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 Elderly patients with mild MS who develop AF with elevated ventricular response should receive beta-blockers to control ventricular response, unless there are contraindications IIa C In the previously described cases, nondihydropyridine calcium channel blockers or digitalis may be used, in the event that beta-blockers are contraindicated IIa C MS patients with signs of RVF and hepatomegaly, without adequate response to loop diuretics, should receive spironolactone. IIb C AF: atrial fibrillation; bpm: beats per minute; FC: New York Heart Association functional class; HR: heart rate; INR: international normalized ratio; MS: mitral stenosis; MVA: mitral valve area; RVF: right ventricle failure; SR: sinus rhythm. Indications for intervention in elderly rheumatic mitral stenosis patients Recommendation Grade of recommendation Level of evidence Elderly symptomatic rheumatic MS patients (FC II-IV), with MVA ≤ 1.5 cm 2 , who have favorable valve morphology and no contraindications, should undergo PBMV I A Elderly rheumatic MS patients who, although they are very symptomatic (FC III/IV) with MVA ≤ 1.5 cm 2 , but with unfavorable valve morphology or contraindication to PBMV, without elevated surgical risk or low life expectancy, should be referred for open valvuloplasty or valve replacement surgery I B If the MS patient is in FC II with MVA ≤ 1.5 cm 2 , but is not a candidate for PBMV, it is prudent to maintain medical treatment as long as the patient does not become more symptomatic IIb C Rheumatic MS patients with MVA ≤ 1.5 cm 2 who are indicated for AVR, ascending aorta surgery, or MRS, should also undergo valvuloplasty or mitral valve replacement I C PBMV is indicated for rheumatic MS patients, with MVA ≤ 1.5 cm 2 , even if they are asymptomatic, notwithstanding pulmonary arterial hypertension (PASP > 50 mmHg), whose probably etiology is MS, when valve morphology is favorable, in the absence of contraindication IIa C Severe rheumatic MS patients (MVA ≤ 1.0 cm 2 ), who are asymptomatic and who have favorable valve morphology for PBMV and no contraindications, should undergo the procedure IIb C AVR: aortic valve replacement; FC: New York Heart Association functional class; MS: mitral stenosis; MRS: myocardial revascularization surgery; MVA: mitral valve area; PASP: pulmonary artery systolic pressure; PBMV: percutaneous balloon mitral valvuloplasty. Indications for intervention in elderly degenerative mitral stenosis patients Recommendation Grade of recommendation Level of evidence MVR in elderly degenerative MS patients who do not respond adequately to clinical treatment and who have low surgical risk and high life expectancy IIa C PBMV in elderly degenerative MS patients, FC III/IV, who do not respond to clinical treatment, with high surgical risk IIb C Percutaneous implants of mitral prosthesis in very symptomatic patients who do not respond to clinical treatment and who are not candidates for open surgery or PBMV IIb C FC: New York Heart Association functional class; MS: mitral stenosis; MVR: mitral valve replacement; PBMV: percutaneous balloon mitral valvuloplasty. 6.2. Mitral Regurgitation 6.2.1. Diagnostic Peculiarities From the etiological point of view, mitral regurgitation (MR) may be: (a) primary: when there are histological changes in the valve, for example, myxomatous degeneration, degenerative fibroelastic disease, and IE; or (b) secondary: when MR is functional and the valve is histologically normal, for example, poor leaflet coaptation with dilated cardiomyopathy. MR is common in elderly patients; the degenerative cause is the most frequent, followed by ischemia, and, less frequently, rheumatic disease and IE. 215,216 Acute MR is mainly linked to CAD by papillary muscle dysfunction or chordae tendineae rupture, with condition of acute HF. Symptoms – symptoms of chronic MR are related to severity, rate of disease progression, pulmonary BP, presence of arrhythmias (e.g., AF), and associated diseases. The most common symptoms are stress dyspnea and fatigue. Physical examination – The following are present: protosystolic murmur in mitral focus, variable intensity, and displaced ictus, with characteristics of volumetric overload. Thoracic deformities, which are common at this age, may modify ictus, sounds, and murmurs. 102,202 Complementary exams – During EKG, frequent abnormalities are LAO, AF and left ventricular overload (LVO). 217 In the presence of ischemic MR, electrocardiographic signs of coronary insufficiency, such as electrically inactive zones and alterations in ventricular repolarization, may occur. 218 In cases of acute MR, EKG may be normal, or it may show only sinus tachycardia. 217,219 Chest radiography aids detection of comorbidities, evaluation of pulmonary congestion, and distinction between acute and chronic cases. In cases of acute MR, the heart may have normal dimensions, and pulmonary congestion may, nevertheless, be present. In cases of chronic MR, there will be an increase in the LA and LV. 217,218,220 Transthoracic echocardiography is indispensable for diagnosing and evaluating degree of mitral regurgitation, chamber size, and ventricular function. The sizes of the LA and LV and measurements of pulmonary 679