ABC | Volume 114, Nº3, March 2020

Viewpoint Tavares et al. Cardiogeriatrics in Brazil - current panorama Arq Bras Cardiol. 2020; 114(3):571-573 a Comprehensive Geriatric Assessment with the aid of the 10-TaGA (10-Minute Targeted Geriatric Assessment) tool. 10,11 Trends in geriatric cardiology Over the years, medical, scientific and life conditions advances have caused individuals to reach advanced ages in large numbers, in physical conditions and future expectations that exceed what was once observed, changing concepts of what “getting old” means. 12 We observe that, save for a few exceptions, cardiovascular diseases are aging-related diseases. In the 17th century, Dr Thomas Sydenham had already declared that “a man is as old as his arteries”. Therefore, the typical cardiology patient is an older person who has, beyond more expectations and aspirations, also an increasingly number of comorbidities and age-related deteriorations that complicate traditional guideline directed management. 13 It is also known that aging provides the cardiovascular system with characteristics diverse from those of young people, 14-16 which makes the care of the elderly even more unique. The traditional dogma that “after a certain age, the patient is too old for being submitted to invasive cardiac procedures” has no longer room in the current scenario. Notably, with the technological progress, we have seen the joining of the cardiologist’s therapeutic arsenal options that have allowed for the care of cardiovascular affections that disproportionally affect the elderly. The forthcoming of Direct Oral Anticoagulants, Cardiac Resynchronization Therapy, Left Ventricular Assist Devices, TAVR and Mitral Clips open up new therapeutic horizons. Paradoxically, interventional risks (clinical or surgical) remain high in the very elderly, making geriatric and frailty evaluation useful and necessary tools for therapeutic decision making, including distinguishing those individuals who might benefit from a certain procedure from those who will not. 9,17 We live in a multimorbidity age: Medicare data shows that, among its users, it occurs in 63% of those between 65 and 75 years old, progressing with age until it occurs in 83% of users over 85 years of age. 18 Its economic impact is equally impressive, for only 14% of beneficiaries (those who report 6 or more chronic conditions) consume 46% of the programs annual budget (over $500 billion). 13 Current treatment paradigms for treating cardiovascular disease are limited for elderly patients. Usual approach for cardiological care is widely driven by clinical practice single disease guidelines – largely based on Randomized Clinical Trials that often deliberately and systematically exclude elderly patients with multimorbidity; they evaluate predominantly hard endpoints and do not consider physical preservation, cognition or life quality associated with health in their analysis, which would be much more relevant for evaluating the patients in their last decades or years of life. Another limitation for applying those guidelines is that focus on disease may inadvertently cause harmful effects in the multimorbidity context – this issue is extremely complex, since a treatment often entails the emergence of a new disease or decompensation of another preexisting condition. 19 The Sliding Doors 20 phenomenon was proposed to describe how, in the current model of care, patients with multiple comorbidities may have different outcomes, depending on the door through which they go first. For example, a patient with an occult colorectal cancer and coronary artery disease, by going first to an Oncologist, is diagnosed with neoplasia, goes under surgery/chemotherapy and during treatment develops heart failure; by going first to a Cardiologist, the same patient has a severe coronary obstruction diagnosed, has an angioplasty made, uses dual antiplatelet therapy and, after a few months, presents significant gastrointestinal bleeding, and is diagnosed with cancer at a more advanced stage. We believe, as Forman DE, 19 in a new model: in which multimorbidity elderly patients care is centered on one professional with a geriatric point of view, who coordinates the care in a horizontal fashion, with specialists acting punctually and under communication, preferably with shared electronic medical records. In such model, our hypothetical patient would have had both diseases evaluated and treated in an opportune moment. It is, indeed, a new look on illness, with the patients as the primary focus, not onlywith their multiple biological components, but also within their biography, which makes each of them unique, but not really excluded from the benefits of technological advances that have proven effective for other age groups and were also tested and proven in this advanced life stage. Since we were given the invaluable opportunity of living longer, may it also be an option for a better life. Conclusion Geriatric Cardiology is an evolving field, still in the process of forming its identity and defining which training is mandatory and fundamental. In a couple of decades only, we have evolved a lot. Gaps within the knowledge of the elderly were identified, we took the first steps to establish a Geriatric Cardiology curriculum and develop specific tools for evaluating the eldery with cardiovascular diseases – initial steps for a subspecialty that is still in the making. Formal clinical training is still rare – to our knowledge, in North America, it is only offered in New York University, Vanderbilt University, University of Pittsburgh – in the United States – and McGill University – in Canada. In Brazil, we have fellowships at the InCor (Heart Institute), Instituto Dante Pazzanese and Escola Paulista de Medicina, open to Cardiologists and Geriatricians. Gladly, this year we have 6 professionals under training in our institution – the greatest number since the program was opened. We expect that this represents the evolution of Geriatric Cardiology and an incentive on the long journey we have ahead. After all, the challenges are not few: i) narrowing the gaps on the knowledge of the elderly; ii) increase the participation of the elderly included in clinical trials; iii) evaluate endpoints that are relevant for our patients – cognition and quality of life; iv) increase the ability to form professionals with specific training in Geriatric Cardiology. Author contributions Conception and design of the research and Critical revision of the manuscript for intellectual content: Tavares CAM, Cavalcanti AFW, Jacob Filho W; Writing of the manuscript: Tavares CAM, Cavalcanti AFW. 572