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 between 150 and 140 mmHg may be considered; 7 in fragile elderly patients or patients with multiple comorbidities, the therapeutic goal should be individualized, considering each case’s risk-benefit ratios. 196 5.2.2. Medical and Non-Medical Treatments Salt reduction should be cautious and well accompanied by the doctor, given that the elderly patient’s diminished taste sensitivity may make food appear blander, causing the patient to eat less and thus bringing about the risk of malnutrition. It is also necessary to remember that elderly patients rarely present only one chronic disease. The evaluation of multimorbidities generally defines what the best treatment is and what drugs should be avoided in each specific case. Treatment should be initiated with low doses, and dose adjustments should be gradual. Adherence needs to be stimulated, if possible, by monthly control at the beginning of treatment and at each dose adjustment. The most commonly used drugs in elderly patients are: a) Diuretics: thiazides and correlates (hydrochlorothiazide, chlorthalidone, indapamide) are considered first-line drugs in elderly patients without comorbidities. Their use is preferential in osteoporosis patients, as they decrease urinary excretion of calcium, and in initial phases of congestive heart failure (CHF), as they reduce preload, volume, and pulmonary congestion. Recommended doses of hydrochlorothiazide: 6.25 to 25 mg/day, maintaining efficacy and reducing adverse metabolic effects. 191 In most cases, diuretics are associated with therapeutic schedules. However, they should be avoided in elderly patients with incipient urinary incontinence, gout (because they increase uric acid) and prostatism. 191 Attention should be paid to blood glucose in elderly patients with concomitant use of thiazides and oral antidiabetics or insulin, given that thiazides may increase blood glucose and interfere with diabetes control.  b) Calcium channel blockers: they include both dihydropyridine and non-dihydropyridine derivatives. Dihydropyridine derivatives have major vasodilatory effects. The most recent generation provokes less edema. They are very commonly used in elderly SAH and symptomatic coronary disease patients. Non-dihydropyridine derivatives, especially verapamil, have fewer vasodilatory effects, and they are not usually prescribed to elderly patients, as they may alter electrical impulses of atrioventricular conduction. Verapamil may, furthermore, provoke intestinal constipation. c) ACEI: they continue to be efficacious in elderly patients, notwithstanding the decrease in renin with aging. They decrease cardiovascular events and should be used in elderly patients with SAH and HF or asymptomatic ventricular dysfunction. Adverse effects include changes in taste, especially with captopril, which may reduce food intake, and dry cough, which limit their use. It is fundamental to check potassium, due to frequent reductions in renal function. d) Angiotensin II receptor antagonists (ARA-II): they are effective in HF, and they have an established renal and cardiac protective action in type 2 diabetes with nefropathy. 191 ARA-II have a favorable tolerability profile, with few adverse effects (occasional dizziness and, rarely, hypersensitive skin reaction). They are well used in cases of ACEI intolerance. 193 e) Beta-blockers: they are not used as initial monotherapy in elderly patients without comorbidities, due to their lower effects on BP reduction; however, in association with diuretics, they present good results. They are mainly used in elderly patients with SAH and coronary insufficiency or HF. Less liposoluble beta-blockers, such as atenolol, metoprolol, and bisoprolol, are recommended for elderly patients because they have lower risks of collateral effects on the central nervous system (depression, drowsiness, confusion, sleep disturbances). 193 In summary, elderly patients have particularities regarding SAH diagnosis and approach. It is necessary to consider each patient’s comorbidities and particularities, including functional status, which may be determining factors for setting BP goals and for patient decision making. Recommendation Grade of recommendation Level of evidence SBP ≤ 130 mmHg for elderly patients ≥ age 65, without frailty I A SBP < 140 mmHg for elderly patients ≤ age 80, without frailty IIb C For elderly patients > age 80, with initial SBP ≥ 160 mmHg, initial SBP reduction between 150 and 140 mmHg I B In fragile elderly patients or patients with multiple comorbidities, the therapeutic goal should be individualized, considering risk-benefit ratios IIa C SBP: systolic blood pressure. 6. Valvulopathies 6.1. Mitral Stenosis 6.1.1. Diagnostic Peculiarities Mitral stenosis (MS) is rare in elderly patients (present in 6% of patients with mitral annulus calcification). 197 Etiology – Sequel of rheumatic carditis or calcification of the mitral valve apparatus in patients > 85 years old. 198 Symptoms – similar to those observed in non-elderly patients. Symptoms may be absent. The most frequent are dyspnea and cough, whichmay be accompanied by hemoptoic sputum. It may manifest as systemic embolism or AF. Physical examination – Hyperphonetic first heart sound and apical mid-diastolic murmur with thrill may be absent. The opening snap of the mitral valve is rarely auscultated. Most patients > age 80 present AF with elevated HR which, in association with a greater anteroposterior thorax diameter, makes auscultation difficult. The more fibrosis and calcification are present in the mitral valve, the less audible the auscultatory signs of MS will be. Diagnostic suspicion may be established based on signs of pulmonary arterial hypertension (P2 hyperphonesis in the second heart sound, RV insufficiency, 677