CAPTURE represents the first multinational, standardized study to estimate CVD prevalence in adults with T2D. Among the 13 participating countries, Brazil had the highest recruitment, with 9.3% (n = 912/9823) of all patients recruited to the CAPTURE study, and the second highest weighted prevalence of CVD (after Israel, which had a prevalence of 50.7%). Analysis of data for the CAPTURE Brazil sample demonstrated that almost one in two adults (43.9%) with T2D had established CVD, which is a higher prevalence than that seen in the overall multinational sample (34.8%) (14).
In Brazil, ASCVD was highly prevalent among patients with T2D (37.6%; n = 343/912) and among those with T2D and CVD (85.8%; n = 343/400). Within the subtypes of CVD, CHD was the most prevalent one, with CHD, heart failure, cerebrovascular disease, and PAD being more prevalent compared with other subtypes (carotid artery disease, cardiac arrhythmia and thromboembolic disease), albeit at lower rates than ASCVD, as ASCVD is a combination of several CVD subtypes. The prevalence of all CVD subtypes were higher in the Brazil sample compared with the multinational sample, with the exception of carotid artery disease, which was lower in the Brazil sample than in the multinational sample (3.4% vs 8.4%) (14). It is possible that patients recruited to CAPTURE in Brazil had higher numbers of complications compared with the multinational sample, as the Brazilian centers carrying out research tended to serve complex patients.
Analysis of the sample from Brazil according to CVD status showed that patients in the CVD subgroup compared with the Non-CVD subgroup were older and fewer were female. A higher proportion of the CVD group than the Non-CVD group was also observed to have hypertension, kidney dysfunction, microalbuminuria, and microvascular complications. However, the differences between the CVD subgroups were not formally tested and should, therefore, be interpreted with caution. Hypertension – a common risk factor for CVD (19) – appeared to be more prevalent in the Brazil sample than in the multinational sample (80.9% vs 70.1%, respectively), despite the higher use of blood pressure medications in the Brazil sample (use of medications for hypertension and other CVDs: 79.5% vs 61.4%, respectively (14)). Additionally, kidney dysfunction (eGFR < 59 mL/min/1.73 m2) was seen in more patients in the Brazil sample (35.4%) compared with the multinational sample (21.0%). The median HbA1c levels in Brazil appeared slightly higher versus the multinational sample (7.7% vs 7.3%, respectively (14)), which would be consistent with the results of a previous study reporting poor glycemic control among Brazilian patients with T2D (20).
Use of any GLA with proven CV benefit (GLP-1 RA and/or SGLT2i) was lower in the Brazil sample than in the overall multinational study population (18.4% vs 21.9%, respectively (14)). Moreover, the results from the Brazil sample showed that numerically fewer patients in the CVD subgroup, compared with the Non-CVD subgroup, were prescribed any GLAs with proven CV protection or an SGLT2i specifically, while slightly more in the CVD subgroup were prescribed GLP1 RAs. Potential reasons for the relatively low rate of prescribing GLP-1 RAs, despite their proven CV benefit, might be due to their injectable route of administration, the high cost of these medications and therapeutic inertia (21, 22). The low rate of prescription of GLAs with proven CV benefit may suggest that patients with T2D in Brazil may be managed sub-optimally in this regard. Indeed, in Brazil, a high proportion of patients with diabetes are treated solely in primary care (20), where physicians may not be well-equipped to manage many of these complex patients with established CVD; however, a larger percentage of the CVD group was prescribed antihypertensives compared with the Non-CVD group, indicating that physicians were aware of their increased CV risk and medication need.
There may also have been medication-specific reasons why the rate of the prescription of SGLT2is was lower in the Brazil sample compared with the global sample. For example, in the CAPTURE global sample, a total of 91 patients were treated with the SGLT2i canagliflozin, which has proven CV benefit (23); however, no patient was treated with canagliflozin in the CAPTURE Brazil sample. A potential reason why no patient within the Brazil study sample was prescribed this medication is the label warning (contained within local package inserts/summary of product characteristics/labels) regarding amputations that have been associated with patients that received this medication (23–25). This association with amputations is also mentioned in the Brazilian Ministry for Health’s therapeutic guidelines for T2D (26).
Linked to differences in prescribing patterns, a previous sub-analysis of an online survey explored the perceptions and routines of patients with T2D and physicians in Brazil, compared with other countries (USA, UK, Spain, India, and Japan) (27). Preventing CV events was highlighted as the primary concern of healthcare professionals, while reducing microvascular complications that impacted quality of life was the priority of patients with T2D in Brazil (27). This discrepancy in priorities between healthcare professionals and patients with T2D in Brazil may lead to poor understanding of the condition and, consequently, a lower use of GLAs with proven CV benefit in Brazil than in the multinational study sample. Given the relatively low rates of prescription of GLAs with proven CV benefit in the Brazil sample, education should be delivered to all healthcare professionals in Brazil regarding the CV benefit of SGLT2is and GLP-1 RAs to assist in the prevention of CV events.
The CAPTURE study in Brazil had a number of limitations. There was the potential for selection bias in this cross-sectional study that may have resulted in study sites and a population sample that were not representative of the management of T2D in Brazil, and the sample size of patients with T2D in secondary care setting is small. Relative to the size of the T2D population in Brazil, the CAPTURE study sample was small (n = 912 patients). Data were not formally tested statistically, limiting the robustness of any comparisons. Finally, this non-interventional study did not screen or adjudicate for the presence of CV complications; thus, there may have been under-or over-diagnosis of CVD.