The use of reperfusion and revascularization procedures in acute coronary syndrome in Portugal: A systematic review

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CABG: coronary artery bypass grafting; PCI: percutaneous coronary intervention; STEMI: 90% or more patients with diagnosis of ST-segment elevation myocardial infarction or Q-wave myocardial infarction; NSTE-ACS: 90% or more patients with diagnosis of non-ST-segment elevation ACS; mixed ACS: mixture of patients with several types of ACS. * If a study provided data on treatment with both reperfusion and revascularization, it contributed to both groups. If a study provided data on more than one diagnostic category, it contributed to all groups. † The sample was considered selected when inclusion of patients was dependent on having undergone some diagnosis or treatment procedure; otherwise, it was considered unselected." ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "Luísa Lopes-Conceição, Marta Pereira, Carla Araújo, Olga Laszczýnska, Nuno Lunet, Ana Azevedo" "autores" => array:6 [ 0 => array:2 [ "nombre" => "Luísa" "apellidos" => "Lopes-Conceição" ] 1 => array:2 [ "nombre" => "Marta" "apellidos" => "Pereira" ] 2 => array:2 [ "nombre" => "Carla" "apellidos" => "Araújo" ] 3 => array:2 [ "nombre" => "Olga" "apellidos" => "Laszczýnska" ] 4 => array:2 [ "nombre" => "Nuno" "apellidos" => "Lunet" ] 5 => array:2 [ "nombre" => "Ana" "apellidos" => "Azevedo" ] ] ] ] ] "idiomaDefecto" => "en" "Traduccion" => array:1 [ "en" => array:9 [ "pii" => "S0870255114002601" "doi" => "10.1016/j.repc.2013.11.013" "estado" => "S300" "subdocumento" => "" "abierto" => array:3 [ "ES" => true "ES2" => true "LATM" => true ] "gratuito" => true "lecturas" => array:1 [ "total" => 0 ] "idiomaDefecto" => "en" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0870255114002601?idApp=UINPBA00004E" ] ] "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2174204914002657?idApp=UINPBA00004E" "url" => "/21742049/0000003300000011/v1_201412120159/S2174204914002657/v1_201412120159/en/main.assets" ] ] "itemSiguiente" => array:19 [ "pii" => "S0870255114002686" "issn" => "08702551" "doi" => "10.1016/j.repc.2014.05.008" "estado" => "S300" "fechaPublicacion" => "2014-11-01" "aid" => "553" "copyright" => "Sociedade Portuguesa de Cardiologia" "documento" => "article" "licencia" => "http://creativecommons.org/licenses/by-nc-nd/4.0/" "subdocumento" => "ssu" "cita" => "Rev Port Cardiol. 2014;33:717-25" "abierto" => array:3 [ "ES" => true "ES2" => true "LATM" => true ] "gratuito" => true "lecturas" => array:2 [ "total" => 4468 "formatos" => array:3 [ "EPUB" => 187 "HTML" => 3420 "PDF" => 861 ] ] "en" => array:13 [ "idiomaDefecto" => true "cabecera" => "Review article" "titulo" => "Cardiac resynchronization therapy in patients with atrial fibrillation: A meta-analysis" "tienePdf" => "en" "tieneTextoCompleto" => "en" "tieneResumen" => array:2 [ 0 => "en" 1 => "pt" ] "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "717" "paginaFinal" => "725" ] ] "titulosAlternativos" => array:1 [ "pt" => array:1 [ "titulo" => "Terapêutica de ressincronização cardíaca em doentes com fibrilhação auricular: uma metanálise" ] ] "contieneResumen" => array:2 [ "en" => true "pt" => true ] "contieneTextoCompleto" => array:1 [ "en" => true ] "contienePdf" => array:1 [ "en" => true ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0015" "etiqueta" => "Figure 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 823 "Ancho" => 2667 "Tamanyo" => 196775 ] ] "descripcion" => array:1 [ "en" => "Cardiovascular mortality for patients with atrial fibrillation versus sinus rhythm. 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F: first episode; mixed ACS: mixture of patients with several types of ACS; NSTE-ACS: 90% or more patients with diagnosis of non-ST-segment elevation ACS; PCI: percutaneous coronary intervention; R: recurrent episode; STEMI: 90% or more patients with diagnosis of ST-segment elevation myocardial infarction or Q-wave myocardial infarction. * Age is presented as mean (SD) unless otherwise specified; † mean age; ‡ median age." ] ] ] "textoCompleto" => "IntroductionCoronary heart disease (CHD) is responsible for 7.3 million deaths yearly worldwide, corresponding to 12.8% of all deaths.<a class="elsevierStyleCrossRef" href="#bib0005">1</a> In Portugal, CHD was responsible for 23% of cardiovascular deaths in 2009,<a class="elsevierStyleCrossRef" href="#bib0010">2</a> though mortality rates have been decreasing since the 1980s, as in most developed countries.<a class="elsevierStyleCrossRef" href="#bib0015">3</a>The increasing use of evidence-based treatments for acute coronary syndrome (ACS), including reperfusion therapy and revascularization procedures, has been reported to explain up to half of the decrease in CHD mortality rates in several developed countries.<a class="elsevierStyleCrossRefs" href="#bib0020">4,5</a> Continuous and comprehensive monitoring of the use of reperfusion and revascularization therapies for ACS patients in routine clinical practice is thus essential to evaluate the quality of care.The Portuguese Registry of Acute Coronary Syndromes provides data on a large number of ACS events in the last decade, but only patients admitted to some cardiology departments in the country are registered and consecutive recruitment is not ensured, possibly limiting its representativeness.<a class="elsevierStyleCrossRef" href="#bib0030">6</a> Other studies, based on samples of episodes, mainly single-center and resulting from the initiative of local physicians or academic researchers, have been published and could complement the registry data with coverage of other institutions and departments and a greater time span.Therefore, we performed a systematic review of published studies reporting on the use of reperfusion and revascularization procedures in patients with ACS in Portugal.MethodsSearch strategyWe searched PubMed from inception until July 2012 to identify original reports providing data on the proportion of patients with ACS, stable angina and heart failure treated with pharmacological and non-pharmacological therapies in Portugal. The search expression is provided in the systematic review flowchart (<a class="elsevierStyleCrossRef" href="#fig0005">Figure 1</a>). This report focuses on reperfusion and revascularization procedures in ACS. The reference lists of review articles on treatment of ACS patients were screened to identify other potentially eligible original studies.<elsevierMultimedia ident="fig0005"></elsevierMultimedia>Screening of reference listsTwo reviewers independently assessed the studies in two steps, following the same predefined criteria, to determine the eligibility of each report. In the first step irrelevant studies were excluded on the basis of the title and abstract only; when the abstract of a particular article was not available, the article was selected for further assessment, except when the title unequivocally presented evidence for exclusion (e.g. case report). The full texts of studies selected for the second step were then assessed to decide on their eligibility and availability of relevant data.The decisions made independently by the two reviewers were compared in the two phases and disagreements were resolved by consensus or after discussion with a third researcher, if necessary.The criteria for exclusion of studies were the following: not involving humans (e.g. in-vitro studies; animal research); case reports; reviews, editorials or comments; not involving Portuguese hospitals; involving ACS patients whose selection was dependent on having undergone a particular diagnosis or treatment procedure under study and with no information on any other procedure (e.g. samples including only patients who underwent PCI); not providing data on treatments in ACS patients; providing insufficient information to characterize the population (e.g. not providing information on patients’ age or sex, or sample size).When more than one study provided data on patients with the same diagnosis, selected using the same criteria, from the same institution and in overlapping periods, we included the one that covered the longest time period; if the same time period was considered, the one with the largest sample size was included, or in cases of similar sample size, the one that provided information on more eligible treatments. When there were two studies that included ACS patients admitted to the same hospital with part of the data collection period overlapping, we included only the one with the larger sample size, even though over a shorter time period,<a class="elsevierStyleCrossRef" href="#bib0035">7</a> since the other included a group selected from all patients with ACS.<a class="elsevierStyleCrossRef" href="#bib0040">8</a> When two publications studied the same sample, but reported complementary results on eligible treatments, both articles were included but the information on each eligible treatment for each specific diagnosis was considered only once in the data analyses.Data extractionPapers were scrutinized using a standardized data extraction sheet, to collect information on: first author, publication year, year or period of data collection, geographical coverage and department where patients were recruited, sample characteristics (study population, diagnosis, type of episode [first vs. recurrent], sex, age and sample size), proportion of patients who received treatments (fibrinolysis, primary and non-specified PCI and coronary artery bypass grafting [CABG]). If only the absolute number of patients treated was available, the proportion was calculated by dividing by the stratum-specific sample size. When an article presented data stratified by a variable with no relevance to our analysis (e.g. diabetic vs. non-diabetic patients), we calculated the weighted average of the proportions over all strata.All types of PCI (including primary PCI) were considered in the analysis of this procedure as revascularization therapy. The proportions of patients undergoing percutaneous and surgical revascularization procedures were described only when performed during the initial hospitalization for the acute event. We considered two types of study population in terms of their representativeness of ACS patients treated in Portuguese institutions: when patient selection was dependent on having undergone a treatment or a diagnostic procedure (e.g. patients referred for viability tests; patients undergoing coronary angiography), the population was considered selected; otherwise, it was considered unselected.When possible, year-, sex-, age- and diagnosis-specific estimates were extracted.Data analysisAll studies are described in the Supplementary Table available online; only those relying on unselected samples of patients are represented in the forest plots. Although sex- and age-specific estimates were extracted and are shown in the detailed Supplementary Table, these were seldom available and for descriptive purposes the results for the total sample are always presented in the forest plots, stratified only by diagnosis.The proportion of patients who underwent each procedure was described according to type of ACS. However, given that reports did not systematically stratify according to this criterion, patient samples were classified into one of the following three categories, according to the proportion of different ACS patients included: STEMI (90% or more patients with a diagnosis of ST-segment elevation myocardial infarction (STEMI) or Q-wave myocardial infarction [MI]), NSTE-ACS (90% or more patients with a diagnosis of non-ST-segment elevation ACS [NSTE-ACS]), and mixed ACS (if neither of these criteria was satisfied).ResultsWe identified 41 eligible studies providing data on ACS patients who underwent reperfusion and/or revascularization therapies, 21 presenting data on reperfusion and 28 on revascularization (<a class="elsevierStyleCrossRef" href="#fig0005">Figure 1</a>), published between 1989 and 2011 (Supplementary Table 1, available online).Over three-quarters of the studies reported data from a single institution, mainly from the Lisbon region. Three studies were based on national registries that covered several regions of the country.<a class="elsevierStyleCrossRefs" href="#bib0030">6,9,10</a> The vast majority of studies recruited patients in cardiology departments. Two-thirds of the studies included unselected populations. More than half of the studies included both first and recurrent episodes and four studies reported exclusively on first episodes.<a class="elsevierStyleCrossRefs" href="#bib0055">11–14</a> The sample size ranged from 21 to 22482 patients, and almost 40% of the studies involved samples between 100 and 500 patients. Seven samples included mostly STEMI patients, 10 mostly NSTE-ACS patients and 27 a mixture of patients with several types of ACS. Five studies presented sex-specific estimates,<a class="elsevierStyleCrossRefs" href="#bib0050">10,14–17</a> and only two presented age-specific estimates<a class="elsevierStyleCrossRefs" href="#bib0090">18,19</a> (Supplementary Table 1, available online).As expected, data on reperfusion were available only for STEMI and mixed ACS patients (<a class="elsevierStyleCrossRef" href="#fig0005">Figure 1</a>). Only three studies provided estimates of the use of reperfusion in STEMI patients. In more recent years, one study conducted in Faro reported the use of fibrinolysis in 16.5% of STEMI patients in 2008,<a class="elsevierStyleCrossRef" href="#bib0100">20</a> while a report from the National Registry of Acute Coronary Syndromes showed a mean of 43.7%, representing many cardiology centers across the country over several years.<a class="elsevierStyleCrossRef" href="#bib0030">6</a> The same two studies reported the use of primary PCI in 41.4% and 19.2% of STEMI patients, respectively.<a class="elsevierStyleCrossRefs" href="#bib0030">6,20</a> For mixed ACS patients there was a larger number of observations; fibrinolysis was used in a quarter to a half of patients in the late 1990s, decreasing to less than 10% over the next decade. Two reports published 10 years apart, in 2001 and 2011, showed an increase in the use of primary PCI in mixed ACS patients, from less than 10% in a sample of patients from several cardiology centers across the country<a class="elsevierStyleCrossRef" href="#bib0050">10</a> to approximately 50% in a single cardiology center in Lisbon<a class="elsevierStyleCrossRef" href="#bib0095">19</a> (<a class="elsevierStyleCrossRef" href="#fig0010">Figure 2</a>).<elsevierMultimedia ident="fig0010"></elsevierMultimedia>Percutaneous revascularization, including both emergent and elective procedures during hospitalization for an acute event, was performed in approximately half of STEMI patients according to a report from Faro in 2008<a class="elsevierStyleCrossRef" href="#bib0100">20</a> and the report of the National Registry of Acute Coronary Syndromes covering several years and centers across the country.<a class="elsevierStyleCrossRef" href="#bib0030">6</a> For NTSE-ACS, two studies published in 1993 report contrasting experiences in small single-center samples, while from 2003 to 2011 several estimates consistently point to one third to one half of patients being revascularized percutaneously during the acute hospitalization, with no clear time trend. With a larger number of reports and more regular publication over 15 years, the proportion of mixed ACS patients revascularized percutaneously increased from under 10% in the mid-1990s to approximately 70% in recent years (<a class="elsevierStyleCrossRef" href="#fig0015">Figure 3</a>).<elsevierMultimedia ident="fig0015"></elsevierMultimedia>CABG was used in 1.0% of STEMI patients (this figure available only from the National Registry of Acute Coronary Syndromes). In NSTE-ACS and mixed ACS, 1–10% of patients were reported as undergoing CABG, with no clear time trend. An exception for several reports is a single institution (Hospital de Santa Cruz, in Carnaxide) over the years, with a proportion closer to 20% of NTSE-ACS patients having undergone surgical revascularization during hospitalization for the acute event (<a class="elsevierStyleCrossRef" href="#fig0020">Figure 4</a>).<elsevierMultimedia ident="fig0020"></elsevierMultimedia>DiscussionDespite considerable heterogeneity in the methodology and presentation of results of available studies, this review shows that the proportion of ACS patients in Portugal treated with fibrinolysis has decreased in the last 20 years and the use of PCI has increased, while the use of CABG has not changed.Since the late 1970s, more aggressive and effective treatments have been developed and implemented for the treatment of CHD, including fibrinolysis, PCI and CABG.<a class="elsevierStyleCrossRef" href="#bib0105">21</a> Of the primary studies included in the present review, the oldest with data on fibrinolysis was published in 1989,<a class="elsevierStyleCrossRef" href="#bib0110">22</a> while PCI and CABG were first mentioned in an article published in 1993 (data collection in 1982).<a class="elsevierStyleCrossRef" href="#bib0115">23</a> Data from previous years were reported in a few publications which were excluded mainly due to the reporting format, for example lack of data on sample size or patients’ sex and age, or because the use of procedures in the acute hospitalization or over variable follow-up periods could not be distinguished.During the last decade, mechanical or pharmacological reperfusion therapy has been recommended for all patients with STEMI who present within 12 hours of the onset of symptoms.<a class="elsevierStyleCrossRefs" href="#bib0120">24–26</a> A growing body of evidence has also demonstrated beneficial effects of reperfusion therapy in patients presenting more than 12 hours from symptom onset. In this group of patients, recent recommendations consider this treatment a strong indication, preferably by primary PCI (class I) if there is evidence of ongoing ischemia or if pain and electrocardiographic changes have been stuttering. Primary PCI may be also considered even in asymptomatic patients presenting 12–24 hours after symptom onset.<a class="elsevierStyleCrossRef" href="#bib0125">25</a> For years, fibrinolysis was chosen over primary PCI, mainly due to its greater ease of access and use.<a class="elsevierStyleCrossRef" href="#bib0105">21</a> However, mechanical reperfusion has been preferred since several randomized clinical trials and meta-analyses comparing primary PCI with in-hospital fibrinolytic therapy in patients presenting within 6–12 hours of symptom onset showed more effective restoration of vessel patency, less reocclusion, reinfarction and stroke, improved left ventricular function and less short-term mortality with primary PCI.<a class="elsevierStyleCrossRefs" href="#bib0135">27,28</a> National<a class="elsevierStyleCrossRefs" href="#bib0030">6,29</a> and international registries in Europe<a class="elsevierStyleCrossRefs" href="#bib0150">30,31</a> and the USA<a class="elsevierStyleCrossRefs" href="#bib0160">32,33</a> suggest an increase in the use of reperfusion therapies accompanied by a significant shift from fibrinolysis therapy to primary PCI. A significant decrease in mortality after STEMI has been observed in countries switching from fibrinolysis to primary PCI.<a class="elsevierStyleCrossRef" href="#bib0170">34</a> In our study, we observed decreased use of fibrinolysis and increased use of primary PCI. In this review, most of the studies providing data on fibrinolysis were published in the 1990s, with data collected in the 1980s and 1990s. By contrast, the studies addressing primary PCI were only published in the current century. Although the trends cannot be quantified, fibrinolysis appears to have been replaced by primary PCI.Since its introduction in 1977, angioplasty has become the most frequently performed major intervention in medicine,<a class="elsevierStyleCrossRef" href="#bib0175">35</a> as both a reperfusion (primary PCI) and revascularization procedure. Among the included studies addressing the use of revascularization by a percutaneous procedure, one sixth were published in the 1990s and the remainder afterwards. Surgical revascularization with CABG was first introduced in 1969, and become the most thoroughly studied procedure in the history of surgery.<a class="elsevierStyleCrossRef" href="#bib0180">36</a> In our review, a quarter of the studies were published in the 1990s and the remainder after 2000. Although the primary studies provided information on surgeries performed at different times related to the acute event (e.g. during a variable time of follow-up after the acute event), we only included studies with data on CABG performed during the initial hospitalization. Otherwise, the data to be compared would be even more heterogeneous. Particularly for this procedure, it is important to point out that many patients referred for CABG are expected to have undergone surgery after discharge or have been transferred to a different institution while awaiting the procedure,<a class="elsevierStyleCrossRef" href="#bib0030">6</a> thus reducing the proportion of patients treated that were captured by this analysis.The results on revascularization therapies are consistent with the findings of previous studies showing an increase in PCI use and non-significant changes in use of CABG in recent years.<a class="elsevierStyleCrossRefs" href="#bib0150">30,37,38</a> In patients stabilized after an episode of acute coronary syndrome, the choice of revascularization modality can be made as in stable coronary heart disease.<a class="elsevierStyleCrossRefs" href="#bib0125">25,39,40</a> In single-vessel disease, which occurs in one-third of patients with ACS, ad-hoc PCI is feasible in most cases, whereas in patients with multivessel disease (approximately half of cases) the decision on the type of revascularization is more complex.<a class="elsevierStyleCrossRefs" href="#bib0205">41,42</a> Options for this condition have evolved over time, and currently include culprit lesion PCI, multivessel PCI, CABG or hybrid (combined) revascularization, according to clinical status, lesion characteristics and the severity and distribution of coronary artery disease.<a class="elsevierStyleCrossRefs" href="#bib0125">25,39,40</a>Our methodology has some limitations. The use of a single search engine may have limited our results. However, the inclusion of relevant studies identified in the reference lists of the review articles should have helped identify older and non-PubMed-indexed publications. The probability of identifying relevant studies from among those published is also influenced by their results because, despite the descriptive nature of the studies, publication bias can be expected, with higher likelihood of publication from higher-quality or at least higher-volume centers. It is noteworthy that the majority of studies came from cardiology departments, some of which also contributed to the National Registry of Acute Coronary Syndromes. Therefore, the main gain with this review is its coverage of a greater time span, but not the representation of less specialized centers than those included in the National Registry of Acute Coronary Syndromes. The results are affected by the methodological heterogeneity of the studies, particularly inclusion criteria, sample size, and patients’ age and sex, as well as the relatively small number of estimates for each type of treatment under study. Another limitation for more informative conclusions stems from the small number of studies with sex-, age-, and year-specific estimates, as authors mainly reported overall data. Some reported data referring to a period longer than one year; however, it was not possible to obtain year-specific estimates.Given these limitations, an alternative approach to the study of trends in the use of these treatments in the past could be to rely on administrative databases, using data collected, coded and stored, immediately available for analysis.<a class="elsevierStyleCrossRef" href="#bib0215">43</a> The national register of hospital discharges<a class="elsevierStyleCrossRef" href="#bib0145">29</a> could be used to quantify the number of procedures performed, but the usefulness of these datasets is limited: it is not possible to classify the subtypes of ACS according to current recommendations<a class="elsevierStyleCrossRef" href="#bib0220">44</a> when departing from data coded using the International Classification of Diseases, 9th revision, Clinical Modification (ICD-9-CM). Furthermore, there is no information available in the database to ascertain the timing of PCI or to identify recurrent episodes in the same patient.<a class="elsevierStyleCrossRef" href="#bib0145">29</a>ConclusionsThe general pattern of treatment reflects what is reported in other developed countries and can be viewed as a favorable time trend in the quality of care of ACS patients. Future investigation should focus on the prospective and systematic recording of high-quality information to monitor the use of treatments in this acute condition, while past trends can only be properly clarified by an original retrospective study on a representative sample of ACS patients, involving review of hospital records.Ethical disclosuresProtection of human and animal subjectsThe authors declare that no experiments were performed on humans or animals for this study.Confidentiality of dataThe authors declare that no patient data appear in this article.Right to privacy and informed consentThe authors declare that no patient data appear in this article.FundingThis study was funded by a grant from Fundação para a Ciência e a Tecnologia (PIC/IC/83006/2007).Conflicts of interestThe authors have no conflicts of interest to declare." "textoCompletoSecciones" => array:1 [ "secciones" => array:14 [ 0 => array:2 [ "identificador" => "xres384019" "titulo" => array:5 [ 0 => "Abstract" 1 => "Introduction and Objectives" 2 => "Methods" 3 => "Results" 4 => "Conclusions" ] ] 1 => array:2 [ "identificador" => "xpalclavsec362885" "titulo" => "Keywords" ] 2 => array:2 [ "identificador" => "xres384020" "titulo" => array:5 [ 0 => "Resumo" 1 => "Introdução e objetivos" 2 => "Métodos" 3 => "Resultados" 4 => "Conclusões" ] ] 3 => array:2 [ "identificador" => "xpalclavsec362884" "titulo" => "Palavras-chave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:3 [ "identificador" => "sec0010" "titulo" => "Methods" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "sec0015" "titulo" => "Search strategy" ] 1 => array:2 [ "identificador" => "sec0020" "titulo" => "Screening of reference lists" ] 2 => array:2 [ "identificador" => "sec0025" "titulo" => "Data extraction" ] 3 => array:2 [ "identificador" => "sec0030" "titulo" => "Data analysis" ] ] ] 6 => array:2 [ "identificador" => "sec0035" "titulo" => "Results" ] 7 => array:2 [ "identificador" => "sec0040" "titulo" => "Discussion" ] 8 => array:2 [ "identificador" => "sec0045" "titulo" => "Conclusions" ] 9 => array:3 [ "identificador" => "sec0050" "titulo" => "Ethical disclosures" "secciones" => array:3 [ 0 => array:2 [ "identificador" => "sec0055" "titulo" => "Protection of human and animal subjects" ] 1 => array:2 [ "identificador" => "sec0060" "titulo" => "Confidentiality of data" ] 2 => array:2 [ "identificador" => "sec0065" "titulo" => "Right to privacy and informed consent" ] ] ] 10 => array:2 [ "identificador" => "sec0070" "titulo" => "Funding" ] 11 => array:2 [ "identificador" => "sec0075" "titulo" => "Conflicts of interest" ] 12 => array:2 [ "identificador" => "xack104189" "titulo" => "Acknowledgments" ] 13 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2013-03-22" "fechaAceptado" => "2013-11-03" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec362885" "palabras" => array:5 [ 0 => "Acute coronary syndrome" 1 => "Angioplasty" 2 => "Coronary artery bypass" 3 => "Fibrinolysis" 4 => "Myocardial revascularization" ] ] ] "pt" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palavras-chave" "identificador" => "xpalclavsec362884" "palabras" => array:5 [ 0 => "Síndrome coronária aguda" 1 => "Angioplastia" 2 => "Cirurgia de revascularização coronária" 3 => "Fibrinólise" 4 => "Revascularização miocárdica" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:2 [ "titulo" => "Abstract" "resumen" => "Introduction and ObjectivesReperfusion and revascularization therapies play an important role in the management of coronary heart disease and have contributed to decreases in case fatality rates. We aimed to describe the use of these therapies for the treatment of acute coronary syndrome (ACS) patients over time in Portugal. MethodsPubMed was searched in July 2012. The proportion of patients treated with fibrinolysis, primary percutaneous coronary intervention (PCI), any PCI and coronary artery bypass grafting (CABG) was described according to type of ACS: STEMI (≥90% patients with ST-segment elevation or Q-wave myocardial infarction), NSTE-ACS (≥90% patients with non-ST-segment elevation ACS) and mixed ACS (all others). ResultsWe identified 41 eligible studies, published between 1989 and 2011. Twenty-eight reported on samples considered representative of ACS patients treated in Portugal. The small number of estimates of the use of each treatment in STEMI and NSTE-ACS patients precluded identification of any time trend. In the last 20 years, the proportion of mixed ACS patients treated with fibrinolysis decreased and the use of PCI increased, while the use of CABG did not change. ConclusionsThe general pattern of the use of reperfusion and revascularization is in accordance with that reported in other developed countries, reflecting a favorable trend in the quality of care of ACS patients. The relatively small number of estimates on the same procedure in comparable patients limits the generalizability of the conclusions, and highlights the need for systematic approaches to monitor the use of treatments over time." ] "pt" => array:2 [ "titulo" => "Resumo" "resumen" => "Introdução e objetivosA reperfusão e revascularização desempenham um importante papel no tratamento da doença coronária contribuindo para a diminuição da letalidade. Foi nosso objetivo descrever o uso destes procedimentos no tratamento da síndrome coronária aguda (SCA) ao longo do tempo em Portugal. MétodosA pesquisa foi efetuada na Pubmed em julho de 2012. A proporção de doentes tratados com fibrinólise, angioplastia primária, qualquer tipo de angioplastia e cirurgia de revascularização coronária (CABG) foi descrita de acordo com o tipo de SCA: SCA supra-ST (quando a proporção de doentes com elevação do segmento ST ou enfarte do miocárdio com ondas Q era ≥90%), SCA sem-ST (quando a proporção de doentes com SCA sem elevação do segmento ST era ≥90%) e SCA misto (restantes casos). ResultadosForam identificados 41 estudos publicados entre 1989 e 2011. Vinte e oito estudos descreveram amostras representativas dos doentes com SCA tratados em Portugal. O baixo número de estimativas de cada tratamento nos doentes com SCA supra-ST e sem-ST, impossibilitou a observação de tendências temporais. Nos últimos 20 anos, a proporção de doentes com SCA misto tratados com fibrinólise diminuiu, o uso de angioplastia aumentou, enquanto o uso de CABG não se alterou. ConclusõesO padrão do uso destes tratamentos está de acordo com dados publicados noutros países desenvolvidos, refletindo uma tendência favorável na qualidade dos cuidados prestados. O baixo número de estimativas do mesmo procedimento limitou a generalização de conclusões, reforçando a necessidade de alternativas para monitorizar o uso de tratamentos ao longo do tempo." ] ] "apendice" => array:1 [ 0 => array:1 [ "seccion" => array:1 [ 0 => array:4 [ "apendice" => "<elsevierMultimedia ident="upi0005"></elsevierMultimedia>" "etiqueta" => "Appendix A" "titulo" => "Supplementary data" "identificador" => "sec0085" ] ] ] ] "multimedia" => array:5 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 3478 "Ancho" => 2333 "Tamanyo" => 1008869 ] ] "descripcion" => array:1 [ "en" => "Flowchart of the systematic review. CABG: coronary artery bypass grafting; PCI: percutaneous coronary intervention; STEMI: 90% or more patients with diagnosis of ST-segment elevation myocardial infarction or Q-wave myocardial infarction; NSTE-ACS: 90% or more patients with diagnosis of non-ST-segment elevation ACS; mixed ACS: mixture of patients with several types of ACS. * If a study provided data on treatment with both reperfusion and revascularization, it contributed to both groups. If a study provided data on more than one diagnostic category, it contributed to all groups. † The sample was considered selected when inclusion of patients was dependent on having undergone some diagnosis or treatment procedure; otherwise, it was considered unselected." ] ] 1 => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 1687 "Ancho" => 2327 "Tamanyo" => 287368 ] ] "descripcion" => array:1 [ "en" => "Proportion of acute coronary syndrome patients treated with reperfusion therapies (fibrinolysis and primary PCI) in Portugal, estimated in unselected samples of patients. F: first episode; mixed ACS: mixture of patients with several types of ACS; NSTE-ACS: 90% or more patients with diagnosis of non-ST-segment elevation ACS; PCI: percutaneous coronary intervention; R: recurrent episode; STEMI: 90% or more patients with diagnosis of ST-segment elevation myocardial infarction or Q-wave myocardial infarction. * Age is presented as mean (SD) unless otherwise specified; † mean age; ‡ median age." ] ] 2 => array:7 [ "identificador" => "fig0015" "etiqueta" => "Figure 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 1860 "Ancho" => 2337 "Tamanyo" => 354610 ] ] "descripcion" => array:1 [ "en" => "Proportion of acute coronary syndrome patients treated with PCI in Portugal, estimated in unselected samples of patients. F: first episode; mixed ACS: mixture of patients with several types of ACS; NSTE-ACS: 90% or more patients with diagnosis of non-ST-segment elevation ACS; PCI: percutaneous coronary intervention; R: recurrent episode; STEMI: 90% or more patients with diagnosis of ST-segment elevation myocardial infarction or Q-wave myocardial infarction. * Age is presented as mean (SD) unless otherwise specified; † mean age; ‡ median age." ] ] 3 => array:7 [ "identificador" => "fig0020" "etiqueta" => "Figure 4" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr4.jpeg" "Alto" => 1467 "Ancho" => 2313 "Tamanyo" => 283029 ] ] "descripcion" => array:1 [ "en" => "Proportion of acute coronary syndrome patients treated with CABG in Portugal, estimated in unselected samples of patients. CABG: coronary artery bypass grafting; F: first episode; mixed ACS: mixture of patients with several types of ACS; NSTE-ACS: 90% or more patients with diagnosis of non-ST-segment elevation ACS; R: recurrent episode; STEMI: 90% or more patients with diagnosis of ST-segment elevation myocardial infarction or Q-wave myocardial infarction. * Age is presented as mean (SD) unless otherwise specified; † mean age; ‡ median age." ] ] 4 => array:5 [ "identificador" => "upi0005" "tipo" => "MULTIMEDIAECOMPONENTE" "mostrarFloat" => false "mostrarDisplay" => true "Ecomponente" => array:2 [ "fichero" => "mmc1.pdf" "ficheroTamanyo" => 104001 ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:44 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "The top ten causes of death. 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Estatísticas

Original Article

Uso de procedimentos de reperfusão e revascularização na síndrome coronária aguda em Portugal: revisão sistemática

Luísa Lopes-Conceiçãoa,b, Marta Pereiraa,b, Carla Araújoa,b,c, Olga Laszczýnskaa,b, Nuno Luneta,b, Ana Azevedoa,b,

Autor para correspondência

anazev@med.up.pt

Corresponding author.

a Department of Clinical Epidemiology, Predictive Medicine and Public Health, University of Porto Medical School, Porto, Portugal

b EPIUnit - Institute of Public Health, University of Porto, Porto, Portugal

c Centro Hospitalar de Trás-Os-Montes e Alto Douro EPE, Vila Real, Portugal

Lido

7735

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que se leu este artigo

2005

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    "titulo" => "The use of reperfusion and revascularization procedures in acute coronary syndrome in Portugal&#58; A systematic review"
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        "titulo" => "Uso de procedimentos de reperfus&#227;o e revasculariza&#231;&#227;o na s&#237;ndrome coron&#225;ria aguda em Portugal&#58; revis&#227;o sistem&#225;tica"
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          "en" => "<p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">Proportion of acute coronary syndrome patients treated with reperfusion therapies &#40;fibrinolysis and primary PCI&#41; in Portugal&#44; estimated in unselected samples of patients&#46; F&#58; first episode&#59; mixed ACS&#58; mixture of patients with several types of ACS&#59; NSTE-ACS&#58; 90&#37; or more patients with diagnosis of non-ST-segment elevation ACS&#59; PCI&#58; percutaneous coronary intervention&#59; R&#58; recurrent episode&#59; STEMI&#58; 90&#37; or more patients with diagnosis of ST-segment elevation myocardial infarction or Q-wave myocardial infarction&#46; &#42; Age is presented as mean &#40;SD&#41; unless otherwise specified&#59; <span class="elsevierStyleSup">&#8224;</span> mean age&#59; <span class="elsevierStyleSup">&#8225;</span> median age&#46;</p>"
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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Coronary heart disease &#40;CHD&#41; is responsible for 7&#46;3 million deaths yearly worldwide&#44; corresponding to 12&#46;8&#37; of all deaths&#46;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> In Portugal&#44; CHD was responsible for 23&#37; of cardiovascular deaths in 2009&#44;<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> though mortality rates have been decreasing since the 1980s&#44; as in most developed countries&#46;<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">The increasing use of evidence-based treatments for acute coronary syndrome &#40;ACS&#41;&#44; including reperfusion therapy and revascularization procedures&#44; has been reported to explain up to half of the decrease in CHD mortality rates in several developed countries&#46;<a class="elsevierStyleCrossRefs" href="#bib0020"><span class="elsevierStyleSup">4&#44;5</span></a> Continuous and comprehensive monitoring of the use of reperfusion and revascularization therapies for ACS patients in routine clinical practice is thus essential to evaluate the quality of care&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">The Portuguese Registry of Acute Coronary Syndromes provides data on a large number of ACS events in the last decade&#44; but only patients admitted to some cardiology departments in the country are registered and consecutive recruitment is not ensured&#44; possibly limiting its representativeness&#46;<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> Other studies&#44; based on samples of episodes&#44; mainly single-center and resulting from the initiative of local physicians or academic researchers&#44; have been published and could complement the registry data with coverage of other institutions and departments and a greater time span&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">Therefore&#44; we performed a systematic review of published studies reporting on the use of reperfusion and revascularization procedures in patients with ACS in Portugal&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Methods</span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Search strategy</span><p id="par0025" class="elsevierStylePara elsevierViewall">We searched PubMed from inception until July 2012 to identify original reports providing data on the proportion of patients with ACS&#44; stable angina and heart failure treated with pharmacological and non-pharmacological therapies in Portugal&#46; The search expression is provided in the systematic review flowchart &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Figure 1</a>&#41;&#46; This report focuses on reperfusion and revascularization procedures in ACS&#46; The reference lists of review articles on treatment of ACS patients were screened to identify other potentially eligible original studies&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Screening of reference lists</span><p id="par0030" class="elsevierStylePara elsevierViewall">Two reviewers independently assessed the studies in two steps&#44; following the same predefined criteria&#44; to determine the eligibility of each report&#46; In the first step irrelevant studies were excluded on the basis of the title and abstract only&#59; when the abstract of a particular article was not available&#44; the article was selected for further assessment&#44; except when the title unequivocally presented evidence for exclusion &#40;e&#46;g&#46; case report&#41;&#46; The full texts of studies selected for the second step were then assessed to decide on their eligibility and availability of relevant data&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">The decisions made independently by the two reviewers were compared in the two phases and disagreements were resolved by consensus or after discussion with a third researcher&#44; if necessary&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">The criteria for exclusion of studies were the following&#58; not involving humans &#40;e&#46;g&#46; in-vitro studies&#59; animal research&#41;&#59; case reports&#59; reviews&#44; editorials or comments&#59; not involving Portuguese hospitals&#59; involving ACS patients whose selection was dependent on having undergone a particular diagnosis or treatment procedure under study and with no information on any other procedure &#40;e&#46;g&#46; samples including only patients who underwent PCI&#41;&#59; not providing data on treatments in ACS patients&#59; providing insufficient information to characterize the population &#40;e&#46;g&#46; not providing information on patients&#8217; age or sex&#44; or sample size&#41;&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">When more than one study provided data on patients with the same diagnosis&#44; selected using the same criteria&#44; from the same institution and in overlapping periods&#44; we included the one that covered the longest time period&#59; if the same time period was considered&#44; the one with the largest sample size was included&#44; or in cases of similar sample size&#44; the one that provided information on more eligible treatments&#46; When there were two studies that included ACS patients admitted to the same hospital with part of the data collection period overlapping&#44; we included only the one with the larger sample size&#44; even though over a shorter time period&#44;<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a> since the other included a group selected from all patients with ACS&#46;<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a> When two publications studied the same sample&#44; but reported complementary results on eligible treatments&#44; both articles were included but the information on each eligible treatment for each specific diagnosis was considered only once in the data analyses&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Data extraction</span><p id="par0050" class="elsevierStylePara elsevierViewall">Papers were scrutinized using a standardized data extraction sheet&#44; to collect information on&#58; first author&#44; publication year&#44; year or period of data collection&#44; geographical coverage and department where patients were recruited&#44; sample characteristics &#40;study population&#44; diagnosis&#44; type of episode &#91;first vs&#46; recurrent&#93;&#44; sex&#44; age and sample size&#41;&#44; proportion of patients who received treatments &#40;fibrinolysis&#44; primary and non-specified PCI and coronary artery bypass grafting &#91;CABG&#93;&#41;&#46; If only the absolute number of patients treated was available&#44; the proportion was calculated by dividing by the stratum-specific sample size&#46; When an article presented data stratified by a variable with no relevance to our analysis &#40;e&#46;g&#46; diabetic vs&#46; non-diabetic patients&#41;&#44; we calculated the weighted average of the proportions over all strata&#46;</p><p id="par0055" class="elsevierStylePara elsevierViewall">All types of PCI &#40;including primary PCI&#41; were considered in the analysis of this procedure as revascularization therapy&#46; The proportions of patients undergoing percutaneous and surgical revascularization procedures were described only when performed during the initial hospitalization for the acute event&#46; We considered two types of study population in terms of their representativeness of ACS patients treated in Portuguese institutions&#58; when patient selection was dependent on having undergone a treatment or a diagnostic procedure &#40;e&#46;g&#46; patients referred for viability tests&#59; patients undergoing coronary angiography&#41;&#44; the population was considered selected&#59; otherwise&#44; it was considered unselected&#46;</p><p id="par0060" class="elsevierStylePara elsevierViewall">When possible&#44; year-&#44; sex-&#44; age- and diagnosis-specific estimates were extracted&#46;</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Data analysis</span><p id="par0065" class="elsevierStylePara elsevierViewall">All studies are described in the Supplementary Table available online&#59; only those relying on unselected samples of patients are represented in the forest plots&#46; Although sex- and age-specific estimates were extracted and are shown in the detailed Supplementary Table&#44; these were seldom available and for descriptive purposes the results for the total sample are always presented in the forest plots&#44; stratified only by diagnosis&#46;</p><p id="par0070" class="elsevierStylePara elsevierViewall">The proportion of patients who underwent each procedure was described according to type of ACS&#46; However&#44; given that reports did not systematically stratify according to this criterion&#44; patient samples were classified into one of the following three categories&#44; according to the proportion of different ACS patients included&#58; STEMI &#40;90&#37; or more patients with a diagnosis of ST-segment elevation myocardial infarction &#40;STEMI&#41; or Q-wave myocardial infarction &#91;MI&#93;&#41;&#44; NSTE-ACS &#40;90&#37; or more patients with a diagnosis of non-ST-segment elevation ACS &#91;NSTE-ACS&#93;&#41;&#44; and mixed ACS &#40;if neither of these criteria was satisfied&#41;&#46;</p></span></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Results</span><p id="par0075" class="elsevierStylePara elsevierViewall">We identified 41 eligible studies providing data on ACS patients who underwent reperfusion and&#47;or revascularization therapies&#44; 21 presenting data on reperfusion and 28 on revascularization &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Figure 1</a>&#41;&#44; published between 1989 and 2011 &#40;Supplementary Table 1&#44; available online&#41;&#46;</p><p id="par0080" class="elsevierStylePara elsevierViewall">Over three-quarters of the studies reported data from a single institution&#44; mainly from the Lisbon region&#46; Three studies were based on national registries that covered several regions of the country&#46;<a class="elsevierStyleCrossRefs" href="#bib0030"><span class="elsevierStyleSup">6&#44;9&#44;10</span></a> The vast majority of studies recruited patients in cardiology departments&#46; Two-thirds of the studies included unselected populations&#46; More than half of the studies included both first and recurrent episodes and four studies reported exclusively on first episodes&#46;<a class="elsevierStyleCrossRefs" href="#bib0055"><span class="elsevierStyleSup">11&#8211;14</span></a> The sample size ranged from 21 to 22<span class="elsevierStyleHsp" style=""></span>482 patients&#44; and almost 40&#37; of the studies involved samples between 100 and 500 patients&#46; Seven samples included mostly STEMI patients&#44; 10 mostly NSTE-ACS patients and 27 a mixture of patients with several types of ACS&#46; Five studies presented sex-specific estimates&#44;<a class="elsevierStyleCrossRefs" href="#bib0050"><span class="elsevierStyleSup">10&#44;14&#8211;17</span></a> and only two presented age-specific estimates<a class="elsevierStyleCrossRefs" href="#bib0090"><span class="elsevierStyleSup">18&#44;19</span></a> &#40;Supplementary Table 1&#44; available online&#41;&#46;</p><p id="par0085" class="elsevierStylePara elsevierViewall">As expected&#44; data on reperfusion were available only for STEMI and mixed ACS patients &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Figure 1</a>&#41;&#46; Only three studies provided estimates of the use of reperfusion in STEMI patients&#46; In more recent years&#44; one study conducted in Faro reported the use of fibrinolysis in 16&#46;5&#37; of STEMI patients in 2008&#44;<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">20</span></a> while a report from the National Registry of Acute Coronary Syndromes showed a mean of 43&#46;7&#37;&#44; representing many cardiology centers across the country over several years&#46;<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> The same two studies reported the use of primary PCI in 41&#46;4&#37; and 19&#46;2&#37; of STEMI patients&#44; respectively&#46;<a class="elsevierStyleCrossRefs" href="#bib0030"><span class="elsevierStyleSup">6&#44;20</span></a> For mixed ACS patients there was a larger number of observations&#59; fibrinolysis was used in a quarter to a half of patients in the late 1990s&#44; decreasing to less than 10&#37; over the next decade&#46; Two reports published 10 years apart&#44; in 2001 and 2011&#44; showed an increase in the use of primary PCI in mixed ACS patients&#44; from less than 10&#37; in a sample of patients from several cardiology centers across the country<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a> to approximately 50&#37; in a single cardiology center in Lisbon<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">19</span></a> &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Figure 2</a>&#41;&#46;</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0090" class="elsevierStylePara elsevierViewall">Percutaneous revascularization&#44; including both emergent and elective procedures during hospitalization for an acute event&#44; was performed in approximately half of STEMI patients according to a report from Faro in 2008<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">20</span></a> and the report of the National Registry of Acute Coronary Syndromes covering several years and centers across the country&#46;<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> For NTSE-ACS&#44; two studies published in 1993 report contrasting experiences in small single-center samples&#44; while from 2003 to 2011 several estimates consistently point to one third to one half of patients being revascularized percutaneously during the acute hospitalization&#44; with no clear time trend&#46; With a larger number of reports and more regular publication over 15 years&#44; the proportion of mixed ACS patients revascularized percutaneously increased from under 10&#37; in the mid-1990s to approximately 70&#37; in recent years &#40;<a class="elsevierStyleCrossRef" href="#fig0015">Figure 3</a>&#41;&#46;</p><elsevierMultimedia ident="fig0015"></elsevierMultimedia><p id="par0095" class="elsevierStylePara elsevierViewall">CABG was used in 1&#46;0&#37; of STEMI patients &#40;this figure available only from the National Registry of Acute Coronary Syndromes&#41;&#46; In NSTE-ACS and mixed ACS&#44; 1&#8211;10&#37; of patients were reported as undergoing CABG&#44; with no clear time trend&#46; An exception for several reports is a single institution &#40;Hospital de Santa Cruz&#44; in Carnaxide&#41; over the years&#44; with a proportion closer to 20&#37; of NTSE-ACS patients having undergone surgical revascularization during hospitalization for the acute event &#40;<a class="elsevierStyleCrossRef" href="#fig0020">Figure 4</a>&#41;&#46;</p><elsevierMultimedia ident="fig0020"></elsevierMultimedia></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">Discussion</span><p id="par0100" class="elsevierStylePara elsevierViewall">Despite considerable heterogeneity in the methodology and presentation of results of available studies&#44; this review shows that the proportion of ACS patients in Portugal treated with fibrinolysis has decreased in the last 20 years and the use of PCI has increased&#44; while the use of CABG has not changed&#46;</p><p id="par0105" class="elsevierStylePara elsevierViewall">Since the late 1970s&#44; more aggressive and effective treatments have been developed and implemented for the treatment of CHD&#44; including fibrinolysis&#44; PCI and CABG&#46;<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">21</span></a> Of the primary studies included in the present review&#44; the oldest with data on fibrinolysis was published in 1989&#44;<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">22</span></a> while PCI and CABG were first mentioned in an article published in 1993 &#40;data collection in 1982&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">23</span></a> Data from previous years were reported in a few publications which were excluded mainly due to the reporting format&#44; for example lack of data on sample size or patients&#8217; sex and age&#44; or because the use of procedures in the acute hospitalization or over variable follow-up periods could not be distinguished&#46;</p><p id="par0110" class="elsevierStylePara elsevierViewall">During the last decade&#44; mechanical or pharmacological reperfusion therapy has been recommended for all patients with STEMI who present within 12 hours of the onset of symptoms&#46;<a class="elsevierStyleCrossRefs" href="#bib0120"><span class="elsevierStyleSup">24&#8211;26</span></a> A growing body of evidence has also demonstrated beneficial effects of reperfusion therapy in patients presenting more than 12 hours from symptom onset&#46; In this group of patients&#44; recent recommendations consider this treatment a strong indication&#44; preferably by primary PCI &#40;class I&#41; if there is evidence of ongoing ischemia or if pain and electrocardiographic changes have been stuttering&#46; Primary PCI may be also considered even in asymptomatic patients presenting 12&#8211;24 hours after symptom onset&#46;<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">25</span></a> For years&#44; fibrinolysis was chosen over primary PCI&#44; mainly due to its greater ease of access and use&#46;<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">21</span></a> However&#44; mechanical reperfusion has been preferred since several randomized clinical trials and meta-analyses comparing primary PCI with in-hospital fibrinolytic therapy in patients presenting within 6&#8211;12 hours of symptom onset showed more effective restoration of vessel patency&#44; less reocclusion&#44; reinfarction and stroke&#44; improved left ventricular function and less short-term mortality with primary PCI&#46;<a class="elsevierStyleCrossRefs" href="#bib0135"><span class="elsevierStyleSup">27&#44;28</span></a> National<a class="elsevierStyleCrossRefs" href="#bib0030"><span class="elsevierStyleSup">6&#44;29</span></a> and international registries in Europe<a class="elsevierStyleCrossRefs" href="#bib0150"><span class="elsevierStyleSup">30&#44;31</span></a> and the USA<a class="elsevierStyleCrossRefs" href="#bib0160"><span class="elsevierStyleSup">32&#44;33</span></a> suggest an increase in the use of reperfusion therapies accompanied by a significant shift from fibrinolysis therapy to primary PCI&#46; A significant decrease in mortality after STEMI has been observed in countries switching from fibrinolysis to primary PCI&#46;<a class="elsevierStyleCrossRef" href="#bib0170"><span class="elsevierStyleSup">34</span></a> In our study&#44; we observed decreased use of fibrinolysis and increased use of primary PCI&#46; In this review&#44; most of the studies providing data on fibrinolysis were published in the 1990s&#44; with data collected in the 1980s and 1990s&#46; By contrast&#44; the studies addressing primary PCI were only published in the current century&#46; Although the trends cannot be quantified&#44; fibrinolysis appears to have been replaced by primary PCI&#46;</p><p id="par0115" class="elsevierStylePara elsevierViewall">Since its introduction in 1977&#44; angioplasty has become the most frequently performed major intervention in medicine&#44;<a class="elsevierStyleCrossRef" href="#bib0175"><span class="elsevierStyleSup">35</span></a> as both a reperfusion &#40;primary PCI&#41; and revascularization procedure&#46; Among the included studies addressing the use of revascularization by a percutaneous procedure&#44; one sixth were published in the 1990s and the remainder afterwards&#46; Surgical revascularization with CABG was first introduced in 1969&#44; and become the most thoroughly studied procedure in the history of surgery&#46;<a class="elsevierStyleCrossRef" href="#bib0180"><span class="elsevierStyleSup">36</span></a> In our review&#44; a quarter of the studies were published in the 1990s and the remainder after 2000&#46; Although the primary studies provided information on surgeries performed at different times related to the acute event &#40;e&#46;g&#46; during a variable time of follow-up after the acute event&#41;&#44; we only included studies with data on CABG performed during the initial hospitalization&#46; Otherwise&#44; the data to be compared would be even more heterogeneous&#46; Particularly for this procedure&#44; it is important to point out that many patients referred for CABG are expected to have undergone surgery after discharge or have been transferred to a different institution while awaiting the procedure&#44;<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> thus reducing the proportion of patients treated that were captured by this analysis&#46;</p><p id="par0120" class="elsevierStylePara elsevierViewall">The results on revascularization therapies are consistent with the findings of previous studies showing an increase in PCI use and non-significant changes in use of CABG in recent years&#46;<a class="elsevierStyleCrossRefs" href="#bib0150"><span class="elsevierStyleSup">30&#44;37&#44;38</span></a> In patients stabilized after an episode of acute coronary syndrome&#44; the choice of revascularization modality can be made as in stable coronary heart disease&#46;<a class="elsevierStyleCrossRefs" href="#bib0125"><span class="elsevierStyleSup">25&#44;39&#44;40</span></a> In single-vessel disease&#44; which occurs in one-third of patients with ACS&#44; ad-hoc PCI is feasible in most cases&#44; whereas in patients with multivessel disease &#40;approximately half of cases&#41; the decision on the type of revascularization is more complex&#46;<a class="elsevierStyleCrossRefs" href="#bib0205"><span class="elsevierStyleSup">41&#44;42</span></a> Options for this condition have evolved over time&#44; and currently include culprit lesion PCI&#44; multivessel PCI&#44; CABG or hybrid &#40;combined&#41; revascularization&#44; according to clinical status&#44; lesion characteristics and the severity and distribution of coronary artery disease&#46;<a class="elsevierStyleCrossRefs" href="#bib0125"><span class="elsevierStyleSup">25&#44;39&#44;40</span></a></p><p id="par0125" class="elsevierStylePara elsevierViewall">Our methodology has some limitations&#46; The use of a single search engine may have limited our results&#46; However&#44; the inclusion of relevant studies identified in the reference lists of the review articles should have helped identify older and non-PubMed-indexed publications&#46; The probability of identifying relevant studies from among those published is also influenced by their results because&#44; despite the descriptive nature of the studies&#44; publication bias can be expected&#44; with higher likelihood of publication from higher-quality or at least higher-volume centers&#46; It is noteworthy that the majority of studies came from cardiology departments&#44; some of which also contributed to the National Registry of Acute Coronary Syndromes&#46; Therefore&#44; the main gain with this review is its coverage of a greater time span&#44; but not the representation of less specialized centers than those included in the National Registry of Acute Coronary Syndromes&#46; The results are affected by the methodological heterogeneity of the studies&#44; particularly inclusion criteria&#44; sample size&#44; and patients&#8217; age and sex&#44; as well as the relatively small number of estimates for each type of treatment under study&#46; Another limitation for more informative conclusions stems from the small number of studies with sex-&#44; age-&#44; and year-specific estimates&#44; as authors mainly reported overall data&#46; Some reported data referring to a period longer than one year&#59; however&#44; it was not possible to obtain year-specific estimates&#46;</p><p id="par0130" class="elsevierStylePara elsevierViewall">Given these limitations&#44; an alternative approach to the study of trends in the use of these treatments in the past could be to rely on administrative databases&#44; using data collected&#44; coded and stored&#44; immediately available for analysis&#46;<a class="elsevierStyleCrossRef" href="#bib0215"><span class="elsevierStyleSup">43</span></a> The national register of hospital discharges<a class="elsevierStyleCrossRef" href="#bib0145"><span class="elsevierStyleSup">29</span></a> could be used to quantify the number of procedures performed&#44; but the usefulness of these datasets is limited&#58; it is not possible to classify the subtypes of ACS according to current recommendations<a class="elsevierStyleCrossRef" href="#bib0220"><span class="elsevierStyleSup">44</span></a> when departing from data coded using the International Classification of Diseases&#44; 9th revision&#44; Clinical Modification &#40;ICD-9-CM&#41;&#46; Furthermore&#44; there is no information available in the database to ascertain the timing of PCI or to identify recurrent episodes in the same patient&#46;<a class="elsevierStyleCrossRef" href="#bib0145"><span class="elsevierStyleSup">29</span></a></p></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0105">Conclusions</span><p id="par0135" class="elsevierStylePara elsevierViewall">The general pattern of treatment reflects what is reported in other developed countries and can be viewed as a favorable time trend in the quality of care of ACS patients&#46; Future investigation should focus on the prospective and systematic recording of high-quality information to monitor the use of treatments in this acute condition&#44; while past trends can only be properly clarified by an original retrospective study on a representative sample of ACS patients&#44; involving review of hospital records&#46;</p></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0110">Ethical disclosures</span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0115">Protection of human and animal subjects</span><p id="par0140" class="elsevierStylePara elsevierViewall">The authors declare that no experiments were performed on humans or animals for this study&#46;</p></span><span id="sec0060" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0120">Confidentiality of data</span><p id="par0145" class="elsevierStylePara elsevierViewall">The authors declare that no patient data appear in this article&#46;</p></span><span id="sec0065" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0125">Right to privacy and informed consent</span><p id="par0150" class="elsevierStylePara elsevierViewall">The authors declare that no patient data appear in this article&#46;</p></span></span><span id="sec0070" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0130">Funding</span><p id="par0155" class="elsevierStylePara elsevierViewall">This study was funded by a grant from <span class="elsevierStyleGrantSponsor" id="gs1">Funda&#231;&#227;o para a Ci&#234;ncia e a Tecnologia</span> &#40;<span class="elsevierStyleGrantNumber" refid="gs1">PIC&#47;IC&#47;83006&#47;2007</span>&#41;&#46;</p></span><span id="sec0075" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0135">Conflicts of interest</span><p id="par0160" class="elsevierStylePara elsevierViewall">The authors have no conflicts of interest to declare&#46;</p></span></span>"
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    "fechaRecibido" => "2013-03-22"
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            0 => "Acute coronary syndrome"
            1 => "Angioplasty"
            2 => "Coronary artery bypass"
            3 => "Fibrinolysis"
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            1 => "Angioplastia"
            2 => "Cirurgia de revasculariza&#231;&#227;o coron&#225;ria"
            3 => "Fibrin&#243;lise"
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        "titulo" => "Abstract"
        "resumen" => "<span class="elsevierStyleSectionTitle" id="sect0010">Introduction and Objectives</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Reperfusion and revascularization therapies play an important role in the management of coronary heart disease and have contributed to decreases in case fatality rates&#46; We aimed to describe the use of these therapies for the treatment of acute coronary syndrome &#40;ACS&#41; patients over time in Portugal&#46;</p> <span class="elsevierStyleSectionTitle" id="sect0015">Methods</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">PubMed was searched in July 2012&#46; The proportion of patients treated with fibrinolysis&#44; primary percutaneous coronary intervention &#40;PCI&#41;&#44; any PCI and coronary artery bypass grafting &#40;CABG&#41; was described according to type of ACS&#58; STEMI &#40;&#8805;90&#37; patients with ST-segment elevation or Q-wave myocardial infarction&#41;&#44; NSTE-ACS &#40;&#8805;90&#37; patients with non-ST-segment elevation ACS&#41; and mixed ACS &#40;all others&#41;&#46;</p> <span class="elsevierStyleSectionTitle" id="sect0020">Results</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">We identified 41 eligible studies&#44; published between 1989 and 2011&#46; Twenty-eight reported on samples considered representative of ACS patients treated in Portugal&#46; The small number of estimates of the use of each treatment in STEMI and NSTE-ACS patients precluded identification of any time trend&#46; In the last 20 years&#44; the proportion of mixed ACS patients treated with fibrinolysis decreased and the use of PCI increased&#44; while the use of CABG did not change&#46;</p> <span class="elsevierStyleSectionTitle" id="sect0025">Conclusions</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">The general pattern of the use of reperfusion and revascularization is in accordance with that reported in other developed countries&#44; reflecting a favorable trend in the quality of care of ACS patients&#46; The relatively small number of estimates on the same procedure in comparable patients limits the generalizability of the conclusions&#44; and highlights the need for systematic approaches to monitor the use of treatments over time&#46;</p>"
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        "resumen" => "<span class="elsevierStyleSectionTitle" id="sect0035">Introdu&#231;&#227;o e objetivos</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">A reperfus&#227;o e revasculariza&#231;&#227;o desempenham um importante papel no tratamento da doen&#231;a coron&#225;ria contribuindo para a diminui&#231;&#227;o da letalidade&#46; Foi nosso objetivo descrever o uso destes procedimentos no tratamento da s&#237;ndrome coron&#225;ria aguda &#40;SCA&#41; ao longo do tempo em Portugal&#46;</p> <span class="elsevierStyleSectionTitle" id="sect0040">M&#233;todos</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">A pesquisa foi efetuada na Pubmed em julho de 2012&#46; A propor&#231;&#227;o de doentes tratados com fibrin&#243;lise&#44; angioplastia prim&#225;ria&#44; qualquer tipo de angioplastia e cirurgia de revasculariza&#231;&#227;o coron&#225;ria &#40;CABG&#41; foi descrita de acordo com o tipo de SCA&#58; SCA supra-ST &#40;quando a propor&#231;&#227;o de doentes com eleva&#231;&#227;o do segmento ST ou enfarte do mioc&#225;rdio com ondas Q era &#8805;90&#37;&#41;&#44; SCA sem-ST &#40;quando a propor&#231;&#227;o de doentes com SCA sem eleva&#231;&#227;o do segmento ST era &#8805;90&#37;&#41; e SCA misto &#40;restantes casos&#41;&#46;</p> <span class="elsevierStyleSectionTitle" id="sect0045">Resultados</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Foram identificados 41 estudos publicados entre 1989 e 2011&#46; Vinte e oito estudos descreveram amostras representativas dos doentes com SCA tratados em Portugal&#46; O baixo n&#250;mero de estimativas de cada tratamento nos doentes com SCA supra-ST e sem-ST&#44; impossibilitou a observa&#231;&#227;o de tend&#234;ncias temporais&#46; Nos &#250;ltimos 20 anos&#44; a propor&#231;&#227;o de doentes com SCA misto tratados com fibrin&#243;lise diminuiu&#44; o uso de angioplastia aumentou&#44; enquanto o uso de CABG n&#227;o se alterou&#46;</p> <span class="elsevierStyleSectionTitle" id="sect0050">Conclus&#245;es</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">O padr&#227;o do uso destes tratamentos est&#225; de acordo com dados publicados noutros pa&#237;ses desenvolvidos&#44; refletindo uma tend&#234;ncia favor&#225;vel na qualidade dos cuidados prestados&#46; O baixo n&#250;mero de estimativas do mesmo procedimento limitou a generaliza&#231;&#227;o de conclus&#245;es&#44; refor&#231;ando a necessidade de alternativas para monitorizar o uso de tratamentos ao longo do tempo&#46;</p>"
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          "en" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Flowchart of the systematic review&#46; CABG&#58; coronary artery bypass grafting&#59; PCI&#58; percutaneous coronary intervention&#59; STEMI&#58; 90&#37; or more patients with diagnosis of ST-segment elevation myocardial infarction or Q-wave myocardial infarction&#59; NSTE-ACS&#58; 90&#37; or more patients with diagnosis of non-ST-segment elevation ACS&#59; mixed ACS&#58; mixture of patients with several types of ACS&#46;</p> <p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">&#42; If a study provided data on treatment with both reperfusion and revascularization&#44; it contributed to both groups&#46; If a study provided data on more than one diagnostic category&#44; it contributed to all groups&#46;</p> <p id="spar0055" class="elsevierStyleSimplePara elsevierViewall"><span class="elsevierStyleSup">&#8224;</span> The sample was considered selected when inclusion of patients was dependent on having undergone some diagnosis or treatment procedure&#59; otherwise&#44; it was considered unselected&#46;</p>"
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          "en" => "<p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">Proportion of acute coronary syndrome patients treated with reperfusion therapies &#40;fibrinolysis and primary PCI&#41; in Portugal&#44; estimated in unselected samples of patients&#46; F&#58; first episode&#59; mixed ACS&#58; mixture of patients with several types of ACS&#59; NSTE-ACS&#58; 90&#37; or more patients with diagnosis of non-ST-segment elevation ACS&#59; PCI&#58; percutaneous coronary intervention&#59; R&#58; recurrent episode&#59; STEMI&#58; 90&#37; or more patients with diagnosis of ST-segment elevation myocardial infarction or Q-wave myocardial infarction&#46; &#42; Age is presented as mean &#40;SD&#41; unless otherwise specified&#59; <span class="elsevierStyleSup">&#8224;</span> mean age&#59; <span class="elsevierStyleSup">&#8225;</span> median age&#46;</p>"
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          "en" => "<p id="spar0065" class="elsevierStyleSimplePara elsevierViewall">Proportion of acute coronary syndrome patients treated with PCI in Portugal&#44; estimated in unselected samples of patients&#46; F&#58; first episode&#59; mixed ACS&#58; mixture of patients with several types of ACS&#59; NSTE-ACS&#58; 90&#37; or more patients with diagnosis of non-ST-segment elevation ACS&#59; PCI&#58; percutaneous coronary intervention&#59; R&#58; recurrent episode&#59; STEMI&#58; 90&#37; or more patients with diagnosis of ST-segment elevation myocardial infarction or Q-wave myocardial infarction&#46; &#42; Age is presented as mean &#40;SD&#41; unless otherwise specified&#59; <span class="elsevierStyleSup">&#8224;</span> mean age&#59; <span class="elsevierStyleSup">&#8225;</span> median age&#46;</p>"
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          "en" => "<p id="spar0070" class="elsevierStyleSimplePara elsevierViewall">Proportion of acute coronary syndrome patients treated with CABG in Portugal&#44; estimated in unselected samples of patients&#46; CABG&#58; coronary artery bypass grafting&#59; F&#58; first episode&#59; mixed ACS&#58; mixture of patients with several types of ACS&#59; NSTE-ACS&#58; 90&#37; or more patients with diagnosis of non-ST-segment elevation ACS&#59; R&#58; recurrent episode&#59; STEMI&#58; 90&#37; or more patients with diagnosis of ST-segment elevation myocardial infarction or Q-wave myocardial infarction&#46; &#42; Age is presented as mean &#40;SD&#41; unless otherwise specified&#59; <span class="elsevierStyleSup">&#8224;</span> mean age&#59; <span class="elsevierStyleSup">&#8225;</span> median age&#46;</p>"
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                      "titulo" => "The top ten causes of death&#46; The ten leading causes of death by broad income group"
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                      "titulo" => "SDR&#44; ischaemic heart disease&#44; all ages per 100000&#46; January 2011 ed&#58; European HFA database"
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                      "titulo" => "Explanation for the decline in coronary heart disease mortality rates in Auckland New Zealand&#44; between 1982 and 1993"
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                        "tituloSerie" => "Circulation"
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                      "titulo" => "What explains declining coronary mortality&#63;"
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Informação do artigo

ISSN: 08702551
Idioma original: Inglês

DOI:10.1016/j.repc.2013.11.013

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2024 Junho	32	18	50
2024 Maio	51	17	68
2024 Abril	43	27	70
2024 Mar�o	46	19	65
2024 Fevereiro	41	32	73
2024 Janeiro	40	39	79
2023 Dezembro	36	24	60
2023 Novembro	41	21	62
2023 Outubro	24	21	45
2023 Setembro	43	23	66
2023 Agosto	49	17	66
2023 Julho	44	12	56
2023 Junho	43	12	55
2023 Maio	62	22	84
2023 Abril	20	11	31
2023 Mar�o	29	21	50
2023 Fevereiro	26	28	54
2023 Janeiro	20	7	27
2022 Dezembro	28	17	45
2022 Novembro	42	18	60
2022 Outubro	36	21	57
2022 Setembro	43	23	66
2022 Agosto	33	27	60
2022 Julho	41	36	77
2022 Junho	18	18	36
2022 Maio	26	27	53
2022 Abril	36	24	60
2022 Mar�o	29	29	58
2022 Fevereiro	24	19	43
2022 Janeiro	37	28	65
2021 Dezembro	24	26	50
2021 Novembro	36	34	70
2021 Outubro	57	39	96
2021 Setembro	42	32	74
2021 Agosto	46	34	80
2021 Julho	29	22	51
2021 Junho	29	24	53
2021 Maio	39	24	63
2021 Abril	93	49	142
2021 Mar�o	103	14	117
2021 Fevereiro	92	17	109
2021 Janeiro	42	14	56
2020 Dezembro	55	8	63
2020 Novembro	52	18	70
2020 Outubro	39	25	64
2020 Setembro	81	7	88
2020 Agosto	69	3	72
2020 Julho	59	14	73
2020 Junho	49	11	60
2020 Maio	55	10	65
2020 Abril	59	8	67
2020 Mar�o	52	8	60
2020 Fevereiro	175	27	202
2020 Janeiro	26	7	33
2019 Dezembro	50	12	62
2019 Novembro	37	3	40
2019 Outubro	40	10	50
2019 Setembro	42	4	46
2019 Agosto	31	12	43
2019 Julho	45	10	55
2019 Junho	33	13	46
2019 Maio	40	8	48
2019 Abril	23	15	38
2019 Mar�o	76	7	83
2019 Fevereiro	54	14	68
2019 Janeiro	31	7	38
2018 Dezembro	69	10	79
2018 Novembro	130	25	155
2018 Outubro	288	13	301
2018 Setembro	100	10	110
2018 Agosto	46	9	55
2018 Julho	25	6	31
2018 Junho	33	10	43
2018 Maio	53	13	66
2018 Abril	42	8	50
2018 Mar�o	57	7	64
2018 Fevereiro	38	6	44
2018 Janeiro	31	9	40
2017 Dezembro	76	9	85
2017 Novembro	55	10	65
2017 Outubro	44	12	56
2017 Setembro	52	4	56
2017 Agosto	45	11	56
2017 Julho	32	6	38
2017 Junho	60	16	76
2017 Maio	78	14	92
2017 Abril	40	12	52
2017 Mar�o	27	10	37
2017 Fevereiro	18	3	21
2017 Janeiro	30	5	35
2016 Dezembro	28	10	38
2016 Novembro	30	7	37
2016 Outubro	60	6	66
2016 Setembro	47	3	50
2016 Agosto	22	1	23
2016 Julho	8	6	14
2016 Junho	4	5	9
2016 Maio	27	0	27
2016 Abril	34	1	35
2016 Mar�o	51	17	68
2016 Fevereiro	67	38	105
2016 Janeiro	55	20	75
2015 Dezembro	55	14	69
2015 Novembro	47	19	66
2015 Outubro	49	17	66
2015 Setembro	40	17	57
2015 Agosto	48	7	55
2015 Julho	40	11	51
2015 Junho	32	8	40
2015 Maio	44	9	53
2015 Abril	35	21	56
2015 Mar�o	30	15	45
2015 Fevereiro	49	18	67
2015 Janeiro	36	26	62
2014 Dezembro	113	74	187
2014 Novembro	30	22	52

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