Case report
Superior vena cava syndrome early after pacemaker implantation in a patient with lung carcinoma: A case report
Síndrome da veia cava superior logo após a implantação de um pacemaker num doente com carcinoma no pulmão: um relato de caso
Liting Pan, Pengyong Yan, Daying Wang, Zongjun Liu
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Department of Cardiology, Putuo Hospital, Shanghai University of Traditional Chinese Medicine, Shanghai, China
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(B) left coronary artery with no atherosclerotic disease; (C) aortography showing mild aortic regurgitation and no signs of ascending aortic dissection; the origin of the left coronary artery can be visualized but the right coronary artery cannot; (D-G) computed tomography angiography showing circumferential wall thickening of the thoracic aorta (arrows), causing occlusion of the right coronary ostium (arrowheads); (H) transesophageal echocardiography (TOE) showing circumferential thickening of the thoracic aorta; (I) TOE showing dilated right ventricle.</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "Marisa Passos Silva, Marta Ponte, Eulália Pereira, Daniel Caeiro, Lino Santos, Vasco Ribeiro" "autores" => array:6 [ 0 => array:2 [ "nombre" => "Marisa" "apellidos" => "Passos Silva" ] 1 => array:2 [ "nombre" => "Marta" "apellidos" => "Ponte" ] 2 => array:2 [ "nombre" => "Eulália" "apellidos" => "Pereira" ] 3 => array:2 [ "nombre" => "Daniel" "apellidos" => "Caeiro" ] 4 => array:2 [ "nombre" => "Lino" "apellidos" => "Santos" ] 5 => array:2 [ "nombre" => "Vasco" "apellidos" => "Ribeiro" ] ] ] ] ] "idiomaDefecto" => "en" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0870255117304985?idApp=UINPBA00004E" "url" => "/08702551/0000003800000001/v5_201911281009/S0870255117304985/v5_201911281009/en/main.assets" ] "itemAnterior" => array:20 [ "pii" => "S0870255118300994" "issn" => "08702551" "doi" => "10.1016/j.repc.2018.03.013" "estado" => "S300" "fechaPublicacion" => "2019-01-01" "aid" => "1263" "copyright" => "Sociedade Portuguesa de Cardiologia" "documento" => "article" "crossmark" => 1 "licencia" => "http://creativecommons.org/licenses/by-nc-nd/4.0/" "subdocumento" => "rev" "cita" => "Rev Port Cardiol. 2019;38:53-63" "abierto" => array:3 [ "ES" => true "ES2" => true "LATM" => true ] "gratuito" => true "lecturas" => array:2 [ "total" => 4049 "formatos" => array:3 [ "EPUB" => 102 "HTML" => 3246 "PDF" => 701 ] ] "pt" => array:13 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Artigo de Revisão</span>" "titulo" => "Nova abordagem para o tratamento da diabetes: da glicemia à doença cardiovascular" "tienePdf" => "pt" "tieneTextoCompleto" => "pt" "tieneResumen" => array:2 [ 0 => "pt" 1 => "en" ] "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "53" "paginaFinal" => "63" ] ] "titulosAlternativos" => array:1 [ "en" => array:1 [ "titulo" => "New approach to diabetes care: from blood glucose to cardiovascular disease" ] ] "contieneResumen" => array:2 [ "pt" => true "en" => true ] "contieneTextoCompleto" => array:1 [ "pt" => true ] "contienePdf" => array:1 [ "pt" => true ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figura 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1507 "Ancho" => 2917 "Tamanyo" => 295133 ] ] "descripcion" => array:1 [ "pt" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Fatores que contribuem para o risco cardiovascular aumentado na diabetes <span class="elsevierStyleItalic">mellitus</span> tipo 2.</p> <p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">AGL, ácidos gordos livres; HDL, lipoproteínas de alta densidade; LDL, lipoproteínas de baixa densidade; PAI‐1, inibidor do ativador do plasminogénio tipo 1; PCR, proteína C‐reativa; TG, triglicéridos; TNF‐α, fator de necrose de tumores alfa; VLDL, lipoproteínas de muito baixa densidade. Adaptado de <a class="elsevierStyleCrossRef" href="#bib0635"><span class="elsevierStyleSup">62</span></a>.</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "Carlos Aguiar, Rui Duarte, Davide Carvalho" "autores" => array:3 [ 0 => array:2 [ "nombre" => "Carlos" "apellidos" => "Aguiar" ] 1 => array:2 [ "nombre" => "Rui" "apellidos" => "Duarte" ] 2 => array:2 [ "nombre" => "Davide" "apellidos" => "Carvalho" ] ] ] ] ] "idiomaDefecto" => "pt" "Traduccion" => array:1 [ "en" => array:9 [ "pii" => "S2174204919300017" "doi" => "10.1016/j.repce.2019.01.001" "estado" => "S300" "subdocumento" => "" "abierto" => array:3 [ "ES" => true "ES2" => true "LATM" => true ] "gratuito" => true "lecturas" => array:1 [ "total" => 0 ] "idiomaDefecto" => "en" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2174204919300017?idApp=UINPBA00004E" ] ] "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0870255118300994?idApp=UINPBA00004E" "url" => "/08702551/0000003800000001/v5_201911281009/S0870255118300994/v5_201911281009/pt/main.assets" ] "en" => array:20 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Case report</span>" "titulo" => "Superior vena cava syndrome early after pacemaker implantation in a patient with lung carcinoma: A case report" "tieneTextoCompleto" => true "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "65.e1" "paginaFinal" => "65.e3" ] ] "autores" => array:1 [ 0 => array:4 [ "autoresLista" => "Liting Pan, Pengyong Yan, Daying Wang, Zongjun Liu" "autores" => array:4 [ 0 => array:2 [ "nombre" => "Liting" "apellidos" => "Pan" ] 1 => array:2 [ "nombre" => "Pengyong" "apellidos" => "Yan" ] 2 => array:2 [ "nombre" => "Daying" "apellidos" => "Wang" ] 3 => array:4 [ "nombre" => "Zongjun" "apellidos" => "Liu" "email" => array:1 [ 0 => "liuzongjun164@sina.com" ] "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] ] "afiliaciones" => array:1 [ 0 => array:2 [ "entidad" => "Department of Cardiology, Putuo Hospital, Shanghai University of Traditional Chinese Medicine, Shanghai, China" "identificador" => "aff0005" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "pt" => array:1 [ "titulo" => "Síndrome da veia cava superior logo após a implantação de um <span class="elsevierStyleItalic">pacemaker</span> num doente com carcinoma no pulmão: um relato de caso" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 553 "Ancho" => 950 "Tamanyo" => 79191 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">The patient of superior vena cava syndrome.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Superior vena cava (SVC) syndrome, first described by William Hunter in 1757, is typically dramatic. Although the diagnosis is usually easy, elucidation of the etiology is more difficult. In the past, infectious lesions such as syphilitic aortic aneurysm were common causes, but nowadays malignancy such as bronchial carcinoma or mediastinal lymphoma, and the use of intravascular devices and cardiac pacemakers, have become the main causes.<a class="elsevierStyleCrossRefs" href="#bib0030"><span class="elsevierStyleSup">1,2</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">In this paper, we report an unusual case that presented with SVC syndrome early after pacemaker implantation and diagnosis of lung carcinoma.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Case report</span><p id="par0015" class="elsevierStylePara elsevierViewall">The patient was an 84-year-old male with a medical history of type 2 diabetes and symptomatic sick sinus syndrome. He was treated by permanent transvenous single-chamber pacing (VVI) via the right subclavian vein (Talos SR, Biotronik) the day after admission to our hospital.</p><p id="par0020" class="elsevierStylePara elsevierViewall">On the second postoperative day, the patient developed cyanotic lips and ears, and swelling of the face, neck, and bilateral upper extremities. These symptoms worsened gradually. Physical examination revealed raised jugular venous pressure and distended superficial veins of the chest at the site of the pacemaker implantation, consistent with SVC syndrome (<a class="elsevierStyleCrossRef" href="#fig0005">Figure 1</a>).</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0025" class="elsevierStylePara elsevierViewall">The patient had elevated D-dimers (6.93 mg/l, normal 0-0.55 mg/l) and two tumor markers (Ca19-9 59.45 U/ml, normal 0-37 U/ml; Ca-211 4.24 ng/ml, normal 0-3.3 ng/ml). He also presented with hypoxemia (pH: 7.48, pO<span class="elsevierStyleInf">2</span>: 7.30 kPa, pCO<span class="elsevierStyleInf">2</span>: 3.70 kPa, SO<span class="elsevierStyleInf">2</span>: 91.00%) in arterial blood gas analysis. He underwent a duplex venous scan of the upper extremities and neck, which showed extensive thrombosis of bilateral axillary veins. A computed tomography (CT) chest scan with intravenous contrast showed thrombosis of the SVC with multiple collateral vessels and alterations indicative of chronic bronchitis. However, it was not clear from the CT whether there was extrinsic compression on the SVC due to interference from the pacemaker electrode.</p><p id="par0030" class="elsevierStylePara elsevierViewall">The patient was prescribed anticoagulation with enoxaparin and warfarin, and traditional Chinese medicine (including hirudo, lumbricus, ginseng and scorpion venom) by intravenous drip and oral administration, in order to promote blood circulation and prevent blood stasis. After one month of therapy, symptoms began to improve, with decreased edema of the face, neck and arms and disappearance of the superficial veins of the chest. The duplex venous scan showed no evidence of thrombosis of bilateral axillary veins.</p><p id="par0035" class="elsevierStylePara elsevierViewall">We retrieved the patient's CT scan performed three months previous to this hospitalization for chronic dry cough and shortness of breath, and discovered that tissue derived from the upper right mediastinum (the source probably being pulmonary tissue) had already severely compressed and narrowed the SVC. Obstructive pneumonia, a pulmonary metastatic node and bronchial stenosis could also be seen on this CT (<a class="elsevierStyleCrossRef" href="#fig0010">Figure 2</a>). However, a diagnosis had been missed on the basis of the previous CT scan, which had not been paid due attention. So finally lung carcinoma was considered for this patient, owing to the presence of SVC obstruction, the signs of the CT scan performed three months previously, elevated tumor markers and history of chronic dry cough. The patient refused any invasive intervention for examination or therapy, but was willing to undergo long-term anticoagulation (warfarin) and cancer therapy with traditional Chinese medicine. No recurrence of SVC syndrome was seen at one month of follow-up, but sadly, two months after discharge he died from traumatic subarachnoid hemorrhage related to anticoagulant therapy.</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Discussion</span><p id="par0040" class="elsevierStylePara elsevierViewall">SVC syndrome results from the obstruction of blood flow through the SVC into the right atrium. Generally, malignancy is considered to be the most common etiology of SVC syndrome, but benign iatrogenic causes, mainly intravascular devices (catheters, cardiac defibrillators and pacemaker wires), are becoming increasingly common.<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">1</span></a> Obstruction can be caused by invasion or external compression of the SVC by adjacent pathologic processes involving the lung, lymph nodes, and other mediastinal structures or by thrombosis of blood within the SVC.<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">2</span></a> Malignancy may not only narrow the SVC by invasion or external compression but also by changes in the coagulation and fibrinolytic systems, leading to a hypercoagulable state. SVC thrombosis with or without stenosis from pacemaker leads was described by Kosowsky and Barr in 1972. SVC syndrome is an extremely rare but serious complication after pacemaker lead implantation, characterized by symptomatic occlusion of the SVC.<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">3</span></a> Most patients with SVC syndrome are asymptomatic due to the development of an adequate venous collateral circulation. Symptomatic cases of SVC syndrome from transvenous pacemaker implantation are rare, thought to be less than 0.5% of all patients.<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">4</span></a> The mechanism may be mechanical stress caused by the transvenous leads, causing inflammation of the blood vessel wall and fibrosis, eventually leading to venous thrombosis and occlusion. In the case presented, lung carcinoma, by causing external compression of the SVC and a hypercoagulable state, may explain the SVC obstruction. However, the use of venous catheters may have enhanced venous thrombosis as a result of active inflammation in the endothelium. Balloon angioplasty or surgery was considered, as in other reports, but the patient refused. If the diagnosis of lung carcinoma has been recognized before the indication for a pacemaker, an epicardial route might have been preferred for pacemaker implantation.<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">5</span></a></p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Conclusion</span><p id="par0045" class="elsevierStylePara elsevierViewall">SVC syndrome is usually easily diagnosed but elucidation of the etiology is more difficult. In this case report we present a patient who developed SVC syndrome early after transvenous permanent pacemaker implantation and who was subsequently diagnosed with lung carcinoma. The pathogenesis seems to be explained by a combination of two etiologies: lung carcinoma plus transvenous pacemaker implantation. Although nowadays the extensive use of intravascular devices and cardiac pacemakers has become one of the most common causes of SVC syndrome, common etiologies such as malignancy should be considered first when faced with this complicated disease.</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Conflicts of interest</span><p id="par0050" class="elsevierStylePara elsevierViewall">The authors have no conflicts of interest to declare.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:11 [ 0 => array:3 [ "identificador" => "xres1269337" "titulo" => "Abstract" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0005" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec1174853" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres1269338" "titulo" => "Resumo" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0010" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec1174854" "titulo" => "Palavras-chave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:2 [ "identificador" => "sec0010" "titulo" => "Case report" ] 6 => array:2 [ "identificador" => "sec0015" "titulo" => "Discussion" ] 7 => array:2 [ "identificador" => "sec0020" "titulo" => "Conclusion" ] 8 => array:2 [ "identificador" => "sec0025" "titulo" => "Conflicts of interest" ] 9 => array:2 [ "identificador" => "xack435591" "titulo" => "Acknowledgments" ] 10 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2016-11-12" "fechaAceptado" => "2018-05-13" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec1174853" "palabras" => array:3 [ 0 => "Superior vena cava syndrome" 1 => "Lung neoplasms" 2 => "Artificial pacemaker" ] ] ] "pt" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palavras-chave" "identificador" => "xpalclavsec1174854" "palabras" => array:3 [ 0 => "Síndrome da veia cava superior" 1 => "Neoplasia do pulmão" 2 => "<span class="elsevierStyleItalic">Pacemaker</span>" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:2 [ "titulo" => "Abstract" "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Superior vena cava (SVC) syndrome is typically dramatic. Although the diagnosis is usually easy, elucidation of the etiology is difficult. We present a patient who developed SVC syndrome early after transvenous pacemaker implantation and who was subsequently diagnosed with lung carcinoma. The pathogenesis seems to be explained by a combination of two etiologies: lung carcinoma plus transvenous pacemaker implantation. We emphasize that common etiologies such as malignancy should be considered first when faced with SVC syndrome.</p></span>" ] "pt" => array:2 [ "titulo" => "Resumo" "resumen" => "<span id="abst0010" class="elsevierStyleSection elsevierViewall"><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">A síndrome da veia cava superior (VCS) é normalmente uma situação dramática. Embora o diagnóstico seja habitualmente fácil, todo o esclarecimento sobre esta etiologia é difícil. Apresentamos o caso de um doente que desenvolveu a síndrome da VCS logo após a implantação de um <span class="elsevierStyleItalic">pacemaker</span> em que o diagnóstico de carcinoma no pulmão foi estabelecido posteriormente. A patogénese parece ser explicada por uma combinação de duas etiologias patogénicas: o carcinoma do pulmão e a implantação de um <span class="elsevierStyleItalic">pacemaker</span> transvenoso. Destacamos que as etiologias comuns tais como a malignidade devem ser consideradas em primeiro lugar ao enfrentar a síndrome da VCS.</p></span>" ] ] "multimedia" => array:2 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 553 "Ancho" => 950 "Tamanyo" => 79191 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">The patient of superior vena cava syndrome.</p>" ] ] 1 => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 503 "Ancho" => 1250 "Tamanyo" => 92052 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Computed tomography scan performed three months previously, showing that tissue derived from the upper right mediastinum had already severely compressed and narrowed the superior vena cava. Obstructive pneumonia, a pulmonary metastatic node and bronchial stenosis can be seen.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0015" "bibliografiaReferencia" => array:5 [ 0 => array:3 [ "identificador" => "bib0030" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "The superior vena cava syndrome: clinical characteristics and evolving etiology" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "T.W. Rice" 1 => "R.M. Rodriguez" 2 => "R.W. 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Poerner" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:5 [ "tituloSerie" => "Ann Thorac Surg" "fecha" => "2006" "volumen" => "82" "paginaInicial" => "41" "paginaFinal" => "42" ] ] ] ] ] ] 4 => array:3 [ "identificador" => "bib0050" "etiqueta" => "5" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Pacemaker induced superior vena cava syndrome: a case report" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:3 [ 0 => "E. Senthilvel" 1 => "A. Papadakis" 2 => "V. Jain" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.4076/1757-1626-2-6463" "Revista" => array:5 [ "tituloSerie" => "Cases J" "fecha" => "2009" "volumen" => "2" "paginaInicial" => "6463" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/19829810" "web" => "Medline" ] ] ] ] ] ] ] ] ] ] ] ] "agradecimientos" => array:1 [ 0 => array:4 [ "identificador" => "xack435591" "titulo" => "Acknowledgments" "texto" => "<p id="par0055" class="elsevierStylePara elsevierViewall">This work was supported by a college project of <span class="elsevierStyleGrantSponsor" id="gs1">Putuo Hospital, Shanghai University of Traditional Chinese Medicine</span> (<span class="elsevierStyleGrantNumber" refid="gs1">2016316A</span>) to Liting Pan, <span class="elsevierStyleGrantSponsor" id="gs2">National Natural Science Foundation of China</span> (<span class="elsevierStyleGrantNumber" refid="gs2">81370331</span>) to Daying Wang, <span class="elsevierStyleGrantSponsor" id="gs3">Shanghai medical key specialty construction plan – cardiology</span> (<span class="elsevierStyleGrantNumber" refid="gs3">ZK2015A17</span>).</p>" "vista" => "all" ] ] ] "idiomaDefecto" => "en" "url" => "/08702551/0000003800000001/v5_201911281009/S0870255116303511/v5_201911281009/en/main.assets" "Apartado" => array:4 [ "identificador" => "75833" "tipo" => "SECCION" "en" => array:2 [ "titulo" => "Caso Clínico" "idiomaDefecto" => true ] "idiomaDefecto" => "en" ] "PDF" => "https://static.elsevier.es/multimedia/08702551/0000003800000001/v5_201911281009/S0870255116303511/v5_201911281009/en/main.pdf?idApp=UINPBA00004E&text.app=https://revportcardiol.org/" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0870255116303511?idApp=UINPBA00004E" ]
| Ano/Mês | Html | Total | |
|---|---|---|---|
| 2024 Novembro | 5 | 3 | 8 |
| 2024 Outubro | 39 | 39 | 78 |
| 2024 Setembro | 44 | 27 | 71 |
| 2024 Agosto | 45 | 32 | 77 |
| 2024 Julho | 42 | 30 | 72 |
| 2024 Junho | 57 | 21 | 78 |
| 2024 Maio | 46 | 23 | 69 |
| 2024 Abril | 37 | 30 | 67 |
| 2024 Maro | 45 | 25 | 70 |
| 2024 Fevereiro | 49 | 23 | 72 |
| 2024 Janeiro | 44 | 33 | 77 |
| 2023 Dezembro | 41 | 33 | 74 |
| 2023 Novembro | 54 | 28 | 82 |
| 2023 Outubro | 48 | 21 | 69 |
| 2023 Setembro | 34 | 22 | 56 |
| 2023 Agosto | 38 | 28 | 66 |
| 2023 Julho | 51 | 17 | 68 |
| 2023 Junho | 48 | 21 | 69 |
| 2023 Maio | 66 | 24 | 90 |
| 2023 Abril | 48 | 7 | 55 |
| 2023 Maro | 66 | 23 | 89 |
| 2023 Fevereiro | 51 | 26 | 77 |
| 2023 Janeiro | 34 | 14 | 48 |
| 2022 Dezembro | 56 | 23 | 79 |
| 2022 Novembro | 41 | 24 | 65 |
| 2022 Outubro | 46 | 22 | 68 |
| 2022 Setembro | 39 | 31 | 70 |
| 2022 Agosto | 41 | 31 | 72 |
| 2022 Julho | 40 | 38 | 78 |
| 2022 Junho | 34 | 22 | 56 |
| 2022 Maio | 43 | 32 | 75 |
| 2022 Abril | 45 | 30 | 75 |
| 2022 Maro | 38 | 51 | 89 |
| 2022 Fevereiro | 37 | 30 | 67 |
| 2022 Janeiro | 37 | 29 | 66 |
| 2021 Dezembro | 30 | 25 | 55 |
| 2021 Novembro | 48 | 43 | 91 |
| 2021 Outubro | 68 | 43 | 111 |
| 2021 Setembro | 55 | 27 | 82 |
| 2021 Agosto | 62 | 37 | 99 |
| 2021 Julho | 32 | 20 | 52 |
| 2021 Junho | 40 | 20 | 60 |
| 2021 Maio | 61 | 30 | 91 |
| 2021 Abril | 50 | 41 | 91 |
| 2021 Maro | 72 | 24 | 96 |
| 2021 Fevereiro | 80 | 12 | 92 |
| 2021 Janeiro | 61 | 20 | 81 |
| 2020 Dezembro | 56 | 17 | 73 |
| 2020 Novembro | 60 | 16 | 76 |
| 2020 Outubro | 49 | 23 | 72 |
| 2020 Setembro | 73 | 18 | 91 |
| 2020 Agosto | 34 | 11 | 45 |
| 2020 Julho | 42 | 11 | 53 |
| 2020 Junho | 40 | 15 | 55 |
| 2020 Maio | 30 | 7 | 37 |
| 2020 Abril | 27 | 10 | 37 |
| 2020 Maro | 27 | 18 | 45 |
| 2020 Fevereiro | 71 | 29 | 100 |
| 2020 Janeiro | 32 | 13 | 45 |
| 2019 Dezembro | 33 | 12 | 45 |
| 2019 Novembro | 37 | 8 | 45 |
| 2019 Outubro | 29 | 6 | 35 |
| 2019 Setembro | 30 | 6 | 36 |
| 2019 Agosto | 21 | 10 | 31 |
| 2019 Julho | 19 | 14 | 33 |
| 2019 Junho | 29 | 27 | 56 |
| 2019 Maio | 23 | 14 | 37 |
| 2019 Abril | 38 | 27 | 65 |
| 2019 Maro | 47 | 28 | 75 |
| 2019 Fevereiro | 45 | 41 | 86 |
| 2019 Janeiro | 4 | 4 | 8 |
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