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 Figure 2 – Flowchart for investigating syncope in elderly patients. SFS: San Francisco Syncope Rules. Elderly patient with confirmed syncope Clinical history and physical examination Non-cardiogenic syncope Risk stratification ≤ age 75 > age 75 SFS < 1 SFS ≥ 1 Outpatient follow- up Cardiogenic syncope 1. Admission to hospital for evaluation; syncope may be multifactorial 2. Treat possible reversible triggering causes/ factors with inconclusive 24-h Holter or loop monitor results and unexplained recurrent syncope. General recommendations for diagnosing bradyarrhythmias in elderly patients Recommendation Grade of recommendation Level of evidence 12-derivation EKG for patients with suspected bradyarrhythmia I C Investigate negative chronotropic drug use and effort-induced symptoms in asymptomatic patients with bradycardia I C 24-h Holter for electrocardiographic correlation of symptoms with bradycardia (pre-syncope, syncope, palpitations, effort dyspnea, fatigue disproportionate to effort, or non-rotatory dizziness) I C 24-h Holter for patients with resting sinus bradycardia, asymptomatic patients IIb C 24-h Holter for patients with resting sinus bradycardia with effort symptoms to evaluate advanced degrees of block or pauses I C 24-h Holter for patients with high-degree AVB or total intermittent AVB, asymptomatic patients without negative chronotropic drugs I C 24-h Holter for patients with syncope, pre-syncope, and dizziness, whose probable cause (with the exception of bradyarrhythmias) has been identified, but whose symptoms persist in spite of treatment of the probably cause, and patients recovered from CRA IIa C 24-h Holter for electrocardiographic correlation of unspecific symptoms such as rotatory dizziness, dyspnea, and sweating in patients with documented bradycardia III C 24-h Holter for patients with dizziness III C 7-day Holter or loop monitor for patients with infrequent pre-syncope, syncope, palpitations, effort dyspnea, fatigue disproportionate to effort, or non-rotatory dizziness I C 7-day Holter or loop monitor for patients with infrequent syncope, pre-syncope, and dizziness, whose probable cause (with the exception of bradyarrhythmias) has been identified but whose symptoms persist in spite of treatment of the probably cause IIa C 7-day Holter or loop monitor for electrocardiographic correlation of unspecific symptoms such as rotatory dizziness, dyspnea, and sweating in patients without documented bradycardia III C Treadmill ergometric test for patients with effort-induced symptoms and resting sinus bradycardia to evaluate de chronotropic incompetence I C Treadmill ergometric test for patients without symptoms and resting sinus bradycardia IIa C Electrophysiological study for patients with clinical suspicion of bradyarrhythmia and inconclusive non-invasive exams to measure AH intervals, HV intervals, and sinus node recovery time (investigating sinus node disease and degenerative disease of the AV node) IIa C AVB: atrioventricular block; CRA: cardiorespiratory arrest; EKG: electrocardiogram. 687