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 syncope also suggests cardiogenic etiology. 258 Syncope due to postural hypotension is common in dehydrated patients and patients with diminished intravascular volume. Its prevalence increases with age, varying from 6% in population studies to 70% in hospitalized, institutionalized, or Parkinson’s disease patients. 260 In patients with dementia, 48% of syncope episodes occur due to OH. 261 Syncope episodes up to 2 hours after a meal should lead to a diagnosis of postprandial hypotension. Neuromediated syncope is common in elderly patients, of which the most prevalent types are situational (associated with urination, defecation, coughing, and carotid sinus hypersensitivity). 258,259 The presence of nausea, blurred vision, and sweating suggests a non-cardiogenic cause (OH or neurocardiogenic). 258 Neurological syncope, due to preexisting bilateral vertebrobasilar insufficiency is often accompanied by symptoms such as vertigo and ataxia, and it has a lower prevalence. It is also necessary to consider syncope an atypical manifestation of severe diseases such as AMI, which occurs in 3% of elderly patients > age 65 262 and is common in patients > age 85 with prevalence reaching 20%, 263 as well as of pulmonary thromboembolism (PTE) (24% of elderly patients > age 65) 264 and acute aortic dissection (5% to 10%). 265 7.1.1.1. Stratifying Risk of Death The San Francisco Syncope Rules (SFS) are simple rules that evaluate risk of adverse events in syncope patients. It has 74% to 98% sensitivity and 56% specificity. 266  The low specificity is owing to the fact that it is not very specific for cardiogenic syncope, but it makes it possible to discharge low-risk patients and hospitalize more severe cases. The following mnemonic device is used for the SFS: C – History of CHF. H – Hematocrit < 30%. E – EKG abnormalities. S – Shortness of breath. S – SBP at admission < 90 mmHg. (A) – Age > 75. In a patient with syncope, any one of these findings is considered a high risk for events such as death, AMI, arrhythmia, PTE, stroke, subarachnoid hemorrhage, or emergency room re-admission and hospitalization related to a new syncope episode. When age is included, sensitivity increases to 100%, while specificity is reduced. In conjunction with the SFS, the Short-Term Prognosis of Syncope (STePS) Study is another useful score, 267 which evaluates the risk of events 10 days after a syncope episode. It includes only 4 independent risk factors: • EKG abnormalities (the best predictor). • Concomitant trauma. • Absence of prodromes. • Male sex. Predictors of poor long-term (1-year) prognosis include: EKG abnormalities, ventricular arrhythmia, HF, and age > 45. The 1-year event rate (severe arrhythmia or death) varies from 0% for patients with none of the 4 risk factors to 27% in patients with ≥ 3 factors. We may, thus, consider a high risk of short-term (7 to 10 days) and long-term (1 year) events for elderly patients who have syncope and: • Are male. • Do not have prodromes and have syncope with concomitant trauma. • Have dyspnea or sustained hypotension associated with the syncopal event. • Have previous diagnosis of HF and/or ventricular arrhythmias. • Have altered EKG at admission. 7.1.1.2. General Recommendations Elderly patients with unexplained recurrent falls, which are not witnessed by third parties and which are associated with trauma, should be interpreted as possible cardiogenic syncope. Investigation should occur in a hospital environment for episodes which occurred < 1 week prior, with trauma or in patients with known heart disease. Patients with a single episode, which occurred > 1 week prior, without trauma, may be investigated as outpatients. All elderly patients > age 75 with previous heart disease diagnosis and abnormal EKG should be investigated in a hospital environment, due to the high probability of cardiogenic syncope. The flowchart in Figure 2 suggests investigation routes, based on risk stratification, clinical history, and physical examination, which will define investigation strategy and treatment. 7.1.2. Diagnostic Peculiarities of Bradyarrhythmias First-degree AVB have a prevalence of 6% to 8% in individuals ≥ age 70, and, like Mobitz I second-degree AVB, they are not predictive of cardiovascular events. Mobitz II second-degree AVB and third-degree AVB, on the other hand, have worse prognoses and require treatment. Extreme bradycardia (< 35 bpm), sinus pauses > 2 seconds, and advanced AVB are associated with structural heart disease, and they are frequently symptomatic. The association of bradycardia induced by negative chronotropic drugs, acetylcholinesterase or anticholinesterase inhibitors (rivastigmine, donepezil, and galantamine) and central alpha- blockers used for prostatic symptoms or SAH is common. Many cases are asymptomatic and are casually diagnosed during a routine check-up, especially in sedentary patients or patients with functional limitations. 268 Common symptoms include non-rotatory dizziness, effort-induced dyspnea or fatigue, caused by chronotropic deficit. The classic “on- off” syncope (Stokes-Adams syndrome) caused by total or intermittent high-degree AVB is an alert symptom. 269 Diagnosis may be performed via 12-derivation EKG, 24-h Holter, loop event monitor, and electrophysiological studies (EPS). Holter is indicated for bradycardia patients who have daily symptoms. Event monitors (implantable or portable) are indicated for detecting symptoms which occur rarely, but which have significant hemodynamic impairment and prolonged duration and which place the elderly patient’s life at risk. 270-274 In cases of effort-induced symptoms, treadmill ET may clarify diagnostic suspicion (chronotropic incompetence or advanced degree of AVB). EPS is indicated for patients 686