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 The presence of fibrosis, cardiac hypertrophy, cardiac chamber dilation, intracardiac thrombus, pericardial thickening, in addition to the study of right ventricle (RV) function, may be evaluated by cardiac resonance. This has become an integral part of the evaluation of myocardial disease patients, as it identifies the cause (inflammation [myocarditis], amyloidosis, sarcoidosis, Chagas disease), cardiomyopathies, and ischemic disease. 176 Myocardial scintigraphy is a useful method in individuals with suspected ischemic heart disease with systolic dysfunction; it is requested to investigate ischemia and/or myocardial viability. Technetium pyrophosphate bone scintigraphy may be useful in diagnosing transthyretin cardiac amyloidosis in elderly hypertrophy and HF patients. 176 4.2. Peculiarities of Heart Failure Treatment in Elderly Patients HF is prevalent among the elderly, affecting up to 20% of patients > 75 years old. 1 It is characterized by the presentation of systolic dysfunction (HFrEF) or diastolic dysfunction (HFpEF) and high mortality (2-fold risk of all- cause mortality adjusting for age and sex and 4-fold risk of cardiovascular death). 180,181 Over the past decades, HFpEF has become the main clinical phenotype. 2 Polypharmacy is extremely common in this context, with a strong impact on drug interactions, higher rates of adverse effects and poor adherence; however, multidisciplinary and adherence programs have been shown to be useful in this group of patients. 182 Exercise training, in comparison with habitual care, in elderly HFrEF patients in New York Heart Association (NYHA) classes II and III, was shown to be safe, without an increase in mortality and hospitalization and with improvements in the walking test. 183 The objectives of pharmacological treatment of HF are: reducing mortality and hospitalization; improving functional capacity and quality of life; and including the use of ACEI, ARB, beta-blockers, and aldosterone antagonists. Elderly individuals have frequently been excluded or under-represented in studies performed on HF patients. 184 Several influential clinical trials have demonstrated the efficacy of ACEI in younger patients (average age of 60/66); however, subgroup analysis of the Heart Outcomes Prevention Evaluation (HOPE) study demonstrated a higher risk reduction in patients > 65 years old, in comparison with the younger group. 184 ARB have been little evaluated in elderly patients; however, subanalysis of the Candesartan in Heart Failure: Assessment of Reduction in Mortality and Morbidity (CHARM- Alternative) study, with 23.3% of its study population ≥ age 75, demonstrated benefits similar to those reported for the general group. 185 Regarding beta-blockers, a recent meta-analysis of 12,719 patients did not find any differences in benefits between those defined as “elderly” in the clinical trials included and their younger counterparts. It is important to underline the fact that the oldest patient from the individual clinical trials analyzed was 71 years old. 5 The Study of Effects of Nebivolol Intervention on Outcomes and Rehospitalization in Seniors with Heart Failure (SENIORS) demonstrated the efficacy of nebivolol in CHF patients > 70 years old. Subanalysis of the Organized Program to Initiate Lifesaving Treatment in Hospitalized Patients with Heart Failure (OPTIMIZE-HF) study provided evidence that beta-blockers may be associated with beneficial effects in patients ≥ 75 years old. 186,187 The Euro Heart Failure Survey II has suggested that the use of ACEI and/or beta-blockers is associated with a significant decrease in short-term mortality in octogenarians. The Euro HF Survey II, on the other hand, did not show improvements in mortality during 1 year with the use of beta-blockers; this is possibly related to the higher number of elderly HFpEF patients in this study. 188 In the most important studies with aldosterone antagonists, the Randomized Aldactone Evaluation Study (RALES) and the Eplerenone Post-Acute Myocardial Infarction Heart Failure Efficacy and Survival Study (EPHESUS), the average patient age was 67 and 64, respectively. Their use, in elderly patients, however, should be carefully monitored in accordance with renal dysfunction and the underlying drug interaction. In the Prospective Comparison of ARNI with ACEI to Determine Impact on Global Mortality and Morbidity in Heart Failure (PARADIGM) study, symptomatic hypotension in patients > age 75 was more frequent in the sacubitril/valsartan group (18%) than in the enalapril group (12%). 189 In summary, current orientations recommend a therapeutic approach similar to the one applied to younger patients for HF treatment, with caution regarding interactions and tolerance. 176,190 4.3. General Recommendations for Elderly Heart Failure Patients Complementary diagnostic methods of CHF in elderly patients Grade of recommendation Level of evidence Transthoracic echocardiogram recommended for evaluating structure and function in HF and establishing diagnosis of HFrEF and/or HFpEF I C Transthoracic echocardiogram recommended for evaluating resynchronization/ICD candidates I C Repeat evaluation of ventricular function and measures of structural remodeling in patients with CHF, change in clinical status, or decompensation I C MR with delayed enhancement should be considered in patients with dilated cardiomyopathy to differentiate between ischemic and non-ischemic etiology IIa C MR recommended for cardiac tissue characterization when myocarditis, amyloidosis, sarcoidosis, or non- compacted myocardium are suspected I C Non-invasive stress exams (resonance, echocardiogram, SPECT, PET) are recommended for evaluating myocardial ischemia and viability in patients with CAD and CHF before deciding on revascularization IIb B 672