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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">As a result of recent technological advances&#44; cardiac magnetic resonance &#40;CMR&#41; and cardiac computed tomography angiography &#40;CCTA&#41; are of increasing importance as diagnostic methods in clinical practice&#44; and there has been a considerable broadening of indications for these exams&#46;<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#8211;3</span></a> Nevertheless&#44; the relative newness and rapid development of these imaging modalities pose challenges for practicing physicians in terms of awareness of their indications and contraindications&#44; as well as their advantages and pitfalls compared to established methods&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">The aim of this study was to assess the familiarity&#44; perceptions and patterns of use concerning CMR and CCTA among Portuguese cardiologists&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Methods</span><p id="par0015" class="elsevierStylePara elsevierViewall">Physician members of the Portuguese Society of Cardiology &#40;SPC&#41; were invited to respond anonymously to an online questionnaire via a mailing in January 2011 to the email addresses contained in the SPC database&#46; The study was identified as an initiative of the SPC&#39;s Working Group on Nuclear Cardiology&#44; Magnetic Resonance and Cardiac Computed Tomography &#40;GECNRMTC&#41;&#59; the physicians were asked to respond without consulting any sources&#46; A second mailing was sent in October 2011 to those who had not responded to the first&#59; an electronic identification code was used in both mailings so that the same person could not respond more than once&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">Questionnaires returned with demographic data only &#40;n<span class="elsevierStyleMonospace">&#61;</span>18&#41; were excluded from the analysis&#46; To maintain the homogeneity of the population&#44; responses from physicians in specialties other than cardiology&#44; cardiothoracic surgery&#44; pediatric cardiology or internal medicine were also excluded&#46; This exclusion applied to four respondents&#58; general and family medicine &#40;n<span class="elsevierStyleMonospace">&#61;</span>2&#41;&#59; physical medicine and rehabilitation &#40;n<span class="elsevierStyleMonospace">&#61;</span>1&#41;&#59; and radiology &#40;n<span class="elsevierStyleMonospace">&#61;</span>1&#41;&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">Results are presented as frequencies and percentages&#46; Continuous variables are expressed as means &#177; standard deviation&#46;</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Results</span><p id="par0030" class="elsevierStylePara elsevierViewall">The responses from 205 physicians &#40;21&#37; of SPC members contacted in the first mailing&#41; were analyzed&#46; The mean age of respondents was 47&#177;11 years&#44; most were male &#40;67&#37;&#44; n<span class="elsevierStyleMonospace">&#61;</span>137&#41; and had been specialists &#40;89&#37;&#44; n<span class="elsevierStyleMonospace">&#61;</span>183&#41; for 15&#177;10 years&#46; The great majority &#40;87&#37;&#44; n<span class="elsevierStyleMonospace">&#61;</span>178&#41; were cardiologists&#44; and there were also 15 cardiac surgeons &#40;7&#37;&#41;&#44; six pediatric cardiologists &#40;3&#37;&#41;&#44; and six specialists in internal medicine &#40;3&#37;&#41;&#46; The districts with the most respondents were Lisbon &#40;38&#37;&#44; n<span class="elsevierStyleMonospace">&#61;</span>77&#41;&#44; Porto &#40;20&#37;&#44; n<span class="elsevierStyleMonospace">&#61;</span>40&#41;&#44; Coimbra &#40;9&#37;&#44; n<span class="elsevierStyleMonospace">&#61;</span>19&#41; and Viseu &#40;3&#37;&#44; n<span class="elsevierStyleMonospace">&#61;</span>7&#41;&#44; although responses were received from all districts and autonomous regions of Portugal except Beja&#44; Bragan&#231;a and Guarda&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">Most &#40;80&#37;&#44; n<span class="elsevierStyleMonospace">&#61;</span>164&#41; stated that they regularly performed transthoracic echocardiograms&#44; 10&#37; &#40;n<span class="elsevierStyleMonospace">&#61;</span>20&#41; CCTA&#44; 7&#37; &#40;n<span class="elsevierStyleMonospace">&#61;</span>15&#41; myocardial perfusion scintigraphy &#40;MPS&#41;&#44; and 7&#37; &#40;n<span class="elsevierStyleMonospace">&#61;</span>14&#41; CMR&#59; only 17&#37; &#40;n<span class="elsevierStyleMonospace">&#61;</span>34&#41; stated they performed more than one of these imaging modalities&#44; while another 17&#37; &#40;n<span class="elsevierStyleMonospace">&#61;</span>34&#41; performed none of them&#46; The vast majority &#40;94&#37;&#44; n<span class="elsevierStyleMonospace">&#61;</span>192&#41; said they were able to interpret transthoracic echocardiographic images&#44; without an accompanying report&#44; whereas only 17&#37; &#40;n<span class="elsevierStyleMonospace">&#61;</span>34&#41; said they could make a correct diagnostic assessment of CMR images &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Figure 1</a>&#41;&#46; The number of exams requested in a typical working week are shown in <a class="elsevierStyleCrossRef" href="#fig0010">Figure 2</a>&#46; With regard to patterns of use&#44; most respondents &#40;60&#37;&#44; n<span class="elsevierStyleMonospace">&#61;</span>122&#41; stated they had never requested a calcium score&#44; 15&#37; &#40;n<span class="elsevierStyleMonospace">&#61;</span>30&#41; CCTA&#44; and 5&#37; &#40;n<span class="elsevierStyleMonospace">&#61;</span>11&#41; CMR&#46; In 18&#37; &#40;n<span class="elsevierStyleMonospace">&#61;</span>37&#41; and 20&#37; &#40;n<span class="elsevierStyleMonospace">&#61;</span>40&#41; of cases respectively&#44; the last request for CCTA or CMR had been made more than six months previously&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0040" class="elsevierStylePara elsevierViewall">When asked to classify a set of eight indications for CMR&#44; most respondents considered them good or excellent&#44; except for coronary angiography &#40;<a class="elsevierStyleCrossRef" href="#fig0015">Figure 3</a>&#41;&#46; Cardiac masses&#44; congenital heart disease and cardiomyopathies were considered good or excellent indications for CMR by over 90&#37; of respondents&#44; while assessment of myocardial viability and acute myocardial infarction with angiographically normal coronary arteries were considered good or excellent indications by 75&#37; and 65&#37;&#44; respectively&#46; The best indications for CCTA were considered to be assessment of asymptomatic patients with positive exercise ECG test&#44; evaluation of aortocoronary bypasses&#44; assessment of symptomatic patients with intermediate pretest probability of obstructive coronary artery disease &#40;as second-line exam&#41;&#44; and exclusion of coronary artery disease prior to valve surgery &#40;<a class="elsevierStyleCrossRef" href="#fig0020">Figure 4</a>&#41;&#46; Suspected coronary artery disease in symptomatic patients with intermediate pretest probability was considered a good or excellent indication for CCTA as the first-line exam by 29&#37; of respondents&#46;</p><elsevierMultimedia ident="fig0015"></elsevierMultimedia><elsevierMultimedia ident="fig0020"></elsevierMultimedia><p id="par0050" class="elsevierStylePara elsevierViewall">With regard to contraindications for CMR&#44; the majority &#40;91&#37;&#41; identified the presence of a pacemaker or implantable cardioverter-defibrillator&#44; but a significant percentage considered that a mechanical valve or sternotomy wires also contraindicated the exam &#40;45&#37; and 25&#37;&#44; respectively&#41; &#40;<a class="elsevierStyleCrossRef" href="#fig0025">Figure 5</a>&#41;&#46; Only 43&#37; &#40;79&#47;185&#41; responded correctly to all questions regarding contraindications for CMR&#46;</p><elsevierMultimedia ident="fig0025"></elsevierMultimedia><p id="par0055" class="elsevierStylePara elsevierViewall">Participants were then asked to classify in ascending order the mean radiation dose employed in the following four techniques&#58; 99mTc MPS &#40;stress-rest protocol&#41;&#44; invasive diagnostic coronary angiography &#40;without ventriculography&#41;&#44; CCTA and CMR&#46; Of the 173 physicians who answered this question&#44; 40&#37; &#40;n<span class="elsevierStyleMonospace">&#61;</span>69&#41; considered that MPS involved the highest mean radiation dose&#44; while 27&#37; &#40;n<span class="elsevierStyleMonospace">&#61;</span>46&#41; and 25&#37; &#40;n<span class="elsevierStyleMonospace">&#61;</span>44&#41; chose CCTA and diagnostic coronary angiography&#44; respectively&#46; Around half of respondents &#40;54&#37;&#44; n<span class="elsevierStyleMonospace">&#61;</span>94&#41; believed that the mean radiation dose in CCTA is higher than in invasive coronary angiography&#44; and 45&#37; &#40;n<span class="elsevierStyleMonospace">&#61;</span>78&#41; believed it is higher in CCTA than in MPS&#46; As for CMR&#44; 15&#37; &#40;n<span class="elsevierStyleMonospace">&#61;</span>26&#41; appear to be unaware that this technique does not involve ionizing radiation&#46;</p><p id="par0060" class="elsevierStylePara elsevierViewall">The participants were then asked to classify in ascending order the average cost of the following exams &#40;without taking account of state funding or reimbursement&#41;&#58; stress echocardiography&#44; MPS&#44; invasive diagnostic coronary angiography&#44; CCTA and CMR&#46; Of the 163 physicians who answered this question&#44; 50&#37; &#40;n<span class="elsevierStyleMonospace">&#61;</span>81&#41; considered invasive coronary angiography the most costly&#44; while 40&#37; &#40;n<span class="elsevierStyleMonospace">&#61;</span>65&#41; and 7&#37; &#40;n<span class="elsevierStyleMonospace">&#61;</span>12&#41; chose CMR and MPS&#44; respectively&#44; and 2&#37; &#40;n<span class="elsevierStyleMonospace">&#61;</span>3&#41; chose CCTA&#46; Nevertheless&#44; 66&#37; &#40;n<span class="elsevierStyleMonospace">&#61;</span>108&#41; and 63&#37; &#40;n<span class="elsevierStyleMonospace">&#61;</span>102&#41; believed CCTA to be more costly than MPS and invasive angiography&#44; respectively&#46; As for CMR&#44; 67&#37; &#40;n<span class="elsevierStyleMonospace">&#61;</span>109&#41; and 53&#37; &#40;n<span class="elsevierStyleMonospace">&#61;</span>87&#41; believed that this technique is more costly than MPS and invasive angiography&#44; respectively&#46;</p><p id="par0065" class="elsevierStylePara elsevierViewall">When asked about the main obstacle to wider use of CMR in clinical practice&#44; 45&#37; of respondents &#40;n<span class="elsevierStyleMonospace">&#61;</span>84&#41; cited problems of availability&#44; 36&#37; &#40;n<span class="elsevierStyleMonospace">&#61;</span>66&#41; cost&#44; and 15&#37; &#40;n<span class="elsevierStyleMonospace">&#61;</span>27&#41; lack of familiarity with the technique&#46; The views of respondents with regard to calcium scoring are shown in <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Discussion</span><p id="par0070" class="elsevierStylePara elsevierViewall">To our knowledge&#44; this is the first study designed to assess the familiarity of Portuguese cardiologists with CMR and CCTA&#46; In general&#44; they appear to be moderately familiar with these imaging modalities and aware of their indications&#44; contraindications&#44; advantages and pitfalls&#46; However&#44; there appears to be some discrepancy between the acknowledged usefulness of these techniques and the extent to which they are used in clinical practice&#46; For example&#44; even though most respondents considered CMR a useful or very useful tool for a wide range of common clinical indications&#44; a quarter had not requested CMR in the previous six months&#44; and 5&#37; had never requested it in their entire careers&#46; This may mean that Portuguese cardiologists tend to reserve this exam for more complex cases in which conventional tests have been unable to provide an adequate clinical assessment&#44; but hesitate to use CMR as an alternative to methods with which they are more familiar&#46; Even in situations in which CMR has shown excellent performance&#44; including assessment of myocardial viability&#44;<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> differential diagnosis of myocardial infarction with angiographically normal coronary arteries<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> and in myocarditis&#44;<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> 25&#8211;35&#37; did not consider these sufficiently good reasons to refer patients for CMR&#46; Perhaps less surprisingly&#44; since the technique is relatively new and as yet not widely available in some regions&#44; assessment of ischemia was considered an important indication for CMR by barely more than half of respondents&#46; However&#44; given that stress CMR has been shown to be superior to MPS and stress echocardiography in head-to-head comparisons&#44;<a class="elsevierStyleCrossRefs" href="#bib0035"><span class="elsevierStyleSup">7&#44;8</span></a> significant growth in use of this method is expected in the coming years&#46;</p><p id="par0075" class="elsevierStylePara elsevierViewall">Various reasons were given by participants in the study for not requesting CMR in clinical practice&#44; limited availability being the one identified by the largest proportion &#40;45&#37;&#41;&#46; Although the availability of the technique has increased considerably in recent years&#44; particularly in large centers&#44; where most of the respondents work&#44; it is still not available in many public hospitals&#44; which may be reluctant&#44; or find it difficult&#44; to refer patients to other institutions&#46; At the same time&#44; over a third of respondents cited the cost of CMR as the main limiting factor&#44; a reason that appears to stem from the mistaken idea that CMR is more costly than&#44; for example&#44; MPS or invasive coronary angiography&#44; when in fact it is less costly than either&#46;<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a> As already pointed out&#44; CMR is unavailable in many hospitals and is not covered by the national health service&#44; which may be an obstacle to its wider use in clinical practice&#46; On the other hand&#44; only a minority of cardiologists &#40;15&#37;&#41; cite unfamiliarity with the technique as a major reason for non-referral&#46; However&#44; a lack of familiarity is nonetheless evident&#44; as reflected in the small proportion of respondents who consider themselves capable of correctly interpreting CMR images without an accompanying report&#44; the percentage who are unaware of several of the contraindications for CMR&#44; and the fact that 15&#37; believe the technique involves ionizing radiation&#46; These findings&#44; which would have been worse if physicians experienced in the technique had been excluded from the analysis &#40;data not presented&#41;&#44; highlight the need for training in this area of cardiac imaging&#44; which until recently received little attention in cardiology curricula&#46;</p><p id="par0085" class="elsevierStylePara elsevierViewall">Cardiologists appear to be slightly more familiar with CCTA than with CMR&#44; with 29&#37; of respondents considering themselves capable of interpreting the exams without an accompanying report&#59; this may be a reflection of the greater availability of CCTA in Portugal and the fact that it is technically less complex&#46; A significant proportion of cardiologists &#40;almost 30&#37;&#41; consider the technique a good or excellent first-line exam to assess symptomatic patients with intermediate pretest probability of coronary artery disease&#44; an innovation that is in line with recently published clinical guidelines&#46;<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#44;10</span></a> It thus appears that in general Portuguese cardiologists have an adequate understanding of the clinical usefulness of CCTA&#44; identifying patients who would benefit most from the technique&#44; namely those with intermediate or low pretest probability&#46; Nevertheless&#44; around a third of respondents had not requested CCTA in the previous six months&#44; and 15&#37; had never requested it in their careers&#46; As with CMR&#44; there appears to be a discrepancy between the acknowledged usefulness of the technique and the extent to which it is used in clinical practice&#44; which may be due to problems of availability and&#47;or to perceptions concerning cost&#44; radiation dose&#44; and others&#46; With regard to cost&#44; it is interesting that CCTA is seen by around two-thirds of respondents as being more costly than invasive coronary angiography or MPS&#44; whereas in reality the average cost of CCTA is less than half that of either of these exams&#46;<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a> The fact that a large proportion did not identify invasive diagnostic coronary angiography as the most costly exam of all those under analysis may be due to clinicians&#8217; easy access to this technique and the fact that most such exams are performed within the national health service&#44; and so referring physicians and patients are unaware of the costs involved&#46; Regarding radiation dose&#44; around half of respondents believe that the mean dose in CCTA is higher than in invasive coronary angiography or MPS&#46; However&#44; studies on everyday clinical practice have shown that this is not in fact the case&#44; and mean radiation doses currently used in CCTA are significantly lower than in MPS&#44; and similar to or lower than in diagnostic catheterization&#46;<a class="elsevierStyleCrossRefs" href="#bib0055"><span class="elsevierStyleSup">11&#44;12</span></a></p><p id="par0090" class="elsevierStylePara elsevierViewall">The fact that invasive coronary angiography is more readily available than CCTA&#44; together with misconceptions concerning their relative costs and radiation doses&#44; may partly explain the high percentage of diagnostic catheterizations that reveal no obstructive coronary artery disease &#40;41&#8211;62&#37; in published series&#41;&#46;<a class="elsevierStyleCrossRefs" href="#bib0065"><span class="elsevierStyleSup">13&#8211;15</span></a> Wider use of CCTA would help to minimize this problem&#44; since the technique&#44; when used appropriately&#44; appears to reduce the number of normal coronary angiograms&#46;<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">16</span></a></p><p id="par0095" class="elsevierStylePara elsevierViewall">With regard to coronary calcium score&#44; it is interesting that&#44; while only a small percentage of respondents consider that it provides no additional prognostic information to conventional cardiovascular risk assessment&#44; most &#40;60&#37;&#41; have never requested the test&#46; It is probably underused&#44; especially since it appears to be superior to other markers in terms of discriminatory power and risk reclassification<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">17</span></a> and is a class IIa recommendation in European and American guidelines for cardiovascular risk stratification in asymptomatic individuals with intermediate risk&#46;<a class="elsevierStyleCrossRefs" href="#bib0090"><span class="elsevierStyleSup">18&#44;19</span></a> Portuguese cardiologists appear to recognize its potential&#44; but feel the evidence is still insufficient to make it part of everyday clinical practice&#44; which may reflect the lack of clear therapeutic guidelines based on calcium scores&#46;</p><p id="par0100" class="elsevierStylePara elsevierViewall">To summarize&#44; there appears to be a certain lack of familiarity with CMR and CCTA on the part of Portuguese cardiologists&#46; This is no doubt due in part to the relative newness of the two techniques and the fact that they are not readily available in cardiology departments&#46; Their recent inclusion in cardiology intern training programs in Portugal may prove effective in improving knowledge and implementation of these methods&#46; At the same time&#44; there appears to be a need to strengthen continuing training in this area in Portugal&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Study limitations</span><p id="par0105" class="elsevierStylePara elsevierViewall">Certain limitations of this study should be borne in mind&#46; Firstly&#44; only physicians with a valid email address in the SPC database were contacted and of these&#44; only those who responded to the questionnaire were included in the analysis&#46; This probably led to selection bias&#44; resulting in over-representation of physicians with an interest and knowledge in this area&#44; who would have been more likely to respond to a survey on the subject&#46; Furthermore&#44; since there has been no national or regional survey on the availability of CMR and CCTA&#44; the relationship between availability and the responses obtained could not be analyzed&#46; Even so&#44; it seems clear that there are genuine problems with access which need to be addressed by the relevant bodies&#44; as only in this way can appropriate diagnostic exams be selected for each clinical situation based on the evidence and cost&#47;benefit ratios&#46;</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Conclusions</span><p id="par0110" class="elsevierStylePara elsevierViewall">Portuguese cardiologists appear to be moderately aware of the indications&#44; contraindications&#44; advantages and pitfalls of CMR and CCTA&#46; Patterns of use of these imaging modalities indicate that they are used less than would be expected from clinicians&#8217; recognition of their usefulness&#44; probably due to limited availability and certain misconceptions concerning the exams&#44; particularly with regard to their costs and radiation dose&#46; Greater efforts should be made to improve Portuguese cardiologists&#8217; familiarity with CMR and CCTA&#44; in order to achieve a more rational and appropriate use of these diagnostic techniques&#46;</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Ethical disclosures</span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">Protection of human and animal subjects</span><p id="par0115" class="elsevierStylePara elsevierViewall">The authors declare that no experiments were performed on humans or animals for this investigation&#46;</p></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0105">Confidentiality of data</span><p id="par0120" class="elsevierStylePara elsevierViewall">The authors declare that no patient data appear in this article&#46;</p></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0110">Right to privacy and informed consent</span><p id="par0125" class="elsevierStylePara elsevierViewall">The authors declare that no patient data appear in this article&#46;</p></span></span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0115">Conflicts of interest</span><p id="par0130" class="elsevierStylePara elsevierViewall">The authors have no conflicts of interest to declare&#46;</p></span></span>"
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        "titulo" => "Abstract"
        "resumen" => "<span class="elsevierStyleSectionTitle" id="sect0010">Introduction</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Rapid advances in cardiac magnetic resonance &#40;CMR&#41; and cardiac computed tomography angiography &#40;CCTA&#41; pose challenges for practicing physicians in terms of awareness of their indications&#44; contraindications&#44; advantages and pitfalls&#46;</p> <span class="elsevierStyleSectionTitle" id="sect0015">Methods</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">We conducted a nationwide online survey assessing the familiarity&#44; perceptions and patterns of use concerning these imaging modalities based on a questionnaire sent to all physician members of the Portuguese Society of Cardiology&#46;</p> <span class="elsevierStyleSectionTitle" id="sect0020">Results</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">The responses from 205 physicians &#40;21&#37; response rate&#41; were analyzed&#46; Roughly half of them requested less than one CMR &#40;51&#37;&#41; or CCTA &#40;52&#37;&#41; per week&#46;</p><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Suspected coronary artery disease in symptomatic patients with intermediate pretest probability was considered a good or excellent indication for CCTA by 59&#37; of respondents when performed as a second-line exam&#44; and by 29&#37; as a first-line exam&#46; Cardiac masses&#44; congenital heart disease and cardiomyopathies were considered good or excellent indications for CMR by over 90&#37; of respondents&#44; while assessment of myocardial viability and acute myocardial infarction with normal coronary arteries were considered good or excellent indications by 75&#37; and 65&#37; of respondents&#44; respectively&#46; Less than half &#40;39&#37;&#41; answered all the questions regarding contraindications for CMR correctly&#44; and 15&#37; were unaware that CMR does not involve ionizing radiation&#46; The main reasons for not referring a patient for CMR were limited availability &#40;45&#37;&#41; and cost &#40;36&#37;&#41;&#46;</p> <span class="elsevierStyleSectionTitle" id="sect0025">Conclusions</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Portuguese cardiologists appear to be moderately aware of the indications&#44; contraindications and advantages of these new imaging modalities&#46; Greater efforts should be made to improve physician education on this subject in order to improve patient care&#46;</p>"
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      "pt" => array:2 [
        "titulo" => "Resumo"
        "resumen" => "<span class="elsevierStyleSectionTitle" id="sect0035">Introdu&#231;&#227;o</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">A r&#225;pida evolu&#231;&#227;o da resson&#226;ncia magn&#233;tica card&#237;aca &#40;RMC&#41; e da angio-TC card&#237;aca colocam desafios aos cl&#237;nicos quanto ao conhecimento das suas indica&#231;&#245;es&#44; contraindica&#231;&#245;es&#44; vantagens e desvantagens&#46;</p> <span class="elsevierStyleSectionTitle" id="sect0040">M&#233;todos</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Efetu&#225;mos um question&#225;rio <span class="elsevierStyleItalic">online</span> a todos os m&#233;dicos s&#243;cios da Sociedade Portuguesa de Cardiologia com o intuito de avaliar a familiaridade&#44; perce&#231;&#245;es e padr&#245;es de uso dos novos m&#233;todos de imagem&#46;</p> <span class="elsevierStyleSectionTitle" id="sect0045">Resultados</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">O question&#225;rio foi respondido por 205 m&#233;dicos &#40;21&#37; do total&#41;&#46; Cerca de metade disse requisitar menos de uma RMC &#40;51&#37;&#41; ou angio-TC card&#237;aca &#40;52&#37;&#41; por semana&#46; A suspeita de doen&#231;a coron&#225;ria em doentes sintom&#225;ticos com probabilidade pr&#233;-teste interm&#233;dia foi considerada uma indica&#231;&#227;o boa ou excelente para angio-TC por 59&#37; dos respondedores quando efetuada como exame de 2&#46;<span class="elsevierStyleSup">a</span> linha&#44; e por 29&#37; como exame de 1&#46;<span class="elsevierStyleSup">a</span> linha&#46; Massas card&#237;acas&#44; cardiopatias cong&#233;nitas e miocardiopatias foram consideradas indica&#231;&#245;es boas&#47;excelentes para RMC por mais de 90&#37; dos respondedores&#44; ao passo que a avalia&#231;&#227;o de viabilidade e enfarte com coron&#225;rias normais foram consideradas indica&#231;&#245;es boas&#47;excelentes por 75 e 65&#37; dos respondedores&#44; respetivamente&#46; Menos de metade &#40;39&#37;&#41; respondeu corretamente a todas as perguntas acerca das contraindica&#231;&#245;es para RMC e 15&#37; desconheciam que a RMC n&#227;o utiliza radia&#231;&#227;o ionizante&#46; As principais raz&#245;es para n&#227;o referenciar doentes para RMC foram a disponibilidade &#40;45&#37;&#41; e o custo &#40;36&#37;&#41;&#46;</p> <span class="elsevierStyleSectionTitle" id="sect0050">Conclus&#245;es</span><p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Os cardiologistas portugueses parecem moderadamente familiarizados e conhecedores das indica&#231;&#245;es&#44; contraindica&#231;&#245;es e vantagens dos novos m&#233;todos de imagem&#46; Devem ser envidados esfor&#231;os no sentido de melhorar estes indicadores por forma a permitir um uso racional destes exames complementares de diagn&#243;stico&#46;</p>"
      ]
    ]
    "NotaPie" => array:1 [
      0 => array:2 [
        "etiqueta" => "&#9734;"
        "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as&#58; Ferreira AM&#44; Bettencourt N&#44; Matos P&#44; et al&#46; Familiaridade e perce&#231;&#245;es dos cardiologistas portugueses acerca da resson&#226;ncia magn&#233;tica card&#237;aca e angio-TC card&#237;aca - dimens&#227;o da tarefa &#224; nossa frente&#46; Rev Port Cardiol&#46; 2013&#59;32&#58;601&#8211;608&#46;</p>"
      ]
    ]
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      0 => array:7 [
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        "etiqueta" => "Figure 1"
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          "en" => "<p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">Responses to the question&#58; &#8220;In which of the following imaging modalities do you think you would be capable of correctly interpreting the test based only on images or videos &#40;without report&#41;&#63;&#8221;&#46; Cath&#58; invasive coronary angiography&#59; CCTA&#58; cardiac computed tomography angiography&#59; CMR&#58; cardiac magnetic resonance&#59; Echo&#58; transthoracic echocardiography&#59; SPECT&#58; myocardial single-photon emission computed tomography&#46;</p>"
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          "en" => "<p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">Responses to the question&#58; &#8220;How many of these imaging tests do you request in a typical working week&#63; &#40;If you work in more than one institution&#44; please enter the total&#46;&#41;&#8221;&#46; Stress echo&#58; stress echocardiography&#59; Ca score&#58; calcium score&#46; Other abbreviations as in <a class="elsevierStyleCrossRef" href="#fig0005">Figure 1</a>&#46;</p>"
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          "en" => "<p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">Responses to the question&#58; &#8220;How would you classify the following indications for cardiac magnetic resonance&#63;&#8221;&#46; AMI NCA&#58; acute myocardial infarction with normal coronary arteries&#59; ARVC&#58; arrhythmogenic right ventricular cardiomyopathy&#59; CHD&#58; congenital heart disease&#59; CMR&#58; cardiac magnetic resonance&#59; DK&#47;NR&#58; don&#8217;t know&#47;no response&#59; HCM&#58; hypertrophic cardiomyopathy&#59; MRA&#58; magnetic resonance coronary angiography&#46;</p>"
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          "en" => "<p id="spar0065" class="elsevierStyleSimplePara elsevierViewall">Responses to the question&#58; &#8220;How would you classify the following indications for cardiac computed tomography angiography&#63;&#58; A&#58; symptomatic patient with intermediate pretest probability of obstructive coronary artery disease &#40;as second-line test&#41;&#59; B&#58; symptomatic patient with intermediate pretest probability of obstructive coronary artery disease &#40;as first-line test&#41;&#59; C&#58; asymptomatic patient with positive exercise ECG&#59; D&#58; asymptomatic patient with several cardiovascular risk factors&#59; E&#58; evaluation of aortocoronary bypasses&#59; F&#58; patient with known coronary artery disease&#59; G&#58; evaluation of coronary stents&#59; H&#58; exclusion of coronary artery disease prior to valve surgery&#8221;&#46; DK&#47;NR&#58; don&#8217;t know&#47;no response&#46;</p>"
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          "en" => "<p id="spar0070" class="elsevierStyleSimplePara elsevierViewall">Responses to the question&#58; &#8220;Which of the following do you think are contraindications for cardiac magnetic resonance&#63;&#8221;&#46; DK&#47;NR&#58; don&#8217;t know&#47;no response&#59; PM&#47;ICD&#58; pacemaker or implantable cardioverter defibrillator&#46; Correct answers in green&#44; incorrect answers in red&#46;</p>"
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                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">Opinion&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">Potentially useful&#44; but the evidence is still insufficient to make it part of everyday clinical practice&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">41&#37; &#40;n<span class="elsevierStyleMonospace">&#61;</span>76&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">A useful tool that should be used more often&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">27&#37; &#40;n<span class="elsevierStyleMonospace">&#61;</span>51&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Results in unnecessary tests and costs&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">15&#37; &#40;n<span class="elsevierStyleMonospace">&#61;</span>27&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">I have no opinion on the subject&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">7&#37; &#40;n<span class="elsevierStyleMonospace">&#61;</span>13&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">Adds nothing to conventional cardiovascular risk assessment&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">6&#37; &#40;n<span class="elsevierStyleMonospace">&#61;</span>11&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
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                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Its role in cardiology should be similar to that of mammography in senology&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">4&#37; &#40;n<span class="elsevierStyleMonospace">&#61;</span>7&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
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          "en" => "<p id="spar0075" class="elsevierStyleSimplePara elsevierViewall">Responses to the question&#58; &#8220;Which of the following statements is closest to your opinion on coronary calcium score&#63;&#8221;&#46;</p>"
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    ]
    "bibliografia" => array:2 [
      "titulo" => "References"
      "seccion" => array:1 [
        0 => array:2 [
          "identificador" => "bibs0005"
          "bibliografiaReferencia" => array:19 [
            0 => array:3 [
              "identificador" => "bib0005"
              "etiqueta" => "1"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "ACCF&#47;SCCT&#47;ACR&#47;AHA&#47;ASE&#47;ASNC&#47;NASCI&#47;SCAI&#47;SCMR 2010 appropriate use criteria for cardiac computed tomography&#46; A report of the American College of Cardiology Foundation Appropriate Use Criteria Task Force&#44; the Society of Cardiovascular Computed Tomography&#44; the American College of Radiology&#44; the American Heart Association&#44; the American Society of Echocardiography&#44; the American Society of Nuclear Cardiology&#44; the North American Society for Cardiovascular Imaging&#44; the Society for Cardiovascular Angiography and Interventions&#44; and the Society for Cardiovascular Magnetic Resonance"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:3 [
                            0 => "A&#46;J&#46; Taylor"
                            1 => "M&#46; Cerqueira"
                            2 => "J&#46;M&#46; Hodgson"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1016/j.jacc.2010.07.005"
                      "Revista" => array:6 [
                        "tituloSerie" => "J Am Coll Cardiol"
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                        "volumen" => "56"
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                        "link" => array:1 [
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            ]
            1 => array:3 [
              "identificador" => "bib0010"
              "etiqueta" => "2"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Comparison of cardiac computed tomography examination appropriateness under the 2010 revised versus the 2006 original Appropriate Use Criteria"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:3 [
                            0 => "M&#46;M&#46; Wasfy"
                            1 => "T&#46;J&#46; Brady"
                            2 => "S&#46; Abbara"
                          ]
                        ]
                      ]
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                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1016/j.jcct.2011.12.005"
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                            "web" => "Medline"
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            ]
            2 => array:3 [
              "identificador" => "bib0015"
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              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "ACCF&#47;ACR&#47;AHA&#47;NASCI&#47;SCMR 2010 expert consensus document on cardiovascular magnetic resonance&#58; a report of the American College of Cardiology Foundation Task Force on Expert Consensus Documents"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
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                            0 => "W&#46;G&#46; Hundley"
                            1 => "D&#46;A&#46; Bluemke"
                            2 => "J&#46;P&#46; Finn"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1016/j.jacc.2009.11.011"
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                        "paginaInicial" => "2614"
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                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/20513610"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            3 => array:3 [
              "identificador" => "bib0020"
              "etiqueta" => "4"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "The use of contrast-enhanced magnetic resonance imaging to identify reversible myocardial dysfunction"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:3 [
                            0 => "R&#46;J&#46; Kim"
                            1 => "E&#46; Wu"
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                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1056/NEJM200011163432003"
                      "Revista" => array:6 [
                        "tituloSerie" => "N Engl J Med"
                        "fecha" => "2000"
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                        "paginaInicial" => "1445"
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                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/11078769"
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                          ]
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                ]
              ]
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              "identificador" => "bib0025"
              "etiqueta" => "5"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "The role of cardiovascular magnetic resonance in patients presenting with chest pain&#44; raised troponin&#44; and unobstructed coronary arteries"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
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                            0 => "R&#46;G&#46; Assomull"
                            1 => "J&#46;C&#46; Lyne"
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                          ]
                        ]
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                  ]
                  "host" => array:1 [
                    0 => array:2 [
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                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            5 => array:3 [
              "identificador" => "bib0030"
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              "referencia" => array:1 [
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                  "contribucion" => array:1 [
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                      "titulo" => "Cardiovascular magnetic resonance in myocarditis&#58; a JACC White Paper"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
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                            0 => "M&#46;G&#46; Friedrich"
                            1 => "U&#46; Sechtem"
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                        ]
                      ]
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                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1016/j.jacc.2009.02.007"
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                        "tituloSerie" => "J Am Coll Cardiol"
                        "fecha" => "2009"
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                          0 => array:2 [
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                            "web" => "Medline"
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                        ]
                      ]
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            ]
            6 => array:3 [
              "identificador" => "bib0035"
              "etiqueta" => "7"
              "referencia" => array:1 [
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                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Noninvasive diagnosis of ischemia-induced wall motion abnormalities with the use of high-dose dobutamine stress MRI&#58; comparison with dobutamine stress echocardiography"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:3 [
                            0 => "E&#46; Nagel"
                            1 => "H&#46;B&#46; Lehmkuhl"
                            2 => "W&#46; Bocksch"
                          ]
                        ]
                      ]
                    ]
                  ]
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Original Article
Familiarity and perceptions of Portuguese cardiologists concerning cardiac magnetic resonance and cardiac computed tomography: The extent of the task ahead
António Miguel Ferreiraa,b,
Corresponding author
amferreira.md@gmail.com

Corresponding author.
, Nuno Bettencourtc, Pedro Matosd, Luís Oliveirae, Ana G. Almeidaf,g, On behalf of the Grupo de Estudo de Cardiologia Nuclear, Ressonância Magnética e TC Cardíaca da Sociedade Portuguesa de Cardiologia
a Serviço de Cardiologia, Hospital Santa Cruz, Centro Hospitalar de Lisboa Ocidental, Lisboa, Portugal
b Unidade de Imagiologia Cardiovascular por AngioTC e RM, Hospital da Luz, Lisboa, Portugal
c Serviço de Cardiologia, Centro Hospitalar de Vila Nova de Gaia/Espinho, Vila Nova de Gaia, Portugal
d Serviço de Cardiologia, Hospital CUF Infante Santo, Lisboa, Portugal
e Serviço de Cardiologia, Centro Hospitalar Cova da Beira, Covilhã, Portugal
f Serviço de Cardiologia, Hospital de Santa Maria, Centro Hospitalar de Lisboa Norte, Lisboa, Portugal
g Faculdade de Medicina da Universidade de Lisboa, Lisboa, Portugal
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          "en" => "<p id="spar0065" class="elsevierStyleSimplePara elsevierViewall">Responses to the question&#58; &#8220;How would you classify the following indications for cardiac computed tomography angiography&#63;&#58; A&#58; symptomatic patient with intermediate pretest probability of obstructive coronary artery disease &#40;as second-line test&#41;&#59; B&#58; symptomatic patient with intermediate pretest probability of obstructive coronary artery disease &#40;as first-line test&#41;&#59; C&#58; asymptomatic patient with positive exercise ECG&#59; D&#58; asymptomatic patient with several cardiovascular risk factors&#59; E&#58; evaluation of aortocoronary bypasses&#59; F&#58; patient with known coronary artery disease&#59; G&#58; evaluation of coronary stents&#59; H&#58; exclusion of coronary artery disease prior to valve surgery&#8221;&#46; DK&#47;NR&#58; don&#8217;t know&#47;no response&#46;</p>"
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perceptions and patterns of use concerning CMR and CCTA among Portuguese cardiologists&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Methods</span><p id="par0015" class="elsevierStylePara elsevierViewall">Physician members of the Portuguese Society of Cardiology &#40;SPC&#41; were invited to respond anonymously to an online questionnaire via a mailing in January 2011 to the email addresses contained in the SPC database&#46; The study was identified as an initiative of the SPC&#39;s Working Group on Nuclear Cardiology&#44; Magnetic Resonance and Cardiac Computed Tomography &#40;GECNRMTC&#41;&#59; the physicians were asked to respond without consulting any sources&#46; A second mailing was sent in October 2011 to those who had not responded to the first&#59; an electronic identification code was used in both mailings so that the same person could not respond more than once&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">Questionnaires returned with demographic data only &#40;n<span class="elsevierStyleMonospace">&#61;</span>18&#41; were excluded from the analysis&#46; To maintain the homogeneity of the population&#44; responses from physicians in specialties other than cardiology&#44; cardiothoracic surgery&#44; pediatric cardiology or internal medicine were also excluded&#46; This exclusion applied to four respondents&#58; general and family medicine &#40;n<span class="elsevierStyleMonospace">&#61;</span>2&#41;&#59; physical medicine and rehabilitation &#40;n<span class="elsevierStyleMonospace">&#61;</span>1&#41;&#59; and radiology &#40;n<span class="elsevierStyleMonospace">&#61;</span>1&#41;&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">Results are presented as frequencies and percentages&#46; Continuous variables are expressed as means &#177; standard deviation&#46;</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Results</span><p id="par0030" class="elsevierStylePara elsevierViewall">The responses from 205 physicians &#40;21&#37; of SPC members contacted in the first mailing&#41; were analyzed&#46; The mean age of respondents was 47&#177;11 years&#44; most were male &#40;67&#37;&#44; n<span class="elsevierStyleMonospace">&#61;</span>137&#41; and had been specialists &#40;89&#37;&#44; n<span class="elsevierStyleMonospace">&#61;</span>183&#41; for 15&#177;10 years&#46; The great majority &#40;87&#37;&#44; n<span class="elsevierStyleMonospace">&#61;</span>178&#41; were cardiologists&#44; and there were also 15 cardiac surgeons &#40;7&#37;&#41;&#44; six pediatric cardiologists &#40;3&#37;&#41;&#44; and six specialists in internal medicine &#40;3&#37;&#41;&#46; The districts with the most respondents were Lisbon &#40;38&#37;&#44; n<span class="elsevierStyleMonospace">&#61;</span>77&#41;&#44; Porto &#40;20&#37;&#44; n<span class="elsevierStyleMonospace">&#61;</span>40&#41;&#44; Coimbra &#40;9&#37;&#44; n<span class="elsevierStyleMonospace">&#61;</span>19&#41; and Viseu &#40;3&#37;&#44; n<span class="elsevierStyleMonospace">&#61;</span>7&#41;&#44; although responses were received from all districts and autonomous regions of Portugal except Beja&#44; Bragan&#231;a and Guarda&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">Most &#40;80&#37;&#44; n<span class="elsevierStyleMonospace">&#61;</span>164&#41; stated that they regularly performed transthoracic echocardiograms&#44; 10&#37; &#40;n<span class="elsevierStyleMonospace">&#61;</span>20&#41; CCTA&#44; 7&#37; &#40;n<span class="elsevierStyleMonospace">&#61;</span>15&#41; myocardial perfusion scintigraphy &#40;MPS&#41;&#44; and 7&#37; &#40;n<span class="elsevierStyleMonospace">&#61;</span>14&#41; CMR&#59; only 17&#37; &#40;n<span class="elsevierStyleMonospace">&#61;</span>34&#41; stated they performed more than one of these imaging modalities&#44; while another 17&#37; &#40;n<span class="elsevierStyleMonospace">&#61;</span>34&#41; performed none of them&#46; The vast majority &#40;94&#37;&#44; n<span class="elsevierStyleMonospace">&#61;</span>192&#41; said they were able to interpret transthoracic echocardiographic images&#44; without an accompanying report&#44; whereas only 17&#37; &#40;n<span class="elsevierStyleMonospace">&#61;</span>34&#41; said they could make a correct diagnostic assessment of CMR images &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Figure 1</a>&#41;&#46; The number of exams requested in a typical working week are shown in <a class="elsevierStyleCrossRef" href="#fig0010">Figure 2</a>&#46; With regard to patterns of use&#44; most respondents &#40;60&#37;&#44; n<span class="elsevierStyleMonospace">&#61;</span>122&#41; stated they had never requested a calcium score&#44; 15&#37; &#40;n<span class="elsevierStyleMonospace">&#61;</span>30&#41; CCTA&#44; and 5&#37; &#40;n<span class="elsevierStyleMonospace">&#61;</span>11&#41; CMR&#46; In 18&#37; &#40;n<span class="elsevierStyleMonospace">&#61;</span>37&#41; and 20&#37; &#40;n<span class="elsevierStyleMonospace">&#61;</span>40&#41; of cases respectively&#44; the last request for CCTA or CMR had been made more than six months previously&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0040" class="elsevierStylePara elsevierViewall">When asked to classify a set of eight indications for CMR&#44; 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of respondents&#46;</p><elsevierMultimedia ident="fig0015"></elsevierMultimedia><elsevierMultimedia ident="fig0020"></elsevierMultimedia><p id="par0050" class="elsevierStylePara elsevierViewall">With regard to contraindications for CMR&#44; the majority &#40;91&#37;&#41; identified the presence of a pacemaker or implantable cardioverter-defibrillator&#44; but a significant percentage considered that a mechanical valve or sternotomy wires also contraindicated the exam &#40;45&#37; and 25&#37;&#44; respectively&#41; &#40;<a class="elsevierStyleCrossRef" href="#fig0025">Figure 5</a>&#41;&#46; Only 43&#37; &#40;79&#47;185&#41; responded correctly to all questions regarding contraindications for CMR&#46;</p><elsevierMultimedia ident="fig0025"></elsevierMultimedia><p id="par0055" class="elsevierStylePara elsevierViewall">Participants were then asked to classify in ascending order the mean radiation dose employed in the following four techniques&#58; 99mTc MPS &#40;stress-rest protocol&#41;&#44; invasive diagnostic coronary angiography &#40;without ventriculography&#41;&#44; CCTA and CMR&#46; Of the 173 physicians who answered this question&#44; 40&#37; &#40;n<span class="elsevierStyleMonospace">&#61;</span>69&#41; considered that MPS involved the highest mean radiation dose&#44; while 27&#37; &#40;n<span class="elsevierStyleMonospace">&#61;</span>46&#41; and 25&#37; &#40;n<span class="elsevierStyleMonospace">&#61;</span>44&#41; chose CCTA and diagnostic coronary angiography&#44; respectively&#46; Around half of respondents &#40;54&#37;&#44; n<span class="elsevierStyleMonospace">&#61;</span>94&#41; believed that the mean radiation dose in CCTA is higher than in invasive coronary angiography&#44; and 45&#37; &#40;n<span class="elsevierStyleMonospace">&#61;</span>78&#41; believed it is higher in CCTA than in MPS&#46; As for CMR&#44; 15&#37; &#40;n<span class="elsevierStyleMonospace">&#61;</span>26&#41; appear to be unaware that this technique does not involve ionizing radiation&#46;</p><p id="par0060" class="elsevierStylePara elsevierViewall">The participants were then asked to classify in ascending order the average cost of the following exams &#40;without taking account of state funding or reimbursement&#41;&#58; stress echocardiography&#44; MPS&#44; invasive diagnostic coronary angiography&#44; CCTA and CMR&#46; Of the 163 physicians who answered this question&#44; 50&#37; &#40;n<span class="elsevierStyleMonospace">&#61;</span>81&#41; considered invasive coronary angiography the most costly&#44; while 40&#37; &#40;n<span class="elsevierStyleMonospace">&#61;</span>65&#41; and 7&#37; &#40;n<span class="elsevierStyleMonospace">&#61;</span>12&#41; chose CMR and MPS&#44; respectively&#44; and 2&#37; &#40;n<span class="elsevierStyleMonospace">&#61;</span>3&#41; chose CCTA&#46; Nevertheless&#44; 66&#37; &#40;n<span class="elsevierStyleMonospace">&#61;</span>108&#41; and 63&#37; &#40;n<span class="elsevierStyleMonospace">&#61;</span>102&#41; believed CCTA to be more costly than MPS and invasive angiography&#44; respectively&#46; As for CMR&#44; 67&#37; &#40;n<span class="elsevierStyleMonospace">&#61;</span>109&#41; and 53&#37; &#40;n<span class="elsevierStyleMonospace">&#61;</span>87&#41; believed that this technique is more costly than MPS and invasive angiography&#44; respectively&#46;</p><p id="par0065" class="elsevierStylePara elsevierViewall">When asked about the main obstacle to wider use of CMR in clinical practice&#44; 45&#37; of respondents &#40;n<span class="elsevierStyleMonospace">&#61;</span>84&#41; cited problems of availability&#44; 36&#37; &#40;n<span class="elsevierStyleMonospace">&#61;</span>66&#41; cost&#44; and 15&#37; &#40;n<span class="elsevierStyleMonospace">&#61;</span>27&#41; lack of familiarity with the technique&#46; The views of respondents with regard to calcium scoring are shown in <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Discussion</span><p id="par0070" class="elsevierStylePara elsevierViewall">To our knowledge&#44; this is the first study designed to assess the familiarity of Portuguese cardiologists with CMR and CCTA&#46; In general&#44; they appear to be moderately familiar with these imaging modalities and aware of their indications&#44; contraindications&#44; advantages and pitfalls&#46; However&#44; there appears to be some discrepancy between the acknowledged usefulness of these techniques and the extent to which they are used in clinical practice&#46; For example&#44; even though most respondents considered CMR a useful or very useful tool for a wide range of common clinical indications&#44; a quarter had not requested CMR in the previous six months&#44; and 5&#37; had never requested it in their entire careers&#46; This may mean that Portuguese cardiologists tend to reserve this exam for more complex cases in which conventional tests have been unable to provide an adequate clinical assessment&#44; but hesitate to use CMR as an alternative to methods with which they are more familiar&#46; Even in situations in which CMR has shown excellent performance&#44; including assessment of myocardial viability&#44;<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> differential diagnosis of myocardial infarction with angiographically normal coronary arteries<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> and in myocarditis&#44;<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> 25&#8211;35&#37; did not consider these sufficiently good reasons to refer patients for CMR&#46; Perhaps less surprisingly&#44; since the technique is relatively new and as yet not widely available in some regions&#44; assessment of ischemia was considered an important indication for CMR by barely more than half of respondents&#46; However&#44; given that stress CMR has been shown to be superior to MPS and stress echocardiography in head-to-head comparisons&#44;<a class="elsevierStyleCrossRefs" href="#bib0035"><span class="elsevierStyleSup">7&#44;8</span></a> significant growth in use of this method is expected in the coming years&#46;</p><p id="par0075" class="elsevierStylePara elsevierViewall">Various reasons were given by participants in the study for not requesting CMR in clinical practice&#44; limited availability being the one identified by the largest proportion &#40;45&#37;&#41;&#46; Although the availability of the technique has increased considerably in recent years&#44; particularly in large centers&#44; where most of the respondents work&#44; it is still not available in many public hospitals&#44; which may be reluctant&#44; or find it difficult&#44; to refer patients to other institutions&#46; At the same time&#44; over a third of respondents cited the cost of CMR as the main limiting factor&#44; a reason that appears to stem from the mistaken idea that CMR is more costly than&#44; for example&#44; MPS or invasive coronary angiography&#44; when in fact it is less costly than either&#46;<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a> As already pointed out&#44; CMR is unavailable in many hospitals and is not covered by the national health service&#44; which may be an obstacle to its wider use in clinical practice&#46; On the other hand&#44; only a minority of cardiologists &#40;15&#37;&#41; cite unfamiliarity with the technique as a major reason for non-referral&#46; However&#44; a lack of familiarity is nonetheless evident&#44; as reflected in the small proportion of respondents who consider themselves capable of correctly interpreting CMR images without an accompanying report&#44; the percentage who are unaware of several of the contraindications for CMR&#44; and the fact that 15&#37; believe the technique involves ionizing radiation&#46; These findings&#44; which would have been worse if physicians experienced in the technique had been excluded from the analysis &#40;data not presented&#41;&#44; highlight the need for training in this area of cardiac imaging&#44; which until recently received little attention in cardiology curricula&#46;</p><p id="par0085" class="elsevierStylePara elsevierViewall">Cardiologists appear to be slightly more familiar with CCTA than with CMR&#44; with 29&#37; of respondents considering themselves capable of interpreting the exams without an accompanying report&#59; this may be a reflection of the greater availability of CCTA in Portugal and the fact that it is technically less complex&#46; A significant proportion of cardiologists &#40;almost 30&#37;&#41; consider the technique a good or excellent first-line exam to assess symptomatic patients with intermediate pretest probability of coronary artery disease&#44; an innovation that is in line with recently published clinical guidelines&#46;<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#44;10</span></a> It thus appears that in general Portuguese cardiologists have an adequate understanding of the clinical usefulness of CCTA&#44; identifying patients who would benefit most from the technique&#44; namely those with intermediate or low pretest probability&#46; Nevertheless&#44; around a third of respondents had not requested CCTA in the previous six months&#44; and 15&#37; had never requested it in their careers&#46; As with CMR&#44; there appears to be a discrepancy between the acknowledged usefulness of the technique and the extent to which it is used in clinical practice&#44; which may be due to problems of availability and&#47;or to perceptions concerning cost&#44; radiation dose&#44; and others&#46; With regard to cost&#44; it is interesting that CCTA is seen by around two-thirds of respondents as being more costly than invasive coronary angiography or MPS&#44; whereas in reality the average cost of CCTA is less than half that of either of these exams&#46;<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a> The fact that a large proportion did not identify invasive diagnostic coronary angiography as the most costly exam of all those under analysis may be due to clinicians&#8217; easy access to this technique and the fact that most such exams are performed within the national health service&#44; and so referring physicians and patients are unaware of the costs involved&#46; Regarding radiation dose&#44; around half of respondents believe that the mean dose in CCTA is higher than in invasive coronary angiography or MPS&#46; However&#44; studies on everyday clinical practice have shown that this is not in fact the case&#44; and mean radiation doses currently used in CCTA are significantly lower than in MPS&#44; and similar to or lower than in diagnostic catheterization&#46;<a class="elsevierStyleCrossRefs" href="#bib0055"><span class="elsevierStyleSup">11&#44;12</span></a></p><p id="par0090" class="elsevierStylePara elsevierViewall">The fact that invasive coronary angiography is more readily available than CCTA&#44; together with misconceptions concerning their relative costs and radiation doses&#44; may partly explain the high percentage of diagnostic catheterizations that reveal no obstructive coronary artery disease &#40;41&#8211;62&#37; in published series&#41;&#46;<a class="elsevierStyleCrossRefs" href="#bib0065"><span class="elsevierStyleSup">13&#8211;15</span></a> Wider use of CCTA would help to minimize this problem&#44; since the technique&#44; when used appropriately&#44; appears to reduce the number of normal coronary angiograms&#46;<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">16</span></a></p><p id="par0095" class="elsevierStylePara elsevierViewall">With regard to coronary calcium score&#44; it is interesting that&#44; while only a small percentage of respondents consider that it provides no additional prognostic information to conventional cardiovascular risk assessment&#44; most &#40;60&#37;&#41; have never requested the test&#46; It is probably underused&#44; especially since it appears to be superior to other markers in terms of discriminatory power and risk reclassification<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">17</span></a> and is a class IIa recommendation in European and American guidelines for cardiovascular risk stratification in asymptomatic individuals with intermediate risk&#46;<a class="elsevierStyleCrossRefs" href="#bib0090"><span class="elsevierStyleSup">18&#44;19</span></a> Portuguese cardiologists appear to recognize its potential&#44; but feel the evidence is still insufficient to make it part of everyday clinical practice&#44; which may reflect the lack of clear therapeutic guidelines based on calcium scores&#46;</p><p id="par0100" class="elsevierStylePara elsevierViewall">To summarize&#44; there appears to be a certain lack of familiarity with CMR and CCTA on the part of Portuguese cardiologists&#46; This is no doubt due in part to the relative newness of the two techniques and the fact that they are not readily available in cardiology departments&#46; Their recent inclusion in cardiology intern training programs in Portugal may prove effective in improving knowledge and implementation of these methods&#46; At the same time&#44; there appears to be a need to strengthen continuing training in this area in Portugal&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Study limitations</span><p id="par0105" class="elsevierStylePara elsevierViewall">Certain limitations of this study should be borne in mind&#46; Firstly&#44; only physicians with a valid email address in the SPC database were contacted and of these&#44; only those who responded to the questionnaire were included in the analysis&#46; This probably led to selection bias&#44; resulting in over-representation of physicians with an interest and knowledge in this area&#44; who would have been more likely to respond to a survey on the subject&#46; Furthermore&#44; since there has been no national or regional survey on the availability of CMR and CCTA&#44; the relationship between availability and the responses obtained could not be analyzed&#46; Even so&#44; it seems clear that there are genuine problems with access which need to be addressed by the relevant bodies&#44; as only in this way can appropriate diagnostic exams be selected for each clinical situation based on the evidence and cost&#47;benefit ratios&#46;</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Conclusions</span><p id="par0110" class="elsevierStylePara elsevierViewall">Portuguese cardiologists appear to be moderately aware of the indications&#44; contraindications&#44; advantages and pitfalls of CMR and CCTA&#46; Patterns of use of these imaging modalities indicate that they are used less than would be expected from clinicians&#8217; recognition of their usefulness&#44; probably due to limited availability and certain misconceptions concerning the exams&#44; particularly with regard to their costs and radiation dose&#46; Greater efforts should be made to improve Portuguese cardiologists&#8217; familiarity with CMR and CCTA&#44; in order to achieve a more rational and appropriate use of these diagnostic techniques&#46;</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Ethical disclosures</span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">Protection of human and animal subjects</span><p id="par0115" class="elsevierStylePara elsevierViewall">The authors declare that no experiments were performed on humans or animals for this investigation&#46;</p></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0105">Confidentiality of data</span><p id="par0120" class="elsevierStylePara elsevierViewall">The authors declare that no patient data appear in this article&#46;</p></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0110">Right to privacy and informed consent</span><p id="par0125" class="elsevierStylePara elsevierViewall">The authors declare that no patient data appear in this article&#46;</p></span></span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0115">Conflicts of interest</span><p id="par0130" class="elsevierStylePara elsevierViewall">The authors have no conflicts of interest to declare&#46;</p></span></span>"
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    "fechaRecibido" => "2012-10-24"
    "fechaAceptado" => "2012-11-01"
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          "clase" => "keyword"
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            0 => "Cardiovascular magnetic resonance"
            1 => "Cardiac computed tomography"
            2 => "Medical knowledge"
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          "palabras" => array:3 [
            0 => "Resson&#226;ncia magn&#233;tica card&#237;aca"
            1 => "Angiotomografia computorizada card&#237;aca"
            2 => "Conhecimento m&#233;dico"
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        "titulo" => "Abstract"
        "resumen" => "<span class="elsevierStyleSectionTitle" id="sect0010">Introduction</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Rapid advances in cardiac magnetic resonance &#40;CMR&#41; and cardiac computed tomography angiography &#40;CCTA&#41; pose challenges for practicing physicians in terms of awareness of their indications&#44; contraindications&#44; advantages and pitfalls&#46;</p> <span class="elsevierStyleSectionTitle" id="sect0015">Methods</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">We conducted a nationwide online survey assessing the familiarity&#44; perceptions and patterns of use concerning these imaging modalities based on a questionnaire sent to all physician members of the Portuguese Society of Cardiology&#46;</p> <span class="elsevierStyleSectionTitle" id="sect0020">Results</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">The responses from 205 physicians &#40;21&#37; response rate&#41; were analyzed&#46; Roughly half of them requested less than one CMR &#40;51&#37;&#41; or CCTA &#40;52&#37;&#41; per week&#46;</p><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Suspected coronary artery disease in symptomatic patients with intermediate pretest probability was considered a good or excellent indication for CCTA by 59&#37; of respondents when performed as a second-line exam&#44; and by 29&#37; as a first-line exam&#46; Cardiac masses&#44; congenital heart disease and cardiomyopathies were considered good or excellent indications for CMR by over 90&#37; of respondents&#44; while assessment of myocardial viability and acute myocardial infarction with normal coronary arteries were considered good or excellent indications by 75&#37; and 65&#37; of respondents&#44; respectively&#46; Less than half &#40;39&#37;&#41; answered all the questions regarding contraindications for CMR correctly&#44; and 15&#37; were unaware that CMR does not involve ionizing radiation&#46; The main reasons for not referring a patient for CMR were limited availability &#40;45&#37;&#41; and cost &#40;36&#37;&#41;&#46;</p> <span class="elsevierStyleSectionTitle" id="sect0025">Conclusions</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Portuguese cardiologists appear to be moderately aware of the indications&#44; contraindications and advantages of these new imaging modalities&#46; Greater efforts should be made to improve physician education on this subject in order to improve patient care&#46;</p>"
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        "resumen" => "<span class="elsevierStyleSectionTitle" id="sect0035">Introdu&#231;&#227;o</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">A r&#225;pida evolu&#231;&#227;o da resson&#226;ncia magn&#233;tica card&#237;aca &#40;RMC&#41; e da angio-TC card&#237;aca colocam desafios aos cl&#237;nicos quanto ao conhecimento das suas indica&#231;&#245;es&#44; contraindica&#231;&#245;es&#44; vantagens e desvantagens&#46;</p> <span class="elsevierStyleSectionTitle" id="sect0040">M&#233;todos</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Efetu&#225;mos um question&#225;rio <span class="elsevierStyleItalic">online</span> a todos os m&#233;dicos s&#243;cios da Sociedade Portuguesa de Cardiologia com o intuito de avaliar a familiaridade&#44; perce&#231;&#245;es e padr&#245;es de uso dos novos m&#233;todos de imagem&#46;</p> <span class="elsevierStyleSectionTitle" id="sect0045">Resultados</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">O question&#225;rio foi respondido por 205 m&#233;dicos &#40;21&#37; do total&#41;&#46; Cerca de metade disse requisitar menos de uma RMC &#40;51&#37;&#41; ou angio-TC card&#237;aca &#40;52&#37;&#41; por semana&#46; A suspeita de doen&#231;a coron&#225;ria em doentes sintom&#225;ticos com probabilidade pr&#233;-teste interm&#233;dia foi considerada uma indica&#231;&#227;o boa ou excelente para angio-TC por 59&#37; dos respondedores quando efetuada como exame de 2&#46;<span class="elsevierStyleSup">a</span> linha&#44; e por 29&#37; como exame de 1&#46;<span class="elsevierStyleSup">a</span> linha&#46; Massas card&#237;acas&#44; cardiopatias cong&#233;nitas e miocardiopatias foram consideradas indica&#231;&#245;es boas&#47;excelentes para RMC por mais de 90&#37; dos respondedores&#44; ao passo que a avalia&#231;&#227;o de viabilidade e enfarte com coron&#225;rias normais foram consideradas indica&#231;&#245;es boas&#47;excelentes por 75 e 65&#37; dos respondedores&#44; respetivamente&#46; Menos de metade &#40;39&#37;&#41; respondeu corretamente a todas as perguntas acerca das contraindica&#231;&#245;es para RMC e 15&#37; desconheciam que a RMC n&#227;o utiliza radia&#231;&#227;o ionizante&#46; As principais raz&#245;es para n&#227;o referenciar doentes para RMC foram a disponibilidade &#40;45&#37;&#41; e o custo &#40;36&#37;&#41;&#46;</p> <span class="elsevierStyleSectionTitle" id="sect0050">Conclus&#245;es</span><p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Os cardiologistas portugueses parecem moderadamente familiarizados e conhecedores das indica&#231;&#245;es&#44; contraindica&#231;&#245;es e vantagens dos novos m&#233;todos de imagem&#46; Devem ser envidados esfor&#231;os no sentido de melhorar estes indicadores por forma a permitir um uso racional destes exames complementares de diagn&#243;stico&#46;</p>"
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        "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as&#58; Ferreira AM&#44; Bettencourt N&#44; Matos P&#44; et al&#46; Familiaridade e perce&#231;&#245;es dos cardiologistas portugueses acerca da resson&#226;ncia magn&#233;tica card&#237;aca e angio-TC card&#237;aca - dimens&#227;o da tarefa &#224; nossa frente&#46; Rev Port Cardiol&#46; 2013&#59;32&#58;601&#8211;608&#46;</p>"
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          "en" => "<p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">Responses to the question&#58; &#8220;In which of the following imaging modalities do you think you would be capable of correctly interpreting the test based only on images or videos &#40;without report&#41;&#63;&#8221;&#46; Cath&#58; invasive coronary angiography&#59; CCTA&#58; cardiac computed tomography angiography&#59; CMR&#58; cardiac magnetic resonance&#59; Echo&#58; transthoracic echocardiography&#59; SPECT&#58; myocardial single-photon emission computed tomography&#46;</p>"
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          "en" => "<p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">Responses to the question&#58; &#8220;How many of these imaging tests do you request in a typical working week&#63; &#40;If you work in more than one institution&#44; please enter the total&#46;&#41;&#8221;&#46; Stress echo&#58; stress echocardiography&#59; Ca score&#58; calcium score&#46; Other abbreviations as in <a class="elsevierStyleCrossRef" href="#fig0005">Figure 1</a>&#46;</p>"
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          "en" => "<p id="spar0065" class="elsevierStyleSimplePara elsevierViewall">Responses to the question&#58; &#8220;How would you classify the following indications for cardiac computed tomography angiography&#63;&#58; A&#58; symptomatic patient with intermediate pretest probability of obstructive coronary artery disease &#40;as second-line test&#41;&#59; B&#58; symptomatic patient with intermediate pretest probability of obstructive coronary artery disease &#40;as first-line test&#41;&#59; C&#58; asymptomatic patient with positive exercise ECG&#59; D&#58; asymptomatic patient with several cardiovascular risk factors&#59; E&#58; evaluation of aortocoronary bypasses&#59; F&#58; patient with known coronary artery disease&#59; G&#58; evaluation of coronary stents&#59; H&#58; exclusion of coronary artery disease prior to valve surgery&#8221;&#46; DK&#47;NR&#58; don&#8217;t know&#47;no response&#46;</p>"
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          "en" => "<p id="spar0070" class="elsevierStyleSimplePara elsevierViewall">Responses to the question&#58; &#8220;Which of the following do you think are contraindications for cardiac magnetic resonance&#63;&#8221;&#46; DK&#47;NR&#58; don&#8217;t know&#47;no response&#59; PM&#47;ICD&#58; pacemaker or implantable cardioverter defibrillator&#46; Correct answers in green&#44; incorrect answers in red&#46;</p>"
        ]
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      5 => array:7 [
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        "etiqueta" => "Table 1"
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                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t" style="border-bottom: 2px solid black">Opinion&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="\n
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                  \t\t\t\t">Potentially useful&#44; but the evidence is still insufficient to make it part of everyday clinical practice&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t">41&#37; &#40;n<span class="elsevierStyleMonospace">&#61;</span>76&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">A useful tool that should be used more often&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t">27&#37; &#40;n<span class="elsevierStyleMonospace">&#61;</span>51&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Results in unnecessary tests and costs&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">15&#37; &#40;n<span class="elsevierStyleMonospace">&#61;</span>27&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">I have no opinion on the subject&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t">7&#37; &#40;n<span class="elsevierStyleMonospace">&#61;</span>13&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">Adds nothing to conventional cardiovascular risk assessment&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t">6&#37; &#40;n<span class="elsevierStyleMonospace">&#61;</span>11&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
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                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Its role in cardiology should be similar to that of mammography in senology&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t">4&#37; &#40;n<span class="elsevierStyleMonospace">&#61;</span>7&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
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          "en" => "<p id="spar0075" class="elsevierStyleSimplePara elsevierViewall">Responses to the question&#58; &#8220;Which of the following statements is closest to your opinion on coronary calcium score&#63;&#8221;&#46;</p>"
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    "bibliografia" => array:2 [
      "titulo" => "References"
      "seccion" => array:1 [
        0 => array:2 [
          "identificador" => "bibs0005"
          "bibliografiaReferencia" => array:19 [
            0 => array:3 [
              "identificador" => "bib0005"
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                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "ACCF&#47;SCCT&#47;ACR&#47;AHA&#47;ASE&#47;ASNC&#47;NASCI&#47;SCAI&#47;SCMR 2010 appropriate use criteria for cardiac computed tomography&#46; A report of the American College of Cardiology Foundation Appropriate Use Criteria Task Force&#44; the Society of Cardiovascular Computed Tomography&#44; the American College of Radiology&#44; the American Heart Association&#44; the American Society of Echocardiography&#44; the American Society of Nuclear Cardiology&#44; the North American Society for Cardiovascular Imaging&#44; the Society for Cardiovascular Angiography and Interventions&#44; and the Society for Cardiovascular Magnetic Resonance"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:3 [
                            0 => "A&#46;J&#46; Taylor"
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                            2 => "J&#46;M&#46; Hodgson"
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                  ]
                  "host" => array:1 [
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                      "titulo" => "ACCF&#47;ACR&#47;AHA&#47;NASCI&#47;SCMR 2010 expert consensus document on cardiovascular magnetic resonance&#58; a report of the American College of Cardiology Foundation Task Force on Expert Consensus Documents"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
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                            0 => "W&#46;G&#46; Hundley"
                            1 => "D&#46;A&#46; Bluemke"
                            2 => "J&#46;P&#46; Finn"
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                  "host" => array:1 [
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                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
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                            0 => "R&#46;J&#46; Kim"
                            1 => "E&#46; Wu"
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                  ]
                  "host" => array:1 [
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                        0 => array:2 [
                          "etal" => true
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                            0 => "E&#46; Nagel"
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                0 => array:1 [
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                0 => array:2 [
                  "contribucion" => array:1 [
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                          ]
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                        0 => array:2 [
                          "etal" => true
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                    0 => array:1 [
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                  "contribucion" => array:1 [
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                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:3 [
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                            1 => "E&#46;D&#46; Peterson"
                            2 => "D&#46; Dai"
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                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1056/NEJMoa0907272"
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              "etiqueta" => "14"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "A clinical prediction rule for the diagnosis of coronary artery disease&#58; validation&#44; updating&#44; and extension"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:3 [
                            0 => "T&#46;S&#46; Genders"
                            1 => "E&#46;W&#46; Steyerberg"
                            2 => "H&#46; Alkadhi"
                          ]
                        ]
                      ]
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ISSN: 21742049
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