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 Recommendations for medical treatment of AS Recommendation Grade of recommendation Level of evidence Systemic arterial hypertension should be treated in asymptomatic AS patients, starting with a low dose of anti- hypertensive and gradually increasing, as necessary, with frequent clinical follow-up I B Vasodilator therapy may be used in association with invasive hemodynamic monitoring to treat patients with severe decompensated AS, with New York Heart Association class IV symptoms of HF IIb C Statin use is not indicated to prevent the progression of AS in patients with mild to moderate calcified lesions III A AS: aortic stenosis, HF: heart failure. Recommendations for surgical treatment of AS Recommendation Grade of recommendation Level of evidence Symptomatic patients with severe AS I B Asymptomatic patients with severe AS and LVEF < 50% I B Patients with severe AS scheduled to undergo other cardiac surgeries I B Asymptomatic patients with very severe AS (transvalvular jet velocity ≥ 5.0 m/s) and low surgical risk IIa B Asymptomatic patients with severe AS and diminished exercise tolerance or IIa B effort hypotension IIa C Patients with moderate AS scheduled to undergo other cardiac surgeries IIb C AS: aortic stenosis; LVEF: left ventricular ejection fraction. The choice between surgical aortic valve replacement and TAVI Recommendation Grade of recommendation Level of evidence Surgical aortic valve replacement is recommended in patients who have indications for surgical treatment and who have low or intermediate surgical risks I A In patients under consideration for TAVI and in those with high surgical risk for valve replacement, members of a Heart Team should collaborate to provide the patient with the best care possible I C TAVI is recommended for patients indicated for surgical aortic valve replacement, with prohibitive surgical risk and post-TAVI life expectancy of more than 12 months I B TAVI is a reasonable alternative to surgical aortic valve replacement in patients who meet indications for surgical treatment and who have high surgical risks IIa B Balloon aortic valvuloplasty may be considered as a bridge to surgical or percutaneous valve replacement in severely symptomatic patients with severe aortic stenosis IIb C TAVI is not recommended for patients whose existent comorbidities would impede the benefits expected from correction of aortic stenosis III B TAVI: transcatheter aortic valve implantation. 6.4. Aortic Regurgitation 6.4.1. Diagnostic Peculiarities AR is less common in elderly patients than AS and MR. Etiology – The most common causes of chronic AR in elderly patients are ascending aorta dilation due to SAH, primary aortic disease, calcified valve disease, and, rarely, atrioventricular block (AVB). Another cause is rheumatic cardiac disease (especially in developing countries). 232 Symptoms – Chronic AR evolves slowly and insidiously in most cases, with very low morbidity during the asymptomatic phase. After this phase, some patients present progression of the regurgitant lesion, with subsequent LV dilation, systolic dysfunction, and, eventually, HF. 233 Mortality rates for patients with severe AR with NYHA class II symptoms are approximately 6% yearly and almost 25% in patients in NYHA classes III or IV. 234 Physical examination – The murmur is diastolic, decrescendo, blowing, and high frequency, and it is best heard in the left sternal border or in aortic focus. Its severity is more related to duration of murmur than to intensity. The ictus is dislocated, revealing LV volumetric overload, and its dimension is related to lesion severity. Peripheral alterations, which are characteristics of severity in young patients (increased PP, arterial neck pulsation, and systolic pulsation in the head), may be exacerbated in elderly patients, given that alterations resulting from the loss of elasticity of the great arteries may accentuate them. Complementary exams – EKG is not very specific in AR, and the routine finding is LVO in cases with long duration. Chest radiography helps detect comorbidities, evaluate pulmonary congestion, and distinguish between acute and chronic cases. Acute cases present pulmonary congestion and normal or slightly enlarged cardiac area. Chronic cases present increased cardiac area secondary to LV dilation. Ascending aorta dilation, on the other hand, suggests that the AR is secondary to aneurysmal dilatation of the aorta. Echocardiography is the pillar of serial monitoring and evaluation of chronic AR patients. It is useful for confirming diagnosis, evaluating cause and valve morphology, estimating lesion severity, and evaluating LV dimensions, mass, and systolic function, as well as aortic root dimensions. 203 For patients with suspected moderate or severe AR, cardiovascular magnetic resonance (CMR) provides precise quantification 682