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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">Coronary heart disease &#40;CHD&#41; is responsible for 7&#46;3 million deaths yearly worldwide&#44; corresponding to 12&#46;8&#37; of all deaths&#46;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> In Portugal&#44; CHD was responsible for 23&#37; of cardiovascular deaths in 2009&#44;<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> though mortality rates have been decreasing since the 1980s&#44; as in most developed countries&#46;<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">The increasing use of evidence-based treatments for acute coronary syndrome &#40;ACS&#41;&#44; including reperfusion therapy and revascularization procedures&#44; has been reported to explain up to half of the decrease in CHD mortality rates in several developed countries&#46;<a class="elsevierStyleCrossRefs" href="#bib0020"><span class="elsevierStyleSup">4&#44;5</span></a> Continuous and comprehensive monitoring of the use of reperfusion and revascularization therapies for ACS patients in routine clinical practice is thus essential to evaluate the quality of care&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">The Portuguese Registry of Acute Coronary Syndromes provides data on a large number of ACS events in the last decade&#44; but only patients admitted to some cardiology departments in the country are registered and consecutive recruitment is not ensured&#44; possibly limiting its representativeness&#46;<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> Other studies&#44; based on samples of episodes&#44; mainly single-center and resulting from the initiative of local physicians or academic researchers&#44; have been published and could complement the registry data with coverage of other institutions and departments and a greater time span&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">Therefore&#44; we performed a systematic review of published studies reporting on the use of reperfusion and revascularization procedures in patients with ACS in Portugal&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Methods</span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Search strategy</span><p id="par0025" class="elsevierStylePara elsevierViewall">We searched PubMed from inception until July 2012 to identify original reports providing data on the proportion of patients with ACS&#44; stable angina and heart failure treated with pharmacological and non-pharmacological therapies in Portugal&#46; The search expression is provided in the systematic review flowchart &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Figure 1</a>&#41;&#46; This report focuses on reperfusion and revascularization procedures in ACS&#46; The reference lists of review articles on treatment of ACS patients were screened to identify other potentially eligible original studies&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Screening of reference lists</span><p id="par0030" class="elsevierStylePara elsevierViewall">Two reviewers independently assessed the studies in two steps&#44; following the same predefined criteria&#44; to determine the eligibility of each report&#46; In the first step irrelevant studies were excluded on the basis of the title and abstract only&#59; when the abstract of a particular article was not available&#44; the article was selected for further assessment&#44; except when the title unequivocally presented evidence for exclusion &#40;e&#46;g&#46; case report&#41;&#46; The full texts of studies selected for the second step were then assessed to decide on their eligibility and availability of relevant data&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">The decisions made independently by the two reviewers were compared in the two phases and disagreements were resolved by consensus or after discussion with a third researcher&#44; if necessary&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">The criteria for exclusion of studies were the following&#58; not involving humans &#40;e&#46;g&#46; in-vitro studies&#59; animal research&#41;&#59; case reports&#59; reviews&#44; editorials or comments&#59; not involving Portuguese hospitals&#59; involving ACS patients whose selection was dependent on having undergone a particular diagnosis or treatment procedure under study and with no information on any other procedure &#40;e&#46;g&#46; samples including only patients who underwent PCI&#41;&#59; not providing data on treatments in ACS patients&#59; providing insufficient information to characterize the population &#40;e&#46;g&#46; not providing information on patients&#8217; age or sex&#44; or sample size&#41;&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">When more than one study provided data on patients with the same diagnosis&#44; selected using the same criteria&#44; from the same institution and in overlapping periods&#44; we included the one that covered the longest time period&#59; if the same time period was considered&#44; the one with the largest sample size was included&#44; or in cases of similar sample size&#44; the one that provided information on more eligible treatments&#46; When there were two studies that included ACS patients admitted to the same hospital with part of the data collection period overlapping&#44; we included only the one with the larger sample size&#44; even though over a shorter time period&#44;<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a> since the other included a group selected from all patients with ACS&#46;<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a> When two publications studied the same sample&#44; but reported complementary results on eligible treatments&#44; both articles were included but the information on each eligible treatment for each specific diagnosis was considered only once in the data analyses&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Data extraction</span><p id="par0050" class="elsevierStylePara elsevierViewall">Papers were scrutinized using a standardized data extraction sheet&#44; to collect information on&#58; first author&#44; publication year&#44; year or period of data collection&#44; geographical coverage and department where patients were recruited&#44; sample characteristics &#40;study population&#44; diagnosis&#44; type of episode &#91;first vs&#46; recurrent&#93;&#44; sex&#44; age and sample size&#41;&#44; proportion of patients who received treatments &#40;fibrinolysis&#44; primary and non-specified PCI and coronary artery bypass grafting &#91;CABG&#93;&#41;&#46; If only the absolute number of patients treated was available&#44; the proportion was calculated by dividing by the stratum-specific sample size&#46; When an article presented data stratified by a variable with no relevance to our analysis &#40;e&#46;g&#46; diabetic vs&#46; non-diabetic patients&#41;&#44; we calculated the weighted average of the proportions over all strata&#46;</p><p id="par0055" class="elsevierStylePara elsevierViewall">All types of PCI &#40;including primary PCI&#41; were considered in the analysis of this procedure as revascularization therapy&#46; The proportions of patients undergoing percutaneous and surgical revascularization procedures were described only when performed during the initial hospitalization for the acute event&#46; We considered two types of study population in terms of their representativeness of ACS patients treated in Portuguese institutions&#58; when patient selection was dependent on having undergone a treatment or a diagnostic procedure &#40;e&#46;g&#46; patients referred for viability tests&#59; patients undergoing coronary angiography&#41;&#44; the population was considered selected&#59; otherwise&#44; it was considered unselected&#46;</p><p id="par0060" class="elsevierStylePara elsevierViewall">When possible&#44; year-&#44; sex-&#44; age- and diagnosis-specific estimates were extracted&#46;</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Data analysis</span><p id="par0065" class="elsevierStylePara elsevierViewall">All studies are described in the Supplementary Table available online&#59; only those relying on unselected samples of patients are represented in the forest plots&#46; Although sex- and age-specific estimates were extracted and are shown in the detailed Supplementary Table&#44; these were seldom available and for descriptive purposes the results for the total sample are always presented in the forest plots&#44; stratified only by diagnosis&#46;</p><p id="par0070" class="elsevierStylePara elsevierViewall">The proportion of patients who underwent each procedure was described according to type of ACS&#46; However&#44; given that reports did not systematically stratify according to this criterion&#44; patient samples were classified into one of the following three categories&#44; according to the proportion of different ACS patients included&#58; STEMI &#40;90&#37; or more patients with a diagnosis of ST-segment elevation myocardial infarction &#40;STEMI&#41; or Q-wave myocardial infarction &#91;MI&#93;&#41;&#44; NSTE-ACS &#40;90&#37; or more patients with a diagnosis of non-ST-segment elevation ACS &#91;NSTE-ACS&#93;&#41;&#44; and mixed ACS &#40;if neither of these criteria was satisfied&#41;&#46;</p></span></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Results</span><p id="par0075" class="elsevierStylePara elsevierViewall">We identified 41 eligible studies providing data on ACS patients who underwent reperfusion and&#47;or revascularization therapies&#44; 21 presenting data on reperfusion and 28 on revascularization &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Figure 1</a>&#41;&#44; published between 1989 and 2011 &#40;Supplementary Table 1&#44; available online&#41;&#46;</p><p id="par0080" class="elsevierStylePara elsevierViewall">Over three-quarters of the studies reported data from a single institution&#44; mainly from the Lisbon region&#46; Three studies were based on national registries that covered several regions of the country&#46;<a class="elsevierStyleCrossRefs" href="#bib0030"><span class="elsevierStyleSup">6&#44;9&#44;10</span></a> The vast majority of studies recruited patients in cardiology departments&#46; Two-thirds of the studies included unselected populations&#46; More than half of the studies included both first and recurrent episodes and four studies reported exclusively on first episodes&#46;<a class="elsevierStyleCrossRefs" href="#bib0055"><span class="elsevierStyleSup">11&#8211;14</span></a> The sample size ranged from 21 to 22<span class="elsevierStyleHsp" style=""></span>482 patients&#44; and almost 40&#37; of the studies involved samples between 100 and 500 patients&#46; Seven samples included mostly STEMI patients&#44; 10 mostly NSTE-ACS patients and 27 a mixture of patients with several types of ACS&#46; Five studies presented sex-specific estimates&#44;<a class="elsevierStyleCrossRefs" href="#bib0050"><span class="elsevierStyleSup">10&#44;14&#8211;17</span></a> and only two presented age-specific estimates<a class="elsevierStyleCrossRefs" href="#bib0090"><span class="elsevierStyleSup">18&#44;19</span></a> &#40;Supplementary Table 1&#44; available online&#41;&#46;</p><p id="par0085" class="elsevierStylePara elsevierViewall">As expected&#44; data on reperfusion were available only for STEMI and mixed ACS patients &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Figure 1</a>&#41;&#46; Only three studies provided estimates of the use of reperfusion in STEMI patients&#46; In more recent years&#44; one study conducted in Faro reported the use of fibrinolysis in 16&#46;5&#37; of STEMI patients in 2008&#44;<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">20</span></a> while a report from the National Registry of Acute Coronary Syndromes showed a mean of 43&#46;7&#37;&#44; representing many cardiology centers across the country over several years&#46;<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> The same two studies reported the use of primary PCI in 41&#46;4&#37; and 19&#46;2&#37; of STEMI patients&#44; respectively&#46;<a class="elsevierStyleCrossRefs" href="#bib0030"><span class="elsevierStyleSup">6&#44;20</span></a> For mixed ACS patients there was a larger number of observations&#59; fibrinolysis was used in a quarter to a half of patients in the late 1990s&#44; decreasing to less than 10&#37; over the next decade&#46; Two reports published 10 years apart&#44; in 2001 and 2011&#44; showed an increase in the use of primary PCI in mixed ACS patients&#44; from less than 10&#37; in a sample of patients from several cardiology centers across the country<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a> to approximately 50&#37; in a single cardiology center in Lisbon<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">19</span></a> &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Figure 2</a>&#41;&#46;</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0090" class="elsevierStylePara elsevierViewall">Percutaneous revascularization&#44; including both emergent and elective procedures during hospitalization for an acute event&#44; was performed in approximately half of STEMI patients according to a report from Faro in 2008<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">20</span></a> and the report of the National Registry of Acute Coronary Syndromes covering several years and centers across the country&#46;<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> For NTSE-ACS&#44; two studies published in 1993 report contrasting experiences in small single-center samples&#44; while from 2003 to 2011 several estimates consistently point to one third to one half of patients being revascularized percutaneously during the acute hospitalization&#44; with no clear time trend&#46; With a larger number of reports and more regular publication over 15 years&#44; the proportion of mixed ACS patients revascularized percutaneously increased from under 10&#37; in the mid-1990s to approximately 70&#37; in recent years &#40;<a class="elsevierStyleCrossRef" href="#fig0015">Figure 3</a>&#41;&#46;</p><elsevierMultimedia ident="fig0015"></elsevierMultimedia><p id="par0095" class="elsevierStylePara elsevierViewall">CABG was used in 1&#46;0&#37; of STEMI patients &#40;this figure available only from the National Registry of Acute Coronary Syndromes&#41;&#46; In NSTE-ACS and mixed ACS&#44; 1&#8211;10&#37; of patients were reported as undergoing CABG&#44; with no clear time trend&#46; An exception for several reports is a single institution &#40;Hospital de Santa Cruz&#44; in Carnaxide&#41; over the years&#44; with a proportion closer to 20&#37; of NTSE-ACS patients having undergone surgical revascularization during hospitalization for the acute event &#40;<a class="elsevierStyleCrossRef" href="#fig0020">Figure 4</a>&#41;&#46;</p><elsevierMultimedia ident="fig0020"></elsevierMultimedia></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">Discussion</span><p id="par0100" class="elsevierStylePara elsevierViewall">Despite considerable heterogeneity in the methodology and presentation of results of available studies&#44; this review shows that the proportion of ACS patients in Portugal treated with fibrinolysis has decreased in the last 20 years and the use of PCI has increased&#44; while the use of CABG has not changed&#46;</p><p id="par0105" class="elsevierStylePara elsevierViewall">Since the late 1970s&#44; more aggressive and effective treatments have been developed and implemented for the treatment of CHD&#44; including fibrinolysis&#44; PCI and CABG&#46;<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">21</span></a> Of the primary studies included in the present review&#44; the oldest with data on fibrinolysis was published in 1989&#44;<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">22</span></a> while PCI and CABG were first mentioned in an article published in 1993 &#40;data collection in 1982&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">23</span></a> Data from previous years were reported in a few publications which were excluded mainly due to the reporting format&#44; for example lack of data on sample size or patients&#8217; sex and age&#44; or because the use of procedures in the acute hospitalization or over variable follow-up periods could not be distinguished&#46;</p><p id="par0110" class="elsevierStylePara elsevierViewall">During the last decade&#44; mechanical or pharmacological reperfusion therapy has been recommended for all patients with STEMI who present within 12 hours of the onset of symptoms&#46;<a class="elsevierStyleCrossRefs" href="#bib0120"><span class="elsevierStyleSup">24&#8211;26</span></a> A growing body of evidence has also demonstrated beneficial effects of reperfusion therapy in patients presenting more than 12 hours from symptom onset&#46; In this group of patients&#44; recent recommendations consider this treatment a strong indication&#44; preferably by primary PCI &#40;class I&#41; if there is evidence of ongoing ischemia or if pain and electrocardiographic changes have been stuttering&#46; Primary PCI may be also considered even in asymptomatic patients presenting 12&#8211;24 hours after symptom onset&#46;<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">25</span></a> For years&#44; fibrinolysis was chosen over primary PCI&#44; mainly due to its greater ease of access and use&#46;<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">21</span></a> However&#44; mechanical reperfusion has been preferred since several randomized clinical trials and meta-analyses comparing primary PCI with in-hospital fibrinolytic therapy in patients presenting within 6&#8211;12 hours of symptom onset showed more effective restoration of vessel patency&#44; less reocclusion&#44; reinfarction and stroke&#44; improved left ventricular function and less short-term mortality with primary PCI&#46;<a class="elsevierStyleCrossRefs" href="#bib0135"><span class="elsevierStyleSup">27&#44;28</span></a> National<a class="elsevierStyleCrossRefs" href="#bib0030"><span class="elsevierStyleSup">6&#44;29</span></a> and international registries in Europe<a class="elsevierStyleCrossRefs" href="#bib0150"><span class="elsevierStyleSup">30&#44;31</span></a> and the USA<a class="elsevierStyleCrossRefs" href="#bib0160"><span class="elsevierStyleSup">32&#44;33</span></a> suggest an increase in the use of reperfusion therapies accompanied by a significant shift from fibrinolysis therapy to primary PCI&#46; A significant decrease in mortality after STEMI has been observed in countries switching from fibrinolysis to primary PCI&#46;<a class="elsevierStyleCrossRef" href="#bib0170"><span class="elsevierStyleSup">34</span></a> In our study&#44; we observed decreased use of fibrinolysis and increased use of primary PCI&#46; In this review&#44; most of the studies providing data on fibrinolysis were published in the 1990s&#44; with data collected in the 1980s and 1990s&#46; By contrast&#44; the studies addressing primary PCI were only published in the current century&#46; Although the trends cannot be quantified&#44; fibrinolysis appears to have been replaced by primary PCI&#46;</p><p id="par0115" class="elsevierStylePara elsevierViewall">Since its introduction in 1977&#44; angioplasty has become the most frequently performed major intervention in medicine&#44;<a class="elsevierStyleCrossRef" href="#bib0175"><span class="elsevierStyleSup">35</span></a> as both a reperfusion &#40;primary PCI&#41; and revascularization procedure&#46; Among the included studies addressing the use of revascularization by a percutaneous procedure&#44; one sixth were published in the 1990s and the remainder afterwards&#46; Surgical revascularization with CABG was first introduced in 1969&#44; and become the most thoroughly studied procedure in the history of surgery&#46;<a class="elsevierStyleCrossRef" href="#bib0180"><span class="elsevierStyleSup">36</span></a> In our review&#44; a quarter of the studies were published in the 1990s and the remainder after 2000&#46; Although the primary studies provided information on surgeries performed at different times related to the acute event &#40;e&#46;g&#46; during a variable time of follow-up after the acute event&#41;&#44; we only included studies with data on CABG performed during the initial hospitalization&#46; Otherwise&#44; the data to be compared would be even more heterogeneous&#46; Particularly for this procedure&#44; it is important to point out that many patients referred for CABG are expected to have undergone surgery after discharge or have been transferred to a different institution while awaiting the procedure&#44;<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> thus reducing the proportion of patients treated that were captured by this analysis&#46;</p><p id="par0120" class="elsevierStylePara elsevierViewall">The results on revascularization therapies are consistent with the findings of previous studies showing an increase in PCI use and non-significant changes in use of CABG in recent years&#46;<a class="elsevierStyleCrossRefs" href="#bib0150"><span class="elsevierStyleSup">30&#44;37&#44;38</span></a> In patients stabilized after an episode of acute coronary syndrome&#44; the choice of revascularization modality can be made as in stable coronary heart disease&#46;<a class="elsevierStyleCrossRefs" href="#bib0125"><span class="elsevierStyleSup">25&#44;39&#44;40</span></a> In single-vessel disease&#44; which occurs in one-third of patients with ACS&#44; ad-hoc PCI is feasible in most cases&#44; whereas in patients with multivessel disease &#40;approximately half of cases&#41; the decision on the type of revascularization is more complex&#46;<a class="elsevierStyleCrossRefs" href="#bib0205"><span class="elsevierStyleSup">41&#44;42</span></a> Options for this condition have evolved over time&#44; and currently include culprit lesion PCI&#44; multivessel PCI&#44; CABG or hybrid &#40;combined&#41; revascularization&#44; according to clinical status&#44; lesion characteristics and the severity and distribution of coronary artery disease&#46;<a class="elsevierStyleCrossRefs" href="#bib0125"><span class="elsevierStyleSup">25&#44;39&#44;40</span></a></p><p id="par0125" class="elsevierStylePara elsevierViewall">Our methodology has some limitations&#46; The use of a single search engine may have limited our results&#46; However&#44; the inclusion of relevant studies identified in the reference lists of the review articles should have helped identify older and non-PubMed-indexed publications&#46; The probability of identifying relevant studies from among those published is also influenced by their results because&#44; despite the descriptive nature of the studies&#44; publication bias can be expected&#44; with higher likelihood of publication from higher-quality or at least higher-volume centers&#46; It is noteworthy that the majority of studies came from cardiology departments&#44; some of which also contributed to the National Registry of Acute Coronary Syndromes&#46; Therefore&#44; the main gain with this review is its coverage of a greater time span&#44; but not the representation of less specialized centers than those included in the National Registry of Acute Coronary Syndromes&#46; The results are affected by the methodological heterogeneity of the studies&#44; particularly inclusion criteria&#44; sample size&#44; and patients&#8217; age and sex&#44; as well as the relatively small number of estimates for each type of treatment under study&#46; Another limitation for more informative conclusions stems from the small number of studies with sex-&#44; age-&#44; and year-specific estimates&#44; as authors mainly reported overall data&#46; Some reported data referring to a period longer than one year&#59; however&#44; it was not possible to obtain year-specific estimates&#46;</p><p id="par0130" class="elsevierStylePara elsevierViewall">Given these limitations&#44; an alternative approach to the study of trends in the use of these treatments in the past could be to rely on administrative databases&#44; using data collected&#44; coded and stored&#44; immediately available for analysis&#46;<a class="elsevierStyleCrossRef" href="#bib0215"><span class="elsevierStyleSup">43</span></a> The national register of hospital discharges<a class="elsevierStyleCrossRef" href="#bib0145"><span class="elsevierStyleSup">29</span></a> could be used to quantify the number of procedures performed&#44; but the usefulness of these datasets is limited&#58; it is not possible to classify the subtypes of ACS according to current recommendations<a class="elsevierStyleCrossRef" href="#bib0220"><span class="elsevierStyleSup">44</span></a> when departing from data coded using the International Classification of Diseases&#44; 9th revision&#44; Clinical Modification &#40;ICD-9-CM&#41;&#46; Furthermore&#44; there is no information available in the database to ascertain the timing of PCI or to identify recurrent episodes in the same patient&#46;<a class="elsevierStyleCrossRef" href="#bib0145"><span class="elsevierStyleSup">29</span></a></p></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0105">Conclusions</span><p id="par0135" class="elsevierStylePara elsevierViewall">The general pattern of treatment reflects what is reported in other developed countries and can be viewed as a favorable time trend in the quality of care of ACS patients&#46; Future investigation should focus on the prospective and systematic recording of high-quality information to monitor the use of treatments in this acute condition&#44; while past trends can only be properly clarified by an original retrospective study on a representative sample of ACS patients&#44; involving review of hospital records&#46;</p></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0110">Ethical disclosures</span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0115">Protection of human and animal subjects</span><p id="par0140" class="elsevierStylePara elsevierViewall">The authors declare that no experiments were performed on humans or animals for this study&#46;</p></span><span id="sec0060" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0120">Confidentiality of data</span><p id="par0145" class="elsevierStylePara elsevierViewall">The authors declare that no patient data appear in this article&#46;</p></span><span id="sec0065" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0125">Right to privacy and informed consent</span><p id="par0150" class="elsevierStylePara elsevierViewall">The authors declare that no patient data appear in this article&#46;</p></span></span><span id="sec0070" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0130">Funding</span><p id="par0155" class="elsevierStylePara elsevierViewall">This study was funded by a grant from <span class="elsevierStyleGrantSponsor" id="gs1">Funda&#231;&#227;o para a Ci&#234;ncia e a Tecnologia</span> &#40;<span class="elsevierStyleGrantNumber" refid="gs1">PIC&#47;IC&#47;83006&#47;2007</span>&#41;&#46;</p></span><span id="sec0075" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0135">Conflicts of interest</span><p id="par0160" class="elsevierStylePara elsevierViewall">The authors have no conflicts of interest to declare&#46;</p></span></span>"
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            0 => "Acute coronary syndrome"
            1 => "Angioplasty"
            2 => "Coronary artery bypass"
            3 => "Fibrinolysis"
            4 => "Myocardial revascularization"
          ]
        ]
      ]
      "pt" => array:1 [
        0 => array:4 [
          "clase" => "keyword"
          "titulo" => "Palavras-chave"
          "identificador" => "xpalclavsec368063"
          "palabras" => array:5 [
            0 => "S&#237;ndrome coron&#225;ria aguda"
            1 => "Angioplastia"
            2 => "Cirurgia de revasculariza&#231;&#227;o coron&#225;ria"
            3 => "Fibrin&#243;lise"
            4 => "Revasculariza&#231;&#227;o mioc&#225;rdica"
          ]
        ]
      ]
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      "en" => array:2 [
        "titulo" => "Abstract"
        "resumen" => "<span class="elsevierStyleSectionTitle" id="sect0010">Introduction and Objectives</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Reperfusion and revascularization therapies play an important role in the management of coronary heart disease and have contributed to decreases in case fatality rates&#46; We aimed to describe the use of these therapies for the treatment of acute coronary syndrome &#40;ACS&#41; patients over time in Portugal&#46;</p> <span class="elsevierStyleSectionTitle" id="sect0015">Methods</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">PubMed was searched in July 2012&#46; The proportion of patients treated with fibrinolysis&#44; primary percutaneous coronary intervention &#40;PCI&#41;&#44; any PCI and coronary artery bypass grafting &#40;CABG&#41; was described according to type of ACS&#58; STEMI &#40;&#8805;90&#37; patients with ST-segment elevation or Q-wave myocardial infarction&#41;&#44; NSTE-ACS &#40;&#8805;90&#37; patients with non-ST-segment elevation ACS&#41; and mixed ACS &#40;all others&#41;&#46;</p> <span class="elsevierStyleSectionTitle" id="sect0020">Results</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">We identified 41 eligible studies&#44; published between 1989 and 2011&#46; Twenty-eight reported on samples considered representative of ACS patients treated in Portugal&#46; The small number of estimates of the use of each treatment in STEMI and NSTE-ACS patients precluded identification of any time trend&#46; In the last 20 years&#44; the proportion of mixed ACS patients treated with fibrinolysis decreased and the use of PCI increased&#44; while the use of CABG did not change&#46;</p> <span class="elsevierStyleSectionTitle" id="sect0025">Conclusions</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">The general pattern of the use of reperfusion and revascularization is in accordance with that reported in other developed countries&#44; reflecting a favorable trend in the quality of care of ACS patients&#46; The relatively small number of estimates on the same procedure in comparable patients limits the generalizability of the conclusions&#44; and highlights the need for systematic approaches to monitor the use of treatments over time&#46;</p>"
      ]
      "pt" => array:2 [
        "titulo" => "Resumo"
        "resumen" => "<span class="elsevierStyleSectionTitle" id="sect0035">Introdu&#231;&#227;o e objetivos</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">A reperfus&#227;o e revasculariza&#231;&#227;o desempenham um importante papel no tratamento da doen&#231;a coron&#225;ria contribuindo para a diminui&#231;&#227;o da letalidade&#46; Foi nosso objetivo descrever o uso destes procedimentos no tratamento da s&#237;ndrome coron&#225;ria aguda &#40;SCA&#41; ao longo do tempo em Portugal&#46;</p> <span class="elsevierStyleSectionTitle" id="sect0040">M&#233;todos</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">A pesquisa foi efetuada na Pubmed em julho de 2012&#46; A propor&#231;&#227;o de doentes tratados com fibrin&#243;lise&#44; angioplastia prim&#225;ria&#44; qualquer tipo de angioplastia e cirurgia de revasculariza&#231;&#227;o coron&#225;ria &#40;CABG&#41; foi descrita de acordo com o tipo de SCA&#58; SCA supra-ST &#40;quando a propor&#231;&#227;o de doentes com eleva&#231;&#227;o do segmento ST ou enfarte do mioc&#225;rdio com ondas Q era &#8805;90&#37;&#41;&#44; SCA sem-ST &#40;quando a propor&#231;&#227;o de doentes com SCA sem eleva&#231;&#227;o do segmento ST era &#8805;90&#37;&#41; e SCA misto &#40;restantes casos&#41;&#46;</p> <span class="elsevierStyleSectionTitle" id="sect0045">Resultados</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Foram identificados 41 estudos publicados entre 1989 e 2011&#46; Vinte e oito estudos descreveram amostras representativas dos doentes com SCA tratados em Portugal&#46; O baixo n&#250;mero de estimativas de cada tratamento nos doentes com SCA supra-ST e sem-ST&#44; impossibilitou a observa&#231;&#227;o de tend&#234;ncias temporais&#46; Nos &#250;ltimos 20 anos&#44; a propor&#231;&#227;o de doentes com SCA misto tratados com fibrin&#243;lise diminuiu&#44; o uso de angioplastia aumentou&#44; enquanto o uso de CABG n&#227;o se alterou&#46;</p> <span class="elsevierStyleSectionTitle" id="sect0050">Conclus&#245;es</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">O padr&#227;o do uso destes tratamentos est&#225; de acordo com dados publicados noutros pa&#237;ses desenvolvidos&#44; refletindo uma tend&#234;ncia favor&#225;vel na qualidade dos cuidados prestados&#46; O baixo n&#250;mero de estimativas do mesmo procedimento limitou a generaliza&#231;&#227;o de conclus&#245;es&#44; refor&#231;ando a necessidade de alternativas para monitorizar o uso de tratamentos ao longo do tempo&#46;</p>"
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            "apendice" => "<p id="par0175" class="elsevierStylePara elsevierViewall"><elsevierMultimedia ident="upi0005"></elsevierMultimedia></p>"
            "etiqueta" => "Appendix A"
            "titulo" => "Supplementary data"
            "identificador" => "sec0085"
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      0 => array:7 [
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        "etiqueta" => "Figure 1"
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          "en" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Flowchart of the systematic review&#46; CABG&#58; coronary artery bypass grafting&#59; PCI&#58; percutaneous coronary intervention&#59; STEMI&#58; 90&#37; or more patients with diagnosis of ST-segment elevation myocardial infarction or Q-wave myocardial infarction&#59; NSTE-ACS&#58; 90&#37; or more patients with diagnosis of non-ST-segment elevation ACS&#59; mixed ACS&#58; mixture of patients with several types of ACS&#46;</p> <p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">&#42; If a study provided data on treatment with both reperfusion and revascularization&#44; it contributed to both groups&#46; If a study provided data on more than one diagnostic category&#44; it contributed to all groups&#46;</p> <p id="spar0055" class="elsevierStyleSimplePara elsevierViewall"><span class="elsevierStyleSup">&#8224;</span> The sample was considered selected when inclusion of patients was dependent on having undergone some diagnosis or treatment procedure&#59; otherwise&#44; it was considered unselected&#46;</p>"
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          "en" => "<p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">Proportion of acute coronary syndrome patients treated with reperfusion therapies &#40;fibrinolysis and primary PCI&#41; in Portugal&#44; estimated in unselected samples of patients&#46; F&#58; first episode&#59; mixed ACS&#58; mixture of patients with several types of ACS&#59; NSTE-ACS&#58; 90&#37; or more patients with diagnosis of non-ST-segment elevation ACS&#59; PCI&#58; percutaneous coronary intervention&#59; R&#58; recurrent episode&#59; STEMI&#58; 90&#37; or more patients with diagnosis of ST-segment elevation myocardial infarction or Q-wave myocardial infarction&#46; &#42; Age is presented as mean &#40;SD&#41; unless otherwise specified&#59; <span class="elsevierStyleSup">&#8224;</span> mean age&#59; <span class="elsevierStyleSup">&#8225;</span> median age&#46;</p>"
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          "en" => "<p id="spar0065" class="elsevierStyleSimplePara elsevierViewall">Proportion of acute coronary syndrome patients treated with PCI in Portugal&#44; estimated in unselected samples of patients&#46; F&#58; first episode&#59; mixed ACS&#58; mixture of patients with several types of ACS&#59; NSTE-ACS&#58; 90&#37; or more patients with diagnosis of non-ST-segment elevation ACS&#59; PCI&#58; percutaneous coronary intervention&#59; R&#58; recurrent episode&#59; STEMI&#58; 90&#37; or more patients with diagnosis of ST-segment elevation myocardial infarction or Q-wave myocardial infarction&#46; &#42; Age is presented as mean &#40;SD&#41; unless otherwise specified&#59; <span class="elsevierStyleSup">&#8224;</span> mean age&#59; <span class="elsevierStyleSup">&#8225;</span> median age&#46;</p>"
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          "en" => "<p id="spar0070" class="elsevierStyleSimplePara elsevierViewall">Proportion of acute coronary syndrome patients treated with CABG in Portugal&#44; estimated in unselected samples of patients&#46; CABG&#58; coronary artery bypass grafting&#59; F&#58; first episode&#59; mixed ACS&#58; mixture of patients with several types of ACS&#59; NSTE-ACS&#58; 90&#37; or more patients with diagnosis of non-ST-segment elevation ACS&#59; R&#58; recurrent episode&#59; STEMI&#58; 90&#37; or more patients with diagnosis of ST-segment elevation myocardial infarction or Q-wave myocardial infarction&#46; &#42; Age is presented as mean &#40;SD&#41; unless otherwise specified&#59; <span class="elsevierStyleSup">&#8224;</span> mean age&#59; <span class="elsevierStyleSup">&#8225;</span> median age&#46;</p>"
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      "titulo" => "References"
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                            0 => "S&#46; Capewell"
                            1 => "R&#46; Beaglehole"
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                          ]
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                          "etal" => true
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                            0 => "J&#46;F&#46; Santos"
                            1 => "C&#46; Aguiar"
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                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Smoking in acute coronary syndromes &#8211; the &#8220;smoker&#39;s paradox&#8221; revisited"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:3 [
                            0 => "A&#46; Gaspar"
                            1 => "S&#46; Nabalis"
                            2 => "S&#46; Rocha"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "Rev Port Cardiol"
                        "fecha" => "2009"
                        "volumen" => "28"
                        "paginaInicial" => "425"
                        "paginaFinal" => "437"
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                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/19634499"
                            "web" => "Medline"
                          ]
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                  ]
                ]
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            ]
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              "identificador" => "bib0040"
              "etiqueta" => "8"
              "referencia" => array:1 [
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                  "contribucion" => array:1 [
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                      "titulo" => "Proton pump inhibitors in patients treated with aspirin and clopidogrel after acute coronary syndrome"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:3 [
                            0 => "A&#46; Gaspar"
                            1 => "S&#46; Ribeiro"
                            2 => "S&#46; Nabais"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "Rev Port Cardiol"
                        "fecha" => "2010"
                        "volumen" => "29"
                        "paginaInicial" => "1511"
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                            "web" => "Medline"
                          ]
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              "etiqueta" => "9"
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                  "contribucion" => array:1 [
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                      "titulo" => "Elective and primary angioplasty at hospitals without on-site surgery versus with on-site surgery&#58; results from a national registry"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:3 [
                            0 => "H&#46; Pereira"
                            1 => "P&#46;C&#46; da Silva"
                            2 => "L&#46; Goncalves"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
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                        "fecha" => "2008"
                        "volumen" => "27"
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                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            9 => array:3 [
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              "etiqueta" => "10"
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                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Management of acute myocardial infarction in Portugal&#46; Results of a nationwide survey"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:3 [
                            0 => "J&#46; Morais"
                            1 => "D&#46; Ferreira"
                            2 => "R&#46; Soares"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "Rev Port Cardiol"
                        "fecha" => "2001"
                        "volumen" => "20"
                        "paginaInicial" => "709"
                        "paginaFinal" => "722"
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                            "web" => "Medline"
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            10 => array:3 [
              "identificador" => "bib0055"
              "etiqueta" => "11"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Acute coronary syndrome in a diabetic population &#8211; risk factors and clinical and angiographic characteristics"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:3 [
                            0 => "R&#46; Duarte"
                            1 => "S&#46; Castela"
                            2 => "R&#46;P&#46; Reis"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "Rev Port Cardiol"
                        "fecha" => "2003"
                        "volumen" => "22"
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              "identificador" => "bib0060"
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                  "contribucion" => array:1 [
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                      "titulo" => "Thrombolytic therapy impact on prognosis after twelve months of first acute myocardial infarction"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:3 [
                            0 => "G&#46; Caires"
                            1 => "D&#46; Pereira"
                            2 => "A&#46;D&#46; Freitas"
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                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
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                        "tituloSerie" => "Rev Port Cardiol"
                        "fecha" => "2000"
                        "volumen" => "19"
                        "paginaInicial" => "1103"
                        "paginaFinal" => "1119"
                        "link" => array:1 [
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                  ]
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                  "contribucion" => array:1 [
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Original Article
The use of reperfusion and revascularization procedures in acute coronary syndrome in Portugal: A systematic review
Uso de procedimentos de reperfusão e revascularização na síndrome coronária aguda em Portugal: revisão sistemática
Luísa Lopes-Conceiçãoa,b, Marta Pereiraa,b, Carla Araújoa,b,c, Olga Laszczýnskaa,b, Nuno Luneta,b, Ana Azevedoa,b,
Corresponding author
anazev@med.up.pt

Corresponding author.
a Department of Clinical Epidemiology, Predictive Medicine and Public Health, University of Porto Medical School, Porto, Portugal
b EPIUnit - Institute of Public Health, University of Porto, Porto, Portugal
c Centro Hospitalar de Trás-Os-Montes e Alto Douro EPE, Vila Real, Portugal
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          "en" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Flowchart of the systematic review&#46; CABG&#58; coronary artery bypass grafting&#59; PCI&#58; percutaneous coronary intervention&#59; STEMI&#58; 90&#37; or more patients with diagnosis of ST-segment elevation myocardial infarction or Q-wave myocardial infarction&#59; NSTE-ACS&#58; 90&#37; or more patients with diagnosis of non-ST-segment elevation ACS&#59; mixed ACS&#58; mixture of patients with several types of ACS&#46;</p> <p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">&#42; If a study provided data on treatment with both reperfusion and revascularization&#44; it contributed to both groups&#46; If a study provided data on more than one diagnostic category&#44; it contributed to all groups&#46;</p> <p id="spar0055" class="elsevierStyleSimplePara elsevierViewall"><span class="elsevierStyleSup">&#8224;</span> The sample was considered selected when inclusion of patients was dependent on having undergone some diagnosis or treatment procedure&#59; otherwise&#44; it was considered unselected&#46;</p>"
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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">Coronary heart disease &#40;CHD&#41; is responsible for 7&#46;3 million deaths yearly worldwide&#44; corresponding to 12&#46;8&#37; of all deaths&#46;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> In Portugal&#44; CHD was responsible for 23&#37; of cardiovascular deaths in 2009&#44;<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> though mortality rates have been decreasing since the 1980s&#44; as in most developed countries&#46;<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">The increasing use of evidence-based treatments for acute coronary syndrome &#40;ACS&#41;&#44; including reperfusion therapy and revascularization procedures&#44; has been reported to explain up to half of the decrease in CHD mortality rates in several developed countries&#46;<a class="elsevierStyleCrossRefs" href="#bib0020"><span class="elsevierStyleSup">4&#44;5</span></a> Continuous and comprehensive monitoring of the use of reperfusion and revascularization therapies for ACS patients in routine clinical practice is thus essential to evaluate the quality of care&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">The Portuguese Registry of Acute Coronary Syndromes provides data on a large number of ACS events in the last decade&#44; but only patients admitted to some cardiology departments in the country are registered and consecutive recruitment is not ensured&#44; possibly limiting its representativeness&#46;<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> Other studies&#44; based on samples of episodes&#44; mainly single-center and resulting from the initiative of local physicians or academic researchers&#44; have been published and could complement the registry data with coverage of other institutions and departments and a greater time span&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">Therefore&#44; we performed a systematic review of published studies reporting on the use of reperfusion and revascularization procedures in patients with ACS in Portugal&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Methods</span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Search strategy</span><p id="par0025" class="elsevierStylePara elsevierViewall">We searched PubMed from inception until July 2012 to identify original reports providing data on the proportion of patients with ACS&#44; stable angina and heart failure treated with pharmacological and non-pharmacological therapies in Portugal&#46; The search expression is provided in the systematic review flowchart &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Figure 1</a>&#41;&#46; This report focuses on reperfusion and revascularization procedures in ACS&#46; The reference lists of review articles on treatment of ACS patients were screened to identify other potentially eligible original studies&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Screening of reference lists</span><p id="par0030" class="elsevierStylePara elsevierViewall">Two reviewers independently assessed the studies in two steps&#44; following the same predefined criteria&#44; to determine the eligibility of each report&#46; In the first step irrelevant studies were excluded on the basis of the title and abstract only&#59; when the abstract of a particular article was not available&#44; the article was selected for further assessment&#44; except when the title unequivocally presented evidence for exclusion &#40;e&#46;g&#46; case report&#41;&#46; The full texts of studies selected for the second step were then assessed to decide on their eligibility and availability of relevant data&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">The decisions made independently by the two reviewers were compared in the two phases and disagreements were resolved by consensus or after discussion with a third researcher&#44; if necessary&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">The criteria for exclusion of studies were the following&#58; not involving humans &#40;e&#46;g&#46; in-vitro studies&#59; animal research&#41;&#59; case reports&#59; reviews&#44; editorials or comments&#59; not involving Portuguese hospitals&#59; involving ACS patients whose selection was dependent on having undergone a particular diagnosis or treatment procedure under study and with no information on any other procedure &#40;e&#46;g&#46; samples including only patients who underwent PCI&#41;&#59; not providing data on treatments in ACS patients&#59; providing insufficient information to characterize the population &#40;e&#46;g&#46; not providing information on patients&#8217; age or sex&#44; or sample size&#41;&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">When more than one study provided data on patients with the same diagnosis&#44; selected using the same criteria&#44; from the same institution and in overlapping periods&#44; we included the one that covered the longest time period&#59; if the same time period was considered&#44; the one with the largest sample size was included&#44; or in cases of similar sample size&#44; the one that provided information on more eligible treatments&#46; When there were two studies that included ACS patients admitted to the same hospital with part of the data collection period overlapping&#44; we included only the one with the larger sample size&#44; even though over a shorter time period&#44;<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a> since the other included a group selected from all patients with ACS&#46;<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a> When two publications studied the same sample&#44; but reported complementary results on eligible treatments&#44; both articles were included but the information on each eligible treatment for each specific diagnosis was considered only once in the data analyses&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Data extraction</span><p id="par0050" class="elsevierStylePara elsevierViewall">Papers were scrutinized using a standardized data extraction sheet&#44; to collect information on&#58; first author&#44; publication year&#44; year or period of data collection&#44; geographical coverage and department where patients were recruited&#44; sample characteristics &#40;study population&#44; diagnosis&#44; type of episode &#91;first vs&#46; recurrent&#93;&#44; sex&#44; age and sample size&#41;&#44; proportion of patients who received treatments &#40;fibrinolysis&#44; primary and non-specified PCI and coronary artery bypass grafting &#91;CABG&#93;&#41;&#46; If only the absolute number of patients treated was available&#44; the proportion was calculated by dividing by the stratum-specific sample size&#46; When an article presented data stratified by a variable with no relevance to our analysis &#40;e&#46;g&#46; diabetic vs&#46; non-diabetic patients&#41;&#44; we calculated the weighted average of the proportions over all strata&#46;</p><p id="par0055" class="elsevierStylePara elsevierViewall">All types of PCI &#40;including primary PCI&#41; were considered in the analysis of this procedure as revascularization therapy&#46; The proportions of patients undergoing percutaneous and surgical revascularization procedures were described only when performed during the initial hospitalization for the acute event&#46; We considered two types of study population in terms of their representativeness of ACS patients treated in Portuguese institutions&#58; when patient selection was dependent on having undergone a treatment or a diagnostic procedure &#40;e&#46;g&#46; patients referred for viability tests&#59; patients undergoing coronary angiography&#41;&#44; the population was considered selected&#59; otherwise&#44; it was considered unselected&#46;</p><p id="par0060" class="elsevierStylePara elsevierViewall">When possible&#44; year-&#44; sex-&#44; age- and diagnosis-specific estimates were extracted&#46;</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Data analysis</span><p id="par0065" class="elsevierStylePara elsevierViewall">All studies are described in the Supplementary Table available online&#59; only those relying on unselected samples of patients are represented in the forest plots&#46; Although sex- and age-specific estimates were extracted and are shown in the detailed Supplementary Table&#44; these were seldom available and for descriptive purposes the results for the total sample are always presented in the forest plots&#44; stratified only by diagnosis&#46;</p><p id="par0070" class="elsevierStylePara elsevierViewall">The proportion of patients who underwent each procedure was described according to type of ACS&#46; However&#44; given that reports did not systematically stratify according to this criterion&#44; patient samples were classified into one of the following three categories&#44; according to the proportion of different ACS patients included&#58; STEMI &#40;90&#37; or more patients with a diagnosis of ST-segment elevation myocardial infarction &#40;STEMI&#41; or Q-wave myocardial infarction &#91;MI&#93;&#41;&#44; NSTE-ACS &#40;90&#37; or more patients with a diagnosis of non-ST-segment elevation ACS &#91;NSTE-ACS&#93;&#41;&#44; and mixed ACS &#40;if neither of these criteria was satisfied&#41;&#46;</p></span></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Results</span><p id="par0075" class="elsevierStylePara elsevierViewall">We identified 41 eligible studies providing data on ACS patients who underwent reperfusion and&#47;or revascularization therapies&#44; 21 presenting data on reperfusion and 28 on revascularization &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Figure 1</a>&#41;&#44; published between 1989 and 2011 &#40;Supplementary Table 1&#44; available online&#41;&#46;</p><p id="par0080" class="elsevierStylePara elsevierViewall">Over three-quarters of the studies reported data from a single institution&#44; mainly from the Lisbon region&#46; Three studies were based on national registries that covered several regions of the country&#46;<a class="elsevierStyleCrossRefs" href="#bib0030"><span class="elsevierStyleSup">6&#44;9&#44;10</span></a> The vast majority of studies recruited patients in cardiology departments&#46; Two-thirds of the studies included unselected populations&#46; More than half of the studies included both first and recurrent episodes and four studies reported exclusively on first episodes&#46;<a class="elsevierStyleCrossRefs" href="#bib0055"><span class="elsevierStyleSup">11&#8211;14</span></a> The sample size ranged from 21 to 22<span class="elsevierStyleHsp" style=""></span>482 patients&#44; and almost 40&#37; of the studies involved samples between 100 and 500 patients&#46; Seven samples included mostly STEMI patients&#44; 10 mostly NSTE-ACS patients and 27 a mixture of patients with several types of ACS&#46; Five studies presented sex-specific estimates&#44;<a class="elsevierStyleCrossRefs" href="#bib0050"><span class="elsevierStyleSup">10&#44;14&#8211;17</span></a> and only two presented age-specific estimates<a class="elsevierStyleCrossRefs" href="#bib0090"><span class="elsevierStyleSup">18&#44;19</span></a> &#40;Supplementary Table 1&#44; available online&#41;&#46;</p><p id="par0085" class="elsevierStylePara elsevierViewall">As expected&#44; data on reperfusion were available only for STEMI and mixed ACS patients &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Figure 1</a>&#41;&#46; Only three studies provided estimates of the use of reperfusion in STEMI patients&#46; In more recent years&#44; one study conducted in Faro reported the use of fibrinolysis in 16&#46;5&#37; of STEMI patients in 2008&#44;<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">20</span></a> while a report from the National Registry of Acute Coronary Syndromes showed a mean of 43&#46;7&#37;&#44; representing many cardiology centers across the country over several years&#46;<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> The same two studies reported the use of primary PCI in 41&#46;4&#37; and 19&#46;2&#37; of STEMI patients&#44; respectively&#46;<a class="elsevierStyleCrossRefs" href="#bib0030"><span class="elsevierStyleSup">6&#44;20</span></a> For mixed ACS patients there was a larger number of observations&#59; fibrinolysis was used in a quarter to a half of patients in the late 1990s&#44; decreasing to less than 10&#37; over the next decade&#46; Two reports published 10 years apart&#44; in 2001 and 2011&#44; showed an increase in the use of primary PCI in mixed ACS patients&#44; from less than 10&#37; in a sample of patients from several cardiology centers across the country<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a> to approximately 50&#37; in a single cardiology center in Lisbon<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">19</span></a> &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Figure 2</a>&#41;&#46;</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0090" class="elsevierStylePara elsevierViewall">Percutaneous revascularization&#44; including both emergent and elective procedures during hospitalization for an acute event&#44; was performed in approximately half of STEMI patients according to a report from Faro in 2008<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">20</span></a> and the report of the National Registry of Acute Coronary Syndromes covering several years and centers across the country&#46;<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> For NTSE-ACS&#44; two studies published in 1993 report contrasting experiences in small single-center samples&#44; while from 2003 to 2011 several estimates consistently point to one third to one half of patients being revascularized percutaneously during the acute hospitalization&#44; with no clear time trend&#46; With a larger number of reports and more regular publication over 15 years&#44; the proportion of mixed ACS patients revascularized percutaneously increased from under 10&#37; in the mid-1990s to approximately 70&#37; in recent years &#40;<a class="elsevierStyleCrossRef" href="#fig0015">Figure 3</a>&#41;&#46;</p><elsevierMultimedia ident="fig0015"></elsevierMultimedia><p id="par0095" class="elsevierStylePara elsevierViewall">CABG was used in 1&#46;0&#37; of STEMI patients &#40;this figure available only from the National Registry of Acute Coronary Syndromes&#41;&#46; In NSTE-ACS and mixed ACS&#44; 1&#8211;10&#37; of patients were reported as undergoing CABG&#44; with no clear time trend&#46; An exception for several reports is a single institution &#40;Hospital de Santa Cruz&#44; in Carnaxide&#41; over the years&#44; with a proportion closer to 20&#37; of NTSE-ACS patients having undergone surgical revascularization during hospitalization for the acute event &#40;<a class="elsevierStyleCrossRef" href="#fig0020">Figure 4</a>&#41;&#46;</p><elsevierMultimedia ident="fig0020"></elsevierMultimedia></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">Discussion</span><p id="par0100" class="elsevierStylePara elsevierViewall">Despite considerable heterogeneity in the methodology and presentation of results of available studies&#44; this review shows that the proportion of ACS patients in Portugal treated with fibrinolysis has decreased in the last 20 years and the use of PCI has increased&#44; while the use of CABG has not changed&#46;</p><p id="par0105" class="elsevierStylePara elsevierViewall">Since the late 1970s&#44; more aggressive and effective treatments have been developed and implemented for the treatment of CHD&#44; including fibrinolysis&#44; PCI and CABG&#46;<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">21</span></a> Of the primary studies included in the present review&#44; the oldest with data on fibrinolysis was published in 1989&#44;<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">22</span></a> while PCI and CABG were first mentioned in an article published in 1993 &#40;data collection in 1982&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">23</span></a> Data from previous years were reported in a few publications which were excluded mainly due to the reporting format&#44; for example lack of data on sample size or patients&#8217; sex and age&#44; or because the use of procedures in the acute hospitalization or over variable follow-up periods could not be distinguished&#46;</p><p id="par0110" class="elsevierStylePara elsevierViewall">During the last decade&#44; mechanical or pharmacological reperfusion therapy has been recommended for all patients with STEMI who present within 12 hours of the onset of symptoms&#46;<a class="elsevierStyleCrossRefs" href="#bib0120"><span class="elsevierStyleSup">24&#8211;26</span></a> A growing body of evidence has also demonstrated beneficial effects of reperfusion therapy in patients presenting more than 12 hours from symptom onset&#46; In this group of patients&#44; recent recommendations consider this treatment a strong indication&#44; preferably by primary PCI &#40;class I&#41; if there is evidence of ongoing ischemia or if pain and electrocardiographic changes have been stuttering&#46; Primary PCI may be also considered even in asymptomatic patients presenting 12&#8211;24 hours after symptom onset&#46;<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">25</span></a> For years&#44; fibrinolysis was chosen over primary PCI&#44; mainly due to its greater ease of access and use&#46;<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">21</span></a> However&#44; mechanical reperfusion has been preferred since several randomized clinical trials and meta-analyses comparing primary PCI with in-hospital fibrinolytic therapy in patients presenting within 6&#8211;12 hours of symptom onset showed more effective restoration of vessel patency&#44; less reocclusion&#44; reinfarction and stroke&#44; improved left ventricular function and less short-term mortality with primary PCI&#46;<a class="elsevierStyleCrossRefs" href="#bib0135"><span class="elsevierStyleSup">27&#44;28</span></a> National<a class="elsevierStyleCrossRefs" href="#bib0030"><span class="elsevierStyleSup">6&#44;29</span></a> and international registries in Europe<a class="elsevierStyleCrossRefs" href="#bib0150"><span class="elsevierStyleSup">30&#44;31</span></a> and the USA<a class="elsevierStyleCrossRefs" href="#bib0160"><span class="elsevierStyleSup">32&#44;33</span></a> suggest an increase in the use of reperfusion therapies accompanied by a significant shift from fibrinolysis therapy to primary PCI&#46; A significant decrease in mortality after STEMI has been observed in countries switching from fibrinolysis to primary PCI&#46;<a class="elsevierStyleCrossRef" href="#bib0170"><span class="elsevierStyleSup">34</span></a> In our study&#44; we observed decreased use of fibrinolysis and increased use of primary PCI&#46; In this review&#44; most of the studies providing data on fibrinolysis were published in the 1990s&#44; with data collected in the 1980s and 1990s&#46; By contrast&#44; the studies addressing primary PCI were only published in the current century&#46; Although the trends cannot be quantified&#44; fibrinolysis appears to have been replaced by primary PCI&#46;</p><p id="par0115" class="elsevierStylePara elsevierViewall">Since its introduction in 1977&#44; angioplasty has become the most frequently performed major intervention in medicine&#44;<a class="elsevierStyleCrossRef" href="#bib0175"><span class="elsevierStyleSup">35</span></a> as both a reperfusion &#40;primary PCI&#41; and revascularization procedure&#46; Among the included studies addressing the use of revascularization by a percutaneous procedure&#44; one sixth were published in the 1990s and the remainder afterwards&#46; Surgical revascularization with CABG was first introduced in 1969&#44; and become the most thoroughly studied procedure in the history of surgery&#46;<a class="elsevierStyleCrossRef" href="#bib0180"><span class="elsevierStyleSup">36</span></a> In our review&#44; a quarter of the studies were published in the 1990s and the remainder after 2000&#46; Although the primary studies provided information on surgeries performed at different times related to the acute event &#40;e&#46;g&#46; during a variable time of follow-up after the acute event&#41;&#44; we only included studies with data on CABG performed during the initial hospitalization&#46; Otherwise&#44; the data to be compared would be even more heterogeneous&#46; Particularly for this procedure&#44; it is important to point out that many patients referred for CABG are expected to have undergone surgery after discharge or have been transferred to a different institution while awaiting the procedure&#44;<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> thus reducing the proportion of patients treated that were captured by this analysis&#46;</p><p id="par0120" class="elsevierStylePara elsevierViewall">The results on revascularization therapies are consistent with the findings of previous studies showing an increase in PCI use and non-significant changes in use of CABG in recent years&#46;<a class="elsevierStyleCrossRefs" href="#bib0150"><span class="elsevierStyleSup">30&#44;37&#44;38</span></a> In patients stabilized after an episode of acute coronary syndrome&#44; the choice of revascularization modality can be made as in stable coronary heart disease&#46;<a class="elsevierStyleCrossRefs" href="#bib0125"><span class="elsevierStyleSup">25&#44;39&#44;40</span></a> In single-vessel disease&#44; which occurs in one-third of patients with ACS&#44; ad-hoc PCI is feasible in most cases&#44; whereas in patients with multivessel disease &#40;approximately half of cases&#41; the decision on the type of revascularization is more complex&#46;<a class="elsevierStyleCrossRefs" href="#bib0205"><span class="elsevierStyleSup">41&#44;42</span></a> Options for this condition have evolved over time&#44; and currently include culprit lesion PCI&#44; multivessel PCI&#44; CABG or hybrid &#40;combined&#41; revascularization&#44; according to clinical status&#44; lesion characteristics and the severity and distribution of coronary artery disease&#46;<a class="elsevierStyleCrossRefs" href="#bib0125"><span class="elsevierStyleSup">25&#44;39&#44;40</span></a></p><p id="par0125" class="elsevierStylePara elsevierViewall">Our methodology has some limitations&#46; The use of a single search engine may have limited our results&#46; However&#44; the inclusion of relevant studies identified in the reference lists of the review articles should have helped identify older and non-PubMed-indexed publications&#46; The probability of identifying relevant studies from among those published is also influenced by their results because&#44; despite the descriptive nature of the studies&#44; publication bias can be expected&#44; with higher likelihood of publication from higher-quality or at least higher-volume centers&#46; It is noteworthy that the majority of studies came from cardiology departments&#44; some of which also contributed to the National Registry of Acute Coronary Syndromes&#46; Therefore&#44; the main gain with this review is its coverage of a greater time span&#44; but not the representation of less specialized centers than those included in the National Registry of Acute Coronary Syndromes&#46; The results are affected by the methodological heterogeneity of the studies&#44; particularly inclusion criteria&#44; sample size&#44; and patients&#8217; age and sex&#44; as well as the relatively small number of estimates for each type of treatment under study&#46; Another limitation for more informative conclusions stems from the small number of studies with sex-&#44; age-&#44; and year-specific estimates&#44; as authors mainly reported overall data&#46; Some reported data referring to a period longer than one year&#59; however&#44; it was not possible to obtain year-specific estimates&#46;</p><p id="par0130" class="elsevierStylePara elsevierViewall">Given these limitations&#44; an alternative approach to the study of trends in the use of these treatments in the past could be to rely on administrative databases&#44; using data collected&#44; coded and stored&#44; immediately available for analysis&#46;<a class="elsevierStyleCrossRef" href="#bib0215"><span class="elsevierStyleSup">43</span></a> The national register of hospital discharges<a class="elsevierStyleCrossRef" href="#bib0145"><span class="elsevierStyleSup">29</span></a> could be used to quantify the number of procedures performed&#44; but the usefulness of these datasets is limited&#58; it is not possible to classify the subtypes of ACS according to current recommendations<a class="elsevierStyleCrossRef" href="#bib0220"><span class="elsevierStyleSup">44</span></a> when departing from data coded using the International Classification of Diseases&#44; 9th revision&#44; Clinical Modification &#40;ICD-9-CM&#41;&#46; Furthermore&#44; there is no information available in the database to ascertain the timing of PCI or to identify recurrent episodes in the same patient&#46;<a class="elsevierStyleCrossRef" href="#bib0145"><span class="elsevierStyleSup">29</span></a></p></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0105">Conclusions</span><p id="par0135" class="elsevierStylePara elsevierViewall">The general pattern of treatment reflects what is reported in other developed countries and can be viewed as a favorable time trend in the quality of care of ACS patients&#46; Future investigation should focus on the prospective and systematic recording of high-quality information to monitor the use of treatments in this acute condition&#44; while past trends can only be properly clarified by an original retrospective study on a representative sample of ACS patients&#44; involving review of hospital records&#46;</p></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0110">Ethical disclosures</span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0115">Protection of human and animal subjects</span><p id="par0140" class="elsevierStylePara elsevierViewall">The authors declare that no experiments were performed on humans or animals for this study&#46;</p></span><span id="sec0060" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0120">Confidentiality of data</span><p id="par0145" class="elsevierStylePara elsevierViewall">The authors declare that no patient data appear in this article&#46;</p></span><span id="sec0065" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0125">Right to privacy and informed consent</span><p id="par0150" class="elsevierStylePara elsevierViewall">The authors declare that no patient data appear in this article&#46;</p></span></span><span id="sec0070" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0130">Funding</span><p id="par0155" class="elsevierStylePara elsevierViewall">This study was funded by a grant from <span class="elsevierStyleGrantSponsor" id="gs1">Funda&#231;&#227;o para a Ci&#234;ncia e a Tecnologia</span> &#40;<span class="elsevierStyleGrantNumber" refid="gs1">PIC&#47;IC&#47;83006&#47;2007</span>&#41;&#46;</p></span><span id="sec0075" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0135">Conflicts of interest</span><p id="par0160" class="elsevierStylePara elsevierViewall">The authors have no conflicts of interest to declare&#46;</p></span></span>"
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              "titulo" => "Screening of reference lists"
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              "titulo" => "Protection of human and animal subjects"
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    "fechaRecibido" => "2013-03-22"
    "fechaAceptado" => "2013-11-03"
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          "clase" => "keyword"
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          "identificador" => "xpalclavsec368062"
          "palabras" => array:5 [
            0 => "Acute coronary syndrome"
            1 => "Angioplasty"
            2 => "Coronary artery bypass"
            3 => "Fibrinolysis"
            4 => "Myocardial revascularization"
          ]
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      ]
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          "palabras" => array:5 [
            0 => "S&#237;ndrome coron&#225;ria aguda"
            1 => "Angioplastia"
            2 => "Cirurgia de revasculariza&#231;&#227;o coron&#225;ria"
            3 => "Fibrin&#243;lise"
            4 => "Revasculariza&#231;&#227;o mioc&#225;rdica"
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    "resumen" => array:2 [
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        "titulo" => "Abstract"
        "resumen" => "<span class="elsevierStyleSectionTitle" id="sect0010">Introduction and Objectives</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Reperfusion and revascularization therapies play an important role in the management of coronary heart disease and have contributed to decreases in case fatality rates&#46; We aimed to describe the use of these therapies for the treatment of acute coronary syndrome &#40;ACS&#41; patients over time in Portugal&#46;</p> <span class="elsevierStyleSectionTitle" id="sect0015">Methods</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">PubMed was searched in July 2012&#46; The proportion of patients treated with fibrinolysis&#44; primary percutaneous coronary intervention &#40;PCI&#41;&#44; any PCI and coronary artery bypass grafting &#40;CABG&#41; was described according to type of ACS&#58; STEMI &#40;&#8805;90&#37; patients with ST-segment elevation or Q-wave myocardial infarction&#41;&#44; NSTE-ACS &#40;&#8805;90&#37; patients with non-ST-segment elevation ACS&#41; and mixed ACS &#40;all others&#41;&#46;</p> <span class="elsevierStyleSectionTitle" id="sect0020">Results</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">We identified 41 eligible studies&#44; published between 1989 and 2011&#46; Twenty-eight reported on samples considered representative of ACS patients treated in Portugal&#46; The small number of estimates of the use of each treatment in STEMI and NSTE-ACS patients precluded identification of any time trend&#46; In the last 20 years&#44; the proportion of mixed ACS patients treated with fibrinolysis decreased and the use of PCI increased&#44; while the use of CABG did not change&#46;</p> <span class="elsevierStyleSectionTitle" id="sect0025">Conclusions</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">The general pattern of the use of reperfusion and revascularization is in accordance with that reported in other developed countries&#44; reflecting a favorable trend in the quality of care of ACS patients&#46; The relatively small number of estimates on the same procedure in comparable patients limits the generalizability of the conclusions&#44; and highlights the need for systematic approaches to monitor the use of treatments over time&#46;</p>"
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        "resumen" => "<span class="elsevierStyleSectionTitle" id="sect0035">Introdu&#231;&#227;o e objetivos</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">A reperfus&#227;o e revasculariza&#231;&#227;o desempenham um importante papel no tratamento da doen&#231;a coron&#225;ria contribuindo para a diminui&#231;&#227;o da letalidade&#46; Foi nosso objetivo descrever o uso destes procedimentos no tratamento da s&#237;ndrome coron&#225;ria aguda &#40;SCA&#41; ao longo do tempo em Portugal&#46;</p> <span class="elsevierStyleSectionTitle" id="sect0040">M&#233;todos</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">A pesquisa foi efetuada na Pubmed em julho de 2012&#46; A propor&#231;&#227;o de doentes tratados com fibrin&#243;lise&#44; angioplastia prim&#225;ria&#44; qualquer tipo de angioplastia e cirurgia de revasculariza&#231;&#227;o coron&#225;ria &#40;CABG&#41; foi descrita de acordo com o tipo de SCA&#58; SCA supra-ST &#40;quando a propor&#231;&#227;o de doentes com eleva&#231;&#227;o do segmento ST ou enfarte do mioc&#225;rdio com ondas Q era &#8805;90&#37;&#41;&#44; SCA sem-ST &#40;quando a propor&#231;&#227;o de doentes com SCA sem eleva&#231;&#227;o do segmento ST era &#8805;90&#37;&#41; e SCA misto &#40;restantes casos&#41;&#46;</p> <span class="elsevierStyleSectionTitle" id="sect0045">Resultados</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Foram identificados 41 estudos publicados entre 1989 e 2011&#46; Vinte e oito estudos descreveram amostras representativas dos doentes com SCA tratados em Portugal&#46; O baixo n&#250;mero de estimativas de cada tratamento nos doentes com SCA supra-ST e sem-ST&#44; impossibilitou a observa&#231;&#227;o de tend&#234;ncias temporais&#46; Nos &#250;ltimos 20 anos&#44; a propor&#231;&#227;o de doentes com SCA misto tratados com fibrin&#243;lise diminuiu&#44; o uso de angioplastia aumentou&#44; enquanto o uso de CABG n&#227;o se alterou&#46;</p> <span class="elsevierStyleSectionTitle" id="sect0050">Conclus&#245;es</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">O padr&#227;o do uso destes tratamentos est&#225; de acordo com dados publicados noutros pa&#237;ses desenvolvidos&#44; refletindo uma tend&#234;ncia favor&#225;vel na qualidade dos cuidados prestados&#46; O baixo n&#250;mero de estimativas do mesmo procedimento limitou a generaliza&#231;&#227;o de conclus&#245;es&#44; refor&#231;ando a necessidade de alternativas para monitorizar o uso de tratamentos ao longo do tempo&#46;</p>"
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          "en" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Flowchart of the systematic review&#46; CABG&#58; coronary artery bypass grafting&#59; PCI&#58; percutaneous coronary intervention&#59; STEMI&#58; 90&#37; or more patients with diagnosis of ST-segment elevation myocardial infarction or Q-wave myocardial infarction&#59; NSTE-ACS&#58; 90&#37; or more patients with diagnosis of non-ST-segment elevation ACS&#59; mixed ACS&#58; mixture of patients with several types of ACS&#46;</p> <p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">&#42; If a study provided data on treatment with both reperfusion and revascularization&#44; it contributed to both groups&#46; If a study provided data on more than one diagnostic category&#44; it contributed to all groups&#46;</p> <p id="spar0055" class="elsevierStyleSimplePara elsevierViewall"><span class="elsevierStyleSup">&#8224;</span> The sample was considered selected when inclusion of patients was dependent on having undergone some diagnosis or treatment procedure&#59; otherwise&#44; it was considered unselected&#46;</p>"
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