Letter to the Editor
Risk stratification in acute coronary syndromes: Graced by a new score?
Estratificação de risco nas síndromas coronárias agudas: como poderá o Grace ser destronado?
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Francisco, Eduardo Infante de Oliveira, Miguel Nobre Menezes, Pedro Carrilho Ferreira, Pedro Canas da Silva, Ângelo Nobre, Fausto J. Pinto" "autores" => array:7 [ 0 => array:2 [ "nombre" => "Ana Rita G." "apellidos" => "Francisco" ] 1 => array:2 [ "nombre" => "Eduardo" "apellidos" => "Infante de Oliveira" ] 2 => array:2 [ "nombre" => "Miguel" "apellidos" => "Nobre Menezes" ] 3 => array:2 [ "nombre" => "Pedro" "apellidos" => "Carrilho Ferreira" ] 4 => array:2 [ "nombre" => "Pedro" "apellidos" => "Canas da Silva" ] 5 => array:2 [ "nombre" => "Ângelo" "apellidos" => "Nobre" ] 6 => array:2 [ "nombre" => "Fausto J." 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"tieneTextoCompleto" => true "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "677" "paginaFinal" => "679" ] ] "autores" => array:1 [ 0 => array:4 [ "autoresLista" => "Luís Paiva, Sérgio Barra, Lino Gonçalves" "autores" => array:3 [ 0 => array:4 [ "nombre" => "Luís" "apellidos" => "Paiva" "email" => array:1 [ 0 => "luisvpaiva@gmail.com" ] "referencia" => array:3 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] 2 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] 1 => array:3 [ "nombre" => "Sérgio" "apellidos" => "Barra" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">c</span>" "identificador" => "aff0015" ] ] ] 2 => array:3 [ "nombre" => "Lino" "apellidos" => "Gonçalves" "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:3 [ 0 => array:3 [ "entidad" => "Hospital Geral, Centro Hospitalar e Universitário de Coimbra, Coimbra, Portugal" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Universidade de Coimbra, Coimbra, Portugal" "etiqueta" => "b" "identificador" => "aff0010" ] 2 => array:3 [ "entidad" => "Cardiology Department, Papworth Hospital NHS Foundation Trust, Cambridge, UK" "etiqueta" => "c" "identificador" => "aff0015" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "pt" => array:1 [ "titulo" => "Estratificação de risco nas síndromas coronárias agudas: como poderá o Grace ser destronado?" ] ] "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" => 1645 "Ancho" => 1587 "Tamanyo" => 183499 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Receiver operating characteristic curve analysis for the prediction of in-hospital mortality using the ProACS and GRACE scores. AUC: area under the curve; CI: confidence interval; SE: standard error.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">We read with much interest the recently published paper by Timóteo et al.<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">1</span></a> This study makes an important contribution to the expanding field of risk stratification in myocardial infarction (MI), which is the cornerstone for patient management. The authors developed a simple risk model from a large cohort of real-world MI patients, comprising common and easily accessible clinical variables, constructing a high-performing in-hospital mortality risk score.</p><p id="par0010" class="elsevierStylePara elsevierViewall">Several risk scores have been developed to predict outcomes in patients with acute coronary syndromes. The GRACE score<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">2</span></a> is the most widely used and has been shown to outperform other previously developed mortality risk models.<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">3</span></a> The ACHTUNG-Rule,<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">4</span></a> based on clinical and laboratory parameters, outperformed the GRACE score in its derivation and validation sets but, in addition to requiring a calculator, it still lacks calibration and validation in larger and external cohorts. McNamara et al.<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">5</span></a> recently developed a novel in-hospital mortality risk score from a large contemporary cohort, with calibration curves demonstrating its utility even in patients presenting with cardiac arrest, a significant advantage in the context of MI given the difficulty in accurately predicting outcomes in this patient subgroup.</p><p id="par0015" class="elsevierStylePara elsevierViewall">Although the GRACE and ProACS<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">1</span></a> scores share some variables, the latter does have some advantages: (i) it is simpler to use in clinical practice, with fewer variables and no need for a calculator; (ii) it uses the same cutoffs for ST-elevation (STEMI) and non-ST-elevation (NSTEMI) MI, unlike GRACE; and (iii) it is particularly useful in identifying truly low-risk patients, as a score of 0 is associated with very low risk of in-hospital mortality (0.4%). In contrast, the GRACE score predicts mortality risk as a continuum, although low-risk strata have been proposed for STEMI and NSTEMI cases.</p><p id="par0020" class="elsevierStylePara elsevierViewall">We validated the ProACS risk model in an independent and somewhat more contemporary (2010-2013) cohort of 1000 consecutive MI patients (43.5% with STEMI). <a class="elsevierStyleCrossRef" href="#fig0005">Figure 1</a> illustrates the performance of both GRACE and ProACS for predicting in-hospital mortality in our cohort. Although the intermediate and high-risk strata of the ProACS score identified nearly 98% of in-hospital deaths, confirming the utility of the score in the stratification of ACS patients, its discriminative power was significantly inferior to that reported in its internal and external validation cohorts. Perhaps more importantly, the discriminative performance of ProACS was significantly inferior to that of GRACE.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0025" class="elsevierStylePara elsevierViewall">We believe that any new risk score should provide simplicity without significantly compromising accuracy of risk stratification. Using a more intuitive approach with a measure of risk reclassification, known as the integrated discrimination improvement (IDI) index,<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">6</span></a> we noticed that compared with GRACE, the ProACS score is indeed particularly useful in identifying truly low-risk patients who could potentially be considered for conservative management or early discharge (a 56.3% improvement in prediction for patients who did not die during hospitalization). However, this comes at the expense of a significantly lower (61.8%) predictive ability in the identification of patients who eventually die during their hospitalization. The relative IDI index was -5.5%. We further expanded on this by using a category-based measure of risk reclassification known as net reclassification improvement (NRI).<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">6</span></a> A positive and significant NRI index translates a net overall successful reclassification of subjects into more appropriate risk categories (e.g. a patient who reaches the primary endpoint who is reclassified into a higher risk group with the new model or a subject who does not reach the primary endpoint who is reclassified into a lower risk category). We used the same risk categories proposed by the GRACE and ProACS investigators. As seen in <a class="elsevierStyleCrossRefs" href="#tbl0005">Tables 1 and 2</a>, altogether the ProACS score reclassified 26.2% of STEMI patients and 17.7% of NSTEMI patients into risk strata which were less accurate representations of their observed mortality risks. However, ProACS did reclassify low-risk NSTEMI patients into more appropriate (lower) risk categories (partial NRI of +9.3%). The above observations suggest that the GRACE score is superior in identifying high-risk patients, whereas ProACS may be more useful in identifying low-risk patients who present with NSTEMI (but not STEMI).</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><p id="par0030" class="elsevierStylePara elsevierViewall">Furthermore, the ability to also estimate mortality during clinical follow-up and across different types of MI would surely improve the applicability of ProACS, since risk models differ significantly in their predictive performance when applied to MI that arises from a primary coronary event (type 1) vs. supply/demand mismatch (type 2).<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">7</span></a></p><p id="par0035" class="elsevierStylePara elsevierViewall">In summary, although the authors should be commended for their attempt to improve and simplify risk stratification of MI patients, it remains to be determined whether the simplicity of this new score, derived from a large Portuguese registry, is offset by its inferior prognostic power compared to the gold standard ACS risk score.</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Conflicts of interest</span><p id="par0040" class="elsevierStylePara elsevierViewall">The authors have 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 "multimedia" => array:3 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1645 "Ancho" => 1587 "Tamanyo" => 183499 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Receiver operating characteristic curve analysis for the prediction of in-hospital mortality using the ProACS and GRACE scores. AUC: area under the curve; CI: confidence interval; SE: standard error.</p>" ] ] 1 => array:8 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at1" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:2 [ "leyenda" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">NRI: net reclassification improvement.</p><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">For patients with ST-elevation myocardial infarction (STEMI), a GRACE score below 126 was considered low risk, a score between 126 and 154 was assigned to the intermediate risk category and above 154 was assigned to the high risk group.</p>" "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " colspan="3" align="center" valign="top" scope="col">In-hospital all-cause mortality</th><th class="td" title="table-head " colspan="3" align="center" valign="top" scope="col" style="border-bottom: 2px solid black">GRACE (STEMI)</th><th class="td" title="table-head " align="" valign="top" scope="col"> \t\t\t\t\t\t\n \t\t\t\t</th></tr><tr title="table-row"><th class="td" title="table-head " align="" valign="top" scope="col" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="" valign="top" scope="col" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="" valign="top" scope="col" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Low risk \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Moderate risk \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">High risk \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="" valign="top" scope="col" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry " rowspan="3" align="left" valign="top">Events (n=48)</td><td class="td" title="table-entry " rowspan="6" align="left" valign="middle">ProACS</td><td class="td" title="table-entry " align="left" valign="top">Low risk \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " rowspan="6" align="left" valign="top">NRI: -26.5%<br>p<0.001</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Moderate risk \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">9 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">High risk \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">36 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " rowspan="3" align="left" valign="top">Non-Events (n=387)</td><td class="td" title="table-entry " align="left" valign="top">Low risk \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">4 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Moderate risk \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">81 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">86 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">56 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">High risk \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">12 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">146 \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1520525.png" ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Net reclassification improvement for in-hospital all-cause mortality, comparing ProACS and GRACE scores for ST-elevation myocardial infarction.</p>" ] ] 2 => array:8 [ "identificador" => "tbl0010" "etiqueta" => "Table 2" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at2" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:2 [ "leyenda" => "<p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">NRI: net reclassification improvement.</p><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">For patients with non-ST-segment elevation myocardial infarction (NSTEMI), a GRACE score below 109 was considered low risk, while scores between 109 and 140 and above 140 were assigned to intermediate and high risk categories, respectively.</p>" "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " rowspan="2" align="center" valign="top" scope="col" colspan="3" style="border-bottom: 2px solid black">In-hospital all-cause mortality</th><th class="td" title="table-head " colspan="3" align="center" valign="top" scope="col" style="border-bottom: 2px solid black">GRACE (NSTEMI)</th><th class="td" title="table-head " align="" valign="top" scope="col"> \t\t\t\t\t\t\n \t\t\t\t</th></tr><tr title="table-row"><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Low risk \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Moderate risk \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">High risk \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="" valign="top" scope="col" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry " rowspan="3" align="left" valign="top">Events (n=37)</td><td class="td" title="table-entry " rowspan="6" align="left" valign="middle">ProACS</td><td class="td" title="table-entry " align="left" valign="top">Low risk \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " rowspan="6" align="left" valign="top">NRI: -17.6%<br>p=0.051</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Moderate risk \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">8 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">High risk \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">26 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " rowspan="3" align="left" valign="top">Non-Events (n=528)</td><td class="td" title="table-entry " align="left" valign="top">Low risk \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">20 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">18 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">12 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Moderate risk \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">55 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">82 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">101 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">High risk \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">27 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">213 \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1520526.png" ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Net reclassification improvement for in-hospital all-cause mortality, comparing ProACS and GRACE scores for non-ST-elevation myocardial infarction.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0015" "bibliografiaReferencia" => array:7 [ 0 => array:3 [ "identificador" => "bib0045" "etiqueta" => "1" "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. Afonso 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" ] ] ] ] ] ] ] ] 1 => array:3 [ "identificador" => "bib0050" "etiqueta" => "2" "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:3 [ "colaboracion" => "Global Registry of Acute Coronary Events Investigators" "etal" => true "autores" => array:3 [ 0 => "C.B. Granger" 1 => "R.J. Goldberg" 2 => "O.H. Dabbous" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1001/archinte.163.19.2345" "Revista" => array:7 [ "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" ] ] "itemHostRev" => array:3 [ "pii" => "S1058274615004437" "estado" => "S300" "issn" => "10582746" ] ] ] ] ] ] ] 2 => array:3 [ "identificador" => "bib0055" "etiqueta" => "3" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "TIMI, PURSUIT, and GRACE risk scores: sustained prognostic value an interaction with revascularizatiton in NSTE-ACS" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:3 [ 0 => "P. De Araújo Gonçalves" 1 => "J. Ferreira" 2 => "C. Aguiar" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1093/eurheartj/ehi187" "Revista" => array:6 [ "tituloSerie" => "Eur Heart J" "fecha" => "2015" "volumen" => "26" "paginaInicial" => "865" "paginaFinal" => "872" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/15764619" "web" => "Medline" ] ] ] ] ] ] ] ] 3 => array:3 [ "identificador" => "bib0060" "etiqueta" => "4" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "ACHTUNG-Rule: a new and improved model for prognostic assessment in myocardial infarction" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:3 [ 0 => "S. Barra" 1 => "R. Providencia" 2 => "L. Paiva" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1177/2048872612466536" "Revista" => array:6 [ "tituloSerie" => "Eur Heart J Acute Cardiovasc Care" "fecha" => "2012" "volumen" => "1" "paginaInicial" => "320" "paginaFinal" => "334" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/24062923" "web" => "Medline" ] ] ] ] ] ] ] ] 4 => array:3 [ "identificador" => "bib0065" "etiqueta" => "5" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Predicting in-hospital mortality in patients with acute myocardial infarction" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:3 [ 0 => "R.L. McNamara" 1 => "K.F. Kennedy" 2 => "D.J. Cohen" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.jacc.2016.05.049" "Revista" => array:6 [ "tituloSerie" => "J Am Coll Cardiol" "fecha" => "2016" "volumen" => "68" "paginaInicial" => "626" "paginaFinal" => "635" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/27491907" "web" => "Medline" ] ] ] ] ] ] ] ] 5 => array:3 [ "identificador" => "bib0070" "etiqueta" => "6" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Evaluating the added predictive ability of a new biomarker: from area under the ROC curve to reclassification and beyond" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:3 [ 0 => "M.J. Pencina" 1 => "R.B.S. D’Agostino" 2 => "R.B.J. D’Agostino" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1002/sim.2929" "Revista" => array:6 [ "tituloSerie" => "Stat Med" "fecha" => "2008" "volumen" => "27" "paginaInicial" => "157" "paginaFinal" => "172" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/17569110" "web" => "Medline" ] ] ] ] ] ] ] ] 6 => array:3 [ "identificador" => "bib0080" "etiqueta" => "7" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Universal definition of myocardial infarction: clinical insights" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:3 [ 0 => "L. Paiva" 1 => "R. Providência" 2 => "S. Barra" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1159/000371739" "Revista" => array:7 [ "tituloSerie" => "Cardiology" "fecha" => "2015" "volumen" => "131" "paginaInicial" => "13" "paginaFinal" => "21" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/25831989" "web" => "Medline" ] ] "itemHostRev" => array:3 [ "pii" => "S1058274611000218" "estado" => "S300" "issn" => "10582746" ] ] ] ] ] ] ] ] ] ] ] ] "idiomaDefecto" => "en" "url" => "/21742049/0000003600000009/v1_201709220127/S2174204917302489/v1_201709220127/en/main.assets" "Apartado" => array:4 [ "identificador" => "29282" "tipo" => "SECCION" "en" => array:2 [ "titulo" => "Letters to the editor" "idiomaDefecto" => true ] "idiomaDefecto" => "en" ] "PDF" => "https://static.elsevier.es/multimedia/21742049/0000003600000009/v1_201709220127/S2174204917302489/v1_201709220127/en/main.pdf?idApp=UINPBA00004E&text.app=https://revportcardiol.org/" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2174204917302489?idApp=UINPBA00004E" ]
| Year/Month | Html | Total | |
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| 2024 November | 10 | 4 | 14 |
| 2024 October | 39 | 26 | 65 |
| 2024 September | 48 | 24 | 72 |
| 2024 August | 49 | 27 | 76 |
| 2024 July | 54 | 27 | 81 |
| 2024 June | 24 | 17 | 41 |
| 2024 May | 29 | 11 | 40 |
| 2024 April | 27 | 28 | 55 |
| 2024 March | 29 | 23 | 52 |
| 2024 February | 38 | 22 | 60 |
| 2024 January | 21 | 24 | 45 |
| 2023 December | 32 | 26 | 58 |
| 2023 November | 32 | 22 | 54 |
| 2023 October | 25 | 18 | 43 |
| 2023 September | 23 | 11 | 34 |
| 2023 August | 22 | 26 | 48 |
| 2023 July | 21 | 8 | 29 |
| 2023 June | 24 | 15 | 39 |
| 2023 May | 35 | 24 | 59 |
| 2023 April | 27 | 0 | 27 |
| 2023 March | 47 | 19 | 66 |
| 2023 February | 31 | 22 | 53 |
| 2023 January | 19 | 20 | 39 |
| 2022 December | 44 | 26 | 70 |
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| 2022 October | 38 | 18 | 56 |
| 2022 September | 20 | 30 | 50 |
| 2022 August | 26 | 37 | 63 |
| 2022 July | 22 | 35 | 57 |
| 2022 June | 21 | 25 | 46 |
| 2022 May | 18 | 26 | 44 |
| 2022 April | 29 | 44 | 73 |
| 2022 March | 26 | 43 | 69 |
| 2022 February | 16 | 33 | 49 |
| 2022 January | 20 | 25 | 45 |
| 2021 December | 19 | 28 | 47 |
| 2021 November | 24 | 35 | 59 |
| 2021 October | 32 | 41 | 73 |
| 2021 September | 24 | 23 | 47 |
| 2021 August | 17 | 31 | 48 |
| 2021 July | 22 | 25 | 47 |
| 2021 June | 18 | 18 | 36 |
| 2021 May | 28 | 39 | 67 |
| 2021 April | 47 | 43 | 90 |
| 2021 March | 23 | 22 | 45 |
| 2021 February | 42 | 15 | 57 |
| 2021 January | 26 | 13 | 39 |
| 2020 December | 22 | 17 | 39 |
| 2020 November | 21 | 13 | 34 |
| 2020 October | 12 | 10 | 22 |
| 2020 September | 32 | 12 | 44 |
| 2020 August | 17 | 9 | 26 |
| 2020 July | 27 | 4 | 31 |
| 2020 June | 27 | 8 | 35 |
| 2020 May | 19 | 9 | 28 |
| 2020 April | 34 | 6 | 40 |
| 2020 March | 24 | 12 | 36 |
| 2020 February | 38 | 25 | 63 |
| 2020 January | 19 | 9 | 28 |
| 2019 December | 20 | 9 | 29 |
| 2019 November | 11 | 15 | 26 |
| 2019 October | 15 | 4 | 19 |
| 2019 September | 32 | 7 | 39 |
| 2019 August | 22 | 10 | 32 |
| 2019 July | 18 | 10 | 28 |
| 2019 June | 24 | 13 | 37 |
| 2019 May | 20 | 15 | 35 |
| 2019 April | 14 | 12 | 26 |
| 2019 March | 9 | 13 | 22 |
| 2019 February | 16 | 10 | 26 |
| 2019 January | 12 | 9 | 21 |
| 2018 December | 17 | 9 | 26 |
| 2018 November | 49 | 13 | 62 |
| 2018 October | 112 | 17 | 129 |
| 2018 September | 33 | 8 | 41 |
| 2018 August | 24 | 5 | 29 |
| 2018 July | 16 | 7 | 23 |
| 2018 June | 18 | 9 | 27 |
| 2018 May | 26 | 13 | 39 |
| 2018 April | 19 | 8 | 27 |
| 2018 March | 28 | 5 | 33 |
| 2018 February | 7 | 3 | 10 |
| 2018 January | 18 | 6 | 24 |
| 2017 December | 27 | 16 | 43 |
| 2017 November | 18 | 15 | 33 |
| 2017 October | 32 | 20 | 52 |
| 2017 September | 11 | 5 | 16 |
Show all
