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Guidelines of the Cardiogeriatrics Department of the Brazilian Cardiology Society: Commentary by Editorial Board Members of The American Journal of Geriatric Cardiology

Nanette K. Wenger, MD; Gabriel Gregoratos, MD; Dalane W. Kitzman, MD; Stephen Scheidt, MD; Michael A. Weber, MD; Joseph S. Alpert, MD 
Am J Geriatr Cardiol 13(4):209-216, 2004. © 2004 Le Jacq Communications, Inc.

Posted 08/18/2004 

Introduction

Cardiovascular disease at elderly age is superimposed on the cardiovascular changes of aging, most of which underlie many common disorders of aging and limit the physiologic compensatory mechanisms for disease. Concomitantly, changes in multiple organ systems may compound problems of clinical presentation and the responses to both medical and surgical therapies. In particular, information is lacking for octogenarians, the most rapidly increasing subset of the elderly population. Almost half of all octogenarians have some clinical manifestation of cardiovascular illness; a major challenge is the ascertainment of those lifestyle, pharmacologic, and high technology therapies that are likely to provide benefit for the oldest old. Appropriate guidelines, in particular addressing technology, can help shape the recommendations and decisions made by treating physicians, patients, and patients' families, and the design of reimbursement and public health policies to enhance not only survival but also functional status and quality of life.

In 2002 the Cardiogeriatrics Department of the Brazilian Cardiology Society published guidelines for the care of geriatric patients with cardiovascular diseases.[1] An English-language version of the guidelines is available on The American Journal of Geriatric Cardiology page at www.lejacq.com .[2] Selected members of the Editorial Board of The American Journal of Geriatric Cardiology reviewed the guidelines, adding contemporary information and references and highlighting similarities and differences between these and other guideline documents. A number of issues that emerged subsequent to the publication of the Brazilian guidelines are also addressed.

The Society of Geriatric Cardiology and The American Journal of Geriatric Cardiology applaud the Brazilian Cardiology Society for committing to the enormous expenditure of time and expertise that is requisite for the production of credible guidelines for care. Because of the explosive expansion of the elderly population worldwide and this population's incredible burden of cardiovascular illness, we trust this exemplary effort will serve as an impetus to other national and international groups to create specific guidelines for the care of cardiovascular disease in the elderly population or to address issues involving elderly and very aged cardiac patients during the process of updating existing cardiovascular guidelines.

References

Directives in Cardiogeriatria from the Society Brazilian of Cardiologia [in Portugese]. Arq Bras Cardiol. 2002;79:1–45. 

Guidelines for care of geriatric patients with cardiovascular disease. Available at: http://www.lejacq.com/pdinfo/BrazilianGuidelines.doc. Accessed June 10, 2004.

Cardiac Arrhythmias

The prevalence of ventricular and supraventricular arrhythmias increases with advancing age parallel to the increasing prevalence of coronary artery disease and other forms of heart disease among the elderly. The Guidelines of the Cardiogeriatrics Department of the Brazilian Cardiology Society [1] devote 15.5 pages to this important topic. A narrative portion presenting the epidemiology of cardiac arrhythmias in elderly populations is followed by a detailed series of recommendations for the treatment of symptomatic and asymptomatic patients with and without heart disease and with ventricular and supraventricular arrhythmias and/or syncope. The indications for noninvasive and electrophysiologic evaluation of such patients are also listed. Several additions and clarifications are warranted.

In one part of the text the authors quote a study reporting that Holter monitoring of persons older than age 80 years demonstrated no pauses longer than 2 seconds. Later, they mention the high incidence of sinus node dysfunction in persons of this age group. No attempt is made to reconcile or critique these two disparate positions. The guideline should highlight that sinus node dysfunction is the most common reason for permanent pacing in elderly patients. [2,3]

In discussing atrial fibrillation, the authors correctly point out its high prevalence among elderly persons. However, when discussing management of atrial fibrillation, the authors should discuss the advantages and disadvantages of rate control vs. sinus rhythm restoration and cite important studies [4] that predated the recent Atrial Fibrillation Follow-up Investigation of Rhythm Management (AFFIRM) study. [5] The 2002 AFFIRM report concluded that sinus rhythm maintenance is not superior to rate control.

In the section on syncope, mention should be made of studies [6,7] that concluded that many elderly patients who sustain unexplained falls have hypersensitive carotid sinus syndrome and thus may benefit from pacemaker implantation. In the same section, the authors point out the increased susceptibility of elderly patients to the hypotensive effect of drugs. Attempts should be made to differentiate between culprit drugs and drugs that are better tolerated by elderly persons.

The recommendations listed for the management of ventricular and supraventricular arrhythmias in elderly persons are in general agreement with existing guidelines and general practice standards, with a few exceptions. The recommendations for the treatment of sustained monomorphic ventricular tachycardia should make a distinction between patients with normal and impaired left ventricular (LV) function. The class B2 (equivalent to IIb in the American College of Cardiology [ACC]/American Heart Association [AHA] format) recommendation to use class I antiarrhythmic drugs for the prevention of recurrent ventricular tachycardia and sudden death prophylaxis should be qualified as applying primarily to patients with normal LV function. In the same section on sudden death and recurrent ventricular tachycardia prevention, a class B1 (IIa) recommendation is made to use amiodarone with or without implantable cardioverter-defibrillator (ICD) placement in patients with an ejection fraction (EF) >/=35%. However, metoprolol is relegated to a class B2 (IIb) recommendation, whereas many physicians would opt initially for ß-blocker therapy in patients with normal or mildly impaired LV function. It is not clear why metoprolol is mentioned rather than the entire ß-blocker class.

In the section on primary prevention of sudden death after myocardial infarction (MI), ß blockers are appropriately assigned class A status and class I antiarrhythmics class C. However, distinction should be made between patients with severely impaired LV function and other post-infarction patients. No mention is made of ICD therapy either with or without a prior inducibility study. The seminal studies [8–11] of the past 7 years showing the superiority of ICD over antiarrhythmic drug therapy for sudden death prevention should be cited.

The recommendations for primary prophylaxis against sudden death in patients with heart failure are appropriate if the heart failure is due to idiopathic cardiomyopathy (although this is not specified); if the heart failure is due to ischemic heart disease, the guideline should mention ICD therapy. The ongoing Sudden Cardiac Death in Heart Failure Trial (SCD-HeFT) trial should have been mentioned, as it will likely provide definitive answers to many questions regarding prevention of sudden death.

References

Directives in Cardiogeriatria from the Society Brazilian of Cardiologia [in Portugese]. Arq Bras Cardiol. 2002;79:1–45. 
Rodriguez RD, Schocken DD. Update on sick sinus syndrome, a disorder of aging. Geriatrics. 1990;45:26–36. 
Kusumoto FM, Phillips R, Goldschlager N. Pacing therapy in the elderly. Am J Geriatr Cardiol. 2002;11:305–316. 
Hohnloser SH, Kuck KH, Lilienthal J, et al. Rhythm or rate control in atrial fibrillation: a randomized trial. Lancet. 2000;356:1789–1794. 
Wyse DG, Waldo AL, DiMarco JP, et al. A comparison of rate control and rhythm control in patients with atrial fibrillation. N Engl J Med. 2002;347:1825–1833. 
Bexton RS, Davies A, Kenny RA. The rate-drop response in carotid sinus syndrome: the Newcastle experience. Pacing Clin Electrophysiol. 1997;20:840–844. 
Kenny RA, Richardson DA, Steen N, et al. Carotid sinus syndrome: a modifiable risk factor for non-accidental falls in older adults (SAFE PACE). J Am Coll Cardiol. 2001;38:1491–1496. 
Moss AJ, Hall WJ, Cannom DS, et al. Improved survival with an implanted defibrillator in patients with coronary artery disease at high risk for ventricular arrhythmia. N Engl J Med. 1996;335:1933–1940. 
The AVID Investigators. A comparison of antiarrhythmic-drug therapy with implantable defibrillators in patients resuscitated from near-fatal ventricular arrhythmias. N Engl J Med. 1997;337:1576–1583. 
Buxton AE, Lee KL, Fisher JD, et al. A randomized study of the prevention of sudden death in patients with coronary artery disease. Multicenter Unsustained Tachycardia Trial Investigators. N Engl J Med. 1999;341:1882–1890. 
Moss AJ, Zareba W, Hall WJ, et al. Prophylactic implantation of a defibrillator in patients with myocardial infarction and reduced ejection fraction. N Engl J Med. 2002;346:877–883.

Heart Failure

The section on heart failure merits a few additional comments. There is currently a lively debate regarding whether the symptoms associated with heart failure with a normal EF are primarily due to diastolic dysfunction. The statement, "...diastolic dysfunction is an important cause of heart failure in the elderly," [1] may be a bit overly simplistic, since it is not yet proven that intrinsic abnormalities of diastolic function are the cause of heart failure with a normal EF.

The statement that "The percentage of diastolic heart failure in this population is high, corresponding to 40%–50% of the cases in individuals over 75 years old" [1] may actually be an underestimate. The Cardiovascular Health Study (CHS), Framingham Heart Study, and Strong Heart Study, among others, indicated that more than 50% of older patients with heart failure have a normal EF. In CHS, this was true for nearly 90% of the population (women older than age 75 years).

The statement that "Myocardial contractility is not significantly altered as a function of age" [1] is not completely correct. Whereas resting measures of EF in human beings at rest show no decrease, there is definitely an age-related decrease in EF and increase in end systolic volume in human beings during peak exercise. Animal studies well document mildly decreased contractility reserve, as well.

The guidelines state that "Alterations of plasmatic concentrations of noradrenalin, renin, angiotensin II, aldosterone, vasopressin, and natriuretic peptides contribute to the increase of arterial pressure with aging." [1] This may be an oversimplification. While this seems a reasonable assumption, there are relatively few data to support causative mechanisms.

The steps for management are highlighted by the use of bold lettering and are a great outline of the principles. Nutrition is an area of heart failure management that has been sorrowfully overlooked but is directly addressed by these authors. One should be cautious though, given the paucity of disease-specific literature. For example, the guidelines state, "Patients who present [with] malnutrition (cardiac cachexia), must have nutritional support, with a high-energy diet in small amounts. In case of oral feeding impossibility, enteral or parenteral nutrition is indicated." [1] Although cardiac cachexia is an important problem in end-stage heart failure, no data, to our knowledge, firmly document that aggressive enteral or parenteral nutrition is associated with improved outcomes. Merely encouraging good oral nutrition seems prudent for now. In addition, the body mass index (BMI) chart that is included is probably not appropriate, at least for US patients, because numerous studies document that heart failure patients have higher BMIs and commonly have obesity. Given the lack of causative links and the problem of cachexia, it is probably not wise to try to move a patient to a specific BMI through interventions.

The authors eloquently and wisely state, "Prescription of physical activity must be individualized." The National Heart, Lung, and Blood Institute–sponsored Heart Failure: A Controlled Trial Investigating Outcomes of exercise TraiNing (HF-ACTION) trial is now underway and is designed to definitively address whether a program of moderate to vigorous exercise can improve mortality in patients with severe systolic heart failure. In this trial, specific measures are underway to ensure inclusion of older patients.

The guidelines point out, "The determination of serum concentration of digoxin—which in the elderly must vary between 0.5 and 1.5 mg/mL—is useful to adjust the doses and in case intoxication is suspected." [1] Based on the Digitalis Investigation Group (DIG)study, most US-based physician guidelines recommend specific starting doses based on age, renal function, and other characteristics and without routine measurement of digoxin levels, even for elderly persons.

In the statement, "Although the efficacy of diuretics in heart failure has been evaluated with the same strictness as angiotensin-converting enzyme (ACE) inhibitors," I suspect the authors intended for the word "not" to be included.

Finally, some recent reports from important trials were released since this document was completed, including the Carvedilol Or Metoprolol European Trial (COMET), [3] and the Eplerenone Post-AMI Heart failure Efficacy and SUrvival Study (EPHESUS) [4] (a study of eplerenone in patients with EF of 40% or less and acute MI). In addition, there have been a number of important reports regarding the role of synchronization therapy with pacemakers for improvement in symptoms and remodeling, and internal defibrillators for reduction of sudden death. [5,6] 

References

Directives in Cardiogeriatria from the Society Brazilian of Cardiologia [in Portugese]. Arq Bras Cardiol. 2002;79:1–45. 
Rich MW, McSherry F, Williford WO, et al. Effect of age on mortality, hospitalizations, and response to digoxin in patients with heart failure: The DIG Study. J Am Coll Cardiol. 2001;38:806–813. 
Poole-Wilson PA, Swedberg K, Cleland JG, et al. Comparison of carvedilol and metoprolol on clinical outcomes in patients with chronic heart failure in the Carvedilol Or Metoprolol European Trial (COMET): randomised controlled trial. Lancet. 2003;362:7–13. 
Pitt B, Remme W, Zannad F, et al. Eplerenone, a selective aldosterone blocker, in patients with left ventricular dysfunction after myocardial infarction. N Engl J Med. 2003;348:1309–1321. 
Abraham WT, Fisher WG, Smith AL, et al. Cardiac resynchronization in chronic heart failure. N Engl J Med. 2002;346:1845–1853. 
Moss AJ, Zareba W, Hall WJ, et al. Prophylactic implantation of a defibrillator in patients with myocardial infarction and reduced ejection fraction. N Engl J Med. 2002;346:877–883. 

Coronary Artery Disease (Chronic Stable Angina, Acute Coronary Syndrome, Acute MI)

The Brazilian guidelines[1] follow current practice in the United States in almost all respects, and are quite similar to the recently published ACC/AHA guidelines on stable angina[2] and acute coronary syndrome.[3] The Brazilian alphanumeric system for recommendations is quite confusing at first as the code is close to, but not the same as, the ACC/ AHA's well known system, in which class I denotes conditions for which there is evidence or general agreement that a given procedure or treatment is useful and effective, class II indicates conflicting evidence or a divergence of opinion about usefulness/efficacy of a procedure or treatment, class IIa is weight of opinion in favor of usefulness/efficacy, class IIb is for procedures or treatments less well established by evidence/opinion, and class III indicates evidence and/or general agreement that the procedure or treatment is not useful/effective and in some cases may be harmful. The strength of the supporting evidence is also classified: Level of evidence A is data derived from multiple randomized clinical trials, B is data from a single randomized trial or nonrandomized studies, C is consensus opinion of experts. In contrast, the Brazilians use A, B, B1, B2, and C in place of the American class I, II, IIa, IIb, and III respectively, and use Arabic numerals 1–4 for level of evidence, with level 1 similar to the ACC/AHA's level A, level 2 similar to B, level 3 being small sample studies, and level 4 being similar to the ACC/AHA's level C.

With regard to stable angina, the Brazilian guidelines' recommended diagnostic workup includes relatively bare-bones blood tests, including lipids and blood sugar; an electrocardiogram; and then generally a stress test (with nuclear and echo stress tests a reasonable option, and adenosine or dobutamine pharmacologic stress mentioned as useful for the many elderly persons who are unable to do sufficient physical exercise). Although hinted at in the somewhat stronger recommendations for performing stress tests in those with intermediate pretest probability of coronary disease, the Bayesian basis for these recommendations could be more explicit. Many US experts dispense entirely with standard treadmill exercise tests for elderly persons because the ability to reach reasonable target heart rates is often suboptimal, and the false positive and false negative rates in elderly women are high.

Brazilian recommendations for proceeding to coronary angiography are very similar to current US procedures, as are comments on percutaneous coronary intervention (PCI) vs. surgical revascularization vs. medical (pharmacologic) therapy in those cases where anatomy does not lend itself to PCI. The recommendations concerning the various pharmacologic agents (very strongly in favor of ß blockers, statins, and aspirin with lesser enthusiasm for rate-lowering calcium-channel blockers and antiplatelet agents such as clopidogrel and admonitions against using dihydropyridine calcium-channel blockers) are standard in the United States. The Brazilian guidelines do not address less established therapies for patients with angina refractory to the standard therapy, where guidance would be most valuable; examples might have included external counterpulsation, agents like ranolazine that supposedly alter cardiac metabolism, and physical exercise/ rehabilitation programs—but the amount of high quality data available to evaluate the less established therapies is probably insufficient for committees to make data-based recommendations.

The Brazilian guidelines are quite up-to-date regarding the acute coronary syndrome, strongly recommending aspirin, ß blockers, low-molecular-weight or unfractionated heparin, statins, ACE inhibitors, and clopidogrel; more modest recommendations are given for nitrates, administered oxygen, morphine, and other analgesics and there is little enthusiasm voiced for fibrinolytic therapy with recommendation against dihydropyridine calcium antagonists and direct thrombin inhibitors. The text suggests that early revascularization (as in Fast Revascularization during InStability in Coronary artery disease [FRISC II][4] and Treat angina with Aggrastat and determine Costs of Therapy with Invasive or Conservative Strategies [TACTICS-TIMI 18][5] ) may be beneficial in some patients; continued pharmacologic vs. early revascularization therapy, one of the most controversial areas of decision making today, and how to select patients for each group should have received more attention. Getting the decision right is probably more crucial in the United States, where access to revascularization is often simpler and there is often pressure for early cardiac catheterization, especially in patients with elevated troponin levels—even if the elevations are small, creatine kinase levels are normal, and the patient is free of pain and hemodynamically stable. Brazilian recommendations for the use of IIb-IIIa platelet glycoprotein inhibitors are also standard, suggesting abciximab mainly for patients who will undergo PCI (this is due to the lack of benefit for patients without PCI found in the Global Use of Strategies To Open Occluded Coronary Arteries IV—Acute Coronary Syndrome [GUSTO-IV-ACS][6] trial, although subsequent trials have questioned this conclusion[7] ). Although widely used also in the United States, we question the Brazilian A1 recommendation for tirofiban in acute coronary syndrome without planned PCI. The ACC/AHA guidelines for acute coronary syndrome give a IIa recommendation for high-risk patients (i.e., patients with continuing ischemia, an elevated troponin level, or other high-risk features), and only a IIb recommendation for patients not at high risk in whom PCI is not planned.[3] 

Finally, with regard to acute MI, the Brazilian guidelines mirror common practice in the United States, preferring primary PCI but agreeing that thrombolysis is also useful, recognizing that tissue-plasminogen activator may not be superior and may even be inferior to streptokinase in patients over age 75 years, and noting that heparin is necessary in conjunction with thrombolytic therapy but has not definitively been proven effective when used without thrombolysis. The Brazilian guidelines recommend ß blockers, ACE inhibitors, and aspirin routinely, but nitrates only in special situations. The guidelines do not discuss some highly controversial areas pertaining to therapy of acute MI, including the use of delayed PCI (i.e., the open artery hypothesis, which suggests that delayed opening of a coronary artery, perhaps 1 week after acute MI when myocardium cannot possibly be salvaged, might benefit long-term survival outcomes); early interventional therapy for cardiogenic shock; and an omission that may be noted by experts south of the US border, the possible use of glucose-insulin-potassium as early therapy for acute MI, which has been championed for several decades in a series of investigations in Mexico and recently has become the subject of renewed investigation.[8] 

References

Directives in Cardiogeriatria from the Society Brazilian of Cardiologia [in Portugese]. Arq Bras Cardiol. 2002;79:1–45. 
Gibbons RJ, Abrams J, Chatterjee K, et al. ACC/AHA 2002 guideline update for the management of patients with chronic stable angina—summary article: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee on the Management of Patients With Chronic Stable Angina). Circulation. 2003;107:149–158. 
Braunwald E, Antman EM, Beasley JW, et al. ACC/AHA 2002 guideline update for the management of patients with unstable angina and non-ST-segment elevation myocardial infarction: a report of the American College of Cardiology/ American Heart Association Task Force on Practice Guidelines (Committee on the Management of Patients with Unstable Angina). Circulation. 2002;106:1893–1900. 
Fragmin and Fast Revascularization during InStability in Coronary artery disease Investigators. Invasive compared with non-invasive strategy in unstable coronary-artery disease: FRISC II prospective randomized multicentre study. Lancet. 1999;354:708–715. 
Cannon CP, Weintraub WS, Demopoulos LA, et al. Comparison of early invasive and conservative strategies in patients with unstable coronary syndromes treated with the glycoprotein IIb/IIIa inhibitor tirofiban. N Engl J Med. 2001;344:1879–1887. 
Simoons ML, and GUSTO-IV-ACS Investigators. Effect of glycoprotein IIb/IIIa receptor blocker abciximab on outcome in patients with acute coronary syndromes without early coronary revascularization: the GUSTO IV-ACS randomized trial. Lancet. 2001;357:1915–1924. 
Boersma E, Harrington RA, Moliterno DJ, et al. Platelet glycoprotein IIb/IIIa inhibitors in acute coronary syndromes: a meta-analysis of all major randomised clinical trials. Lancet. 2002;359:189–198. 
Apstein CS. The benefits of glucose-insulin-potassium for acute myocardial infarction (and some concerns). J Am Coll Cardiol. 2003;42:792–795.

Systemic Arterial Hypertension

The Brazilian guidelines dealing with hypertension are an interesting composite of other guidelines currently in use around the world. Wisely, the Brazilian authors have selected what they believe to be the most useful ideas in terms of diagnosis, global risk assessment, treatment goals, and therapeutics that can be applied to their own population.

The recommendations for diagnosis reflect the criteria used in the sixth report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC VI). [1] They use the accepted criteria of 140/90 mm Hg for stage 1 and 160/100 mm Hg for stage 2 hypertension, but stay with the designations of "normal" and "high-normal" for persons in the range 120/80–139/89 mm Hg. This terminology, of course, has now been abandoned in the seventh Joint National Committee report (JNC 7), [2] which prefers the term "prehypertension."

There is perhaps a bigger difference between the Brazilian and US approaches in the area of risk assessment. JNC 7 [2] focuses on the primacy of blood pressure, and virtually eliminates other cardiovascular risk factors as contributors to decisions of whether or not to offer therapy. In contrast, the Brazilian guidelines remain fully in concert with the European and World Health Organization guidelines, indicating that the presence of concomitant risk factors can accelerate a decision to start antihypertensive drug treatment, whereas the absence of such factors can allow a longer period during which lifestyle modifications can be attempted.

It is interesting that the Brazilian recommendations are identical to those in the United States in setting goals for therapy in most persons with hypertension: blood pressure should be reduced to <140/90 mm Hg. Like the American recommendations, the Brazilian document acknowledges that high risk patients can require even lower targets, such as 130/80 mm Hg, although they do not specify as rigidly as their American counterparts that this should be confined to patients with diabetes or renal insufficiency.

To their credit, the Brazilian authors acknowledge that there may need to be some flexibility in the guidelines when it comes to choosing target blood pressures. In particular, for elderly patients in whom treatment is often difficult, and where side effects can often have a negative impact on quality of life, they argue that a systolic blood pressure as high as 160 mm Hg may be acceptable in patients without other major risk factors or conditions. It is also reasonable to suspect that this approach may also have been partly motivated by the financial realities of medicine in Brazil, where a more pragmatic approach to treatment decisions may be in order.

No set of hypertension guidelines would be complete without some debate over drug recommendations. The JNC 7 writers, [2] under political pressure from their sponsor at the National Heart, Lung, and Blood Institute, recommend that diuretics be the usually selected first drugs. To their credit, though, they explicitly state that drugs from other classes should also be considered, in essence opening the door for clinicians to select whichever drugs they believe most appropriate for their individual patients. The Brazilian recommendations hearken back to older JNC reports and suggest starting with diuretics or ß blockers. Interestingly, JNC 7 [2] dismissed ß blockers from their previous first-step position because of an absence of evidence to support their use in that role. At the same time, the European guidelines boldly go even beyond the JNC 7 recommendation, advising that clinicians make individual decisions based on clinical, demographic, and cost issues for each patient. Hopefully, future US and Brazilian guidelines will embrace this more thoughtful and contemporary approach.

References

Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure. The sixth report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure. Arch Intern Med. 1997;157:2413–2466. 
Chobanian AV, Bakris GL, Black HR, et al. The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of high blood pressure: the JNC 7 report. JAMA. 2003;289:2560–2572. 

Valvulopathies

The valvular heart disease section of the Brazilian guidelines combines brief discussions of the pathophysiology and clinical presentation of four forms of valvular heart disease in older adults (mitral regurgitation, mitral stenosis, aortic regurgitation, and aortic stenosis) with advice about management of these patients. The topics covered are equitable and the recommendations for evaluation and therapy are similar, although briefer, to material that can be found in the most recent ACC/AHA guidelines for the management of patients with valvular heart disease.[1] One difference is that the Brazilian document mentions ACE-inhibitor therapy as a possible option for these patients although it acknowledges that "further studies are needed to prove their effectiveness."[1] The ACC/AHA guidelines mention ACE inhibitors as a possible option for these patients. Also, the Brazilian authors use "valvulopathies" in place of the more usual American term "valvular heart disease." Two other terms that deserve clarification are "mitral failure," which in this document means mitral regurgitation with LV failure, and "aortic failure," which denotes aortic regurgitation with LV failure.

The Brazilian document can be used by American geriatric cardiologists. However, there are a few minor differences between the situation in Brazil and in the United States, and these deserve emphasis. First, because acute rheumatic fever occurs rarely in the United States, mitral stenosis has become increasingly unusual in US cardiology practices. Second, almost all patients with mitral stenosis in the United States fall into the geriatric category; however, the standard recommendations cited in the Brazilian document are applicable to American patients. In addition, the Brazilian guidelines note that nearly 40% of geriatric patients with aortic regurgitation and LV failure have rheumatic heart disease. This percentage is much lower in the United States.

It is difficult to know whether valvular heart disease is more common in Brazil than in the United States. Of course, chronic rheumatic heart disease will be much more common in Brazil and perhaps calcific atherosclerotic aortic stenosis will be more common in the United States. However, the management of these conditions is similar in both countries.

References

Directives in Cardiogeriatria from the Society Brazilian of Cardiologia [in Portugese]. Arq Bras Cardiol. 2002;79:1–45. 

Cardiovascular Risk Prevention

Subsequent to the presentation of the Brazilian Cardiology Society guidelines, the AHA published its scientific statement on the secondary prevention of coronary heart disease in the elderly (with emphasis on patients >/=75 years of age).[1] The document highlights the increasing evidence over the past two decades that elderly persons with coronary heart disease can benefit from exercise training and other aspects of secondary prevention.[2] It is designed to increase awareness by physicians and health care personnel, reimbursement agencies, and elderly patients and their families of the benefits of secondary prevention.

There is evidence that the smoking cessation-related reduction in the relative risk of MI and death in coronary patients over age 70 years is similar to that in younger persons, that is, advanced age does not attenuate the benefits of smoking cessation. At least half of the benefit is evident within the first year.

In the United States, up to 90% of octogenarians are likely to be hypertensive and nearly two thirds of persons aged 75 years and older have uncontrolled hypertension, despite comparable blood pressure goals promulgated for older and younger persons in the JNC 7.[3] Meta-analysis has demonstrated substantial benefits of antihypertensive therapy in patients aged 60–80 years; further nonpharmacologic therapy that includes exercise, weight reduction, and sodium restriction is more effective in older than in younger populations. Data remain limited for the hypertensive population aged 80 years and older.

The US National Cholesterol Education Program Adult Treatment Panel (NCEP-ATP III)[4] goals do not differ for older and younger persons, likely reflecting the extensive burden and adverse outcomes of cardiovascular illness at very elderly age. Very few earlier studies of pharmacologic lipid-lowering therapy included subjects in the eighth decade of life, but data from the Heart Protection Study[5] showed equal benefit in patients at high risk for coronary events who were older and younger than age 70 years in reducing all-cause mortality, coronary death or nonfatal MI, and transient ischemic attack. In the GREek Atorvastatin and Coronary heart disease Evaluation (GREACE) study, coronary patients older than age 70 years treated aggressively with atorvastatin vs. usual therapy benefited equally as much as younger patients, with an overall mortality reduction up to 43%.[6] The Prospective Study of Pravastatin in the Elderly at Risk (PROSPER)[7] showed benefit of statin use in very elderly persons (>/=70 years) in reducing the composite primary endpoint of coronary heart disease mortality, nonfatal MI, and fatal or nonfatal stroke. However isolated stroke risk was unaltered and cancer risk increased. As well, benefit was present only for patients with established coronary disease. The Anglo-Scandinavian Cardiac Outcomes Trial–Lipid Lowering Arm (ASCOT–LLA)[8] randomized high-risk hypertensive patients up to age 79 years to atorvastatin vs. placebo. Fatal coronary heart disease and nonfatal MI were reduced by 34%. Unexplored is the balance of benefit and risk for elderly populations at lower risk status. Risk reduction with statin therapy appears to occur within 1–2 years of statin treatment initiation.

Although older coronary patients have lower obesity rates than their younger counterparts, diet and exercise are reasonable interventions. Central obesity appears to dictate the risk-factor constellation of the metabolic syndrome.[9] Because diabetes is a powerful predictor of secondary coronary events in older coronary patients, diabetes control and treatment of other risk factors in patients with diabetes is essential.

Despite lower absolute baseline levels of physical function, increased physical activity equally benefits older and younger patients. Physical activity further favorably affects other coronary risk factors such as obesity, hypertension, and insulin resistance. Physical activity level in the Cardiovascular Health Study independently predicted 5-year mortality, suggesting that patients should be encouraged to participate not only in structured exercise regimens but also in occupational, leisure, and daily living activities. Individualized modification of the exercise regimen should address significant comorbidities that limit mobility. Strength training is recommended to improve muscular strength and endurance.

Although depression and social isolation are associated with adverse morbidity and mortality outcomes in elderly patients post-MI, a recent intervention trial failed to impact mortality or reinfarction despite improvement in psychosocial outcomes.[10] 

Structured cardiac rehabilitation services provide the optimal format for implementation of secondary preventive care; however, these services have been underutilized by elderly patients, particularly elderly women.[2] Strategies are needed to enhance the involvement of elderly patients in such programs.

References

Williams MA, Fleg JL, Ades PA, et al. Secondary prevention of coronary heart disease in the elderly (with emphasis on patients >/=75 years of age). An American Heart Association Scientific Statement from the Council on Clinical Cardiology Subcommittee on Exercise, Cardiac Rehabilitation, and Prevention. Circulation. 2002;105:1735–1743. 
Wenger NK, Froelicher ES, Smith LK, et al. Cardiac Rehabilitation, Clinical Practice Guideline No. 17. Rockville, MD: US Dept of Health and Human Services; 1995. AHCPR Publication No. 96–0672. 
Chobanian AV, Bakris GL, Black HR, et al. The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of high blood pressure: the JNC 7 report. JAMA. 2003;289:2560–2572. 
National Cholesterol Education Program (NCEP) Expert Panel. National Cholesterol Education Program (NCEP) Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel III final report). Circulation. 2002;106:3143–3421. 
Heart Protection Study Collaborative Group. Heart Protection Study of cholesterol lowering with simvastatin in 20536 high-risk individuals: a randomised placebo-controlled trial. Lancet. 2002;360:7–22. 
Athyros VG, Papageorgiou AA, Mercouris BR, et al. Treatment with atorvastatin to the National Cholesterol Education Program goal versus "usual" care in secondary coronary heart disease prevention. The GREek Atorvastatin and Coronary heart disease Evaluation (GREACE) study. Curr Med Res Opin. 2002;18:220–228. 
Shepherd J, Blauw GJ, Murphy MB, et al. Pravastatin in elderly individuals at risk of vascular disease (PROSPER): a randomised controlled trial. Lancet. 2002;360:1623–1630. 
Sever PS, Dahlöf B, Poulter NR, et al. Prevention of coronary and stroke events with atorvastatin in hypertensive patients who have average or lower-than-average cholesterol concentrations, in the Anglo-Scandinavian Cardiac Outcomes Trial—Lipid Lowering Arm (ASCOT-LLA): a multicentre randomized controlled trial. Lancet. 2003;361:1149–1158. 
Turcato E, Bosello O, DiFrancesco V, et al. Waist circumference and abdominal sagittal diameter as surrogates of body fat distribution in the elderly: their relation with cardiovascular risk factors. Int J Obes Relat Metab Disord. 2000;24:1005–1010. 
ENRICHD Investigators. Effects of treating depression and low perceived social support on clinical events after myocardial infarction. JAMA. 2003;289:3106–3116.

Reprint Address

Address for correspondence: Nanette K. Wenger, MD, Emory University School of Medicine, 49 Jesse Hill Jr. Drive, Atlanta, GA 30303.

Nanette K. Wenger, MD, Editor in Chief, 1 Gabriel Gregoratos, MD, 2 Dalane W. Kitzman, MD, 3 Stephen Scheidt, MD, Senior Editor, 4 Michael A. Weber, MD, Senior Editor, 5 and Joseph S. Alpert, MD, 6

1Emory University School of Medicine, Atlanta, GA; 2University of California, San Francisco, San Francisco, CA; 3Wake Forest University School of Medicine, Winston-Salem, NC; 4New York-Cornell Medical Center, New York, NY; 5SUNY Downstate College of Medicine, New York, NY; and 6Arizona Health Sciences Center, Tucson, AZ