Letter to the Editor
Fighting mortality from cardiovascular disease: A challenge to society – but only after health professionals have shown the way
Lutar contra a mortalidade por doenças cardiovasculares: um desafio para a sociedade – apenas depois dos profissionais de saúde definirem o seu rumo
Miguel Soares-Oliveira
Escola Superior de Enfermagem de Lisboa, Lisboa, Portugal
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"apellidos" => "Soares-Oliveira" "email" => array:1 [ 0 => "miguel.soares.oliveira@gmail.com" ] ] ] "afiliaciones" => array:1 [ 0 => array:2 [ "entidad" => "Escola Superior de Enfermagem de Lisboa, Lisboa, Portugal" "identificador" => "aff0005" ] ] ] ] "titulosAlternativos" => array:1 [ "pt" => array:1 [ "titulo" => "Lutar contra a mortalidade por doenças cardiovasculares: um desafio para a sociedade – apenas depois dos profissionais de saúde definirem o seu rumo" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1028 "Ancho" => 1653 "Tamanyo" => 84070 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Numbers of stroke patients undergoing thrombolysis in the study period.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">In a recent Editorial Comment in this <span class="elsevierStyleItalic">Journal</span><a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> on my article on the implementation of a regional system for the emergency care of acute ischemic stroke,<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> Carlos Morais states “There is still a long way to go in terms of optimizing patients’ access to specialized health centers … for which it is necessary to implement dedicated clinical pathways within institutions.”</p><p id="par0010" class="elsevierStylePara elsevierViewall">This is precisely the reasoning behind the project implemented in the North region of Portugal that is presented in the article and that has had excellent results (<a class="elsevierStyleCrossRef" href="#fig0005">Figure 1</a>). Its success springs from campaigns to raise public awareness of the signs of stroke; specific training for members of the pre-hospital emergency response team; the establishment of acute stroke teams on call 24 hours a day in all emergency departments classified as ‘general’ or ‘medical and surgical’; priority routing of stroke patients for access to imaging facilities and laboratory testing in the emergency department; permanently available computed tomography imaging and reporting; and the existence of ward beds designated for acute stroke patients. The number of patients undergoing thrombolysis increased by over 300% in four years, which unequivocally demonstrates greater and better access.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0015" class="elsevierStylePara elsevierViewall">Prof. Morais also quotes another article by me in the same issue of the <span class="elsevierStyleItalic">Journal</span>, on the implementation of a national automated external defibrillator (AED) program in Portugal,<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> and states that the program “has at times been subject to excessive centralization, over-control and legislative inflexibility, which has made its large-scale implementation in public places more difficult … incentives should be established for companies and societies, state and non-state, which decide on their own initiative to participate in the program by acquiring AEDs and placing them prominently in busy places.” He cites the example of Brescia, Italy, which shows that “a strategy of placing AEDs in public places with large concentrations of people, to be used by volunteers with minimal training or even laypersons, is safe and associated with better survival of victims of cardiac arrest.”<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> But he overlooks the important results presented in the article: an exponential increase in the number of people trained in basic life support and AEDs and in the number of public places with large concentrations of people that during the period of study have been provided with AEDs and people trained in their use (<a class="elsevierStyleCrossRef" href="#fig0010">Figure 2</a>). At the end of 2010 there were around 100 ambulances equipped with AEDs; by the end of 2012 there were 442, while the number of public places with AEDs rose from four in 2010 to 322 by the end of 2012, including airports, shopping centers, sports and leisure venues, hotels, etc., representing an increase of over 8000% in two years. The article on the experience of Brescia<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> describes a similar process to the one in our study: defibrillation was originally a medical act, then legislation was passed and defibrillators were introduced into ambulances, and finally AEDs are placed in public places where they can be used by people who are not medically qualified first responders but are duly trained and certified in their use. In Brescia 49 AEDs were installed in public places, as opposed to 463 in Portugal during the same period, and 366 individuals were trained, compared to 6133 trained in Portugal by the end of 2012.</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0020" class="elsevierStylePara elsevierViewall">With regard to the question of legislation, it is important to note the chronology of developments in this area. Until 2009 there was no relevant legislation, defibrillation being exclusively the responsibility of physicians; in that year this responsibility could be delegated to non-medical personnel (a considerable advance),<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> and in 2012 the legislation was revised to make provision of AEDs in large and busy public places a legal obligation.<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> A proposal has also been presented to the Government to make basic life support part of the curriculum in secondary schools.</p><p id="par0025" class="elsevierStylePara elsevierViewall">It is desirable, and arguably inevitable, that when there is sufficient momentum in society to support such a move the next legislative step will be to further liberalize the use of AEDs in public places, reducing centralized control over the process, so that any citizen – even if not certified – can use them. But for this to happen, in my opinion the previous steps described above were essential.</p><p id="par0030" class="elsevierStylePara elsevierViewall">In truth, the good results presented in the article show, as the author of the editorial admits, that the path followed up to now has been at least acceptable and compares favorably with experiences and results in other countries.</p><p id="par0035" class="elsevierStylePara elsevierViewall">The strategy suggested by the author of the editorial on the two articles is thus precisely the one followed by this author, as clearly explained in both articles.</p></span>" "pdfFichero" => "main.pdf" "tienePdf" => true "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Soares-Oliveira M. Lutar contra a mortalidade por doenças cardiovasculares: um desafio para a sociedade – apenas depois dos profissionais de saúde definirem o seu rumo. Rev Port Cardiol. 2014;33:817–818.</p>" ] ] "multimedia" => array:2 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1028 "Ancho" => 1653 "Tamanyo" => 84070 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Numbers of stroke patients undergoing thrombolysis in the study period.</p>" ] ] 1 => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 1111 "Ancho" => 1667 "Tamanyo" => 101422 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Number of licensed automatic external defibrillator programs in public places.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:6 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Lutar contra a mortalidade por doenças cardiovasculares: um desafio para a sociedade" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:1 [ 0 => "C. Morais" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.repc.2014.04.001" "Revista" => array:6 [ "tituloSerie" => "Rev Port Cardiol" "fecha" => "2014" "volumen" => "33" "paginaInicial" => "337" "paginaFinal" => "338" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/25001163" "web" => "Medline" ] ] ] ] ] ] ] ] 1 => array:3 [ "identificador" => "bib0010" "etiqueta" => "2" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Implementação de um sistema regional de resposta emergente ao acidente vascular cerebral. Primeiros resultados" "autores" => array:1 [ 0 => array:3 [ "colaboracion" => "Grupo de AVC da Administração Regional de Saúde do Norte" "etal" => false "autores" => array:2 [ 0 => "M. Soares-Oliveira" 1 => "F. Araújo" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.repc.2013.11.004" "Revista" => array:6 [ "tituloSerie" => "Rev Port Cardiol" "fecha" => "2014" "volumen" => "33" "paginaInicial" => "329" "paginaFinal" => "335" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/25001166" "web" => "Medline" ] ] ] ] ] ] ] ] 2 => array:3 [ "identificador" => "bib0015" "etiqueta" => "3" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Implementação do Programa Nacional de Desfibrilhação Automática Externa em Portugal" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "M. Soares-Oliveira" 1 => "R. Ramos" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.repc.2013.10.006" "Revista" => array:6 [ "tituloSerie" => "Rev Port Cardiol" "fecha" => "2014" "volumen" => "33" "paginaInicial" => "323" "paginaFinal" => "328" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/24999265" "web" => "Medline" ] ] ] ] ] ] ] ] 3 => array:3 [ "identificador" => "bib0020" "etiqueta" => "4" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Prospective assessment of integrating the existing emergency medical system with automated external defibrillators fully operated by volunteers and laypersons for out-of-hospital cardiac arrest: the Brescia Early Defibrillation Study (BEDS)" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:3 [ 0 => "R. Cappato" 1 => "A. Curnis" 2 => "Marzollo" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1093/eurheartj/ehi654" "Revista" => array:6 [ "tituloSerie" => "Eur Heart J" "fecha" => "2006" "volumen" => "27" "paginaInicial" => "553" "paginaFinal" => "561" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/16321992" "web" => "Medline" ] ] ] ] ] ] ] ] 4 => array:3 [ "identificador" => "bib0025" "etiqueta" => "5" "referencia" => array:1 [ 0 => array:1 [ "referenciaCompleta" => "Decreto-lei n° 188/2009. Diário da Republica 1 a série, 12 de Agosto de 2009: 5247–52." ] ] ] 5 => array:3 [ "identificador" => "bib0030" "etiqueta" => "6" "referencia" => array:1 [ 0 => array:1 [ "referenciaCompleta" => "Decreto-lei n° 184/2012. Diário da Republica 1 a série, 8 de Agosto de 2012: 4182–3." ] ] ] ] ] ] ] ] "idiomaDefecto" => "en" "url" => "/21742049/0000003300000012/v1_201501081043/S2174204914002621/v1_201501081043/en/main.assets" "Apartado" => array:4 [ "identificador" => "21592" "tipo" => "SECCION" "en" => array:2 [ "titulo" => "Letter to the Editor" "idiomaDefecto" => true ] "idiomaDefecto" => "en" ] "PDF" => "https://static.elsevier.es/multimedia/21742049/0000003300000012/v1_201501081043/S2174204914002621/v1_201501081043/en/main.pdf?idApp=UINPBA00004E&text.app=https://revportcardiol.org/" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2174204914002621?idApp=UINPBA00004E" ]
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| 2021 February | 38 | 15 | 53 |
| 2021 January | 17 | 8 | 25 |
| 2020 December | 26 | 9 | 35 |
| 2020 November | 36 | 5 | 41 |
| 2020 October | 23 | 5 | 28 |
| 2020 September | 35 | 10 | 45 |
| 2020 August | 13 | 1 | 14 |
| 2020 July | 52 | 8 | 60 |
| 2020 June | 25 | 2 | 27 |
| 2020 May | 32 | 3 | 35 |
| 2020 April | 38 | 12 | 50 |
| 2020 March | 23 | 6 | 29 |
| 2020 February | 38 | 21 | 59 |
| 2020 January | 35 | 5 | 40 |
| 2019 December | 24 | 7 | 31 |
| 2019 November | 39 | 9 | 48 |
| 2019 October | 16 | 5 | 21 |
| 2019 September | 15 | 6 | 21 |
| 2019 August | 42 | 5 | 47 |
| 2019 July | 35 | 13 | 48 |
| 2019 June | 30 | 9 | 39 |
| 2019 May | 27 | 6 | 33 |
| 2019 April | 26 | 11 | 37 |
| 2019 March | 81 | 9 | 90 |
| 2019 February | 81 | 10 | 91 |
| 2019 January | 86 | 7 | 93 |
| 2018 December | 86 | 12 | 98 |
| 2018 November | 61 | 6 | 67 |
| 2018 October | 78 | 10 | 88 |
| 2018 September | 41 | 16 | 57 |
| 2018 August | 37 | 6 | 43 |
| 2018 July | 25 | 7 | 32 |
| 2018 June | 25 | 3 | 28 |
| 2018 May | 79 | 8 | 87 |
| 2018 April | 39 | 3 | 42 |
| 2018 March | 72 | 6 | 78 |
| 2018 February | 32 | 5 | 37 |
| 2018 January | 42 | 4 | 46 |
| 2017 December | 72 | 4 | 76 |
| 2017 November | 27 | 3 | 30 |
| 2017 October | 32 | 8 | 40 |
| 2017 September | 35 | 10 | 45 |
| 2017 August | 39 | 14 | 53 |
| 2017 July | 32 | 7 | 39 |
| 2017 June | 35 | 5 | 40 |
| 2017 May | 34 | 7 | 41 |
| 2017 April | 17 | 0 | 17 |
| 2017 March | 26 | 27 | 53 |
| 2017 February | 32 | 7 | 39 |
| 2017 January | 29 | 4 | 33 |
| 2016 December | 25 | 12 | 37 |
| 2016 November | 18 | 2 | 20 |
| 2016 October | 23 | 10 | 33 |
| 2016 September | 27 | 6 | 33 |
| 2016 August | 6 | 1 | 7 |
| 2016 July | 13 | 2 | 15 |
| 2016 June | 7 | 4 | 11 |
| 2016 May | 12 | 5 | 17 |
| 2016 April | 34 | 1 | 35 |
| 2016 March | 41 | 18 | 59 |
| 2016 February | 53 | 25 | 78 |
| 2016 January | 39 | 18 | 57 |
| 2015 December | 28 | 12 | 40 |
| 2015 November | 35 | 9 | 44 |
| 2015 October | 57 | 10 | 67 |
| 2015 September | 39 | 12 | 51 |
| 2015 August | 35 | 12 | 47 |
| 2015 July | 63 | 9 | 72 |
| 2015 June | 30 | 3 | 33 |
| 2015 May | 31 | 9 | 40 |
| 2015 April | 33 | 21 | 54 |
| 2015 March | 26 | 8 | 34 |
| 2015 February | 42 | 20 | 62 |
| 2015 January | 107 | 39 | 146 |
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