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maioritariamente decorrente de EAM da parede anterior&#44; precipita a ativa&#231;&#227;o de v&#225;rios mecanismos envolvidos na g&#233;nese e na perpetua&#231;&#227;o do CC&#46; Entre estes&#44; a cascata neuro-hormonal assume um papel central&#44; levando &#224; liberta&#231;&#227;o de mediadores pr&#243;-inflamat&#243;rios&#44; tais como as citoquinas e o &#243;xido n&#237;trico&#46; Estes mediadores est&#227;o envolvidos na resposta inflamat&#243;ria sist&#233;mica que ocorre no CC&#44; provocando um estado de hipoperfus&#227;o tecidular sist&#233;mica com fal&#234;ncia multiorg&#226;nica<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">3&#44;4</span></a>&#46; A suspeita cl&#237;nica precoce&#44; baseada sobretudo na presen&#231;a de sinais de instabilidade hemodin&#226;mica&#44; &#233; crucial para uma melhor abordagem destes doentes&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">A &#250;nica interven&#231;&#227;o que demonstrou ter impacto na redu&#231;&#227;o da mortalidade em doentes com CC associado ao EAM foi a revasculariza&#231;&#227;o coron&#225;ria emergente<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a>&#46; Esta interven&#231;&#227;o n&#227;o deve ser retardada&#44; independentemente da realiza&#231;&#227;o pr&#233;via ou n&#227;o de tromb&#243;lise<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a>&#46; Assim&#44; nos &#250;ltimos anos o n&#250;mero de doentes submetidos a interven&#231;&#227;o coron&#225;ria percut&#226;nea no contexto de CC tem aumentado progressivamente<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a>&#46; Contrariamente aos doentes com EAM sem instabilidade hemodin&#226;mica&#44; nos quais apenas dever&#225; ser intervencionada a &#171;les&#227;o culpada&#187;&#44; nos doentes com CC recomenda-se a revasculariza&#231;&#227;o completa de todas as les&#245;es coron&#225;rias cr&#237;ticas &#40;classe I&#44; n&#237;vel de evid&#234;ncia B das recomenda&#231;&#245;es da Sociedade Europeia de Cardiologia para a revasculariza&#231;&#227;o mioc&#225;rdica&#41;<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a>&#46; Esta recomenda&#231;&#227;o reflete o envolvimento frequente de 2 ou mais territ&#243;rios coron&#225;rios na g&#233;nese do CC por fal&#234;ncia de bomba<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a>&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">A institui&#231;&#227;o de outras medidas adjuvantes &#224; revasculariza&#231;&#227;o&#44; diagn&#243;sticas e terap&#234;uticas&#44; s&#227;o tamb&#233;m fundamentais no manejo do CC&#46; Entre estas&#44; destacam-se a terap&#234;utica com f&#225;rmacos vasopressores e inotr&#243;picos&#44; a ventila&#231;&#227;o mec&#226;nica invasiva&#44; as t&#233;cnicas de substitui&#231;&#227;o da fun&#231;&#227;o renal e de suporte mec&#226;nico&#44; como a contrapulsa&#231;&#227;o com bal&#227;o intra-a&#243;rtico<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a>&#46; Quando justific&#225;vel&#44; algumas destas medidas poder&#227;o mesmo ser iniciadas e implementadas em contexto pr&#233;-hospitalar&#46; A monitoriza&#231;&#227;o hemodin&#226;mica invasiva&#44; linha arterial e cateterismo da art&#233;ria pulmonar que permite medir press&#245;es e d&#233;bitos direito e esquerdo e a deriva&#231;&#227;o de resist&#234;ncias vasculares pulmonar e sist&#233;mica s&#227;o fundamentais para avaliar a efic&#225;cia destas medidas&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">Apesar dos avan&#231;os na abordagem e no tratamento dos doentes com CC&#44; a taxa de mortalidade n&#227;o tem variado significativamente nos &#250;ltimos anos&#44; permanecendo muito elevada&#46; Cerca de 50&#37; dos doentes que desenvolvem CC ap&#243;s EAM t&#234;m morte intra-hospitalar<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a>&#46; Por outro lado&#44; os que recuperam t&#234;m uma elevada sobrevida a longo prazo&#44; facto que torna imperioso o desenvolvimento de medidas terap&#234;uticas que permitam uma melhor estabiliza&#231;&#227;o destes doentes&#44; sobretudo nas primeiras horas ap&#243;s o evento&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">O objetivo deste trabalho foi analisar a evolu&#231;&#227;o nas caracter&#237;sticas cl&#237;nicas&#44; tratamento e mortalidade em doentes com EAM complicado por choque cardiog&#233;nico devido a fal&#234;ncia ventricular esquerda&#44; com um intervalo temporal de 10 anos&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Material e m&#233;todos</span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Popula&#231;&#227;o</span><p id="par0035" class="elsevierStylePara elsevierViewall">An&#225;lise retrospetiva de 2 popula&#231;&#245;es de doentes admitidos em Unidade de Cuidados Intensivos de Cardiologia &#40;UCIC&#41; com o diagn&#243;stico de CC ap&#243;s EAM&#58;<ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005"><span class="elsevierStyleLabel">-</span><p id="par0040" class="elsevierStylePara elsevierViewall">Grupo A&#58; doentes admitidos entre maio&#47;1998 e maio&#47;2001&#46;</p></li><li class="elsevierStyleListItem" id="lsti0010"><span class="elsevierStyleLabel">-</span><p id="par0045" class="elsevierStylePara elsevierViewall">Grupo B&#58; doentes admitidos entre maio&#47;2008 e maio&#47;2011&#46;</p></li></ul></p><p id="par0050" class="elsevierStylePara elsevierViewall">Foram exclu&#237;dos desta an&#225;lise os doentes que desenvolveram CC durante o internamento hospitalar e aqueles com CC associado a complica&#231;&#245;es mec&#226;nicas ou fal&#234;ncia ventricular direita ap&#243;s EAM &#40;caracter&#237;sticas avaliadas por ecocardiografia transtor&#225;cica&#41;&#46; A sele&#231;&#227;o dos doentes foi efetuada atrav&#233;s dos dados registados prospetivamente na plataforma inform&#225;tica <span class="elsevierStyleItalic">Cardiobase</span><span class="elsevierStyleSup">&#174;</span> &#40;Infortucano&#44; Lisboa&#44; Portugal&#41;<span class="elsevierStyleItalic">&#46;</span></p><p id="par0055" class="elsevierStylePara elsevierViewall">O diagn&#243;stico de CC foi estabelecido &#224; admiss&#227;o hospitalar por crit&#233;rios cl&#237;nicos&#58; hipotens&#227;o arterial &#40;press&#227;o arterial sist&#243;lica &#60;&#160;90<span class="elsevierStyleHsp" style=""></span>mmHg&#41; persistente ap&#243;s hidrata&#231;&#227;o hidroeletrol&#237;tica endovenosa ou necessidade de suporte vasopressor para manter press&#227;o arterial sist&#243;lica &#8805;&#160;90<span class="elsevierStyleHsp" style=""></span>mmHg associados a sinais de hipoperfus&#227;o perif&#233;rica &#40;oligoan&#250;ria ou extremidades frias e diafor&#233;ticas&#41;<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a>&#46; Nos 2 per&#237;odos considerados&#44; a abordagem terap&#234;utica envolveu a realiza&#231;&#227;o imediata de angiografia coron&#225;ria com vista a revasculariza&#231;&#227;o&#46; Na maioria dos doentes&#44; a coloca&#231;&#227;o do bal&#227;o intra-a&#243;rtico e a entuba&#231;&#227;o orotraqueal para ventila&#231;&#227;o mec&#226;nica foram realizadas no Laborat&#243;rio de Hemodin&#226;mica e o cateterismo da art&#233;ria pulmonar foi efetuado na UCIC&#44; ap&#243;s a realiza&#231;&#227;o de angiografia coron&#225;ria&#46; A implementa&#231;&#227;o destas t&#233;cnicas invasivas foi efetuada &#224; descri&#231;&#227;o do operador&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Eventos cl&#237;nicos do estudo</span><p id="par0060" class="elsevierStylePara elsevierViewall">Analisaram-se as complica&#231;&#245;es isqu&#233;micas &#40;re-enfarte e acidente vascular cerebral &#91;AVC&#93;&#41;&#44; arr&#237;tmicas &#40;fibrilha&#231;&#227;o auricular&#44; fibrilha&#231;&#227;o ventricular e bloqueio auriculoventricular completo&#41;&#44; hemorr&#225;gicas &#40;crit&#233;rio TIMI <span class="elsevierStyleItalic">major</span>&#41; e mortalidade ocorridas durante o internamento hospitalar&#46; O re-enfarte foi definido como a re-eleva&#231;&#227;o da troponina I acima do limite de decis&#227;o&#44; associada a sintomas ou sinais eletrocardiogr&#225;ficos <span class="elsevierStyleItalic">de novo</span>&#44; sugestivos de isquemia mioc&#225;rdica&#46; O AVC foi definido com a ocorr&#234;ncia de sinais neurol&#243;gicos focais com persist&#234;ncia superior a 24&#160;h com &#40;AVC isqu&#233;mico&#41; ou sem &#40;AVC indeterminado&#41; sinais de enfarte na imagiologia cerebral&#46;</p><p id="par0065" class="elsevierStylePara elsevierViewall">Os eventos cl&#237;nicos do estudo avaliados durante o seguimento foram a mortalidade por todas as causas aos 30&#160;dias e aos 6 meses de seguimento&#46; Nenhum doente se perdeu no seguimento e os respetivos dados cl&#237;nicos foram obtidos por consulta de processo cl&#237;nico e de dados informatizados ou por contacto telef&#243;nico com o doente ou familiares&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">An&#225;lise estat&#237;stica</span><p id="par0070" class="elsevierStylePara elsevierViewall">As vari&#225;veis categ&#243;ricas foram expressas em percentagem &#40;com valores num&#233;ricos entre par&#234;ntesis&#41; e comparadas pelo teste <span class="elsevierStyleItalic">qui-quadrado</span>&#46; As vari&#225;veis cont&#237;nuas foram expressas sob a forma de m&#233;dia&#160;&#177;&#160;desvio padr&#227;o e comparadas pelo teste <span class="elsevierStyleItalic">t</span>-<span class="elsevierStyleItalic">Student</span> quando verificadas as condi&#231;&#245;es de aplicabilidade &#40;teste de <span class="elsevierStyleItalic">Shapiro-Wilks</span>&#41;&#46; Os eventos intra-hospitalares e a mortalidade durante o per&#237;odo de seguimento foram avaliados por an&#225;lise de <span class="elsevierStyleItalic">Kaplan-Meier</span>&#44; testando-se eventuais diferen&#231;as estat&#237;sticas entre as 2 popula&#231;&#245;es atrav&#233;s do teste <span class="elsevierStyleItalic">Log-Rank</span>&#46; Realizou-se an&#225;lise multivari&#225;vel com modelos de riscos proporcionais de <span class="elsevierStyleItalic">Cox</span> para identificar os preditores independentes de mortalidade aos 6 meses&#46; No primeiro modelo foram incorporadas as covari&#225;veis descritas como caracter&#237;sticas basais &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">Tabela 1</a>&#41; associadas ao evento cl&#237;nico do estudo com p &#60;&#160;0&#44;10 em an&#225;lise univari&#225;vel&#46; Nos modelos subsequentes&#44; as covari&#225;veis relativas &#224; terap&#234;utica farmacol&#243;gica na fase aguda &#40;<a class="elsevierStyleCrossRef" href="#tbl0010">Tabela 2</a>&#41; e &#224;s t&#233;cnicas invasivas e de revasculariza&#231;&#227;o mioc&#225;rdica &#40;<a class="elsevierStyleCrossRef" href="#tbl0015">Tabela 3</a>&#41; foram adicionadas ao modelo das caracter&#237;sticas basais&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><elsevierMultimedia ident="tbl0015"></elsevierMultimedia><p id="par0075" class="elsevierStylePara elsevierViewall">Foram considerados estatisticamente significativos os resultados com p&#160;&#60;&#160;0&#44;05&#46; Os dados recolhidos foram analisados atrav&#233;s do <span class="elsevierStyleItalic">software Statistical Package for Social Sciences</span><span class="elsevierStyleSup">&#174;</span> para <span class="elsevierStyleItalic">Windows</span>&#44; vers&#227;o 19&#46;0 &#40;SPSS&#44; Inc&#44; Chicago&#44; Illinois&#44; Estados Unidos&#41;&#46;</p></span></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">Resultados</span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0105">Caracter&#237;sticas da popula&#231;&#227;o</span><p id="par0080" class="elsevierStylePara elsevierViewall">No presente estudo&#44; a incid&#234;ncia de CC foi 3&#44;7&#37; &#40;25&#47;683 doentes&#41; e 4&#44;8&#37; &#40;42&#47;875 doentes&#41; no 1&#46;&#176; e 2&#46;&#176; per&#237;odo&#44; respetivamente &#40;p&#160;&#61;&#160;0&#44;330&#41;&#46; A idade foi significativamente superior no Grupo B &#40;66&#44;5&#160;&#177;&#160;11&#44;3 <span class="elsevierStyleItalic">versus</span> 60&#44;2&#160;&#177;&#160;12&#44;3 no Grupo A&#44; p&#160;&#61;&#160;0&#44;043&#41;&#46; A propor&#231;&#227;o de doentes admitidos com menos de 6&#160;h ap&#243;s o in&#237;cio de sintomas tamb&#233;m foi significativamente superior no Grupo B &#40;54&#44;8 <span class="elsevierStyleItalic">versus</span> 29&#44;2&#37; no Grupo A&#44; p&#160;&#61;&#160;0&#44;045&#41;&#46; As restantes caracter&#237;sticas demogr&#225;ficas e cl&#237;nicas basais n&#227;o diferiram significativamente entre os 2 grupos de doentes analisados &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">Tabela 1</a>&#41;&#46;</p><p id="par0085" class="elsevierStylePara elsevierViewall">Quanto &#224; apresenta&#231;&#227;o cl&#237;nica&#44; a maioria dos doentes&#44; tanto no Grupo A como no Grupo B&#44; foi admitida por EAM com supradesnivelamento do segmento ST&#44; nomeadamente da parede anterior&#46;</p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0110">Abordagem diagn&#243;stica e terap&#234;utica</span><p id="par0090" class="elsevierStylePara elsevierViewall">Os f&#225;rmacos vasopressores e inotr&#243;picos foram administrados na grande maioria dos doentes&#44; em ambos os grupos &#40;<a class="elsevierStyleCrossRef" href="#tbl0010">Tabela 2</a>&#41;&#46; A propor&#231;&#227;o de utiliza&#231;&#227;o de dopamina n&#227;o variou significativamente entre os 2 grupos&#44; mas a dobutamina&#44; foi mais usada no grupo A &#40;96&#44;0 <span class="elsevierStyleItalic">versus</span> 57&#44;1&#37; no Grupo B&#44; p&#160;&#61;&#160;0&#44;001&#41;&#46; A noradrenalina e o levosimendano foram utilizados exclusivamente no Grupo B&#46; Cerca de metade dos doentes&#44; nos 2 grupos&#44; receberam terap&#234;utica com inibidores da glicoproteina <span class="elsevierStyleSmallCaps">ii</span>b&#47;<span class="elsevierStyleSmallCaps">iii</span>a&#46;</p><p id="par0095" class="elsevierStylePara elsevierViewall">O ecocardiograma transtor&#225;cico realizado na fase aguda revelou uma fra&#231;&#227;o de eje&#231;&#227;o inferior a 40&#37; na maioria dos doentes&#44; n&#227;o havendo diferen&#231;a significativa entre os 2 grupos &#40;83&#44;3&#37; no Grupo A <span class="elsevierStyleItalic">versus</span> 78&#44;6&#37; no Grupo B&#44; p&#160;&#61;&#160;0&#44;793&#41;&#46; As t&#233;cnicas invasivas efetuadas&#44; as modalidades de reperfus&#227;o nas primeiras 12&#160;h e os procedimentos de revasculariza&#231;&#227;o mioc&#225;rdica utilizados encontram-se representados na <a class="elsevierStyleCrossRef" href="#tbl0015">Tabela 3</a>&#46; Entre o 1&#46;&#176; e o 2&#46;&#176; per&#237;odo observou-se uma redu&#231;&#227;o estatisticamente significativa na propor&#231;&#227;o de doentes submetidos a cateteriza&#231;&#227;o da art&#233;ria pulmonar &#40;52&#44;0 <span class="elsevierStyleItalic">versus</span> 19&#44;0&#37;&#44; p&#160;&#61;&#160;0&#44;005&#41; e a um aumento na utiliza&#231;&#227;o de t&#233;cnicas de di&#225;lise &#40;4&#44;0 <span class="elsevierStyleItalic">versus</span> 28&#44;6&#37;&#44; p&#160;&#61;&#160;0&#44;014&#41;&#46; N&#227;o se observaram diferen&#231;as significativas na propor&#231;&#227;o de doentes reperfundidos nas primeiras 12&#160;h ap&#243;s o in&#237;cio da sintomatologia ou submetidos a revasculariza&#231;&#227;o mioc&#225;rdica&#46; Contudo&#44; a taxa de interven&#231;&#227;o coron&#225;ria percut&#226;nea foi significativamente superior no Grupo B &#40;92&#44;9 <span class="elsevierStyleItalic">versus</span> 75&#44;0&#37; no Grupo A&#44; p&#160;&#61;&#160;0&#44;042&#41;&#44; observando-se o inverso na propor&#231;&#227;o de doentes revascularizados cirurgicamente&#44; entre os 2 per&#237;odos estudados &#40;32&#44;0 no Grupo A <span class="elsevierStyleItalic">versus</span> 7&#44;1&#37; no Grupo B&#44; p&#160;&#61;&#160;0&#44;008&#41;&#46;</p><p id="par0100" class="elsevierStylePara elsevierViewall">Todos os doentes nos 2 grupos realizaram angiografia coron&#225;ria&#44; tendo a maioria&#44; em ambos os grupos&#44; doen&#231;a multivaso &#40;<a class="elsevierStyleCrossRef" href="#tbl0020">Tabela 4</a>&#41;&#46; A estenose da art&#233;ria descendente anterior foi mais frequente nos doentes do Grupo A &#40;91&#44;7 <span class="elsevierStyleItalic">versus</span> 64&#44;3&#37; no Grupo B&#44; p&#160;&#61;&#160;0&#44;014&#41;&#46; Relativamente &#224; angioplastia coron&#225;ria&#44; a interven&#231;&#227;o da coron&#225;ria direita &#40;29&#44;3 <span class="elsevierStyleItalic">versus</span> 4&#44;2&#37;&#44; p&#160;&#61;&#160;0&#44;015&#41; e da circunflexa &#40;53&#44;7 <span class="elsevierStyleItalic">versus</span> 12&#44;5&#37;&#44; p&#160;&#61;&#160;0&#44;001&#41;&#44; a interven&#231;&#227;o multivaso &#40;39&#44;0 <span class="elsevierStyleItalic">versus</span> 8&#44;3&#37;&#44; p&#160;&#61;&#160;0&#44;008&#41; e a utiliza&#231;&#227;o de <span class="elsevierStyleItalic">stent</span> &#40;45&#44;8 <span class="elsevierStyleItalic">versus</span> 88&#44;1&#37;&#41; foram mais comuns nos doentes do Grupo B&#44; em compara&#231;&#227;o com os do Grupo A&#46; A taxa de revasculariza&#231;&#227;o completa na popula&#231;&#227;o total foi 54&#44;5&#37;&#44; significativamente mais elevada no Grupo A &#40;70&#44;8 <span class="elsevierStyleItalic">versus</span> 45&#44;2&#37;&#44; p&#160;&#61;&#160;0&#44;045&#41;&#46; A implanta&#231;&#227;o de <span class="elsevierStyleItalic">stents</span> revestidos por f&#225;rmaco e a aspira&#231;&#227;o percut&#226;nea de trombos intracoron&#225;rios foram realizadas exclusivamente nos doentes do Grupo B&#46;</p><elsevierMultimedia ident="tbl0020"></elsevierMultimedia></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0115">Eventos cl&#237;nicos</span><p id="par0105" class="elsevierStylePara elsevierViewall">Na <a class="elsevierStyleCrossRef" href="#tbl0025">Tabela 5</a> encontram-se representadas as complica&#231;&#245;es intra-hospitalares registadas&#46; N&#227;o se observaram diferen&#231;as significativas na incid&#234;ncia de complica&#231;&#245;es isqu&#233;micas&#44; arr&#237;tmicas&#44; hemorr&#225;gicas ou letais ocorridas durante o internamento inicial entre os 2 grupos&#46;</p><elsevierMultimedia ident="tbl0025"></elsevierMultimedia><p id="par0110" class="elsevierStylePara elsevierViewall">A mortalidade por todas as causas aos 30&#160;dias e aos 6 meses de seguimento tamb&#233;m n&#227;o variou significativamente entre os 2 grupos estudados &#40;<a class="elsevierStyleCrossRef" href="#tbl0025">Tabela 5</a> e <a class="elsevierStyleCrossRef" href="#fig0005">Figura 1</a>&#41;&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0120">Preditores independentes de mortalidade aos 6 meses</span><p id="par0115" class="elsevierStylePara elsevierViewall">Em an&#225;lise multivari&#225;vel&#44; considerando as caracter&#237;sticas basais&#44; a diabetes foi o &#250;nico preditor independente de morte aos 6 meses &#40;HR ajustado 3&#44;02&#59; IC 95&#37; 1&#44;38 a 6&#44;60&#44; p&#160;&#61;&#160;0&#44;006&#41;&#46; Os doentes submetidos a revasculariza&#231;&#227;o mioc&#225;rdica apresentaram menor mortalidade aos 6 meses&#44; em compara&#231;&#227;o com os n&#227;o revascularizados &#40;HR ajustado 0&#44;11&#59; IC 95&#37; 0&#44;03 a 0&#44;42&#59; p&#160;&#61;&#160;0&#44;001&#41;&#46;</p></span></span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0125">Discuss&#227;o</span><p id="par0120" class="elsevierStylePara elsevierViewall">Na presente an&#225;lise de doentes admitidos por CC associado a fal&#234;ncia ventricular esquerda por EAM em 2 per&#237;odos de tempo intervalados por 10 anos&#44; a mortalidade&#44; a curto e a m&#233;dio prazo&#44; n&#227;o variou significativamente&#46; Este achado ocorreu independentemente da chegada mais precoce dos doentes ao hospital&#44; do aumento de algumas medidas de suporte e da maior utiliza&#231;&#227;o da interven&#231;&#227;o coron&#225;ria percut&#226;nea no grupo de doentes mais recentes&#46; No entanto&#44; esta observa&#231;&#227;o pode ser devida ao facto de a revasculariza&#231;&#227;o mioc&#225;rdica&#44; a &#250;nica interven&#231;&#227;o que demonstrou reduzir a mortalidade no CC associado ao EAM<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a>&#44; ter sido utilizada na mesma propor&#231;&#227;o nos 2 grupos considerados &#8211; 92&#44;0 no Grupo A e 95&#44;2&#37; no Grupo B&#46; No nosso estudo&#44; a revasculariza&#231;&#227;o mioc&#225;rdica foi a &#250;nica interven&#231;&#227;o terap&#234;utica que se associou&#44; de modo independente&#44; a menor mortalidade aos 6 meses&#46; Entre as caracter&#237;sticas basais&#44; apenas a diabetes foi preditora independente de mortalidade aos 6 meses&#44; sendo a sua preval&#234;ncia semelhante nos 2 grupos&#46; O impacto da diabetes na mortalidade em doentes com CC foi tamb&#233;m descrito por outros autores<a class="elsevierStyleCrossRefs" href="#bib0045"><span class="elsevierStyleSup">9&#44;10</span></a>&#46;</p><p id="par0125" class="elsevierStylePara elsevierViewall">Apesar da elevada propor&#231;&#227;o de doentes revascularizados&#44; as taxas de mortalidade observadas nos Grupos A e B foram elevadas&#44; sendo de 28&#44;0 e 33&#44;3&#37; durante o internamento inicial&#44; 32&#44;0 e 35&#44;7&#37; aos 30&#160;dias e 36&#44;0 e 42&#44;9&#37; aos 6 meses&#44; respetivamente&#44; mas s&#227;o concordantes com as de outras s&#233;ries contempor&#226;neas&#46; No registo nacional de EAM dos Estados Unidos da Am&#233;rica&#44; com um per&#237;odo de inclus&#227;o entre 1995 e 2004&#44; a mortalidade intra-hospitalar por CC tamb&#233;m permaneceu elevada&#44; embora diminuindo ao longo do tempo &#40;60&#44;3&#37; em 1994 <span class="elsevierStyleItalic">versus</span> 47&#44;9&#37; em 2005&#44; p &#60;&#160;0&#44;001&#41;<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a>&#46; No registo <span class="elsevierStyleItalic">Melbourne Interventional Group</span>&#44; a mortalidade aos 30&#160;dias em doentes com CC submetidos a angioplastia coron&#225;ria entre 2004 e 2007 foi de 36&#44;1&#37; nos de idade inferior a 75 anos e 43&#44;2&#37; nos que tinham pelo menos 75 anos<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a>&#46; Greenberg et al&#46; reportaram uma mortalidade aos 6 meses de 52&#37; entre 2001 e 2005 e de 59&#37; entre 2006 e 2011 em 170 doentes com CC submetidos a angioplastia coron&#225;ria num centro israelita de refer&#234;ncia<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a>&#46;</p><p id="par0130" class="elsevierStylePara elsevierViewall">Estes resultados poder&#227;o dever-se &#224; influ&#234;ncia de mecanismos fisiopatol&#243;gicos eventualmente envolvidos na hist&#243;ria natural do CC&#44; que ainda n&#227;o s&#227;o modificados pelo tratamento atual&#46; No CC existe uma resposta inflamat&#243;ria sist&#233;mica com ativa&#231;&#227;o do complemento&#44; liberta&#231;&#227;o de citoquinas e aumento da produ&#231;&#227;o de &#243;xido n&#237;trico por hiperexpress&#227;o da sua sintetase indut&#237;vel<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">11</span></a>&#46; Por outro lado&#44; apesar do benef&#237;cio inquestion&#225;vel da revasculariza&#231;&#227;o mioc&#225;rdica nos doentes com CC&#44; a reperfus&#227;o coron&#225;ria poder&#225;&#44; paradoxalmente&#44; contribuir para a manuten&#231;&#227;o do CC pela denominada &#171;les&#227;o de reperfus&#227;o&#187;&#46; V&#225;rios mecanismos poder&#227;o estar envolvidos na origem desta les&#227;o&#44; tais como a microemboliza&#231;&#227;o distal&#44; a infiltra&#231;&#227;o leucocit&#225;ria&#44; a produ&#231;&#227;o de radicais livres do oxig&#233;nio e a ativa&#231;&#227;o do sistema do complemento&#44; agravando a les&#227;o microvascular<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">12</span></a>&#46;</p><p id="par0135" class="elsevierStylePara elsevierViewall">No grupo de doentes admitido mais recentemente&#44; a angioplastia coron&#225;ria foi significativamente mais utilizada do que no grupo internado entre 1998 e 2001&#44; o mesmo se observando na taxa de utiliza&#231;&#227;o de <span class="elsevierStyleItalic">stents</span>&#46; Por outro lado&#44; os <span class="elsevierStyleItalic">stents</span> revestidos por f&#225;rmacos e a aspira&#231;&#227;o de trombos intracoron&#225;rios foram exclusivamente utilizados entre 2008 e 2011&#44; por n&#227;o estarem dispon&#237;veis durante o 1&#46;&#176; per&#237;odo&#46; O aumento da utiliza&#231;&#227;o da t&#233;cnica percut&#226;nea ocorreu &#224; custa da diminui&#231;&#227;o da revasculariza&#231;&#227;o cir&#250;rgica&#44; apesar de o centro integrar um Servi&#231;o de Cirurgia Card&#237;aca&#46; Estes achados s&#227;o sobrepon&#237;veis aos descritos por outros autores em estudos de CC associado ao EAM<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2&#44;9&#44;10</span></a>&#46; Nos doentes tratados entre 2008 e 2011&#44; a angioplastia multivaso foi uma estrat&#233;gia significativamente mais usada&#44; como atualmente recomendado<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a>&#44; devido a um aumento significativo da interven&#231;&#227;o sobre as art&#233;rias coron&#225;ria direita e circunflexa&#46; Contudo&#44; a taxa de revasculariza&#231;&#227;o completa foi superior no primeiro grupo analisado&#44; facto decorrente da elevada taxa de doentes submetidos a revasculariza&#231;&#227;o cir&#250;rgica nesse per&#237;odo&#46; Importa real&#231;ar que n&#227;o existem estudos aleatorizados que comprovem o benef&#237;cio no progn&#243;stico da ado&#231;&#227;o desta estrat&#233;gia&#44; a angioplastia de todas as les&#245;es angiogr&#225;ficas significativas&#46; Por exemplo&#44; no estudo SHOCK&#44; a sobrevida dos doentes tratados com revasculariza&#231;&#227;o cir&#250;rgica &#40;completa&#41; foi sobrepon&#237;vel&#44; independentemente do n&#250;mero de vasos intervencionados&#44; mas nos doentes submetidos a angioplastia isolada da &#171;les&#227;o culpada&#187;&#44; a mortalidade foi aumentando de acordo com o n&#250;mero de vasos com les&#245;es significativas na angiografia<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">13</span></a>&#44; o que &#233; sugestivo de um benef&#237;cio potencial da revasculariza&#231;&#227;o completa&#46; No entanto&#44; no registo EHS-PCI&#44; recentemente publicado&#44; a revasculariza&#231;&#227;o multivaso n&#227;o se associou a menor taxa de mortalidade<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">14</span></a>&#46;</p><p id="par0140" class="elsevierStylePara elsevierViewall">Em 1942 Stead e Ebert descreveram pela primeira vez que as manifesta&#231;&#245;es sist&#233;micas do CC resultam da fal&#234;ncia ventricular esquerda&#44; caracterizada clinicamente por sinais de marcada redu&#231;&#227;o do d&#233;bito card&#237;aco e hipoxia tecidular<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">15</span></a>&#46; Cerca de 70 anos volvidos ap&#243;s estes relatos iniciais&#44; ainda muito persiste por esclarecer e definir relativamente &#224; abordagem do CC&#44; condicionando um progn&#243;stico semelhante ao longo dos anos<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a>&#46; Dada a complexidade dos mecanismos fisiopatol&#243;gicos envolvidos no CC&#44; muitas das terap&#234;uticas desenvolvidas e testadas nestes doentes cr&#237;ticos n&#227;o demonstraram benef&#237;cio nem impacto progn&#243;stico favor&#225;vel&#46;</p><p id="par0145" class="elsevierStylePara elsevierViewall">O cateterismo da art&#233;ria pulmonar com cateter de <span class="elsevierStyleItalic">Swan-Ganz</span>&#44; tradicionalmente usado na avalia&#231;&#227;o hemodin&#226;mica para guiar a terap&#234;utica&#44; tamb&#233;m n&#227;o se associa a menor mortalidade<a class="elsevierStyleCrossRefs" href="#bib0080"><span class="elsevierStyleSup">16&#44;17</span></a>&#46; A controv&#233;rsia em torno do seu benef&#237;cio traduziu-se numa diminui&#231;&#227;o da sua utiliza&#231;&#227;o ao longo tempo&#44; de 52 para 19&#37; dos doentes no presente estudo&#44; o que &#233; concordante com outras s&#233;ries<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">18</span></a>&#46;</p><p id="par0150" class="elsevierStylePara elsevierViewall">A contrapulsa&#231;&#227;o com bal&#227;o intra-a&#243;rtico foi utilizada em cerca de 70&#37; dos doentes nos 2 per&#237;odos considerados&#46; Apesar de o conceito do suporte circulat&#243;rio ser intuitivo e baseado na fal&#234;ncia ventricular esquerda&#44; o benef&#237;cio da sua utiliza&#231;&#227;o n&#227;o se baseia em ensaios cl&#237;nicos aleatorizados<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">19</span></a>&#46; A assist&#234;ncia ventricular esquerda demonstrou melhorar os par&#226;metros hemodin&#226;micos&#44; em compara&#231;&#227;o com o bal&#227;o intra-a&#243;rtico&#44; contudo&#44; sem impacto na mortalidade<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">20</span></a>&#46;</p><p id="par0155" class="elsevierStylePara elsevierViewall">No nosso estudo&#44; a necessidade da realiza&#231;&#227;o de t&#233;cnicas de suporte renal aumentou entre os 2 per&#237;odos &#40;Grupo A 4&#44;0&#37; e Grupo B 28&#44;6&#37;&#41;&#46; A hemofiltra&#231;&#227;o venovenosa cont&#237;nua&#44; para al&#233;m do seu papel na remo&#231;&#227;o de &#225;gua e sais&#44; contribui para a corre&#231;&#227;o da acidose metab&#243;lica&#44; que tem uma a&#231;&#227;o inotr&#243;pica negativa e vasodilatadora delet&#233;ria&#44; e tamb&#233;m remove citoquinas inflamat&#243;rias<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">21</span></a>&#46;</p><p id="par0160" class="elsevierStylePara elsevierViewall">A inibi&#231;&#227;o da liberta&#231;&#227;o de &#243;xido n&#237;trico&#44; apesar de ser um mediador comprovadamente ativado e envolvido no CC e dos resultados promissores de estudos preliminares&#44; n&#227;o foi validada em ensaios aleatorizados subsequentes&#46; Por exemplo&#44; no estudo TRIUMPH&#44; a tilarginina&#44; inibidor n&#227;o seletivo da sintetase do &#243;xido n&#237;trico&#44; n&#227;o diminuiu a mortalidade dos doentes com CC<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">22</span></a>&#46; Uma interven&#231;&#227;o que tamb&#233;m poder&#225; ter impacto progn&#243;stico dos doentes com CC &#233; a hipotermia terap&#234;utica&#46; A hipotermia limita a rea&#231;&#227;o inflamat&#243;ria sist&#233;mica ap&#243;s paragem cardiorrespirat&#243;ria&#44; entre outros mecanismos pela redu&#231;&#227;o da liberta&#231;&#227;o de radicais livres de oxig&#233;nio e de citoquinas pr&#243;-inflamat&#243;rias&#44; mecanismos ativados no CC<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">23</span></a>&#46; Contudo&#44; ser&#227;o necess&#225;rios estudos prospetivos e aleatorizados que comprovem esta hip&#243;tese&#46; No respeitante ao suporte inotr&#243;pico e vasopressor&#44; fundamental na estabiliza&#231;&#227;o cl&#237;nica e hemodin&#226;mica dos doentes com fal&#234;ncia ventricular esquerda&#44; f&#225;rmacos usualmente menos utilizados neste contexto&#44; como o levosimendan&#44; poder&#227;o ser alternativas eficazes e seguras<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">24</span></a>&#46; No grupo de doentes admitido mais recentemente usaram-se f&#225;rmacos como a noradrenalina e o levosimendan&#44; que&#44; no per&#237;odo de inclus&#227;o do primeiro grupo&#44; tinham uma indica&#231;&#227;o ainda controversa ou n&#227;o estavam dispon&#237;veis&#44; respetivamente<a class="elsevierStyleCrossRefs" href="#bib0125"><span class="elsevierStyleSup">25&#8211;27</span></a>&#46; Por outro lado&#44; observ&#225;mos uma redu&#231;&#227;o na utiliza&#231;&#227;o de dobutamina&#44; a favor das aminas com a&#231;&#227;o vasoconstritora&#46;</p><p id="par0165" class="elsevierStylePara elsevierViewall">O presente estudo tem&#44; entre outras limita&#231;&#245;es&#44; o facto de ter sido realizado num centro terci&#225;rio&#44; o que pode ter originado um vi&#233;s de sele&#231;&#227;o&#46; Os doentes mais graves podem ter falecido mais precocemente&#44; antes da transfer&#234;ncia hospitalar&#44; sobretudo no primeiro grupo de doentes&#44; per&#237;odo no qual o tempo decorrido entre o in&#237;cio dos sintomas e a admiss&#227;o foi mais prolongado&#46; No estudo SHOCK&#44; os doentes transferidos para hospitais terci&#225;rios apresentaram uma mortalidade inferior em compara&#231;&#227;o com a observada nos que foram admitidos diretamente nos centros especializados onde se realizou o estudo<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a>&#46; Outras limita&#231;&#245;es incluem o car&#225;ter retrospetivo da an&#225;lise&#44; o pequeno n&#250;mero de doentes inclu&#237;dos&#44; o facto de ser realizado num &#250;nico centro&#44; a dificuldade em estabelecer com exatid&#227;o o in&#237;cio do choque e os par&#226;metros hemodin&#226;micos no momento do diagn&#243;stico&#46;</p></span><span id="sec0060" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0130">Conclus&#245;es</span><p id="par0170" class="elsevierStylePara elsevierViewall">O choque cardiog&#233;nico por fal&#234;ncia ventricular esquerda associada ao enfarte agudo mioc&#225;rdio &#233; respons&#225;vel por uma elevada mortalidade&#44; apesar da elevada utiliza&#231;&#227;o da revasculariza&#231;&#227;o mioc&#225;rdica&#46; No presente estudo&#44; de doentes admitidos com 10 anos de intervalo&#44; a mortalidade foi sobrepon&#237;vel&#44; apesar do aumento da propor&#231;&#227;o de doentes internados com menos 6&#160;h desde o in&#237;cio de sintomas&#44; da maior utiliza&#231;&#227;o da angioplastia coron&#225;ria e de algumas medidas de suporte&#46; Este facto reflete&#44; provavelmente&#44; o desconhecimento da fisiopatologia do choque cardiog&#233;nico&#44; n&#227;o sendo poss&#237;vel&#44; com as op&#231;&#245;es terap&#234;uticas atuais&#44; controlar os mecanismos que est&#227;o envolvidos na sua g&#233;nese e manuten&#231;&#227;o&#46; Torna-se assim imperiosa a investiga&#231;&#227;o de novas terapias que permitam aumentar a sobrevida dos doentes ap&#243;s enfarte agudo do mioc&#225;rdio complicado por choque cardiog&#233;nico&#46;</p></span><span id="sec0065" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0135">Responsabilidades &#233;ticas</span><span id="sec0070" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0140">Prote&#231;&#227;o dos seres humanos e animais</span><p id="par0175" class="elsevierStylePara elsevierViewall">Os autores declaram que os procedimentos seguidos estavam de acordo com os regulamentos estabelecidos pelos respons&#225;veis da Comiss&#227;o de Investiga&#231;&#227;o Cl&#237;nica e &#201;tica e de acordo com os e da Declara&#231;&#227;o de Hels&#237;nquia para &#40;Declara&#231;&#227;o de Hels&#237;nquia&#41;&#46;</p></span><span id="sec0075" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0145">Confidencialidade dos dados</span><p id="par0180" class="elsevierStylePara elsevierViewall">Os autores declaram ter seguido os protocolos de seu centro de trabalho acerca da publica&#231;&#227;o dos dados de pacientes e que todos os pacientes inclu&#237;dos no estudo receberam informa&#231;&#245;es suficientes e deram o seu consentimento informado por escrito para participar nesse estudo&#46;</p></span><span id="sec0080" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0150">Direito &#224; privacidade e consentimento escrito</span><p id="par0185" class="elsevierStylePara elsevierViewall">Os autores declaram ter recebido consentimento escrito dos pacientes e&#47;ou sujeitos mencionados no artigo&#46; O autor para correspond&#234;ncia tem estes documento na sua posse&#46;</p></span></span><span id="sec0085" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0155">Conflito de interesses</span><p id="par0190" class="elsevierStylePara elsevierViewall">Os autores declaram n&#227;o haver conflito de interesses&#46;</p></span></span>"
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        "resumen" => "<span class="elsevierStyleSectionTitle" id="sect0010">Introdu&#231;&#227;o</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Apesar dos avan&#231;os terap&#234;uticos&#44; a letalidade do choque cardiog&#233;nico &#40;<span class="elsevierStyleSmallCaps">CC</span>&#41; associado ao enfarte agudo do mioc&#225;rdio &#40;EAM&#41; permanece elevada&#46;</p> <span class="elsevierStyleSectionTitle" id="sect0015">Objetivo</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Comparar 2 grupos de doentes com CC associado ao EAM&#44; admitidos com um intervalo de 10 anos&#46;</p> <span class="elsevierStyleSectionTitle" id="sect0020">M&#233;todos</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">An&#225;lise retrospetiva de 2 popula&#231;&#245;es de doentes com CC associado ao EAM admitidos entre maio&#47;1998-maio&#47;2001 &#40;Grupo A&#41; e maio&#47;2008-maio&#47;2011 &#40;Grupo B&#41;&#46; Compararam-se as caracter&#237;sticas cl&#237;nicas&#44; diagn&#243;stico&#44; tratamento e complica&#231;&#245;es e analisaram-se os preditores de morte aos 6 meses&#46;</p> <span class="elsevierStyleSectionTitle" id="sect0025">Resultados</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">A incid&#234;ncia de CC foi 3&#44;7&#37; no Grupo A &#40;n&#160;&#61;&#160;25&#41; e 4&#44;8&#37; no Grupo B &#40;n&#160;&#61;&#160;42&#41;&#46; N&#227;o existiram diferen&#231;as significativas nas caracter&#237;sticas demogr&#225;ficas e cl&#237;nicas&#44; exceto na idade &#40;60&#44;2&#160;&#177;&#160;12&#44;3 <span class="elsevierStyleItalic">versus</span> 66&#44;5&#160;&#177;&#160;11&#44;3<span class="elsevierStyleHsp" style=""></span>anos&#59; p&#160;&#61;&#160;0&#44;043&#41; e doentes admitidos com &#60;&#160;6<span class="elsevierStyleHsp" style=""></span>h de sintomas &#40;29&#44;2 <span class="elsevierStyleItalic">versus</span> 54&#44;8&#37;&#44; p&#160;&#61;&#160;0&#44;045&#41;&#46; O cateterismo da art&#233;ria pulmonar diminuiu &#40;52&#44;0 <span class="elsevierStyleItalic">versus</span> 19&#44;0&#37;&#44; p&#160;&#61;&#160;0&#44;005&#41; e as t&#233;cnicas dial&#237;ticas aumentaram &#40;4&#44;0 <span class="elsevierStyleItalic">versus</span> 28&#44;6&#37;&#44; p&#160;&#61;&#160;0&#44;014&#41;&#46; A propor&#231;&#227;o de doentes reperfundidos nas primeiras 12<span class="elsevierStyleHsp" style=""></span>h ou revascularizados foi semelhante&#44; mas a interven&#231;&#227;o coron&#225;ria percut&#226;nea &#40;ICP&#41; aumentou &#40;75&#44;0 <span class="elsevierStyleItalic">versus</span> 92&#44;9&#37;&#44; p&#160;&#61;&#160;0&#44;042&#41;&#46; As complica&#231;&#245;es intra-hospitalares&#44; mortalidade aos 30&#160;d &#40;32&#44;0 <span class="elsevierStyleItalic">versus</span> 35&#44;7&#37;&#59; p&#160;&#61;&#160;0&#44;757&#41; e 6 meses &#40;36&#44;0 <span class="elsevierStyleItalic">versus</span> 42&#44;9&#37;&#59; p&#160;&#61;&#160;0&#44;683&#41; n&#227;o diferiram&#46; A diabetes foi a &#250;nica caracter&#237;stica basal preditora independente de morte aos 6 meses &#40;HR 3&#44;02&#59; IC 95&#37; 1&#44;38-6&#44;60&#59; p&#160;&#61;&#160;0&#44;006&#41; e os doentes revascularizados apresentaram menor mortalidade &#40;HR 0&#44;11&#59; IC95&#37; 0&#44;03-0&#44;42&#59; p&#160;&#61;&#160;0&#44;001&#41;&#46;</p> <span class="elsevierStyleSectionTitle" id="sect0030">Conclus&#227;o</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Nos &#250;ltimos 10 anos&#44; apesar da chegada mais precoce dos doentes ao hospital&#44; da maior utiliza&#231;&#227;o de algumas medidas de suporte e acesso &#224; ICP&#44; a mortalidade a curto e m&#233;dio prazo n&#227;o se alterou&#46;</p>"
      ]
      "en" => array:2 [
        "titulo" => "Abstract"
        "resumen" => "<span class="elsevierStyleSectionTitle" id="sect0040">Background</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Despite improvements in treatment&#44; mortality associated with cardiogenic shock &#40;CS&#41; following acute myocardial infarction remains high&#46;</p> <span class="elsevierStyleSectionTitle" id="sect0045">Aim</span><p id="spar0105" class="elsevierStyleSimplePara elsevierViewall">To compare two groups of patients admitted with CS over a 10-year time span&#46;</p> <span class="elsevierStyleSectionTitle" id="sect0050">Methods</span><p id="spar0110" class="elsevierStyleSimplePara elsevierViewall">We performed a retrospective analysis of two patient populations presenting with CS admitted in the periods May 1998-May 2001 &#40;group A&#41; and May 2008-May 2011 &#40;group B&#41;&#46; Clinical characteristics&#44; diagnostic methods&#44; treatment and outcomes were compared&#44; and independent predictors of death at six months were analyzed&#46;</p> <span class="elsevierStyleSectionTitle" id="sect0055">Results</span><p id="spar0115" class="elsevierStyleSimplePara elsevierViewall">The incidence of CS was 3&#46;7&#37; in group A &#40;n&#61;25&#41; and 4&#46;8&#37; in group B &#40;n&#61;42&#41;&#46; There were no significant differences in clinical characteristics except for age &#40;60&#46;2&#177;12&#46;3 vs&#46; 66&#46;5&#177;11&#46;3 years&#59; p&#61;0&#46;043&#41; and the proportion of patients admitted within six hours of symptom onset &#40;29&#46;2&#37; vs&#46; 54&#46;8&#37;&#44; p&#61;0&#46;045&#41;&#46; There was a reduction in use of pulmonary artery catheterization &#40;52&#46;0&#37; vs&#46; 19&#46;0&#37;&#44; p&#61;0&#46;005&#41; but an increase in dialysis &#40;4&#46;0&#37; vs&#46; 28&#46;6&#37;&#44; p&#61;0&#46;014&#41;&#46; There was no difference in the proportion of patients reperfused within 12 hours or revascularized&#44; but use of percutaneous coronary intervention &#40;PCI&#41; increased &#40;75&#46;0&#37; vs&#46; 92&#46;9&#37;&#44; p&#61;0&#46;042&#41;&#46; There were no differences in outcomes&#44; including mortality at 30 days &#40;32&#46;0 vs&#46; 35&#46;7&#37;&#59; p&#61;0&#46;757&#41; and six months &#40;36&#46;0 vs&#46; 42&#46;9&#37;&#59; p&#61;0&#46;683&#41;&#46; Diabetes was the sole baseline characteristic identified as an independent predictor of death at six months &#40;hazard ratio &#91;HR&#93; 3&#46;02&#59; 95&#37; confidence interval &#91;CI&#93; 1&#46;38-6&#46;60&#59; p&#61;0&#46;006&#41; and mortality was lower among revascularized patients &#40;HR 0&#46;11&#59; 95&#37; CI 0&#46;03-0&#46;42&#59; p&#61;0&#46;001&#41;&#46;</p> <span class="elsevierStyleSectionTitle" id="sect0060">Conclusions</span><p id="spar0120" class="elsevierStyleSimplePara elsevierViewall">Over a 10-year time span&#44; despite earlier hospital admission and increased use of support therapies and PCI&#44; short- and medium-term mortality remained unchanged&#46;</p>"
      ]
    ]
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        "identificador" => "fig0005"
        "etiqueta" => "Figura 1"
        "tipo" => "MULTIMEDIAFIGURA"
        "mostrarFloat" => true
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          "pt" => "<p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">An&#225;lise de mortalidade por todas as causas por curvas de <span class="elsevierStyleItalic">Kaplan-Meier</span> aos 6 meses de seguimento&#46;</p>"
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        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => true
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          "leyenda" => "<p id="spar0065" class="elsevierStyleSimplePara elsevierViewall">AVC&#58; acidente vascular cerebral&#59; FC&#58; frequ&#234;ncia card&#237;aca&#59; PA&#58; press&#227;o arterial&#46;</p>"
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                  \t\t\t\t" style="border-bottom: 2px solid black">Vari&#225;veis &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t" style="border-bottom: 2px solid black">Grupo A&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t" style="border-bottom: 2px solid black">Grupo B&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">69&#44;3&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t">0&#44;929&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " colspan="4" align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">Hipertens&#227;o arterial</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">56&#44;0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t">54&#44;8&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t">0&#44;921&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">32&#44;0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t">31&#44;0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t">0&#44;929&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">Dislipidemia</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">52&#44;0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t">50&#44;0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t">0&#44;874&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">Tabagismo</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">36&#44;0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">33&#44;3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t">0&#44;824&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="4" align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="4" align="left" valign="\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">32&#44;0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">16&#44;7&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#44;145&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">Angioplastia coron&#225;ria</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">20&#44;0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">19&#44;0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#44;924&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">Cirurgia coron&#225;ria</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">4&#44;0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2&#44;4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#44;706&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">0&#44;276&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Inibidores da glicoprote&#237;na <span class="elsevierStyleSmallCaps">ii</span>b&#47;<span class="elsevierStyleSmallCaps">iii</span>a&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttop\n
                  \t\t\t\t">52&#44;0&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">0&#44;976&nbsp;\t\t\t\t\t\t\n
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          "leyenda" => "<p id="spar0080" class="elsevierStyleSimplePara elsevierViewall">AP&#58; art&#233;ria pulmonar&#59; BiAo&#58; bal&#227;o intra-a&#243;rtico&#46;</p><p id="spar0085" class="elsevierStyleSimplePara elsevierViewall"><span class="elsevierStyleSup">&#43;</span>Revasculariza&#231;&#227;o completa&#58; casos com angioplastia de todas as les&#245;es angiograficamente significativas &#40;estenoses luminais &#62;&#160;50&#37;&#41; ou submetidos a revasculariza&#231;&#227;o cir&#250;rgica&#46;</p>"
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t" style="border-bottom: 2px solid black">Vari&#225;veis &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t" style="border-bottom: 2px solid black">Grupo A&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">Grupo B&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">Valor de p&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " colspan="4" align="left" valign="\n
                  \t\t\t\t\ttop\n
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                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Cateterismo da AP&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t">52&#44;0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">19&#44;0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#44;005&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Contrapulsa&#231;&#227;o com BiAo&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">72&#44;0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">69&#44;0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t">0&#44;798&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
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                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Ventila&#231;&#227;o mec&#226;nica&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">84&#44;0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t">88&#44;1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#44;634&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Di&#225;lise&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">4&#44;0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">28&#44;6&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t">0&#44;014&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">Reperfus&#227;o &#60;&#160;12&#160;h de sintomas</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t">52&#44;0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">66&#44;7&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#44;233&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Fibrin&#243;lise&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">28&#44;0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">14&#44;3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#44;170&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Angioplastia prim&#225;ria&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">44&#44;0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">66&#44;7&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#44;069&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="4" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Revasculariza&#231;&#227;o</span></td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Global&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">92&#44;0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">95&#44;2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#44;588&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Angioplastia coron&#225;ria&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">75&#44;0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">92&#44;9&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#44;042&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Cirurgia coron&#225;ria&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">32&#44;0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">7&#44;1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#44;008&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Completa<span class="elsevierStyleSup">&#43;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">64&#44;3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">37&#44;5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#44;036&nbsp;\t\t\t\t\t\t\n
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          "pt" => "<p id="spar0075" class="elsevierStyleSimplePara elsevierViewall">T&#233;cnicas invasivas e de revasculariza&#231;&#227;o mioc&#225;rdica efetuadas</p>"
        ]
      ]
      4 => array:7 [
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        "tabla" => array:1 [
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                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">Vari&#225;veis &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">Grupo A&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">Grupo B&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">Valor de p&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="4" align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleItalic">Estenoses &#62;&#160;50&#37;</span></td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Tronco comum&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">12&#44;5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">28&#44;6&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
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                  \t\t\t\t\ttop\n
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                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">91&#44;7&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttop\n
                  \t\t\t\t">64&#44;3&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t">41&#44;7&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">61&#44;9&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttop\n
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                  \t\t\t\t">54&#44;2&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">61&#44;9&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#44;539&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
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                  \t\t\t\t">4&#44;0&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">2&#44;4&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#44;706&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Multivaso&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t">59&#44;5&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Descendente anterior&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Circunflexa&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">53&#44;7&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">0&#44;001&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Coron&#225;ria direita&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t\ttop\n
                  \t\t\t\t">4&#44;2&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Multivaso&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">8&#44;3&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Implanta&#231;&#227;o de <span class="elsevierStyleItalic">stent</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">88&#44;1&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">&#60;&#160;0&#44;001&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">Stent</span> revestido por f&#225;rmaco&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">-&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">47&#44;6&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">-&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="char" valign="\n
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                  """
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                  \t\t\t\t" style="border-bottom: 2px solid black">Grupo B&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t" style="border-bottom: 2px solid black">Valor de p&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">0&#44;172&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Fibrilha&#231;&#227;o auricular&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t">24&#44;0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t">14&#44;3&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">0&#44;316&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Fibrilha&#231;&#227;o ventricular&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t">12&#44;1&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">23&#44;8&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">0&#44;237&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>BAV completo&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">8&#44;0&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">9&#44;5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t">0&#44;833&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Hemorragia&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">12&#44;0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t">26&#44;2&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">0&#44;167&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Morte&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">33&#44;3&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">0&#44;649&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="\n
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                  \t\t\t\t"><span class="elsevierStyleItalic">Mortalidade no seguimento</span></td></tr><tr title="table-row"><td class="td" title="\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>30&#160;d&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">35&#44;7&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t">0&#44;757&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>6 meses&nbsp;\t\t\t\t\t\t\n
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