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    "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">An invasive strategy is increasingly used in patients with non-ST-segment elevation acute coronary syndrome &#40;NSTE-ACS&#41;&#44; especially when the risk of events is intermediate or high&#46;<a class="elsevierStyleCrossRefs" href="#bib0085"><span class="elsevierStyleSup">1&#44;2</span></a> In confirmed obstructive coronary artery disease&#44; coronary revascularization reduces both mortality and non-fatal events&#46;<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">1</span></a> Around 50&#37; of patients with NSTE-ACS have multivessel disease&#44; and so the type and form of revascularization may require an individualized decision-making process&#44; including discussion in the heart team&#46;<a class="elsevierStyleCrossRefs" href="#bib0085"><span class="elsevierStyleSup">1&#44;3</span></a> One of the issues facing the care team is whether revascularization of patients with NSTE-ACS and multivessel disease should be incomplete &#40;only the culprit artery&#41; or complete&#44; and in the latter case&#44; whether it should be carried out during the same procedure or in subsequent procedures&#46; There is growing evidence that multivessel revascularization&#44; including of non-culprit lesions&#44; in patients with ST-segment elevation myocardial infarction is safe and reduces the risk of recurrent events&#46;<a class="elsevierStyleCrossRefs" href="#bib0100"><span class="elsevierStyleSup">4&#8211;6</span></a> Although it is tempting to extrapolate these results to the NSTE-ACS patient population&#44; it is important to note that there have been no prospective randomized trials that confirm the superiority and safety of a multivessel revascularization strategy in the latter group&#46; Furthermore&#44; in patients with myocardial infarction presenting in cardiogenic shock&#44; revascularization of the culprit artery only may be superior to multivessel revascularization&#44; as recently demonstrated in a randomized trial&#46;<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">7</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">In this issue of the <span class="elsevierStyleItalic">Journal</span>&#44; Correia et al&#46;<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">8</span></a> compare a multivessel revascularization strategy with culprit-only revascularization in a population of patients with NSTE-ACS and multivessel disease&#46; This observational&#44; retrospective and longitudinal study included all patients with ACS who underwent percutaneous coronary intervention at a single hospital between 2010 and 2013&#46; Among NSTE-ACS patients&#44; the proportion with multivessel disease was 46&#37;&#44; defined as the presence of at least two lesions deemed angiographically significant &#40;&#8805;50&#37; stenosis&#41; in different coronary artery territories&#46; The population analyzed consisted of 202 patients&#44; 71 &#40;35&#37;&#41; of whom underwent multivessel revascularization&#44; while 131 &#40;65&#37;&#41; underwent culprit-only revascularization&#46; The culprit artery was identified using a combination of clinical&#44; electrocardiographic&#44; echocardiographic and angiographic data&#44; and the decision to perform coronary revascularization of non-culprit arteries and the timing of the procedure were determined by the interventional cardiologist and clinical cardiologist&#44; or by the heart team&#44; as appropriate&#46; Multivessel revascularization was defined as intervention &#40;percutaneous or surgical&#41; on two or more lesions in different coronary artery territories&#44; during the initial procedure &#40;first stage&#41; or planned in the following 30 days &#40;second stage&#41;&#46; The minimum follow-up was three years&#44; with a median of 1520 days &#40;4&#46;1 years&#41;&#44; and the analysis included occurrence of death&#44; reinfarction&#44; unplanned revascularization and major adverse cardiovascular events &#40;mortality&#44; reinfarction&#44; stroke or heart failure&#41;&#46; To minimize the bias created by factors influencing the selection of revascularization type&#44; a survival analysis was performed on a population divided by propensity score matching&#44; which included 66 patients in each group&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">It is important to note that the NSTE-ACS patients analyzed by Correia et al&#46;<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">8</span></a> constituted a selected population&#44; since they only included those with confirmed multivessel disease for whom it was decided to adopt an invasive strategy by percutaneous intervention&#46; Nevertheless&#44; their demographic and clinical characteristics are consistent with those reported in real-world registries&#46;<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">2</span></a> Additionally&#44; there were no significant differences between groups with different revascularization strategies&#44; either before or after propensity score matching&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">In patients who underwent multivessel revascularization&#44; most &#40;66&#37;&#41; were treated in a single procedure&#44; but only 52&#37; underwent complete revascularization&#46; In those in whom only the culprit artery was treated&#44; 35&#37; did not have their other stenoses treated because these were considered insignificant &#40;&#60;70&#37;&#41;&#44; 18&#37; because they had diffuse or complex disease&#44; 8&#37; because they had chronic occlusions&#44; and for more than one reason in the remainder&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">There were no significant differences between the groups with regard to clinical events during hospital stay&#46; However&#44; in medium- to long-term follow-up&#44; patients who underwent multivessel revascularization had a lower incidence of reinfarction &#40;5&#46;6&#37; vs&#46; 16&#46;8&#37;&#41; and unplanned revascularization &#40;5&#46;6&#37; vs&#46; 15&#46;3&#37;&#41;&#44; with no differences in mortality&#44; stroke or heart failure&#46; Patients who underwent culprit-only revascularization thus had around twice as many events in long-term follow-up of the composite endpoint of death&#44; reinfarction or unplanned revascularization&#46; The results before and after propensity score matching were similar&#46; A meta-analysis by Jang et al&#46;&#44; which analyzed eight observational studies comparing multivessel with culprit-only revascularization&#44; showed that the former strategy reduces the rate of unplanned revascularization by 25&#37; and is associated with a non-significant reduction of approximately 15&#37; in reinfarction and death&#46;<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">9</span></a></p><p id="par0030" class="elsevierStylePara elsevierViewall">If multivessel revascularization is to become the rule in patients with NSTE-ACS&#44; it is important to discuss its timing&#46; In the study by Correia et al&#46;&#44;<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">8</span></a> around a third of patients who underwent multivessel revascularization did so in a second procedure up to 30 days after the acute event&#46; This staged strategy is questionable&#44; since in the SMILE trial&#44; single-stage multivessel revascularization reduced the risk of recurrent events by almost 50&#37; compared with deferred multivessel revascularization &#40;second procedure performed three to seven days after the first&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">10</span></a> This reduction was mainly due to a significant reduction in the rate of unplanned revascularization&#46; However&#44; it is important to note that a trend toward less mortality and reinfarction was also found in patients who underwent single-stage revascularization&#44; with no increase in complications such as contrast-induced nephropathy or periprocedural infarction&#46;<a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">10</span></a></p><p id="par0035" class="elsevierStylePara elsevierViewall">Another factor to consider when deciding on the type of revascularization is coronary anatomy and disease extent&#46; In the study by Correia et al&#46;&#44;<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">8</span></a> over a quarter of the patients did not undergo multivessel revascularization because they had complex disease and&#47;or chronic occlusions&#46; The authors do not report the SYNTAX score or any other marker of the severity and extent of coronary artery disease&#44; so the decision to revascularize only the culprit artery may have been due to the patient&#39;s anatomical characteristics&#46;<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">1</span></a> More complex coronary artery disease is known to be associated with a higher rate of recurrent events in patients with NSTE-ACS&#46; It is therefore important to consider which strategy will enable the most complete revascularization in an individual patient with complex lesions&#46;<a class="elsevierStyleCrossRefs" href="#bib0085"><span class="elsevierStyleSup">1&#44;11</span></a> Similarly&#44; intermediate lesions should also be assessed thoroughly&#46; In Correia et al&#46;&#8217;s study&#44; in 35&#37; of patients only the culprit artery was revascularized because the other lesions were defined as moderate&#44; i&#46;e&#46; with &#60;70&#37; stenosis&#46; In this group&#44; functional assessment of the lesions could have modified the revascularization strategy&#46;<a class="elsevierStyleCrossRef" href="#bib0140"><span class="elsevierStyleSup">12</span></a> In a sub-analysis of the FAME study&#44; which included 328 patients with NSTE-ACS&#44; the decision to revascularize on the basis of fractional flow reserve was associated with a 19&#37; relative reduction and a 5&#37; absolute reduction in the risk of events &#40;including death from any cause&#44; infarction&#44; and any repeat revascularization&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0145"><span class="elsevierStyleSup">13</span></a> The value of using functional assessment to guide the revascularization strategy has also been validated in another study&#44; which included a sample of Portuguese NSTE-ACS patients&#46;<a class="elsevierStyleCrossRef" href="#bib0150"><span class="elsevierStyleSup">14</span></a></p><p id="par0040" class="elsevierStylePara elsevierViewall">The decision to revascularize only the culprit artery should also take into account the difficulty in identifying this artery&#44; which may be an additional challenge in selecting the strategy&#46;<a class="elsevierStyleCrossRef" href="#bib0145"><span class="elsevierStyleSup">13</span></a> In the study by Correia et al&#46;&#44;<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">8</span></a> the culprit artery was determined without the use of a predefined protocol and in a somewhat subjective manner&#46; However&#44; in around half of patients with NSTE-ACS&#44; there may be multiple complex plaques responsible for the infarction&#44; and identification of the culprit artery may not be straightforward&#46;<a class="elsevierStyleCrossRefs" href="#bib0155"><span class="elsevierStyleSup">15&#44;16</span></a> Additionally&#44; incomplete revascularization is associated with increased risk of events&#44; especially in patients with NSTE-ACS&#44; as demonstrated in various studies&#46;<a class="elsevierStyleCrossRefs" href="#bib0085"><span class="elsevierStyleSup">1&#44;16</span></a> These facts further support the role of a multivessel revascularization strategy in NSTE-ACS&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">In conclusion&#44; the study by Correia et al&#46;<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">8</span></a> supports the idea that multivessel revascularization should be the rule in patients with NSTE-ACS&#44; since it is a proven and safe strategy that can have a significant impact on reducing the risk of events in the medium to long term&#46;</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Conflicts of interest</span><p id="par0050" class="elsevierStylePara elsevierViewall">The author has no conflicts of interest to declare&#46;</p></span></span>"
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        "etiqueta" => "&#9734;"
        "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as&#58; Santos JF&#46; Revasculariza&#231;&#227;o multivaso na s&#237;ndrome coron&#225;ria aguda sem supradesnivelamento do segmento st&#58; deve ser a regra em todos os doentes&#63; Rev Port Cardiol&#46; 2018&#59;37&#58;155&#8211;157&#46;</p>"
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Multivessel revascularization in non-ST-elevation acute coronary syndrome: Should it become the rule in all patients?
Revascularização multivaso na síndrome coronária aguda sem supradesnivelamento do segmento st: deve ser a regra em todos os doentes?
José Ferreira Santos
Serviço de Cardiologia, Hospital da Luz, Setúbal, Portugal
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    "titulo" => "Multivessel revascularization in non-ST-elevation acute coronary syndrome&#58; Should it become the rule in all patients&#63;"
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    "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">An invasive strategy is increasingly used in patients with non-ST-segment elevation acute coronary syndrome &#40;NSTE-ACS&#41;&#44; especially when the risk of events is intermediate or high&#46;<a class="elsevierStyleCrossRefs" href="#bib0085"><span class="elsevierStyleSup">1&#44;2</span></a> In confirmed obstructive coronary artery disease&#44; coronary revascularization reduces both mortality and non-fatal events&#46;<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">1</span></a> Around 50&#37; of patients with NSTE-ACS have multivessel disease&#44; and so the type and form of revascularization may require an individualized decision-making process&#44; including discussion in the heart team&#46;<a class="elsevierStyleCrossRefs" href="#bib0085"><span class="elsevierStyleSup">1&#44;3</span></a> One of the issues facing the care team is whether revascularization of patients with NSTE-ACS and multivessel disease should be incomplete &#40;only the culprit artery&#41; or complete&#44; and in the latter case&#44; whether it should be carried out during the same procedure or in subsequent procedures&#46; There is growing evidence that multivessel revascularization&#44; including of non-culprit lesions&#44; in patients with ST-segment elevation myocardial infarction is safe and reduces the risk of recurrent events&#46;<a class="elsevierStyleCrossRefs" href="#bib0100"><span class="elsevierStyleSup">4&#8211;6</span></a> Although it is tempting to extrapolate these results to the NSTE-ACS patient population&#44; it is important to note that there have been no prospective randomized trials that confirm the superiority and safety of a multivessel revascularization strategy in the latter group&#46; Furthermore&#44; in patients with myocardial infarction presenting in cardiogenic shock&#44; revascularization of the culprit artery only may be superior to multivessel revascularization&#44; as recently demonstrated in a randomized trial&#46;<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">7</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">In this issue of the <span class="elsevierStyleItalic">Journal</span>&#44; Correia et al&#46;<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">8</span></a> compare a multivessel revascularization strategy with culprit-only revascularization in a population of patients with NSTE-ACS and multivessel disease&#46; This observational&#44; retrospective and longitudinal study included all patients with ACS who underwent percutaneous coronary intervention at a single hospital between 2010 and 2013&#46; Among NSTE-ACS patients&#44; the proportion with multivessel disease was 46&#37;&#44; defined as the presence of at least two lesions deemed angiographically significant &#40;&#8805;50&#37; stenosis&#41; in different coronary artery territories&#46; The population analyzed consisted of 202 patients&#44; 71 &#40;35&#37;&#41; of whom underwent multivessel revascularization&#44; while 131 &#40;65&#37;&#41; underwent culprit-only revascularization&#46; The culprit artery was identified using a combination of clinical&#44; electrocardiographic&#44; echocardiographic and angiographic data&#44; and the decision to perform coronary revascularization of non-culprit arteries and the timing of the procedure were determined by the interventional cardiologist and clinical cardiologist&#44; or by the heart team&#44; as appropriate&#46; Multivessel revascularization was defined as intervention &#40;percutaneous or surgical&#41; on two or more lesions in different coronary artery territories&#44; during the initial procedure &#40;first stage&#41; or planned in the following 30 days &#40;second stage&#41;&#46; The minimum follow-up was three years&#44; with a median of 1520 days &#40;4&#46;1 years&#41;&#44; and the analysis included occurrence of death&#44; reinfarction&#44; unplanned revascularization and major adverse cardiovascular events &#40;mortality&#44; reinfarction&#44; stroke or heart failure&#41;&#46; To minimize the bias created by factors influencing the selection of revascularization type&#44; a survival analysis was performed on a population divided by propensity score matching&#44; which included 66 patients in each group&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">It is important to note that the NSTE-ACS patients analyzed by Correia et al&#46;<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">8</span></a> constituted a selected population&#44; since they only included those with confirmed multivessel disease for whom it was decided to adopt an invasive strategy by percutaneous intervention&#46; Nevertheless&#44; their demographic and clinical characteristics are consistent with those reported in real-world registries&#46;<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">2</span></a> Additionally&#44; there were no significant differences between groups with different revascularization strategies&#44; either before or after propensity score matching&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">In patients who underwent multivessel revascularization&#44; most &#40;66&#37;&#41; were treated in a single procedure&#44; but only 52&#37; underwent complete revascularization&#46; In those in whom only the culprit artery was treated&#44; 35&#37; did not have their other stenoses treated because these were considered insignificant &#40;&#60;70&#37;&#41;&#44; 18&#37; because they had diffuse or complex disease&#44; 8&#37; because they had chronic occlusions&#44; and for more than one reason in the remainder&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">There were no significant differences between the groups with regard to clinical events during hospital stay&#46; However&#44; in medium- to long-term follow-up&#44; patients who underwent multivessel revascularization had a lower incidence of reinfarction &#40;5&#46;6&#37; vs&#46; 16&#46;8&#37;&#41; and unplanned revascularization &#40;5&#46;6&#37; vs&#46; 15&#46;3&#37;&#41;&#44; with no differences in mortality&#44; stroke or heart failure&#46; Patients who underwent culprit-only revascularization thus had around twice as many events in long-term follow-up of the composite endpoint of death&#44; reinfarction or unplanned revascularization&#46; The results before and after propensity score matching were similar&#46; A meta-analysis by Jang et al&#46;&#44; which analyzed eight observational studies comparing multivessel with culprit-only revascularization&#44; showed that the former strategy reduces the rate of unplanned revascularization by 25&#37; and is associated with a non-significant reduction of approximately 15&#37; in reinfarction and death&#46;<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">9</span></a></p><p id="par0030" class="elsevierStylePara elsevierViewall">If multivessel revascularization is to become the rule in patients with NSTE-ACS&#44; it is important to discuss its timing&#46; In the study by Correia et al&#46;&#44;<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">8</span></a> around a third of patients who underwent multivessel revascularization did so in a second procedure up to 30 days after the acute event&#46; This staged strategy is questionable&#44; since in the SMILE trial&#44; single-stage multivessel revascularization reduced the risk of recurrent events by almost 50&#37; compared with deferred multivessel revascularization &#40;second procedure performed three to seven days after the first&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">10</span></a> This reduction was mainly due to a significant reduction in the rate of unplanned revascularization&#46; However&#44; it is important to note that a trend toward less mortality and reinfarction was also found in patients who underwent single-stage revascularization&#44; with no increase in complications such as contrast-induced nephropathy or periprocedural infarction&#46;<a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">10</span></a></p><p id="par0035" class="elsevierStylePara elsevierViewall">Another factor to consider when deciding on the type of revascularization is coronary anatomy and disease extent&#46; In the study by Correia et al&#46;&#44;<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">8</span></a> over a quarter of the patients did not undergo multivessel revascularization because they had complex disease and&#47;or chronic occlusions&#46; The authors do not report the SYNTAX score or any other marker of the severity and extent of coronary artery disease&#44; so the decision to revascularize only the culprit artery may have been due to the patient&#39;s anatomical characteristics&#46;<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">1</span></a> More complex coronary artery disease is known to be associated with a higher rate of recurrent events in patients with NSTE-ACS&#46; It is therefore important to consider which strategy will enable the most complete revascularization in an individual patient with complex lesions&#46;<a class="elsevierStyleCrossRefs" href="#bib0085"><span class="elsevierStyleSup">1&#44;11</span></a> Similarly&#44; intermediate lesions should also be assessed thoroughly&#46; In Correia et al&#46;&#8217;s study&#44; in 35&#37; of patients only the culprit artery was revascularized because the other lesions were defined as moderate&#44; i&#46;e&#46; with &#60;70&#37; stenosis&#46; In this group&#44; functional assessment of the lesions could have modified the revascularization strategy&#46;<a class="elsevierStyleCrossRef" href="#bib0140"><span class="elsevierStyleSup">12</span></a> In a sub-analysis of the FAME study&#44; which included 328 patients with NSTE-ACS&#44; the decision to revascularize on the basis of fractional flow reserve was associated with a 19&#37; relative reduction and a 5&#37; absolute reduction in the risk of events &#40;including death from any cause&#44; infarction&#44; and any repeat revascularization&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0145"><span class="elsevierStyleSup">13</span></a> The value of using functional assessment to guide the revascularization strategy has also been validated in another study&#44; which included a sample of Portuguese NSTE-ACS patients&#46;<a class="elsevierStyleCrossRef" href="#bib0150"><span class="elsevierStyleSup">14</span></a></p><p id="par0040" class="elsevierStylePara elsevierViewall">The decision to revascularize only the culprit artery should also take into account the difficulty in identifying this artery&#44; which may be an additional challenge in selecting the strategy&#46;<a class="elsevierStyleCrossRef" href="#bib0145"><span class="elsevierStyleSup">13</span></a> In the study by Correia et al&#46;&#44;<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">8</span></a> the culprit artery was determined without the use of a predefined protocol and in a somewhat subjective manner&#46; However&#44; in around half of patients with NSTE-ACS&#44; there may be multiple complex plaques responsible for the infarction&#44; and identification of the culprit artery may not be straightforward&#46;<a class="elsevierStyleCrossRefs" href="#bib0155"><span class="elsevierStyleSup">15&#44;16</span></a> Additionally&#44; incomplete revascularization is associated with increased risk of events&#44; especially in patients with NSTE-ACS&#44; as demonstrated in various studies&#46;<a class="elsevierStyleCrossRefs" href="#bib0085"><span class="elsevierStyleSup">1&#44;16</span></a> These facts further support the role of a multivessel revascularization strategy in NSTE-ACS&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">In conclusion&#44; the study by Correia et al&#46;<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">8</span></a> supports the idea that multivessel revascularization should be the rule in patients with NSTE-ACS&#44; since it is a proven and safe strategy that can have a significant impact on reducing the risk of events in the medium to long term&#46;</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Conflicts of interest</span><p id="par0050" class="elsevierStylePara elsevierViewall">The author has no conflicts of interest to declare&#46;</p></span></span>"
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        "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as&#58; Santos JF&#46; Revasculariza&#231;&#227;o multivaso na s&#237;ndrome coron&#225;ria aguda sem supradesnivelamento do segmento st&#58; deve ser a regra em todos os doentes&#63; Rev Port Cardiol&#46; 2018&#59;37&#58;155&#8211;157&#46;</p>"
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