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 of regurgitant volume and fraction, in addition to precise measurements of LV volumes and function. CMR is particularly useful when the degree of LV dilatation in echocardiography seems to be greater than what would be expected. Cardiac catheterization should be performed routinely in all patients referred for surgical correction or coronary disease evaluation, or when clinical and laboratory tests are unclear or divergent regarding AR severity. 203 6.4.2. Treatment Peculiarities In cases of severe acute AR, surgical treatment should be implemented as early as possible, especially if there are signs and symptoms of low cardiac output. In these cases, clinical treatment is inferior to surgical treatment. Inotropic drugs and vasodilators may aid clinical control while the patient is waiting for surgery. 203,235 Clinical treatment – Clinical treatment of AR patients with vasodilators is applied to those with associated SAH and those with severe symptomatic AR and high surgical risks, especially owing to comorbidities, in order to alleviate symptoms. They are not routinely recommended for patients with mild, moderate, or severe asymptomatic chronic AR and normal systolic function. 203,235 Studies have not demonstrated the efficacy of these drugs in slowing surgical indication in AR patients, and they do not substitute surgery when it is indicated. 236 Surgical treatment – Patients with severe symptomatic AR, as well as some asymptomatic patients, have reduced quality of life and life expectancy without surgical treatment. Selecting the appropriate moment for and type of procedure is paramount for a satisfactory surgical result; it is, naturally, necessary to observe and respect functionality and associated comorbidities in this group of patients. 235 Surgical treatment is indicated for patients with severe symptomatic AR or for asymptomatic patients with reduced LVEF or significant LV dilatation. 203,235 There has recently been some speculation regarding aortic valve repair for this pathology, given that complications resulting from anticoagulant use in patients who receive mechanical prostheses are not uncommon. Scientific studies have demonstrated that valve repair is an independent predictor of better survival, with a great reduction in the need for reoperation. 237 Few centers, however, have the experience necessary to perform this procedure, and, in elderly patients, thickened, deformed, or calcified leaflets are common findings, which complicate the procedure. 203 Percutaneous treatment – Percutaneous aortic valve implantation is an effective option for AR patients with moderate or high risks for conventional valve replacement surgery. The use of TAVI is still off-label for AR patients, but studies have demonstrated that it is feasible and will be able to be a treatment alternative. 238 Recommendations for surgical treatment of aortic regurgitation Recommendation Grade of recommendation Level of evidence Symptomatic patients with severe AR, regardless of LV systolic function I B Asymptomatic patients, with severe AR and LVEF < 50% I B Patients with severe AR scheduled to undergo other cardiac surgeries I C Asymptomatic patients with severe AR, normal LV systolic function (LVEF ≥ 50%), and significant LF dilatation (LVSD > 50 mm) IIa B Patients with moderate AR scheduled to undergo other cardiac surgeries IIa C Asymptomatic patients with severe AR, normal LV systolic function (LVEF > 50%), progressive severe LV dilatation (LVEDD > 65 mm), and low surgical risk IIb C AR: aortic regurgitation; LV: left ventricle; LVEDD: left ventricular end- diastolic diameter; LVEF: left ventricular ejection fraction; LVSD: left ventricular systolic diameter. 6.5. Infective Endocarditis 6.5.1. Diagnostic Peculiarities IE, which was previously prevalent in young and middle- aged patients, owing to its association with rheumatic valve disease, has progressively increased in the elderly population. 239 In Europe and the United States, more than half of cases occur in patients > age 60. Diagnosis of IE in elderly patients may be more difficult owing to the fact that signs and symptoms such as mental confusion, fatigue, weight loss, and murmur may be attributed to age itself. The forms in which IE is present in elderly patients, such as clinical signs of stroke, HF, pneumonia, and abdominal pain, may also confuse the initial diagnosis. In some case registries, fever appears in only 2% of cases in elderly patients, in comparison with 90% of patients < age 60. Other not very specific symptoms, such as anorexia, weight loss, arthralgia, dyspnea, and headache, similarly appear in elderly patients. Classic peripheral signs of IE such as Osler’s nodes, Roth spots, and petechiae, are less frequent in elderly patients, being found in 1% to 14% of cases. 240 Laboratory and echocardiography data – hemogram may be normal or present leucocytosis, with the frequent presence of normochromic, normocytic anaemia. Erythrocyte sedimentation rate (ESR) may be elevated in 90% of cases. Positive rheumatoid factor is found in 50% of cases, and the majority of patients have proteinuria and microscopic hematuria. 241 Blood cultures: at least 3 blood samples should be collected during the first 24 hours, with intervals of less than 15 minutes between samples, and they must be collected before beginning antibiotic therapy, given that antibiotic use is the leading cause of failure to identify the germ responsible for endocarditis. In the most developed countries, blood cultures reach 80% to 95% positivity. Echocardiogram: with the advent of echocardiography in the 1980’s, 242 the probability of diagnosing IE has increased, given that it is used to confirm the presence of vegetations, which are one of the 3 diagnostic pillars of IE, along with identification of the germ in blood culture and signs of affected valves, such as murmurs. In elderly patients, the sensitivity and specificity of transthoracic echocardiography is lower owing to the higher frequency of 683