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    "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">The article by Lobo et al&#46; in this issue of the <span class="elsevierStyleItalic">Journal</span><a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">1</span></a> aims to &#8220;compare access to new health technologies to treat coronary heart disease &#40;CHD&#41; in the health systems of Portugal and the US&#44; characterizing the needs of the populations and the resources available&#8221;&#46; Their analysis of access to these new technologies &#40;drugs and medical devices&#41; is based on differences between the dates of approval or marketing in the two countries&#46; The article is interesting&#44; informative and original&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">There are two points to be considered at the outset&#46; Firstly&#44; the article has 12 co-authors&#44; seven of whom work with CINTESIS&#44; the Center for Research in Health Technologies and Services &#40;of whom only one &#8211; Bruno Melica &#8211; is a cardiologist&#41;&#44; two are from the Portuguese Institute for Environmental Health &#40;ISAMB&#41;&#44; and three work in Boston&#44; USA&#46; CINTESIS<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">2</span></a> is a new strategic national research and development unit that aims to strengthen Portugal&#39;s science and technology system through cost-effective but highly complex research to meet the societal challenges of the Horizon 2020 program&#46; It has a regional impact&#44; since it involves six institutions in four regions in the north&#44; center and the Algarve&#46; One of its research lines&#44; known as TL1&#44; is clinical and health services research&#44; and the present article is within this ambit&#46; This large virtual institution is unique in Portugal&#44; with 16 research groups able to carry out translational research and innovation in the real-world healthcare environment&#46; ISAMB<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">3</span></a> is a new autonomous multidisciplinary research unit that brings together contributors from various research centers and institutions of the Faculty of Medicine of the University of Lisbon to carry out research&#44; dissemination and social intervention in the field of health sciences&#46; This&#44; to the best of my knowledge&#44; is the first article involving these two institutions in the area of cardiology&#46; I am also unaware of the level of the authors&#8217; knowledge of actual cardiological practice in Portugal&#44; and the article&#39;s reference list does not shed light on this question&#46; But the article appears to spring from the creation in 2015 of a national system for health technology assessment &#40;SiNATS&#41;&#44;<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">4</span></a> focusing on drugs and medical devices&#44; under the aegis of the Portuguese National Authority for Medicines and Health Products &#40;INFARMED&#41;&#44; which seeks to harmonize Portugal&#39;s health system with that of other European nations&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">The second point of interest is that the article compares data from countries with very different characteristics&#46; The population of the US is thirty times larger than Portugal&#39;s&#59; healthcare accounts for 10&#37; of gross national product in Portugal and 18&#37; in the US&#59; the literacy rate is also lower in Portugal &#40;95&#37; in 2011 compared to 99&#37; in the US in 2003&#41;&#44; as is health literacy&#59; and overall mortality is higher in Portugal &#40;11&#37; vs&#46; 8&#37; in 2014&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">5</span></a> Epidemiological data and available resources also differ greatly between the two countries&#46; Comparing Portugal and the US is at first sight a considerable challenge that is by no means guaranteed to succeed&#44; since&#44; for example&#44; Portugal lacks reliable epidemiological data&#44; especially on CHD &#40;the PULSAR registry<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">6</span></a> being one of the few exceptions&#41;&#44; while data on the US are available from the National Health and Nutrition Examination Survey&#44;<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">7</span></a> which regularly publishes national data with a much greater degree of reliability&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">Without going into the details of the Portuguese data&#44; including their sources or how they were collected&#44; it appears that risk profiles are lower than in the US&#44; which may explain the lower per capita hospitalization rates and mortality from CHD and myocardial infarction &#40;MI&#41; in Portugal&#46; It is impossible to ascertain the prevalence of CHD in Portugal&#59; except for the high prevalence of hypertension in the country&#44; rates of all other risk factors are lower than in the US&#46; As global coronary risk is lower in Portugal&#44; there is a significant difference in overall mortality from CHD &#40;72&#46;8 age- and gender-adjusted deaths per 100<span class="elsevierStyleHsp" style=""></span>000 population in Portugal vs&#46; 168 in the US in 2010&#41;&#46; We may wonder whether the data on CHD-related mortality in Portugal are accurate&#46; Information on mortality outside hospital may be incorrect&#59; for example&#44; sudden death is rarely recorded as CHD-related&#44; usually being considered as due to stroke&#44; and only recently have death certificates begun to be properly completed&#44; making diagnoses more credible&#46; It is estimated that 82&#37; of individuals who died from MI in 2006 did so outside hospital&#46;<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">8</span></a> There is no significant difference in MI-related mortality between Portugal and the US&#44; which may be due to lower global risk and the fact that medical care&#44; both pre- and in-hospital&#44; and hospital facilities are adequate in Portugal and comparable to those in the US&#46; Primary angioplasty rates have increased &#40;despite the small number of centers with 24-hour catheterization facilities&#41;&#44; reaching 338 per million population in 2013&#46;<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">9</span></a> The number of centers offering interventional cardiology in Portugal is relatively low &#40;25&#41;&#44; while only 69 offer cardiac surgery&#46; It does not therefore seem feasible to compare Portugal and the US in terms of available resources&#44; even considering the relative sizes of the two countries&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">With regard to the stated aim of comparing access to new technologies &#40;medical devices and drugs&#41; in the two countries&#44; the article is particularly interesting and informative&#44; and much will be new for most Portuguese cardiologists&#46; CHD was the basis of this comparison&#44; largely because of the rising expenditure on medical devices in this area&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">The US serves as a benchmark for Portugal&#44; even though it has an essentially private health system&#44; much higher per capita health expenditure&#44; and a regulatory agency&#44; the Food and Drug Administration &#40;FDA&#41;&#44; that is a worldwide reference for assessment of medical devices and drugs&#44; while the Portuguese health system is basically public&#44; and within the European Union &#40;EU&#41; each country can have completely different regulations and practices&#44; depending on the effectiveness of the regulatory process&#44; limitations on reimbursement&#44; individual economic capacity&#44; availability of resources&#44; etc&#46; Portuguese physicians are generally unaware of the process by which drugs are assessed&#44; approved and marketed&#44; and tend to think that the CE &#40;Conformit&#233; Europ&#233;enne&#41; mark is all that is required for a medical device to be used in Portugal&#46; The article by Lobo et al&#46; is particularly enlightening in this regard&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">It is telling that a national system for health technology assessment &#40;SiNATS&#41;<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">4</span></a> was only introduced in 2015&#46; The study by Lobo et al&#46; thus aimed to assess access to new health technologies before the implementation of SiNATS&#46; I do not know whether the system is already functioning in the field&#44; but it is clear that differences between Portugal and the US will remain&#46; It is also not clear whether implementation of the system will speed up or further complicate the process of assessment&#44; approval and marketing of drugs and medical devices&#46; One reason for the earlier introduction and adoption of new health technologies in Portugal&#44; as in Europe generally&#44; compared to the US&#44; may be because all that is needed is the CE mark&#44; although in Portugal high-risk devices also need to be registered with INFARMED before entering the market&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">The article states that more than 70&#37; of drugs are marketed sooner after approval in the US than in Portugal and other European countries&#44; whereas the approval and marketing process in the EU is faster for medical devices &#40;12 out of the 16 devices included in the study were approved earlier in Portugal&#41;&#46; On this point&#44; the contrast between Portugal and the US is interesting&#44; but it is hard to tell whether this is merely a curiosity or whether it actually affects the quality of healthcare&#44; leaving aside the fact that new technologies may be more cost-effective&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">The European Medicines Agency &#40;EMA&#41; authorizes marketing of drugs in the EU&#44; but centralized approval is only compulsory for certain medications&#46; In 2012&#44; the EMA was only responsible for issuing 13&#37; of marketing approvals of drugs in Portugal&#46;</p><p id="par0050" class="elsevierStylePara elsevierViewall">Like other countries&#44; Portugal has in recent years suffered cuts to healthcare expenditure&#44; not only in the budgets for hospitals&#44; health centers and staff&#44; but also in funds for approval and marketing of new drugs and medical devices&#46; Regarding drugs&#44; the government states that generics are identical to the original brand &#40;although this is not always true&#44; as for example the original brand Lasix is much more effective than generic furosemide for both outpatient and in-hospital use&#41;&#44; and there are incentives for pharmacies and physicians to prescribe them&#46; It is thus difficult for new drugs to gain approval&#44; as well as to decide on whether to reimburse them and their recommended cost&#44; before they enter the market and their efficacy is confirmed&#46;</p><p id="par0055" class="elsevierStylePara elsevierViewall">Before SiNATS began operating&#44; the introduction of new medical devices in Portugal was relatively straightforward&#46; The main stumbling-block was generally cost&#44; but this was an issue for hospitals&#44; which had to decide whether a new device could be covered by the institution&#39;s budget&#44; a decision that in turn depended on the extent to which the hospital&#39;s administration prioritized the provision of the best and latest health care for their patients&#46; Typical examples would be prosthetic aortic valves for percutaneous implantation&#44; left atrial appendage closure devices&#44; and new absorbable stents&#46; Assessment and approval of new medical devices in Europe does not require randomized trials&#44; which is the main reason that they are brought to market earlier than in the US&#46; Despite this advantage&#44; there are many cases of post-marketing safety alerts and recalls of devices in Europe&#44; due to insufficient time and experience before marketing&#44; in contrast to the requirement by the FDA in the US for clinical trials&#46; This question is currently under discussion in the European Parliament&#44; which is investigating changes in regulation&#46;<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">10</span></a></p><p id="par0060" class="elsevierStylePara elsevierViewall">The article by Lobo et al&#46; is highly informative&#44; even though a comparison between Portugal and the US&#44; in healthcare as in any other area&#44; is an almost impossible mission&#46;</p><p id="par0065" class="elsevierStylePara elsevierViewall">The main message is that differences between the two countries&#44; with drugs being approved earlier and devices being available sooner in Portugal&#44; may have contributed to improvements in healthcare in this country&#44; reducing the disparities between Portugal and the US in epidemiological risk profiles&#46;</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&#46;</p></span></span>"
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Editorial comment
Mission (almost) impossible
Missão (quase) impossível
Ricardo Seabra Gomes
Instituto do Coração, Carnaxide, Portugal
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            "en" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Lag in access to selected interventional cardiology devices between the US and Portugal&#46; Dashed line represents median time lag &#40;US-Portugal&#41;&#46; N&#47;A&#58; not available&#59; PT&#58; Portugal&#59; PTCA&#58; percutaneous transluminal coronary angioplasty&#59; TAVR&#58; transcatheter aortic valve repair&#46; The lag in access to devices was determined based on approval dates for the US available from the Food and Drug Administration &#40;in one case from a medical journal&#41;&#44; and&#44; for Portugal&#44; dates of CE marking retrieved from personal communication with medical device industry representatives&#44; online press releases&#44; EUCOMED&#44; and scientific journals&#44; and first use dates in Santa Cruz Hospital &#40;raw data available in Table A4 in <a class="elsevierStyleCrossRef" href="#sec0100">Appendix A</a>&#46; Supplementary Material&#41;&#46;</p>"
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    "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">The article by Lobo et al&#46; in this issue of the <span class="elsevierStyleItalic">Journal</span><a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">1</span></a> aims to &#8220;compare access to new health technologies to treat coronary heart disease &#40;CHD&#41; in the health systems of Portugal and the US&#44; characterizing the needs of the populations and the resources available&#8221;&#46; Their analysis of access to these new technologies &#40;drugs and medical devices&#41; is based on differences between the dates of approval or marketing in the two countries&#46; The article is interesting&#44; informative and original&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">There are two points to be considered at the outset&#46; Firstly&#44; the article has 12 co-authors&#44; seven of whom work with CINTESIS&#44; the Center for Research in Health Technologies and Services &#40;of whom only one &#8211; Bruno Melica &#8211; is a cardiologist&#41;&#44; two are from the Portuguese Institute for Environmental Health &#40;ISAMB&#41;&#44; and three work in Boston&#44; USA&#46; CINTESIS<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">2</span></a> is a new strategic national research and development unit that aims to strengthen Portugal&#39;s science and technology system through cost-effective but highly complex research to meet the societal challenges of the Horizon 2020 program&#46; It has a regional impact&#44; since it involves six institutions in four regions in the north&#44; center and the Algarve&#46; One of its research lines&#44; known as TL1&#44; is clinical and health services research&#44; and the present article is within this ambit&#46; This large virtual institution is unique in Portugal&#44; with 16 research groups able to carry out translational research and innovation in the real-world healthcare environment&#46; ISAMB<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">3</span></a> is a new autonomous multidisciplinary research unit that brings together contributors from various research centers and institutions of the Faculty of Medicine of the University of Lisbon to carry out research&#44; dissemination and social intervention in the field of health sciences&#46; This&#44; to the best of my knowledge&#44; is the first article involving these two institutions in the area of cardiology&#46; I am also unaware of the level of the authors&#8217; knowledge of actual cardiological practice in Portugal&#44; and the article&#39;s reference list does not shed light on this question&#46; But the article appears to spring from the creation in 2015 of a national system for health technology assessment &#40;SiNATS&#41;&#44;<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">4</span></a> focusing on drugs and medical devices&#44; under the aegis of the Portuguese National Authority for Medicines and Health Products &#40;INFARMED&#41;&#44; which seeks to harmonize Portugal&#39;s health system with that of other European nations&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">The second point of interest is that the article compares data from countries with very different characteristics&#46; The population of the US is thirty times larger than Portugal&#39;s&#59; healthcare accounts for 10&#37; of gross national product in Portugal and 18&#37; in the US&#59; the literacy rate is also lower in Portugal &#40;95&#37; in 2011 compared to 99&#37; in the US in 2003&#41;&#44; as is health literacy&#59; and overall mortality is higher in Portugal &#40;11&#37; vs&#46; 8&#37; in 2014&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">5</span></a> Epidemiological data and available resources also differ greatly between the two countries&#46; Comparing Portugal and the US is at first sight a considerable challenge that is by no means guaranteed to succeed&#44; since&#44; for example&#44; Portugal lacks reliable epidemiological data&#44; especially on CHD &#40;the PULSAR registry<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">6</span></a> being one of the few exceptions&#41;&#44; while data on the US are available from the National Health and Nutrition Examination Survey&#44;<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">7</span></a> which regularly publishes national data with a much greater degree of reliability&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">Without going into the details of the Portuguese data&#44; including their sources or how they were collected&#44; it appears that risk profiles are lower than in the US&#44; which may explain the lower per capita hospitalization rates and mortality from CHD and myocardial infarction &#40;MI&#41; in Portugal&#46; It is impossible to ascertain the prevalence of CHD in Portugal&#59; except for the high prevalence of hypertension in the country&#44; rates of all other risk factors are lower than in the US&#46; As global coronary risk is lower in Portugal&#44; there is a significant difference in overall mortality from CHD &#40;72&#46;8 age- and gender-adjusted deaths per 100<span class="elsevierStyleHsp" style=""></span>000 population in Portugal vs&#46; 168 in the US in 2010&#41;&#46; We may wonder whether the data on CHD-related mortality in Portugal are accurate&#46; Information on mortality outside hospital may be incorrect&#59; for example&#44; sudden death is rarely recorded as CHD-related&#44; usually being considered as due to stroke&#44; and only recently have death certificates begun to be properly completed&#44; making diagnoses more credible&#46; It is estimated that 82&#37; of individuals who died from MI in 2006 did so outside hospital&#46;<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">8</span></a> There is no significant difference in MI-related mortality between Portugal and the US&#44; which may be due to lower global risk and the fact that medical care&#44; both pre- and in-hospital&#44; and hospital facilities are adequate in Portugal and comparable to those in the US&#46; Primary angioplasty rates have increased &#40;despite the small number of centers with 24-hour catheterization facilities&#41;&#44; reaching 338 per million population in 2013&#46;<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">9</span></a> The number of centers offering interventional cardiology in Portugal is relatively low &#40;25&#41;&#44; while only 69 offer cardiac surgery&#46; It does not therefore seem feasible to compare Portugal and the US in terms of available resources&#44; even considering the relative sizes of the two countries&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">With regard to the stated aim of comparing access to new technologies &#40;medical devices and drugs&#41; in the two countries&#44; the article is particularly interesting and informative&#44; and much will be new for most Portuguese cardiologists&#46; CHD was the basis of this comparison&#44; largely because of the rising expenditure on medical devices in this area&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">The US serves as a benchmark for Portugal&#44; even though it has an essentially private health system&#44; much higher per capita health expenditure&#44; and a regulatory agency&#44; the Food and Drug Administration &#40;FDA&#41;&#44; that is a worldwide reference for assessment of medical devices and drugs&#44; while the Portuguese health system is basically public&#44; and within the European Union &#40;EU&#41; each country can have completely different regulations and practices&#44; depending on the effectiveness of the regulatory process&#44; limitations on reimbursement&#44; individual economic capacity&#44; availability of resources&#44; etc&#46; Portuguese physicians are generally unaware of the process by which drugs are assessed&#44; approved and marketed&#44; and tend to think that the CE &#40;Conformit&#233; Europ&#233;enne&#41; mark is all that is required for a medical device to be used in Portugal&#46; The article by Lobo et al&#46; is particularly enlightening in this regard&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">It is telling that a national system for health technology assessment &#40;SiNATS&#41;<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">4</span></a> was only introduced in 2015&#46; The study by Lobo et al&#46; thus aimed to assess access to new health technologies before the implementation of SiNATS&#46; I do not know whether the system is already functioning in the field&#44; but it is clear that differences between Portugal and the US will remain&#46; It is also not clear whether implementation of the system will speed up or further complicate the process of assessment&#44; approval and marketing of drugs and medical devices&#46; One reason for the earlier introduction and adoption of new health technologies in Portugal&#44; as in Europe generally&#44; compared to the US&#44; may be because all that is needed is the CE mark&#44; although in Portugal high-risk devices also need to be registered with INFARMED before entering the market&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">The article states that more than 70&#37; of drugs are marketed sooner after approval in the US than in Portugal and other European countries&#44; whereas the approval and marketing process in the EU is faster for medical devices &#40;12 out of the 16 devices included in the study were approved earlier in Portugal&#41;&#46; On this point&#44; the contrast between Portugal and the US is interesting&#44; but it is hard to tell whether this is merely a curiosity or whether it actually affects the quality of healthcare&#44; leaving aside the fact that new technologies may be more cost-effective&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">The European Medicines Agency &#40;EMA&#41; authorizes marketing of drugs in the EU&#44; but centralized approval is only compulsory for certain medications&#46; In 2012&#44; the EMA was only responsible for issuing 13&#37; of marketing approvals of drugs in Portugal&#46;</p><p id="par0050" class="elsevierStylePara elsevierViewall">Like other countries&#44; Portugal has in recent years suffered cuts to healthcare expenditure&#44; not only in the budgets for hospitals&#44; health centers and staff&#44; but also in funds for approval and marketing of new drugs and medical devices&#46; Regarding drugs&#44; the government states that generics are identical to the original brand &#40;although this is not always true&#44; as for example the original brand Lasix is much more effective than generic furosemide for both outpatient and in-hospital use&#41;&#44; and there are incentives for pharmacies and physicians to prescribe them&#46; It is thus difficult for new drugs to gain approval&#44; as well as to decide on whether to reimburse them and their recommended cost&#44; before they enter the market and their efficacy is confirmed&#46;</p><p id="par0055" class="elsevierStylePara elsevierViewall">Before SiNATS began operating&#44; the introduction of new medical devices in Portugal was relatively straightforward&#46; The main stumbling-block was generally cost&#44; but this was an issue for hospitals&#44; which had to decide whether a new device could be covered by the institution&#39;s budget&#44; a decision that in turn depended on the extent to which the hospital&#39;s administration prioritized the provision of the best and latest health care for their patients&#46; Typical examples would be prosthetic aortic valves for percutaneous implantation&#44; left atrial appendage closure devices&#44; and new absorbable stents&#46; Assessment and approval of new medical devices in Europe does not require randomized trials&#44; which is the main reason that they are brought to market earlier than in the US&#46; Despite this advantage&#44; there are many cases of post-marketing safety alerts and recalls of devices in Europe&#44; due to insufficient time and experience before marketing&#44; in contrast to the requirement by the FDA in the US for clinical trials&#46; This question is currently under discussion in the European Parliament&#44; which is investigating changes in regulation&#46;<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">10</span></a></p><p id="par0060" class="elsevierStylePara elsevierViewall">The article by Lobo et al&#46; is highly informative&#44; even though a comparison between Portugal and the US&#44; in healthcare as in any other area&#44; is an almost impossible mission&#46;</p><p id="par0065" class="elsevierStylePara elsevierViewall">The main message is that differences between the two countries&#44; with drugs being approved earlier and devices being available sooner in Portugal&#44; may have contributed to improvements in healthcare in this country&#44; reducing the disparities between Portugal and the US in epidemiological risk profiles&#46;</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&#46;</p></span></span>"
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Article information
ISSN: 21742049
Original language: English
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Idiomas
Revista Portuguesa de Cardiologia (English edition)
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