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 (EKG) for the elderly has limited application as a pre-selection exam for physical activity. If possible, an exercise test (ET) should be performed in all elderly patients before initiating physical activity. The prevalence of coronary disease increases with age; the rationale behind the ET in this population may, thus, be even greater than in the general adult population. 72,79,80 The ET is a procedure during which the patient undergoes programmed and individualized exercise, with the aim of evaluating clinical, metabolic, hemodynamic, autonomic, electrocardiographic, and, eventually, ventilatory responses to exercise. In elderly patients, modified protocols are used to perform the ET. 79 If there are contraindications to performing the ET, stress EKG or scintigraphy should be performed. A Holter monitor is used to stratify risk in elderly patients with arrhythmias detected during EKG or ET, as well as those with a history of syncope. 72,82 Adherence to physical activity in this group has been increasingly positive. It is always necessary to consider that an active or latent pathological process may by present in an elderly individual and that the ET may contribute to defining it. 83,84 Recommendations Grade of recommendation Level of evidence Clinical exam and electrocardiogram I C Electrocardiogram, exercise test, or myocardial scintigraphy in medium-risk patients or in moderate to intense exercise IIa C Physical exercise I A Resistance exercise IIa C 1.9. Dyslipidemia in Elderly Patients Dyslipidemia is a frequent diagnosis in elderly patients, mainly in women, owing to the fact that LDL-c levels tend to rise as they advance in age, especially after menopause; in men, however, LDL-c tends to decrease after age 55. Unlike in young adults, cases of de novo dyslipidemia are rare, and cases of dyslipidemia secondary to hypothyroidism (especially in women), diabetes mellitus, glucose intolerance, nephrotic syndrome, obesity, alcoholism, or use of medications such as thiazide diuretics and non-selective beta-adrenergic receptor blockers, are more common. 85 In relation to treatment, as elderly patients are often already at high risks (owing to the factor of age), the approach to dyslipidemia, regarding therapeutic decisions, should give greater consideration to the patient’s good general and mental state, his or her socio-economic conditions, family support, comorbidities present, and the use of other drugs that may influence adherence to and maintenance of therapy. Non- pharmacological orientations should follow the same principals of indication for young adults, more carefully observing caloric, protein, and vitamin intake needs and physical conditions for practicing exercise (recommendation I, evidence B). It is necessary to reiterate the importance of ceasing habits of smoking and excessive consumption of alcoholic beverages. After 90 days, if there is no response, drug treatment may be initiated, with the following precautions: (1) always start with low doses and, if necessary, increase, progressively; (2) analyze the cost-benefit ratio; and (3) verify the existence of socioeconomic conditions for maintaining long-term treatment and performing periodical clinical and laboratory exams, due to the higher likelihood of collateral effects and drug interactions. 85 For hypercholesterolemia, statins are the first choice. 86 Tolerance is good; there is not a high incidence of undesired effects, even though muscle pain, cramps, and weakness, which are sometimes confounded with osteomuscular disease, may occur, even in low doses. Evidence from subgroup analyses in primary and secondary prevention studies and the Pravastatin in Elderly Individuals at Risk of Vascular Disease (PROSPER) study, 87 specially designed for elderly patients with or without previous manifestations of atherosclerosis, demonstrated the following benefits to treatment for this age group: reduction of coronary events (grade of recommendation IIa, level of evidence B), stroke (grade of recommendation IIa, level of evidence B), and preservation of cognitive functions (grade of recommendation IIb, level of evidence B). When maximum statin dosages are not sufficient to meet recommended LDL-c goals, ezetimibe may be associated with the statins (grade of recommendation IIb, level of evidence B). 88 In cases of hypertriglyceridemia, fibrates are used (provided there are no gallstones or renal insufficiency). Fibrates and statins may be associated in cases of mixed dyslipidemia (elevated LDL-c and triglycerides), mainly with reduced HDL-c (grade of recommendation IIb, level of evidence D). 88 In secondary dyslipidemias, the fundamental concern is treating the triggering disease and substituting or removing inductor drugs. We should remember that elderly individuals, generally, use other drugs metabolized by cytochrome P450 (CYP450), which have the possibility of interacting with lipid- lowering agents, thus altering their blood concentration (grade of recommendation IIb, level of evidence D). 88 1.10. Depression and Cardiovascular Disease Depression and anxiety are highly prevalent in individuals with CAD and other CVD. They have been also been considered independent risk factors for CAD and CVD, in addition to altering their natural history. 89,90 Depression is disproportionally more frequent among CAD patients, with prevalence between 20% and 40%. It has also been reported that depression is prospectively associated with an increased risk of developing CAD, 91,92 including AMI, 93 at some point during life, as well as an increased risk of mortality. 94 A 60-month follow-up study of 158 patients who suffered AMI revealed that greater depression was a significant predictor of mortality and adverse cardiac events. 95 Collateral effects of antidepressants on the cardiovascular system have been reported. These include bradycardia, tachycardia, hypertension, hypotension, orthostatic hypotension (OH), EKG alterations, altered electrolytes, reduced cardiac conduction, arrhythmias, and sudden cardiac death. 96 660