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 Carvedilol 3.12 5mg 2×/day 50 mg/day None Metoprolol succinate 12.5–25 mg 200 mg/day None Nebivolol 1.25 mg 10 mg None Spironolactone 12.5–25 mg 25–50 mg None Increased risk of hyperkalemia and renal dysfunction Monitor K and creatinine Furosemide 20–40 mg/day 1 or 2×/day 600 mg (usual 40–240 mg/day) Start 20 mg/day Frequent monitoring Increased risk of alterations in water balance and electrolyte disturbances Bumetanide 0.5–1 mg 1 or 2×/day 10 mg Usual (1–5 mg/day) None Frequent monitoring Increased risk of alterations in water balance and electrolyte disturbances Hydrochlorothiazide 25 mg 200 mg/day Usual (12.5–100 mg/day) Start 12.5 mg–25 mg Monitor fluid volume and electrolyte status Chlorthalidone 12.5–25 mg 100 mg None Monitor fluid volume and electrolyte status ACEI: angiotensin converting enzyme inhibitors; AUC: area under curve; NHAI: non-hormonal anti-inflammatory. 5. Arterial Hypertension in The Elderly 5.1. Diagnostic Peculiarities A Brazilian epidemiological study titled the Multicenter Study of Elderly Patients in Outpatient Clinics of Cardiology and Geriatric Brazilian Institutions (EMI, acronym in Portuguese) 191 demonstrated that SAH is the main risk factor among elderly Brazilians. It is found in 65% of elderly outpatients and 80% of women > 75 years old. Aging produces vascular alterations, such as arterial stiffening, reduced elasticity and vascular compliance, reduced vasodilation capacity, increased SBP, decreased sensitivity to volume changes, slowed ventricular relaxation, increased cardiac workload, loss of myocytes, and compensatory hypertrophy. 192 These alterations lead to peculiarities in diagnosing and treating SAH in elderly patients. 5.1.1. Peculiarities in Measuring Blood Pressure In elderly patients, BP has high variability. It is necessary to take special care in measuring BP, owing to the possible presence of the following factors: a) OH: defined as a drop in SBP of > 20 mmHg or in diastolic blood pressure (DBP) of > 10 mmHg, following 3 minutes in the orthostatic position. BP should be checked in the sitting, lying, and standing positions, given that atherosclerotic alterations in the carotid sinus regions may reduce baroreceptor sensitivity, leading to reduced postural reflexes and, thus, predisposing the patient to OH. 3 Furthermore, comorbidities, such as peripheral polyneuropathy and Parkinson’s disease, as well as the use of diuretic, antidepressant, vasodilator, and beta-blocker drugs may also lead to OH in up to 34% of elderly patients > age 75. b) Auscultatory gap: a sitution in which, after auscultation of the first Korotkoff sound, the sound disappears completely and only reappears after the decrease in SBP, but before the beginning of the last phase of Korotkoff sounds. This leads to errors in diagnosing SBP at lower levels and false diagnoses of normotension. In order to avoid this measurement error, it is necessary to estimate systolic pressure using the radial pulse palpatory method, raising cuff pressure 20 to 30 mmHg above this point. 193 c) Pseudo-hypertension: pseudo-hypertension may appear in elderly patients with pronounced atherosclerosis, arterial wall calcification, and vessel stiffening. In this situation, it is sufficient to inflate the cuff in order to collapse the brachial artery. 193 Osler’s maneuver is used to identify this. The maneuver consists of inflating the cuff above systolic pressure levels and, concomitantly, palpating the radial artery. If it continues to be palpable, this suggests that the artery is stiff and indicates that the index obtained by auscultation does not express the true SBP. Pseudo-arterial hypertension may also be suspected when SBP is elevated in patients who do not present injuries in target organs or in those who manifest hypotension following treatment with low doses of anti-hypertensive drugs. d) Arterial hypertension during exercise: although BP is habitually higher during physical exercise, this increase is greater in elderly adults, due to arterial stiffness. Values for diagnosing SAH during exercise are not clear. Physically deconditioned patients respond with greater increases in BP than conditioned patients. e) White coat hypertension: this occurs when BP increases during a clinical visit but remains normal during daily activity. This can be better evaluated by 24-hour ambulatory blood pressure monitoring (ABPM) or home blood pressure monitoring (HBPM). 193 Serial measurements may minimize this condition. f) Masked arterial hypertension: this is the opposite of white coat hypertension, namely, pressure is high during daily activities and normal during the clinical visit. 193 This may also be evaluated by 24-h ABPM or HBPM. g) Isolated systolic hypertension (ISH) and pulse pressure (PP): ISH and PP are cardiovascular risk factors in elderly patients. 191 ISH is due to lower distensibility and elasticity in the large capacitance vessels, such as the aorta, which results in increased pulse wave velocity (PWV). This increase in PWV 675