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 is accompanied by an increase in reflex wave velocity, which returns from peripheral to central circulation. 191,192 In elderly patients, the reflex wave reaches the ascending aorta during systole, leading to an even higher increase in SBP. Loss of reflex wave in protodiastole makes diastolic pressure remain equal or decrease. 192 The final effect consists of a predominant increase in SBP, with DBP remaining normal or even low. Characteristics of ISH include SBP ≥ 140 mmHg and DBP < 90 mmHg. 193 PP is defined as the difference between SBP and DBP. This occurs due to the progressive loss of arterial elasticity, with a consequent decrease in vascular complacency. DBP tends to remain normal or even low. Limits for abnormal PP values have yet to be defined. 191 The Framingham study demonstrated a higher cardiovascular risk associated with higher PP, in patients between the ages of 50 and 79, as well as an important role of low DBP in this association. 3 In addition to the factors mentioned, target organ injuries should be investigated (eye fundus changes, LV hypertrophy, and peripheral and renal atherosclerosis), and the possibility of secondary SAH should be evaluated. The following are suspicious factors: 193 a) Sudden onset of SAH or acute worsening b) Abdominal murmur c) SAH resistant to 3 or more drugs d) Creatinine increase over 30%with the use of ACEI or ARB e) Systemic atherosclerotic disease in smokers and patients with dyslipidemia f) Recurrent hypertensive pulmonary edema g) Pheochromocytoma and hyperaldosteronism should be adequately investigated with more specific exams, because, even though they are less frequent in elderly patients, once they are diagnosed and treated, they may result in the patient being cured. Among secondary causes of SAH, the following stand out: aortic regurgitation (AR), hyperthyroidism, renovascular atherosclerosis, and use of drugs that increase pressure, such as non-hormonal anti-inflammatory agents, antihistamines, decongestants, corticosteroides, MAOI, and TCA. 5.1.2. Peculiarities of Clinical Laboratory Investigation The objective of clinical laboratory investigation is to confirm that BP is increased; identify causes of SAH, target organ injuries, and associated diseases; and stratify cardiovascular risk. In addition to clinical history, cognitive tests, and physical examination including BMI and abdominal circumference, the following should be performed: a) Resting EKG. b) Urine examination (biochemical and sediment) c) Blood tests: complete blood count, creatinine, blood glucose, potassium, fasting blood glucose, glycohemoglobin, total cholesterol and fractions, triglycerides, and uric acid. Blood levels of creatinine may be normal, in spite of declined renal function. This fact results from the progressive loss of muscle mass, a determining factor of creatinine production. Thus, creatinine levels > 1.5 mg/dL are considered abnormal in elderly patients. The formula most used to calculate estimated glomerular filtration rate (eGFR) is the Cockroff-Gault (mL/ min): (140 – age) × weight (kg)/plasma creatinine (mg/dL) × 72 , with a coefficient of 0.85 for women. Interpretation: normal renal function, > 90 mL/min; slight renal dysfunction, 60 to 90 mL/min; moderate renal dysfunction, 30 to 60 mL/ min; severe renal dysfunction, < 30 mL/min. d) ABPM and HBPM: to investigate white coat SAH and masked SAH, in cases where it is necessary to investigate episodes of arterial hypotension, or to evaluate the efficacy of SAH therapy. 193 5.2. Treatment Peculiarities 5.2.1. Therapeutic Goals for Elderly Patients Treating SAH in elderly patients represents a great challenge, as it involves a heterogeneous group, with multiple comorbidities, cognitive problems, risk of falling, polypharmacy, and frailty syndrome. Therapeutic goals for elderly patients should thus be individualized based on multidisciplinary team judgment, and they should consider patient preferences. 193,194 Dose adjustments should occur every 4 weeks, in order to avoid abrupt reductions of BP. The Hypertension in the Very Elderly Trial (HYVET) randomized, placebo-controlled study 194 included 3,845 patients with SBP ≥ 160 mmHg over the age of 80, with an average age of 83.6. Target blood pressure was 150/80 mmHg. They demonstrated that treatment with indapamide, with or without perindopril, was beneficial in octogenarians. In the intention-to-treat analysis, there was a 30% reduction in rate of fatal or non-fatal stroke, 39% reduction in the rate of death from stroke, a 21% reduction in death from any cause, a 23% reduction of in the rate of death from cardiovascular causes, and a 64% reduction in the rate of HF. Fewer severe adverse events occurred in the active treatment group (358 versus 448 in the placebo group). There is evidence that greatly lowering BP in elderly patients may be harmful; this fact is known as the J- or U-curve. 191 The recent SPRINT study 149 sought to evaluate two different BP goals. In the standard group, the goal was SBP < 140 mmHg and, in the intensive treatment group, the goal was SBP < 120 mmHg. The intensive treatment group had a significant reduction in primary events (infarction, other acute coronary syndromes, stroke, HF, or death from cardiovascular causes) in comparison with the standard treatment group. Although the initial impression may be that more intensive goals may be more beneficial, it is necessary to consider that there was an increase in the number of severe adverse events, such as hypotension, syncope, electrolytic disorders, and acute renal insufficiency, in the intensive treatment group. Another important study was the ACCORD, 35 performed with 10,251 diabetic patients, ages 40 to 79, 4,733 of which were also randomized for BP reduction < 140 mmHg or < 120 mmHg. However, BP reduction with more intensive goals did not succeed in significantly reducing the risk of the study’s primary outcome (death from CVD, nonfatal infarction, and nonfatal stroke). Thus, to date, the III Geriatric Cardiology Guidelines recommends SBP levels ≤ 130 mmHg for elderly patients ≥ age 65, who are considered robust and who do not have frailty criteria. 195,196 For patients ≤ 80 years old, without frailty, SBP levels < 140 mmHg may be considered; 195 in patients ≥ age 80 with SBP ≥ 160 mmHg, an initial reduction to SBP 676