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 7 – Threshold diameters for indicating aortic aneurysm surgery, according to current guidelines Aorta Marfan/BAV Non-marfan Ascending 5.0 cm 5.5 cm Descending 6.0 cm 6.5 cm BAV: bicuspid aortic valve. require annual measurement, preferably by angiotomography (gold standard, but subject to radiation) or magnetic angioresonance. In non-genetic cases of TAA of ≥ 5 cm, measurements should be performed biannually. EKG tends to underestimate aorta caliber. 113-116 Elective TAA surgery mortality in highly specialized centers is 2.9%. The risk of stroke or paraplegia is much higher in descending aorta. In this case, the option of endovascular intervention, with stent collocation, presents lower risk of paraplegia. 1.12.2. Abdominal Aortic Aneurysm Abdominal aortic aneurysms (AAA) tend to affect elderly individuals (≥ age 65) and are atherosclerotic in nature; in this manner, AAA places patients in secondary prevention. Tobacco use is the main etiological factor of AAA, which is 3 to 5 times more common in smokers than in non-smokers. AAA is also common in patients with peripheral arterial disease (PAD). 115 AAA is found in 1.3% of men between the ages of 45 and 54, and in 12.5% of those between the ages of 75 and 84. In women, the maximum prevalence was 5.2% in the elderly age group, being found in 0% of young women. The fact that men smoke more than women likely contributes to this pronounced difference between age groups by sex. This notwithstanding, evolution and prognosis of AAA are worse in women. 113-115 Initial discriminatory evaluation by ultrasonography is recommended, especially in male patients who have been smokers, starting at age 65. In the event that the result is normal, there is no need for periodic reevaluation. 113-115 AAAwith diameters of ≥4 cm require annual measurement, which may only be performed by abdominal ultrasonography, which, in this area, has excellent sensitivity and specificity. If it is ≥ 5 cm, screening should be performed biannually. The cutoff point for indicating intervention is 5.5 cm. Open surgery poses a higher risk, but it lasts longer and should preferably be indicated in younger individuals with longer life expectancy. Endovascular intervention has evolved considerably and should preferably be indicated in older patients or patients considered high risk for surgery. 113-116 1.12.2.1. Carotid Arteries There is no solid evidence regarding the eventual advantage of interventional treatment in intensive clinical control of cardiovascular risk factors, especially if we consider the use of full dosages of latest generation of statins, although many services opt for aggressive treatment, based only on registers and specialist opinion. 117,118 Routine carotid ultrasonography is only indicated for patients who have suffered stroke/transient ischemic attack (TIA), or when physical examination identifies decreased, absent, or asymmetric pulse or carotid murmur. 1.12.3. The Original and 10-Year CREST Studies The original Carotid Revascularization Endarterectomy vs. Stenting Trial (CREST) study (n = 2,502) aimed to observe the medium- and long-term reduction in risk of ischemic stroke associated with carotid endarterectomy (CEA) and angioplasty with carotid-artery stenting (CAS) in patients with significant carotid atherosclerotic disease. The proportion of cerebrovascular asymptomatic patients and of those who had suffered stroke/TIA was very similar. The main study objective was to evaluate the risk of death, AMI, or stroke during the first 30 days after the procedure and of ipsilateral stroke during the following 4 years. They did not, however, find an optimized clinical treatment group. The risk of minor stroke was higher in the CAS group during the first 30 days, whereas the risk of AMI was higher in the CEA group. At the end of the 4-year period, the risk of stroke was low and similar in both groups analyzed (2.0% and 2.4%; p = 0.85). The main conclusion was that both CEA and CAS may be alternatively indicated as interventional carotid treatments. Additional findings suggest that CEA seems to be more beneficial in elderly patients, while CAS would be more useful in subpopulations under age 65. 117 The main lesson of the 10-year CREST study was that, once the initial critical phase was over, patients who underwent interventional treatment tended to evolve very well long-term. The 10-year risk of stroke was 6.9% in the CAS group and 5.6% in the CEA group, with no significant statistical difference (p = 0.96). The primary composite endpoint (death, AMI, and stroke) occurred in 11.8% of participants in the CAS group and in 9.9% of those in the CEA group, with no statistical difference (p = 0.51). Nevertheless, the primary composite endpoint death/stroke over 10 years was worse in the CAS group (11.0% vs. 7.9%; hazard ratio [HR]: 1.37%; p = 0.04). 118 The Asymptomatic Carotid Trial (ACT) 1 study (n = 1,453) included patients with significant asymptomatic carotid disease, randomized into interventional treatment by CEA (n = 364; 25%) or CAS (n = 1,089; 75%). Elderly patients > age and those who had suffered stroke/TIA during the past 180 days were excluded. The carotid anatomical pattern was required to be viable for both procedures, with a minimum degree of stenosis of 70% diagnosed by either ultrasonography or angiography. 119,120 The main objective was to demonstrate the noninferiority of CAS to CEA in relation to a composite endpoint, represented by death, AMI, and stroke during the first 30 days and ipsilateral stroke within 1 year. The results during 30 days showed that the incidence of this endpoint was only 2.95%. There were more cases of stroke and stroke or death in the CAS group and more cases of AMI in the CEA subgroup. The risk of major stroke was low (0.4%) and mortality was 0.2%. Medium- and long-term survival free of stroke was excellent in both groups, 97.5% over 1 year and 93.9% over 5 years. In 5 years, 97.5% of participants did not require carotid reintervention, and total mortality was 11.8%. 119 663