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 11 – Adaptations of the 2015 guidelines for elderly patients in accordance with comorbidities and functional status 252 Guidelines Suggestion for elderly patients Transesophageal echocardiography Consider in all cases, in accordance with clinical suspicion Assess risk-benefit of the procedure Aminoglycosides Combined to penicillin or vancomycin as first choice Avoid, due to nephrotoxicity. Evaluate alternatives Vancomycin First-line treatment in beta-lactam allergic patients or in cases of MRSA Consider daptomicine to avoid nephrotoxicity Monitoring of antibiotic serum levels Vancomycin and aminoglycosides Consider also for all beta-lactam antibiotics Intravenous therapy All cases Consider oral or subcutaneous route Outpatient parenteral therapy Only in compliant patients who have easy access to a hospital Consider for patients for whom prolonged hospital stay may be deleterious to functional and cognitive status MRSA: Methicillin-resistant Staphylococcus aureus. Adapted from Forestier et al., 2016. 252 prostheses, and intracardiac devices. 248 In defining treatment, the international literature makes no considerations regarding age and its consequences for treatment choice. 248-250 AGA data and the presence of frailty syndrome are factors which should be considered in deciding on a proposed treatment. 207,240,250,251 Table 11 shows examples of possible adaptations for elderly patients. The majority of elderly patients have decreased renal function; nephrotoxic antibiotics should, thus, be used carefully and, in some cases, even avoided in this population. 252 Treatment of IE often entails prolonged hospital stay, which is associated with functional and cognitive decline in the elderly population. The use of outpatient parenteral antibiotic therapy should be encouraged in this population, thus avoiding the complications of prolonged hospital stay; this requires that the patient’s infection be controlled and the clinical situation stabilized, in addition to long-term venous access. In the event of difficult venous access, the subcutaneous or even the oral route may be considered, depending on the antibiotic in use. 252 Regarding surgical treatment, the indications are the same as in the general population (severe valvular lesion with HF, large vegetation with a risk of systemic embolism, and uncontrolled infection); in this context, however, AGA becomes more important in deciding on surgical treatment due to the fact that the risks of existing multimorbidities may interfere with the planned procedures. In these cases, a careful risk-benefit assessment of the procedures must be performed in an individualized manner. 253 When surgery is indicated, the decision should be made in a multidisciplinary fashion, and, when possible, it should involve the opinion of an infectologist, cardiologist, cardiac surgeon, anesthesiologist, and geriatrician, in order to define patients who may or may not benefit from a surgical procedure with the highest possible accuracy. 252 7. Cardiac Arrhythmias Arrhythmias and conduction disorders are common in elderly patients, and they are an important cause of emergency room visits and hospitalization in this age group. 1 Structural alterations in the cardiovascular system, which are promoted by aging and are associated with a higher incidence of comorbidities such as LVH, CAD, degenerative valvulopathy, SAH, LV dysfunction, and pulmonary disease, in addition to polypharmacy, are responsible for the increased prevalence of arrhythmias in this population. 254-258 Clinical evaluation should be meticulous, as many elderly patients have atypical manifestations such as unexplained falls, intermittent mental confusion, thromboembolic events, and syncope; some are even asymptomatic and are casually detected during routine EKG. 257 Multimorbidities, frailty syndrome, and impaired functionality and cognitive function interfere with the management of arrhythmias in this group, which should be individualized. This section will discuss the diagnostic and treatment peculiarities of the main cardiac arrhythmias in elderly patients. 7.1. Syncope and Bradyarrhythmias 7.1.1. Syncope and its Differential Diagnoses in Elderly Patients Syncope has a multifactorial etiology in elderly patients. Postural hypotension, also known as orthostatic hypotension (OH) is common, secondary to medication use and severe arrhythmias. It has an average prevalence of 6%, increasing exponentially with age. 254 It has a recurrence rate of 25% to 30% per year, in the first 2 years. 255 It is an independent predictor of morbimortality, reduced functional capacity and institutionalization, 257 as well as a frequent cause of hospital admission. Cardiogenic syncope has the worst prognoses, accounting for up to 20% of cases in elderly patients. 258 Bradyarrhythmias (sinus node disease or advanced AVB) are commonly related to syncope in elderly patients. Tachyarrhythmias manifest with syncope less frequently; they are “on-off” type manifestations, with sudden onset and without short-duration prodromes. They are unrelated to orthostatic position and characterized by fast recovery. It is worthwhile to remember that AS is a possible cause of effort-induced syncope in elderly patients. The following are considered to be predictors of cardiogenic syncope, according to the Evaluation of Guidelines in Syncope Study 2 (EGSYS-2) score: EKG abnormalities, structural heart disease, palpitations before syncope, syncope during effort or in the supine position, absence of autonomic prodromes, and absence of triggering or precipitating factors (≥ 3 points suggest cardiogenic syncope). 259 The presence of dyspnea before 685