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 Intervention Recommendation Grade of recommendation Level of evidence Oxygen In patients with arterial saturation below 90%, respiratory failure, or a high risk of hypoxemia, it is necessary to maintain during the first 6 h or until hemodynamic stabilization is reached I C Nitrates In sublingual form, it is recommended for patients with ischemic type chest pain. It may be used in intravenous form in elderly patients with persistent pain and conditions associated with hypertension and heart failure. It should be avoided in cases of hypotension, right ventricular infarction, and severe aortic stenosis I C Morphine This should be reserved for patients with unacceptable pain levels. The initial dose is 2 to 4 mg, with 2 to 8 mg increments repeated in 5 to 15 minute intervals I C Beta-blockers Great benefits in comparison with younger groups, regarding prevention of ACS and death. Intravenous administration should only be used in specific cases I B ACEI Benefits especially in CHF or LV dysfunction I A Statins Dyslipidemia treatment in elderly patients up to age 75 should follow the same orientations as in non-elderly patients I A After age 75, doses of lipid-lowering agents should be individualized according to the presence of comorbidities, life expectancy, and polypharmacy I B ASA Indicated for all elderly patients, if there are no contraindications. Benefits are greater in elderly patients I A Clopidogrel Indicated for elderly ACS patients with high risks, especially those who will undergo angioplasty. Loading doses are not recommended in elderly patients who are eligible for thrombolytic therapy I A Ticagrelor Better evolution than clopidogrel, comparing groups over and under age 75, with no differences in bleeding in either of the 2 groups I B Prasugrel Contraindicated in patients ≥ 75 years old, weight < 60 kg, and stroke/TIA history III A Antithrombins Should be administered with caution in ACS patients. Enoxaparin may be administered at reduced doses in patients > 75 years old (0.75 mg/kg, SC, 12/12h) I A Glycoprotein inhibitor IIb/IIIa Indicated in the most elderly subgroups at the moment of intervention, excluding renal insufficiency: I A ACS-NSTE – Early intervention strategies, when thienopyridine is not administered IIa C Thrombolysis When indicated, evaluate with attention to contraindications, as they are more frequent in elderly patients. In the event of tenecteplase use in elderly patients > age 75, administer a half-dose I A Primary angioplasty Better risk-benefit compared to thrombolytic drugs I A Early catheterization Improved short- and long-term evolution. Evidence from randomized, controlled studies are limited in elderly patients and should take risk of bleeding into account. Data are lacking in the ≥ age 80 subgroup IIa B ACS-STE – Elderly patients should be considered for early invasive strategies, with the possible option of revascularization I A Cardiac rehabilitation The same benefits as in younger groups regarding death prevention I B ACEI: angiotensin converting enzyme inhibitors; ACS: acute coronary syndrome; ACS-NSTE: acute coronary syndrome without ST-segment elevation; ACS-STE: acute coronary syndrome with ST-segment elevation;ASA: acetylsalicylic acid; CHF: congestive heart failure; LV: left ventricle; TIA: transient ischemic accident. though patients with HF with reduced ejection fraction (HFrEF) (LVEF < 40%) and HF with preserved ejection fraction (HFpEF) (LVEF > 50%) are well defined, there is some uncertainty in elderly patients with moderate HF (LVEF 41% to 49%). A recent study demonstrated that this intermediate profile is a distinct entity and it should be categorized as HFrEF due to the elevated prevalence of coronary disease and to the similar benefits of using the standard of treatment indicated for this biomarker. 178 Echocardiography study allows for evaluation of indexed left atrial (LA) volume, the presence of LV hypertrophy, analysis of filling pressures (E/A ratio, E/E’ ratio, and pulmonary flow), diastolic function, inferior vena cava variation, pulmonary BP evaluation, degree of mitral regurgitation, and the presence or absence of aortic stenosis (AS) (especially the low-flow, low-gradient phenotype with normal ejection fraction). It also allows for investigation of etiology, where senile amyloidosis is currently a growing condition in individuals over the age of 70. 176,177,179 In clinical practice, evaluation of functional state using ergospirometry aids prognostic evaluation and cardiac rehabilitation planning. 671