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 Indication for revascularization in elderly patients refractory to clinical treatment PCI – Patients with angina Grade of recommendation Level of evidence PCI feasible and easily applied I C Low SYNTAX score I B High SYNTAX score IIb B Surgery – Patients com angina Grade of recommendation Level of evidence Multivascular, with low surgical risk I B Low SYNTAX score and moderate to high surgical risk IIb B PCI: percutaneous intervention; SYNTAX: Synergy Between Percutaneous Coronary Intervention with Taxus and Cardiac Surgery. Recommendations for antianginal medications Medication Grade of recommendation Level of evidence Beta-blockers I A Calcium channel blockers IIa B Nitrates for anginal crises I A Nitrates for chronic use IIb B Trimetazidine IIa B Ivabradine IIa B Indication for revascularization in asymptomatic elderly patients Severe ischemic load Grade of recommendation Level of evidence Percutaneous intervention IIa C Surgery IIa C 3. Acute Coronary Disease 3.1. Diagnostic Peculiarities Elderly patients have a higher incidence of acute coronary syndrome (ACS), and their prognosis is worse in comparison with younger patients. The causes of this unfavorable evolution include: (a) delayed arrival at the hospital; (b) diagnostic difficulties; (c) lower likelihood of receiving interventional treatment; (d) less use of beta-blockers; (e) previous HF; and (f) comorbidities. 152 As age increases, the effects of risk factors such as hypertension, diabetes, and tobacco use decreases, and the importance of associated comorbidities, such as stroke and renal and cardiac insufficiency increases. 153,154 Atypical presentation is more common in this age group; chest pain is present in 40% of patients ≥ age 80, compared to 80% in those ≤ age 65. In elderly heart attack patients, 8.4% do not present precordial pain (43.3% in patients ≥ 75 years old, compared to 29.4% in those ≤ 65 years old). More common symptoms include: dyspnea (29.4%), sweating (26.2%), nausea and vomiting (24.3%), and syncope and pre-syncope (19.1%), which are denominated ischemic equivalents. Although physical examination may be normal, the presence or absence of signs of peripheral hypoperfusion, vital signs, presence or absence of arterial pulses, jugular vein distention, cardiac auscultation (blowing, friction, third heart sound), and pulmonary auscultation with signs of congestion are important data to evaluate. Initial EKG is less solicited and more delayed, in elderly patients: 40% of patients ≥ age 85, compared to 25% of those ≤ age 65, do not have diagnostic EKG. The presence of non-specific EKG alterations and blocks is more frequent in elderly patients, increasing diagnostic difficulties in this age group, especially in the presence of left bundle branch block. 102,155 Elevated myocardial necrosis markers unrelated to ACS are common in other situations, such as increased plasma N-terminal brain natriuretic propeptide (NT-pro-BNP), diabetes, renal insufficiency, anemia, dehydration, metabolic and hydroelectrolytic disorders, infections, and echocardiography abnormalities in chronic heart diseases. 156-159 Risk scores, such as the Thrombolysis in Myocardial Infarction (TIMI) Risk 160 and the Global Registry of Acute Coronary Events (GRACE), 161 are important for risk stratification of elderly ACS patients, ensuring better strategy in diagnostic and therapeutic approach, increasing the use of antithrombotic and anticoagulant medications and myocardial revascularization, with a consequent decrease in risk of death, heart attack, and recurring ischemia. 162,163 Being over age 70 confers a moderate (ages 70 to 75) to high (> age 75) risk of coronary disease. Frailty is an important independent predictor of mortality, longer hospital stays, increased risk of bleeding and morbidity in the elderly population with ACS. 164,165 Functional decline in elderly patients is a predictor of poor evolution. 166 The Gold Standards Framework (GSF) score, which associates end-stage disease criteria, has shown to be an independent predictor of non-cardiovascular events in ACS, while the GRACE score has demonstrated that it is an excellent predictor of cardiovascular events in elderly patients. 167 Chest radiography, resting transthoracic echocardiography, myocardial scintigraphy, coronary angiotomography, cardiac magnetic resonance, and CCA follow the same indications as in younger patients for diagnosis of ACS in this age group. 156,157 3.2. Peculiarities of Treatment Even though the elderly population is the one that most benefits from more aggressive strategies, they have a higher risk of bleeding, with a 2-fold risk of mortality compared to younger patients (< 75 years old). Higher intra-hospital mortality and higher bleeding rates with thrombolytic therapy are part of this scenario. Approach to ACS in elderly patients should be individualized, based on risk of complications, estimated life expectancy, comorbidities, quality of life, and the patient’s wishes and preferences. 153,154,156,157,168-170 Elderly patients (> age 75) with acute coronary syndrome with ST-segment elevation (ACS-STE) and without ST-segment 669