Editorial comment
Risk stratification after acute coronary syndromes: Scores, scores and yet another score
Estratificação de risco após síndromes coronárias agudas. Scores, scores e mais (um) score
Daniel Ferreira
Cardiovascular Centre, Hospital da Luz Lisboa, Lisbon, Portugal
Read
4499
Timeswas read the article
1610
Total PDF
2889
Total HTML
Share statistics
array:25 [ "pii" => "S2174204917300284" "issn" => "21742049" "doi" => "10.1016/j.repce.2017.02.004" "estado" => "S300" "fechaPublicacion" => "2017-02-01" "aid" => "929" "copyright" => "Sociedade Portuguesa de Cardiologia" "copyrightAnyo" => "2016" "documento" => "simple-article" "crossmark" => 1 "licencia" => "http://creativecommons.org/licenses/by-nc-nd/4.0/" "subdocumento" => "dis" "cita" => "Rev Port Cardiol. 2017;36:85-7" "abierto" => array:3 [ "ES" => true "ES2" => true "LATM" => true ] "gratuito" => true "lecturas" => array:2 [ "total" => 1491 "formatos" => array:3 [ "EPUB" => 178 "HTML" => 1008 "PDF" => 305 ] ] "Traduccion" => array:1 [ "en" => array:20 [ "pii" => "S087025511630378X" "issn" => "08702551" "doi" => "10.1016/j.repc.2016.12.001" "estado" => "S300" "fechaPublicacion" => "2017-02-01" "aid" => "929" "copyright" => "Sociedade Portuguesa de Cardiologia" "documento" => "simple-article" "crossmark" => 1 "licencia" => "http://creativecommons.org/licenses/by-nc-nd/4.0/" "subdocumento" => "dis" "cita" => "Rev Port Cardiol. 2017;36:85-7" "abierto" => array:3 [ "ES" => true "ES2" => true "LATM" => true ] "gratuito" => true "lecturas" => array:2 [ "total" => 2288 "formatos" => array:3 [ "EPUB" => 177 "HTML" => 1665 "PDF" => 446 ] ] "en" => array:10 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Editorial comment</span>" "titulo" => "Risk stratification after acute coronary syndromes: Scores, scores and yet another score" "tienePdf" => "en" "tieneTextoCompleto" => "en" "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "85" "paginaFinal" => "87" ] ] "titulosAlternativos" => array:1 [ "pt" => array:1 [ "titulo" => "Estratificação de risco após síndromes coronárias agudas. <span class="elsevierStyleItalic">Scores</span>, <span class="elsevierStyleItalic">scores</span> e mais (um) <span class="elsevierStyleItalic">score</span>" ] ] "contieneTextoCompleto" => array:1 [ "en" => true ] "contienePdf" => array:1 [ "en" => true ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "Daniel Ferreira" "autores" => array:1 [ 0 => array:2 [ "nombre" => "Daniel" "apellidos" => "Ferreira" ] ] ] ] ] "idiomaDefecto" => "en" "Traduccion" => array:1 [ "en" => array:9 [ "pii" => "S2174204917300284" "doi" => "10.1016/j.repce.2017.02.004" "estado" => "S300" "subdocumento" => "" "abierto" => array:3 [ "ES" => true "ES2" => true "LATM" => true ] "gratuito" => true "lecturas" => array:1 [ "total" => 0 ] "idiomaDefecto" => "en" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2174204917300284?idApp=UINPBA00004E" ] ] "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S087025511630378X?idApp=UINPBA00004E" "url" => "/08702551/0000003600000002/v1_201702090011/S087025511630378X/v1_201702090011/en/main.assets" ] ] "itemSiguiente" => array:20 [ "pii" => "S2174204917300260" "issn" => "21742049" "doi" => "10.1016/j.repce.2017.02.002" "estado" => "S300" "fechaPublicacion" => "2017-02-01" "aid" => "930" "copyright" => "Sociedade Portuguesa de Cardiologia" "documento" => "article" "crossmark" => 1 "licencia" => "http://creativecommons.org/licenses/by-nc-nd/4.0/" "subdocumento" => "fla" "cita" => "Rev Port Cardiol. 2017;36:89-93" "abierto" => array:3 [ "ES" => true "ES2" => true "LATM" => true ] "gratuito" => true "lecturas" => array:2 [ "total" => 2104 "formatos" => array:3 [ "EPUB" => 192 "HTML" => 1510 "PDF" => 402 ] ] "en" => array:13 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Original Article</span>" "titulo" => "Comparison of the presence of fragmented QRS complexes in the inferior versus the anterior leads for predicting coronary artery disease severity" "tienePdf" => "en" "tieneTextoCompleto" => "en" "tieneResumen" => array:2 [ 0 => "en" 1 => "pt" ] "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "89" "paginaFinal" => "93" ] ] "titulosAlternativos" => array:1 [ "pt" => array:1 [ "titulo" => "Comparação da presença dos complexos QRS fragmentados nas derivações anteriores <span class="elsevierStyleItalic">versus</span> inferiores na predição da severidade da doença arterial coronária" ] ] "contieneResumen" => array:2 [ "en" => true "pt" => true ] "contieneTextoCompleto" => array:1 [ "en" => true ] "contienePdf" => array:1 [ "en" => true ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 910 "Ancho" => 1601 "Tamanyo" => 302913 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">An example of fragmented QRS in the inferior leads.</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "Mehmet Eyuboglu, Ugur Kucuk, Omer Senarslan, Bahri Akdeniz" "autores" => array:4 [ 0 => array:2 [ "nombre" => "Mehmet" "apellidos" => "Eyuboglu" ] 1 => array:2 [ "nombre" => "Ugur" "apellidos" => "Kucuk" ] 2 => array:2 [ "nombre" => "Omer" "apellidos" => "Senarslan" ] 3 => array:2 [ "nombre" => "Bahri" "apellidos" => "Akdeniz" ] ] ] ] ] "idiomaDefecto" => "en" "Traduccion" => array:1 [ "en" => array:9 [ "pii" => "S0870255116303791" "doi" => "10.1016/j.repc.2016.07.008" "estado" => "S300" "subdocumento" => "" "abierto" => array:3 [ "ES" => true "ES2" => true "LATM" => true ] "gratuito" => true "lecturas" => array:1 [ "total" => 0 ] "idiomaDefecto" => "en" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0870255116303791?idApp=UINPBA00004E" ] ] "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2174204917300260?idApp=UINPBA00004E" "url" => "/21742049/0000003600000002/v1_201702240018/S2174204917300260/v1_201702240018/en/main.assets" ] "itemAnterior" => array:20 [ "pii" => "S2174204917300259" "issn" => "21742049" "doi" => "10.1016/j.repce.2017.02.001" "estado" => "S300" "fechaPublicacion" => "2017-02-01" "aid" => "928" "copyright" => "Sociedade Portuguesa de Cardiologia" "documento" => "article" "crossmark" => 1 "licencia" => "http://creativecommons.org/licenses/by-nc-nd/4.0/" "subdocumento" => "fla" "cita" => "Rev Port Cardiol. 2017;36:77-83" "abierto" => array:3 [ "ES" => true "ES2" => true "LATM" => true ] "gratuito" => true "lecturas" => array:2 [ "total" => 1814 "formatos" => array:3 [ "EPUB" => 182 "HTML" => 1277 "PDF" => 355 ] ] "en" => array:13 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Original Article</span>" "titulo" => "ProACS risk score: An early and simple score for risk stratification of patients with acute coronary syndromes" "tienePdf" => "en" "tieneTextoCompleto" => "en" "tieneResumen" => array:2 [ 0 => "en" 1 => "pt" ] "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "77" "paginaFinal" => "83" ] ] "titulosAlternativos" => array:1 [ "pt" => array:1 [ "titulo" => "<span class="elsevierStyleItalic">Score</span> de risco ProACS: em <span class="elsevierStyleItalic">score</span> simples e precoce para estratificação de risco em doentes com síndromes coronárias agudas" ] ] "contieneResumen" => array:2 [ "en" => true "pt" => true ] "contieneTextoCompleto" => array:1 [ "en" => true ] "contienePdf" => array:1 [ "en" => true ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 1260 "Ancho" => 1602 "Tamanyo" => 115037 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">Fit of the final multivariate logistic regression model in the development cohort. df: degrees of freedom.</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "Ana Teresa Timóteo, Sílvia Aguiar Rosa, Marta Afonso Nogueira, Adriana Belo, Rui Cruz Ferreira" "autores" => array:6 [ 0 => array:2 [ "nombre" => "Ana Teresa" "apellidos" => "Timóteo" ] 1 => array:2 [ "nombre" => "Sílvia" "apellidos" => "Aguiar Rosa" ] 2 => array:2 [ "nombre" => "Marta" "apellidos" => "Afonso Nogueira" ] 3 => array:2 [ "nombre" => "Adriana" "apellidos" => "Belo" ] 4 => array:2 [ "nombre" => "Rui" "apellidos" => "Cruz Ferreira" ] 5 => array:1 [ "colaborador" => "on behalf of the ProACS Investigators" ] ] ] ] ] "idiomaDefecto" => "en" "Traduccion" => array:1 [ "en" => array:9 [ "pii" => "S0870255116303778" "doi" => "10.1016/j.repc.2016.05.010" "estado" => "S300" "subdocumento" => "" "abierto" => array:3 [ "ES" => true "ES2" => true "LATM" => true ] "gratuito" => true "lecturas" => array:1 [ "total" => 0 ] "idiomaDefecto" => "en" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0870255116303778?idApp=UINPBA00004E" ] ] "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2174204917300259?idApp=UINPBA00004E" "url" => "/21742049/0000003600000002/v1_201702240018/S2174204917300259/v1_201702240018/en/main.assets" ] "en" => array:12 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Editorial comment</span>" "titulo" => "Risk stratification after acute coronary syndromes: Scores, scores and yet another score" "tieneTextoCompleto" => true "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "85" "paginaFinal" => "87" ] ] "autores" => array:1 [ 0 => array:3 [ "autoresLista" => "Daniel Ferreira" "autores" => array:1 [ 0 => array:3 [ "nombre" => "Daniel" "apellidos" => "Ferreira" "email" => array:1 [ 0 => "dferreira@hospitaldaluz.pt" ] ] ] "afiliaciones" => array:1 [ 0 => array:2 [ "entidad" => "Cardiovascular Centre, Hospital da Luz Lisboa, Lisbon, Portugal" "identificador" => "aff0005" ] ] ] ] "titulosAlternativos" => array:1 [ "pt" => array:1 [ "titulo" => "Estratificação de risco após síndromes coronárias agudas. <span class="elsevierStyleItalic">Scores</span>, <span class="elsevierStyleItalic">scores</span> e mais (um) <span class="elsevierStyleItalic">score</span>" ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Identification of high-risk patients soon after an acute coronary syndrome (ACS) event has been a challenge for clinicians in the past two or three decades. Numerous studies have clearly demonstrated that more intensive, even aggressive, management of these patients results in significantly better outcomes, in particular in the reduction of major adverse cardiac events.</p><p id="par0010" class="elsevierStylePara elsevierViewall">Both ST-elevation myocardial infarction (STEMI) and non-STEMI (NSTEMI) patients have been the subject of risk stratification studies and a number of risk scores have been proposed. Some of these scores were tested in populations of clinical trials (of which the TIMI scores<a class="elsevierStyleCrossRefs" href="#bib0055"><span class="elsevierStyleSup">1,2</span></a> are the best known), but others (such as the GRACE score<a class="elsevierStyleCrossRefs" href="#bib0065"><span class="elsevierStyleSup">3,4</span></a>) were derived from large registries, with the obvious advantages of reflecting real-life patients, including older and sicker patients.</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Identifying high-risk patients</span><p id="par0015" class="elsevierStylePara elsevierViewall">ACS risk scores aim to identify high-risk patients who should be managed with the best available care, in the shortest possible timeframe. This is in contrast with, for example, the CHA<span class="elsevierStyleInf">2</span>DS<span class="elsevierStyleInf">2</span>-VASc score<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">5</span></a> for non-valvular atrial fibrillation, which aims to identify very low-risk patients who do not need to be anticoagulated, since the risk of cerebral or peripheral embolism is minimal.</p><p id="par0020" class="elsevierStylePara elsevierViewall">Early referral of these high-risk ACS patients to reference centers with percutaneous coronary intervention (PCI) capabilities and cardiac intensive care units has been shown to result in better short- and long-term outcomes.</p><p id="par0025" class="elsevierStylePara elsevierViewall">Risk stratification can be particularly useful to identify high-risk NSTEMI patients who should be referred for more intensive management at an earlier stage of their ACS episode.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Low-risk patients should be properly treated too</span><p id="par0030" class="elsevierStylePara elsevierViewall">A word of caution for the management of patients stratified as low-risk on presentation shortly after an ACS episode, who should also be referred for the best care possible, particularly those presenting with STEMI. Emergency response services should be ready to provide immediate referral to a PCI center, provided it is available in the timeframe defined by the ACS and PCI guidelines.<a class="elsevierStyleCrossRefs" href="#bib0080"><span class="elsevierStyleSup">6,7</span></a></p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Do we need yet another score?</span><p id="par0035" class="elsevierStylePara elsevierViewall">All existing risk stratification scores have their strengths and weaknesses. The TIMI scores have been used for some time now but they were derived from clinical trials and their application to real-world patients has been the subject of debate.</p><p id="par0040" class="elsevierStylePara elsevierViewall">The robust GRACE score<a class="elsevierStyleCrossRefs" href="#bib0065"><span class="elsevierStyleSup">3,4</span></a> has the advantage of being based on a large registry, but the disadvantage of including variables that are not available on admission (such as some laboratory results), meaning that it is not applicable for immediate stratification after presentation in the pre-hospital or emergency room environments.</p><p id="par0045" class="elsevierStylePara elsevierViewall">A more immediately applicable score was proposed in 2013 by Huynh et al.<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">8</span></a> based on a Canadian population registry. The Canada Acute Coronary Syndrome (C-ACS) risk score is a simple-to-use score with only four variables (age, Killip class, systolic blood pressure and heart rate) that the investigators have shown enables rapid identification of high-risk patients with ACS, even before biological markers can be obtained.</p><p id="par0050" class="elsevierStylePara elsevierViewall">The question then arises: if we already have good and reliable scores for ACS risk stratification, why would we want yet another score?</p><p id="par0055" class="elsevierStylePara elsevierViewall">The main reason is concern about the applicability of scores derived from populations from North America (US and Canada) to European ACS patients. There are a number of reasons to question this extrapolation. There are relevant epidemiological, genetic, environmental and cultural differences as well as differences in organizational aspects of healthcare systems. Also, ACS management differs considerably between countries on opposite sides of the ocean.</p><p id="par0060" class="elsevierStylePara elsevierViewall">To resolve this question, in this issue of the <span class="elsevierStyleItalic">Journal</span> Timóteo et al.<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">9</span></a> propose a new score derived from the Portuguese Registry on Acute Coronary Syndromes (ProACS), a multicenter nationwide ACS registry. It is a prospective, continuous, and observational registry that includes more than 40<span class="elsevierStyleHsp" style=""></span>000 patients from 33 participating cardiology departments in Portugal.</p><p id="par0065" class="elsevierStylePara elsevierViewall">Thus, this study has the advantage of being based on a large, continuous, national ACS registry, that likely reflects local real-world practice. The validation (both internal and external) was well designed, the score's performance was similar when comparing patients with STEMI and NSTEMI, and its predictive ability was only slightly lower than that of the robust GRACE risk score. The external validation of the score has been previously published in this journal.<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">10</span></a></p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Creating a new ACS risk score? Keep it simple</span><p id="par0070" class="elsevierStylePara elsevierViewall">Having learned the lessons of the C-ACS score, Timóteo et al. designed the ProACS score to be simple to use and without the need for laboratory results.</p><p id="par0075" class="elsevierStylePara elsevierViewall">Simplicity is a key factor for widespread applicability of a risk score. As the authors mention in the discussion, the need to wait for laboratory results has led to the underuse of the GRACE score in daily clinical practice.</p><p id="par0080" class="elsevierStylePara elsevierViewall">The proposed ProACS score can be easily calculated with clinical variables only, and has nonetheless showed good discriminatory ability in the identification of high-risk ACS patients (both STEMI and NSTEMI).</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Could we make it even simpler?</span><p id="par0085" class="elsevierStylePara elsevierViewall">As mentioned above, one of the major advantages of the C-ACS score is its simplicity, as it has only four variables to consider, 1 point for each variable and clear cut-off values (age ≥75 years, Killip class >1, systolic blood pressure <100 mm Hg, and heart rate >100 beats/min). Huynh et al.<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">8</span></a> could justifiably point out in their conclusions “Because this risk score is simple and easy to memorize and calculate, it can be rapidly applied by health care professionals without advanced medical training.”</p><p id="par0090" class="elsevierStylePara elsevierViewall">The ProACS score is also simple to calculate, but the cut-off values for some of the variables are not so easy to memorize. We may wonder if the score's discriminatory value would decrease significantly if more straightforward numbers were used as cut-offs, e.g. 70 (or 75) instead of 72 years for age and/or 115 mmHg instead of 116 mmHg for systolic blood pressure.</p><p id="par0095" class="elsevierStylePara elsevierViewall">The exact transposition of the multivariate statistical analysis is understandable, but sometimes some loss of discriminatory value (as long as it is only marginal) can be compensated by more user-friendly cut-off variables.</p><p id="par0100" class="elsevierStylePara elsevierViewall">That being said, the authors of the ProACS score are to be congratulated for their work, which deserves the attention of other investigators in this research area. Validation of their proposed score by other groups in other European countries would be most welcome.</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Conflicts of interest</span><p id="par0105" class="elsevierStylePara elsevierViewall">The author has no conflicts of interest to declare.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:7 [ 0 => array:2 [ "identificador" => "sec0005" "titulo" => "Identifying high-risk patients" ] 1 => array:2 [ "identificador" => "sec0010" "titulo" => "Low-risk patients should be properly treated too" ] 2 => array:2 [ "identificador" => "sec0015" "titulo" => "Do we need yet another score?" ] 3 => array:2 [ "identificador" => "sec0020" "titulo" => "Creating a new ACS risk score? Keep it simple" ] 4 => array:2 [ "identificador" => "sec0025" "titulo" => "Could we make it even simpler?" ] 5 => array:2 [ "identificador" => "sec0030" "titulo" => "Conflicts of interest" ] 6 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:10 [ 0 => array:3 [ "identificador" => "bib0055" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "The TIMI risk score for unstable angina/non-ST-elevation MI. A method for prognostication and therapeutic decision making" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:3 [ 0 => "E.M. Antman" 1 => "M. Cohen" 2 => "P.J. Bernink" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "JAMA" "fecha" => "2000" "volumen" => "284" "paginaInicial" => "835" "paginaFinal" => "842" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/10938172" "web" => "Medline" ] ] ] ] ] ] ] ] 1 => array:3 [ "identificador" => "bib0060" "etiqueta" => "2" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "TIMI risk score for ST-elevation myocardial infarction: a convenient, bedside, clinical score for risk assessment at presentation" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:3 [ 0 => "D.A. Morrow" 1 => "E.M. Antman" 2 => "A. Charlesworth" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Circulation" "fecha" => "2000" "volumen" => "102" "paginaInicial" => "2031" "paginaFinal" => "2037" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/11044416" "web" => "Medline" ] ] ] ] ] ] ] ] 2 => array:3 [ "identificador" => "bib0065" "etiqueta" => "3" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Predictors of hospital mortality in the global registry of acute coronary events" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:3 [ 0 => "C.B. Granger" 1 => "R.J. Goldberg" 2 => "O. Dabbous" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1001/archinte.163.19.2345" "Revista" => array:6 [ "tituloSerie" => "Arch Intern Med" "fecha" => "2003" "volumen" => "163" "paginaInicial" => "2345" "paginaFinal" => "2353" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/14581255" "web" => "Medline" ] ] ] ] ] ] ] ] 3 => array:3 [ "identificador" => "bib0070" "etiqueta" => "4" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "A validated prediction model for all forms of acute coronary syndrome: estimating the risk of 6-month postdischarge death in an international registry" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:3 [ 0 => "K.A. Eagle" 1 => "M.J. Lim" 2 => "O.H. Dabbous" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:5 [ "tituloSerie" => "J Am Med Assoc" "fecha" => "2004" "volumen" => "291" "paginaInicial" => "2727" "paginaFinal" => "2733" ] ] ] ] ] ] 4 => array:3 [ "identificador" => "bib0075" "etiqueta" => "5" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Refining clinical risk stratification for predicting stroke and thromboembolism in atrial fibrillation using a novel risk factor-based approach: the euro heart survey on atrial fibrillation" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:3 [ 0 => "G.Y. Lip" 1 => "R. Nieuwlaat" 2 => "R. Pisters" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1378/chest.09-1584" "Revista" => array:6 [ "tituloSerie" => "Chest" "fecha" => "2010" "volumen" => "137" "paginaInicial" => "263" "paginaFinal" => "272" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/19762550" "web" => "Medline" ] ] ] ] ] ] ] ] 5 => array:3 [ "identificador" => "bib0080" "etiqueta" => "6" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "ESC Guidelines for the management of acute myocardial infarction in patients presenting with ST-segment elevation" "autores" => array:1 [ 0 => array:3 [ "colaboracion" => "Task Force on the management of ST-segment elevation acute myocardial infarction of the European Society of Cardiology (ESC)" "etal" => true "autores" => array:3 [ 0 => "G. Steg" 1 => "S.K. James" 2 => "D. Atar" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1093/eurheartj/ehs215" "Revista" => array:6 [ "tituloSerie" => "Eur Heart J" "fecha" => "2012" "volumen" => "33" "paginaInicial" => "2569" "paginaFinal" => "2619" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/22922416" "web" => "Medline" ] ] ] ] ] ] ] ] 6 => array:3 [ "identificador" => "bib0085" "etiqueta" => "7" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "2014 ESC/EACTS Guidelines on myocardial revascularization: The Task Force on Myocardial Revascularization of the European Society of Cardiology (ESC) and the European Association for Cardio-Thoracic Surgery (EACTS) Developed with the special contribution of the European Association of Percutaneous Cardiovascular Interventions (EAPCI)" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:3 [ 0 => "S. Windecker" 1 => "P. Kolh" 2 => "F. Alfonso" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1093/eurheartj/ehu278" "Revista" => array:6 [ "tituloSerie" => "Eur Heart J" "fecha" => "2014" "volumen" => "35" "paginaInicial" => "2541" "paginaFinal" => "2619" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/25173339" "web" => "Medline" ] ] ] ] ] ] ] ] 7 => array:3 [ "identificador" => "bib0090" "etiqueta" => "8" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Canada Acute Coronary Syndrome Risk Score: a new risk score for early prognostication in acute coronary syndromes" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:3 [ 0 => "T. Huynh" 1 => "S. Krouz" 2 => "A. Yan" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.ahj.2013.03.023" "Revista" => array:6 [ "tituloSerie" => "Am Heart J" "fecha" => "2013" "volumen" => "166" "paginaInicial" => "58" "paginaFinal" => "63" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/23816022" "web" => "Medline" ] ] ] ] ] ] ] ] 8 => array:3 [ "identificador" => "bib0095" "etiqueta" => "9" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "ProACS risk score: an early and simple score for risk stratification of patients with acute coronary syndromes" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:3 [ 0 => "A.T. Timóteo" 1 => "S. Aguiar Rosa" 2 => "M.A. Nogueira" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.repc.2016.05.010" "Revista" => array:6 [ "tituloSerie" => "Rev Port Cardiol" "fecha" => "2017" "volumen" => "36" "paginaInicial" => "77" "paginaFinal" => "83" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/28153630" "web" => "Medline" ] ] ] ] ] ] ] ] 9 => array:3 [ "identificador" => "bib0100" "etiqueta" => "10" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "External validation of the ProACS score for risk stratification of patients with acute coronary syndromes" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:3 [ 0 => "A.T. Timóteo" 1 => "S. Aguiar Rosa" 2 => "M.A. Nogueira" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.repc.2015.11.010" "Revista" => array:6 [ "tituloSerie" => "Rev Port Cardiol" "fecha" => "2016" "volumen" => "35" "paginaInicial" => "323" "paginaFinal" => "328" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/27255171" "web" => "Medline" ] ] ] ] ] ] ] ] ] ] ] ] ] "idiomaDefecto" => "en" "url" => "/21742049/0000003600000002/v1_201702240018/S2174204917300284/v1_201702240018/en/main.assets" "Apartado" => array:4 [ "identificador" => "9917" "tipo" => "SECCION" "en" => array:2 [ "titulo" => "Original Articles" "idiomaDefecto" => true ] "idiomaDefecto" => "en" ] "PDF" => "https://static.elsevier.es/multimedia/21742049/0000003600000002/v1_201702240018/S2174204917300284/v1_201702240018/en/main.pdf?idApp=UINPBA00004E&text.app=https://revportcardiol.org/" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2174204917300284?idApp=UINPBA00004E" ]
| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 November | 10 | 4 | 14 |
| 2024 October | 53 | 34 | 87 |
| 2024 September | 52 | 29 | 81 |
| 2024 August | 61 | 39 | 100 |
| 2024 July | 44 | 31 | 75 |
| 2024 June | 39 | 25 | 64 |
| 2024 May | 44 | 16 | 60 |
| 2024 April | 28 | 33 | 61 |
| 2024 March | 38 | 22 | 60 |
| 2024 February | 29 | 37 | 66 |
| 2024 January | 23 | 38 | 61 |
| 2023 December | 19 | 30 | 49 |
| 2023 November | 32 | 19 | 51 |
| 2023 October | 33 | 16 | 49 |
| 2023 September | 23 | 22 | 45 |
| 2023 August | 32 | 28 | 60 |
| 2023 July | 21 | 9 | 30 |
| 2023 June | 21 | 16 | 37 |
| 2023 May | 35 | 17 | 52 |
| 2023 April | 19 | 5 | 24 |
| 2023 March | 44 | 24 | 68 |
| 2023 February | 30 | 20 | 50 |
| 2023 January | 17 | 20 | 37 |
| 2022 December | 31 | 21 | 52 |
| 2022 November | 32 | 21 | 53 |
| 2022 October | 38 | 14 | 52 |
| 2022 September | 28 | 31 | 59 |
| 2022 August | 41 | 26 | 67 |
| 2022 July | 25 | 29 | 54 |
| 2022 June | 23 | 22 | 45 |
| 2022 May | 30 | 25 | 55 |
| 2022 April | 23 | 25 | 48 |
| 2022 March | 30 | 47 | 77 |
| 2022 February | 46 | 35 | 81 |
| 2022 January | 39 | 22 | 61 |
| 2021 December | 29 | 34 | 63 |
| 2021 November | 43 | 37 | 80 |
| 2021 October | 51 | 49 | 100 |
| 2021 September | 31 | 27 | 58 |
| 2021 August | 33 | 29 | 62 |
| 2021 July | 24 | 24 | 48 |
| 2021 June | 18 | 20 | 38 |
| 2021 May | 37 | 38 | 75 |
| 2021 April | 42 | 27 | 69 |
| 2021 March | 42 | 15 | 57 |
| 2021 February | 66 | 24 | 90 |
| 2021 January | 29 | 11 | 40 |
| 2020 December | 36 | 12 | 48 |
| 2020 November | 24 | 11 | 35 |
| 2020 October | 15 | 18 | 33 |
| 2020 September | 47 | 14 | 61 |
| 2020 August | 15 | 11 | 26 |
| 2020 July | 30 | 12 | 42 |
| 2020 June | 45 | 13 | 58 |
| 2020 May | 30 | 6 | 36 |
| 2020 April | 28 | 9 | 37 |
| 2020 March | 32 | 7 | 39 |
| 2020 February | 34 | 22 | 56 |
| 2020 January | 29 | 8 | 37 |
| 2019 December | 14 | 1 | 15 |
| 2019 November | 22 | 9 | 31 |
| 2019 October | 21 | 5 | 26 |
| 2019 September | 11 | 7 | 18 |
| 2019 August | 34 | 8 | 42 |
| 2019 July | 31 | 11 | 42 |
| 2019 June | 22 | 6 | 28 |
| 2019 May | 28 | 10 | 38 |
| 2019 April | 15 | 14 | 29 |
| 2019 March | 20 | 9 | 29 |
| 2019 February | 27 | 7 | 34 |
| 2019 January | 15 | 5 | 20 |
| 2018 December | 20 | 9 | 29 |
| 2018 November | 36 | 10 | 46 |
| 2018 October | 70 | 11 | 81 |
| 2018 September | 29 | 16 | 45 |
| 2018 August | 38 | 5 | 43 |
| 2018 July | 11 | 3 | 14 |
| 2018 June | 25 | 7 | 32 |
| 2018 May | 24 | 3 | 27 |
| 2018 April | 54 | 7 | 61 |
| 2018 March | 39 | 2 | 41 |
| 2018 February | 22 | 5 | 27 |
| 2018 January | 34 | 3 | 37 |
| 2017 December | 49 | 9 | 58 |
| 2017 November | 31 | 6 | 37 |
| 2017 October | 16 | 12 | 28 |
| 2017 September | 15 | 6 | 21 |
| 2017 August | 26 | 6 | 32 |
| 2017 July | 18 | 5 | 23 |
| 2017 June | 26 | 8 | 34 |
| 2017 May | 33 | 7 | 40 |
| 2017 April | 16 | 9 | 25 |
| 2017 March | 47 | 34 | 81 |
| 2017 February | 7 | 5 | 12 |
Show all
