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Risk assessment in percutaneous coronary intervention and appropriate use criteria: Manual or automatic?
Avaliação do risco e uso apropriado da intervenção coronária percutânea. Portagem manual ou via verde eletrónica automática?
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Portagem manual ou via verde eletrónica automática?" 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"tieneTextoCompleto" => true "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "79" "paginaFinal" => "81" ] ] "autores" => array:1 [ 0 => array:3 [ "autoresLista" => "Rui Campante Teles" "autores" => array:1 [ 0 => array:4 [ "nombre" => "Rui" "apellidos" => "Campante Teles" "email" => array:1 [ 0 => "rcteles@outlook.com" ] "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] ] "afiliaciones" => array:2 [ 0 => array:3 [ "entidad" => "Unidade de Intervenção Cardiovascular (UNICARV), Hospital de Santa Cruz, CHLO, Carnaxide, Portugal" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Centro de Estudos de Doenças Crónicas (CEDOC), Faculdade de Ciências Médicas, Universidade Nova de Lisboa, Lisboa, Portugal" "etiqueta" => "b" "identificador" => "aff0010" ] ] ] ] "titulosAlternativos" => array:1 [ "pt" => array:1 [ "titulo" => "Avaliação do risco e uso apropriado da intervenção coronária percutânea. Portagem manual ou via verde eletrónica automática?" ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Coronary artery disease is the leading cause of death in developed countries. Percutaneous coronary intervention (PCI) alleviates patients’ symptoms and in many cases reduces mortality in settings of cardiac decompensation, particularly acute coronary syndromes (ACS).<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">1</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">In the thirty years since PCI was introduced in Portugal, its indications have widened following improvement in techniques and results, and now include more complex and higher-risk situations. Advances have been seen in drug-eluting stents, adjuvant therapy, arterial access, imaging and understanding of the underlying physiology.<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">2</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">The benefits of PCI must be weighed against the risk associated with intervention, which depends on clinical and angiographic variables. The ability to predict the outcome for a patient before and after PCI is extremely useful, in order to assess individual risk, to counsel patients and their families, and to plan revascularization strategies.<a class="elsevierStyleCrossRefs" href="#bib0115"><span class="elsevierStyleSup">3–5</span></a> It also helps in identifying opportunities to improve quality and in comparing results between centers and operators.</p><p id="par0020" class="elsevierStylePara elsevierViewall">The main requirements for cardiovascular risk scores are accessibility, ease and speed of use, ability to integrate with the institution's computer systems, and low cost. Risk scores must be validated, ideally for both short-term and long-term application (up to five years).</p><p id="par0025" class="elsevierStylePara elsevierViewall">Most existing risk scores for PCI have significant limitations. The most widely used in interventional cardiology is the SYNTAX score, both the original and the updated clinical SYNTAX score, which are referred to in the European guidelines but can be complex and laborious to calculate, while the EuroSCORE II uses clinical variables and is easy to calculate. Both have been the subject of extensive external validation.<a class="elsevierStyleCrossRefs" href="#bib0130"><span class="elsevierStyleSup">6–11</span></a> A variety of other interesting risk scores have been developed, but with limited applicability and external validation (especially in European populations), and with outcome restricted to in-hospital adverse events.<a class="elsevierStyleCrossRef" href="#bib0160"><span class="elsevierStyleSup">12</span></a></p><p id="par0030" class="elsevierStylePara elsevierViewall">The article by Timóteo et al. in this issue of the <span class="elsevierStyleItalic">Journal</span> is timely, specifically addressing these limitations and analyzing the role of risk scores derived from populations with ACS.<a class="elsevierStyleCrossRef" href="#bib0205"><span class="elsevierStyleSup">13</span></a> It concludes that the Global Registry of Acute Coronary Events (GRACE) score is to be preferred to the Mayo Clinic risk score (MCRS) and the National Cardiovascular Data Registry (NCDR) risk score for predicting in-hospital mortality in Portuguese patients undergoing PCI, mainly for ST-elevation myocardial infarction (STEMI).</p><p id="par0035" class="elsevierStylePara elsevierViewall">The study population was large, reflecting the experience of a reference center between January 2005 and October 2013.</p><p id="par0040" class="elsevierStylePara elsevierViewall">The proportion of STEMI was high (70.9%), which explains the demographic and clinical differences between this population and others, both Portuguese and non-Portuguese, used to derive risk scores, which had a lower prevalence of comorbidities that are generally associated with greater clinical complexity.<a class="elsevierStyleCrossRefs" href="#bib0165"><span class="elsevierStyleSup">14–16</span></a></p><p id="par0045" class="elsevierStylePara elsevierViewall">This prospective observational registry was notable for the robustness of the statistical methods used to compare the different risk scores, which were calculated retrospectively.</p><p id="par0050" class="elsevierStylePara elsevierViewall">The merit of the study lies in its comparison of the three scores in a Portuguese population, showing that they fulfill some of the main requirements of a risk score: they are freely accessible, easy to apply and free of charge. Ease of calculation was not evaluated, presumably because the GRACE score is available via computers and mobile devices, and although its calculation based on eight variables is manual, it is fast.<a class="elsevierStyleCrossRef" href="#bib0180"><span class="elsevierStyleSup">17</span></a> Calculation of the MCRS is also manual, but is more complex and therefore more time-consuming and less practical.<a class="elsevierStyleCrossRef" href="#bib0185"><span class="elsevierStyleSup">18</span></a> With regard to the NCDR score, presumably the simplified version 3, with eight variables, was used in the study; the simplified version 4 is now available, which uses 13 clinical variables, but only the full version includes significant angiographic predictors such as treated chronic total occlusions and stent thrombosis.<a class="elsevierStyleCrossRef" href="#bib0190"><span class="elsevierStyleSup">19</span></a></p><p id="par0055" class="elsevierStylePara elsevierViewall">The study focuses on in-hospital mortality, which was 4.5%. On the basis of the inclusion criteria, borderline cases, such as patients who did not undergo angiography or who had mild disease on angiography, were excluded, as were those who needed surgery or did not survive to be treated by PCI. Validation of the scores for events at 30 days and in the longer term would be valuable, since it is over this time-scale that there are the most gaps in our knowledge and the most interest for patients. From this standpoint, the inclusion of biomarkers could be particularly useful.<a class="elsevierStyleCrossRefs" href="#bib0210"><span class="elsevierStyleSup">20,21</span></a></p><p id="par0060" class="elsevierStylePara elsevierViewall">In my opinion, the central question is the implementation and usefulness of risk assessment. First of all, risk scores should be available automatically at the patient's bedside, preferably via the institution's computer systems, in order to facilitate decisions regarding catheterization and treatment strategy. This is especially important given that, for long-term prognosis, the more complex and comprehensive scores are clearly more accurate and sensitive than simplified ones. Secondly, in this study in which two-thirds of the patients had STEMI and were revascularized, it would be of considerable interest to analyze what could have been done to reduce in-hospital mortality. The complications reported (stroke, major bleeding and mechanical complications) are of course associated with mortality, which leads to the question of the appropriate use of PCI, adjuvant therapy and arterial access according to the risk score.</p><p id="par0065" class="elsevierStylePara elsevierViewall">In conclusion, the study by Timóteo et al. is original and significant, validating three risk scores for PCI in Portuguese patients with ACS. Physicians should be able to calculate risk automatically at the patient's bedside, but cannot as yet always do so. Prognostic risk assessment is included in most guidelines and is a valuable aid in counseling, planning, improving quality and assessing outcomes.</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Conflicts of interest</span><p id="par0070" class="elsevierStylePara elsevierViewall">The author has no conflicts of interest to declare.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:2 [ 0 => array:2 [ "identificador" => "sec0005" "titulo" => "Conflicts of interest" ] 1 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Campante Teles R. Avaliação do risco e uso apropriado da intervenção coronária percutânea. Portagem manual ou via verde eletrónica automática? Rev Port Cardiol. 2016;35:79–81.</p>" ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:21 [ 0 => array:3 [ "identificador" => "bib0105" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:1 [ "titulo" => "Health at a 2015: OECD INDICATORS" ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1787/health_glance-2015-en" "Libro" => array:2 [ "fecha" => "2015" "editorial" => "OECD" ] ] ] ] ] ] 1 => array:3 [ "identificador" => "bib0110" "etiqueta" => "2" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Trends in percutaneous coronary intervention from 2004 to 2013 according to the Portuguese National Registry of Interventional Cardiology" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:3 [ 0 => "H. Pereira" 1 => "R. Campante Teles" 2 => "M. 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| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 November | 7 | 2 | 9 |
| 2024 October | 45 | 26 | 71 |
| 2024 September | 50 | 21 | 71 |
| 2024 August | 54 | 23 | 77 |
| 2024 July | 44 | 34 | 78 |
| 2024 June | 32 | 22 | 54 |
| 2024 May | 34 | 24 | 58 |
| 2024 April | 33 | 26 | 59 |
| 2024 March | 38 | 20 | 58 |
| 2024 February | 27 | 17 | 44 |
| 2024 January | 30 | 24 | 54 |
| 2023 December | 27 | 26 | 53 |
| 2023 November | 36 | 32 | 68 |
| 2023 October | 40 | 16 | 56 |
| 2023 September | 23 | 23 | 46 |
| 2023 August | 24 | 18 | 42 |
| 2023 July | 24 | 12 | 36 |
| 2023 June | 33 | 15 | 48 |
| 2023 May | 29 | 22 | 51 |
| 2023 April | 18 | 7 | 25 |
| 2023 March | 35 | 26 | 61 |
| 2023 February | 32 | 24 | 56 |
| 2023 January | 25 | 12 | 37 |
| 2022 December | 40 | 27 | 67 |
| 2022 November | 44 | 28 | 72 |
| 2022 October | 33 | 18 | 51 |
| 2022 September | 36 | 19 | 55 |
| 2022 August | 28 | 39 | 67 |
| 2022 July | 39 | 42 | 81 |
| 2022 June | 34 | 19 | 53 |
| 2022 May | 28 | 34 | 62 |
| 2022 April | 23 | 24 | 47 |
| 2022 March | 25 | 33 | 58 |
| 2022 February | 27 | 18 | 45 |
| 2022 January | 38 | 23 | 61 |
| 2021 December | 22 | 33 | 55 |
| 2021 November | 41 | 39 | 80 |
| 2021 October | 37 | 60 | 97 |
| 2021 September | 31 | 46 | 77 |
| 2021 August | 34 | 38 | 72 |
| 2021 July | 23 | 35 | 58 |
| 2021 June | 26 | 32 | 58 |
| 2021 May | 32 | 29 | 61 |
| 2021 April | 54 | 28 | 82 |
| 2021 March | 54 | 13 | 67 |
| 2021 February | 47 | 21 | 68 |
| 2021 January | 31 | 16 | 47 |
| 2020 December | 40 | 12 | 52 |
| 2020 November | 37 | 13 | 50 |
| 2020 October | 21 | 19 | 40 |
| 2020 September | 49 | 14 | 63 |
| 2020 August | 20 | 8 | 28 |
| 2020 July | 60 | 10 | 70 |
| 2020 June | 37 | 6 | 43 |
| 2020 May | 45 | 9 | 54 |
| 2020 April | 39 | 10 | 49 |
| 2020 March | 62 | 4 | 66 |
| 2020 February | 54 | 57 | 111 |
| 2020 January | 31 | 8 | 39 |
| 2019 December | 46 | 6 | 52 |
| 2019 November | 27 | 5 | 32 |
| 2019 October | 29 | 5 | 34 |
| 2019 September | 15 | 8 | 23 |
| 2019 August | 27 | 6 | 33 |
| 2019 July | 31 | 12 | 43 |
| 2019 June | 18 | 10 | 28 |
| 2019 May | 24 | 12 | 36 |
| 2019 April | 21 | 15 | 36 |
| 2019 March | 78 | 15 | 93 |
| 2019 February | 64 | 12 | 76 |
| 2019 January | 89 | 9 | 98 |
| 2018 December | 79 | 9 | 88 |
| 2018 November | 108 | 9 | 117 |
| 2018 October | 270 | 15 | 285 |
| 2018 September | 97 | 10 | 107 |
| 2018 August | 35 | 7 | 42 |
| 2018 July | 25 | 0 | 25 |
| 2018 June | 37 | 7 | 44 |
| 2018 May | 59 | 8 | 67 |
| 2018 April | 41 | 11 | 52 |
| 2018 March | 101 | 6 | 107 |
| 2018 February | 49 | 6 | 55 |
| 2018 January | 72 | 12 | 84 |
| 2017 December | 111 | 6 | 117 |
| 2017 November | 46 | 16 | 62 |
| 2017 October | 33 | 9 | 42 |
| 2017 September | 30 | 13 | 43 |
| 2017 August | 29 | 12 | 41 |
| 2017 July | 32 | 8 | 40 |
| 2017 June | 39 | 8 | 47 |
| 2017 May | 48 | 20 | 68 |
| 2017 April | 25 | 12 | 37 |
| 2017 March | 43 | 22 | 65 |
| 2017 February | 38 | 5 | 43 |
| 2017 January | 31 | 1 | 32 |
| 2016 December | 30 | 14 | 44 |
| 2016 November | 21 | 10 | 31 |
| 2016 October | 26 | 6 | 32 |
| 2016 September | 20 | 4 | 24 |
| 2016 August | 2 | 1 | 3 |
| 2016 July | 10 | 4 | 14 |
| 2016 June | 5 | 4 | 9 |
| 2016 May | 11 | 4 | 15 |
| 2016 April | 35 | 1 | 36 |
| 2016 March | 127 | 59 | 186 |
| 2016 February | 8 | 4 | 12 |
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