ABC | Volume 112, Nº5, May 2019

Updated Updated Geriatric Cardiology Guidelines of the Brazilian Society of Cardiology – 2019 Arq Bras Cardiol. 2019; 112(5):649-705 prevention following AMI, 26 provide orientation regarding problems related to self-medication, consider modifications in pharmacology related to age which, generally, recommend reducing doses, and evaluate possible drug interactions, given that “polypharmacy” is common. Beers Criteria, informally known as the “Beers List,” are a reference on safety in prescribing medications to the elderly. They were created in 1991, by the geriatrician Mark H. Beers, and they are periodically revised, the 2015 version being the most recent. 27 In the United States, more than one third of emergency room visits due to adverse effects of substances occur in individuals over age 65. They imply hospitalization of more than 40% of cases, and this frequency is increasing over time. Of these visits, nearly 60% were related to the use of anticoagulants, antidiabetic agents, and opioid analgesics, and nearly 2% were related to restricted use medications, in accordance with the Beers Criteria. 28 Recently, the Food and Drug Administration Adverse Event Reporting System (FAERS) drew attention to evaluating the eventual need for regulatory action for the following: the anticoagulants apixaban, edoxaban, rivaroxaban, and dabigatran, due to reports of vasculitis; ivabradine, due to potential signs of ventricular arrhythmias; and midodrine, due to reports of interactions with monoamine oxidase inhibitors (MAOI) which could trigger a stroke. 29 Interventional treatments should be carefully based on criteria, with the participation of heart teams, and performed by experienced and qualified teams, given that they present more frequent and severe complications. A noteworthy example of this scenario is the need for hospitalization and admission to skilled nursing facilities in 4 of every 5 elderly patients who received an implantable cardioverter-defibrillator for secondary prevention of sudden cardiac death, even though they survived at least 2 years. 30 1.5. Diabetes Mellitus in Elderly Patients The National Health Survey conducted by the Brazilian Institute of Geography and Statistics (IBGE, 2013) showed a 19.9% prevalence of diabetes mellitus in individuals in the 65–74 age group. 1 In diabetic adults, there is an increase in mortality and a decrease in functional capacity with consequent increase in the risk of institutionalization. 31 The presence of multimorbidities and comorbidities associated with this group’s high heterogeneity means that the elderly are often excluded from randomized clinical trials, making disease management more difficult in this population. 31,32 Diagnostic criteria for diabetes mellitus in the elderly are similar to those in younger populations: (1) fasting blood glucose ≥ 126 mg/dL; or (2) random blood glucose ≥ 200 mg/ dL, associated with disease symptoms; or (3) blood glucose 2 hours after a 75-g glucose load ≥ 200 mg/dL; or (4) glycated hemoglobin (HbA1C) ≥ 6.5% (provided that the laboratory is standardized). The American Diabetes Association (ADA) recommends that individuals who are overweight as a risk factor and all adults ≥ age 45 be screened for diabetes every 1 to 3 years, with fasting blood glucose, glycated hemoglobin dosage, or oral glucose tolerance test, for the benefit of early diagnosis, early treatment, and prevention of complications. 31 Elderly individuals with diabetes are at a higher risk of developing geriatric syndromes, such as polypharmacy, cognitive impairment, urinary incontinence, falls, and chronic pain. When individuals with these syndromes develop diabetes, their clinical condition worsens. Thus, in addition to screening for complications, multidimensional evaluation of elderly diabetic individuals is also fundamental. It becomes imperative to performAGA with mental, functional, nutritional, and social evaluations for these individuals in order to define goals to be met for each patient. 32 The objective should be defined between two options: intensive blood glucose control, with less progression of chronic complications; or standard blood glucose control, in order to avoid only symptoms of hyperglycemia and acute complications. The United Kingdom Prospective Diabetes Study (UKPDS), although it excluded elderly patients, showed the benefits of intensive blood glucose control in individuals as they age, with posterior follow-up. 33,34 There are 3 main randomized clinical trials with the participation of elderly patients and intensive blood glucose control. The Action to Control Cardiovascular Risk in Diabetes (ACCORD) study was interrupted due to mortality in the youngest group; however, hypoglycemia and other adverse effects of treatment were more common in elderly patients; 35,36 in the Action in Diabetes and Vascular Disease: Preteraax and Diamicron MR Controlled Evaluation (ADVANCE) study, the risk of hypoglycemia and hospitalization increased significantly; 37 and in the Veterans Affairs Diabetes Trial (VADT) study, there were no benefits, with the exception of decreased progression of microalbuminuria. 38 Two retrospective studies (U.K. General Practice Research Database, 2009 39 and The Diabetes and Aging Study, 2011) show a U-shaped curve relating mortality and blood glucose levels. 40 Individualization of treatment is, thus, imperative in elderly patients in accordance with their clinical, functional, and life expectancy profile, as demonstrated in Table 5, with treatment goals for arterial hypertension and dyslipidemia in elderly patients with diabetes. 1.6. Tobacco Use The influence of tobacco use in elderly individuals occurs due to anatomical and physiological alterations in a cumulative process which leads to endothelial dysfunction, increased platelet adhesion, decreased high-density lipoprotein cholesterol (HDL-c), and increased low-density lipoprotein cholesterol (LDL-c), among other alterations. 41 Tobacco use is common in the elderly population, and it is an important cause of morbidity and mortality, including CVD, peripheral vascular disease, cerebrovascular disease, cancer, and obstructive pulmonary disease. On the other hand, the tobacco cessation has benefits, even in elderly patients, with respect to the prevention of these diseases or, at least, to slowing the decline of pulmonary function. 42 The Systolic Hypertension in the Elderly Program Study 43 observed patients with an average age of 72 and showed a significant increase in AMI, sudden death, and stroke in smokers, compared with non-smokers. Exposure to long periods of passive tobacco use increases the risk of developing CAD. Kawachi et al. (1997) 44 followed 32,000 non- smoking women, between the ages of 36 and 71, for 10 years, and found that the relative risk of developing coronary heart 657