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 24-h Holter for evaluation of HR control IIa B 24-h Holter as follow-up, after rhythm control, in asymptomatic patients IIa C 24-h Holter for patients who complain of palpitations and for those with sinus rhythm following rhythm control I C 24-h Holter for patients with sinus rhythm, after stroke, to investigate paroxysmal AF I C Transthoracic echocardiography in all patients with AF, with no prior diagnosis of CHF I C Transthoracic echocardiography in all patients with AF IIa C Transesophageal echocardiography in patients with AF > 48 h, for reversion to SR I C Transesophageal echocardiography in patients with AF, after stroke, to investigate emboligenic focus IIb C AF: atrial fibrillation; CHF: congestive heart failure; EKG: electrocardiogram; HR: heart rate; SR: sinus rhythm. 7.3.2. Treatment Peculiarities Treatment of AF in elderly patients does not differ from that in younger patients. Oral anticoagulation (unless contraindicated) and the elimination of precipitating or reversible factors that induce paroxysmal AF or loss of ventricular frequency control in patients with persistent or permanent AF are the bases of AF treatment in elderly patients. 307,308 The decision to control HR or SR should be individualized; however, as an initial routine strategy, rhythm control has no benefits over HR control in asymptomatic patients in this age range. 309,310 7.3.2.1. Heart Rate Control Lenient strategies for HR control (target baseline HR < 110 bpm) is as effective for controlling symptoms as restrictive HR control (target resting HR < 80 bpm), except in cases of ventricular dysfunction, where caution is necessary to avoid significant bradycardias (HR < 50 bpm). 311,312 Beta-blockers, used alone, manage to adequately control HR in 42% of elderly patients, 312 and they should be the first-choice drug for this purpose. Combination with non-dihydropyridine calcium channel blockers should be used cautiously and only in patients without LV dysfunction. Attention should be paid to the condition worsening or to constipation appearing with their use, notably with verapamil, in addition to bradycardia and inferior member edema. Digoxin is less effective when used alone for controlling HR during effort. It is an acceptable choice for physically inactive patients, patients > age 80, and patients in whom other treatments have been ineffective or are contraindicated, and it should be used with due caution. 311,313 In cases of tachycardia-bradycardia syndrome and in patients who do not tolerate pharmacological HR control, pacemaker implant or atrioventricular node ablation followed by pacemaker implant may be indicated. 314,315 Rhythm control should be reserved for specific circumstances, particularly when symptoms cannot be contained by HR control, given that it is related to a higher number of hospitalizations due to the collateral effects of antiarrhythmic drugs (AAD) and the complications of invasive procedures, mainly in persistent AF with long duration. The strategy of rhythm control does not dispense with anticoagulation. 316 Control may be via AAD, electric cardioversion, or interventional procedures. Electric cardioversion restores SR and is indicated for acute cases of AF that do not respond to pharmacological therapy and that have hemodynamic instability. The basis for choosing AAD either for chemical cardioversion or for maintenance of rhythm depends on the baseline heart disease and the comorbidities, taking the occurrence of major collateral effects into consideration, due to decreased physiological function and the interactions between multiple medications common in elderly patients. Propafenone, sotalol, and amiodarone may be used for patients with minimal or no structural heart disease, bearing in mind that there is a higher risk of collateral and proarrhythmic effects in elderly patients when using propafenone and sotalol. For patients with structural heart disease (LVH with interventricular septum > 12 mm or coronary disease), sotalol or amiodarone are indicated. Amiodarone is reserved for elderly patients with reduced HF and LVEF. 317 Catheter ablation may be useful in healthy elderly patients who are symptomatic, without many comorbidities, without underlying heart disease, with AF paroxysms, and patients who are refractory to treatment or patients who do not wish to use AAD and who have no renal dysfunction. This procedure should be performed in a center with a great deal of experience. 318 7.3.3. Oral Anticoagulants in Elderly Atrial Fibrillation Patients The most feared complication in AF is thromboembolic events, notably stroke, whose incidence and severity increase with age. 319 It is the cause of up to 25% of strokes in elderly patients. 320 Oral anticoagulant therapy reduces the risk of stroke in elderly patients with non-valvular AF by 64%. It is thus superior to aspirin, which reduces the risk by only 22%, and is no longer recommended for stroke prevention in AF patients. 319,320 Double antiplatelet aggregation has not demonstrated benefits for preventing thromboembolic events in patients with AF and is not recommended. 321 The risk of thromboembolism in AF may be calculated using risk factor scores. 322 For evaluation of thromboembolic risk, the congestive heart failure, hypertension, age ≥ 75, diabetes mellitus, prior stroke, or transient ischemic attack (CHADS 2 ) score has been the most used. Its variables are age (≥ 75) and the presence of comorbidities (HF, SAH, diabetes mellitus, and previous history of thromboembolism). Thromboembolism is worth 2 points, and the other variables are worth 1. Anticoagulation is indicated for patients with scores ≥ 2, as they are at a high risk of events. 323 In 2010, the CHA 2 DS 2 - VASc score was proposed, considering a higher risk for female patients over age 65 and patients with peripheral arterial disease (1 point for the following variables: HF, hypertension, age between 65 and 74, diabetes mellitus, and peripheral arterial disease; 2 points for age 75 or over and previous 692