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 calcified lesions and valve prostheses, as well as the presence of obesity and thoracic deformities. 243 TEE improves diagnostic accuracy, and it may be performed in elderly patients as safely as in younger patients. Diagnostic criteria – In various cases of IE, diagnosis is uncertain due to the impossibility of demonstrating the existence of vegetations and to unspecific clinical manifestations, resulting in diagnostic errors. The Duke criteria, modified by Li et al. 244 (Table 10), are the most widely used to establish IE diagnosis. Nevertheless, IE diagnosis is a difficult process, but the inclusion of clinical, laboratory, and echocardiography data reduces the chance of error. Table 10 – Criteria for diagnosing IE Major criteria Microbiological Comments Typical isolated microorganism from two separate blood cultures: Streptococcus viridans , Streptococcus bovis , HACEK group, Staphylococcus aureus , or community-acquired enterococcal bacteremia, in the absence of a primary focus In patients with possible IE, at least 2 blood cultures must be obtained in 2 different veins during the first 2 hours. In patients with septic shock, 3 blood cultures must be collected at 5–10 min intervals, after which point empirical antibiotic therapy should be initiated. Or Persistently positive blood cultures consistent with isolated IE Or Blood culture positive for Coxiella burnetii or antibody titre (lgG) > 1:800 for C. burnetii C. burnetii is not cultivated in most laboratory analyses Evidence of endocardial involvement New valvular regurgitation (increases and changes in preexisting murmurs are not sufficient) Or Positive echocardiogram (TEE recommended for patients with prostheses, possible IE based on clinical criteria, or complicated IE) Three TTE findings are considered major criteria: discrete oscillating intracardiac mass located on a valve or subvalvular structure, periannular abscess, and new dehiscence of prosthetic valve Minor criteria Comments Predisposition to IE, including certain heart conditions and IV drug use Cardiac abnormalities that are associated with IE are classified into 3 groups: ● High risk: previous IE, aortic valve disease, rheumatic valve disease, prosthetic valve, coarctation of the aorta, and complex cyanotic heart diseases ● Medium risk: mitral valve prolapse with leaflet insufficiency or thickening, isolated mitral stenosis, tricuspid valvulopathy, pulmonary stenosis, hypertrophic cardiomyopathy ● Low risk: Ostium secundum IAC, ischemic disease, previous revascularization surgery, and mitral valve prolapse without previous regurgitation, and mitral valve prolapse without regurgitation and with thin leaflets Fever Temperature > 38° C Vascular phenomena Except petechiae and hemorrhagic suffusions No peripheral lesions are pathognomonic of IE Immunologic phenomena Rheumatoid factor, glomerulonephritis, Osler nodes, Roth spots Microbiological findings Positive blood cultures that do not meet major criteria. Serological evidence of active infection, isolation of coagulase-negative staphylococci and organisms that rarely cause IE are excluded from this category Cases are clinically defined as “definite IE” if they meet 2 major criteria, 1 major criterion and 3 minor criteria, or 5 minor criteria and “possible IE” if they meet 1 major criterion and 1 minor criterion or 3 minor criteria. HACEK: Haemophilus aphrophilus, Actinobacillus actinomycetemcomitans, Cardiobacterium hominis, Eikenella corrodens and Kingella kingae; IAC: interatrial communication; IE: infective endocarditis; IgG: immunoglobulin G; IV: intravenous; TEE: transesophageal echocardiography; TTE: transthoracic echocardiography. 6.5.2. Treatment Peculiarities As the population ages, IE affects more and more elderly individuals. More than a third of IE patients in Western countries are over age 70. 245 Mortality in elderly patients is also higher when compared to the general population. 246 Aging is a heterogeneous process, and it is always recommended to use AGA, which considers nutritional, functional, and cognitive status to better define prognosis as well as treatment options for this population. 247 The majority of elderly IE patients have multimorbidities, and the most common entryways for bacteria are the digestive and urinary tracts. Furthermore, these patients have predisposing factors, such as AS, valve 684