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 (a) LV status – systolic and diastolic function, parietal mobility, and hypertrophy; (b) presence of valvulopathy; (c) situation of the aortic root. The use of functional tests for ischemia (ET, stress echocardiography and myocardial perfusion scintigraphy [MPS]) or anatomical tests (coronary computed tomography angiography [CCTA] and coronary cine angiogram [CCA]) depends on pre-test estimates on the likelihood of obstructive CAD. 137 When the probability is low (< 20%), it is not necessary to continue investigation. On the other hand, when the probability is high, (> 80%), negative results of non-invasive exams cannot exclude obstructive CAD; invasive strategies may, thus, be considered. In patients with intermediate pre-test probability, a stress test is indicated. In elderly patients, the diagnostic sensitivity and specificity of ET have been questioned, 138 as a result of low exercise capacity (reducedmuscle mass, deconditioning, comorbidities) and the presence of alterations in baseline EKG; nevertheless, this method may be useful in clinical management, offering relevant information on symptoms, exercise capacity, chronotropic response, arrhythmias, etc. Both stress tests and MPS may be used in association with the ET to increment sensitivity and specificity for ischemia. 139,140 Diagnosis and prognosis of both modalities are similar and the preference for a determined method depends on the experience and/or equipment available at the investigating center. For elderly patients incapable of exercising, pharmacological stress may be used both in the stress test (dobutamine) and the MPS (vasodilatory agents). The CCS, obtained in conjunction with CCTA, is useful for risk stratification in asymptomatic elderly patients, due to its high negative predictive value; 141 its value, however, is limited in symptomatic patients with suspected CAD. Due to the high prevalence of coronary calcification in the elderly, CCTA has shown to be of reduced accuracy in demonstrated obstructive CAD. 142 CCA continues to be the “gold standard” for definitive evaluation of epicardial CAD; it is generally recommended for patients whose clinical characteristics and/or non-invasive test results indicate a high likelihood of severe coronary disease, with a high risk of coronary events or death. Even though it is well tolerated, it deserves attention due to the risk of bleeding, stroke, and contrast-induced nephropathy. 2.2. Peculiarities of Treating Chronic Coronary Artery Disease In Elderly Patients During the last decades, the treatment of coronary disease has been founded on general clinical measures related to the development of healthy habits, such as a balanced diet, weight control, regular practice of physical activity, vaccination schedule completion, tobacco cessation, intensive BP control, and appropriate use of antiatherosclerotic medications such as statins, antiplatelet medications, and renin-angiotensin system inhibitors, in addition to antianginal agents. 143-145 Additionally, well selected cases are treated with myocardial revascularization procedures, through percutaneous coronary intervention or surgery. In elderly patients, these principles are largely applicable with evidence which it has been possible to extrapolate from randomized clinical trials, that have begun to include “young” elderly individuals (ages 60 to 75) in their observations, with less frequently evaluation of “truly elderly” individuals (ages 75 to 85) are scarce evaluation of “very elderly” individuals (over age 85). 143-145 Regarding diet, the Lyon, Dietary Approaches to Stop Hypertension (DASH), and, more recently, Prevención con Dieta Mediterránea (PREDIMED) studies have validated the concept of a healthy diet; the PREDIMED included patients up to age 80. Weight control represents a particular consideration in the elderly owing to the apparent existence of a paradox between BMI and age. 146 In a more conclusive analysis of the topic of CAD, the reduction of obesity is associated with better results. Regular practice of activities which are appropriate for the elderly individual’s physical conditions bring innumerable psychological benefits that impact improvements in general healthcare and which justify their implementation. Inflammation caused by infections plays a recognized role on the emergence of coronary disease complications, and influenza and pneumococcal vaccination is a recommendable measure in elderly coronary disease patients. 147 Analysis of the Coronary Artery Study (CASS) registry has been definitive in demonstrating the benefits of tobacco cessation in elderly coronary disease patients. 148 A systolic blood pressure (SBP) control goal of < 140 mmHg has been established for the elderly population. A recent study, the Systolic Blood Pressure Intervention Trial (SPRINT), recommends that this goal be even more intensive, even in elderly coronary disease patients (< 130 mmHg, if tolerated), without verifying the J curve or undesired events in relation to reduced diastolic BP. Special caution needs to be taken in this population when comorbidities are present. 149 Antiatherosclerotic medications such as statins have confirmed demonstration, in clinical trials, up to age 79. If tolerated, they should be used to stimulate an LDL-c goal of < 70 mg/dL. Acetylsalicylic acid (ASA) is recommended, as well as the use of angiotensin converting enzyme inhibitors (ACEI) or angiotensin receptor blockers (ARB), even in the absence of SAH or HF, notwithstanding the fact that both of these conditions are frequently associated with CAD in the elderly. Anti-ischemic medications, such as beta-blockers (and calcium channel blockers, when beta-blockers are not possible, or in association with them) for control and nitrates for crises, as well as new anti-ischemic medications, such as trimetazidine, should be used with due caution regarding progressive doses, due to the higher incidence of side effects. Ivabradine may be considered for HR control when it is not possible to use beta-blockers. 150 In relation to revascularizing elderly patients without frailty by either percutaneous or surgical intervention, this should be considered with the aim of controlling refractory symptoms or in cases with severe ischemic burden. With respect to deciding which procedure should be performed, whether percutaneous intervention or surgery, this depends wholly on the feasibility of using the techniques, it being necessary to consider that age adds a considerable weight to risk of both procedures and that scores that include 667