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 thromboembolic event), resulting in higher scores for more elderly patients, women, and peripheral arterial disease patients. These Guidelines, following the recommendations of the most recent guidelines 324,325 for treating AF, recommend the use of the CHA 2 DS 2 -VASc clinical score for defining start of anticoagulation in men with scores of 2 or more and women with score of 3 or more. In low-risk patients (men with scores of 0 and women with scores of 1), we recommend the use of echocardiography parameters, such as increased LA and auricular flow velocity, the presence of moderate to accentuated spontaneous contrast, or LA/auricular thrombus as an additional stratification for CHA 2 DS 2 -VASc. If a patient presents any one of these findings, anticoagulation is indicated. 326,327 After defining the risk of a thromboembolic event, it becomes necessary to stratify the risk of bleeding, before beginning anticoagulant therapy. The most used risk score for bleeding during anticoagulation is the HAS-BLED, where a score > 3 indicates a high risk of hemorrhage due to oral anticoagulants and includes, in addition to age range (> 65), variables such as SAH with SBP > 160 mmHg (1 point), renal or hepatic dysfunction (1 point each), prior history of stroke (1 point), bleeding (1 point), labile INR (1 point), and drug or alcohol use (1 point each). 328 Data on the isolated influence of age on the risk of bleeding are conflicting; for this reason, age should not be used to contraindicate anticoagulation. 329 Vitamin K antagonists, especially warfarin, are the pillar of oral anticoagulation in patients with AF, significantly reducing stroke and mortality attributed to AF. 330 Variability of INR with warfarin use depends not only on the dose used, but also on other medications and certain types of foods. 331 In an observational study, labile INR has been described in 21.3% of patients ages 40 to 89, 328,329 according to which the risk of INR ≥ 5 increases by 15% with each 10- year increment. As a result of this greater risk, it is necessary to monitor INR in elderly patients (especially those > age 75) more regularly and at more frequent intervals (grade of recommendation I, level of evidence B). These Guidelines recommend the use of low initial doses for elderly patients < age 85 (3 to 4 mg) and 2.5 mg for elderly patients ≥ age 85, patients with frailty syndrome, malnutrition, or hepatic disease and moderate to advanced renal insufficiency (creatinine clearance < 30 mL/min). The INR is at 3 days, with a new dose at 7 days, if there is dose adjustment, and 14 days, if the dose remains stable. It is weekly during the first 90 days in patients with greater risks, whatever they may be, > age 85, frailty, hepatic or renal insufficiency, history of falls, cognitive impairment, low level of education, and initial treatment. In other patients, evaluation of INR may occur every 15 days during the first 90 days of treatment, and may be monthly afterwards, in cases with stable INR. Oral anticoagulation with warfarin is, thus, safe in elderly patients, provided that precautions in indication and follow-up are respected. Warfarin is the least expensive oral anticoagulant, and its antagonist (vitamin K) is widely available to reverse the drug’s anticoagulant effect. Recently, non-vitamin K antagonist oral anticoagulants have become available with the advantages of not requiring constant monitoring of blood coagulation and presenting fewer drug interactions. They include direct thrombin inhibitors (dabigatran) and direct inhibitors of factor Xa (rivaroxaban, apixaban, and edoxaban). A meta-analysis of the main randomized clinical trials with non-vitamin K antagonist oral anticoagulants 330 has shown a significantly lower risk of stroke or systemic embolism compared with warfarin (relative risk [RR] = 0.81, 95% confidence interval [95% CI] = 0.73 to 0.91), as well as a lower risk of intracranial bleeding (RR = 0.48, 95% CI = 0.39 to 0.59), but not of major bleeding (RR = 0.86, HF 95% = 0.73 to 1.00). Findings were similar to those described in a second meta-analysis 331 with participants ≥ age 75. Notwithstanding the clear benefit of non-vitamin K antagonist oral anticoagulants, as well as the fact that they are safer regarding intracranial bleeding, this complication has relatively low rates (< 1%/year) even with warfarin (0.76% to 0.85% with warfarin and 0.26% to 0.49% with non-vitamin K antagonists). 331 The new oral anticoagulants are, thus, the safest option for anticoagulation in elderly patients with higher risks of bleeding, patients with difficulties in adhering to INR monitoring, patients using multiple medications, or patients who individually opt for them. It is, nonetheless, necessary to adjust doses according to renal function and age (< or > 75) 330,331 (grade of recommendation I, level of evidence B). Until recently, there were some concerns due to the lack of a specific antidote for reversing the anticoagulant effects of non-vitamin K antagonists; idarucizumab, however, has been introduced and was recently approved for use in humans in order to reverse the effects of dabigatran. 332 7.3.3.1. General Recommendations 1. Unless there are formal contraindications to anticoagulation, elderly AF patients should begin anticoagulation, if their CHADS 2 VCAS 2 scores are ≥ 2 for men and ≥ 3 for women (grade of recommendation I, level of evidence A). 324,325 If the CHADS 2 VCAS 2 score is < 2 for men or < 3 for women and LA size is > 5.0 cm (or area indexed by body surface > 30 mm/m 2 ) on transthoracic echocardiography, anticoagulation should also be initiated (grade of recommendation IIa, level of evidence B). Elderly patients < age 65, with CHADS 2 VCAS 2 = 0 for men or 1 for women should only start anticoagulation if LA > 5.0 cm or in the presence of moderate to severe spontaneous contrast or thrombus on transesophageal echocardiography (grade of recommendation IIa, level of evidence B). 2. The HAS-BLED score is recommended to evaluate risk of bleeding during anticoagulation (grade of recommendation I, level of evidence B). Elderly patients are considered at higher risks if they are > age 85, are fragile, have renal or hepatic insufficiency, have moderate to severe cognitive impairment, or have low levels of education, as well as during the first 90 days of treatment with anticoagulants. In these patients, anticoagulation is recommended with dose adjustment and more regular follow-up; however, it should not be contraindicated (grade of recommendation I, level of evidence C). 3. In parallel, the risk of hemorrhagic complications may further be reduced by controlling SAH and the risk of falls, as well as by paying attention to the introduction of new drugs in association with antiplatelet medications and antibiotics, which may interfere with serum levels or increase the risk of bleeding. 693