall&#44; and therefore high LDL-C levels are the most important direct risk factor in atherosclerosis&#46;<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">1</span></a> Prevention of ischemic atherothrombotic disease centers on promoting healthy lifestyles and&#44; at the individual level&#44; by combating unhealthy conditions and reducing the impact of direct and indirect cardiovascular risk factors&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">Atherosclerosis can affect arteries in any part of the body and is the cause of important diseases such as myocardial infarction&#44; ischemic stroke and peripheral arterial disease&#46; Ischemic heart disease and stroke are the leading causes of death worldwide &#40;accounting for 15 million deaths per year&#41; and have been for the past 15 years&#46;<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">2</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">With the latest advances in invasive medicine and new drugs&#44; more individuals survive the first ischemic event&#44; but they are at high risk for recurrence&#46; In patients who have had a myocardial infarction and survived&#44; daily aspirin decreases the chance of recurrence of an atherosclerotic event within five years by 25&#37;&#44; beta-blockers by 25&#37;&#44; angiotensin-converting enzyme inhibitors by 25&#37; and statins by more than 40&#37;&#46; So&#44; hypothetically&#44; if a person could only take one medication after a myocardial infarction &#40;which of course is not desirable&#41;&#44; the most effective would be a statin&#46;<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">3</span></a> There is strong evidence that lowering blood cholesterol levels using low-cost statins or ezetimibe is cost-effective for secondary and even primary prevention&#46; An effective statin regimen for about five years in 10<span class="elsevierStyleHsp" style=""></span>000 patients would typically prevent major vascular events in about 1000 &#40;10&#37;&#41; patients at high risk of clinical events and in 500 patients &#40;5&#37; absolute benefit&#41; who are at high risk but without events &#40;primary prevention&#41;&#46; The evidence indicates that generic statin-based treatments are cost-effective for people at least down to 1&#37; annual total cardiovascular risk and could be cost-effective at even lower risk&#46;<a class="elsevierStyleCrossRefs" href="#bib0070"><span class="elsevierStyleSup">4&#44;5</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">The article by Costa et al&#46; published in this issue of the <span class="elsevierStyleItalic">Journal</span><a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">6</span></a> gives an estimate of the costs of atherosclerosis in Portugal&#44; based on a prevalence approach&#44; and using national epidemiological sources&#46; These costs were estimated at 1&#46;9 billion euros per year &#40;11&#37; of all health expenditure&#41;&#44; including direct &#40;58&#37;&#41; and indirect &#40;42&#37;&#41; costs&#46; Surprisingly &#40;or perhaps not&#41;&#44; most of the direct costs were related to primary health care &#40;55&#37;&#41; rather than hospitalizations &#40;18&#37;&#41;&#44; which include surgical and percutaneous procedures that are often necessary&#44; such as angioplasty&#44; revascularization surgery&#44; thrombectomy and defibrillator implantation&#46; In recent years there has been wider use of new drugs&#44; leading to longer survival of patients with atherothrombotic disease&#44; although at the expense of increasing the number of so-called mandatory drugs&#44; which have a clear influence on prognosis&#46; Regarding indirect costs&#44; it was not surprising that the largest slice &#40;91&#37;&#41; was due to absenteeism in the workplace&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">Estimating the costs related to atherosclerosis in a country like Portugal necessitates estimation of the costs of all these diseases and their risk factors&#46; From a methodological point of view&#44; this calculation is very difficult and the result will be probably less than the actual figure&#44; as it is practically impossible to predict all the consequences of an entity such as atherosclerosis&#46; Examples of other diseases not directly accounted for in this study and strongly associated with atherosclerotic processes are some forms of dementia and kidney failure&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">Regardless of the methodology used in this and similar studies&#44;<a class="elsevierStyleCrossRefs" href="#bib0085"><span class="elsevierStyleSup">7&#44;8</span></a> the same conclusion is always reached &#8211; variables are missing and the costs related to atherosclerosis are probably even higher than those presented&#46; All of this leads to the main question&#58; can these costs be reduced&#63; Probably yes&#44; if more money is spent on prevention measures&#44; in order to avoid symptomatic atherosclerosis&#44; which is more expensive&#46; We also need to increase the use of available cost-effectiveness analyses of drugs and hospital interventions&#46; Finally&#44; it is still necessary to educate doctors&#44; institutions and government decision-makers&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">The value of new antiatherosclerotic drugs and hospital interventions is maximized when they are used in the right way in clinical practice&#46; Clinical trials conducted during drug development help predict the real value of a specific therapy&#46; Regulatory approval is an indication of value&#44; which is complemented by an assessment of clinical value for decisions about reimbursement&#44; using the methodology of health technology assessment&#46; Formal cost-effectiveness studies are an important part of this methodology&#44; to guide decisions on health care spending&#46; For instance&#44; incremental cost-effectiveness ratios&#44; quality-adjusted life-years and life expectancy are valuable parameters for assessing the usefulness of a given therapeutic intervention&#44; and so all physicians should be familiar with these tools&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">According to the American Heart Association&#39;s Heart Disease and Stroke Statistics 2020 Update&#44;<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">9</span></a> the mean annual direct and indirect cost in the USA of cardiovascular disease and stroke&#44; caused primarily by atherosclerosis&#44; was estimated at &#36;351&#46;3 billion &#40;&#36;1048 per capita&#41;&#46; The same report estimates that by 2035&#44; total projected costs &#40;direct and indirect&#41; will increase markedly for older patients&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">The aging of the population&#44; which is not only occurring in the USA&#44; will increase this health expenditure&#44; particularly direct costs related to outpatient care and hospital interventions that individuals can expect throughout their adult life&#46; Life expectancy for Portuguese adults is currently 80&#46;8 years &#40;77&#46;8 for men and 83&#46;4 for women&#41;&#44; and this is expected to increase in the coming years&#46;<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">10</span></a></p><p id="par0050" class="elsevierStylePara elsevierViewall">To deal with this situation&#44; a new culture of education and responsibility for physicians&#44; hospitals&#44; universities and government entities is needed&#44; to achieve effective reductions in costs related not only to atherosclerosis&#44; but also to other areas of health care&#46;</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Conflicts of interest</span><p id="par0055" class="elsevierStylePara elsevierViewall">The author has no conflicts of interest to declare&#46;</p></span></span>"
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Informação do artigo
ISSN: 08702551
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Revista Portuguesa de Cardiologia
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