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 1.12.4. Precautions and Recommendations The main problemwith interventional carotid treatment lies in the risk of death, AMI, or stroke inherent in the procedures per se, which extends to 30 days after intervention. Once this phase has passed, the annual risk of stroke or need for reintervention is considered low. Intervention by CEA or CAS in patients with asymptomatic carotid disease dos not have a solid base for recommendation in comparison with optimized clinical treatment, and it should preferably be avoided at this moment until studies currently underway help to definitively answer this important question (CREST 2 and ACST-2). 121-123 More than 90% of carotid interventions in the USA currently involve asymptomatic cerebrovascular patients. In Germany and Italy, these indexes are 60%; in Australia and Canada, 15%; and in Denmark, 0%. The annual risk of stroke in asymptomatic patients with significant carotid disease receiving only clinical treatment has reached values as low as 0.5%, or be it, the same index documented in the ACT-1 and the 5 and 10 year CREST studies. 122,123 Contrary to what has been admitted by some guidelines, it is here suggested that interventional carotid treatment be reserved for symptomatic patients (stroke/TIA over the past < 6 months), and that it be indicated for asymptomatic patients only when the degree of stenosis is between 70% and 99% in spite of optimized clinical treatment, and when there is proof that a large cerebral area is at risk or plaque-related microembolism, obtained by imaging exams and cerebral blood flow evaluation. 121-123 1.13. Evaluation of Surgical Risk In Elderly Patients The elderly population is currently growing more than any other. For this reason, a significant increase has been observed in the number of surgical procedures in this age group. The number of surgical procedures in people over age 65 is estimated to be 4 times higher than in the younger population. 124 The prevalence of symptomatic and asymptomatic CVD increases progressively with age, as shown in the results of many studies which suggest that age ≥ 80 is an independent predictor of perioperatory complications and death in patients who undergo non- cardiac or cardiac surgery. 125 Few studies, however, include elderly individuals over age 70 and the results are, generally, extrapolated from younger to older populations, ignoring the latter’s particularities. 126 Clinical evaluation in the elderly population should consider biological processes underlying so-called normative aging, such as physiological decrease in multiple organic functions which may cause inadequate responses to anesthetics, analgesics, and other substances administered and also lead to the appearance of cardiovascular complications, hemorrhagic or neuropsychiatric accidents, et al. It is mandatory to evaluate associated comorbidities and their repercussions on nutrition, overall functionality, independence, and healthy life expectancy, as well as all medication in use, in order both to prevent possible complications and to choose the most adequate procedure for each case. 127 As a general rule, the establishment of a patient’s surgical risk should be individualized and the bioethical principle of patient autonomy should be respected in all patient decisions or, in the event of impossibility, those of the patient’s legal representative, following adequate clarification regarding the risks inherent in the disease and the surgical procedure, during the intraoperative and immediate and late postoperative periods, and the quality of life expected to result from the treatment. It is necessary to document the patient’s and/or legal representative’s decision in the medical records. 128 With these considerations, surgical risk should be established based on a “tripod” comprising: (1) nature and character of the surgery; (2) functional capacity; (3) patient risk profile. The new guidelines have established that elective and minor surgeries where the possibility of heart attack or major adverse cardiovascular events is ≤ 1% are low risk; when the possibility is ≥ 1% they are considered high risk. More recent publications have incorporated intermediate or high risk. 129 Patients indicated for urgent surgery should have their risks established when possible, using information provided by the family or the patients themselves, and then be referred to the surgical center. In the event of elective surgeries where the patient’s hemodynamic conditions are not stable, they must be treated before establishing status and choosing the most opportune moment to perform the operation. Patient functional capacity is a valuable indicator of risk of complications during the course of surgery and the postoperative period. The ability to ascend 2 stories by stairs or by ramp or to walk at a velocity of approximately 4 mph on a level surface corresponds to a metabolic equivalent (MET) ≥ 4, which indicates a good cardiovascular reserve and regular physical capacity; MET ≥ 10 is considered very good. The last step in this strategy is to establish the patient’s risk profile based on his or her clinical history, symptoms, signs, and laboratory data. In the presence of unstable coronary syndromes, decompensated HF, symptomatic valve disease, severe arrhythmias, or pulmonary embolisms which may compromise the course of the perioperative period, non-invasive exams are indicated in order to improve comprehension. When non-invasive exams are suggestive of coronary insufficiency, it is necessary to indicate scintigraphy stress testing, eventual coronary angiography, and even myocardial revascularization, provided that performing this may substantially change patient management or survival, taking the severity of the underlying disease into account. 130 1.14. Vaccination in Elderly Patients 1.14.1. Brazilian Immunization Society (SBIm) Recommendations – 2015/2016 131 Influenza [indicated for all elderly individuals] – Influenza is a highly infectious acute respiratory infection, caused by Myxovirus influenzae , a virus that is not specific to humans (The virus infects different domestic and wild vertebrates which may, in turn, infect humans). There are 3 known types, A, B, and C, and there is no crossed immunity between them. Type A is the most virulent. It causes the largest epidemics, and is 664