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 Notwithstanding the publication of guidelines on the use of US-CRP for predicting CVD risk by several professional organizations, there is still a lack of consensus regarding optimal clinical use of US-CRP. 103 1.11.3. Vitamin D Recent studies show evidence of a strong association between vitamin D deficiency and the presence of SAH, metabolic syndrome, diabetes, and atherosclerosis. It is thus considered an emerging risk factor for CVD. 104 The mechanisms by which vitamin D exercises its role as a cardiovascular protector are still not well established. In the Third National Health and Nutrition Examination Survey (NHANES III), which involved 3,408 elderly patients, followed up for 7 years, after adjusting for cardiovascular risk, season of the year, and demographic data, verified that vitamin D levels are negatively associated with mortality risk, with this association being even stronger for cardiovascular mortality. 105 A meta-analysis of 19 prospective studies with more than 65,000 patients demonstrated that the risk of all CVD, as well as cardiovascular death and CAD, was lower in patients with higher levels of vitamin D. 106,107 1.11.4. Genetic Factors Aging is characterized by the complex interaction of cellular and molecular mechanisms that lead to a series of functional problems. These problems are intimately associated with one another; they include poor vasodilatation, increased arterial stiffness, and evident extracellular matrix remodeling, diffuse carotid intimal thickening, and endothelial dysfunction. The mechanisms by which age truly contributes to cardiovascular risk continue to be the object of speculation. Although this paradigm explains vascular aging, considering classic risk factors as causal mechanisms, a recently proposed alternative view on vascular aging has emerged, which presents new mechanistic alternatives for understanding the vascular aging process. In this new paradigm, causal mechanisms of the aging process in itself, most notably genomic instability, including telomeric wear, drive the harmful changes that increasingly occur with biological aging. 108 1.11.5. Coronary Calcium Score CCS represents an important risk marker for cardiovascular events, especially in predicting risk of AMI in subsequent years, with a score of 0 demonstrating an almost null possibility of coronary events in subsequent years. A score above 100, however, is considered an aggravating risk factor, and scores over 400 indicate a high risk of coronary events. 109 Recommendations Grade of recommendation Level of evidence Coronary calcium score IIa C 1.11.6. Investigating Subclinical Atherosclerosis This is indicated to better stratify cardiovascular risk in elderly patients, with the aim of better identifying cases that will require more aggressive therapy. The Cardiovascular Health Study followed up elderly patients for 10 years and demonstrated that the subclinical atherosclerosis index was a better predictor of cardiovascular events than traditional risk factors in asymptomatic elderly adults. This index is composed of the ankle-brachial index (ABI), carotid artery stenosis, carotid intima-media complex thickness, altered EKG or echocardiogram, positive response to the Rose questionnaire or the intermittent claudication questionnaire. 110 Carotid artery ultrasonography is an important resource for evaluating elderly patients. Patients with carotid blockage of 50% or more are considered at a high risk of coronary events. 111 Recommendations Grade of recommendation Level of evidence Investigating subclinical atherosclerosis I C 1.11.6.1 Ankle-brachial index Peripheral arterial obstructive disease (PAOD) is strongly related to coronary events, and it may be assessed by the ABI, a low-cost, easily applicable exam. ABI < 0.9 is positively associated with a higher number of coronary events and with death of cardiovascular etiology. Its indication is always applicable when there are alterations in the clinical exam which suggest peripheral arterial disease, as well as excluding intermittent claudication (grade of recommendation IIa, level of evidence C). The recommendations of a recent American scientific statement highlight the strong, consistent association of advanced age with PAOD prevalence and incidence. Age > 70 is an independent risk factor for developing PAOD involving lower extremities, notwithstanding other risk factors, with a prevalence rate of > 20% in men and women in this age group. Given the strong effect of age on the prevalence of PAOD, the statement endorses the use of ABI as a class I recommendation (level of evidence C). 112 1.12. Aorta and Carotid Artery Disease 1.12.1. Thoracic Aortic Aneurysm Bicuspid aortic valve (BAV) is the most frequent modality of congenital heart disease (1% to 2%), and it may occur with thoracic aortic aneurysm (TAA), with a high risk of undergoing expansion. As many as 50% of patients with BAV develop ascending aorta dilation. Factors that contribute to progression of TAA in the presence of SAH include obesity and increase in age. As these 3 conditions are frequently present together in elderly adults, TAA has been underdiagnosed in this age group. It is estimated that TAA is present in at least 3% to 4% of elderly individuals. Patients with TAA are in primary prevention. One of the complications of TAA is acute dissection, whose frequency is 2 times higher in men than in women. Rupture, however, is responsible for 60% of deaths attributed to TAA. Current guidelines consider a cutoff point for surgery indication for ascending TAA of 5.5 cm for patients without Marfan or BAV and 5.0 cm in the presence of one of these clinical conditions (Table 7). TAA with diameters ≥ 4 cm 662