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 CVD, especially involving the most elderly population. For this reason, this topic deserves to be covered in this document. According to the WHO, PC is defined as a mode of assistance provided by a multidisciplinary team with the objective of improving patient and family member quality of life, when faced with a life-threatening disease, through prevention and relief of suffering. 132 PC requires early identification, evaluation, and treatment of pain and other physical, social, psychological, and spiritual issues. 132,133 PC should be individualized; it is not an approach to “terminal” patients, but rather to a life-threatening clinical condition. 133 Its indication should be early, at the moment of diagnosis, in a manner that promotes understanding, acceptance, and progressive expansion of the means of support over time. The possibility of whether or not to implement disease-modifying treatments should be discussed in a manner that does not allow for the idea that “there’s nothing to do.” 133 The principles that guide PC in accordance with the WHO consist of: 132 1. Relieve pain and other distressing physical symptoms. 2. Affirm life and consider death as a normal life process. 3. Neither hasten nor postpone death. 4. Integrate psychological and spiritual aspect into patient care. 5. Offer a support system that makes it possible for the patient to live as actively as possible, until the moment of death. 6. Offer a support system that helps family members cope with the disease and bereavement. 7. Improve quality of life and positively influence the course of the disease. 8. Initiate care as early as possible, in conjunction with other life-prolonging measures, such as chemotherapy and radiotherapy, and include all necessary investigations to better comprehend and control existing clinical situations. From the theoretical point of view, all patients with serious, incurable, and progressive diseases that are life-threatening should receive PC. 133 If this reference were put into practice, the number of patients indicated for PC would be enormous, and it would not be possible to provide this type of assistance to all of them. For this reason, the National Academy of Palliative Care (Academia Nacional de Cuidados Paliativos, ANCP) 133 recommends the adoption of the criteria used by Medicare in the United States, 134 which establishes expected survival time as a criterion for indicating PC. Adapting the Medicare criteria, we may suggest the following conditions for indicating PC: 133,134 1. Patient with life expectancy less than or equal to 6 months. 2. Diagnosis with an incurable and irreversible disease. 3. The patient must opt for PC, giving up life-prolonging treatments. 4. The implementation of PC should be operationally available. Prognostic evaluation of patients receiving PC is a complex process involving physiological and social judgments. The ANCP recommends some instruments for evaluating patient functionality, as well as measuring functional and clinical decline, such as the Karnofsky Performance Status Scale and the Palliative Performance Scale. These scales and their methods of evaluation are detailed in the ANCP’s Palliative Care Manual, which is available on their virtual library (http:// paliativo.org.br/) . 133 In relation to CVD, they are known to be the main cause of death in Brazil, as well as in other parts of the world. They may occur at any age, but their prevalence is higher with advanced age. 133 Among CVD, HF represents a challenge to prognostic evaluation, given that many patients die suddenly, even when they are in higher functional classes. Diverse criteria have sought to identify patients with HF at a risk of sudden death, such as left ventricular ejection fraction (LVEF), type B natriuretic peptide, end-diastolic LV diameter, presence of nonsustained ventricular tachycardia, diabetes mellitus, thromboembolic phenomena, history of previous cardiorespiratory arrest, and AIDS diagnosis. 133 The difficulty of prognosis in patients with HF makes it challenging to discuss care preferences with patients; for this reason, these patients have been considered those with the least comprehension of their clinical condition and the least involved in the decision making process related to their care. 133 Patients with CVD suffer severely, and they are among those who least receive home healthcare and PC; for this reason, these Guidelines agree with the idea that PC should be considered earlier during the evolutionary course of CVD and in routine cardiology practice. 2. Chronic Coronary Disease 2.1. Peculiarities of Diagnosing Chronic Coronary Artery Disease in Elderly Patients Clinical history and detailed physical examination are essential when evaluating an elderly patient with suspected chronic CAD; however, in routine practice, this constitutes a challenge, considering the occurrence of comorbidities, atypical symptoms, and alterations in cognition and locomotion. Ischemia is frequently present in the form of anginal equivalents, such as fatigue, dyspnea, and epigastric discomfort, with the presence of typical angina being rare. 135 Physical examination, generally non-specific, may provide some leads, such as SAH, abnormal heart rhythms such as atrial fibrillation (AF), and peripheral arterial disease. Resting EKG may be non-specific in 50% of cases, even in those with severe coronary disease; 136 alterations such as pathological Q waves, T-wave inversions, left ventricular hypertrophy (LVH), His bundle branch blocks, and AF are common in elderly patients. These alterations complicate diagnosis. EKG is particularly useful during episodes of angina, when ST segment depression or pseudonormalization may be observed in up to 50% of cases. Chest radiography should be performed when there is a suspected coexistence of congestive HF, valvulopathy, or respiratory disease. Transthoracic echocardiography provides information which is relevant to diagnosis and management of chronic: 666