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 7.1.3. Treatment Peculiarities Treating syncope – Syncope treatment in elderly patients must be multifactorial, with an approach that covers various components which may be involved in the syncopal episode. Cases of cardiogenic syncope in no way differ from the approach used in younger patients. Treatment of baseline heart disease is in accordance with specific recommendations, respecting the elderly patient’s specificities. 254 It is necessary to avoid hypovolemia and substitute vasodilatadory medications which may promote OH, by accentuating the dysautonomic response, such as beta-blockers with alpha and beta blocking action, calcium channel blockers, and central alpha-blockers. Centrally acting drugs (tricyclics, fluoxetine, aceprometazine, haloperidol, L-dopa, et al.) are also associated with risk of syncope and should be substituted. 275 The non-pharmacological measures commonly prescribed to treat neuromediated syncope have conflicting results in the elderly population, and they also present difficulties in adherence. Not limiting sodium intake and stimulating water intake are effective, but with low adhesion. 276 Avoiding heavy meals and meals in hot environments, as well as standing up immediately after a meal, may reduce the occurrence of postprandial hypotension. Classical medical treatment of neuromediated syncope has also not been shown to be effective in the elderly. 277 Regarding drugs, fludrocortisone has proven efficacy in this age range, at the expense of more collateral effects, mainly edema, hypokalemia, metabolic alkalosis, weight gain, and supine hypertension. 277,278 Treatment of cardioinhibitory syncope with pacemakers was shown to reduce syncope recurrence in a randomized clinical trial carried out in the elderly population (5% versus 61% recurrence in the pacemaker and control groups, respectively, p = 0.00000). 279 Treating bradyarrhythmias – Treatment of bradyarrhythmias in the elderly follows the same recommendations as in younger patients. 280,281 The suspension of negative chronotropic drugs is fundamental. In patients with symptomatic sinus bradycardia, resting HR < 40 bpm, or symptomatic pauses, indicating definitive pacemaker implant reduces symptoms and improves quality of life, but it does not interfere with prognosis. 282,283 In patients with sinus bradycardia and dementia who need to initiate cholinesterase inhibitors, this may aggravate their bradyarrhythmia, the effect being dose dependent. Indication for a pacemaker in these patients should be individualized, as there is no evidence regarding the efficacy of this approach. In patients with advanced AVB, indication for a definitive pacemaker is associated with reduced mortality and should follow the same indications as in younger patients. 280,281 General recommendations – With relation to treating syncope and bradyarrhythmias in the elderly, multiprofessional evaluation is important regarding the functional aspect and prognosis of comorbidities. Generally speaking, there is no specificity regarding the treatment efficacy of interventions with respect to bradyarrhythmias, and the same treatment recommendations used for younger patients should be followed. It is necessary to be attentive to non-cardiovascular use of drugs with negative chronotropic properties, as they may aggravate preexisting bradycardia. 7.2. Tachyarrhythmias in Elderly Patients 7.2.1. Diagnostic Peculiarities Supraventricular tachyarrhythmias (SVT) – SVT are frequent in elderly patients, and their prevalence increases with age. The most common in this age range are: atrial tachycardia, flutter, and AF. 284 Atrial extrasystoles (AES) in patients ages 60 to 86 have an approximate prevalence of 80%, and supraventricular paroxysmal tachycardia (SVPT) has a prevalence from 10% to 15%. In individuals ≥ age 80, the prevalence of AES may reach 100%, and that of SVPT is from 25% to 30%. Effort-induced atrial arrhythmias in patients > age 80 reach a prevalence of > 10%. 285,286 In spite of their high prevalence, SVT (with the exception of AF) are not associated with increased morbimortality. 285,286 AES and non-sustained SVT (duration < 30 seconds) are not very symptomatic, observed with palpitation, “lightheadedness,” dizziness, neck pounding, and “shortness of breath.” Occasionally, dyspnea, chest pain, and syncope may occur, especially in patients with acute sustained arrhythmias, significant diastolic dysfunction, severe AS, HF, or CAD. The higher the HR, the less tolerated the arrhythmia, as a consequence of reduced cardiac output, which results in manifestations of cerebral and myocardial ischemia, arterial hypotension, and pulmonary congestion. 287 Some arrhythmias are peculiar in elderly patients: 288,289 a) Atrial tachycardia with AVB: presents high atrial frequency associated with slow ventricular response due to an AVB. Digitalis toxicity and hypokalemia are common causes. b) Multifocal atrial tachycardia: is common in the presence of COPD. 285,287 Treatment focuses on the baseline disease, considering pre-fibrillatory rhythm. c) Accelerated junctional rhythm: digitalis toxicity and inferior wall AMI are the most common causes in elderly patients. 285,287 Diagnosis is suggested for regular bradycardic rhythm, in the presence of AF. d) Atrial flutter: habitually indicates structural heart disease. CAD and COPD are the most common causes in elderly patients. Elderly patients with atrial flutter have a higher chance of degeneration to AF; they are at a high risk for thromboembolic events, and they should receive a similar approach to AF cases. Ventricular tachyarrhythmias – Ventricular extrasystoles are common in the elderly, with an incidence of 70% to 90%. 284,287,288 They do not generally produce symptoms, unless they are very frequent. Symptomology is variable; patients may perceive repetitive heart beats or the sensation that their “heart is going to stop,” due to compensatory pauses. They are associated with risk of death in the presence of structural heart diseases. Treating arrhythmia in an isolated manner, however, does not reduce risk in elderly patients with CAD. 286,289 Pre-syncope, syncope, low output, pulmonary congestion, behavior disorder, and disorientation are frequent clinical manifestations of poor prognosis. Ventricular tachycardia (VT) is frequently associated with structural heart disease. LVH is an important determinant of ventricular arrhythmia, 287 as well as HF, which increases the incidence of VT from 2% to 4%, in patients without HF, to 20% to 80%. 287 In these patients, the presence of complex ventricular arrhythmia is associated 688