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 Table 5 – Treatment goals regarding blood glucose, and dyslipidemia in elderly patients with diabetes Patient characteristics/ health status Rationale Reasonable HbA1C goal Fasting or preprandial blood glucose (mg/dL) Bedtime blood glucose (mg/dL) Blood pressure (mmHg) Lipids Healthy (few coexisting chronic diseases, cognitive and functional state intact) Long life expectancy < 7.5% 90–130 90–150 < 140/90 Statin, provided there is no contraindication or intolerance Complex/intermediate (multiple coexisting chronic diseases, impaired IADL, or mild to moderate cognitive impairment) Intermediate life expectancy, high treatment burden, vulnerability to hypoglycemia, fall risk < 8.0% 90–150 100–180 < 140/90 Statin, provided there is no contraindication or intolerance Very complex/ poor health (long-term care or end-stage chronic disease, moderate to severe cognitive impairment, or 2+ BADL dependencies) Limited life expectancy makes benefit uncertain < 8.5% 100–180 110–200 < 150/90 Consider the probability of benefits of statin (secondary prevention, rather than primary) BADL: basic activities of daily living; HbA1C: glycosylated hemoglobin; IADL: instrumental activities of daily living. Source: American Diabetes Association. Older adults. Diabetes Care. 2017; 40 (suppl.1):S99-S104. 32 disease increased in women exposed to smoking. Occasional exposure to cigarettes increased their relative risk by 1.58, and regular exposure increased the relative risk by 1.91. 45 Tobacco use constitutes a risk factor for dementia, and cessation may reduce the burden of dementia. Passive exposure to smoking may also increase the risk of dementia. 46 Studies show that elderly smokers have a lower intention of quitting in comparison with younger smokers; they have, on the other hand, a higher likelihood of success when they do try to stop smoking. 47,48 Success in stopping is frequently achieved after an acute coronary event, aggravation of chronic obstructive pulmonary disease (COPD), or symptomatic and limiting peripheral arterial disease. Medical advice to cease smoking should be firm, with emphasis placed on the short- and medium-term benefits. Aggressive practices related to tobacco cessation should be adopted. 49,50 Evidence shows the efficiency of using the 4 As method in elderly patients, namely: ask, advise, assist, and arrange follow up. 51,52 Different approaches, such as interventions through individual counseling performed by healthcare professionals, age-appropriate self-help material, use of nicotine (transdermal patches or chewing gum), or use of specific medications, e.g. bupropion), have also been shown to be efficient in treating tobacco use. 53-55 Recommendations Grade of recommendation Level of evidence Tobacco use is a modifiable risk factor for CVD in elderly individuals and cessation is recommended I C Use of multidisciplinary approaches, with the 4 As Method, is recommended: ask, advise, assist, and arrange follow up I C Nicotine/bupropion transdermal patches or chewing gum may be used to cease tobacco use IIa C CVD: cardiovascular disease. 1.7. Obesity The prevalence of overweight status and obesity has increased over the past decades in all age groups, including the elderly. 56,57 Both obesity and overweight status have been associated with the risk of all cause and CVD mortality, in the general population. 58-60 The majority of these studies mainly involved young adult patients, making this relationship less evident in the elderly. 61-64 Some meta-analysis studies have reported that overweight and obese elderly individuals, when compared with elderly individuals within the normal weight range, had lower mortality rates and lower or no risk of CVD. This effect has been called the “obesity paradox”. 65-67 In addition to possible confounding factors in these studies, other reasons may be involved. The index used to measure and classify body mass was the body mass index (BMI). Degrees of obesity adopted by the World Health Organization (WHO), with respect to BMI, are: overweight (25.0 to 29.9 kg/m 2 ) and obese (over 30.0 kg/m 2 ). 68 Variables such as age, sex, and race may affect BMI. With aging, changes in body composition occur, such as increased visceral fat and decreased muscle mass. Loss of height may also occur, owing to compression of vertebral bodies or kyphosis. In this manner, BMI becomes less precise in measuring fat mass. When used alone, it is not able to be an accurate predictor of CVD risk in elderly patients. For instance, some elderly individuals may be considered overweight by body fat patterns without having a BMI over 25 kg/m 2 . Using BMI alone, we may be underestimating the degree of adiposity in individuals who lost muscle mass. Central obesity and nutrition are factors which seem more important in relation to mortality and CVD risk in this population. Some authors suggest that waist circumference (WC) could be a particularly important measure for elderly patients, 658