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 elevation (ACS-NSTE) should follow the same diagnostic and therapeutic approach as in younger patients, based on guidelines and consensuses, it being necessary to evaluate particularities of pharmacokinetics, sensitivity, and collateral effects and collateral effects of drugs, always taking weight and creatinine clearance into account. 102,153,154,156,157,168-170 During the past 15 years, there has been a significant increase in the rates of pharmacological therapy use based on evidence for ACS patients in all age groups. However, in cases of ACS- STE, elderly patients have a lower chance of receiving primary angioplasty or thrombolysis, as well as the prescription of ASA, clopidogrel, beta-blockers, statins, or ACEI. 171 The Study of Global Ageing and Adult Health (SAGE) compared the effects of intensive (atorvastatin 80 mg) versus moderate statin therapy (pravastatin 40 mg) on reducing myocardial ischemia in elderly patients between the ages of 65 and 85. Both statin regimens were equally effective in reducing the frequency and duration of ischemia; intensive therapy with atorvastatin, however, was demonstrated to be more effective in the reduction of lipids and all-cause mortality, in comparison with pravastatin. 170,172 However, due to the prevalence of collateral effects and intolerance to this medication in this age range, lower doses of statins are suggested for ACS patients, until LDL-c < 70 mg/dL has been reached, maintaining the tolerated dose. After age 85, studies suggest that there are benefits associated with reperfusion strategies for ACS-STE. The choice between fibrinolytic drugs and angioplasty is determined by the presence or absence of cardiogenic shock, presentation time, and comorbidities, which often tend toward angioplasty in elderly patients. The safety and efficacy of reperfusion, especially fibrinolytic therapy, in very elderly patients (≥ 85 years old) are questions which require deeper investigation. 173 The After Eighty study investigators evaluated 457 patients over the age of 80 with ACS-NSTE (AMI and unstable angina) who were randomized to an invasive or a conservative strategy, suggesting that invasive therapy is superior, with a higher incidence of death, myocardial infarction, and stroke in the conservative therapy group. The same results were obtained in the subgroup of elderly patients over age 90. 174 3.3. General Recommendations – Acute Coronary Syndrome in Elderly Patients With elderly ACS patients, cardiologists face the following 3 challenges: 1 st Challenge: summary of diagnostic challenges in elderly patients Atypical presentation: less typical pain and more anginal equivalents (dyspnea, syncope, stroke, HF, etc.) Greater severity: present with more HF and cardiogenic shock Higher prevalence of morbimortality: reinfarction, stroke, more severe hemorrhage, and death Lower effects of risk factors and greater importance of comorbidities Non-specific EKG in 43% of elderly patients > 85 years old Myocardial infarction (ACS-STE) should be strongly suspected in women, diabetes patients, and elderly patients with atypical symptoms Due to frequent atypical presentation, elderly patients (> 75 years old) should be investigated for ACS-NSTE with a lower level of suspicion 2 nd Challenge: summary of challenges regarding approach individualization Heterogeneous population Moderate to high risk in the most utilized risk stratification scores (TIMI, GRACE) Treatment should consider overall health, comorbidities, cognitive status, life expectancy, frailty, patient’s wishes and preferences It is necessary to pay attention to pharmacokinetic alterations and sensitivity to hypotensive drugs 3 rd Challenge: summary of treatment challenges Treat elderly patients (≥ 75 years old) with medical therapy, early invasive strategy, and revascularization, as indicated, in accordance with guidelines It is necessary to pay attention to adjustments in doses of antithrombotic drugs in elderly patients and patients with renal insufficiency Antithrombotic treatment should be adapted in accordance with weight and creatinine clearance Intensive medication strategies and revascularization intervention strategies should always be considered, observing the adverse effects of these therapies Adjustments in doses of beta-blockers, ACEI, ARB, and statins should be considered, with the aim of decreasing or avoiding collateral effects Consider invasive strategies and, if appropriate, revascularization, following careful evaluation of potential risks and benefits, estimated life expectancy, comorbidities, quality of life, frailty, and patient preferences It is reasonable to choose myocardial revascularization surgery over angioplasty in more elderly patients, especially those with diabetes or multiple vessel disease, due to increased survival and reduction of cardiovascular events ACEI: angiotensin converting enzyme inhibitors; ACS-NSTE: acute coronary syndrome without ST-segment elevation; ACS-STE: acute coronary syndrome with ST-segment elevation; ARB: angiotensin receptor blockers; GRACE: Global Registry of Acute Coronary Events; HF: heart failure; TIMI: Thrombolysis in Myocardial Infarction. 4. Heart Failure 4.1. Diagnostic Peculiarities of Heart Failure in Elderly Patients Elderly patients may have atypical presentations of HF due to cognitive alterations, sedentarism, functional limitations, and the presence of comorbidities. These factors contribute to late diagnosis, thus making complementary exams important (Figure 1). 175 The use of biomarkers, such as outpatient values of brain natriuretic peptide (BNP) below 35 ng/mL, excludes the presence of HF in symptomatic individuals. In individuals with acute dyspnea in the emergency room, however, BNP values over 250 ng/mL or pro-BNP over 1,800 ng/mL indicate HF as the cause of the symptoms. Elderly patients have higher natriuretic peptide levels, as well as comorbidities which may increase these values, such as renal insufficiency. 176 Normal EKG results may be useful in making the hypothesis of HF less likely, while findings of AF, complete left bundle branch block, inactive areas, and LVH, increase the probability of this disease. 176,177 Alterations in cardiac geometry and structure occur with aging, including decreases from the base to the apex, right deviation, aortic annulus dilation, and increased interventricular septum thickness, which leads to so-called Sigmoid septum and may cause outflow obstruction. 176 Even 670