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 Recommended doses for elderly patients Dabigatran Rivaroxaban Apixaban Endoxaban Commercial presentation 150 mg 110 mg 20 mg 15 mg 10 mg 5 mg 2.5 mg 30 mg 60 mg Dose 150 mg CrCl > 50 ml/min 20 mg CrCl > 50 ml/min 5 mg CrCl > 30 ml/min 60 mg CrCl > 50 ml/min 110 mg CrCl between 30 and 50 ml/min 15 mg CrCl between 30 and 50 ml/min 2.5 mg CrCl 15-30 ml/min or Two of the following criteria: ≥ 80 years old Weight ≤ 60 kg Creatinine ≥ 1.5 mg 30 mg CrCl 15-50 ml/min or weight ≤ 60 kg Posology 2 x day 1 x day 2 x day 1 x day Particularities Dyspepsia is common Higher risk of GI bleeding than warfarin Avoid if CrCl < 30 ml/min), recent stroke, and severe active hepatic disease Avoid if CrCl < 15 ml/min) and severe active hepatic disease Avoid if CrCl < 15 ml/min) or Creatinine > 2.5 mg and severe active hepatic disease Avoid if CrCl < 15 ml/min or severe hepatic disease CrCl: creatinine clearance; GI: gastrointestinal. Source: European Heart Journal. 324 4. For warfarin patients, INR is recommended 5 to 7 days after beginning antibiotic therapy (grade of recommendation I, level of evidence C). 5. Regarding the choice of anticoagulant, current evidence demonstrates that direct oral anticoagulants (DOAC) are preferable to warfarin, except in patients with moderate to severe mitral stenosis and patients with valve prostheses (grade of recommendation I, level of evidence A). 324,325 These Guidelines, however, also recommend warfarin use, in situations of availability or preference, owing to the fact that it is an oral drug that is well known, inexpensive, and widely available to patients through the public system in Brazil, as well as to the fact that it has an antagonist (vitamin K) available to reverse its anticoagulant effect (grade of recommendation I, level of evidence A). 6. DOAC are a safe option for anticoagulation in elderly patients with higher risks of bleeding, in 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 330,331 (grade of recommendation I, level of evidence A). Rivaroxaban and edoxaban are the DOAC of choice given their use practicality (taken once a day). In patients with dyspepsia, dabigatran should be avoided (grade of recommendation I, level of evidence B). No DOAC have been tested with severe renal insufficiency. 324 For this reason, these Guidelines do not recommend using them in patients with creatinine clearance < 30 ml/min, in which case warfarin is preferable (grade of recommendation I, level of evidence B). 1. Instituto Brasileiro de Geografia e Estatística. (IBGE). Pesquisa Nacional de Saúde (PNS). Rio de Janeiro; 2013. 2. Brasil. Ministério da Saúde. Sistema de informação sobre a mortalidade. Brasília; 2013. 3. Fried LP, Tangen CM, Walston J, Newman AB, Hirsch C, Gottdiener J et al. Frailty in older adults evidence for a phenotype. J Gerontol A Biol Sci Med Sci. 2001;56(3):M146-56. 4. Fried LP, Ferrucci L, Darer J, Williamson JD, Anderson G. Untangling the concepts of disability, frailty, and comorbidity: implications for improved targeting and care. J Gerontol A Biol Sci Med Sci. 2004;59(3):255-63. 5. Morley JE, Vellas B, van Kan A, Anker SD, Bauer JM, Bernabei R et al. Frailty consensus: a call to action. J AmMed Dir Assoc. 2013;14(6):392-7. 6. Collard RM, Boter H, Schoevers RA, Oude Voshaar RC. Prevalence of frailty in community-dwelling older persons: a systematic review. J Am Geriatr Soc. 2012;60(8):1487-92. 7. Afilalo J, Alexander KP, MackMJ, Maurer MS, Green P, Allen LA et al. Frailty assessment in the cardiovascular care of older adults. J Am Coll Cardiol. 2014;63(8):747-62. 8. Puts MT, Toubasi S, Andrew MK, Ashe MC, Ploeg J, Atkinson E et al. Interventions to prevent or reduce the level of frailty in community- dwelling older adults: a scoping review of the literature and international policies. Age Ageing. 2017;46(3):383-92. 9. Rockwood K, Mitnitski A. Frailty in relation to the accumulation of deficits. J Gerontol A Biol Sci Med Sci. 2007;62(7):722-7. References 694