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como o <span class="elsevierStyleItalic">score</span> Thrombolysis in Myocardial Infaction &#40;TIMI&#41;&#44; com a desvantagem de as popula&#231;&#245;es nem sempre serem muito representativas da popula&#231;&#227;o real<a class="elsevierStyleCrossRefs" href="#bib0110"><span class="elsevierStyleSup">5&#44;6</span></a>&#46; Mais recentemente&#44; o <span class="elsevierStyleItalic">score</span> mais aplicado &#233; o <span class="elsevierStyleItalic">score Global Registry of Acute Coronary Events</span> &#40;GRACE&#41;&#44; desenvolvido a partir de um registo mundial de SCA e por isso mais representativo&#44; sendo tamb&#233;m o que apresenta uma maior capacidade discriminativa&#44; quer para os enfartes com eleva&#231;&#227;o de ST quer para as restantes SCA<a class="elsevierStyleCrossRefs" href="#bib0120"><span class="elsevierStyleSup">7&#44;8</span></a>&#46; Contudo&#44; nem sempre estes <span class="elsevierStyleItalic">scores</span> s&#227;o utilizados na pr&#225;tica cl&#237;nica&#44; sendo que a sua complexidade pode representar um dos motivos<a class="elsevierStyleCrossRefs" href="#bib0130"><span class="elsevierStyleSup">9&#44;10</span></a>&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">O nosso grupo tinha demonstrado previamente que seria poss&#237;vel uma simplifica&#231;&#227;o destes <span class="elsevierStyleItalic">scores</span> de risco&#44; embora com ligeira redu&#231;&#227;o da capacidade discriminativa<a class="elsevierStyleCrossRef" href="#bib0140"><span class="elsevierStyleSup">11</span></a>&#46; Por esse motivo foi desenvolvido o <span class="elsevierStyleItalic">score</span> Portuguese Registry on Acute Coronary Syndromes &#40;ProACS&#41; a partir do Registo Nacional de SCA &#40;RNSCA&#41;<a class="elsevierStyleCrossRef" href="#bib0145"><span class="elsevierStyleSup">12</span></a>&#46; Procur&#225;mos com o presente trabalho validar este <span class="elsevierStyleItalic">score</span> numa popula&#231;&#227;o portuguesa e verificar a sua capacidade preditiva a curto e tamb&#233;m a longo prazo&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">M&#233;todos</span><p id="par0015" class="elsevierStylePara elsevierViewall">O <span class="elsevierStyleItalic">score</span> ProACS foi desenvolvido a partir da popula&#231;&#227;o do RNSCA&#44; incluindo todos os doentes inclu&#237;dos no registo de um de janeiro de 2002 a 31 de outubro de 2014&#46; Brevemente&#44; trata&#8208;se de um registo cont&#237;nuo&#44; prospetivo e observacional&#44; com a participa&#231;&#227;o de 33 servi&#231;os de cardiologia de Portugal continental e ilhas&#46; Os crit&#233;rios de inclus&#227;o foram descritos previamente&#44; bem como as suas vari&#225;veis<a class="elsevierStyleCrossRef" href="#bib0150"><span class="elsevierStyleSup">13</span></a>&#46; O <span class="elsevierStyleItalic">score</span> ProACS foi desenvolvido a partir de 37<span class="elsevierStyleHsp" style=""></span>460 registos para mortalidade total intra&#8208;hospitalar&#46; Os doentes inclu&#237;dos de um de janeiro 2002 a 30 de junho de 2011 foram divididos aleatoriamente em 60&#37; para coorte de desenvolvimento e 40&#37; para coorte de valida&#231;&#227;o interna&#46; Os 8586 doentes inclu&#237;dos depois de 1 de julho de 2011 foram utilizados para coorte de valida&#231;&#227;o externa&#46; Uma vez que o nosso servi&#231;o apenas mais recentemente participou no RNSCA&#44; os nossos registos n&#227;o foram inclu&#237;dos na coorte de desenvolvimento&#46; Por esse motivo&#44; decidimos validar externamente o <span class="elsevierStyleItalic">score</span> ProACS numa popula&#231;&#227;o portuguesa&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">O <span class="elsevierStyleItalic">score</span> ProACS inclui as seguintes vari&#225;veis&#58; idade&#160;&#8805;<span class="elsevierStyleHsp" style=""></span>72 anos &#40;2 pontos&#41;&#44; press&#227;o arterial sist&#243;lica &#8804;<span class="elsevierStyleHsp" style=""></span>116<span class="elsevierStyleHsp" style=""></span>mmHg&#44; classe Killip na admiss&#227;o 2 ou 3 e eleva&#231;&#227;o segmento ST &#40;1 ponto cada&#41; e classe Killip quatro &#40;tr&#234;s pontos&#41;&#46; Os indiv&#237;duos com <span class="elsevierStyleItalic">score</span> zero t&#234;m baixo risco&#59; o <span class="elsevierStyleItalic">score</span> 1&#8208;2 representa risco interm&#233;dio e &#8805;<span class="elsevierStyleHsp" style=""></span>3 apresentam alto risco de mortalidade intra&#8208;hospitalar&#46; Os crit&#233;rios de inclus&#227;o no registo do nosso hospital e as vari&#225;veis s&#227;o sobrepon&#237;veis aos do RNSCA&#44; e incluem caracter&#237;sticas demogr&#225;ficas&#44; fatores de risco&#44; doen&#231;a card&#237;aca pr&#233;via&#44; caracter&#237;sticas da admiss&#227;o e tratamento&#46; Foi avaliada a mortalidade total intra&#8208;hospitalar e ao primeiro ano de seguimento&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">Os doentes deram consentimento informado para inclus&#227;o no registo&#46; Este manuscrito foi escrito de acordo com as recomenda&#231;&#245;es <span class="elsevierStyleItalic">Transparent Reporting of a Multivariable Predictor Model for Individual Prognosis or Diagnosis</span> &#40;TRIPOD&#41; sobre a descri&#231;&#227;o apropriada de estudos para valida&#231;&#227;o de <span class="elsevierStyleItalic">scores</span><a class="elsevierStyleCrossRef" href="#bib0155"><span class="elsevierStyleSup">14</span></a>&#46;</p><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">An&#225;lise estat&#237;stica</span><p id="par0030" class="elsevierStylePara elsevierViewall">As vari&#225;veis cont&#237;nuas est&#227;o reportadas como m&#233;dia e desvio&#8208;padr&#227;o e foram comparadas com o teste t <span class="elsevierStyleItalic">Student</span>&#46; A normalidade foi testada com o teste de Kolmogorov&#8208;Smirnov&#46; As vari&#225;veis categ&#243;ricas est&#227;o reportadas como percentagens e as diferen&#231;as entre grupos foram analisadas pelo teste de &#967;<span class="elsevierStyleSup">2</span> ou pelo teste de Fisher&#44; conforme apropriado&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">Para cada doente foi calculado o <span class="elsevierStyleItalic">score</span> ProACS&#46; Para efeitos comparativos com outros <span class="elsevierStyleItalic">scores</span> de estratifica&#231;&#227;o de risco&#44; foi tamb&#233;m calculado o <span class="elsevierStyleItalic">score</span> GRACE e o <span class="elsevierStyleItalic">Canada Acute Coronary Syndrome risk score</span> &#40;C&#8208;ACS&#41;<a class="elsevierStyleCrossRefs" href="#bib0125"><span class="elsevierStyleSup">8&#44;15</span></a>&#46; Este &#250;ltimo foi desenvolvido com os mesmos pressupostos que o <span class="elsevierStyleItalic">score</span> portugu&#234;s numa popula&#231;&#227;o canadiana&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">A capacidade preditiva do <span class="elsevierStyleItalic">score</span> ProACS foi testada por an&#225;lise da <span class="elsevierStyleItalic">area under curve</span> &#40;AUC&#41; das curvas <span class="elsevierStyleItalic">receiver operating characteristics</span> &#40;ROC&#41; e a calibra&#231;&#227;o do modelo pelo teste de Hosmer e Lemeshow &#40;H&#8208;L&#41;&#46; Com o teste H&#8208;L&#44; um modelo ter&#225; uma calibra&#231;&#227;o adequada se o valor de p n&#227;o for significativo&#46; A compara&#231;&#227;o das AUC para amostras dependentes e independentes foi efetuada de acordo com Henley e MacNeill<a class="elsevierStyleCrossRefs" href="#bib0165"><span class="elsevierStyleSup">16&#44;17</span></a>&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">Para a an&#225;lise estat&#237;stica foi utilizado o <span class="elsevierStyleItalic">software</span> IBM SPSS <span class="elsevierStyleItalic">Statistics</span> &#40;<span class="elsevierStyleItalic">version</span> 19&#46;0&#46;0&#46;2&#41;&#46; Um valor de p<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#44;05 foi considerado estatisticamente significativo&#46;</p></span></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Resultados</span><p id="par0050" class="elsevierStylePara elsevierViewall">Foram inclu&#237;dos na coorte de valida&#231;&#227;o externa do nosso centro 3170 registos&#44; tendo os doentes uma idade m&#233;dia de 64<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>13 anos&#44; 71&#37; do sexo masculino e 62&#37; enfarte com eleva&#231;&#227;o do segmento ST&#46; A compara&#231;&#227;o com a coorte de desenvolvimento do <span class="elsevierStyleItalic">score</span> ProACS do RNSCA est&#225; apresentada na <a class="elsevierStyleCrossRef" href="#tbl0005">Tabela 1</a>&#46; De uma maneira geral&#44; os doentes da coorte de valida&#231;&#227;o apresentam menor idade e mais fatores de risco cardiovascular &#40;exceto diabetes&#41;&#46; T&#234;m menos antecedentes de enfarte e acidente vascular cerebral&#44; mas mais de angioplastia coron&#225;ria&#46; O enfarte com eleva&#231;&#227;o de ST &#233; predominante na coorte de valida&#231;&#227;o&#44; com estrat&#233;gia invasiva mais frequente e apresentam melhor perfil de apresenta&#231;&#227;o na admiss&#227;o&#46; A mortalidade intra&#8208;hospitalar foi sobrepon&#237;vel&#46; Na coorte de valida&#231;&#227;o&#46; A mortalidade total aos 30 dias foi de 7&#44;2&#37; e ao primeiro ano de seguimento de 10&#44;3&#37;&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0055" class="elsevierStylePara elsevierViewall">Na nossa popula&#231;&#227;o&#44; o <span class="elsevierStyleItalic">score</span> ProACS mostrou boa capacidade discriminativa para a mortalidade a curto&#44; m&#233;dio e longo prazo&#44; com boa calibra&#231;&#227;o &#40;<a class="elsevierStyleCrossRef" href="#tbl0010">Tabela 2</a>&#41;&#46; A capacidade discriminativa foi sobrepon&#237;vel &#224; do <span class="elsevierStyleItalic">score</span> C&#8208;ACS&#44; mas inferior &#224; do <span class="elsevierStyleItalic">score</span> GRACE&#46; Aplicando os limiares de risco descritos&#44; tamb&#233;m permite identificar adequadamente os indiv&#237;duos com risco baixo&#44; interm&#233;dio e alto de mortalidade intra&#8208;hospitalar &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Figura 1</a>&#41;&#46; Comparando os tipos de SCA&#44; o <span class="elsevierStyleItalic">score</span> teve tamb&#233;m uma capacidade preditiva semelhante para o enfarte com eleva&#231;&#227;o ST e para as restantes SCA&#44; mostrando&#8208;se sempre sobrepon&#237;vel ao <span class="elsevierStyleItalic">score</span> C&#8208;ACS e com menor acuidade comparativamente ao GRACE &#40;<a class="elsevierStyleCrossRef" href="#tbl0015">Tabela 3</a>&#41;&#46;</p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="tbl0015"></elsevierMultimedia></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Discuss&#227;o</span><p id="par0060" class="elsevierStylePara elsevierViewall">Nas &#250;ltimas d&#233;cadas e ap&#243;s a demonstra&#231;&#227;o do benef&#237;cio que as estrat&#233;gias invasivas de tratamento precoces trazem no contexto das SCA&#44; tornou&#8208;se imprescind&#237;vel uma estratifica&#231;&#227;o de risco eficaz por forma a que se identifiquem os indiv&#237;duos de risco alto e interm&#233;dio&#44; que s&#227;o os que mais beneficiam destas estrat&#233;gias invasivas<a class="elsevierStyleCrossRefs" href="#bib0090"><span class="elsevierStyleSup">1&#8211;4</span></a>&#46; Se no caso dos enfartes com eleva&#231;&#227;o ST a estratifica&#231;&#227;o ser&#225; menos importante&#44; uma vez que as estrat&#233;gias de revasculariza&#231;&#227;o prim&#225;ria constituem o tratamento de elei&#231;&#227;o na maioria dos doentes&#44; no contexto das SCA sem eleva&#231;&#227;o de ST&#44; e uma vez que este grupo &#233; constitu&#237;do por doentes com caracter&#237;sticas muito heterog&#233;neas em termos de risco&#44; &#233; particularmente importante uma estratifica&#231;&#227;o de risco atempada<a class="elsevierStyleCrossRefs" href="#bib0090"><span class="elsevierStyleSup">1&#8211;4</span></a>&#46; Mesmo nos doentes com enfarte com eleva&#231;&#227;o de ST&#44; a orienta&#231;&#227;o imediata dos doentes com maior gravidade para centros mais diferenciados &#233; tamb&#233;m desej&#225;vel&#46;</p><p id="par0065" class="elsevierStylePara elsevierViewall">O <span class="elsevierStyleItalic">score</span> TIMI foi um dos primeiros a ser desenvolvido e foi rapidamente disseminado face aos evidentes benef&#237;cios decorrentes da sua utiliza&#231;&#227;o<a class="elsevierStyleCrossRefs" href="#bib0110"><span class="elsevierStyleSup">5&#44;6</span></a>&#46; Contudo&#44; estes primeiros <span class="elsevierStyleItalic">scores</span> foram desenvolvidos a partir de ensaios cl&#237;nicos aleatorizados multic&#234;ntricos&#44; com crit&#233;rios de inclus&#227;o muito espec&#237;ficos&#44; o que n&#227;o permitia uma ampla representatividade da popula&#231;&#227;o de doentes com SCA&#46; Por exemplo&#44; indiv&#237;duos muito idosos ou com disfun&#231;&#227;o renal grave s&#227;o habitualmente exclu&#237;dos destes ensaios e&#44; por isso&#44; n&#227;o foram contempladas no desenvolvimento dos <span class="elsevierStyleItalic">scores</span> de risco&#46; Talvez por esse motivo&#44; alguns anos mais tarde&#44; o <span class="elsevierStyleItalic">score</span> GRACE tenha vindo a substituir o <span class="elsevierStyleItalic">score</span> TIMI em termos de utiliza&#231;&#227;o pela demonstra&#231;&#227;o de uma melhor capacidade preditiva que poder&#225; tamb&#233;m decorrer do seu desenvolvimento&#44; a partir de um registo de SCA e da inclus&#227;o de algumas vari&#225;veis novas com elevado impacto no progn&#243;stico como sejam a fun&#231;&#227;o renal<a class="elsevierStyleCrossRefs" href="#bib0120"><span class="elsevierStyleSup">7&#44;8</span></a>&#46; Contudo&#44; esta melhoria da capacidade preditiva acompanhou&#8208;se de um aumento importante da complexidade destes <span class="elsevierStyleItalic">scores</span>&#44; o que em parte contribui para o afastamento dos cl&#237;nicos &#224; sua utiliza&#231;&#227;o<a class="elsevierStyleCrossRefs" href="#bib0130"><span class="elsevierStyleSup">9&#44;10</span></a>&#46; O desenvolvimento de ferramentas inform&#225;ticas procurou obviar estas dificuldades&#46; Contudo&#44; pelo facto de utilizar vari&#225;veis laboratoriais que s&#243; mais tarde&#44; ap&#243;s admiss&#227;o&#44; podem ser obtidas&#44; atrasa a sua aplica&#231;&#227;o&#44; o que em alguns casos poder&#225; ser importante porque os <span class="elsevierStyleItalic">scores</span> poderiam permitir uma melhor orienta&#231;&#227;o destes doentes urgentes&#46;</p><p id="par0070" class="elsevierStylePara elsevierViewall">O nosso grupo demonstrou previamente a possibilidade de simplifica&#231;&#227;o destes <span class="elsevierStyleItalic">scores</span> de risco&#44; embora com ligeira perda de capacidade preditiva<a class="elsevierStyleCrossRef" href="#bib0140"><span class="elsevierStyleSup">11</span></a>&#46; Contudo&#44; dadas as limita&#231;&#245;es associadas &#224; amostra analisada de doentes&#44; em particular a dimens&#227;o&#44; n&#227;o estabelecemos nenhuma proposta de <span class="elsevierStyleItalic">score</span>&#46; Tamb&#233;m muito recentemente&#44; um grupo canadiano desenvolveu o C&#8208;ACS a partir de grandes registos de SCA do Canad&#225;<a class="elsevierStyleCrossRef" href="#bib0160"><span class="elsevierStyleSup">15</span></a>&#46; Identificaram as vari&#225;veis idade&#44; classe de Killip&#44; press&#227;o arterial sist&#243;lica e frequ&#234;ncia card&#237;aca na admiss&#227;o como as mais significativas&#46; Este <span class="elsevierStyleItalic">score</span> mostrou uma capacidade preditiva inferior &#224; do <span class="elsevierStyleItalic">score</span> GRACE&#44; mas ainda dentro de par&#226;metros que se podem considerar adequados&#44; at&#233; muito pr&#243;ximos do reportado previamente para o <span class="elsevierStyleItalic">score</span> TIMI<a class="elsevierStyleCrossRefs" href="#bib0110"><span class="elsevierStyleSup">5&#44;6</span></a>&#46; Uma vez que as popula&#231;&#245;es norte&#8208;americanas s&#227;o diferentes das europeias&#44; em particular do sul da Europa&#44; opt&#225;mos por desenvolver um <span class="elsevierStyleItalic">score</span> a partir de uma popula&#231;&#227;o representativa portuguesa de doentes com SCA e o RNSCA surgiu&#8208;nos como uma fonte de informa&#231;&#227;o importante para esse fim&#46; Assim&#44; foi criado o <span class="elsevierStyleItalic">score</span> ProACS&#44; que incluiu vari&#225;veis muito simples &#40;idade&#44; classe Killip na admiss&#227;o&#44; tens&#227;o arterial sist&#243;lica e eleva&#231;&#227;o ST na admiss&#227;o&#41;<a class="elsevierStyleCrossRef" href="#bib0145"><span class="elsevierStyleSup">12</span></a>&#46; As vari&#225;veis cont&#237;nuas foram dicotomizadas por forma simplificar a sua avalia&#231;&#227;o&#46; Este <span class="elsevierStyleItalic">score</span> permite uma r&#225;pida estratifica&#231;&#227;o de doentes com SCA&#44; incluindo por profissionais de sa&#250;de sem treino m&#233;dico avan&#231;ado&#44; a n&#237;vel dos cuidados pr&#233;&#8208;hospitalares ou servi&#231;o de urg&#234;ncia&#46; Este novo <span class="elsevierStyleItalic">score</span> mostrou uma capacidade discriminativa muito semelhante &#224; do <span class="elsevierStyleItalic">score</span> C&#8208;ACS e inferior &#224; do GRACE&#44; mas com uma AUC<span class="elsevierStyleHsp" style=""></span>&#8805;<span class="elsevierStyleHsp" style=""></span>0&#44;75&#46;</p><p id="par0075" class="elsevierStylePara elsevierViewall">Na nossa popula&#231;&#227;o de valida&#231;&#227;o externa&#44; o <span class="elsevierStyleItalic">score</span> ProACS mostrou uma capacidade preditiva adequada&#44; n&#227;o apenas para o curto prazo&#44; conforme analisado na valida&#231;&#227;o original do <span class="elsevierStyleItalic">score</span>&#44; mas tamb&#233;m a m&#233;dio e longo prazo&#46; A perda de capacidade preditiva face ao <span class="elsevierStyleItalic">score</span> GRACE n&#227;o &#233; impeditiva &#224; sua aplica&#231;&#227;o&#44; uma vez que uma AUC<span class="elsevierStyleHsp" style=""></span>&#8805;<span class="elsevierStyleHsp" style=""></span>0&#44;75 a permite validar&#44; em particular no primeiro contacto m&#233;dico do doente&#44; onde poder&#225; ser importante decidir qual orienta&#231;&#227;o do doente&#44; nomeadamente para servi&#231;os&#47;unidades com laborat&#243;rios de interven&#231;&#227;o dispon&#237;veis 24 horas&#47;7 dias&#47;semana ou para servi&#231;os menos diferenciados&#46; Tamb&#233;m no contexto do enfarte com eleva&#231;&#227;o ST poder&#225; ser &#250;til&#44; porque alguns doentes poder&#227;o ser enviados diretamente para centros terci&#225;rios mais diferenciados&#46; Contudo&#44; quando estiver dispon&#237;vel a restante informa&#231;&#227;o cl&#237;nica e laboratorial&#44; ser&#225; importante aplicar o <span class="elsevierStyleItalic">score</span> GRACE&#44; uma vez que permite uma estratifica&#231;&#227;o complementar que poder&#225; ser importante para a abordagem subsequente destes doentes&#44; nomeadamente em termos de medica&#231;&#227;o complementar ou eventual alta precoce&#46;</p><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Limita&#231;&#245;es</span><p id="par0080" class="elsevierStylePara elsevierViewall">A nossa popula&#231;&#227;o de valida&#231;&#227;o &#233; significativamente diferente da popula&#231;&#227;o utilizada para o desenvolvimento do <span class="elsevierStyleItalic">score</span> e&#44; genericamente&#44; tamb&#233;m diferente da popula&#231;&#227;o de outros hospitais&#44; em particular com uma elevada percentagem de doentes com enfarte com eleva&#231;&#227;o ST &#40;&#62;<span class="elsevierStyleHsp" style=""></span>60&#37;&#41;&#46; Por isso&#44; a nossa valida&#231;&#227;o pode n&#227;o se aplicar a outros tipos de popula&#231;&#245;es&#44; podendo requerer valida&#231;&#245;es adicionais&#46;</p></span></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Conclus&#245;es</span><p id="par0085" class="elsevierStylePara elsevierViewall">O <span class="elsevierStyleItalic">score</span> ProACS&#44; desenvolvido numa popula&#231;&#227;o portuguesa representativa da realidade nacional com SCA&#44; &#233; um <span class="elsevierStyleItalic">score</span> simples e f&#225;cil de aplicar na estratifica&#231;&#227;o de risco em doentes com SCA que &#233; tamb&#233;m v&#225;lido em coortes externas&#46; Pode ser facilmente aplicado no primeiro contacto m&#233;dico&#44; muito precocemente&#44; devendo&#44; contudo&#44; ser posteriormente complementado com outros <span class="elsevierStyleItalic">scores</span> mais eficazes&#44; em particular o <span class="elsevierStyleItalic">score</span> GRACE&#46;</p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">Responsabilidades &#233;ticas</span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0105">Prote&#231;&#227;o de pessoas e animais</span><p id="par0090" class="elsevierStylePara elsevierViewall">Os autores declaram que para esta investiga&#231;&#227;o n&#227;o se realizaram experi&#234;ncias em seres humanos e&#47;ou animais&#46;</p></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0110">Confidencialidade dos dados</span><p id="par0095" class="elsevierStylePara elsevierViewall">Os autores declaram ter seguido os protocolos do seu centro de trabalho acerca da publica&#231;&#227;o dos dados de pacientes&#46;</p></span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0115">Direito &#224; privacidade e consentimento escrito</span><p id="par0100" class="elsevierStylePara elsevierViewall">Os autores declaram que n&#227;o aparecem dados de pacientes neste artigo&#46;</p></span></span><span id="sec0060" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0120">Conflito de interesses</span><p id="par0105" class="elsevierStylePara elsevierViewall">Os autores declaram n&#227;o haver conflito de interesses&#46;</p></span></span>"
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        6 => array:2 [
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          "titulo" => "Conclus&#245;es"
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              "identificador" => "sec0045"
              "titulo" => "Prote&#231;&#227;o de pessoas e animais"
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            1 => array:2 [
              "identificador" => "sec0050"
              "titulo" => "Confidencialidade dos dados"
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            2 => array:2 [
              "identificador" => "sec0055"
              "titulo" => "Direito &#224; privacidade e consentimento escrito"
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          "titulo" => "Conflito de interesses"
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          "titulo" => "Bibliografia"
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    "fechaRecibido" => "2015-08-27"
    "fechaAceptado" => "2015-11-23"
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          "clase" => "keyword"
          "titulo" => "Palavras&#8208;chave"
          "identificador" => "xpalclavsec679375"
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            0 => "<span class="elsevierStyleItalic">Portuguese Registry on Acute Coronary Syndromes</span>"
            1 => "Estratifica&#231;&#227;o de risco"
            2 => "S&#237;ndrome coron&#225;ria aguda"
            3 => "Progn&#243;stico"
          ]
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      ]
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          "clase" => "keyword"
          "titulo" => "Keywords"
          "identificador" => "xpalclavsec679374"
          "palabras" => array:4 [
            0 => "Portuguese Registry on Acute Coronary Syndromes"
            1 => "Risk stratification"
            2 => "Acute coronary syndrome"
            3 => "Prognosis"
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    "resumen" => array:2 [
      "pt" => array:3 [
        "titulo" => "Resumo"
        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Introdu&#231;&#227;o</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">O <span class="elsevierStyleItalic">score</span> ProACS &#233; um <span class="elsevierStyleItalic">score</span> simples e precoce desenvolvido para estratifica&#231;&#227;o de risco de mortalidade hospitalar nas s&#237;ndromes coron&#225;rias agudas &#40;SCA&#41;&#44; a partir de um registo nacional de SCA&#46; O nosso centro s&#243; participou mais recentemente&#44; pelo que os nossos doentes n&#227;o foram inclu&#237;dos na coorte de desenvolvimento do <span class="elsevierStyleItalic">score</span>&#46; O nosso objetivo &#233; o de validar externamente o <span class="elsevierStyleItalic">score</span> ProACS para mortalidade a curto e longo prazo&#46;</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">M&#233;todos</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Foram inclu&#237;dos doentes consecutivos admitidos no nosso centro por SCA&#46; Obtiveram&#8208;se as caracter&#237;sticas demogr&#225;ficas e da admiss&#227;o&#44; bem como o tratamento e seguimento&#46; O <span class="elsevierStyleItalic">score</span> ProACS inclui as seguintes vari&#225;veis&#58; idade&#160;&#8805;<span class="elsevierStyleHsp" style=""></span>72 anos&#44; press&#227;o arterial sist&#243;lica &#8804;<span class="elsevierStyleHsp" style=""></span>116<span class="elsevierStyleHsp" style=""></span>mmHg&#44; classe Killip na admiss&#227;o e eleva&#231;&#227;o do segmento ST&#46; Para cada doente foi calculado o <span class="elsevierStyleItalic">score</span> ProACS&#44; <span class="elsevierStyleItalic">Global Registry of Acute Coronary Events</span> &#40;GRACE&#41; e o C&#8208;ACS&#46;</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Resultados</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Inclu&#237;ram&#8208;se 3170 doentes&#44; idade m&#233;dia de 64<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>13 anos&#44; 62&#37; com enfarte com eleva&#231;&#227;o de ST&#46; A mortalidade total hospitalar foi de 5&#44;7 e 10&#44;3&#37; a um ano de seguimento&#46; O <span class="elsevierStyleItalic">score</span> ProACS mostrou uma boa capacidade discriminativa &#40;AUC<span class="elsevierStyleHsp" style=""></span>&#62;<span class="elsevierStyleHsp" style=""></span>0&#44;75&#41; e boa calibra&#231;&#227;o&#44; semelhante ao C&#8208;ACS&#44; mas inferior quando comparado com o <span class="elsevierStyleItalic">score</span> GRACE e ligeiramente inferior quando comparado com a coorte de desenvolvimento original&#46; Permite uma boa diferencia&#231;&#227;o entre doentes com risco baixo&#44; interm&#233;dio e alto quer para mortalidade a curto quer a longo prazo &#40;p<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#44;001 para todas as compara&#231;&#245;es&#41;&#46;</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Conclus&#245;es</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">O <span class="elsevierStyleItalic">score</span> ProACS &#233; um <span class="elsevierStyleItalic">score</span> v&#225;lido em coortes externas&#46; Pode ser aplicado muito precocemente no primeiro contacto m&#233;dico&#44; mas posteriormente dever&#225; ser complementado pelo <span class="elsevierStyleItalic">score</span> GRACE&#46;</p></span>"
        "secciones" => array:4 [
          0 => array:2 [
            "identificador" => "abst0005"
            "titulo" => "Introdu&#231;&#227;o"
          ]
          1 => array:2 [
            "identificador" => "abst0010"
            "titulo" => "M&#233;todos"
          ]
          2 => array:2 [
            "identificador" => "abst0015"
            "titulo" => "Resultados"
          ]
          3 => array:2 [
            "identificador" => "abst0020"
            "titulo" => "Conclus&#245;es"
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      "en" => array:3 [
        "titulo" => "Abstract"
        "resumen" => "<span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Introduction</span><p id="spar0080" class="elsevierStyleSimplePara elsevierViewall">The ProACS risk score is an early and simple risk stratification score developed for all&#8208;cause in&#8208;hospital mortality in acute coronary syndromes &#40;ACS&#41; from a Portuguese nationwide ACS registry&#46; Our center only recently participated in the registry and was not included in the cohort used for developing the score&#46; Our objective was to perform an external validation of this risk score for short&#8208; and long&#8208;term follow&#8208;up&#46;</p></span> <span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Methods</span><p id="spar0085" class="elsevierStyleSimplePara elsevierViewall">Consecutive patients admitted to our center with ACS were included&#46; Demographic and admission characteristics&#44; as well as treatment and outcome data were collected&#46; The ProACS risk score variables are age &#40;&#8805;72 years&#41;&#44; systolic blood pressure &#40;&#8804;116 mmHg&#41;&#44; Killip class &#40;2&#47;3 or 4&#41; and ST&#8208;segment elevation&#46; We calculated ProACS&#44; Global Registry of Acute Coronary Events &#40;GRACE&#41; and Canada Acute Coronary Syndrome risk score &#40;C&#8208;ACS&#41; risk scores for each patient&#46;</p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Results</span><p id="spar0090" class="elsevierStyleSimplePara elsevierViewall">A total of 3170 patients were included&#44; with a mean age of 64&#177;13 years&#44; 62&#37; with ST&#8208;segment elevation myocardial infarction&#46; All&#8208;cause in&#8208;hospital mortality was 5&#46;7&#37; and 10&#46;3&#37; at one&#8208;year follow&#8208;up&#46; The ProACS risk score showed good discriminative ability for all considered outcomes &#40;area under the receiver operating characteristic curve &#62;0&#46;75&#41; and a good fit&#44; similar to C&#8208;ACS&#44; but lower than the GRACE risk score and slightly lower than in the original development cohort&#46; The ProACS risk score provided good differentiation between patients at low&#44; intermediate and high mortality risk in both short&#8208; and long&#8208;term follow&#8208;up &#40;p&#60;0&#46;001 for all comparisons&#41;&#46;</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Conclusions</span><p id="spar0095" class="elsevierStyleSimplePara elsevierViewall">The ProACS score is valid in external cohorts for risk stratification for ACS&#46; It can be applied very early&#44; at the first medical contact&#44; but should subsequently be complemented by the GRACE risk score&#46;</p></span>"
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            "titulo" => "Introduction"
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            "identificador" => "abst0030"
            "titulo" => "Methods"
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            "identificador" => "abst0035"
            "titulo" => "Results"
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          "pt" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Mortalidade observada &#40;&#37;&#41; em cada grupo de risco estratificado pelo <span class="elsevierStyleItalic">score</span> ProACS para mortalidade hospitalar&#44; aos 30 dias e a um ano&#46;</p>"
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          "leyenda" => "<p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">AIT&#58; acidente isqu&#233;mico transit&#243;rio&#59; AVC&#58; acidente vascular cerebral&#59; CABG&#58; cirurgia de revasculariza&#231;&#227;o mioc&#225;rdica&#59; EMCST&#58; enfarte mioc&#225;rdio com eleva&#231;&#227;o ST&#59; ICP&#58; interven&#231;&#227;o coron&#225;ria percut&#226;nea&#59; IMC&#58; &#237;ndice massa corporal&#59; TAS&#58; tens&#227;o arterial sist&#243;lica&#46;</p>"
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                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">65&#44;9&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">62&#44;2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#60;<span class="elsevierStyleHsp" style=""></span>0&#44;001&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Frequ&#234;ncia card&#237;aca &#40;bpm&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">78<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>20&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#60;<span class="elsevierStyleHsp" style=""></span>0&#44;001&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>TAS &#40;mmHg&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">141<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>30&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">136<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>29&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#60;<span class="elsevierStyleHsp" style=""></span>0&#44;001&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Classe Killip<span class="elsevierStyleHsp" style=""></span>&#8805;<span class="elsevierStyleHsp" style=""></span>2 &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">18&#44;9&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">12&#44;6&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#60;<span class="elsevierStyleHsp" style=""></span>0&#44;001&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Angiografia coron&#225;ria &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">87&#44;5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#60;<span class="elsevierStyleHsp" style=""></span>0&#44;001&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>ICP &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">63&#44;5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#60;<span class="elsevierStyleHsp" style=""></span>0&#44;001&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>CABG &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">1&#44;4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">1&#44;6&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#44;425&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Morte hospitalar &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">5&#44;4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">5&#44;7&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#44;517&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
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          "pt" => "<p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">Caracter&#237;sticas cl&#237;nicas dos doentes na coorte de desenvolvimento &#40;do RNSCA&#41; e na coorte de valida&#231;&#227;o externa</p>"
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                  <table border="0" frame="\n
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                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>GRACE&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>C&#8208;ACS&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="4" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="4" align="left" valign="top"><span class="elsevierStyleItalic">Mortalidade 30 dias</span></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>ProACS&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#8208;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#44;389&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>GRACE&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#44;098&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>C&#8208;ACS&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="4" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="4" align="char" valign="top"><span class="elsevierStyleItalic">Mortalidade um ano</span></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>ProACS&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#8208;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#44;623&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>GRACE&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#44;018&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
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          "pt" => "<p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">Capacidade preditiva do <span class="elsevierStyleItalic">score</span> ProACS&#44; GRACE e C&#8208;ACS para mortalidade a curto&#44; m&#233;dio e longo prazo&#44; e respetiva calibra&#231;&#227;o &#40;H&#8208;L&#41;</p>"
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                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>EMCST&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">H&#8208;L&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">0&#44;247&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">0&#44;540&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">0&#44;800&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>SCASST&nbsp;\t\t\t\t\t\t\n
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                  """
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          "pt" => "<p id="spar0065" class="elsevierStyleSimplePara elsevierViewall">Compara&#231;&#227;o dos <span class="elsevierStyleItalic">scores</span> no enfarte com eleva&#231;&#227;o ST e nas restantes SCA para mortalidade a curto prazo &#40;intra&#8208;hospitalar&#41; e longo prazo &#40;um ano&#41; pela AUC &#40;IC 95&#37;&#41; e teste H&#8208;L &#40;valor de p&#41;</p>"
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