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 disease, etc. A higher risk of complications and mortality has also been identified in frail elderly patients who undergo cardiovascular interventions such as surgery and angioplasty. 7 Frailty may potentially be prevented or treated, and many studies have demonstrated that exercise, protein/ caloric supplementation, vitamin D supplementation, and reduction and optimization of polypharmacy may decrease levels of frailty, thus minimizing adverse outcomes and risks of interventions. 5,8 The identification of frail elderly patients is advocated so that multidimensional interventions may be implemented, mainly physical and nutritional rehabilitation, which reduces or postpones adverse outcomes and provides risk prognosis. It is necessary to emphasize that the identification of frailty does not need to be seen as a reason to exclude or suspend treatment, but rather as a means of programming individualized, patient-centered interventions. 5,7 Fried et al. (2001), in a longitudinal cardiovascular cohort study, identified the following manifestations for this syndrome: unintentional weight loss, muscular weakness, exhaustion (fatigue), decreased gait speed, and decreased degree of physical activity. Based on this, they proposed diagnostic criteria known as the “Fried et al. Frailty Phenotype”, 3 or “Cardiovascular Health Study Frailty Screening Scale”. 3,5 These criteria have been criticized, insofar as those referring to exhaustion and decreased physical activity are not objective and are difficult to evaluate in daily practice with elderly patients. Other indexes and scales for diagnosis have been proposed, such as Rockwood Clinical Frailty Scale, 9 the Gérontopôle Frailty Screening Tool, 10 the FRAIL scale proposed by Van Kan and Morley, 11 the Groningen Frailty Indicator, 12 the Tilburg Frailty Indicator, 13 the PRISMA-7 questionnaire, 14 the VES-13 Scale, 15 and the Edmonton Frailty Scale. 16 The latter five instruments have been transculturally adapted and/or validated in Brazil. Studies have demonstrated that the 5-meter gait speed test is a useful tool for evaluating frailty in elderly patients referred for percutaneous aortic valve implantation. 17,18 The incorporation of this tool into the Society of Thoracic Surgeons (STS) score improved its ability to predict adverse events. For a given STS score, the risk of mortality or morbidity was 2–3 times greater in patients with slow gait speed. 17,18 Regardless of the instrument used to screen and identify, the syndrome of frailty should be investigated in all individuals over age 70 and in elderly patients with CVD, even if they are below this age group, and prevention and treatment measures should be put into practice. 5,7,8 1.3. Particularities in the Evaluation of Elderly Patients Aging is a risk factor for most CVD, as well as numerous comorbidities, making the elderly the most heterogeneous and most complex adult age group. 19 Generally speaking, the healthcare system is poorly prepared to attend patients with multimorbidities, given that they require greater individualization, as well as assistance from a multiprofessional team that works integratedly. 20,21 Interventions which are clearly beneficial in adults are, generally, also beneficial for elderly patients. However, the peculiarities which exist regarding evaluation of elderly patients are fundamental for their individual treatment. The evaluation of elderly patients should be performed using the Broad Geriatric Assessment ( Avaliação Geriátrica Ampla , AGA). 22 This is a multidimensional, generally interdisciplinary, diagnostic process for determining impairments, inabilities, and disadvantages in elderly patients and, thus, planning their medium- to long-term care and assistance. The AGA prioritizes functional status and quality of life, facilitating communication between interdisciplinary team members. It should be applied to frail elderly patients and patients with multimorbidities. The AGA is also an important predictor of unfavorable outcomes, i.e., it has prognostic value for surgery, oncology, and orthopedic patients. 22 The AGA is fundamental in the context of evaluating elderly patients. It includes, at least, 4 principal dimensions, which are functional capacity, medical conditions, social functionality, and mental health. 22 Independent elderly patients with a long life expectancy should be treated comprehensively in a manner that combines prevention and intervention. On the other hand, pre-frail and frail patients require more attention regarding their individual needs and priorities, as well as risk-benefit assessment for individualized therapeutic decisions. 19,20 Goals to be reached should, equally, depend on functional status, without contraindicating any treatment whatsoever exclusively on account of age. Considering the high prevalence of multimorbidities and the high evolution of therapeutic options, polypharmacy has become very frequent in elderly patients, posing further challenges to case management. 19,20 Understanding the advantages and disadvantages of every treatment is fundamental to adequate elderly treatment. This may only be scaled through the AGA. Familiarity with the AGA is, thus, essential to the evaluation and introduction of a determined treatment in an elderly patient. 21,22 1.4. Particularities in the Treatment of Elderly Patients In treating elderly patients, priority is given to the patient who is ill, rather than to the illness, and to controlling the disease, rather than curing it. It is essential to know the disease, the patient who has the disease, and the treatment. CVD is frequent, and, even when there are few manifestations, it brings increased risks; elderly patients with diseases present comorbidities and high biopsychosocial vulnerability; treatments are more susceptible to undesired effects. Thus, evaluation of multiple clinical and psychosocial domains is fundamental. Owing to the fact that evidence is often lacking, conduct should be individualized. Decisions should be shared, and it is necessary to consider risk-benefit ratio and life expectancy. In elderly patients, treatment indication requires more caution. Although therapeutic goals are less precise, excluding them solely on the basis of age implies omission. 23-26 Orientations regarding lifestyle changes are recommended, as in younger age groups. This may, however, cause undesired effects, especially if the changes are misunderstood or misapplied. Changing old habits requires attention. Pharmacological treatments should: prioritize conditions and restrict number of medications, simplify posology, evaluate and stimulate satisfactory adherence even in secondary 656