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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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