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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Atherosclerotic cardiovascular diseases &#40;ASCVD&#41;&#44; including myocardial infarction&#44; stroke&#44; and peripheral arterial disease&#44; remain major causes of premature death&#44; disability&#44; and healthcare expenditure globally&#46;<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">1</span></a> Cardiovascular risk and disease prevention strategies are crucial to reduce the associated mortality&#44; morbidity and health costs across the world&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">Advances in the current concepts of reducing cumulative exposure to cholesterol-containing lipoproteins and the emergence of novel therapies&#44; provide new opportunities to improve prevention and decrease this burden of ASCVD&#46;<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">2</span></a> Healthcare strategies are needed to prevent ASCVD&#44; including the avoidance of cholesterol-containing atherogenic lipoproteins accumulation in arterial walls&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">The current World Heart Federation &#40;WHF&#41; Cholesterol Roadmap provides a conceptual framework for the development of national policies and health system approaches&#44; so that potential obstacles to cholesterol management&#44; and thus ASCVD prevention&#44; can be adressed&#46;<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">2</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">Through a review of published guidelines and research papers since 2017&#44; and consultation with a committee of experts in clinical management of dyslipidemia and health systems research in low-and-middle income countries&#44; this roadmap identified&#58;<ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005"><span class="elsevierStyleLabel">1&#46;</span><p id="par0025" class="elsevierStylePara elsevierViewall">Key principles to effective ASCVD prevention&#46;</p></li><li class="elsevierStyleListItem" id="lsti0010"><span class="elsevierStyleLabel">2&#46;</span><p id="par0030" class="elsevierStylePara elsevierViewall">Gaps in implementation of these interventions &#40;knowledge-practice gaps&#41;&#46;</p></li><li class="elsevierStyleListItem" id="lsti0015"><span class="elsevierStyleLabel">3&#46;</span><p id="par0035" class="elsevierStylePara elsevierViewall">Health system roadblocks for the treatment of elevated cholesterol in LMICs&#46;</p></li><li class="elsevierStyleListItem" id="lsti0020"><span class="elsevierStyleLabel">4&#46;</span><p id="par0040" class="elsevierStylePara elsevierViewall">Potential strategies for overcoming these gaps and limitations&#46;</p></li></ul></p><p id="par0045" class="elsevierStylePara elsevierViewall">Reducing the burden of ASCVD requires multiple approaches throughout life&#58; greater focus on primordial prevention&#59; availability of affordable cholesterol testing&#59; availability of universal cholesterol screening for inherited dyslipidemias&#59; risk stratification moving from a 10-year risk to a lifetime risk&#44; with adequate risk estimators&#59; wider availability of affordable lipid-lowering therapies &#40;LLT&#41;&#44; which should include statins as global essential medications&#59; use of whenever indicated high-intensity statin regimens&#59; and combination therapies with ezetimibe or other drugs in order to achieving and maintaining robust reductions in low-density lipoprotein cholesterol &#40;LDL-C&#41; in those at highest risk&#46; Continuing efforts are needed in health literacy for both public and healthcare providers&#44; utilizing multidisciplinary teams in healthcare and applications that quantify ASCVD risk and the benefits of treatment&#44; as well as increased adherence to therapies&#46;</p><p id="par0050" class="elsevierStylePara elsevierViewall">The document concludes that the adverse effects of LDL-C and apo B containing lipoprotein exposure are cumulative and result in ASCVD&#46; These consequences are preventable by the implementation of different strategies aimed at efficiently tackling atherosclerosis at different stages throughout the course of life&#46; Preventive strategies should therefore be updated to implement health policy&#44; lifestyle changes&#44; and when needed&#44; earlier pharmacotherapies&#44; with investment and shift in focus toward early preventive strategies&#44; preserving CV health rather than treating the effects of ASCVD&#46;</p><p id="par0055" class="elsevierStylePara elsevierViewall">The WHF invited the National Societies to evaluate closely the problem of hypercholesterolemia in their individual countries&#44; and inspired by the WHF Cholesterol Roadmap&#44; to propose strategies to control hyperlipidemia and create a national roadmap&#46; This article regards the production of a Portuguese cholesterol roadmap&#46;</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Purpose</span><p id="par0060" class="elsevierStylePara elsevierViewall">The main purpose of this paper is&#58;<ul class="elsevierStyleList" id="lis0010"><li class="elsevierStyleListItem" id="lsti0025"><span class="elsevierStyleLabel">1&#46;</span><p id="par0065" class="elsevierStylePara elsevierViewall">To evaluate the burden of hypercholesterolemia in Portugal in the last 10 years and to build a national infographic &#40;scorecard&#41;&#44; including cholesterol and other ASCVD risk factors&#44; to be used for advocacy purposes and</p></li><li class="elsevierStyleListItem" id="lsti0030"><span class="elsevierStyleLabel">2&#46;</span><p id="par0070" class="elsevierStylePara elsevierViewall">To propose preventive strategies to combat hypercholesterolemia in Portugal&#44; helping to create a Portuguese cholesterol roadmap&#46;</p></li></ul></p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Methodology</span><p id="par0075" class="elsevierStylePara elsevierViewall"><ul class="elsevierStyleList" id="lis0015"><li class="elsevierStyleListItem" id="lsti0035"><span class="elsevierStyleLabel">1&#46;</span><p id="par0080" class="elsevierStylePara elsevierViewall">A review of the literature regarding CVD and CV risk factors&#44; in particular hypercholesterolemia&#44; with creation of a national scorecard &#40;infographic&#41;&#46;</p></li><li class="elsevierStyleListItem" id="lsti0040"><span class="elsevierStyleLabel">2&#46;</span><p id="par0085" class="elsevierStylePara elsevierViewall">A discussion of the strategies to control hypercholesterolemia in Portugal by a group of experts&#44; helping to build a national roadmap&#46;</p></li></ul></p><p id="par0090" class="elsevierStylePara elsevierViewall">The hypercholesterolemia burden in Portugal was identified and evaluated in a literature review over the last 10 years&#44; creating the picture of hypercholesterolemia in Portugal&#44; to be inserted in an infographic &#40;scorecard&#41;&#46;</p><p id="par0095" class="elsevierStylePara elsevierViewall">The objective of the WHF&#39;s scorecard project is to create a clear picture of the current state of CV disease &#40;CVD&#41; prevention&#44; CV risk factors &#40;such as hypercholesterolemia&#41; control and management in each country and feed it into a systemized assessment of CV policy on a regional and global scale&#46; The advocates for heart health can improve the campaign to change the current reality if armed with a comprehensive overview of both the burden of CVD and the policies in place to tackle it&#46; By measuring the national response to CVD&#44; countries are better able to distinguish priorities&#44; map progress&#44; and ultimately&#44; be held accountable for action to promote better outcomes&#46;</p><p id="par0100" class="elsevierStylePara elsevierViewall">A workshop was organized at the Portuguese Society of Cardiology &#40;<span class="elsevierStyleItalic">SPC</span>&#41;&#44; including experts in dyslipidemia&#44; prevention&#44; and public health&#46; At this meeting&#44; after the presentation of the WHF Roadmap by one of the authors&#44; participants were grouped and discussed the focus of the WHF Cholesterol Roadmap&#58;<ul class="elsevierStyleList" id="lis0020"><li class="elsevierStyleListItem" id="lsti0045"><span class="elsevierStyleLabel">1&#46;</span><p id="par0105" class="elsevierStylePara elsevierViewall">Awareness improvement strategies&#46;</p></li><li class="elsevierStyleListItem" id="lsti0050"><span class="elsevierStyleLabel">2&#46;</span><p id="par0110" class="elsevierStylePara elsevierViewall">Population-based approaches for CV risk and cholesterol decrease strategies&#46;</p></li><li class="elsevierStyleListItem" id="lsti0055"><span class="elsevierStyleLabel">3&#46;</span><p id="par0115" class="elsevierStylePara elsevierViewall">Risk assessment&#47;population screening strategies&#46;</p></li><li class="elsevierStyleListItem" id="lsti0060"><span class="elsevierStyleLabel">4&#46;</span><p id="par0120" class="elsevierStylePara elsevierViewall">System-level approaches strategies&#46;</p></li><li class="elsevierStyleListItem" id="lsti0065"><span class="elsevierStyleLabel">5&#46;</span><p id="par0125" class="elsevierStylePara elsevierViewall">Surveillance of cholesterol and ASCVD outcomes strategies&#46;</p></li><li class="elsevierStyleListItem" id="lsti0070"><span class="elsevierStyleLabel">6&#46;</span><p id="par0130" class="elsevierStylePara elsevierViewall">Strategies proposed by the groups to combat this problem were then debated by all the participants in an idea generation workshop&#44; with the goal of creating a national cholesterol roadmap to be used for advocacy and as a guide for CV prevention&#46;</p></li></ul></p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Results</span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Results I&#58; Cholesterol picture in Portugal - Literature review</span><p id="par0135" class="elsevierStylePara elsevierViewall">From the review of the relevant literature on the cholesterol problem in Portugal in the last 10 years&#44; we now present the main results of the studies&#44; registries&#44; and guidelines in Portugal&#46;</p><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">The VALSIM study</span><p id="par0140" class="elsevierStylePara elsevierViewall">The VALSIM study&#44;<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">3</span></a> published in 2013&#44; included 16<span class="elsevierStyleHsp" style=""></span>856 individuals &#40;mean age 58&#46;1&#177;15&#46;1 years&#41;&#44; observed in primary healthcare centers in Portugal&#44; which sought to characterize total cholesterol &#40;TC&#41;&#44; LDL-C&#44; high-density lipoprotein cholesterol &#40;HDL-C&#41; and triglycerides &#40;TG&#41;&#44; showed a high prevalence of dyslipidemia in adults &#40;62&#37; female&#44; 58&#177;15 years&#41;&#46; TC &#8805;200 mg&#47;dl was recorded at 47&#37; and LDL-C &#8805;130 mg&#47;dl in 38&#37; of the individuals analyzed&#46; Hypertriglyceridemia &#40;&#8805;200 mg&#47;dl&#41; and low HDL-C &#40;&#60;40 mg&#47;dl&#41; were less prevalent&#44; affecting 13&#37; of the population&#46; Hypercholesterolemia was particularly frequent in males aged 30&#8211;60 years&#44; and in postmenopausal women&#44; which should be target-subgroups for strategic public health strategies&#46;</p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">1st National Health Examination Survey</span><p id="par0145" class="elsevierStylePara elsevierViewall">In 2015&#44; The National Health Institute Doctor Ricardo Jorge published the 1st National Health Examination Survey&#44;<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">4</span></a> as health questionnaires with a physical examination were a strategy from the European Commission to improve quality and to compare the quality of healthcare across Europe&#46;</p><p id="par0150" class="elsevierStylePara elsevierViewall">This survey was an epidemiologic observational transversal study with the main purpose of improving public health and decreasing inequities in Portugal&#46; It examined a population of 4911 individuals aged 25&#8211;74 years old and included three components&#58; physical examination&#44; blood testing and clinical interview&#46;</p><p id="par0155" class="elsevierStylePara elsevierViewall">In summary&#44; the main results were&#58;<ul class="elsevierStyleList" id="lis0025"><li class="elsevierStyleListItem" id="lsti0075"><span class="elsevierStyleLabel">&#8226;</span><p id="par0160" class="elsevierStylePara elsevierViewall">52&#37; of the Portuguese general population aged 25&#8211;74 years had TC &#8805;190 mg&#47;dl&#46;</p></li><li class="elsevierStyleListItem" id="lsti0080"><span class="elsevierStyleLabel">&#8226;</span><p id="par0165" class="elsevierStylePara elsevierViewall">63&#37; were taking medication to reduce cholesterol levels &#40;no differences between male and female individuals&#41;&#46;</p></li><li class="elsevierStyleListItem" id="lsti0085"><span class="elsevierStyleLabel">&#8226;</span><p id="par0170" class="elsevierStylePara elsevierViewall">Prevalence of elevated TC or LLT increased with age&#44; reaching 80&#37; in individuals &#62;55 years old&#46;</p></li><li class="elsevierStyleListItem" id="lsti0090"><span class="elsevierStyleLabel">&#8226;</span><p id="par0175" class="elsevierStylePara elsevierViewall">Prevalence of elevated TC or LLT was higher in central Portugal &#40;74&#46;4&#37;&#41; and lower in Lisbon and Tejo Valley &#40;57&#46;8&#37;&#41; &#40;a trend that remained after standardization of prevalence according to age and gender&#41;&#46;</p></li></ul></p></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0060">Guidelines on dyslipidemias treatment&#44; total cholesterol and triglycerides target values and on clinical audit instruments &#40;DGS&#41;</span><p id="par0180" class="elsevierStylePara elsevierViewall">In 2017&#44; the Portuguese Directorate of Health &#40;DGS&#41; 2011 Norms were updated &#40;the guidelines treatment on dyslipidemias&#44; TC and TG target values and clinical audit instrument&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">5</span></a></p></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">EUROASPIRE IV and V</span><p id="par0185" class="elsevierStylePara elsevierViewall">In Europe&#44; the cross-sectional ESC-EORP EUROASPIRE Survey Registries IV<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">6</span></a> and V&#44;<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">7</span></a> supported by the European Society of Cardiology &#40;ESC&#41;&#44; were conducted in patients with coronary atherosclerotic disease &#40;CAD&#41;&#44; to evaluate the implementation of CV prevention guidelines&#44; which included lipid levels control and target values attainment&#46; In the last EUROASPIRE V&#44; 131 centers&#44; from 81 geographical regions in 27 countries &#40;including Portugal&#41; enrolled 8261 patients between 2016 and 2017&#46;</p><p id="par0190" class="elsevierStylePara elsevierViewall">The summary and main conclusions of this study were<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">7</span></a>&#58;<ul class="elsevierStyleList" id="lis0030"><li class="elsevierStyleListItem" id="lsti0095"><span class="elsevierStyleLabel">&#8226;</span><p id="par0195" class="elsevierStylePara elsevierViewall">71&#37; of CAD patients had LDL-C level &#8805;70 mg&#47;dl in Europe &#40;mean value&#41;&#44; while 69&#37; in Portugal&#44; with large differences among countries&#44; ranging from 51&#37; in Spain to 90&#37; in Lithuania&#46;</p></li><li class="elsevierStyleListItem" id="lsti0100"><span class="elsevierStyleLabel">&#8226;</span><p id="par0200" class="elsevierStylePara elsevierViewall">37&#37; of patients had LDL-C &#8805;100 mg&#47;dl&#44; 29&#37; had never been informed of raised cholesterol&#44; and 21&#37; had not had any cholesterol measurements taken since hospital discharge&#46;</p></li><li class="elsevierStyleListItem" id="lsti0105"><span class="elsevierStyleLabel">&#8226;</span><p id="par0205" class="elsevierStylePara elsevierViewall">84&#37; of patients were prescribed LLT&#44; including 80&#37; on statins and 50&#37; on high-intensity statins or drug combinations &#40;which may reduce LDL-C by &#62;50&#37;&#41;&#46;</p></li><li class="elsevierStyleListItem" id="lsti0110"><span class="elsevierStyleLabel">&#8226;</span><p id="par0210" class="elsevierStylePara elsevierViewall">32&#37; of patients on LLT had LDL-C &#60;70 mg&#47;dl&#44; although significantly less in female patients &#40;p&#60;0&#46;0001&#41;&#59; 76&#37; reported full prescription compliance&#46;</p></li><li class="elsevierStyleListItem" id="lsti0115"><span class="elsevierStyleLabel">&#8226;</span><p id="par0215" class="elsevierStylePara elsevierViewall">29&#37; of all CAD patients reported diabetes&#46;</p></li><li class="elsevierStyleListItem" id="lsti0120"><span class="elsevierStyleLabel">&#8226;</span><p id="par0220" class="elsevierStylePara elsevierViewall">46&#37; were advised to participate in a cardiac rehabilitation program and 69&#37; of those advised attended at least 50&#37; of the sessions&#46;</p></li></ul></p><p id="par0225" class="elsevierStylePara elsevierViewall">The results of the EUROASPIRE V survey showed that most CAD patients have less than optimal management of LDL-C&#46; More professional strategies are needed&#44; aiming at lifestyle changes and LLT adapted to the individual needs of the patient&#46;</p><p id="par0230" class="elsevierStylePara elsevierViewall">Another branch of EUROASPIRE was dedicated to evaluating CV risk in primary care &#40;no CAD&#41;&#44;<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">8</span></a> of which the general results were&#58;<ul class="elsevierStyleList" id="lis0035"><li class="elsevierStyleListItem" id="lsti0125"><span class="elsevierStyleLabel">&#8226;</span><p id="par0235" class="elsevierStylePara elsevierViewall">&#60;50&#37; patients on LLT achieving LDL-C target &#40;better control in male patients&#41;&#46;</p></li><li class="elsevierStyleListItem" id="lsti0130"><span class="elsevierStyleLabel">&#8226;</span><p id="par0240" class="elsevierStylePara elsevierViewall">&#60;50&#37; patients on LLT were aware of their cholesterol levels and &#60;33&#37; knew their cholesterol target&#46;</p></li><li class="elsevierStyleListItem" id="lsti0135"><span class="elsevierStyleLabel">&#8226;</span><p id="par0245" class="elsevierStylePara elsevierViewall">&#62;40&#37; patients with elevated LDL-C had never been told they had high cholesterol&#46;</p></li></ul></p><p id="par0250" class="elsevierStylePara elsevierViewall">The results of EUROASPIRE V are in accordance with earlier surveys of primary prevention in Europe&#44; USA and worldwide&#44; most of them focused on control of a single risk factor&#44; while information on management of multiple risk factors in patients at high risk is limited&#46;</p></span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">The LATINO study</span><p id="par0255" class="elsevierStylePara elsevierViewall">The LATINO study&#44;<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">9</span></a> performed at 14 Portuguese health centers and one central hospital in the North of Portugal&#44; included data from 78<span class="elsevierStyleHsp" style=""></span>459 patients to evaluate lipid control in different CV risk groups&#46; It identified major missed treatment opportunities to optimize LDLC management for every risk category&#44; particularly emphasizing high- and very-high-risk patients&#46; The higher the CV risk&#44; the lower the number of patients with ideal targeted LDL-C&#58;<ul class="elsevierStyleList" id="lis0040"><li class="elsevierStyleListItem" id="lsti0140"><span class="elsevierStyleLabel">&#8226;</span><p id="par0260" class="elsevierStylePara elsevierViewall">44&#37; at low risk&#46;</p></li><li class="elsevierStyleListItem" id="lsti0145"><span class="elsevierStyleLabel">&#8226;</span><p id="par0265" class="elsevierStylePara elsevierViewall">27&#37; at intermediate risk&#46;</p></li><li class="elsevierStyleListItem" id="lsti0150"><span class="elsevierStyleLabel">&#8226;</span><p id="par0270" class="elsevierStylePara elsevierViewall">7&#37; at high risk&#46;</p></li><li class="elsevierStyleListItem" id="lsti0155"><span class="elsevierStyleLabel">&#8226;</span><p id="par0275" class="elsevierStylePara elsevierViewall">3&#37; at very high risk&#46;</p></li></ul></p><p id="par0280" class="elsevierStylePara elsevierViewall">This study also highlighted the need to use high-intensity statins and combination therapy&#44; putting the most recent recommendations into clinical practice&#46; Investment in adequate LDL-C control seems to be the most promising solution to decrease the high burden of ASCVD in Portugal&#46;</p></span></span><span id="sec0060" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Results II&#58; Cholesterol and CV risk burden in Portugal - Infographics</span><p id="par0285" class="elsevierStylePara elsevierViewall">The objective of the scorecard project is to create a clear picture of the current state of CVD prevention&#44; control&#44; and management in each country&#44; and feed it into a systemized assessment of CV policy on a regional and global scale&#46; By measuring the national response to CVD&#44; countries are better able to distinguish priorities&#44; map progress&#44; and ultimately&#44; be held accountable for action to promote better outcomes&#46;</p><p id="par0290" class="elsevierStylePara elsevierViewall">After the evaluation of Portuguese studies referring to cholesterol&#44; and based on present data&#44; a scorecard &#40;infographic&#41; was produced to be included in the WHF collection &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Figure 2</a>&#41;&#44; for a clearer idea of the cholesterol burden and figures on other CV risk factors in Portugal &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Figure 1</a>&#41; and also to gain knowledge on national pharmacological interventions in CV risk factors management&#44; in Clinical practice and guidelines&#44; strategies in CVD governance and stakeholder action &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Figure 1</a>&#41;&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0295" class="elsevierStylePara elsevierViewall">Cardiovascular health advocates can improve campaigns to change the current scenario if they have a comprehensive overview of both the burden of CVD and hypercholesterolemia and the policies in place to tackle it&#46;</p></span></span><span id="sec0065" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Discussion</span><p id="par0300" class="elsevierStylePara elsevierViewall">A roadmap is a clear and general strategic plan to achieve a particular target&#46; Depending on the current situation &#8211; political&#44; social&#44; economic&#44; religious&#44; physical&#47;psychological health&#44; and literacy &#8211; strategies need to be designed and modified to adapt and achieve the target&#46; In this setting&#44; different countries will probably try to achieve the same targets&#44; but with different barriers and starting points&#44; sometimes using also different roads&#46; The <span class="elsevierStyleItalic">SPC</span> was challenged to create a group of experts to generate ideas regarding potential solutions for the problem of inadequate cholesterol management&#46; The main barriers for adequate management of the cholesterol in Portugal identified by the CV prevention experts were the lack of health literacy&#44; low social-economic status&#44; lack of good communication among stakeholders and lack of a structured plan&#46;</p><p id="par0305" class="elsevierStylePara elsevierViewall">It was also emphasized that a national structured plan for cholesterol CV risk management involves different stakeholders identified in <a class="elsevierStyleCrossRef" href="#fig0010">Figure 2</a>&#46; The place for action is very wide and can include ministries&#44; city halls&#44; hospitals&#44; clinics&#44; pharmacies&#44; schools&#44; universities&#44; supermarkets&#44; hairdressers&#44; barbers&#44; TV&#44; radio&#44; social networks&#44; newspapers&#44; and magazines&#46;</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0310" class="elsevierStylePara elsevierViewall">The panel of experts decided a call for action was needed with strategies grouped according to the five main principles of the WHF Cholesterol Roadmap &#40;<a class="elsevierStyleCrossRefs" href="#tbl0005">Tables 1&#8211;5</a>&#41;&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><elsevierMultimedia ident="tbl0015"></elsevierMultimedia><elsevierMultimedia ident="tbl0020"></elsevierMultimedia><elsevierMultimedia ident="tbl0025"></elsevierMultimedia><p id="par0315" class="elsevierStylePara elsevierViewall">It was agreed that the problem of cholesterol is still a reality in Portugal&#46; Despite all the efforts to reduce cholesterol levels&#44; it was also pointed out that we must look more widely to the global risk profile&#44; to the control of many CV risk factors&#44; as smoking cessation&#44; hypertension&#44; obesity and diabetes&#44; more than to isolated risk factors&#44; promoting a healthy lifestyle&#44; with physical activity and adequate nutrition&#44; associated with drugs&#44; as necessary&#44; but mainly to forge different mentalities&#44; with healthy behaviors and environments&#46; In Portugal in 2019&#44; data revealed that hyperglycemia&#44; hypertension&#44; smoking and high body mass index were more associated to coronary and cerebrovascular disease &#40;main causes of death&#41; than cholesterol&#46; It is important to highlight that in the Portuguese cholesterol roadmap we are targeting the CV risk as a whole&#44; despite our main concerns in this discussion having been the hypercholesterolemia burden&#46;</p><p id="par0320" class="elsevierStylePara elsevierViewall">The main points considered in this discussion&#44; which should be part of a general plan to combat the problem&#44; where the SPC can have a crucial role&#44; are summarized as follows&#58;</p></span><span id="sec0070" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Recommendations&#58; key points for action</span><p id="par0325" class="elsevierStylePara elsevierViewall"><ul class="elsevierStyleList" id="lis0045"><li class="elsevierStyleListItem" id="lsti0160"><span class="elsevierStyleLabel">&#8226;</span><p id="par0330" class="elsevierStylePara elsevierViewall">Include all the stakeholders in a multidisciplinary and well conducted national program coordinated by Health National Services Task Force&#44; including scientific societies&#44; universities&#44; associations&#44; foundations&#44; hospitals&#44; and primary care centers&#44; and prioritizing the value of patients&#8217; associations with government&#39;s support&#46;</p></li><li class="elsevierStyleListItem" id="lsti0165"><span class="elsevierStyleLabel">&#8226;</span><p id="par0335" class="elsevierStylePara elsevierViewall">Create a structured activities plan to increase awareness of CVD and risk stratification &#40;with cholesterol and other risk factors&#41; in the population&#44; with simple messages disseminated through competent and appropriate communication channels&#46;</p></li><li class="elsevierStyleListItem" id="lsti0170"><span class="elsevierStyleLabel">&#8226;</span><p id="par0340" class="elsevierStylePara elsevierViewall">Improve the quality of CV health education to healthcare professionals &#40;which needs to be continuous&#41;&#44; patients&#44; public&#44; politicians&#44; journalists and especially children&#46;</p></li><li class="elsevierStyleListItem" id="lsti0175"><span class="elsevierStyleLabel">&#8226;</span><p id="par0345" class="elsevierStylePara elsevierViewall">Increase the interaction between different health professionals and with non-health professionals regarding ASCVD risk and cholesterol burden management&#46;</p></li><li class="elsevierStyleListItem" id="lsti0180"><span class="elsevierStyleLabel">&#8226;</span><p id="par0350" class="elsevierStylePara elsevierViewall">Increment referral of individuals with elevated CV risk and with already established CVD to cardiac rehabilitation&#46;</p></li><li class="elsevierStyleListItem" id="lsti0185"><span class="elsevierStyleLabel">&#8226;</span><p id="par0355" class="elsevierStylePara elsevierViewall">Screen the cholesterol levels &#40;focus on LDL cholesterol levels&#41; in general population&#44; especially high-risk groups&#46;</p></li><li class="elsevierStyleListItem" id="lsti0190"><span class="elsevierStyleLabel">&#8226;</span><p id="par0360" class="elsevierStylePara elsevierViewall">Promote patients&#8217; self-care&#44; engaging patients&#8217; associations to enhance CV risk and cholesterol management&#46;</p></li><li class="elsevierStyleListItem" id="lsti0195"><span class="elsevierStyleLabel">&#8226;</span><p id="par0365" class="elsevierStylePara elsevierViewall">Use specific social networks to spread information on CV risk and dyslipidemia and to educate healthcare professionals and the general population&#44; reach a large range of people and increase health literacy&#46;</p></li><li class="elsevierStyleListItem" id="lsti0200"><span class="elsevierStyleLabel">&#8226;</span><p id="par0370" class="elsevierStylePara elsevierViewall">Create a national database with cholesterol levels and a systematic registry of CV events&#44; accessible to all health units&#46;</p></li><li class="elsevierStyleListItem" id="lsti0205"><span class="elsevierStyleLabel">&#8226;</span><p id="par0375" class="elsevierStylePara elsevierViewall">Evaluate results and redefine strategies&#44; as necessary&#44; according to these results&#46;</p></li><li class="elsevierStyleListItem" id="lsti0210"><span class="elsevierStyleLabel">&#8226;</span><p id="par0380" class="elsevierStylePara elsevierViewall">Create and involve more patients&#8217; associations &#8211; invert the pyramid order&#33;</p></li></ul></p><p id="par0385" class="elsevierStylePara elsevierViewall">Some progress has already made regarding cholesterol prevention and management&#44; with the intervention of the SPC&#44; universities and the Portuguese Cardiology Foundation&#44; highlighted in the activities listed below&#58;</p></span><span id="sec0075" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Work in progress&#58; summary</span><p id="par0390" class="elsevierStylePara elsevierViewall"><ul class="elsevierStyleList" id="lis0050"><li class="elsevierStyleListItem" id="lsti0215"><span class="elsevierStyleLabel">&#8226;</span><p id="par0395" class="elsevierStylePara elsevierViewall">ESC Preventive Guidelines translated to Portuguese by the <span class="elsevierStyleItalic">SPC</span> CV Risk Working Group&#46;</p></li><li class="elsevierStyleListItem" id="lsti0220"><span class="elsevierStyleLabel">&#8226;</span><p id="par0400" class="elsevierStylePara elsevierViewall">Multidisciplinary meeting for CV risk prevention implementation by the Institute of Preventive Medicine of the Faculty of Medicine of the University of Lisbon&#46;</p></li><li class="elsevierStyleListItem" id="lsti0225"><span class="elsevierStyleLabel">&#8226;</span><p id="par0405" class="elsevierStylePara elsevierViewall">CV risk and prevention strategies on health websites&#44; TVs&#44; newspapers&#44; and social networks communication&#46;</p></li><li class="elsevierStyleListItem" id="lsti0230"><span class="elsevierStyleLabel">&#8226;</span><p id="par0410" class="elsevierStylePara elsevierViewall">CV prevention sessions in schools promoted by the <span class="elsevierStyleItalic">SPC</span>&#46;</p></li><li class="elsevierStyleListItem" id="lsti0235"><span class="elsevierStyleLabel">&#8226;</span><p id="par0415" class="elsevierStylePara elsevierViewall">Participation in radio programs about CV prevention promoted by the University of Lisbon&#46;</p></li><li class="elsevierStyleListItem" id="lsti0240"><span class="elsevierStyleLabel">&#8226;</span><p id="par0420" class="elsevierStylePara elsevierViewall">Questionnaire administered this year &#40;2023&#41; by the Portuguese Cardiology Foundation by phone to 800 Portuguese adults&#46; From the inquired individuals&#44; 88&#37; &#40;between 18 and 24 years old&#41;&#44; 86&#37; &#40;between 25 and 44 years old&#41;&#44; 66&#37; &#40;between 45 and 64 years old&#41; and 69&#37; &#40;&#8805;65 years old&#41; did not know their cholesterol level&#46; From these&#44; 89&#37; knew cholesterol is a circulating fat in the body and 64&#37; indicated that the normal value is inferior to 190 mg&#47;dl&#46; Regarding the question which CVD were provoked by high cholesterol&#44; 42&#37; highlighted stroke&#44; 25&#37; myocardial infarction and 18&#37; CVD&#46; As the main cause of myocardial infarction&#44; 49&#37; pointed out high cholesterol and 32&#37; hypertension&#46;</p></li></ul></p><p id="par0425" class="elsevierStylePara elsevierViewall">The SPC&#44; particularly its CV Risk Working Group&#44; is engaged in fighting the cholesterol and global ASCVD risk burden with the WHF and European Societies and Associations&#44; defining strategies for cholesterol control and global CV risk management&#46; A national survey on CV risk with appropriate analysis and follow-up could be a way of monitoring this situation and insisting on action by politicians&#44; which may be part of the solution&#46;</p></span><span id="sec0080" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Conclusions</span><p id="par0430" class="elsevierStylePara elsevierViewall">Cholesterol management remains a global strong issue for both primary and secondary prevention&#44; also in Portugal&#46; The involvement of multiple stakeholders&#44; including politicians&#44; healthcare practitioners&#44; non-health-related practitioners&#44; patients&#44; and the general population&#44; is essential to overcome current limitations in this field&#46; The Portuguese cholesterol roadmap&#44; which arose from the idea generation promoted by the WHF at the <span class="elsevierStyleItalic">SPC</span> involving cardiologists and other specialists&#44; can provide some solutions to urgently help minimize this problem&#46; Population-based approaches to improve awareness and strategies for CV risk assessment&#44; surveillance of cholesterol and ASCVD outcomes&#44; are key factors in this change&#46; A call to action is clearly needed to fight hypercholesterolemia and ASCVD burden&#46;</p></span><span id="sec0090" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">Funding</span><p id="par0440" class="elsevierStylePara elsevierViewall">WHF funded Portuguese Society of Cardiology expert work regarding the Portuguese Cholesterol Roadmap&#46;</p></span><span id="sec0085" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0105">Conflicts of interest</span><p id="par0435" class="elsevierStylePara elsevierViewall">The authors have no conflicts of interest to declare&#46;</p></span></span>"
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        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Atherosclerotic cardiovascular disease &#40;ASCVD&#41; remains the major cause of premature death and disability&#59; effective cardiovascular &#40;CV&#41; risk prevention is fundamental&#46; The World Heart Federation &#40;WHF&#41; Cholesterol Roadmap provides a framework for national policy development and aims to achieve ASCVD prevention&#46;</p><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">At the invitation of the WHF&#44; a group of experts from the Portuguese Society of Cardiology &#40;SPC&#41;&#44; addressed the cholesterol burden at nationally and discussed possible strategies to include in a Portuguese cholesterol roadmap&#46; The literature review showed that the cholesterol burden in Portugal is high and especially uncontrolled in those with the highest CV risk&#46; An infographic scorecard was built to include in the WHF collection&#44; for a clear idea about CV risk and cholesterol burden in Portugal&#44; which would also be useful for health policy advocacy&#46;</p><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">The expert discussion and preventive strategies proposal followed the five pillars of the WHF document&#58; awareness improvement&#59; population-based approaches for CV risk and cholesterol&#59; risk assessment&#47;population screening&#59; system-level approaches&#59; surveillance of cholesterol and ASCVD outcomes&#46; These strategies were debated by all the expert participants&#44; with the goal of creating a national cholesterol roadmap to be used for advocacy and as a guide for CV prevention&#46;</p><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Several key recommendations were outlined&#58; include all stakeholders in a multidisciplinary national program&#59; create a structured activities plan to increase awareness in the population&#59; improve the quality of continuous CV health education&#59; increase the interaction between different health professionals and non-health professionals&#59; increment the referral of patients to cardiac rehabilitation&#59; screen cholesterol levels in the general population&#44; especially high-risk groups&#59; promote patient self-care&#44; engage with patients&#8217; associations&#59; use specific social networks to spread information widely&#59; create a national database of cholesterol levels with systematic registry of CV events&#59; redefine strategies based on the evaluation of results&#59; create and involve more patients&#8217; associations &#8211; invert the pyramid order&#46;</p><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">In conclusion&#44; ASCVD and the cholesterol burden remain a strong global issue in Portugal&#44; requiring the involvement of multiple stakeholders in prevention&#46; The Portuguese cholesterol roadmap can provide some solutions to help urgently mitigate the problem&#46; Population-based approaches to improve awareness and CV risk assessment and surveillance of cholesterol and ASCVD outcomes are key factors in this change&#46; A call to action is clearly needed to fight hypercholesterolemia and ASCVD burden&#46;</p></span>"
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        "resumen" => "<span id="abst0010" class="elsevierStyleSection elsevierViewall"><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">A doen&#231;a ateroscler&#243;tica cardiovascular &#40;DACV&#41; mant&#233;m-se a maior causa de morte prematura e de incapacidade&#44; sendo uma preven&#231;&#227;o eficaz de risco cardiovascular &#40;CV&#41; fundamental&#46; O <span class="elsevierStyleItalic">WHF Cholesterol Roadmap</span> fornece enquadramento para o desenvolvimento de pol&#237;ticas nacionais&#44; tendo como objetivo a preven&#231;&#227;o de DACV&#46; A convite da WHF&#44; um grupo de peritos da Sociedade Portuguesa de Cardiologia &#40;SPC&#41; avaliou a carga do colesterol a n&#237;vel nacional e discutiu poss&#237;veis estrat&#233;gias para um <span class="elsevierStyleItalic">Roadmap</span> portugu&#234;s&#46;</p><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">A revis&#227;o da literatura mostrou uma carga elevada de colesterol em Portugal&#44; sobretudo em pessoas de alto risco CV&#46; Uma infografia&#44; <span class="elsevierStyleItalic">Scorecard</span>&#44; foi constru&#237;da pela WHF&#44; para mostrar claramente o risco CV e o peso do colesterol em Portugal&#44; sendo &#250;til para advocacia em pol&#237;ticas de sa&#250;de&#46;</p><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">A discuss&#227;o de peritos e proposta das estrat&#233;gias preventivas seguiram os cinco pilares do documento da WHF&#58; Melhoria da consciencializa&#231;&#227;o&#59; Abordagens do risco CV e do colesterol nas popula&#231;&#245;es&#59; Avalia&#231;&#227;o de risco&#47;<span class="elsevierStyleItalic">screening</span> das popula&#231;&#245;es&#59; abordagens a n&#237;vel do sistema&#59; Seguimento do colesterol e complica&#231;&#245;es da DACV&#46;</p><p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">V&#225;rias recomenda&#231;&#245;es chave foram definidas&#58; incluir todos os <span class="elsevierStyleItalic">stakeholders</span> em programa multidisciplinar nacional&#59; criar plano de atividades estruturadas para aumentar a consciencializa&#231;&#227;o da popula&#231;&#227;o&#59; aumentar qualidade da educa&#231;&#227;o cont&#237;nua em sa&#250;de CV&#59; aumentar intera&#231;&#227;o entre profissionais de sa&#250;de e outros profissionais&#59; aumentar referencia&#231;&#227;o de doentes para reabilita&#231;&#227;o cardiovascular&#59; avaliar n&#237;veis de colesterol na popula&#231;&#227;o geral&#44; especialmente em alto risco&#59; promover autocuidado dos doentes&#44; envolvendo associa&#231;&#245;es de doentes&#59; usar redes sociais espec&#237;ficas para disseminar informa&#231;&#227;o&#59; criar base nacional de n&#237;veis de colesterol com registo sistem&#225;tico de eventos CV&#59; redefinir estrat&#233;gias baseadas na avalia&#231;&#227;o de resultados&#59; criar e envolver mais doentes em associa&#231;&#245;es &#8211; inverter a ordem da pir&#226;mide&#33;</p><p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">Em conclus&#227;o&#44; a DACV e o peso de colesterol permanecem uma quest&#227;o global forte em Portugal&#44; necessitando o envolvimento de m&#250;ltiplos <span class="elsevierStyleItalic">stakeholders</span> na preven&#231;&#227;o&#46; O <span class="elsevierStyleItalic">Roadmap</span> de colesterol portugu&#234;s pode fornecer algumas solu&#231;&#245;es para urgentemente mitigar o problema&#46; Abordagens a n&#237;vel das popula&#231;&#245;es para melhorar a consciencializa&#231;&#227;o e avaliar o risco CV&#44; seguimento do colesterol e das complica&#231;&#245;es de DACV s&#227;o fatores chave nesta mudan&#231;a&#46; Uma <span class="elsevierStyleItalic">call to action</span> &#233; claramente necess&#225;ria para combater a carga da hipercolesterolemia e DACV&#46;</p></span>"
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                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>&#8226; Slide kit production at SPC for healthcare professionals regarding&#58;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>- CV risk of people with high blood cholesterol levels&#46;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>- Cholesterol target values according to CV risk&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>- High cholesterol treatment&#58; non-pharmacological &#40;lifestyle modification&#41; and pharmacological&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>- Techniques for promoting adherence&#46;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">To use this kit in a structured plan of meetings covering the primary care units and hospitals of the country regions&#59; additionally&#44; can be also used in joint sessions with other scientific societies&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>&#8226; Slide kit production at SPC for patients in SPC website &#40;open to public&#41; and translation of the WHF film of cholesterol roadmap for the population with dissemination through patient associations&#44; in educational sessions plan&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>&#8226; Elaboration of strategies for inclusive communication &#40;simple and solid messages&#41; to be present in daily life &#40;posters&#44; screens&#41;&#58;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>- Targeting healthcare professionals and patients in hospitals and clinics&#46;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>- Targeting the population&#44; to be promoted in supermarkets&#44; pharmacies&#44; gymnasiums&#44; and in social media &#40;very short videos&#41;&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>&#8226; Campaigns involving politicians and using popular ambassadors on radio&#44; TV&#44; social networks&#44; investing in communication techniques&#46;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>&#8226; Convincing health politicians for legislation about food nutrients&#44; reducing trans-fats&#46;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>&#8226; Mandatory introduction of codes &#40;&#8220;traffic-light&#8221; like&#41; in processed food&#44; regarding the degree of healthy&#47;non-healthy and the content of fats and trans-fats&#44; and use of quality stamps&#46;&nbsp;\t\t\t\t\t\t\n
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Guidelines
World Heart Federation Cholesterol Roadmap: The Portuguese case
Roadmap do Colesterol da Federação Mundial de Cardiologia: o caso português
Ana Abreua,
Autor para correspondência
ananabreu@hotmail.com

Corresponding author.
, Hélder Doresb, Lino Gonçalvesc, Fátima Francoc, Conceição Silveirad, Gonçalo Proençae, Ana Teresa Timóteof, Nuno Cardimg, Mónica Pedroh, Manuela Fiuzah, Daniel Ferreirab, Luísa Bentoi, Lino Patrícioj, Daniel Caldeirak, Sérgio Bravo Baptistal, José Santosm, Evangelista Rochad, Anabela Raimundob, Carlos Catarinon, Manuel Carragetao..., Ricardo Mexiap, Francisco Araújoq, Hélder Pereiran, Raul Santosr, Fausto J. PintohVer más
a Serviço Cardiologia, Hospital Santa Maria, Lisboa, Portugal
b Hospital da Luz, Lisboa, Portugal
c Centro Hospitalar e Universitário de Coimbra, EPE, Coimbra, Portugal
d Hospital das Forças Armadas, Polo de Lisboa, Lisboa, Portugal
e Hospital dos Lusíadas, Lisboa, Portugal
f Centro Hospitalar Universitário de Lisboa Central, EPE/Hospital de Santa Marta, Lisboa, Portugal
g Hospital Cuf Descobertas, Lisboa, Portugal
h Centro Hospitalar Lisboa, Portugal Norte, EPE/Hospital Santa Maria, Lisboa, Portugal
i Hospital Garcia de Orta, EPE, Almada, Portugal
j Hospital Espírito Santo, EPE, Évora, Portugal
k Faculdade de Medicina da Universidade de Lisboa, Portugal
l Hospital Prof. Dr. Fernando da Fonseca, EPE/Hospital Amadora Sintra, Amadora, Portugal
m Hospital da Luz, Setúbal, Portugal
n Hospital Garcia da Orta, EPE, Almada, Portugal
o Fundação Portuguesa de Cardiologia, Lisboa, Portugal
p Faculdade Ciências Médicas da Universidade Católica, Lisboa, Portugal
q Hospital Beatriz Ângelo, Loures, Portugal
r Universidade de S. Paulo, S. Paulo, Brazil
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            "entidad" => "Hospital Prof&#46; Dr&#46; Fernando da Fonseca&#44; EPE&#47;Hospital Amadora Sintra&#44; Amadora&#44; Portugal"
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        "titulo" => "<span class="elsevierStyleItalic">Roadmap</span> do Colesterol da Federa&#231;&#227;o Mundial de Cardiologia&#58; o caso portugu&#234;s"
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          "en" => "<p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">Infographic&#58; left side&#58; premature mortality and CV risk factors including high cholesterol&#44; hypertension&#44; physical inactivity&#44; smoking&#44; diabetes in Portugal&#46; Right side&#58; essential medication and interventions for risk factor management&#44; local relevant clinical practice and guidelines&#44; national plans in CVD governance and stakeholder action&#46;</p>"
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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Atherosclerotic cardiovascular diseases &#40;ASCVD&#41;&#44; including myocardial infarction&#44; stroke&#44; and peripheral arterial disease&#44; remain major causes of premature death&#44; disability&#44; and healthcare expenditure globally&#46;<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">1</span></a> Cardiovascular risk and disease prevention strategies are crucial to reduce the associated mortality&#44; morbidity and health costs across the world&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">Advances in the current concepts of reducing cumulative exposure to cholesterol-containing lipoproteins and the emergence of novel therapies&#44; provide new opportunities to improve prevention and decrease this burden of ASCVD&#46;<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">2</span></a> Healthcare strategies are needed to prevent ASCVD&#44; including the avoidance of cholesterol-containing atherogenic lipoproteins accumulation in arterial walls&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">The current World Heart Federation &#40;WHF&#41; Cholesterol Roadmap provides a conceptual framework for the development of national policies and health system approaches&#44; so that potential obstacles to cholesterol management&#44; and thus ASCVD prevention&#44; can be adressed&#46;<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">2</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">Through a review of published guidelines and research papers since 2017&#44; and consultation with a committee of experts in clinical management of dyslipidemia and health systems research in low-and-middle income countries&#44; this roadmap identified&#58;<ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005"><span class="elsevierStyleLabel">1&#46;</span><p id="par0025" class="elsevierStylePara elsevierViewall">Key principles to effective ASCVD prevention&#46;</p></li><li class="elsevierStyleListItem" id="lsti0010"><span class="elsevierStyleLabel">2&#46;</span><p id="par0030" class="elsevierStylePara elsevierViewall">Gaps in implementation of these interventions &#40;knowledge-practice gaps&#41;&#46;</p></li><li class="elsevierStyleListItem" id="lsti0015"><span class="elsevierStyleLabel">3&#46;</span><p id="par0035" class="elsevierStylePara elsevierViewall">Health system roadblocks for the treatment of elevated cholesterol in LMICs&#46;</p></li><li class="elsevierStyleListItem" id="lsti0020"><span class="elsevierStyleLabel">4&#46;</span><p id="par0040" class="elsevierStylePara elsevierViewall">Potential strategies for overcoming these gaps and limitations&#46;</p></li></ul></p><p id="par0045" class="elsevierStylePara elsevierViewall">Reducing the burden of ASCVD requires multiple approaches throughout life&#58; greater focus on primordial prevention&#59; availability of affordable cholesterol testing&#59; availability of universal cholesterol screening for inherited dyslipidemias&#59; risk stratification moving from a 10-year risk to a lifetime risk&#44; with adequate risk estimators&#59; wider availability of affordable lipid-lowering therapies &#40;LLT&#41;&#44; which should include statins as global essential medications&#59; use of whenever indicated high-intensity statin regimens&#59; and combination therapies with ezetimibe or other drugs in order to achieving and maintaining robust reductions in low-density lipoprotein cholesterol &#40;LDL-C&#41; in those at highest risk&#46; Continuing efforts are needed in health literacy for both public and healthcare providers&#44; utilizing multidisciplinary teams in healthcare and applications that quantify ASCVD risk and the benefits of treatment&#44; as well as increased adherence to therapies&#46;</p><p id="par0050" class="elsevierStylePara elsevierViewall">The document concludes that the adverse effects of LDL-C and apo B containing lipoprotein exposure are cumulative and result in ASCVD&#46; These consequences are preventable by the implementation of different strategies aimed at efficiently tackling atherosclerosis at different stages throughout the course of life&#46; Preventive strategies should therefore be updated to implement health policy&#44; lifestyle changes&#44; and when needed&#44; earlier pharmacotherapies&#44; with investment and shift in focus toward early preventive strategies&#44; preserving CV health rather than treating the effects of ASCVD&#46;</p><p id="par0055" class="elsevierStylePara elsevierViewall">The WHF invited the National Societies to evaluate closely the problem of hypercholesterolemia in their individual countries&#44; and inspired by the WHF Cholesterol Roadmap&#44; to propose strategies to control hyperlipidemia and create a national roadmap&#46; This article regards the production of a Portuguese cholesterol roadmap&#46;</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Purpose</span><p id="par0060" class="elsevierStylePara elsevierViewall">The main purpose of this paper is&#58;<ul class="elsevierStyleList" id="lis0010"><li class="elsevierStyleListItem" id="lsti0025"><span class="elsevierStyleLabel">1&#46;</span><p id="par0065" class="elsevierStylePara elsevierViewall">To evaluate the burden of hypercholesterolemia in Portugal in the last 10 years and to build a national infographic &#40;scorecard&#41;&#44; including cholesterol and other ASCVD risk factors&#44; to be used for advocacy purposes and</p></li><li class="elsevierStyleListItem" id="lsti0030"><span class="elsevierStyleLabel">2&#46;</span><p id="par0070" class="elsevierStylePara elsevierViewall">To propose preventive strategies to combat hypercholesterolemia in Portugal&#44; helping to create a Portuguese cholesterol roadmap&#46;</p></li></ul></p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Methodology</span><p id="par0075" class="elsevierStylePara elsevierViewall"><ul class="elsevierStyleList" id="lis0015"><li class="elsevierStyleListItem" id="lsti0035"><span class="elsevierStyleLabel">1&#46;</span><p id="par0080" class="elsevierStylePara elsevierViewall">A review of the literature regarding CVD and CV risk factors&#44; in particular hypercholesterolemia&#44; with creation of a national scorecard &#40;infographic&#41;&#46;</p></li><li class="elsevierStyleListItem" id="lsti0040"><span class="elsevierStyleLabel">2&#46;</span><p id="par0085" class="elsevierStylePara elsevierViewall">A discussion of the strategies to control hypercholesterolemia in Portugal by a group of experts&#44; helping to build a national roadmap&#46;</p></li></ul></p><p id="par0090" class="elsevierStylePara elsevierViewall">The hypercholesterolemia burden in Portugal was identified and evaluated in a literature review over the last 10 years&#44; creating the picture of hypercholesterolemia in Portugal&#44; to be inserted in an infographic &#40;scorecard&#41;&#46;</p><p id="par0095" class="elsevierStylePara elsevierViewall">The objective of the WHF&#39;s scorecard project is to create a clear picture of the current state of CV disease &#40;CVD&#41; prevention&#44; CV risk factors &#40;such as hypercholesterolemia&#41; control and management in each country and feed it into a systemized assessment of CV policy on a regional and global scale&#46; The advocates for heart health can improve the campaign to change the current reality if armed with a comprehensive overview of both the burden of CVD and the policies in place to tackle it&#46; By measuring the national response to CVD&#44; countries are better able to distinguish priorities&#44; map progress&#44; and ultimately&#44; be held accountable for action to promote better outcomes&#46;</p><p id="par0100" class="elsevierStylePara elsevierViewall">A workshop was organized at the Portuguese Society of Cardiology &#40;<span class="elsevierStyleItalic">SPC</span>&#41;&#44; including experts in dyslipidemia&#44; prevention&#44; and public health&#46; At this meeting&#44; after the presentation of the WHF Roadmap by one of the authors&#44; participants were grouped and discussed the focus of the WHF Cholesterol Roadmap&#58;<ul class="elsevierStyleList" id="lis0020"><li class="elsevierStyleListItem" id="lsti0045"><span class="elsevierStyleLabel">1&#46;</span><p id="par0105" class="elsevierStylePara elsevierViewall">Awareness improvement strategies&#46;</p></li><li class="elsevierStyleListItem" id="lsti0050"><span class="elsevierStyleLabel">2&#46;</span><p id="par0110" class="elsevierStylePara elsevierViewall">Population-based approaches for CV risk and cholesterol decrease strategies&#46;</p></li><li class="elsevierStyleListItem" id="lsti0055"><span class="elsevierStyleLabel">3&#46;</span><p id="par0115" class="elsevierStylePara elsevierViewall">Risk assessment&#47;population screening strategies&#46;</p></li><li class="elsevierStyleListItem" id="lsti0060"><span class="elsevierStyleLabel">4&#46;</span><p id="par0120" class="elsevierStylePara elsevierViewall">System-level approaches strategies&#46;</p></li><li class="elsevierStyleListItem" id="lsti0065"><span class="elsevierStyleLabel">5&#46;</span><p id="par0125" class="elsevierStylePara elsevierViewall">Surveillance of cholesterol and ASCVD outcomes strategies&#46;</p></li><li class="elsevierStyleListItem" id="lsti0070"><span class="elsevierStyleLabel">6&#46;</span><p id="par0130" class="elsevierStylePara elsevierViewall">Strategies proposed by the groups to combat this problem were then debated by all the participants in an idea generation workshop&#44; with the goal of creating a national cholesterol roadmap to be used for advocacy and as a guide for CV prevention&#46;</p></li></ul></p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Results</span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Results I&#58; Cholesterol picture in Portugal - Literature review</span><p id="par0135" class="elsevierStylePara elsevierViewall">From the review of the relevant literature on the cholesterol problem in Portugal in the last 10 years&#44; we now present the main results of the studies&#44; registries&#44; and guidelines in Portugal&#46;</p><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">The VALSIM study</span><p id="par0140" class="elsevierStylePara elsevierViewall">The VALSIM study&#44;<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">3</span></a> published in 2013&#44; included 16<span class="elsevierStyleHsp" style=""></span>856 individuals &#40;mean age 58&#46;1&#177;15&#46;1 years&#41;&#44; observed in primary healthcare centers in Portugal&#44; which sought to characterize total cholesterol &#40;TC&#41;&#44; LDL-C&#44; high-density lipoprotein cholesterol &#40;HDL-C&#41; and triglycerides &#40;TG&#41;&#44; showed a high prevalence of dyslipidemia in adults &#40;62&#37; female&#44; 58&#177;15 years&#41;&#46; TC &#8805;200 mg&#47;dl was recorded at 47&#37; and LDL-C &#8805;130 mg&#47;dl in 38&#37; of the individuals analyzed&#46; Hypertriglyceridemia &#40;&#8805;200 mg&#47;dl&#41; and low HDL-C &#40;&#60;40 mg&#47;dl&#41; were less prevalent&#44; affecting 13&#37; of the population&#46; Hypercholesterolemia was particularly frequent in males aged 30&#8211;60 years&#44; and in postmenopausal women&#44; which should be target-subgroups for strategic public health strategies&#46;</p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">1st National Health Examination Survey</span><p id="par0145" class="elsevierStylePara elsevierViewall">In 2015&#44; The National Health Institute Doctor Ricardo Jorge published the 1st National Health Examination Survey&#44;<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">4</span></a> as health questionnaires with a physical examination were a strategy from the European Commission to improve quality and to compare the quality of healthcare across Europe&#46;</p><p id="par0150" class="elsevierStylePara elsevierViewall">This survey was an epidemiologic observational transversal study with the main purpose of improving public health and decreasing inequities in Portugal&#46; It examined a population of 4911 individuals aged 25&#8211;74 years old and included three components&#58; physical examination&#44; blood testing and clinical interview&#46;</p><p id="par0155" class="elsevierStylePara elsevierViewall">In summary&#44; the main results were&#58;<ul class="elsevierStyleList" id="lis0025"><li class="elsevierStyleListItem" id="lsti0075"><span class="elsevierStyleLabel">&#8226;</span><p id="par0160" class="elsevierStylePara elsevierViewall">52&#37; of the Portuguese general population aged 25&#8211;74 years had TC &#8805;190 mg&#47;dl&#46;</p></li><li class="elsevierStyleListItem" id="lsti0080"><span class="elsevierStyleLabel">&#8226;</span><p id="par0165" class="elsevierStylePara elsevierViewall">63&#37; were taking medication to reduce cholesterol levels &#40;no differences between male and female individuals&#41;&#46;</p></li><li class="elsevierStyleListItem" id="lsti0085"><span class="elsevierStyleLabel">&#8226;</span><p id="par0170" class="elsevierStylePara elsevierViewall">Prevalence of elevated TC or LLT increased with age&#44; reaching 80&#37; in individuals &#62;55 years old&#46;</p></li><li class="elsevierStyleListItem" id="lsti0090"><span class="elsevierStyleLabel">&#8226;</span><p id="par0175" class="elsevierStylePara elsevierViewall">Prevalence of elevated TC or LLT was higher in central Portugal &#40;74&#46;4&#37;&#41; and lower in Lisbon and Tejo Valley &#40;57&#46;8&#37;&#41; &#40;a trend that remained after standardization of prevalence according to age and gender&#41;&#46;</p></li></ul></p></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0060">Guidelines on dyslipidemias treatment&#44; total cholesterol and triglycerides target values and on clinical audit instruments &#40;DGS&#41;</span><p id="par0180" class="elsevierStylePara elsevierViewall">In 2017&#44; the Portuguese Directorate of Health &#40;DGS&#41; 2011 Norms were updated &#40;the guidelines treatment on dyslipidemias&#44; TC and TG target values and clinical audit instrument&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">5</span></a></p></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">EUROASPIRE IV and V</span><p id="par0185" class="elsevierStylePara elsevierViewall">In Europe&#44; the cross-sectional ESC-EORP EUROASPIRE Survey Registries IV<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">6</span></a> and V&#44;<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">7</span></a> supported by the European Society of Cardiology &#40;ESC&#41;&#44; were conducted in patients with coronary atherosclerotic disease &#40;CAD&#41;&#44; to evaluate the implementation of CV prevention guidelines&#44; which included lipid levels control and target values attainment&#46; In the last EUROASPIRE V&#44; 131 centers&#44; from 81 geographical regions in 27 countries &#40;including Portugal&#41; enrolled 8261 patients between 2016 and 2017&#46;</p><p id="par0190" class="elsevierStylePara elsevierViewall">The summary and main conclusions of this study were<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">7</span></a>&#58;<ul class="elsevierStyleList" id="lis0030"><li class="elsevierStyleListItem" id="lsti0095"><span class="elsevierStyleLabel">&#8226;</span><p id="par0195" class="elsevierStylePara elsevierViewall">71&#37; of CAD patients had LDL-C level &#8805;70 mg&#47;dl in Europe &#40;mean value&#41;&#44; while 69&#37; in Portugal&#44; with large differences among countries&#44; ranging from 51&#37; in Spain to 90&#37; in Lithuania&#46;</p></li><li class="elsevierStyleListItem" id="lsti0100"><span class="elsevierStyleLabel">&#8226;</span><p id="par0200" class="elsevierStylePara elsevierViewall">37&#37; of patients had LDL-C &#8805;100 mg&#47;dl&#44; 29&#37; had never been informed of raised cholesterol&#44; and 21&#37; had not had any cholesterol measurements taken since hospital discharge&#46;</p></li><li class="elsevierStyleListItem" id="lsti0105"><span class="elsevierStyleLabel">&#8226;</span><p id="par0205" class="elsevierStylePara elsevierViewall">84&#37; of patients were prescribed LLT&#44; including 80&#37; on statins and 50&#37; on high-intensity statins or drug combinations &#40;which may reduce LDL-C by &#62;50&#37;&#41;&#46;</p></li><li class="elsevierStyleListItem" id="lsti0110"><span class="elsevierStyleLabel">&#8226;</span><p id="par0210" class="elsevierStylePara elsevierViewall">32&#37; of patients on LLT had LDL-C &#60;70 mg&#47;dl&#44; although significantly less in female patients &#40;p&#60;0&#46;0001&#41;&#59; 76&#37; reported full prescription compliance&#46;</p></li><li class="elsevierStyleListItem" id="lsti0115"><span class="elsevierStyleLabel">&#8226;</span><p id="par0215" class="elsevierStylePara elsevierViewall">29&#37; of all CAD patients reported diabetes&#46;</p></li><li class="elsevierStyleListItem" id="lsti0120"><span class="elsevierStyleLabel">&#8226;</span><p id="par0220" class="elsevierStylePara elsevierViewall">46&#37; were advised to participate in a cardiac rehabilitation program and 69&#37; of those advised attended at least 50&#37; of the sessions&#46;</p></li></ul></p><p id="par0225" class="elsevierStylePara elsevierViewall">The results of the EUROASPIRE V survey showed that most CAD patients have less than optimal management of LDL-C&#46; More professional strategies are needed&#44; aiming at lifestyle changes and LLT adapted to the individual needs of the patient&#46;</p><p id="par0230" class="elsevierStylePara elsevierViewall">Another branch of EUROASPIRE was dedicated to evaluating CV risk in primary care &#40;no CAD&#41;&#44;<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">8</span></a> of which the general results were&#58;<ul class="elsevierStyleList" id="lis0035"><li class="elsevierStyleListItem" id="lsti0125"><span class="elsevierStyleLabel">&#8226;</span><p id="par0235" class="elsevierStylePara elsevierViewall">&#60;50&#37; patients on LLT achieving LDL-C target &#40;better control in male patients&#41;&#46;</p></li><li class="elsevierStyleListItem" id="lsti0130"><span class="elsevierStyleLabel">&#8226;</span><p id="par0240" class="elsevierStylePara elsevierViewall">&#60;50&#37; patients on LLT were aware of their cholesterol levels and &#60;33&#37; knew their cholesterol target&#46;</p></li><li class="elsevierStyleListItem" id="lsti0135"><span class="elsevierStyleLabel">&#8226;</span><p id="par0245" class="elsevierStylePara elsevierViewall">&#62;40&#37; patients with elevated LDL-C had never been told they had high cholesterol&#46;</p></li></ul></p><p id="par0250" class="elsevierStylePara elsevierViewall">The results of EUROASPIRE V are in accordance with earlier surveys of primary prevention in Europe&#44; USA and worldwide&#44; most of them focused on control of a single risk factor&#44; while information on management of multiple risk factors in patients at high risk is limited&#46;</p></span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">The LATINO study</span><p id="par0255" class="elsevierStylePara elsevierViewall">The LATINO study&#44;<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">9</span></a> performed at 14 Portuguese health centers and one central hospital in the North of Portugal&#44; included data from 78<span class="elsevierStyleHsp" style=""></span>459 patients to evaluate lipid control in different CV risk groups&#46; It identified major missed treatment opportunities to optimize LDLC management for every risk category&#44; particularly emphasizing high- and very-high-risk patients&#46; The higher the CV risk&#44; the lower the number of patients with ideal targeted LDL-C&#58;<ul class="elsevierStyleList" id="lis0040"><li class="elsevierStyleListItem" id="lsti0140"><span class="elsevierStyleLabel">&#8226;</span><p id="par0260" class="elsevierStylePara elsevierViewall">44&#37; at low risk&#46;</p></li><li class="elsevierStyleListItem" id="lsti0145"><span class="elsevierStyleLabel">&#8226;</span><p id="par0265" class="elsevierStylePara elsevierViewall">27&#37; at intermediate risk&#46;</p></li><li class="elsevierStyleListItem" id="lsti0150"><span class="elsevierStyleLabel">&#8226;</span><p id="par0270" class="elsevierStylePara elsevierViewall">7&#37; at high risk&#46;</p></li><li class="elsevierStyleListItem" id="lsti0155"><span class="elsevierStyleLabel">&#8226;</span><p id="par0275" class="elsevierStylePara elsevierViewall">3&#37; at very high risk&#46;</p></li></ul></p><p id="par0280" class="elsevierStylePara elsevierViewall">This study also highlighted the need to use high-intensity statins and combination therapy&#44; putting the most recent recommendations into clinical practice&#46; Investment in adequate LDL-C control seems to be the most promising solution to decrease the high burden of ASCVD in Portugal&#46;</p></span></span><span id="sec0060" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Results II&#58; Cholesterol and CV risk burden in Portugal - Infographics</span><p id="par0285" class="elsevierStylePara elsevierViewall">The objective of the scorecard project is to create a clear picture of the current state of CVD prevention&#44; control&#44; and management in each country&#44; and feed it into a systemized assessment of CV policy on a regional and global scale&#46; By measuring the national response to CVD&#44; countries are better able to distinguish priorities&#44; map progress&#44; and ultimately&#44; be held accountable for action to promote better outcomes&#46;</p><p id="par0290" class="elsevierStylePara elsevierViewall">After the evaluation of Portuguese studies referring to cholesterol&#44; and based on present data&#44; a scorecard &#40;infographic&#41; was produced to be included in the WHF collection &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Figure 2</a>&#41;&#44; for a clearer idea of the cholesterol burden and figures on other CV risk factors in Portugal &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Figure 1</a>&#41; and also to gain knowledge on national pharmacological interventions in CV risk factors management&#44; in Clinical practice and guidelines&#44; strategies in CVD governance and stakeholder action &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Figure 1</a>&#41;&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0295" class="elsevierStylePara elsevierViewall">Cardiovascular health advocates can improve campaigns to change the current scenario if they have a comprehensive overview of both the burden of CVD and hypercholesterolemia and the policies in place to tackle it&#46;</p></span></span><span id="sec0065" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Discussion</span><p id="par0300" class="elsevierStylePara elsevierViewall">A roadmap is a clear and general strategic plan to achieve a particular target&#46; Depending on the current situation &#8211; political&#44; social&#44; economic&#44; religious&#44; physical&#47;psychological health&#44; and literacy &#8211; strategies need to be designed and modified to adapt and achieve the target&#46; In this setting&#44; different countries will probably try to achieve the same targets&#44; but with different barriers and starting points&#44; sometimes using also different roads&#46; The <span class="elsevierStyleItalic">SPC</span> was challenged to create a group of experts to generate ideas regarding potential solutions for the problem of inadequate cholesterol management&#46; The main barriers for adequate management of the cholesterol in Portugal identified by the CV prevention experts were the lack of health literacy&#44; low social-economic status&#44; lack of good communication among stakeholders and lack of a structured plan&#46;</p><p id="par0305" class="elsevierStylePara elsevierViewall">It was also emphasized that a national structured plan for cholesterol CV risk management involves different stakeholders identified in <a class="elsevierStyleCrossRef" href="#fig0010">Figure 2</a>&#46; The place for action is very wide and can include ministries&#44; city halls&#44; hospitals&#44; clinics&#44; pharmacies&#44; schools&#44; universities&#44; supermarkets&#44; hairdressers&#44; barbers&#44; TV&#44; radio&#44; social networks&#44; newspapers&#44; and magazines&#46;</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0310" class="elsevierStylePara elsevierViewall">The panel of experts decided a call for action was needed with strategies grouped according to the five main principles of the WHF Cholesterol Roadmap &#40;<a class="elsevierStyleCrossRefs" href="#tbl0005">Tables 1&#8211;5</a>&#41;&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><elsevierMultimedia ident="tbl0015"></elsevierMultimedia><elsevierMultimedia ident="tbl0020"></elsevierMultimedia><elsevierMultimedia ident="tbl0025"></elsevierMultimedia><p id="par0315" class="elsevierStylePara elsevierViewall">It was agreed that the problem of cholesterol is still a reality in Portugal&#46; Despite all the efforts to reduce cholesterol levels&#44; it was also pointed out that we must look more widely to the global risk profile&#44; to the control of many CV risk factors&#44; as smoking cessation&#44; hypertension&#44; obesity and diabetes&#44; more than to isolated risk factors&#44; promoting a healthy lifestyle&#44; with physical activity and adequate nutrition&#44; associated with drugs&#44; as necessary&#44; but mainly to forge different mentalities&#44; with healthy behaviors and environments&#46; In Portugal in 2019&#44; data revealed that hyperglycemia&#44; hypertension&#44; smoking and high body mass index were more associated to coronary and cerebrovascular disease &#40;main causes of death&#41; than cholesterol&#46; It is important to highlight that in the Portuguese cholesterol roadmap we are targeting the CV risk as a whole&#44; despite our main concerns in this discussion having been the hypercholesterolemia burden&#46;</p><p id="par0320" class="elsevierStylePara elsevierViewall">The main points considered in this discussion&#44; which should be part of a general plan to combat the problem&#44; where the SPC can have a crucial role&#44; are summarized as follows&#58;</p></span><span id="sec0070" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Recommendations&#58; key points for action</span><p id="par0325" class="elsevierStylePara elsevierViewall"><ul class="elsevierStyleList" id="lis0045"><li class="elsevierStyleListItem" id="lsti0160"><span class="elsevierStyleLabel">&#8226;</span><p id="par0330" class="elsevierStylePara elsevierViewall">Include all the stakeholders in a multidisciplinary and well conducted national program coordinated by Health National Services Task Force&#44; including scientific societies&#44; universities&#44; associations&#44; foundations&#44; hospitals&#44; and primary care centers&#44; and prioritizing the value of patients&#8217; associations with government&#39;s support&#46;</p></li><li class="elsevierStyleListItem" id="lsti0165"><span class="elsevierStyleLabel">&#8226;</span><p id="par0335" class="elsevierStylePara elsevierViewall">Create a structured activities plan to increase awareness of CVD and risk stratification &#40;with cholesterol and other risk factors&#41; in the population&#44; with simple messages disseminated through competent and appropriate communication channels&#46;</p></li><li class="elsevierStyleListItem" id="lsti0170"><span class="elsevierStyleLabel">&#8226;</span><p id="par0340" class="elsevierStylePara elsevierViewall">Improve the quality of CV health education to healthcare professionals &#40;which needs to be continuous&#41;&#44; patients&#44; public&#44; politicians&#44; journalists and especially children&#46;</p></li><li class="elsevierStyleListItem" id="lsti0175"><span class="elsevierStyleLabel">&#8226;</span><p id="par0345" class="elsevierStylePara elsevierViewall">Increase the interaction between different health professionals and with non-health professionals regarding ASCVD risk and cholesterol burden management&#46;</p></li><li class="elsevierStyleListItem" id="lsti0180"><span class="elsevierStyleLabel">&#8226;</span><p id="par0350" class="elsevierStylePara elsevierViewall">Increment referral of individuals with elevated CV risk and with already established CVD to cardiac rehabilitation&#46;</p></li><li class="elsevierStyleListItem" id="lsti0185"><span class="elsevierStyleLabel">&#8226;</span><p id="par0355" class="elsevierStylePara elsevierViewall">Screen the cholesterol levels &#40;focus on LDL cholesterol levels&#41; in general population&#44; especially high-risk groups&#46;</p></li><li class="elsevierStyleListItem" id="lsti0190"><span class="elsevierStyleLabel">&#8226;</span><p id="par0360" class="elsevierStylePara elsevierViewall">Promote patients&#8217; self-care&#44; engaging patients&#8217; associations to enhance CV risk and cholesterol management&#46;</p></li><li class="elsevierStyleListItem" id="lsti0195"><span class="elsevierStyleLabel">&#8226;</span><p id="par0365" class="elsevierStylePara elsevierViewall">Use specific social networks to spread information on CV risk and dyslipidemia and to educate healthcare professionals and the general population&#44; reach a large range of people and increase health literacy&#46;</p></li><li class="elsevierStyleListItem" id="lsti0200"><span class="elsevierStyleLabel">&#8226;</span><p id="par0370" class="elsevierStylePara elsevierViewall">Create a national database with cholesterol levels and a systematic registry of CV events&#44; accessible to all health units&#46;</p></li><li class="elsevierStyleListItem" id="lsti0205"><span class="elsevierStyleLabel">&#8226;</span><p id="par0375" class="elsevierStylePara elsevierViewall">Evaluate results and redefine strategies&#44; as necessary&#44; according to these results&#46;</p></li><li class="elsevierStyleListItem" id="lsti0210"><span class="elsevierStyleLabel">&#8226;</span><p id="par0380" class="elsevierStylePara elsevierViewall">Create and involve more patients&#8217; associations &#8211; invert the pyramid order&#33;</p></li></ul></p><p id="par0385" class="elsevierStylePara elsevierViewall">Some progress has already made regarding cholesterol prevention and management&#44; with the intervention of the SPC&#44; universities and the Portuguese Cardiology Foundation&#44; highlighted in the activities listed below&#58;</p></span><span id="sec0075" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Work in progress&#58; summary</span><p id="par0390" class="elsevierStylePara elsevierViewall"><ul class="elsevierStyleList" id="lis0050"><li class="elsevierStyleListItem" id="lsti0215"><span class="elsevierStyleLabel">&#8226;</span><p id="par0395" class="elsevierStylePara elsevierViewall">ESC Preventive Guidelines translated to Portuguese by the <span class="elsevierStyleItalic">SPC</span> CV Risk Working Group&#46;</p></li><li class="elsevierStyleListItem" id="lsti0220"><span class="elsevierStyleLabel">&#8226;</span><p id="par0400" class="elsevierStylePara elsevierViewall">Multidisciplinary meeting for CV risk prevention implementation by the Institute of Preventive Medicine of the Faculty of Medicine of the University of Lisbon&#46;</p></li><li class="elsevierStyleListItem" id="lsti0225"><span class="elsevierStyleLabel">&#8226;</span><p id="par0405" class="elsevierStylePara elsevierViewall">CV risk and prevention strategies on health websites&#44; TVs&#44; newspapers&#44; and social networks communication&#46;</p></li><li class="elsevierStyleListItem" id="lsti0230"><span class="elsevierStyleLabel">&#8226;</span><p id="par0410" class="elsevierStylePara elsevierViewall">CV prevention sessions in schools promoted by the <span class="elsevierStyleItalic">SPC</span>&#46;</p></li><li class="elsevierStyleListItem" id="lsti0235"><span class="elsevierStyleLabel">&#8226;</span><p id="par0415" class="elsevierStylePara elsevierViewall">Participation in radio programs about CV prevention promoted by the University of Lisbon&#46;</p></li><li class="elsevierStyleListItem" id="lsti0240"><span class="elsevierStyleLabel">&#8226;</span><p id="par0420" class="elsevierStylePara elsevierViewall">Questionnaire administered this year &#40;2023&#41; by the Portuguese Cardiology Foundation by phone to 800 Portuguese adults&#46; From the inquired individuals&#44; 88&#37; &#40;between 18 and 24 years old&#41;&#44; 86&#37; &#40;between 25 and 44 years old&#41;&#44; 66&#37; &#40;between 45 and 64 years old&#41; and 69&#37; &#40;&#8805;65 years old&#41; did not know their cholesterol level&#46; From these&#44; 89&#37; knew cholesterol is a circulating fat in the body and 64&#37; indicated that the normal value is inferior to 190 mg&#47;dl&#46; Regarding the question which CVD were provoked by high cholesterol&#44; 42&#37; highlighted stroke&#44; 25&#37; myocardial infarction and 18&#37; CVD&#46; As the main cause of myocardial infarction&#44; 49&#37; pointed out high cholesterol and 32&#37; hypertension&#46;</p></li></ul></p><p id="par0425" class="elsevierStylePara elsevierViewall">The SPC&#44; particularly its CV Risk Working Group&#44; is engaged in fighting the cholesterol and global ASCVD risk burden with the WHF and European Societies and Associations&#44; defining strategies for cholesterol control and global CV risk management&#46; A national survey on CV risk with appropriate analysis and follow-up could be a way of monitoring this situation and insisting on action by politicians&#44; which may be part of the solution&#46;</p></span><span id="sec0080" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Conclusions</span><p id="par0430" class="elsevierStylePara elsevierViewall">Cholesterol management remains a global strong issue for both primary and secondary prevention&#44; also in Portugal&#46; The involvement of multiple stakeholders&#44; including politicians&#44; healthcare practitioners&#44; non-health-related practitioners&#44; patients&#44; and the general population&#44; is essential to overcome current limitations in this field&#46; The Portuguese cholesterol roadmap&#44; which arose from the idea generation promoted by the WHF at the <span class="elsevierStyleItalic">SPC</span> involving cardiologists and other specialists&#44; can provide some solutions to urgently help minimize this problem&#46; Population-based approaches to improve awareness and strategies for CV risk assessment&#44; surveillance of cholesterol and ASCVD outcomes&#44; are key factors in this change&#46; A call to action is clearly needed to fight hypercholesterolemia and ASCVD burden&#46;</p></span><span id="sec0090" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">Funding</span><p id="par0440" class="elsevierStylePara elsevierViewall">WHF funded Portuguese Society of Cardiology expert work regarding the Portuguese Cholesterol Roadmap&#46;</p></span><span id="sec0085" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0105">Conflicts of interest</span><p id="par0435" class="elsevierStylePara elsevierViewall">The authors have no conflicts of interest to declare&#46;</p></span></span>"
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        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Atherosclerotic cardiovascular disease &#40;ASCVD&#41; remains the major cause of premature death and disability&#59; effective cardiovascular &#40;CV&#41; risk prevention is fundamental&#46; The World Heart Federation &#40;WHF&#41; Cholesterol Roadmap provides a framework for national policy development and aims to achieve ASCVD prevention&#46;</p><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">At the invitation of the WHF&#44; a group of experts from the Portuguese Society of Cardiology &#40;SPC&#41;&#44; addressed the cholesterol burden at nationally and discussed possible strategies to include in a Portuguese cholesterol roadmap&#46; The literature review showed that the cholesterol burden in Portugal is high and especially uncontrolled in those with the highest CV risk&#46; An infographic scorecard was built to include in the WHF collection&#44; for a clear idea about CV risk and cholesterol burden in Portugal&#44; which would also be useful for health policy advocacy&#46;</p><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">The expert discussion and preventive strategies proposal followed the five pillars of the WHF document&#58; awareness improvement&#59; population-based approaches for CV risk and cholesterol&#59; risk assessment&#47;population screening&#59; system-level approaches&#59; surveillance of cholesterol and ASCVD outcomes&#46; These strategies were debated by all the expert participants&#44; with the goal of creating a national cholesterol roadmap to be used for advocacy and as a guide for CV prevention&#46;</p><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Several key recommendations were outlined&#58; include all stakeholders in a multidisciplinary national program&#59; create a structured activities plan to increase awareness in the population&#59; improve the quality of continuous CV health education&#59; increase the interaction between different health professionals and non-health professionals&#59; increment the referral of patients to cardiac rehabilitation&#59; screen cholesterol levels in the general population&#44; especially high-risk groups&#59; promote patient self-care&#44; engage with patients&#8217; associations&#59; use specific social networks to spread information widely&#59; create a national database of cholesterol levels with systematic registry of CV events&#59; redefine strategies based on the evaluation of results&#59; create and involve more patients&#8217; associations &#8211; invert the pyramid order&#46;</p><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">In conclusion&#44; ASCVD and the cholesterol burden remain a strong global issue in Portugal&#44; requiring the involvement of multiple stakeholders in prevention&#46; The Portuguese cholesterol roadmap can provide some solutions to help urgently mitigate the problem&#46; Population-based approaches to improve awareness and CV risk assessment and surveillance of cholesterol and ASCVD outcomes are key factors in this change&#46; A call to action is clearly needed to fight hypercholesterolemia and ASCVD burden&#46;</p></span>"
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        "resumen" => "<span id="abst0010" class="elsevierStyleSection elsevierViewall"><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">A doen&#231;a ateroscler&#243;tica cardiovascular &#40;DACV&#41; mant&#233;m-se a maior causa de morte prematura e de incapacidade&#44; sendo uma preven&#231;&#227;o eficaz de risco cardiovascular &#40;CV&#41; fundamental&#46; O <span class="elsevierStyleItalic">WHF Cholesterol Roadmap</span> fornece enquadramento para o desenvolvimento de pol&#237;ticas nacionais&#44; tendo como objetivo a preven&#231;&#227;o de DACV&#46; A convite da WHF&#44; um grupo de peritos da Sociedade Portuguesa de Cardiologia &#40;SPC&#41; avaliou a carga do colesterol a n&#237;vel nacional e discutiu poss&#237;veis estrat&#233;gias para um <span class="elsevierStyleItalic">Roadmap</span> portugu&#234;s&#46;</p><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">A revis&#227;o da literatura mostrou uma carga elevada de colesterol em Portugal&#44; sobretudo em pessoas de alto risco CV&#46; Uma infografia&#44; <span class="elsevierStyleItalic">Scorecard</span>&#44; foi constru&#237;da pela WHF&#44; para mostrar claramente o risco CV e o peso do colesterol em Portugal&#44; sendo &#250;til para advocacia em pol&#237;ticas de sa&#250;de&#46;</p><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">A discuss&#227;o de peritos e proposta das estrat&#233;gias preventivas seguiram os cinco pilares do documento da WHF&#58; Melhoria da consciencializa&#231;&#227;o&#59; Abordagens do risco CV e do colesterol nas popula&#231;&#245;es&#59; Avalia&#231;&#227;o de risco&#47;<span class="elsevierStyleItalic">screening</span> das popula&#231;&#245;es&#59; abordagens a n&#237;vel do sistema&#59; Seguimento do colesterol e complica&#231;&#245;es da DACV&#46;</p><p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">V&#225;rias recomenda&#231;&#245;es chave foram definidas&#58; incluir todos os <span class="elsevierStyleItalic">stakeholders</span> em programa multidisciplinar nacional&#59; criar plano de atividades estruturadas para aumentar a consciencializa&#231;&#227;o da popula&#231;&#227;o&#59; aumentar qualidade da educa&#231;&#227;o cont&#237;nua em sa&#250;de CV&#59; aumentar intera&#231;&#227;o entre profissionais de sa&#250;de e outros profissionais&#59; aumentar referencia&#231;&#227;o de doentes para reabilita&#231;&#227;o cardiovascular&#59; avaliar n&#237;veis de colesterol na popula&#231;&#227;o geral&#44; especialmente em alto risco&#59; promover autocuidado dos doentes&#44; envolvendo associa&#231;&#245;es de doentes&#59; usar redes sociais espec&#237;ficas para disseminar informa&#231;&#227;o&#59; criar base nacional de n&#237;veis de colesterol com registo sistem&#225;tico de eventos CV&#59; redefinir estrat&#233;gias baseadas na avalia&#231;&#227;o de resultados&#59; criar e envolver mais doentes em associa&#231;&#245;es &#8211; inverter a ordem da pir&#226;mide&#33;</p><p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">Em conclus&#227;o&#44; a DACV e o peso de colesterol permanecem uma quest&#227;o global forte em Portugal&#44; necessitando o envolvimento de m&#250;ltiplos <span class="elsevierStyleItalic">stakeholders</span> na preven&#231;&#227;o&#46; O <span class="elsevierStyleItalic">Roadmap</span> de colesterol portugu&#234;s pode fornecer algumas solu&#231;&#245;es para urgentemente mitigar o problema&#46; Abordagens a n&#237;vel das popula&#231;&#245;es para melhorar a consciencializa&#231;&#227;o e avaliar o risco CV&#44; seguimento do colesterol e das complica&#231;&#245;es de DACV s&#227;o fatores chave nesta mudan&#231;a&#46; Uma <span class="elsevierStyleItalic">call to action</span> &#233; claramente necess&#225;ria para combater a carga da hipercolesterolemia e DACV&#46;</p></span>"
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>&#8226; Slide kit production at SPC for healthcare professionals regarding&#58;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>- CV risk of people with high blood cholesterol levels&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>- Cholesterol target values according to CV risk&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>- High cholesterol treatment&#58; non-pharmacological &#40;lifestyle modification&#41; and pharmacological&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>- Techniques for promoting adherence&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">To use this kit in a structured plan of meetings covering the primary care units and hospitals of the country regions&#59; additionally&#44; can be also used in joint sessions with other scientific societies&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>&#8226; Slide kit production at SPC for patients in SPC website &#40;open to public&#41; and translation of the WHF film of cholesterol roadmap for the population with dissemination through patient associations&#44; in educational sessions plan&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>&#8226; Elaboration of strategies for inclusive communication &#40;simple and solid messages&#41; to be present in daily life &#40;posters&#44; screens&#41;&#58;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>- Targeting healthcare professionals and patients in hospitals and clinics&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>- Targeting the population&#44; to be promoted in supermarkets&#44; pharmacies&#44; gymnasiums&#44; and in social media &#40;very short videos&#41;&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>&#8226; Campaigns involving politicians and using popular ambassadors on radio&#44; TV&#44; social networks&#44; investing in communication techniques&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>&#8226; Convincing health politicians for legislation about food nutrients&#44; reducing trans-fats&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>&#8226; Mandatory introduction of codes &#40;&#8220;traffic-light&#8221; like&#41; in processed food&#44; regarding the degree of healthy&#47;non-healthy and the content of fats and trans-fats&#44; and use of quality stamps&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>&#8226; Educational actions at schools&#44; from a very young age&#44; on CV risk and high cholesterol risk&#44; involving scientific societies and universities&#44; with production of educational contents&#46;<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">10</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
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                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>&#8226; Involvement of coffeehouses&#44; restaurants and supermarkets in the reduction of fats intake&#44; reduction of red meat&#44; fat cheese&#44; milk and butter and non-vegetable oils&#59; with availability of a healthy menu scientifically supported by the national society&#46;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>&#8226; Calculation of digital risk scores in the population during big events or in big areas like malls or pharmacies&#44; and education on CV risk&#44; specially targeting those who are forgotten&#44; like women<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">11</span></a> and social minorities&#46;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>&#8226; Screening at schools for cholesterol level and education about healthy lifestyle&#44; nutrition&#44; and physical activity&#46;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>&#8226; Performance of National Questionnaire &#40;2nd&#41; with physical measurements&#44; as per the first in 2015&#46;&nbsp;\t\t\t\t\t\t\n
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                  <table border="0" frame="\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>&#8226; Dissemination in different hospital&#47;primary care units of CV risk scores and implementation of its use and education for it&#44; using the risk level to guide CV management &#40;preferably electronic version&#44; available and transversal to different health institutions&#41;&#46;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>&#8226; Promotion of affordable polypills to decrease CV risk and ASCVD burden to improve adherence and reduce CV events&#46;<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">12</span></a>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>&#8226; Inclusion of CV risk and prevention education as mandatory in schools&#8217; programs from a young age&#44; though collaboration between Ministry of Health and Ministry of Education&#46;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>&#8226; Removal of uniform &#8220;normal values&#8221; of cholesterol from the blood test reports &#40;values dependent on CV risk&#41;&#44; and keep them up to date&#44; according to the last guidelines&#46; Also&#44; the reporting of LDL cholesterol levels &#40;calculated or measured&#41; should be mandatory in blood tests reporting lipid profile&#46;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>&#8226; Increase referral for cardiac rehabilitation of CV patients after acute events &#40;e&#46;g&#46; automatic referral in hospitals&#41; and of high CV risk patients&#44; even before events &#40;signalizing high CV patients in primary care centers for referral&#41;&#46;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>&#8226; Development of an anonymized national web based database for serial cholesterol quantitative levels and CV events sharing&#44; with mandatory registration in all Hospitals and Primary Care Centers&#46;&nbsp;\t\t\t\t\t\t\n
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                    0 => array:2 [
                      "titulo" => "The state of cardiovascular disease in G20&#43; countries"
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                          "autores" => array:3 [
                            0 => "T&#46; Rittiphairoj"
                            1 => "A&#46; Reilly"
                            2 => "C&#46;L&#46; Reddy"
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                      "titulo" => "World Heart Federation Cholesterol Roadmap 2022"
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                          "etal" => true
                          "autores" => array:3 [
                            0 => "K&#46;K&#46; Ray"
                            1 => "B&#46;A&#46; Ference"
                            2 => "T&#46; S&#233;verin"
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                      ]
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                    0 => array:2 [
                      "doi" => "10.5334/gh.1154"
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                        "tituloSerie" => "Glob Heart"
                        "fecha" => "2022"
                        "volumen" => "17"
                        "paginaInicial" => "75"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/36382159"
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                0 => array:2 [
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                      "titulo" => "Caracteriza&#231;&#227;o do perfil lip&#237;dico nos utentes dos cuidados de sa&#250;de prim&#225;rios em Portugal"
                      "tituloTraducido" => "Characterization of lipid profile in primary health care users in Portugal"
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                        0 => array:2 [
                          "etal" => true
                          "autores" => array:3 [
                            0 => "N&#46; Cortez-Dias"
                            1 => "S&#46; Robalo Martins"
                            2 => "A&#46; Belo"
                          ]
                        ]
                      ]
                    ]
                  ]
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                    0 => array:2 [
                      "doi" => "10.1016/j.repc.2013.06.008"
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                        "tituloSerie" => "Rev Port Cardiol"
                        "fecha" => "2013"
                        "volumen" => "32"
                        "paginaInicial" => "987"
                        "paginaFinal" => "996"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/24280078"
                            "web" => "Medline"
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                      "titulo" => "The first Portuguese National Health Examination Survey &#40;2015&#41;&#58; design&#44; planning and implementation"
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                          "etal" => true
                          "autores" => array:3 [
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                            2 => "A&#46;P&#46; Gil"
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                  "host" => array:1 [
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                      "doi" => "10.1093/pubmed/fdy150"
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                        "tituloSerie" => "J Public Health &#40;Oxf&#41;"
                        "fecha" => "2019"
                        "volumen" => "41"
                        "paginaInicial" => "511"
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ISSN: 08702551
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