Editorial comment
Clinical findings remain paramount
E a clínica continua soberana
Gláucia Maria Moraes Oliveira
Universidade Federal do Rio de Janeiro, Rio de Janeiro, Brazil
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However, hemodynamically stable cancer patients stratified as at intermediate risk are more of a challenge. The European Society of Cardiology guidelines on PE have called for them to be reclassified as intermediate-high or intermediate-low risk according to the presence or absence of right ventricular dysfunction and elevated cardiac biomarkers.<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">3</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">In the early 2000s, Kucher et al.<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">4</span></a> highlighted the value of assessing the pretest probability of PE in conjunction with the shock index (SI), calculated as heart rate divided by systolic blood pressure, in starting appropriate therapy, an approach that resulted in reduced 30-day mortality, while Ozsu et al.<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">5</span></a> combined measurement of troponin levels and echocardiographic assessment with the SI, improving stratification of 30-day mortality risk in PE patients. In another cohort of patients with PE, Bach et al.<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">6</span></a> showed that circulatory parameters, easily obtained and at low cost, have the same or better prognostic value than the clinical scores that were applied in their study, which included both the original and the simplified pulmonary embolism severity index.</p><p id="par0025" class="elsevierStylePara elsevierViewall">In this issue of the <span class="elsevierStyleItalic">Journal</span>, Ferreira et al.<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">7</span></a> apply a similar model to that of Kucher et al.<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">4</span></a> in a single-center retrospective cohort of cancer patients, extending the observation period to one year. The prospect of stratifying patients at initial presentation is an attractive one, especially in terms of predicting one-year mortality risk. However, caution is warranted in assessing the results presented by the authors in their analysis, which seems to be more of a hypothesis-generating study. Hypotheses such as theirs need to be tested in multiple cohorts with large study populations in which interactions between prognostic factors can be adequately analyzed, and must then be validated in other populations. In this case, it is particularly important to include the type and staging of the patient's cancer, since these factors will inevitably have a significant impact on medium- and long-term prognosis. In Ferreira et al.’s study, right ventricular myocardial damage was rare, and data on cancer type and stage were not collected, which limits the applicability of their findings.</p><p id="par0030" class="elsevierStylePara elsevierViewall">Nevertheless, the study makes an additional contribution, which is its focus on the importance of the patient's history and physical examination in modern practice, in which technology<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">8</span></a> using a wide range of laboratory and imaging exams plays a central role in clinical decision-making. Ozsu et al.<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">5</span></a> propose combining history and physical examination with imaging methods, and thus emphasize the need for technology, while according to Grüne,<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">9</span></a> correct assessment of the results of anamnesis and clinical examination (which includes diagnostic tests) is essential for the implementation of value-based medicine, currently a hot topic. Ferreira et al.<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">7</span></a> take us back to the first principle of semiology, observation of vital signs.</p><p id="par0035" class="elsevierStylePara elsevierViewall">The physical examination remains an essential part of the physician-patient relationship, even though there is nowadays less emphasis in medical training on the skills required to formulate and confirm hypotheses, mainly because of the greater value placed on data provided by diagnostic exams.<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">10</span></a> An approach guided by data from physical examination – such as the SI – undoubtedly comes closer to the ideal of personalized medicine, enhancing the value and effectiveness of health care, as well as enabling physicians to widen their understanding of their patients as complex human beings in all their dimensions: physical, mental, and spiritual.<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">1</span></a></p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Conflicts of interest</span><p id="par0040" class="elsevierStylePara elsevierViewall">The author has no conflicts of interest to declare.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:2 [ 0 => array:2 [ "identificador" => "sec0005" "titulo" => "Conflicts of interest" ] 1 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Oliveira GM. E a clínica continua soberana. Rev Port Cardiol. 2019;38:417–418.</p>" ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0015" "bibliografiaReferencia" => array:10 [ 0 => array:3 [ "identificador" => "bib0055" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Rumo a uma Cardiologia Centrada no Paciente e Guiada por Dados" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "A.L. Ribeiro" 1 => "G.M.M. 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| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 November | 4 | 6 | 10 |
| 2024 October | 35 | 26 | 61 |
| 2024 September | 33 | 25 | 58 |
| 2024 August | 48 | 30 | 78 |
| 2024 July | 34 | 25 | 59 |
| 2024 June | 22 | 21 | 43 |
| 2024 May | 42 | 21 | 63 |
| 2024 April | 33 | 27 | 60 |
| 2024 March | 22 | 23 | 45 |
| 2024 February | 39 | 19 | 58 |
| 2024 January | 18 | 20 | 38 |
| 2023 December | 19 | 27 | 46 |
| 2023 November | 36 | 35 | 71 |
| 2023 October | 30 | 14 | 44 |
| 2023 September | 53 | 17 | 70 |
| 2023 August | 24 | 19 | 43 |
| 2023 July | 17 | 12 | 29 |
| 2023 June | 28 | 13 | 41 |
| 2023 May | 37 | 24 | 61 |
| 2023 April | 32 | 4 | 36 |
| 2023 March | 55 | 21 | 76 |
| 2023 February | 33 | 14 | 47 |
| 2023 January | 26 | 17 | 43 |
| 2022 December | 36 | 30 | 66 |
| 2022 November | 39 | 24 | 63 |
| 2022 October | 56 | 23 | 79 |
| 2022 September | 25 | 40 | 65 |
| 2022 August | 29 | 26 | 55 |
| 2022 July | 28 | 41 | 69 |
| 2022 June | 28 | 19 | 47 |
| 2022 May | 24 | 30 | 54 |
| 2022 April | 19 | 39 | 58 |
| 2022 March | 21 | 41 | 62 |
| 2022 February | 34 | 40 | 74 |
| 2022 January | 17 | 23 | 40 |
| 2021 December | 12 | 30 | 42 |
| 2021 November | 33 | 36 | 69 |
| 2021 October | 26 | 37 | 63 |
| 2021 September | 18 | 28 | 46 |
| 2021 August | 23 | 32 | 55 |
| 2021 July | 21 | 24 | 45 |
| 2021 June | 23 | 14 | 37 |
| 2021 May | 24 | 39 | 63 |
| 2021 April | 16 | 45 | 61 |
| 2021 March | 38 | 29 | 67 |
| 2021 February | 20 | 5 | 25 |
| 2021 January | 34 | 17 | 51 |
| 2020 December | 21 | 18 | 39 |
| 2020 November | 12 | 10 | 22 |
| 2020 October | 26 | 18 | 44 |
| 2020 September | 11 | 3 | 14 |
| 2020 August | 11 | 12 | 23 |
| 2020 July | 23 | 4 | 27 |
| 2020 June | 14 | 17 | 31 |
| 2020 May | 24 | 9 | 33 |
| 2020 April | 26 | 5 | 31 |
| 2020 March | 11 | 12 | 23 |
| 2020 February | 29 | 14 | 43 |
| 2020 January | 8 | 13 | 21 |
| 2019 December | 18 | 5 | 23 |
| 2019 November | 13 | 6 | 19 |
| 2019 October | 15 | 4 | 19 |
| 2019 September | 41 | 23 | 64 |
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