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 7.2.2. Treatment Peculiarities Treatment principles for tachyarrhythmias in the elderly are similar to those in younger patients; however, treatment is more frequently influenced by the presence of baseline heart diseases such as CAD, LV dysfunction, LVH, and comorbidities such as chronic renal insufficiency (CRI) and COPD. 290 Non- sustained atrial arrhythmias (supraventricular extrasystoles and atrial tachycardias), generally, do not require treatment. In most cases, they are associated with baseline respiratory diseases, whose treatment, associated with avoiding stimulants such as caffeine, cigarettes, soft drinks, black tea, and fast-acting beta-agonist drugs, is normally sufficient to reduce the number of events and symptoms. Otherwise, the use of calcium channel blockers in patients with COPD (contraindicated in cases of LV dysfunction) or beta-blockers (in low doses and selectively, such as bisoprolol or metoprolol), in patients without contraindication, may be indicated. SVPT is usually caused by reentrant mechanisms, and may be interrupted by vagal maneuvers, such as the Valsalva maneuver, coughing, and vomiting. Due to the risk of arterial embolism, carotid sinus massage should be avoided in all elderly patients unless the presence of significant carotid disease has been excluded. If the attempted vagal maneuvers do not succeed in reversing arrhythmia, chemical cardioversion should be attempted. The first-choice drug should initially be adenosine, with electrocardiographic monitoring. Second-line drugs are calcium channel blockers (verapamil, diltiazem), if LV function is normal, and beta-blockers, in the presence of CAD. Digoxin should be restricted to patients with depressed LV function. In cases that do not respond to first- and second-line agents, class III antiarrhythmic drugs (amiodarone or sotalol) should be used. Beta-blockers and calcium channel blockers are equally effective in maintaining SR and avoiding recurrence of arrhythmia 290 (Table 12). In the event of hypotension, signs of low cerebral blood flow, pulmonary congestion, or chest angina, electric cardioversion should be performed at 50 to 75 J. Catheter ablation for treating sustained SVPT whose mechanism is nodal reentrant or an accessory pathway is as effective in elderly patients as it is in younger patients, with a success rate of > 95%. 291-295 Elderly patients have a higher risk of complications such as perforation, vascular lesion, renal insufficiency, a higher tendency to develop AF, and thromboembolic events after the procedure. Nevertheless, larger complications occur in < 3% of elderly patients. 292,293 It should be considered the treatment of choice for patients with frequent episodes (> 2 events/year, in spite of medical treatment) or patients with contraindications to the previously cited drugs, such as sinus bradycardia, hypotension, broncospasms, and severe LV dysfunction, as well as for patients who do not wish to undergo medical treatment. General recommendations – Treatment of tachyarrhythmias in elderly patients: treatment of tachyarrhythmias in elderly patients, especially those between the ages of 65 and 75, should be similar to that in younger patients. In patients > age 75, individualization of conduct is recommended with multiprofessional evaluation that takes into consideration not only age, but also comorbidities, cognitive function, functional capacity, patient preferences, and severity of symptoms. 296,297 7.3. Atrial Fibrillation 7.3.1. Diagnostic Peculiarities AF is the most common persistent arrhythmia in elderly patients. 298 Its prevalence and incidence double every decade after age 60, affecting as many as 8% to 10% of patients > age 80 and 27% of patients > age 90. 287-301 It may occur isolatedly as a consequence of morphological and electrophysiological alterations inherent in aging of the atrial myocardium and sinus node, known as “isolated AF” or “lone atrial fibrillation.” Truly isolated AF is, however, rare in elderly patients. 302 In general, it is associated with structural heart diseases: CAD, SAH, mitral valvulopathy, and HF. 303 Subclinical hyperthyroidism triples the risk of AF. 300 Patients with clinical hyperthyroidismmay present episodes of paroxysmal AF. Other causes of AF in elderly patients include: obstructive sleep apnea-hypopnea syndrome (commonly called paroxysmal AF), 303 sinus node disease, and dilated cardiomyopathy, which are generally associated with AF with low ventricular response. Special attention should be paid to sinus node disease represented by tachycardia- bradycardia syndrome, where recurring paroxysmal AF is observed with a sudden stop followed by a long or asystolic pause, which is a frequent cause of unexplained syncope in the elderly. After adjusting for coexisting CVD, mortality in patients with AF is 1.5 to 1.9 times higher that in patients of the same age without AF. 299 This higher rate of mortality is mainly due to the 4- to 5-fold increase in the occurrence of stroke, a risk which proportionally increases after age 50 (< 1.5% in patients < age 50 and approximately 23.5% in patients > age 80). 304,305 Diagnosis of AF in elderly patients is initially made by physical examination, anamnesis, and EKG. As many as 20% of AF diagnoses in elderly patients occur casually, during clinical visits, in patients without complaints, especially in cases of permanent AF and ventricular response < 100 bpm, which occurs on account of concomitant AV nodal disease or use of beta-blockers. 287 The most frequent symptoms in elderly patients are: dyspnea, asthenia, dizziness, easy fatigue, decreased tolerance to exercise, sweating, polyuria, syncope, and palpitation. Permanent AF is related to silent thromboembolic events which, associated with chronic decreased cerebral blood flow and cerebrovascular alterations inherent in aging, are responsible for cognitive and motor impairments, such as slowing, motor incoordination, and dementia, which are initially discrete, but progressive and which may go unnoticed and delay diagnosis. 306 General recommendations regarding AF diagnosis in the elderly Recommendation Grade of recommendation Level of evidence Inquiry about all medications in use and risk analysis of induced arrhythmias or prolonged QT I C 12-derivation EKG in all patients with irregular rhythm to diagnose AF, even in the absence of symptoms I C 12-derivation EKG in all patients with diagnosis of AF, at each clinical visit IIb C 690