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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Introdu&#231;&#227;o</span><p id="par0065" class="elsevierStylePara elsevierViewall">O enfarte agudo do mioc&#225;rdio com eleva&#231;&#227;o do segmento ST &#40;EAMcST&#41; &#233; considerado uma emerg&#234;ncia m&#233;dica de elevada morbimortalidade se n&#227;o for adequada e atempadamente tratado&#46; Sabendo&#8208;se que a mortalidade por enfarte &#233; maior nas primeiras horas&#44; e que a reperfus&#227;o precoce se associa a uma melhoria progn&#243;stica &#40;idealmente por interven&#231;&#227;o coron&#225;ria percut&#226;nea prim&#225;ria &#91;ICPP&#93;&#41;&#44; &#233; cr&#237;tico que o transporte at&#233; ao laborat&#243;rio de hemodin&#226;mica se proceda em condi&#231;&#245;es m&#225;ximas de seguran&#231;a e com a celeridade necess&#225;ria<a class="elsevierStyleCrossRefs" href="#bib0150"><span class="elsevierStyleSup">1&#44;2</span></a>&#46;</p><p id="par0070" class="elsevierStylePara elsevierViewall">Baseado no conceito &#171;tempo &#233; mioc&#225;rdio&#187;&#44; as <span class="elsevierStyleItalic">guidelines</span> atuais prop&#245;em um tempo porta&#8208;bal&#227;o &#40;TPB&#41;<span class="elsevierStyleHsp" style=""></span>&#8804;<span class="elsevierStyleHsp" style=""></span>90 minutos como o alvo a atingir &#40;idealmente<span class="elsevierStyleHsp" style=""></span>&#8804;<span class="elsevierStyleHsp" style=""></span>60 minutos&#44; especialmente em doentes de alto risco com enfarte em territ&#243;rio anterior que se apresentem precocemente com menos de duas horas de in&#237;cio de sintomas&#44; ou que recorrem a uma institui&#231;&#227;o com capacidade de ICPP 24 horas&#41;&#44; sendo considerado atualmente uma medida de qualidade na presta&#231;&#227;o de cuidados hospitalares aos doentes com EAMcST<a class="elsevierStyleCrossRefs" href="#bib0155"><span class="elsevierStyleSup">2&#44;3</span></a>&#46; Para cumprir tal objetivo&#44; v&#225;rias medidas t&#234;m sido propostas e diversos programas implementados&#44; de forma a melhorar a qualidade de cuidados e reduzir os atrasos no acesso &#224; ICPP&#46; O recurso &#224; emerg&#234;ncia pr&#233;&#8208;hospitalar &#40;EPH&#41; &#233; considerado um elo fundamental da cadeia de sobreviv&#234;ncia no tratamento do EAMcST&#44; pois permite um diagn&#243;stico e orienta&#231;&#227;o para a ICPP mais r&#225;pidos&#44; transportando diretamente o doente para um centro capaz de realizar reperfus&#227;o mec&#226;nica e acompanhado de equipas devidamente treinadas em suporte avan&#231;ado de vida<a class="elsevierStyleCrossRefs" href="#bib0165"><span class="elsevierStyleSup">4&#8211;6</span></a>&#46; O diagn&#243;stico&#44; triagem e tratamento inicial pr&#233;&#8208;hospitalar atrav&#233;s dos servi&#231;os de emerg&#234;ncia m&#233;dica mostraram estar associados a um maior uso de terap&#234;utica de reperfus&#227;o&#44; &#224; redu&#231;&#227;o dos atrasos e uma consequente melhoria dos resultados cl&#237;nicos no EAMcST<a class="elsevierStyleCrossRefs" href="#bib0180"><span class="elsevierStyleSup">7&#44;8</span></a>&#46; No entanto&#44; alguns estudos mostram que a EPH ainda &#233; subutilizada e que muitos doentes continuam a chegar aos hospitais por meios pr&#243;prios<a class="elsevierStyleCrossRefs" href="#bib0165"><span class="elsevierStyleSup">4&#44;9&#44;10</span></a>&#46; O registo portugu&#234;s de cardiologia de interven&#231;&#227;o mostra que&#44; apesar do grande avan&#231;o dos &#250;ltimos anos no acesso e crescimento da ICPP&#44; apenas 38&#37; dos doentes com enfarte ativam os servi&#231;os de EPH<a class="elsevierStyleCrossRef" href="#bib0170"><span class="elsevierStyleSup">5</span></a>&#46;</p><p id="par0075" class="elsevierStylePara elsevierViewall">O objetivo deste estudo foi conhecer a evolu&#231;&#227;o do transporte pr&#233;&#8208;hospitalar nos &#250;ltimos oito anos&#44; caracterizar esta popula&#231;&#227;o e avaliar o impacto do recurso &#224; EPH nos resultados cl&#237;nicos intra&#8208;hospitalares e a um ano&#44; numa s&#233;rie de doentes com EAMcST submetidos a ICPP&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">M&#233;todos</span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Popula&#231;&#227;o estudada e defini&#231;&#245;es</span><p id="par0080" class="elsevierStylePara elsevierViewall">Estudo retrospetivo e unic&#234;ntrico&#44; de uma s&#233;rie consecutiva de doentes admitidos por EAMcST e submetidos a ICPP&#44; no per&#237;odo decorrido entre janeiro de 2008 a julho de 2015&#46; Para cada doente foi aferido o modo de admiss&#227;o hospitalar e&#44; de acordo com esta vari&#225;vel&#44; foram classificados inicialmente em quatro grupos&#58; admiss&#227;o atrav&#233;s do sistema de EPH &#40;composto por equipas m&#233;dicas treinadas capazes de realizar eletrocardiograma &#91;ECG&#93; e desta forma estabelecer o diagn&#243;stico de EAMcST&#44; instituir terap&#234;utica inicial e realizar suporte avan&#231;ado de vida&#41;&#44; meios pr&#243;prios &#40;doentes que se deslocaram at&#233; ao hospital atrav&#233;s de carro&#44; t&#225;xi ou transportes p&#250;blicos&#41;&#44; transporte pelos bombeiros e doentes transferidos de outra unidade de sa&#250;de &#40;p&#250;blica ou privada sem capacidade de ICPP&#41;&#46; Exclu&#237;ram&#8208;se os doentes que j&#225; se encontravam internados por outro motivo aquando do in&#237;cio de sintomas&#46; Posteriormente&#44; para efeitos de compara&#231;&#227;o e an&#225;lise&#44; os doentes foram divididos em grupo EPH &#40;doentes admitidos atrav&#233;s do sistema de emerg&#234;ncia m&#233;dica&#41; e grupo n&#227;o EPH &#40;&#91;N&#8208;EPH&#93; todos os restantes&#41;&#46; Vari&#225;veis cl&#237;nicas&#44; laboratoriais e relacionadas com o procedimento&#44; desde a admiss&#227;o at&#233; &#224; alta hospitalar&#44; foram compiladas atrav&#233;s da consulta da base eletr&#243;nica de dados hospitalares&#46;</p><p id="par0085" class="elsevierStylePara elsevierViewall">O diagn&#243;stico de EAMcST baseou&#8208;se em crit&#233;rios cl&#237;nicos&#44; suportados pelas seguintes altera&#231;&#245;es no ECG&#58; eleva&#231;&#227;o de segmento ST<span class="elsevierStyleHsp" style=""></span>&#8805;<span class="elsevierStyleHsp" style=""></span>0&#44;15<span class="elsevierStyleHsp" style=""></span>mV em V2&#8208;V3 ou<span class="elsevierStyleHsp" style=""></span>&#8805;<span class="elsevierStyleHsp" style=""></span>0&#44;1<span class="elsevierStyleHsp" style=""></span>mV nas outras deriva&#231;&#245;es e em pelo menos duas deriva&#231;&#245;es consecutivas&#44; depress&#227;o de ST em V2&#8208;V3<span class="elsevierStyleHsp" style=""></span>&#8805;<span class="elsevierStyleHsp" style=""></span>0&#44;15<span class="elsevierStyleHsp" style=""></span>mm com onda T positiva ou bloqueio completo de ramo esquerdo &#171;de novo&#187;&#46; O tempo isqu&#233;mico total &#40;TIT&#41; foi definido como o tempo decorrido desde o in&#237;cio dos sintomas &#40;altura em que as queixas se tornaram intensas e persistentes&#41; at&#233; &#224; passagem do fio guia durante a ICPP&#46; Como TPB considerou&#8208;se o tempo decorrido entre o primeiro registo de contacto no hospital at&#233; &#224; passagem do fio guia durante a ICPP&#46; O fen&#243;meno de <span class="elsevierStyleItalic">no&#8208;reflow</span> foi considerado se ap&#243;s a angioplastia n&#227;o se obtivesse fluxo coron&#225;rio distal TIMI &#40;thrombolysis in myocardial infarction&#41;<span class="elsevierStyleHsp" style=""></span>&#8805;<span class="elsevierStyleHsp" style=""></span>2 ou fluxo TIMI 2&#8208;3&#44; mas com impossibilidade do contraste perfundir territ&#243;rio capilar mioc&#225;rdico &#40;grau de perfus&#227;o mioc&#225;rdica<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#41;&#44; ou se ap&#243;s a perfus&#227;o houvesse estagna&#231;&#227;o de contraste &#40;grau de perfus&#227;o mioc&#225;rdica<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>1&#41;&#44; na aus&#234;ncia de espasmo&#44; disse&#231;&#227;o&#44; ou de trombo coron&#225;rio epic&#225;rdico&#44; que persistissem ap&#243;s administra&#231;&#227;o intracoron&#225;ria de nitroglicerina e adenosina&#46; Considerou&#8208;se obten&#231;&#227;o de reperfus&#227;o eficaz nos doentes com aus&#234;ncia de fen&#243;meno de <span class="elsevierStyleItalic">no&#8208;reflow</span>&#46; A <span class="elsevierStyleItalic">clearance</span> da creatinina foi calculada atrav&#233;s da f&#243;rmula de Cockroft&#8208;Gault&#46; A estratifica&#231;&#227;o do risco atrav&#233;s dos <span class="elsevierStyleItalic">scores</span> GRACE &#40;Global Registry of Acute Coronary Events&#41; &#40;pontua&#231;&#227;o para mortalidade hospitalar&#47;seis meses&#41; e TIMI &#40;para EAMcST&#41; foi determinada para todos os doentes&#44; assim como a classifica&#231;&#227;o anat&#243;mica atrav&#233;s do <span class="elsevierStyleItalic">score</span> SYNTAX &#40;<span class="elsevierStyleItalic">Synergy between PCI with Taxus drug&#8208;eluting stent and cardiac surgery&#41;</span> v2&#46;11&#46; A fra&#231;&#227;o de eje&#231;&#227;o ventricular esquerda &#40;FEVE&#41; na fase hospitalar foi calculada por ecocardiografia 2<span class="elsevierStyleHsp" style=""></span>D pelo m&#233;todo de Simpson biplano&#46; Para efeitos de an&#225;lise estat&#237;stica&#44; dicotomizou&#8208;se a FEVE em dois grupos&#58; fun&#231;&#227;o sist&#243;lica ventricular esquerda preservada&#47;disfun&#231;&#227;o ligeira &#40;FEVE<span class="elsevierStyleHsp" style=""></span>&#62;<span class="elsevierStyleHsp" style=""></span>45&#37;&#41; e disfun&#231;&#227;o ventricular esquerda moderada&#47;severa &#40;FEVE<span class="elsevierStyleHsp" style=""></span>&#8804;<span class="elsevierStyleHsp" style=""></span>45&#37;&#41;&#46; Os eventos adversos card&#237;acos <span class="elsevierStyleItalic">major</span> cumulativos &#40;intra&#8208;hospitalares e no seguimento a 12 meses&#41; foram definidos como&#58; mortalidade cumulativa global &#40;card&#237;aca e n&#227;o card&#237;aca&#41;&#44; novo enfarte agudo do mioc&#225;rdio &#40;com ou sem supradesnivelamento do segmento ST&#41;&#44; revasculariza&#231;&#227;o de vaso alvo ou acidente vascular cerebral&#46; A aferi&#231;&#227;o dos eventos cl&#237;nicos foi efetuada atrav&#233;s da consulta do processo cl&#237;nico eletr&#243;nico&#44; ou atrav&#233;s do contacto do doente&#44; m&#233;dico assistente ou familiares&#46;</p></span></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Procedimento e medica&#231;&#227;o</span><p id="par0090" class="elsevierStylePara elsevierViewall">Para a ICPP&#44; o calibre do introdutor arterial usado foi seis ou sete <span class="elsevierStyleItalic">French</span>&#46; Durante o procedimento&#44; foi administrada heparina n&#227;o fracionada &#40;70<span class="elsevierStyleHsp" style=""></span>UI&#47;kg&#41;&#46; O uso de trombectomia aspirativa&#44; inibidores da glicoprote&#237;na 2b&#47;3a&#44; tipo de <span class="elsevierStyleItalic">stent</span>&#44; e outros dispositivos adjuvantes na angioplastia foram deixados ao crit&#233;rio do operador&#46; Todos os doentes se encontravam medicados com aspirina 300<span class="elsevierStyleHsp" style=""></span>mg e clopidogrel 600<span class="elsevierStyleHsp" style=""></span>mg ou ticagrelor 180<span class="elsevierStyleHsp" style=""></span>mg&#44; antes da ICPP&#46;</p><p id="par0095" class="elsevierStylePara elsevierViewall">Ap&#243;s o procedimento&#44; todos os doentes foram admitidos na unidade de cuidados intensivos card&#237;acos&#44; onde permaneceram por um per&#237;odo m&#237;nimo de 48 horas&#46; Foi efetuada seria&#231;&#227;o de marcadores de necrose mioc&#225;rdica&#44; nomeadamente troponina T e creatina <span class="elsevierStyleItalic">kinase</span> &#224;s seis&#44; 12&#44; 24 e 48 horas ap&#243;s reperfus&#227;o&#46; Todos os doentes foram medicados &#224; data de alta com antiagrega&#231;&#227;o plaquet&#225;ria dupla &#40;aspirina 100<span class="elsevierStyleHsp" style=""></span>mg&#47;dia e clopidogrel 75<span class="elsevierStyleHsp" style=""></span>mg&#47;dia&#44; ou ticagrelor 90<span class="elsevierStyleHsp" style=""></span>mg duas vezes&#47;dia&#41;&#44; bem como restante medica&#231;&#227;o considerada apropriada pelo m&#233;dico assistente e de acordo com as recomenda&#231;&#245;es atuais&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">An&#225;lise estat&#237;stica</span><p id="par0100" class="elsevierStylePara elsevierViewall">As vari&#225;veis cont&#237;nuas foram expressas em m&#233;dia&#47;mediana<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>desvio&#8208;padr&#227;o &#40;SD&#41; ou intervalo interquartil &#40;IQR&#41;&#44; respetivamente&#44; para vari&#225;veis de distribui&#231;&#227;o normal ou n&#227;o normal&#46; Vari&#225;veis cont&#237;nuas de distribui&#231;&#227;o normal foram comparadas pelo teste t&#8208;Student para amostras independentes&#59; vari&#225;veis cont&#237;nuas de distribui&#231;&#227;o n&#227;o normal foram comparadas pelo teste Mann&#8208;Whitney&#46; As vari&#225;veis categ&#243;ricas foram expressas em n&#250;mero e percentagens&#44; e comparadas pelo teste do quiquadrado ou pelo teste exato de Fisher&#46; A mortalidade n&#227;o ajustada associada ao modo de admiss&#227;o hospitalar foi calculada atrav&#233;s do m&#233;todo de Kaplan&#8208;Meyer&#44; sendo a diferen&#231;a obtida atrav&#233;s do teste <span class="elsevierStyleItalic">Log&#8208;Rank</span>&#46; Preditores de mortalidade foram determinados atrav&#233;s de um modelo de Cox&#44; com a mortalidade como vari&#225;vel dependente&#44; tendo sido inclu&#237;do no modelo todas as vari&#225;veis com p<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#44;1 em an&#225;lise univariada&#46;</p><p id="par0105" class="elsevierStylePara elsevierViewall">Todos os testes foram considerados significativos se valor de p<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#44;05&#46; A an&#225;lise estat&#237;stica foi efetuada em SPSSv&#46;20 &#40;SPSS&#44; Chicago&#44; IL&#44; EUA&#41;&#46;</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Resultados</span><p id="par0110" class="elsevierStylePara elsevierViewall">Durante o per&#237;odo de estudo&#44; 788 doentes consecutivos foram admitidos no nosso centro por EAMcST e submetidos a ICPP&#46; Exclu&#237;ram&#8208;se 24 por informa&#231;&#227;o insuficiente&#46; Dos 764 doentes analisados&#44; 256 &#40;33&#44;5&#37;&#41; foram referenciados atrav&#233;s da EPH e os restantes 508 atrav&#233;s de meios N&#8208;EPH&#58; 350 &#40;45&#44;8&#37;&#41; foram admitidos no servi&#231;o de urg&#234;ncia por meios pr&#243;prios&#44; 105 &#40;13&#44;7&#37;&#41; transferidos de outro hospital e 53 &#40;6&#44;9&#37;&#41; atrav&#233;s dos bombeiros&#46; A <a class="elsevierStyleCrossRef" href="#fig0005">figura 1</a> expressa a evolu&#231;&#227;o do modo de admiss&#227;o hospitalar nos &#250;ltimos oito anos&#46; Em geral&#44; verificamos uma tend&#234;ncia para uma maior utiliza&#231;&#227;o da EPH em detrimento do uso de meios pr&#243;prios&#44; contudo sem diferen&#231;a estatisticamente significativa &#40;p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;241&#41;&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0115" class="elsevierStylePara elsevierViewall">A <a class="elsevierStyleCrossRef" href="#tbl0005">Tabela 1</a> sumariza as caracter&#237;sticas cl&#237;nicas&#44; demogr&#225;ficas e relacionadas com o procedimento de ambos os grupos&#46; N&#227;o se encontraram diferen&#231;as significativas quanto aos fatores de risco cardiovasculares&#44; terap&#234;utica em curso ou vari&#225;veis relacionadas com o procedimento&#46; Doentes com antecedentes de enfarte recorreram mais frequentemente &#224; EPH&#44; contrariamente aqueles que se apresentaram com angina pr&#233;&#8208;enfarte&#46; Apesar de n&#227;o se verificarem diferen&#231;as significativas relativamente aos <span class="elsevierStyleItalic">scores</span> de risco cl&#237;nicos &#224; admiss&#227;o &#40;GRACE ou TIMI&#41;&#44; os doentes do grupo EPH apresentaram&#8208;se mais frequentemente com insufici&#234;ncia card&#237;aca em classe <span class="elsevierStyleSmallCaps">III</span>&#47;<span class="elsevierStyleSmallCaps">IV</span> de Killip&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0120" class="elsevierStylePara elsevierViewall">A amostra de doentes analisados apresentou um TIT mediano de 240 minutos &#40;com 83&#44;8&#37; dos doentes com TIT<span class="elsevierStyleHsp" style=""></span>&#62;<span class="elsevierStyleHsp" style=""></span>120 minutos&#41; e TPB mediano de 85 minutos&#46; Os doentes transportados atrav&#233;s do sistema de EPH alcan&#231;aram um TIT e um TPB significativamente mais reduzido&#44; 91 e 29 minutos mais curto respetivamente&#44; quando comparado com o grupo N&#8208;EPH &#40;TIT mediana &#91;IQR&#93; de 195 &#91;150&#93; <span class="elsevierStyleItalic">versus</span> 286 &#91;360&#93; minutos&#59; p<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#44;001 e TPB mediana &#91;IQR&#93; de 61 &#91;55&#93; <span class="elsevierStyleItalic">versus</span> 90 &#91;90&#93; minutos&#59; p<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#44;001&#41; &#40;<a class="elsevierStyleCrossRef" href="#tbl0010">Tabela 2</a>&#41;&#46; Uma percentagem significativamente maior de doentes do grupo EHP atingiu o alvo de um TPB<span class="elsevierStyleHsp" style=""></span>&#8804;<span class="elsevierStyleHsp" style=""></span>90 minutos &#40;73&#44;8 <span class="elsevierStyleItalic">versus</span> 55&#44;2&#37;&#59; p<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#44;001&#41; e TPB<span class="elsevierStyleHsp" style=""></span>&#8804;<span class="elsevierStyleHsp" style=""></span>60 minutos &#40;49&#44;6 <span class="elsevierStyleItalic">versus</span> 33&#44;9&#37;&#59; p<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#44;001&#41; &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Figura 2</a>&#41;&#46;</p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0125" class="elsevierStylePara elsevierViewall">Relativamente aos resultados intra&#8208;hospitalares &#40;<a class="elsevierStyleCrossRef" href="#tbl0015">Tabela 3</a>&#41;&#44; n&#227;o se verificaram diferen&#231;as relevantes quanto aos picos enzim&#225;ticos&#44; dias de internamento ou eventos card&#237;acos adversos <span class="elsevierStyleItalic">major</span>&#46; Os doentes do grupo EPH apresentaram uma menor percentagem de disfun&#231;&#227;o sist&#243;lica ventricular esquerda moderada a severa&#44; embora sem significado estat&#237;stico&#46;</p><elsevierMultimedia ident="tbl0015"></elsevierMultimedia><p id="par0130" class="elsevierStylePara elsevierViewall">Ap&#243;s ICPP&#44; o fen&#243;meno de <span class="elsevierStyleItalic">no&#8208;reflow</span> esteve presente em 8&#44;2&#37; dos doentes&#44; obtendo&#8208;se taxas de reperfus&#227;o eficaz de 91&#44;8&#37;&#46; Os doentes que se apresentaram mais precocemente&#44; com TPB<span class="elsevierStyleHsp" style=""></span>&#8804;<span class="elsevierStyleHsp" style=""></span>60 minutos&#44; apresentaram taxas de reperfus&#227;o significativamente mais elevadas &#40;94&#44;8&#37; TPB<span class="elsevierStyleHsp" style=""></span>&#8804;<span class="elsevierStyleHsp" style=""></span>60 minutos <span class="elsevierStyleItalic">versus</span> 90&#44;2&#37; TPB<span class="elsevierStyleHsp" style=""></span>&#62;<span class="elsevierStyleHsp" style=""></span>60 minutos p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;020&#41;&#46; No subgrupo de doentes que se apresentou com TPB<span class="elsevierStyleHsp" style=""></span>&#8804;<span class="elsevierStyleHsp" style=""></span>60 minutos&#44; aqueles que utilizaram a EPH obtiveram um maior benef&#237;cio&#44; com taxas de reperfus&#227;o eficaz de 97&#44;6 <span class="elsevierStyleItalic">versus</span> 92&#44;4&#37; no grupo N&#8208;EPH &#40;p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;042&#41;&#46; A reperfus&#227;o eficaz associou&#8208;se a uma redu&#231;&#227;o significativa das taxas de mortalidade intra&#8208;hospitalares&#44; 6&#44;9&#37; nos doentes com reperfus&#227;o eficaz <span class="elsevierStyleItalic">versus</span> 33&#44;9&#37; nos restantes &#40;p<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#44;001&#41;&#46; Ap&#243;s an&#225;lise multivariada &#40;ajustada para classe Killip &#224; admiss&#227;o&#44; idade&#44; presen&#231;a de diabetes&#44; dislipidemia&#44; tabagismo&#44; angina pr&#233;&#8208;enfarte&#44; <span class="elsevierStyleItalic">clearance</span> de creatinina&#41;&#44; a reperfus&#227;o eficaz foi um preditor independente de mortalidade intra&#8208;hospitalar &#40;<span class="elsevierStyleItalic">hazard ratio</span> &#91;HR&#93;&#58; 3&#44;78 &#91;1&#44;69&#8208;8&#44;47&#93;&#44; p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;001&#41;&#44; juntamente com a apresenta&#231;&#227;o em classe <span class="elsevierStyleSmallCaps">III</span>&#47;<span class="elsevierStyleSmallCaps">IV</span> de Killip e <span class="elsevierStyleItalic">clearance</span> de creatinina reduzida &#40;HR&#58; 10&#44;72 &#91;5&#44;46&#8208;21&#44;06&#93;&#44; p<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#44;001 e HR&#58; 0&#44;98 &#91;0&#44;96&#8208;0&#44;99&#93;&#44; p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;008&#41;&#46;</p><p id="par0135" class="elsevierStylePara elsevierViewall">Na an&#225;lise de seguimento a um ano &#40;Tabela 4&#41;&#44; a taxa de mortalidade foi nominalmente mais elevada no grupo N&#8208;EPH&#44; mas sem atingir significado estat&#237;stico&#46; Tamb&#233;m n&#227;o se verificaram diferen&#231;as significativas quanto aos restantes eventos card&#237;acos adversos&#46; Na <a class="elsevierStyleCrossRef" href="#fig0015">Figura 3</a> encontra&#8208;se expressa a curva de sobrevida cumulativa a um ano de seguimento&#46; Na an&#225;lise univariada a idade&#44; presen&#231;a de diabetes&#44; hipertens&#227;o arterial&#44; tabagismo ativo&#44; antecedentes de enfarte&#44; angina pr&#233;&#8208;enfarte&#44; TIT&#44; TPB&#44; classe Killip <span class="elsevierStyleSmallCaps">III</span>&#47;<span class="elsevierStyleSmallCaps">IV</span> &#224; admiss&#227;o&#44; e disfun&#231;&#227;o ventricular esquerda moderada a severa &#224; data de alta&#44; correlacionaram&#8208;se com a mortalidade cumulativa&#46; Estas vari&#225;veis e o modo de admiss&#227;o &#40;EPH <span class="elsevierStyleItalic">versus</span> N&#8208;EPH&#41; foram inclu&#237;das em an&#225;lise multivariada&#46; Ap&#243;s a an&#225;lise multivariada&#44; apenas a classe Killip <span class="elsevierStyleSmallCaps">III</span>&#47;<span class="elsevierStyleSmallCaps">IV</span> na admiss&#227;o &#40;HR&#58; 6&#44;315&#44; &#91;3&#44;314&#8208;12&#44;042&#93;&#59; p<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#44;001&#41;&#44; a presen&#231;a de disfun&#231;&#227;o ventricular esquerda moderada a severa &#40;HR&#58; 2&#44;486&#44; &#91;1&#46;352&#8208;4&#44;57&#93;&#59; p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;003&#41; e a idade &#40;HR&#58; 1&#44;050&#44; &#91;1&#44;020&#8208;1&#44;082&#93;&#59; p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;001&#41;&#44; se mantiveram como preditores independentes&#44; sendo que a utiliza&#231;&#227;o da EPH n&#227;o teve impacto independente neste <span class="elsevierStyleItalic">outcome</span>&#46; Tamb&#233;m n&#227;o se obtiveram diferen&#231;as estatisticamente significativas quanto &#224; mortalidade a um ano nos doentes com ou sem reperfus&#227;o eficaz &#40;9&#44;8 <span class="elsevierStyleItalic">versus</span> 4&#44;2&#37;&#44; p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;105&#41;&#46;</p><elsevierMultimedia ident="tbl0020"></elsevierMultimedia><elsevierMultimedia ident="fig0015"></elsevierMultimedia></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Discuss&#227;o</span><p id="par0140" class="elsevierStylePara elsevierViewall">De acordo com as medidas e programas implementados nos &#250;ltimos anos em Portugal&#44; o nosso estudo mostra um aumento progressivo do recurso &#224; EPH em detrimento do uso de meios pr&#243;prios&#44; e que esta atitude se associa a uma redu&#231;&#227;o significativa tanto do TPB&#44; como do TIT&#46; Quando comparado com o grupo N&#8208;EPH&#44; os doentes que ativaram a emerg&#234;ncia m&#233;dica pr&#233;&#8208;hospitalar obtiveram tempos de reperfus&#227;o significativamente mais curtos&#44; sendo que o alvo de um TPB<span class="elsevierStyleHsp" style=""></span>&#8804;<span class="elsevierStyleHsp" style=""></span>90 minutos foi atingido em 73&#44;8&#37; e&#44; em 49&#44;6&#37; destes&#44; foi alcan&#231;ado um TPB<span class="elsevierStyleHsp" style=""></span>&#8804;<span class="elsevierStyleHsp" style=""></span>60 minutos&#46; Estes resultados encontram&#8208;se em concord&#226;ncia com v&#225;rios estudos&#44; que mostram o impacto positivo na redu&#231;&#227;o dos tempos de isquemia de medidas como o recurso ao sistema de emerg&#234;ncia m&#233;dica&#44; realiza&#231;&#227;o de ECG a n&#237;vel pr&#233;&#8208;hospitalar e transporte direto dos doentes com EAMcST para os laborat&#243;rios de hemodin&#226;mica<a class="elsevierStyleCrossRefs" href="#bib0165"><span class="elsevierStyleSup">4&#44;9&#8211;13</span></a>&#46; Ainda assim&#44; no nosso estudo&#44; apenas um ter&#231;o dos doentes ativou os servi&#231;os de emerg&#234;ncia m&#233;dica&#44; valor aqu&#233;m do desej&#225;vel&#46; &#192; semelhan&#231;a do trabalho de Fujii et al&#46;&#44; doentes com enfarte pr&#233;vio ativaram mais frequentemente a EPH&#44; bem como aqueles em choque ou com maior grau de insufici&#234;ncia card&#237;aca &#224; admiss&#227;o&#46; Isto sugere&#8208;nos que este grupo engloba doentes de uma maior gravidade&#44; condi&#231;&#227;o esta que os torna capazes de reconhecer mais facilmente a necessidade de recurso ao sistema de emerg&#234;ncia m&#233;dica&#46; Por outro lado&#44; o facto de ter previamente um enfarte agudo do mioc&#225;rdio&#44; a par da educa&#231;&#227;o e conhecimento recebidos&#44; faz com que os doentes com hist&#243;ria de enfarte identifiquem os sintomas e ativem mais frequentemente a EPH<a class="elsevierStyleCrossRef" href="#bib0210"><span class="elsevierStyleSup">13</span></a>&#46; Contrariamente&#44; doentes com angina pr&#233;&#8208;enfarte utilizaram menos a EPH&#46; A altern&#226;ncia de angina com per&#237;odos de acalmia pode diminuir a perce&#231;&#227;o da gravidade do quadro&#44; levando a que o doente recorra menos vezes ao sistema de emerg&#234;ncia m&#233;dica&#46; Al&#233;m disso&#44; no supracitado estudo de Fujii et al&#46;&#44; os doentes que se apresentaram com dor tor&#225;cica como sintoma inicial&#44; ao contr&#225;rio daqueles com s&#237;ncope&#44; dispneia ou altera&#231;&#227;o do estado de consci&#234;ncia&#44; tenderam a ativar menos frequentemente a EPH&#44; mostrando&#44; em parte&#44; o desconhecimento ou o n&#227;o reconhecimento da popula&#231;&#227;o dos sintomas de enfarte&#44; sobretudo as manifesta&#231;&#245;es mais at&#237;picas<a class="elsevierStyleCrossRef" href="#bib0210"><span class="elsevierStyleSup">13</span></a>&#46;</p><p id="par0145" class="elsevierStylePara elsevierViewall">Estudos cl&#237;nicos e experimentais mostram uma rela&#231;&#227;o direta e cont&#237;nua entre tempo de isquemia&#44; necrose transmural e obstru&#231;&#227;o microvascular&#46; Desta forma&#44; o benef&#237;cio em restaurar o fluxo sangu&#237;neo &#233; maior quando este ocorre precocemente&#44; antes da necrose irrevers&#237;vel estar estabelecida<a class="elsevierStyleCrossRefs" href="#bib0215"><span class="elsevierStyleSup">14&#8211;16</span></a>&#46; No estudo de Francone et al&#46;&#44; a percentagem de mioc&#225;rdio salvo&#44; avaliado por resson&#226;ncia magn&#233;tica card&#237;aca&#44; foi maior no grupo de doentes com TIT<span class="elsevierStyleHsp" style=""></span>&#8804;<span class="elsevierStyleHsp" style=""></span>90 minutos&#44; bem como uma menor extens&#227;o da obstru&#231;&#227;o microvascular<a class="elsevierStyleCrossRef" href="#bib0230"><span class="elsevierStyleSup">17</span></a>&#46; Eitel et al&#46;&#44; no seu estudo&#44; mostram tamb&#233;m que o &#237;ndice de mioc&#225;rdio salvo foi superior nas primeiras duas horas de in&#237;cio de sintomas e que os seus preditores mais robustos s&#227;o a completa resolu&#231;&#227;o da eleva&#231;&#227;o do segmento ST&#44; o tempo de sintomas at&#233; reperfus&#227;o e a presen&#231;a de enfarte anterior<a class="elsevierStyleCrossRef" href="#bib0235"><span class="elsevierStyleSup">18</span></a>&#46;</p><p id="par0150" class="elsevierStylePara elsevierViewall">Na &#250;ltima d&#233;cada&#44; v&#225;rios estudos tem refletido sobre o TPB e o seu impacto nos resultados cl&#237;nicos&#59; contudo&#44; os resultados tem sido controversos&#46; Esfor&#231;os em reduzir o TPB n&#227;o se associaram de forma consistente com uma redu&#231;&#227;o da mortalidade<a class="elsevierStyleCrossRefs" href="#bib0175"><span class="elsevierStyleSup">6&#44;19</span></a>&#46; Alguns estudos falharam em mostrar uma melhoria do progn&#243;stico&#44; apesar da redu&#231;&#227;o progressiva dos tempos de isquemia<a class="elsevierStyleCrossRefs" href="#bib0240"><span class="elsevierStyleSup">19&#8211;21</span></a>&#46; No nosso estudo&#44; verificamos que&#44; apesar dos doentes que recorreram &#224; EPH apresentarem um TPB e TIT significativamente inferiores&#44; esta redu&#231;&#227;o n&#227;o se refletiu numa diminui&#231;&#227;o da mortalidade ou eventos card&#237;acas <span class="elsevierStyleItalic">major</span> intra&#8208;hospitalares&#46; Tamb&#233;m no seguimento a um ano&#44; apesar de se verificar uma tend&#234;ncia a menor mortalidade no grupo EPH&#44; com uma diverg&#234;ncia da curva de sobrevida ao longo do seguimento&#44; esta diferen&#231;a n&#227;o se mostrou estatisticamente significativa&#46; Estes dados surgem em linha com outros estudos de grandes dimens&#245;es&#44; nomeadamente de Menees et al&#46;&#44; que inclui 96<span class="elsevierStyleHsp" style=""></span>738 doentes com EAMcST submetidos a ICPP&#44; em que mostraram que apesar da redu&#231;&#227;o anual do TPB a taxa de mortalidade intra&#8208;hospitalar e a curto prazo permaneceu inalterada&#44; incluindo a an&#225;lise de subgrupos de risco<a class="elsevierStyleCrossRef" href="#bib0240"><span class="elsevierStyleSup">19</span></a>&#46; Tamb&#233;m um estudo portugu&#234;s de Bettencourt et al&#46; mostrou que&#44; apesar do impacto significativo do recurso &#224; EPH na redu&#231;&#227;o dos tempos de isquemia&#44; este n&#227;o se traduziu em diferen&#231;as significativas quanto &#224; evolu&#231;&#227;o ou mortalidade intra&#8208;hospitalar ou a um ano<a class="elsevierStyleCrossRef" href="#bib0255"><span class="elsevierStyleSup">22</span></a>&#46; Por outro lado&#44; v&#225;rias outras s&#233;ries afirmam uma associa&#231;&#227;o entre redu&#231;&#227;o do TPB e uma melhoria dos resultados cl&#237;nicos<a class="elsevierStyleCrossRefs" href="#bib0260"><span class="elsevierStyleSup">23&#44;24</span></a>&#46; Esta discord&#226;ncia de resultados pode ser devida &#224; presen&#231;a de m&#250;ltiplos fatores confundidores&#46; O TPB n&#227;o reflete integralmente o tempo total de isquemia&#46; Apesar de ser um componente fundamental&#44; n&#227;o leva em considera&#231;&#227;o o tempo pr&#233;&#8208;hospitalar desde o in&#237;cio de sintomas at&#233; &#224; admiss&#227;o&#44; e n&#227;o implica necessariamente uma redu&#231;&#227;o significativa do TIT&#46; O estudo de Prasad et al&#46;&#44; que avaliou o efeito do TIT e TPB na perfus&#227;o microvascular&#44; mostrou que o TIT &#233; um preditor independente de comprometimento da perfus&#227;o mioc&#225;rdica avaliado tanto pela redu&#231;&#227;o do grau de <span class="elsevierStyleItalic">blush</span> mioc&#225;rdico&#44; como pela resolu&#231;&#227;o incompleta da eleva&#231;&#227;o do segmento ST&#44; e que este se associa &#224; mortalidade a tr&#234;s anos&#46; J&#225; o TPB<span class="elsevierStyleHsp" style=""></span>&#8804;<span class="elsevierStyleHsp" style=""></span>90 minutos apenas mostrou ter impacto nos doentes com TIT inferior a duas horas<a class="elsevierStyleCrossRef" href="#bib0270"><span class="elsevierStyleSup">25</span></a>&#46; Outros estudos&#44; como os de Solhpour et al&#46; e Sardar et al&#46;&#44; que comparam o impacto da redu&#231;&#227;o do TIT e do TPB&#44; mostram que o TIT &#233; um melhor preditor da &#225;rea de enfarte e da mortalidade a 30 dias<a class="elsevierStyleCrossRefs" href="#bib0275"><span class="elsevierStyleSup">26&#44;27</span></a>&#46; Tamb&#233;m o estudo de Shiomi et al&#46; mostrou que uma redu&#231;&#227;o do TPB se associa de forma independente a uma redu&#231;&#227;o do risco do composto de morte e insufici&#234;ncia card&#237;aca nos doentes com apresenta&#231;&#227;o precoce<span class="elsevierStyleHsp" style=""></span>&#8804;<span class="elsevierStyleHsp" style=""></span>120 minutos&#44; mas n&#227;o naqueles com apresenta&#231;&#245;es mais tardias&#44; enfatizando o benef&#237;cio de um recurso c&#233;lere aos cuidados de sa&#250;de<a class="elsevierStyleCrossRef" href="#bib0285"><span class="elsevierStyleSup">28</span></a>&#46; Muitos doentes apresentam&#8208;se tardiamente&#44; fora da janela cr&#237;tica que permite salvar mioc&#225;rdio&#46; Este facto pode explicar&#44; em parte&#44; os resultados apresentados no nosso estudo&#44; uma vez que&#44; apesar do contributo da EPH na redu&#231;&#227;o dos tempos de isquemia&#44; o TIT de ambos os grupos apresentou uma mediana superior a duas horas&#44; o que poder&#225; ter atenuado o poss&#237;vel efeito ben&#233;fico da redu&#231;&#227;o do TPB&#46; Acresce que&#44; na &#250;ltima d&#233;cada&#44; com as novas t&#233;cnicas de reperfus&#227;o e terap&#234;uticas farmacol&#243;gicas dispon&#237;veis&#44; deparamo&#8208;nos com uma redu&#231;&#227;o relevante da mortalidade por EAMcST<a class="elsevierStyleCrossRefs" href="#bib0155"><span class="elsevierStyleSup">2&#44;6</span></a>&#46; Grande &#234;nfase tem sido dada ao TPB e v&#225;rios esfor&#231;os foram criados para a sua redu&#231;&#227;o&#44; n&#227;o s&#243; no pr&#233;&#8208;hospitalar como tamb&#233;m no sistema de triagem e gest&#227;o do doente a n&#237;vel intra&#8208;hospitalar&#46; No nosso estudo&#44; apesar da redu&#231;&#227;o do TPB ter sido significativa no grupo EPH&#44; ambos os grupos apresentaram TPB<span class="elsevierStyleHsp" style=""></span>&#8804;<span class="elsevierStyleHsp" style=""></span>90 minutos com uma diferen&#231;a mediana de 29 minutos&#46; Coloca&#8208;se a quest&#227;o de qual o benef&#237;cio esperado nos resultados cl&#237;nicos&#44; perante uma redu&#231;&#227;o modesta nos tempos de isquemia e numa era em que a mortalidade j&#225; &#233; relativamente baixa&#46; O TPB atual poder&#225; ter atingido o ponto em que redu&#231;&#245;es adicionais tenham pouco impacto na redu&#231;&#227;o da mortalidade intra&#8208;hospitalar ou a curto prazo&#44; mas possam ter impacto nos resultados a longo prazo ou nos internamentos futuros por insufici&#234;ncia card&#237;aca<a class="elsevierStyleCrossRefs" href="#bib0175"><span class="elsevierStyleSup">6&#44;14</span></a>&#46; No entanto&#44; no nosso estudo&#44; verificamos que os doentes que se apresentaram mais precocemente&#44; com TPB<span class="elsevierStyleHsp" style=""></span>&#8804;<span class="elsevierStyleHsp" style=""></span>60 minutos&#44; obtiveram uma taxa de reperfus&#227;o eficaz significativamente mais elevada &#40;especialmente no grupo de doentes que recorreu &#224; EPH&#41;&#44; e que esta se associou de forma independente a uma redu&#231;&#227;o significativa da mortalidade intra&#8208;hospitalar&#46; Estes dados refletem o benef&#237;cio de uma apresenta&#231;&#227;o precoce no resultado angiogr&#225;fico e a sua associa&#231;&#227;o com os resultados cl&#237;nicos intra&#8208;hospitalares&#46;</p><p id="par0155" class="elsevierStylePara elsevierViewall">Quando analisamos o impacto dos tempos de isquemia nos <span class="elsevierStyleItalic">outcomes</span> cl&#237;nicos&#44; outras vari&#225;veis confundidoras devem ser interpretadas&#46; Doentes com TPB mais prolongado podem ter outras raz&#245;es para o atraso na procura de cuidados m&#233;dicos&#44; nomeadamente comorbilidades ou um quadro cl&#237;nico de maior gravidade que necessite de estabiliza&#231;&#227;o pr&#233;via &#224; ICPP e que&#44; por si s&#243;&#44; lhes confira um pior progn&#243;stico&#46; Tamb&#233;m os doentes que recorrem &#224; EPH podem englobar um conjunto de caracter&#237;sticas menos favor&#225;veis&#46; No nosso estudo&#44; verificamos que a percentagem de doentes em classe Killip <span class="elsevierStyleSmallCaps">III</span>&#47;<span class="elsevierStyleSmallCaps">IV</span> &#224; admiss&#227;o foi significativamente maior no grupo EPH&#44; e que esta caracter&#237;stica&#44; juntamente com a idade e a disfun&#231;&#227;o ventricular esquerda moderada a severa&#44; se mostraram preditores independentes de mortalidade cumulativa&#46; O tempo de in&#237;cio de sintomas pode n&#227;o corresponder na realidade ao TIT&#59; muitos doentes podem apresentar isquemia silenciosa&#44; sintomas at&#237;picos ou flutuantes com pr&#243;dromos anginosos&#44; sendo por vezes dif&#237;cil estabelecer o in&#237;cio dos sintomas&#46; Adicionalmente&#44; o nosso estudo&#44; tal como em muitos outros desta tem&#225;tica&#44; n&#227;o incluiu doentes que morreram no pr&#233;&#8208;hospitalar&#44; introduzindo um vi&#233;s de sobreviv&#234;ncia<a class="elsevierStyleCrossRefs" href="#bib0165"><span class="elsevierStyleSup">4&#44;6&#44;13&#44;19&#44;29</span></a>&#46;</p><p id="par0160" class="elsevierStylePara elsevierViewall">Reduzir o TIT em contexto de EAMcST deve continuar a ser uma prioridade&#46; Existe muito a ganhar&#44; especialmente nas regi&#245;es com menos acesso &#224; ICPP e nos subgrupos de doentes que se apresentam tardiamente&#46; Esfor&#231;os adicionais&#44; como alerta p&#250;blico para os sintomas de enfarte e a import&#226;ncia de uma apresenta&#231;&#227;o precoce com vista &#224; redu&#231;&#227;o do intervalo de tempo at&#233; procura de ajuda m&#233;dica e de transfer&#234;ncia&#44; especialmente com recurso &#224; EPH&#44; poder&#227;o resultar em mais doentes que se apresentem nas primeiras horas de isquemia&#44; onde o benef&#237;cio ser&#225; maior e&#44; certamente&#44; se refletir&#225; nos resultados cl&#237;nicos</p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">Limita&#231;&#245;es</span><p id="par0165" class="elsevierStylePara elsevierViewall">As limita&#231;&#245;es deste estudo s&#227;o inerentes &#224; sua natureza retrospetiva&#44; observacional&#44; e basear&#8208;se apenas na experi&#234;ncia de um &#250;nico centro&#44; podendo n&#227;o ser totalmente representativo da realidade nacional&#46; Uma vez que este estudo n&#227;o incluiu os doentes com morte s&#250;bita pr&#233;via &#224; realiza&#231;&#227;o de angiografia coron&#225;ria&#44; nem aferiu os doentes que foram submetidos a manobras de reanima&#231;&#227;o pelas equipas de EPH&#44; pode subestimar o verdadeiro impacto da EPH na mortalidade&#46; Os sintomas de apresenta&#231;&#227;o&#44; dados socioecon&#243;micos e de literacia da popula&#231;&#227;o estudada n&#227;o foram aferidos&#44; bem com as raz&#245;es que levaram os doentes a ativar ou n&#227;o a EPH&#46;</p></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0105">Conclus&#227;o</span><p id="par0170" class="elsevierStylePara elsevierViewall">Verificamos&#44; no nosso estudo&#44; um impacto significativo da ativa&#231;&#227;o da EPH na redu&#231;&#227;o dos tempos de isquemia&#46; Apesar de essa melhoria n&#227;o se ter associado de forma direta a diferen&#231;as significativas na mortalidade e eventos cardiovasculares intra&#8208;hospitalares ou no seguimento a um ano&#44; associou&#8208;se a taxas mais elevadas de reperfus&#227;o eficaz&#44; que se refletiram numa redu&#231;&#227;o da mortalidade intra&#8208;hospitalar&#46; Nos &#250;ltimos anos&#44; verificou&#8208;se uma tend&#234;ncia para um aumento da ativa&#231;&#227;o da EPH&#44; embora aqu&#233;m do desej&#225;vel&#44; e uma percentagem significativa de doentes continua a apresentar&#8208;se tardiamente com TIT<span class="elsevierStyleHsp" style=""></span>&#62;<span class="elsevierStyleHsp" style=""></span>120 minutos&#46; Novas medidas e esfor&#231;os junto da popula&#231;&#227;o devem continuar&#44; numa tentativa de melhorar o progn&#243;stico destes doentes&#46;</p></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0110">Responsabilidades &#233;ticas</span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0115">Prote&#231;&#227;o de pessoas e animais</span><p id="par0180" 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="sec0060" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0120">Confidencialidade dos dados</span><p id="par0185" class="elsevierStylePara elsevierViewall">Os autores declaram que n&#227;o aparecem dados de pacientes neste artigo&#46;</p></span><span id="sec0065" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0125">Direito &#224; privacidade e consentimento escrito&#46;</span><p id="par0190" class="elsevierStylePara elsevierViewall">Os autores declaram que n&#227;o aparecem dados de pacientes neste artigo&#46;</p></span></span><span id="sec0070" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0130">Conflito de interesses</span><p id="par0195" class="elsevierStylePara elsevierViewall">Os autores declaram n&#227;o haver conflito de interesses&#46;</p></span></span>"
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              "titulo" => "Prote&#231;&#227;o de pessoas e animais"
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              "titulo" => "Confidencialidade dos dados"
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    "fechaRecibido" => "2016-11-12"
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            1 => "Enfarte agudo do mioc&#225;rdio"
            2 => "Interven&#231;&#227;o coron&#225;ria percut&#226;nea prim&#225;ria"
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            0 => "Pre&#8208;hospital transport"
            1 => "ST&#8208;elevation myocardial infarction"
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        "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 enfarte agudo do mioc&#225;rdio com eleva&#231;&#227;o de ST &#40;EAMcST&#41; constitui uma emerg&#234;ncia m&#233;dica&#44; beneficiando de um acesso r&#225;pido a cuidados diferenciados&#46; O objetivo deste estudo foi avaliar a evolu&#231;&#227;o do transporte atrav&#233;s da emerg&#234;ncia pr&#233;&#8208;hospitalar &#40;EPH&#41; e o seu impacto nos eventos cl&#237;nicos&#46;</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">M&#233;todos</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Estudo retrospetivo de doentes com EAMcST&#44; submetidos a interven&#231;&#227;o coron&#225;ria percut&#226;nea prim&#225;ria entre janeiro de 2008 e julho de 2015&#46; Os doentes foram divididos de acordo com&#160;o modo&#160;de transporte&#47;admiss&#227;o&#46; Para cada grupo foi analisado tempo isqu&#233;mico total &#40;TIT&#41;&#44; tempo porta&#8208;bal&#227;o &#40;TPB&#41; e eventos intra&#8208;hospitalares e a um ano&#46;</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Resultados</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">De um total de 764 doentes&#44; 33&#44;5&#37; foram transportados pela EPH&#44; 45&#44;8&#37; chegaram por meios pr&#243;prios&#44; 13&#44;7&#37; transferidos de outra institui&#231;&#227;o e 6&#44;9&#37; pelos bombeiros&#46; Nos &#250;ltimos oito anos&#44; verificou&#8208;se uma tend&#234;ncia para uma utiliza&#231;&#227;o crescente da EPH&#46; O grupo EPH&#44; comparado com os restantes &#40;n&#227;o&#8208;EPH&#41;&#44; englobou uma percentagem maior de doentes com enfarte pr&#233;vio&#44; em classe <span class="elsevierStyleSmallCaps">III</span>&#47;<span class="elsevierStyleSmallCaps">IV</span><span class="elsevierStyleItalic">Killip</span> e apresentou uma redu&#231;&#227;o significativa do TIT e TPB &#40;195 <span class="elsevierStyleItalic">versus</span> 286 minutos p<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#44;001 e 61 <span class="elsevierStyleItalic">versus</span> 90 minutos p<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#44;001&#41;&#44; mas n&#227;o se verificaram diferen&#231;as significativas na taxa de eventos hospitalares ou a um ano&#46; Os doentes que se apresentaram mais precocemente obtiveram taxas mais elevadas de reperfus&#227;o eficaz e menor mortalidade intra&#8208;hospitalar &#40;6&#44;9 <span class="elsevierStyleItalic">versus</span> 33&#44;9&#37; p<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#44;001&#41;&#46;</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Conclus&#227;o</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Verificou&#8208;se um impacto significativo da&#160;ativa&#231;&#227;o da&#160;EPH na redu&#231;&#227;o dos tempos de isquemia&#46; Apesar de essa melhoria n&#227;o se ter associado de forma direta a diferen&#231;as significativas na taxa de eventos&#44; associou&#8208;se a taxas mais elevadas de reperfus&#227;o eficaz&#44; que se refletiram numa redu&#231;&#227;o da mortalidade intra&#8208;hospitalar&#46;</p></span>"
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        "resumen" => "<span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Introduction</span><p id="spar0100" class="elsevierStyleSimplePara elsevierViewall">ST&#8208;elevation myocardial infarction &#40;STEMI&#41; is a medical emergency that benefits from rapid access to specialized care&#46; The objective of this study was to describe developments in patient transport via the pre&#8208;hospital emergency medical system &#40;EMS&#41; and its impact on clinical outcomes&#46;</p></span> <span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Methods</span><p id="spar0105" class="elsevierStyleSimplePara elsevierViewall">We retrospectively studied STEMI patients who underwent primary percutaneous coronary intervention between January 2008 and July 2015&#46; Patients were divided according to type of admission&#46; Total ischemic time &#40;TIT&#41;&#44; door&#8208;to&#8208;balloon time &#40;DBT&#41; and in&#8208;hospital and one&#8208;year clinical outcomes were assessed for each group&#46;</p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Results</span><p id="spar0110" class="elsevierStyleSimplePara elsevierViewall">A total of 764 patients were included&#44; of whom 33&#46;5&#37; were transported by the EMS and 45&#46;8&#37; by their own means&#44; 13&#46;7&#37; were transferred from another institution and 6&#46;9&#37; were transported by non&#8208;EMS ambulance&#46; There was a trend for more frequent recourse to the EMS over the eight&#8208;year period&#46; There was a higher percentage of patients with prior myocardial infarction and Killip class III&#47;IV in the EMS group compared to the non&#8208;EMS group&#46; Significant differences were seen between groups in reperfusion times&#44; EMS patients having the shortest TIT and DBT &#40;195 vs&#46; 286 min&#44; p&#60;0&#46;001 and 61 vs&#46; 90 min&#44; p&#60;0&#46;001&#44; respectively&#41;&#44; but no significant difference in event rates was observed&#46; Patients presenting to the hospital early had higher rates of effective reperfusion and lower in&#8208;hospital mortality &#40;6&#46;9&#37; vs&#46; 33&#46;9&#37;&#44; p&#60;0&#46;001&#41;&#46;</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Conclusions</span><p id="spar0115" class="elsevierStyleSimplePara elsevierViewall">Recourse to the EMS significantly reduced ischemic times&#46; Although this improvement was not directly associated with significant differences in event rates&#44; it was associated with higher rates of effective reperfusion that were reflected in lower in&#8208;hospital mortality&#46;</p></span>"
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                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">34 &#40;6&#44;7&#41;&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;030&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>Angina pr&#233;&#8208;enfarte &#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">74 &#40;29&#44;0&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">179 &#40;35&#44;4&#41;&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;045&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>Hemoglobina<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>DP &#224; admiss&#227;o &#40;mg&#47;dl&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">13&#44;87<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>1&#44;71&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">14&#44;16<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>1&#44;82&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;040&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><span class="elsevierStyleItalic">Clearance</span> de creatinina<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>DP &#224; admiss&#227;o &#40;ml&#47;min&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">87&#44;66<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>38&#44;17&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">86&#44;57<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>36&#44;49&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;702&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="4" align="left" valign="top">Medica&#231;&#227;o pr&#233;via</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>Betabloqueador &#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">33 &#40;13&#44;3&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">61 &#40;12&#44;1&#41;&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;370&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>IECA &#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">48 &#40;19&#44;3&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">84 &#40;16&#44;7&#41;&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;219&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>ARA &#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">40 &#40;16&#44;1&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">90 &#40;17&#44;9&#41;&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;303&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>Bloqueadores de canais de c&#225;lcio&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">22 &#40;8&#44;8&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">48 &#40;9&#44;5&#41;&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;433&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>Nitratos &#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">9 &#40;3&#44;6&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">22 &#40;4&#44;4&#41;&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;388&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>Estatina &#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">62 &#40;24&#44;8&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">115 &#40;22&#44;9&#41;&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;307&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>Acido acetilsalic&#237;lico &#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">40 &#40;16&#44;1&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">70 &#40;13&#44;0&#41;&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;248&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>Clopidogrel &#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 &#40;7&#44;2&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">13 &#40;2&#44;6&#41;&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;003&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>Antidiab&#233;ticos orais &#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">46 &#40;18&#44;5&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">89 &#40;17&#44;7&#41;&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;438&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>Insulina &#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">15 &#40;6&#44;0&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">21 &#40;4&#44;2&#41;&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;175&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="4" align="left" valign="top"><span class="elsevierStyleItalic">Scores</span> de risco</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>TIMI &#40;IQR&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">3&#44;76 &#40;3&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">4&#44;13 &#40;3&#41;&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;311&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 &#40;IQR&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">212&#44;96 &#40;63&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">208&#44;69 &#40;58&#41;&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;410&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="elsevierStyleSmallCaps">III</span>&#47;<span class="elsevierStyleSmallCaps">IV</span> &#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">44 &#40;17&#44;3&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">60 &#40;11&#44;9&#41;&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;028&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="4" align="left" valign="top"><span class="elsevierStyleItalic">Vari&#225;veis relacionadas com o procedimento</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>Press&#227;o arterial sist&#243;lica m&#233;dia &#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">118<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>25&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">121<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>27&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;104&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>Acesso radial&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">150 &#40;58&#44;8&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">304 &#40;60&#44;1&#41;&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;345&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>N&#250;mero de vasos&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;88<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>0&#44;85&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;89<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>0&#44;84&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;837&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="4" align="left" valign="top"><span class="elsevierStyleItalic">Vaso alvo</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>DA &#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">105 &#40;41&#44;0&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">222 &#40;43&#44;8&#41;&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>CX &#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">26 &#40;10&#44;2&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">81 &#40;15&#44;8&#41;&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>CD &#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">122 &#40;47&#44;7&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">200 &#40;39&#44;5&#41;&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>TC &#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">3 &#40;1&#44;2&#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 &#40;1&#44;0&#41;&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="elsevierStyleItalic">Trombectomia aspirativa</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">167 &#40;65&#44;2&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">331 &#40;65&#44;3&#41;&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;525&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="elsevierStyleItalic">Drug elutting stent &#40;&#37;&#41;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">156 &#40;60&#44;9&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">295 &#40;58&#44;1&#41;&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;432&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="elsevierStyleItalic">Inibidores de glicoprote&#237;na 2b&#47;3a</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">68 &#40;26&#44;8&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">133 &#40;26&#44;4&#41;&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;488&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="elsevierStyleItalic">Inser&#231;&#227;o de bal&#227;o intra&#8208;a&#243;rtico</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">7 &#40;2&#44;7&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">13 &#40;2&#44;6&#41;&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;528&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="elsevierStyleItalic">SYNTAX score &#40;IQR&#41;</span>&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;95 &#40;12&#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;70 &#40;12&#44;5&#41;&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;792&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="elsevierStyleItalic">ICP de vasos remotos</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">34 &#40;13&#44;4&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">106 &#40;21&#44;1&#41;&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;006&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
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              ]
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          "pt" => "<p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">Caracter&#237;sticas cl&#237;nicas&#44; demogr&#225;ficas e relacionadas com o procedimento</p>"
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          "leyenda" => "<p id="spar0075" class="elsevierStyleSimplePara elsevierViewall">EPH&#58; emerg&#234;ncia pr&#233;&#8208;hospitalar&#59; N&#8208;EPH&#58; n&#227;o emerg&#234;ncia pr&#233;&#8208;hospitalar&#46;</p>"
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                0 => """
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                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="middle" scope="col" style="border-bottom: 2px solid black">EPH&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="middle" scope="col" style="border-bottom: 2px solid black">N&#8208;EPH&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="middle" scope="col" style="border-bottom: 2px solid black">Valor de <span class="elsevierStyleItalic">p</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="middle">Tempo porta bal&#227;o mediano &#40;IQR&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="middle">61 &#40;55&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="middle">90 &#40;90&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="middle">&#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" title="table-entry  " align="left" valign="middle">Tempo isqu&#233;mico total mediano &#40;IQR&#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="char" valign="middle">286 &#40;360&#41;&nbsp;\t\t\t\t\t\t\n
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                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " align="" valign="top" scope="col" style="border-bottom: 2px solid black">&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">6&#44;95<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>8&#44;22&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">6&#44;80<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>8&#44;22&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;821&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">2580&#44;94<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>2669&#44;03&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">2435&#44;12<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>2052&#44;61&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;412&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="elsevierStyleItalic">Dias de internamento</span><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">&#177;</span><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">DP</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">8&#44;28<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>7&#44;10<br>&#40;mediana 6&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">7&#44;44<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>5&#44;71<br>&#40;mediana 6&#41;&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;104&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="elsevierStyleItalic">Bloqueio avan&#231;ado da condu&#231;&#227;o AV &#40;&#37;&#41;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">10 &#40;3&#44;9&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">28 &#40;5&#44;5&#41;&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;216&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="elsevierStyleItalic">Mortalidade &#40;&#37;&#41;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">24 &#40;9&#44;4&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">46 &#40;9&#44;1&#41;&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;490&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="elsevierStyleItalic">Re&#8208;enfarte &#40;&#37;&#41;</span>&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">9 &#40;1&#44;8&#41;&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;387&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="elsevierStyleItalic">AVC &#40;&#37;&#41;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">4 &#40;1&#44;6&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">7 &#40;1&#44;4&#41;&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;533&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="elsevierStyleItalic">Fun&#231;&#227;o sist&#243;lica ventricular esquerda &#40;n</span><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">&#61;</span><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">727&#41;</span>&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="" valign="top">&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;075&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="elsevierStyleItalic">Preservada&#47;disfun&#231;&#227;o ligeira &#40;&#37;&#41;</span>&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">292 &#40;59&#44;9&#41;&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
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                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">195 &#40;40&#44;0&#41;&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></tbody></table>
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          "pt" => "<p id="spar0080" class="elsevierStyleSimplePara elsevierViewall">Resultados intra&#8208;hospitalares</p>"
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                0 => """
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                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " align="" valign="top" scope="col" style="border-bottom: 2px solid black">&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;175&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">5 &#40;1&#44;6&#41;&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;547&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">7 &#40;2&#44;2&#41;&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;611&nbsp;\t\t\t\t\t\t\n
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          "pt" => "<p id="spar0090" class="elsevierStyleSimplePara elsevierViewall">Resultados no seguimento a um ano</p>"
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      ]
    ]
    "bibliografia" => array:2 [
      "titulo" => "Bibliografia"
      "seccion" => array:1 [
        0 => array:2 [
          "identificador" => "bibs0015"
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            0 => array:3 [
              "identificador" => "bib0150"
              "etiqueta" => "1"
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                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Acute myocardial infarction"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:3 [
                            0 => "E&#46; Boersma"
                            1 => "N&#46; Mercado"
                            2 => "D&#46; Poldermans"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
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