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 Table 8 – Severity of mitral stenosis Pressure gradient (LA-LV) in mmHg Mitral valve area (cm²) Mild < 5 > 1.5 Moderate 5 a 10 1 a 1.5 Severe > 10 < 1 LA: left atrium. LV: left ventricle. 202 pulmonary and tricuspid regurgitation). In elderly pulmonary arterial hypertension patients without any other evident cause, it is important to investigate MS. 199-202 Complementary exams – EKG, chest radiography, and echocardiogram are sufficient, in most cases, to confirm diagnosis and estimate severity. The following may be found in the EKG: left atrial overload (LAO), RV hypertrophy, and AF. Chest radiography findings include: increased LA, mitral valve calcification, and posterior displacement of the barium-filled esophagus. Echocardiography data include: mitral annulus calcification (in 60% of elderly patients > age 85), 4 mitral valve area (Table 8), pulmonary BP, and status of the valvular apparatus (mobility, thickening, and subvalvular impairment). 5 6.1.2. Treatment Peculiarities Clinical treatment – Patients with mild MS are generally asymptomatic, and they do not need to receive medication, 203 unless they also suffer from AF. Unlike younger patients, elderly MS patients who develop AF have a higher chance of showing symptoms of HF, owing to the concomitant present of diastolic dysfunction. Thus, in cases of paroxysmal AF with hemodynamic deterioration, even if MS is mild, electrical cardioversion is indicated. Patients with MS and AF, be it permanent, persistent, or paroxysmal, should constantly use warfarin, regardless of risk scores, with the aim of keeping the international normalized ratio (INR) between 2 and 3, unless there is a formal contraindication. 204 Although some publications recommend the use of new oral anticoagulants in this situation, these data have yet to be evaluated in comparative studies. 205 The finding of LA thrombus or the occurrence of a systemic embolic event, even in the presence sinus rhythm (SR), also indicate the need for anticoagulant use. In MS of rheumatic etiology, prophylaxis for rheumatic fever is not necessary, given that elderly patients rarely have relapses of this disease. 206 Early treatment of bacterial infections is recommended with the aim of protecting the patient from the risk of infective endocarditis (IE). Chemoprophylaxis against IE in elderly MS patients is not indicated. 207 In symptomatic patients with moderate to severe MS, loop diuretics are the best option for controlling pulmonary or systemic congestion, and beta-blockers are indicated for reducing HR and facilitating atrial emptying. There is no evidence that the use of beta-blockers is beneficial in patients with SR who do not have elevated HR. 208 In the presence of AF with elevated ventricular response, beta-blockers are the drugs of choice for reducing HR. In cases where they are contraindicated, nondihydropyridine calcium channel blockers or digitalis may be used. In the presence of signs of RV failure with associated hepatomegaly, due to the frequent coexistence of secondary hyperaldosteronism, elevated doses of spironolactone (100 mg/day) are an option. 209 Caution is necessary with the risk of hyperkalemia. Options for correcting MS – When evaluating an elderly patient with MS who has been indicated for intervention, the following should be considered and discussed with the patient and/or family members: etiology, whether rheumatic or degenerative; patient life expectancy; evaluation of functionality; and the presence of multimorbidities. There are 2 options for correcting rheumatic MS: percutaneous balloon mitral valvuloplasty (PBMV) or extracorporeal circulation surgery. Randomized clinical trials have shown that, in selected cases, PBMV offers immediate and long- term results similar to those of open commissurotomy. 210 For this intervention, presence of favorable valve morphology is important. This may be evaluated by several proposed echocardiography criteria, the Wilkins and Block score being the most widely used. 211 It is, additionally, necessary to respect contraindications to this procedure (presence of LA thrombus or mitral regurgitation with more than a mild degree of severity). Unfortunately, elderly patients frequently have valve morphologies which are unfavorable for this procedure, whether the etiology be rheumatic or degenerative. 212 In the latter case, owing to the fact there is no commissural fusion, as occurs in rheumatic disease, the success of PBMV is restricted, and mitral valve replacement surgery is the procedure of choice. As degenerative MS patients frequently have multimorbidities that elevate their risks, clinical treatment should be attempted initially; mitral valve replacement surgery is indicated only in cases that do not respond to clinical treatment. 213 There are reports of small series of percutaneous implants of mitral prostheses in degenerative MS patients, with relative success. 214 Medical treatment of elderly mitral stenosis patients Recommendation Grade of recommendation Level of evidence Regardless of severity, MS patients who have AF, be it permanent, persistent, or paroxysmal, should receive warfarin indefinitely, with the aim of keeping INR between 2 and 3, unless this is contraindicated I B MS patients indicated for warfarin may use direct oral anticoagulants IIb C Elderly rheumatic MS patients should receive prophylaxis to prevent rheumatic fever III C Elderly MS patients with MVA less than or equal to 1.5 cm 2 ; FC II, III, or IV; and/ or signs of RVF should receive loop diuretics to alleviate symptoms I C Elderly MS patients with MVA less than or equal to 1.5 cm 2 ; FC II, III, or IV; and SR, who continue to be symptomatic in spite of diuretic use, if HR is over 60 bpm, should receive beta-blockers, unless there are contraindications IIa B 678