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 9 – Diagnosis and classification of aortic stenosis severity Indicator Mild Moderate Severe Jet velocity (m/s) < 3.0 3.0 to 4.0 > 4.0 Mean gradient (mmHg) < 25 25 to 40 > 40 Valve area (cm 2 ) > 1.5 1.0 to 1.5 < 1.0 Plasty or mitral replacement may be considered for symptomatic patients with chronic primary MR and FE ≤ 30% IIb C Mitral plasty via catheter may be considered for symptomatic patients (FC III/IV) with chronic primary MR and prohibitive surgical risk IIb B Mitral plasty may be considered for symptomatic patients (FC III/IV) with chronic secondary (functional) MR who are refractory to clinical treatment and cardiac resynchronization IIb C For symptomatic patients with severe MR due to degeneration of a bioprosthesis or previously implanted valve rings and prohibitive surgical risks, percutaneous mitral replacement at a specialized center may be considered IIb C Asymptomatic patients with severe MR and preserved left ventricular function (LVEF > 60% and end systolic diameter < 40 mm) III C Plasty or mitral replacement may be considered for patients with moderate MR who are undergoing concomitant myocardial revascularization surgery III A EF: ejection fraction; FC: New York HeartAssociation functional class; LVEF: left ventricular ejection fraction; MR: mitral regurgitation; PASP: pulmonary artery systolic pressure. 6.3. Aortic Stenosis 6.3.1. Diagnostic Peculiarities In order to diagnose AS, the most frequent valvulopathy in elderly patients, it is necessary to consider clinical history, which may be difficult in this age range due to possible cognitive and sensory alterations. Symptoms – Patients may be asymptomatic or present dyspnea, angina pectoris, or syncope. Physical examination – Findings may include: (a) impulsive type ictus cordis , which may be absent in elderly patients due to increased anteroposterior diameter of the rib cage; (b) the parvus et tardus pulse (reduced amplitude and longer duration time), which is characteristic of AS in younger patients, may be absent in elderly patients, due to the stiffening of arterial walls which promotes an increase in PWV, thus masking this semiological finding; (c) mid-systolic murmur in crescendo and decrescendo which radiates toward the neck and clavicles. Gallavardin’s phenomenon is frequently auscultated. This is a radiation of the AS murmur to the apical region; (d) hypophonetic second sound. Complementary exams – EKG may present findings compatible with LAO and LVO. Chest radiography may be normal, in approximately half of elderly patients examined, or there may be aspects of hypertrophy, which may or may not present post-stenotic aortic dilatation. Echocardiography is a fundamental exam for diagnosing and classifying this valvulopathy. Three echocardiography parameters are frequently used to classify severity of AS: (a) peak aortic jet velocity; (b) mean transvalvular gradient; (c) valve area (Table 9). The ET has been indicated for asymptomatic patients with severe AS in order to verify the hemodynamic response to effort; on the other hand, its use in elderly patients should be individualized, owing to the presence of multimorbidities which may impede the procedure. 6.3.2. Treatment Peculiarities Medical treatment – Arterial hypertension is common in elderly AS patients. It contributes to increased total afterload, in conjunction with obstruction, thus promoting LV overload. In elderly patients, it is necessary to begin antihypertensive treatment with low doses and gradually increase posology. It is necessary to be cautious when using diuretics, due to the risk of hypotension. ACEI may be advantageous due to their effect on ventricular fibrosis, and beta-blockers are appropriate in patients with CAD. Statin use is not indicated for preventing the progression of AS. 203 In the presence of HF, beta-blockers should be initiated with low doses, and the same precautions should be taken in prescribing aldosterone antagonists, ACEI, and ARB, and especially with digitalis drugs, as their toxicity and therapeutic thresholds are close. 203 In elderly patients, it is important to evaluate creatinine clearance in order to adjust dosages and thus avoid drug intoxication. Surgical treatment – Indicating surgery, whether aortic valve replacement or transcatheter aortic valve implantation (TAVI), depends on a set of factors, including: severity of valve lesion; complementary exam data; evaluation of multimorbidities; risk scores, for example the STS score; and functional evaluation (frailty and cognitive function). Deciding on percutaneous implantation requires a multidisciplinary team for integrated action. 203,230 The first step in deciding on surgery is establishing that the patient has a severe aortic valve lesion, which, associated with the presence of symptoms, presents a high grade of recommendation. Surgical treatment may still be offered to asymptomatic patients with ventricular dysfunction (LVEF < 50%) or who have already scheduled another cardiac surgery. 203 In relation to the risks of surgical procedures, patients are classified as low risk: STS < 4%, without frailty, without comorbidity; intermediate risk: STS 4% to 8%, mild frailty, affected organic system; high risk: STS > 8%, moderate to severe frailty, more than 2 affected organic systems; prohibitive risk: pre-operative risk > 50% in 1 year, 3 affected organic systems, or extreme frailty. 203,231 In most cases, the decision is complex, making it necessary to involve family and the medical and multidisciplinary team and, above all, to respect the patient’s own wishes. When the benefits are considered less than the risks, palliative care may be the patient’s best option. 681