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Abstract

The review of the need of fasting for lipid profile analysis (total cholesterol, LDL-C, HDL-C, non-HDL-C, and triglycerides [TG]) is based on the following grounds: Since the postprandial state predominates during most of the day, the patient is more exposed to the lipid levels in this condition when compared with the fasting state. Therefore, the postprandial state may represent more effectively the potential impact of the lipid levels on an individual's cardiovascular risk. Measurements in the postprandial state are more practical and provide the patient a greater access to the laboratory, decreasing the number of missed working days and medical appointments due to missed tests, allowing a better assessment of the individual's cardiovascular risk. Blood collection in the postprandial state is safer in several circumstances and may help prevent hypoglycemia secondary to the use of insulin in patients with diabetes mellitus, or due to prolonged fasting in pregnant women, children, and elderly individuals, minimizing complications and increasing the adherence to the tests and the attendance to medical appointments. There are no significant differences in measurements of total cholesterol, HDL-C, non-HDL-C, and LDL-C performed in the postprandial or fasting state. Levels of TG increase in the fed state, but such increase has little relevance as far as a regular meal without fat overload is considered, with the possibility of adjustment in the reference values.1-7 With a flexibility for lipid profiling, there is a greater amplitude of schedules, thereby reducing congestion in the laboratories, especially early in the morning, bringing more comfort to the patient. With the technological advances in diagnostic methods, the main assays available have mitigated the interference caused by increased sample turbidity due to high TG concentrations. However, there are potential limitations, especially related to the calculation of LDL-C, in which performance studies of different methodologies have shown a need for a revision of the practical use of the adopted formulas.
Artigo Especial
Arq Bras Cardiol. 2017; 108(3):195-197
Posicionamento sobre a Flexibilização do Jejum para o Perfil Lipídico
Positioning about the Flexibility of Fasting for Lipid Profiling
Marileia Scartezini,1 Carlos Eduardo dos Santos Ferreira,2 Maria Cristina Oliveira Izar,3 Marcello Bertoluci,4 Sergio
Vencio,5 Gustavo Aguiar Campana,2 Nairo Massakazu Sumita,2 Luiz Fernando Barcelos,1 André A. Faludi,3 Raul D.
Santos,3, Marcus Vinícius Bolívar Malachias,3 Jerolino Lopes Aquino,1 César Alex de Oliveira Galoro,2 Cleide Sabino,4
Maria Helane Costa Gurgel,4 Luiz Alberto Andreotti Turatti,5 Alexandre Hohl,4 Tania Leme da Rocha Martinez3
Sociedade Brasileira de Análises Clínicas (SBAC),1 Rio de Janeiro, RJ; Sociedade Brasileira de Patologia Clínica/Medicina Laboratorial (SBPC/
ML),2 Rio de Janeiro, RJ; Sociedade Brasileira de Cardiologia (SBC),3 Rio de Janeiro, RJ; Sociedade Brasileira de Endocrinologia e Metabologia
(SBEM),4 Rio de Janeiro, RJ; Sociedade Brasileira de Diabetes (SBD),5 São Paulo, SP – Brasil
Palavras-chave
Jejum / metabolismo; Pós-prandial; Perfil Lipídico; Valores
referenciais; Categoria de risco.
Correspondência: Marileia Scartezini •
Rua Paulo Gorski, 1837 Apto 701 C, Mossunguê. CEP 81210-220, Curitiba,
PR – Brasil
E-mail: marileiasca@hotmail.com, marileiascar@gmail.com
DOI: 10.5935/abc.20170039
Justificativas
A revisão da necessidade do jejum para determinação do
perfil lipídico (colesterol total, LDL-C, HDL-C, não-HDL-C e
triglicérides [TG]) baseia-se nas seguintes justificativas:
Como o estado alimentado predomina durante a maior
parte do dia, o paciente está mais exposto aos níveis
de lipídes nesta condição em comparação ao estado
de jejum. Portanto, a condição pós-prandial pode
representar mais eficazmente o potencial impacto dos
níveis lipídicos no risco cardiovascular de um indivíduo.
As dosagens no estado pós-prandial são mais práticas,
viabilizando maior acesso do paciente ao laboratório,
com menor perda de dias de trabalho, abandono de
consultas médicas por falta de exames e maior acesso
à avaliação do risco cardiovascular.
A coleta de sangue no estado pós-prandial é mais
segura em diversas situações e pode ajudar a prevenir
a hipoglicemia por uso de insulina em pacientes
com diabetes mellitus, ou por jejum prolongado no
caso de gestantes, crianças e idosos, minimizando
intercorrências e aumentando a adesão para realização
de exames e o comparecimento às consultas médicas.
As determinações do colesterol total, HDL-C, não-HDL-C
e LDL-C não diferem significativamente se realizadas no
estado pós-prandial ou de jejum. Há aumento nos níveis
de TG no estado alimentado; porém, este aumento é
pouco relevante desde que se considere uma refeição
usual não sobrecarregada em gordura, havendo a
possibilidade de se ajustar os valores de referência.1-7
• Com a flexibilidade do jejum para o perfil lipídico,
há maior amplitude de horários, reduzindo assim o
congestionamento nos laboratórios, especialmente
no início da manhã, o que traz mais conforto para
o paciente.
Com os avanços tecnológicos nas metodologias
diagnósticas, os principais ensaios disponíveis mitigaram
as interferências causadas pela maior turbidez nas
amostras, decorrentes de elevadas concentrações de
TG. Contudo, há potenciais limitações, especialmente
referentes ao cálculo da LDL-C, onde estudos de
desempenho entre diferentes metodologias têm
demonstrado a necessidade de revisão das práticas de
utilização das fórmulas adotadas.
Aspectos Clínicos e Laboratoriais na Flexibilização do
Jejum para a Avaliação do Perl Lipídico
Com o processo de flexibilização do jejum na coleta da
amostra para avaliar o perfil lipídico, algumas recomendações
clínicas e laboratoriais são importantes.
Recomendações para o atendimento do paciente no
laboratório clínico
Coleta de amostra sem jejum para o perfil lipídico:
poderá ser realizada pelo laboratório com a presença
da informação do estado de jejum, no momento da
coleta da amostra, no laudo laboratorial.
Solicitação médica sem definição do tempo de jejum e que
não contenha outros exames sabidamente requerentes de
jejum: recomenda-se incluir o tempo informado de jejum
no momento da coleta no laudo laboratorial.
Presença na mesma solicitação de outros exames
que necessitem de jejum: o laboratório clínico
poderá definir que o perfil lipídico seja coletado com
jejum de 12h quando outros exames laboratoriais,
solicitados na mesma requisição, também necessitem
desse período de jejum. Recomenda-se que o
laboratório especifique a necessidade ou não do
jejum para cada exame: sem jejum, com jejum de
12h, ou conforme a definição do laboratório.
Quando houver a indicação de um tempo específico de
jejum: se na solicitação do médico houver um tempo
específico de jejum, o laboratório deverá seguir tal
recomendação. Poderá ser utilizado o cálculo de horas
de jejum pelo "SIL" (Sistema de Informação Laboratorial)
com base na informação do tempo da última refeição.
Quando os níveis de TG no estado pós-prandial se
encontrarem > 440 mg/dL ou na presença de situações
especiais como recuperação de pancreatite por
hipertrigliceridemia ou no início de tratamento com
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Artigo Especial
Scartezini et al
Flexibilização do jejum para o perfil lipídico
Arq Bras Cardiol. 2017; 108(3):195-197
drogas que causem hipertrigliceridemia grave, será
recomendado ao médico solicitante a prescrição de
uma nova avaliação de TG com jejum de 12h e será
considerado este teste como sendo um novo exame de
TG pelo laboratório clínico.1
Quando ocorrer a segunda coleta de amostra para TG:
ficará a critério de cada laboratório clínico, dependendo
de seu sistema e estratégia, utilizar o mesmo código ou
outro específico para o exame de TG sem jejum e TG
com jejum de 12h.
Recomendações de um modelo para o laudo laboratorial
O laudo laboratorial é de responsabilidade do laboratório
clínico e de seu responsável técnico. Com o intuito
de alinhamento e harmonização entre as instituições,
recomenda-se a adoção das seguintes informações no laudo:
• os valores referenciais e de alvo terapêutico do perfil
lipídico (adultos > 20 anos) de acordo com a avaliação
de risco cardiovascular estimado pelo médico solicitante
estão descritos na Tabela 1.1,8,9
Inserção de observação no laudo referenciando que
os valores de perfil lipídico devem ser interpretados
conforme avaliação e evolução clínica do paciente.
Recomenda-se a seguinte frase: “A interpretação
clínica dos resultados deverá levar em consideração o
motivo da indicação do exame, o estado metabólico do
paciente e a estratificação do risco para estabelecimento
das metas terapêuticas”.
Os valores referenciais desejáveis do perfil lipídico para
crianças e adolescentes são indicados na Tabela 2.10,11
Pacientes com diabetes e sem fatores de risco ou sem
evidência de aterosclerose subclínica devem manter o nível
de LDL-C abaixo de 100 mg/dL. Pacientes com fatores de
risco ou doença aterosclerótica subclínica devem manter
o nível de LDL-C abaixo de 70 mg/dL. Pacientes com
história de infarto agudo do miocárdio; acidente vascular
cerebral (AVC); revascularização coronariana, carotídea
ou periférica; ou história de amputação devem manter o
nível de LDL-C abaixo de 50 mg/dL.12,13
Fica a critério do laboratório a inclusão de uma observação
específica para o rastreamento da hipercolesterolemia
familiar (HF). Recomenda-se a utilização da seguinte frase:
“Valores de colesterol total ≥ 310 mg/dL em adultos ou
230 mg/dL em crianças e adolescentes podem ser
indicativos de hipercolesterolemia familiar, se excluídas as
dislipidemias secundárias”.14
Recomendações sobre fórmulas e dosagem direta de LDL-C
A avaliação do LDL-C pode ser realizada por dosagem
direta ou estimada por cálculo com base nas fórmulas
de Friedewald15 ou de Martin.16 Recomenda-se que os
laboratórios clínicos adotem as seguintes orientações:
Observar, na utilização da fórmula de Friedewald,
as limitações da falta de jejum e de valores de
TG > 400 mg/dL para estimar o LDL-C, podendo nestes
casos ser aplicada a fórmula de Martin, ou utilizada a
dosagem direta.
Na coleta de amostra pós-prandial, a avaliação do
LDL-C pode ser realizada por dosagem direta ou cálculo
através da fórmula de Martin.16
Incluir o cálculo do não-HDL-C junto aos demais resultados
do perfil lipídico para adultos, mesmo sem jejum, pois os
níveis de TG não interferem neste cálculo. Fica a critério do
laboratório reportar ou não o cálculo do VLDL-C.
A principal finalidade desse documento é padronizar
condutas clínicas e laboratoriais em relação à flexibilidade
do jejum na avaliação do perfil lipídico em todo território
nacional, contribuindo para que os médicos e os laboratórios
clínicos tenham segurança em suas tomadas de decisões, com
o respaldo de evidências científicas.
Tabela 1 – Valores referenciais e de alvos terapêuticos para adultos > 20 anos conforme avaliação de risco cardiovascular do paciente pelo
médico solicitante do perl lipídico
Lípides Com jejum (mg/dL) Sem jejum (mg/dL) Categoria referencial
Colesterol total* < 190 < 190 Desejável
HDL-C > 40 > 40 Desejável
Triglicérides** < 150 < 175 Desejável
Categoria de risco
LDL-C
< 130
< 100
< 70
< 50
< 130
< 100
< 70
< 50
Baixo
Intermediário
Alto
Muito alto
Não-HDL-C
< 160
< 130
< 100
< 80
< 160
< 130
< 100
< 80
Baixo
Intermediário
Alto
Muito alto
* Colesterol total > 310 mg/dL: considerar a probabilidade de hipercolesterolemia familiar; **Quando os níveis de triglicérides estiverem acima de 440 mg/dL (sem
jejum), o médico solicitante deverá fazer uma nova requisição para a avaliação de triglicérides com jejum de 12h e o laboratório clínico deverá considerar este teste
como sendo um novo exame de triglicérides.
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Artigo Especial
Scartezini et al
Flexibilização do jejum para o perfil lipídico
Arq Bras Cardiol. 2017; 108(3):195-197
Tabela 2 – Valores referenciais desejáveis do perl lipídico para crianças e adolescentes
Lípides Com jejum (mg/dL) Sem jejum (mg/dL)
Colesterol total* < 170 < 170
HDL-C > 45 > 45
Triglicérides (0-9 anos) ** < 75 < 85
Triglicérides (10-19 anos) ** < 90 < 100
LDL-C < 110 < 110
* Colesterol total > 230 mg/dL: considerar a probabilidade de hipercolesterolemia familiar; **Quando os níveis de triglicérides estiverem acima de 440 mg/dL (sem
jejum) o médico solicitante deverá fazer uma nova requisição para avaliação de triglicérides com jejum de 12h e o laboratório clínico deverá considerar este teste
como sendo um novo exame de triglicérides.
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Referências
Contribuição dos autores
Concepção e desenho da pesquisa, Obtenção de
dados, Análise e interpretação dos dados, Redação do
manuscrito e Revisão crítica do manuscrito quanto ao
conteúdo intelectual importante: Scartezini M, Ferreira
CES, Izar MCO, Bertoluci M, Vencio S, Campana GA,
Sumita NM, Barcelos LF, Faludi AA, Santos RD, Malachias
MVB, Aquino JL, Galoro CAO, Sabino C, Gurgel MHC,
Turatti LAA, Hohl A, Martinez TLR.
Potencial conflito de interesses
Declaro não haver conflito de interesses pertinentes.
Fontes de financiamento
O presente estudo não teve fontes de financiamento externas.
Vinculação acadêmica
Não há vinculação deste estudo a programas de pós-graduação.
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... Blood samples (12-14 h fast) were collected from the median antecubital vein (10 ml) in tubes with no additives or with sodium fluoride and ethylenediaminetetraacetic acid (EDTA), which were immediately centrifuged (1500 × g, 10 min). It is worth noting that nowadays fasting is not required for assessing lipid profile (13) . However, upon the study conduction, the new standardization had not taken place yet. ...
... Insulin resistance (IR) was evaluated by the homeostatic model assessment of insulin resistance index (HOMA-IR), using the formula: serum insulin (μU/ml) × serum glucose (mg/dl)/405 (13) . ...
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Few studies have investigated long-term changes in cardiorespiratory fitness (CRF), defined by indirect measures of CRF, and all-cause mortality. We aimed to investigate whether long-term change in CRF, as assessed by the gold standard method of respiratory gas exchange during exercise, is associated with all-cause mortality. A population-based sample of 579 men aged 42 to 60 years with no missing data at baseline examination (V1) and at reexamination at 11 years (V2) were included. Maximal oxygen uptake (VO2max) was measured at both visits using respiratory gas exchange during maximal exercise testing, and the difference (ΔVO2max) was calculated as VO2max (V2) − VO2max (V1). Deaths were ascertained annually using national death certificates during 15 years of follow-up after V2. The mean ΔVO2max was −5.2 mL/min*kg. During median follow-up of 13.3 years (interquartile range, 12.5-14.0 years), 123 deaths (21.2%) were recorded. In a multivariate analysis adjusted for baseline age, VO2max, systolic blood pressure, smoking status, low- and high-density lipoprotein cholesterol and triglyceride levels, C-reactive protein level, body mass index, alcohol consumption, physical activity, socioeconomic status, and history of type 2 diabetes mellitus and ischemic heart disease, a 1 mL/min*kg higher ΔVO2max was associated with a 9% relative risk reduction of all-cause mortality (hazard ratio, 0.91; 95% CI, 0.87-0.95). This study suggested that in this population, long-term CRF reduction was associated with an increased risk of mortality, emphasizing the importance of maintaining good CRF over the decades.
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Background: The pandemic of physical inactivity is associated with a range of chronic diseases and early deaths. Despite the well documented disease burden, the economic burden of physical inactivity remains unquantified at the global level. A better understanding of the economic burden could help to inform resource prioritisation and motivate efforts to increase levels of physical activity worldwide. Methods: Direct health-care costs, productivity losses, and disability-adjusted life-years (DALYs) attributable to physical inactivity were estimated with standardised methods and the best data available for 142 countries, representing 93·2% of the world's population. Direct health-care costs and DALYs were estimated for coronary heart disease, stroke, type 2 diabetes, breast cancer, and colon cancer attributable to physical inactivity. Productivity losses were estimated with a friction cost approach for physical inactivity related mortality. Analyses were based on national physical inactivity prevalence from available countries, and adjusted population attributable fractions (PAFs) associated with physical inactivity for each disease outcome and all-cause mortality. Findings: Conservatively estimated, physical inactivity cost health-care systems international $ (INT$) 53·8 billion worldwide in 2013, of which $31·2 billion was paid by the public sector, $12·9 billion by the private sector, and $9·7 billion by households. In addition, physical inactivity related deaths contribute to $13·7 billion in productivity losses, and physical inactivity was responsible for 13·4 million DALYs worldwide. High-income countries bear a larger proportion of economic burden (80·8% of health-care costs and 60·4% of indirect costs), whereas low-income and middle-income countries have a larger proportion of the disease burden (75·0% of DALYs). Sensitivity analyses based on less conservative assumptions led to much higher estimates. Interpretation: In addition to morbidity and premature mortality, physical inactivity is responsible for a substantial economic burden. This paper provides further justification to prioritise promotion of regular physical activity worldwide as part of a comprehensive strategy to reduce non-communicable diseases. Funding: None.
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Background: Chronic aerobic exercise training is associated with improved endothelial function and arterial stiffness and favourable long-term cardiovascular effects. Design: We investigated the acute effects of continuous moderate intensity aerobic exercise (CAE) and high intensity interval aerobic exercise (hIAE) on endothelial function and arterial stiffness in healthy participants. Methods: Twenty healthy men were recruited to this cross-over study. They participated in two exercise sessions: (a) CAE, volume at 50% of maximum aerobic work for 30 minutes; and (b) hIAE, interval maximum aerobic work for 30 minutes. Endothelial function was evaluated by flow-mediated dilation in the brachial artery. The carotid femoral pulse wave velocity and the femoral dorsalis pedis pulse wave velocity were measured as indices of central aortic and peripheral arterial stiffness. Measurements were carried out before and immediately after each exercise session. Results: There was no statistically significant difference in the baseline measurements before CAE and hIAE with respect to flow-mediated dilation, the carotid femoral pulse wave velocity and the femoral dorsalis pedis pulse wave velocity (p = NS). Both CAE and hIAE significantly improved the flow-mediated dilation compared with baseline (p < 0.001). Similarly, the femoral dorsalis pedis pulse wave velocity was improved after CAE and hIAE (p < 0.005), whereas the carotid femoral pulse wave velocity was not significantly affected (p = NS). Conclusion: Both CAE and hIAE can favourably affect endothelial function, suggesting another cardioprotective effect of acute exercise. These types of aerobic exercise have a different impact on the central and peripheral arterial stiffness.