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          "pt" => "<p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">Interpreta&#231;&#227;o dos ECG &#40;correta <span class="elsevierStyleItalic">versus</span> incorreta&#41;&#46;</p>"
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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="par0005" class="elsevierStylePara elsevierViewall">A avalia&#231;&#227;o pr&#233;&#8208;competitiva do atleta tem como principal objetivo a identifica&#231;&#227;o precoce e pr&#233;&#8208;cl&#237;nica de patologias associadas a um risco aumentado para a ocorr&#234;ncia de eventos cl&#237;nicos graves&#44; incluindo a morte s&#250;bita&#46; Dados provenientes de It&#225;lia demonstraram uma redu&#231;&#227;o de 89&#37; na incid&#234;ncia de morte s&#250;bita nos atletas de n&#237;vel competitivo ap&#243;s a inclus&#227;o do eletrocardiograma &#40;ECG&#41; na avalia&#231;&#227;o pr&#233;&#8208;competitiva<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">1</span></a>&#46; Neste contexto&#44; na maioria dos pa&#237;ses europeus recomenda&#8208;se atualmente que a avalia&#231;&#227;o pr&#233;&#8208;competitiva do atleta inclua&#58; 1&#41; hist&#243;ria cl&#237;nica &#40;pessoal e familiar&#41;&#59; 2&#41; avalia&#231;&#227;o f&#237;sica&#59; 3&#41; ECG de 12 deriva&#231;&#245;es em repouso<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">2</span></a>&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">Apesar desta evid&#234;ncia e dos m&#250;ltiplos argumentos que justificam a realiza&#231;&#227;o do ECG&#44; a inclus&#227;o deste exame na avalia&#231;&#227;o pr&#233;&#8208;competitiva do atleta permanece controversa&#44; principalmente pela dicotomia entre Europa e Estados Unidos da Am&#233;rica&#44; pa&#237;s onde n&#227;o est&#225; formalmente recomendado<a class="elsevierStyleCrossRefs" href="#bib0095"><span class="elsevierStyleSup">3&#44;4</span></a>&#46; Entre os aspetos mais frequentemente citados contra a realiza&#231;&#227;o do ECG no atleta&#44; sobressai a elevada taxa de falsos&#8208;positivos&#46; Este facto pode levar &#224; realiza&#231;&#227;o desnecess&#225;ria de exames complementares de diagn&#243;stico adicionais e originar a desqualifica&#231;&#227;o inapropriada de indiv&#237;duos saud&#225;veis&#46; A maioria destes falsos&#8208;positivos resulta da interpreta&#231;&#227;o inapropriada do ECG&#44; classificando como potencialmente patol&#243;gicas altera&#231;&#245;es decorrentes de adapta&#231;&#245;es fisiol&#243;gicas card&#237;acas induzidas pelo exerc&#237;cio f&#237;sico<a class="elsevierStyleCrossRefs" href="#bib0105"><span class="elsevierStyleSup">5&#8211;7</span></a>&#46; Assim&#44; a quest&#227;o central desta controv&#233;rsia n&#227;o ser&#225; se o ECG deve ou n&#227;o ser inclu&#237;do na avalia&#231;&#227;o pr&#233;&#8208;competitiva do atleta&#44; mas sim como &#233; que este exame dever&#225; ser interpretado&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">Com o intuito de estandardizar a interpreta&#231;&#227;o do ECG do atleta t&#234;m sido publicados diversos crit&#233;rios&#44; progressivamente mais restritivos&#44; nomeadamente os crit&#233;rios da Sociedade Europeia da Cardiologia&#44; de Seattle e os <span class="elsevierStyleItalic">Refined Criteria</span><a class="elsevierStyleCrossRefs" href="#bib0120"><span class="elsevierStyleSup">8&#8211;11</span></a>&#46; No entanto&#44; apesar da aplica&#231;&#227;o destes crit&#233;rios se refletir numa redu&#231;&#227;o significativa da taxa de falsos&#8208;positivos&#44; continuam subutilizados e a variabilidade na interpreta&#231;&#227;o do ECG do atleta permanece bastante elevada<a class="elsevierStyleCrossRefs" href="#bib0140"><span class="elsevierStyleSup">12&#44;13</span></a>&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">O objetivo deste trabalho foi avaliar a variabilidade na interpreta&#231;&#227;o do ECG de atletas de n&#237;vel competitivo&#44; usando ou n&#227;o crit&#233;rios espec&#237;ficos&#44; numa amostra de cardiologistas e internos de cardiologia em Portugal&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Metodologia</span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Popula&#231;&#227;o em estudo e sele&#231;&#227;o de eletrocardiogramas</span><p id="par0025" class="elsevierStylePara elsevierViewall">Foram selecionados 20 ECG de atletas de n&#237;vel competitivo realizados no contexto de avalia&#231;&#227;o pr&#233;&#8208;competitiva&#46; A maioria correspondia a atletas do g&#233;nero masculino &#40;n<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>18&#41; e de ra&#231;a caucasiana &#40;n<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>17&#41;&#44; com uma mediana de idades de 24 &#40;22&#59; 31&#41; anos&#44; praticantes de pelo menos oito horas de treino semanal&#46; Os atletas estavam envolvidos em m&#250;ltiplas modalidades desportivas&#44; com predomin&#226;ncia de exerc&#237;cio de elevada intensidade din&#226;mica&#58; atletismo de m&#233;dia&#8208;longa dist&#226;ncia &#40;n<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>7&#41;&#44; futebol &#40;n<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>4&#41;&#44; ciclismo &#40;n<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>2&#41;&#44; <span class="elsevierStyleItalic">rugby</span> &#40;n<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>1&#41;&#44; nata&#231;&#227;o &#40;n<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>1&#41;&#44; gin&#225;stica &#40;n<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>1&#41;&#44; t&#233;nis &#40;n<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>1&#41;&#44; boxe &#40;n<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>1&#41;&#44; judo &#40;n<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>1&#41; e <span class="elsevierStyleItalic">kickboxing</span> &#40;n<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>1&#41;&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">Entre os ECG selecionados&#44; 11 eram normais ou apresentavam apenas altera&#231;&#245;es fisiol&#243;gicas&#44; enquanto nove eram patol&#243;gicos&#46; A escolha dos tra&#231;ados ocorreu ap&#243;s valida&#231;&#227;o e classifica&#231;&#227;o de forma un&#226;nime por tr&#234;s cardiologistas com experi&#234;ncia em cardiologia desportiva&#44; nomeadamente na interpreta&#231;&#227;o de ECG de atletas&#46; Nos casos patol&#243;gicos estava estabelecido o diagn&#243;stico de patologia card&#237;aca&#44; decorrente da realiza&#231;&#227;o de exames complementares adicionais&#44; correspondendo a miocardiopatias e doen&#231;as arr&#237;tmicas prim&#225;rias&#46; Na <a class="elsevierStyleCrossRef" href="#tbl0005">Tabela 1</a>&#44; apresentam&#8208;se as principais caracter&#237;sticas dos atletas e respetivos ECG analisados&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0035" class="elsevierStylePara elsevierViewall">Na <a class="elsevierStyleCrossRef" href="#fig0005">Figura 1</a> est&#227;o representados dois exemplos de ECG inclu&#237;dos neste estudo&#44; um n&#227;o patol&#243;gico &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Figura 1</a>A&#41;&#44; apenas com altera&#231;&#245;es fisiol&#243;gicas&#44; independentemente dos crit&#233;rios utilizados para a sua interpreta&#231;&#227;o&#44; e outro patol&#243;gico &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Figura 1</a>B&#41;&#44; correspondendo a um atleta com miocardiopatia hipertr&#243;fica&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia></span></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Interpreta&#231;&#227;o dos eletrocardiogramas</span><p id="par0040" class="elsevierStylePara elsevierViewall">Os ECG selecionados para esta an&#225;lise foram inclu&#237;dos num formul&#225;rio constru&#237;do na plataforma <span class="elsevierStyleItalic">online</span> googleforms &#40;acess&#237;vel atrav&#233;s do seguinte <span class="elsevierStyleItalic">link</span>&#58; <a href="https://docs.google.com/forms/d/1vpVaTKSSlp2TfjiIkGtvX4qZBmkiNnnKnSKHKUYJSR4/viewform">https&#58;&#47;&#47;docs&#46;google&#46;com&#47;forms&#47;d&#47;1vpVaTKSSlp2TfjiIkGtvX4qZBmkiNnnKnSKHKUYJSR4&#47;viewform</a>&#41;&#46; O formul&#225;rio foi enviado por <span class="elsevierStyleItalic">e&#8208;mail</span> a cardiologistas e internos de cardiologia pertencentes a servi&#231;os de cardiologia representativos de todo o territ&#243;rio de Portugal &#40;no total 186 m&#233;dicos&#41;&#46; Ap&#243;s um texto introdut&#243;rio de enquadramento e explica&#231;&#227;o do objetivo do estudo&#44; era pedido que voluntariamente os m&#233;dicos se identificassem como cardiologistas ou internos de cardiologia&#44; referissem a &#225;rea predominante da sua pr&#225;tica cl&#237;nica&#44; nomeadamente se dedicados a subespecialidades dentro da cardiologia&#44; se avaliavam frequentemente ECG de atletas e se usavam crit&#233;rios espec&#237;ficos na sua interpreta&#231;&#227;o&#44; especificando quais no caso de resposta afirmativa&#46; O ECG era acompanhado de informa&#231;&#227;o relativa a caracter&#237;sticas demogr&#225;ficas do atleta &#40;idade&#44; g&#233;nero e ra&#231;a&#41;&#44; bem como da modalidade desportiva praticada&#46; Para cada tra&#231;ado era perguntado se o m&#233;dico o considerava patol&#243;gico ou n&#227;o patol&#243;gico&#46; S&#243; foram considerados v&#225;lidos os question&#225;rios com resposta a todas as perguntas&#44; sendo apenas poss&#237;vel submeter um por cada m&#233;dico&#46; O per&#237;odo de colheita de dados decorreu durante um m&#234;s &#40;novembro de 2015&#41;&#44; sendo o registo efetuado de forma confidencial e apenas o investigador principal teve acesso aos resultados&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">An&#225;lise estat&#237;stica</span><p id="par0045" class="elsevierStylePara elsevierViewall">Os dados recolhidos foram analisados atrav&#233;s do <span class="elsevierStyleItalic">software Statistical Package for Social Sciences</span> &#40;SPSS&#41; para Windows&#44; vers&#227;o 22&#46;0&#46; As vari&#225;veis categ&#243;ricas foram expressas em valor absoluto &#40;n&#41;&#47;percentagem e comparadas pelo teste quiquadrado&#44; enquanto as cont&#237;nuas foram expressas em m&#233;dia<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>desvio padr&#227;o&#44; sendo comparadas pelo teste <span class="elsevierStyleItalic">t&#8208;Student</span> quando verificadas as condi&#231;&#245;es de aplicabilidade &#40;normalidade e homocistecidade&#41; ou mediana com <span class="elsevierStyleItalic">interquartil range</span> &#40;Q25&#59; Q75&#41; para as vari&#225;veis sem distribui&#231;&#227;o normal&#46; Para avaliar a reprodutibilidade do estudo determinou&#8208;se o <span class="elsevierStyleItalic">intraclass correlation coefficient</span> &#40;ICC&#41;&#46; Foram considerados estatisticamente significativos os resultados com <span class="elsevierStyleItalic">p&#8208;value</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#44;05&#46;</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Resultados</span><p id="par0050" class="elsevierStylePara elsevierViewall">Foram inclu&#237;das nesta an&#225;lise as respostas de 58 m&#233;dicos &#40;taxa de resposta 31&#37;&#41;&#44; 42 &#40;72&#44;4&#37;&#41; cardiologistas e os restantes internos de cardiologia&#59; 16 &#40;27&#44;6&#37;&#41; dos quais afirmaram avaliar frequentemente atletas&#46; A maioria&#44; 32 &#40;55&#44;2&#37;&#41; m&#233;dicos&#44; n&#227;o usou crit&#233;rios espec&#237;ficos na interpreta&#231;&#227;o do ECG e entre aqueles que usaram&#44; os mais comuns foram os crit&#233;rios de Seattle &#40;n<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>13&#41;&#44; seguidos dos crit&#233;rios da Sociedade Europeia de Cardiologia &#40;n<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>8&#41;&#46; Na <a class="elsevierStyleCrossRef" href="#tbl0010">Tabela 2</a> encontram&#8208;se representadas estas caracter&#237;sticas basais e a percentagem m&#233;dia de ECG corretamente interpretados de acordo com as mesmas&#46;</p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><p id="par0055" class="elsevierStylePara elsevierViewall">Cada m&#233;dico interpretou corretamente em m&#233;dia 15<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>2 ECG&#44; correspondendo a 74&#37; dos tra&#231;ados analisados&#44; com uma varia&#231;&#227;o entre 45&#8208;100&#37;&#46; Relativamente aos tra&#231;ados patol&#243;gicos&#44; a interpreta&#231;&#227;o foi correta em 68&#37;&#44; variando entre 22&#8208;100&#37;&#44; enquanto entre os n&#227;o patol&#243;gicos a interpreta&#231;&#227;o foi correta em 79&#37;&#44; variando entre 55&#8208;100&#37; &#40;<a class="elsevierStyleCrossRefs" href="#fig0010">Figuras 2 e 3</a>&#41;&#46;</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><elsevierMultimedia ident="fig0015"></elsevierMultimedia><p id="par0060" class="elsevierStylePara elsevierViewall">N&#227;o se verificou diferen&#231;a estatisticamente significativa na interpreta&#231;&#227;o dos ECG entre cardiologistas e internos de cardiologia &#40;74<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>10&#37; <span class="elsevierStyleItalic">versus</span> 75<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>10&#37;&#59; p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;724&#41;&#44; nem entre os m&#233;dicos que avaliam frequentemente atletas e aqueles que n&#227;o avaliam &#40;77<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>12&#37; <span class="elsevierStyleItalic">versus 7</span>3<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>9&#37;&#59; p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;286&#41;&#46; Verificou&#8208;se uma tend&#234;ncia para maior taxa de interpreta&#231;&#227;o correta utilizando crit&#233;rios espec&#237;ficos na interpreta&#231;&#227;o do ECG &#40;77<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>10&#37; <span class="elsevierStyleItalic">versus</span> 72<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>10&#37;&#59; p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;092&#41;&#46; O ICC foi 0&#44;972 &#40;IC95&#37; 0&#44;951&#8208;0&#44;987&#59; p<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#44;001&#41;&#44; demonstrando uma excelente reprodutibilidade do estudo&#46;</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Discuss&#227;o</span><p id="par0065" class="elsevierStylePara elsevierViewall">Este estudo demonstra que a avalia&#231;&#227;o do ECG do atleta permanece sub&#243;tima&#44; havendo uma interpreta&#231;&#227;o incorreta em cerca de um quarto dos tra&#231;ados analisados e uma elevada variabilidade na sua interpreta&#231;&#227;o&#46; Embora a maioria dos m&#233;dicos inquiridos &#40;cardiologistas e internos de cardiologia&#41; tenha afirmado n&#227;o utilizar crit&#233;rios espec&#237;ficos para a interpreta&#231;&#227;o do ECG do atleta&#44; verificou&#8208;se uma tend&#234;ncia para uma melhor acuidade entre aqueles que usaram estes crit&#233;rios&#46;</p><p id="par0070" class="elsevierStylePara elsevierViewall">Apesar destes resultados serem consistentes com dados previamente publicados e de empiricamente existir a perce&#231;&#227;o de que a variabilidade na interpreta&#231;&#227;o do ECG do atleta &#40;intra e interobservador&#41; &#233; elevada&#44; poucos estudos contempor&#226;neos abordaram esta tem&#225;tica&#46; Berte et al&#46;<a class="elsevierStyleCrossRef" href="#bib0140"><span class="elsevierStyleSup">12</span></a> realizaram uma an&#225;lise semelhante&#44; mas utilizando um maior n&#250;mero de ECG &#40;n<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>138&#41; e um menor n&#250;mero de m&#233;dicos &#40;sete cardiologistas e sete especialistas em medicina desportiva&#41;&#46; Nesta an&#225;lise&#44; apesar da interpreta&#231;&#227;o dos tra&#231;ados ter sido realizada segundo crit&#233;rios previamente estabelecidos&#44; a variabilidade foi elevada&#44; havendo globalmente uma discord&#226;ncia em 35&#37; dos ECG analisados&#46; Noutro trabalho&#44; Hill et al&#46;<a class="elsevierStyleCrossRef" href="#bib0150"><span class="elsevierStyleSup">14</span></a>&#44; usando uma amostra semelhante &#224; do presente estudo &#40;18 ECG analisados por 53 m&#233;dicos&#44; cardiologistas pedi&#225;tricos&#41;&#44; a taxa de interpreta&#231;&#227;o incorreta foi de 31&#37;&#46; Mais recentemente&#44; Drezner et al&#46;<a class="elsevierStyleCrossRef" href="#bib0155"><span class="elsevierStyleSup">15</span></a>&#44; em 40 ECG interpretados por 60 m&#233;dicos de diversas especialidades&#44; demonstraram que a acuidade na interpreta&#231;&#227;o do ECG do atleta melhorou significativamente ap&#243;s a ado&#231;&#227;o e aprendizagem dos crit&#233;rios de Seattle&#46; Entre os cardiologistas inclu&#237;dos a taxa de tra&#231;ados incorretamente interpretados passou de 15 para 4&#37;<a class="elsevierStyleCrossRef" href="#bib0155"><span class="elsevierStyleSup">15</span></a>&#46;</p><p id="par0075" class="elsevierStylePara elsevierViewall">Embora n&#227;o se tenha verificado uma diferen&#231;a estatisticamente significativa&#44; a taxa de interpreta&#231;&#227;o correta foi inferior nos tra&#231;ados patol&#243;gicos&#44; ou seja&#44; a taxa de falsos&#8208;negativos foi superior &#224; de falsos&#8208;positivos&#46; Como a principal limita&#231;&#227;o da interpreta&#231;&#227;o do ECG do atleta &#233; a elevada taxa de falsos&#8208;positivos&#44; seria expect&#225;vel o inverso&#46; Independentemente das caracter&#237;sticas estudadas&#44; a identifica&#231;&#227;o correta dos tra&#231;ados patol&#243;gicos foi baixa&#44; exceto com o uso dos <span class="elsevierStyleItalic">Refined Criteria</span><a class="elsevierStyleCrossRef" href="#bib0135"><span class="elsevierStyleSup">11</span></a>&#44; utilizados por um n&#250;mero reduzido de m&#233;dicos&#46; Como estes crit&#233;rios s&#227;o mais recentes&#44; ser&#227;o provavelmente mais conhecidos pelos cl&#237;nicos com mais experi&#234;ncia ou interesse nesta tem&#225;tica&#44; refletindo&#8208;se assim numa melhor interpreta&#231;&#227;o&#46; Nos estudos pr&#233;vios a taxa de falsos&#8208;positivos foi sobrepon&#237;vel&#44; verificando&#8208;se uma melhor acuidade na identifica&#231;&#227;o dos ECG patol&#243;gicos ap&#243;s a ado&#231;&#227;o de crit&#233;rios espec&#237;ficos<a class="elsevierStyleCrossRefs" href="#bib0150"><span class="elsevierStyleSup">14&#8211;16</span></a>&#46; Como exemplo&#44; na avalia&#231;&#227;o da acuidade diagn&#243;stica dos crit&#233;rios de Seattle&#44; a taxa de falsos&#8208;positivos passou de 30 para 9&#37; ap&#243;s a sua aplica&#231;&#227;o<a class="elsevierStyleCrossRef" href="#bib0155"><span class="elsevierStyleSup">15</span></a>&#46; Desta forma&#44; demonstra&#8208;se que &#233; crucial divulgar e aplicar corretamente crit&#233;rios espec&#237;ficos para a interpreta&#231;&#227;o do ECG do atleta&#46;</p><p id="par0080" class="elsevierStylePara elsevierViewall">A variabilidade na interpreta&#231;&#227;o do ECG leva a que muitos atletas realizem exames complementares de diagn&#243;stico adicionais desnecess&#225;rios&#44; acarretando um elevado impacto socioecon&#243;mico&#46; Adicionalmente&#44; n&#227;o pode ser ignorado o stresse ps&#237;quico a que os atletas ficam sujeitos nesta circunst&#226;ncia&#44; o facto de estes exames n&#227;o identificarem todas as causas de morte s&#250;bita&#44; nem garantirem que mesmo assim sejam exclu&#237;dos inapropriadamente atletas da competi&#231;&#227;o&#46; Por outro lado&#44; dada a reduzida preval&#234;ncia de ECG patol&#243;gicos em atletas&#44; a sua identifica&#231;&#227;o torna&#8208;se ainda mais dif&#237;cil e a variabilidade na sua interpreta&#231;&#227;o superior <span class="elsevierStyleItalic">&#40;the prevalence effect&#41;&#46;</span> Outro aspeto muito relevante &#233; o reconhecimento das altera&#231;&#245;es fisiol&#243;gicas card&#237;acas el&#233;tricas induzidas pelo exerc&#237;cio f&#237;sico&#44; dependentes das caracter&#237;sticas demogr&#225;ficas do atleta e do tipo de desporto realizado<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">5</span></a>&#46;</p><p id="par0085" class="elsevierStylePara elsevierViewall">Apesar dos in&#250;meros argumentos que justificam a inclus&#227;o do ECG na avalia&#231;&#227;o pr&#233;&#8208;competitiva do atleta&#44; &#233; fundamental otimizar a sua interpreta&#231;&#227;o&#46; O treino&#44; a estandardiza&#231;&#227;o de metodologias e a centraliza&#231;&#227;o da avalia&#231;&#227;o dos atletas em estruturas dedicadas constituem algumas medidas que poder&#227;o ser adotadas&#46; &#201; fundamental haver maior divulga&#231;&#227;o dos crit&#233;rios espec&#237;ficos para a interpreta&#231;&#227;o do ECG do atleta&#44; das suas vantagens e desvantagens&#44; proporcionando idealmente a cria&#231;&#227;o de consensos e protocolos com a defini&#231;&#227;o daqueles que dever&#227;o ser adotados para uma maior uniformiza&#231;&#227;o&#46; No entanto&#44; os crit&#233;rios em vigor resultam de opini&#245;es de peritos e an&#225;lises retrospetivas&#44; escasseando estudos prospetivos que permitam identificar as altera&#231;&#245;es que mais se correlacionam com a ocorr&#234;ncia de eventos cl&#237;nicos&#44; nomeadamente de morte s&#250;bita&#46; Apesar das lacunas apresentadas pelos crit&#233;rios atualmente dispon&#237;veis&#44; n&#227;o ser&#225; poss&#237;vel aferir nem ultrapassar as suas limita&#231;&#245;es antes de serem aplicados na pr&#225;tica cl&#237;nica&#46;</p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">Limita&#231;&#245;es</span><p id="par0090" class="elsevierStylePara elsevierViewall">Este estudo apresenta algumas limita&#231;&#245;es que importa salientar&#46; A dimens&#227;o da amostra &#233; reduzida&#44; reduzindo a abrang&#234;ncia de aplicabilidade dos seus resultados&#46; O n&#250;mero de respostas correspondeu a menos de um ter&#231;o dos m&#233;dicos contactados&#44; mas por outro lado a dimens&#227;o final da amostra foi superior &#224; de alguns estudos pr&#233;vios&#46; O perfil dos atletas escolhidos foi muito homog&#233;neo&#44; estando os n&#227;o&#8208;caucasianos&#44; do g&#233;nero feminino e veteranos subrepresentados&#46; A metodologia utilizada pode ter limitado as conclus&#245;es deste estudo porque&#44; apesar de ser confidencial&#44; os m&#233;dicos mais dedicados e com mais experi&#234;ncia na avalia&#231;&#227;o de atletas ter&#227;o tido mais interesse e motiva&#231;&#227;o para participar&#46; Alguns m&#233;dicos ter&#227;o analisado os tra&#231;ados com consulta direta dos crit&#233;rios&#44; limitando a avalia&#231;&#227;o real do conhecimento que t&#234;m dos mesmos&#46; Contudo&#44; este facto n&#227;o tem implica&#231;&#245;es no objetivo principal do estudo&#44; sendo mesmo recomend&#225;vel na pr&#225;tica cl&#237;nica&#44; sobretudo pelos m&#233;dicos que avaliam atletas com menor frequ&#234;ncia&#46;</p></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0105">Conclus&#227;o</span><p id="par0095" class="elsevierStylePara elsevierViewall">Na amostra estudada&#44; cerca de um quarto dos ECG de atletas foi incorretamente avaliado&#44; havendo uma elevada variabilidade na sua interpreta&#231;&#227;o&#46; A estandardiza&#231;&#227;o da interpreta&#231;&#227;o do ECG nesta popula&#231;&#227;o com o uso de crit&#233;rios espec&#237;ficos pode melhorar a acuidade deste exame no <span class="elsevierStyleItalic">screening</span> de atletas&#46; No entanto&#44; estes crit&#233;rios s&#227;o ainda subutilizados&#44; realidade que poder&#225; ser alterada com a melhoria da forma&#231;&#227;o m&#233;dica nesta &#225;rea&#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="par0100" 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="par0105" 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</span><p id="par0110" 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="par0115" class="elsevierStylePara elsevierViewall">Os autores declaram n&#227;o haver conflito de interesses&#46;</p></span></span>"
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        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Introdu&#231;&#227;o</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">A interpreta&#231;&#227;o do eletrocardiograma &#40;ECG&#41; do atleta permanece controversa&#44; com aus&#234;ncia de estandardiza&#231;&#227;o e dificuldade na aplica&#231;&#227;o de crit&#233;rios espec&#237;ficos na sua interpreta&#231;&#227;o&#46; O objetivo deste trabalho &#233; avaliar a variabilidade na interpreta&#231;&#227;o do ECG de atletas&#46;</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Metodologia</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Vinte ECG de atletas foram avaliados por cardiologistas e internos de cardiologia&#44; 11 normais ou apenas com altera&#231;&#245;es fisiol&#243;gicas e nove patol&#243;gicos&#46; Cada ECG foi classificado pelos inquiridos em normal&#47;com altera&#231;&#245;es fisiol&#243;gicas ou patol&#243;gico&#44; usando ou n&#227;o crit&#233;rios espec&#237;ficos na sua interpreta&#231;&#227;o&#46;</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Resultados</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Foram inclu&#237;das as respostas de 58 m&#233;dicos&#44; 42 &#40;72&#44;4&#37;&#41; cardiologistas&#46; Dezasseis &#40;27&#44;6&#37;&#41; afirmaram avaliar frequentemente atletas e 32 &#40;55&#44;2&#37;&#41; n&#227;o usar crit&#233;rios espec&#237;ficos na interpreta&#231;&#227;o do ECG&#44; sendo os mais usados os crit&#233;rios de Seattle &#40;n<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>13&#41;&#46; Em m&#233;dia&#44; cada m&#233;dico interpretou corretamente 15<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>2 ECG&#44; correspondendo a 74&#37; dos tra&#231;ados &#40;varia&#231;&#227;o&#58; 45&#8208;100&#37;&#41;&#46; A interpreta&#231;&#227;o dos ECG foi correta em 68&#37; &#40;varia&#231;&#227;o&#58; 22&#8208;100&#37;&#41; dos patol&#243;gicos e em 79&#37; &#40;varia&#231;&#227;o&#58; 55&#8208;100&#37;&#41; dos normais&#47;com altera&#231;&#245;es fisiol&#243;gicas&#46; N&#227;o houve diferen&#231;a significativa na interpreta&#231;&#227;o entre cardiologistas e internos &#40;74<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>10&#37; <span class="elsevierStyleItalic">versus</span> 75<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>10&#37;&#59; p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;724&#41;&#44; nem entre os que avaliam frequentemente ou n&#227;o atletas &#40;77<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>12&#37; <span class="elsevierStyleItalic">versus</span> 73<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>9&#37;&#59; p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;286&#41;&#44; verificando&#8208;se uma tend&#234;ncia para interpreta&#231;&#227;o mais correta com crit&#233;rios espec&#237;ficos &#40;77<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>10&#37; <span class="elsevierStyleItalic">versus</span> 72<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>10&#37;&#59; p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;092&#41;&#46; A reprodutibilidade do estudo foi excelente <span class="elsevierStyleItalic">&#40;intraclass correlation coefficient</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;972&#59; 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">Na amostra estudada&#44; cerca de um quarto dos ECG foi incorretamente avaliados&#44; havendo uma elevada variabilidade na sua interpreta&#231;&#227;o&#46; O uso de crit&#233;rios espec&#237;ficos na interpreta&#231;&#227;o do ECG do atleta pode melhorar a acuidade deste exame no <span class="elsevierStyleItalic">screening</span> de atletas&#44; mas s&#227;o ainda subutilizados&#46;</p></span>"
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        "resumen" => "<span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Introduction</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Assessment of the electrocardiogram &#40;ECG&#41; in athletes remains controversial&#44; with lack of standardization and difficulty in applying specific criteria in its interpretation&#46; The purpose of this study was to assess variability in the interpretation of the ECG in athletes&#46;</p></span> <span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Methods</span><p id="spar0080" class="elsevierStyleSimplePara elsevierViewall">Twenty ECGs of competitive athletes were assessed by cardiologists and cardiology residents&#44; 11 of them normal or with isolated physiological changes and nine pathological&#46; Each ECG was classified as normal&#47;physiological or pathological&#44; with or without the use of specific interpretation criteria&#46;</p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Results</span><p id="spar0085" class="elsevierStyleSimplePara elsevierViewall">The study presents responses from 58 physicians&#44; 42 &#40;72&#46;4&#37;&#41; of them cardiologists&#46; Sixteen &#40;27&#46;6&#37;&#41; physicians reported that they regularly assessed athletes and 32 &#40;55&#46;2&#37;&#41; did not use specific ECG interpretation criteria&#44; of which the Seattle criteria were the most commonly used &#40;n&#61;13&#41;&#46; Each physician interpreted 15&#177;2 ECGs correctly&#44; corresponding to 74&#37; of the total number of ECGs &#40;variation&#58; 45&#37;&#8208;100&#37;&#41;&#46; Interpretation of pathological ECGs was correct in 68&#37; &#40;variation&#58; 22&#37;&#8208;100&#37;&#41; and of normal&#47;physiological in 79&#37; &#40;variation&#58; 55&#37;&#8208;100&#37;&#41;&#46; There was no significant difference in interpretation between cardiologists and residents &#40;74&#177;10&#37; vs&#46; 75&#177;10&#37;&#59; p&#61;0&#46;724&#41; or between those who regularly assessed athletes and those who did not &#40;77&#177;12&#37; vs&#46; 73&#177;9&#37;&#59; p&#61;0&#46;286&#41;&#44; but there was a trend for a higher rate of correct interpretation using specific criteria &#40;77&#177;10&#37; vs&#46; 72&#177;10&#37;&#59; p&#61;0&#46;092&#41;&#46; The reproducibility of the study was excellent &#40;intraclass correlation coefficient&#61;0&#46;972&#59; p&#60;0&#46;001&#41;&#46;</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Conclusions</span><p id="spar0090" class="elsevierStyleSimplePara elsevierViewall">A quarter of the ECGs were not correctly assessed and variability in interpretation was high&#46; The use of specific criteria can improve the accuracy of interpretation of athletes&#8217; ECGs&#44; which is an important part of pre&#8208;competitive screening&#44; but one that is underused&#46;</p></span>"
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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="left" valign="top" scope="col" style="border-bottom: 2px solid black">ECG&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Atleta&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Interpreta&#231;&#227;o&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Principais altera&#231;&#245;es&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-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Homem&#44; caucasiano&#44; 35 anos&#59; atletismo&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Patol&#243;gico &#40;s&#237;ndrome de <span class="elsevierStyleItalic">Brugada</span>&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Padr&#227;o de <span class="elsevierStyleItalic">Brugada</span> tipo 1&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">2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Homem&#44; caucasiano&#44; 24 anos&#59; judo&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Patol&#243;gico &#40;MAVD&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Crit&#233;rios de voltagem para HVD&#59; desvio direito do eixo card&#237;aco &#40;&#62;<span class="elsevierStyleHsp" style=""></span>120&#176;&#41;&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">3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Mulher&#44; negra&#44; 22 anos&#59; andebol&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Patol&#243;gico &#40;MCH&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Ondas T negativas nas deriva&#231;&#245;es inferiores e V5&#8208;V6&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">4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Homem&#44; caucasiano&#44; 23 anos&#59; gin&#225;stica&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Fisiol&#243;gico&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Bradicardia sinusal&#59; bloqueio incompleto do ramo direito&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">5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Homem&#44; caucasiano&#44; 30 anos&#59; futebol 11&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Patol&#243;gico &#40;origem coron&#225;ria an&#243;mala&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Infradesnivelamento do segmento ST nas deriva&#231;&#245;es laterais&#59; ondas T negativas nas deriva&#231;&#245;es inferiores&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">6&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Homem&#44; caucasiano&#44; 23 anos&#59; atletismo&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Patol&#243;gico &#40;MCH&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Ondas Q patol&#243;gicas nas deriva&#231;&#245;es inferiores e laterais&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">7&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Homem&#44; caucasiano&#44; 31 anos&#59; atletismo&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Fisiol&#243;gico&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Bradicardia sinusal&#59; repolariza&#231;&#227;o precoce&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">8&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Homem&#44; caucasiano&#44; 35 anos&#59; atletismo&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Fisiol&#243;gico&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Bradicardia sinusal&#59; crit&#233;rios de voltagem para HVE&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">9&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Homem&#44; caucasiano&#44; 22 anos&#59; atletismo&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Fisiol&#243;gico&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Bradicardia sinusal&#59; repolariza&#231;&#227;o precoce&#59; crit&#233;rios de voltagem para HVE&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">10&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Homem&#44; negro&#44; 24 anos&#59; boxe&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Fisiol&#243;gico&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Bradicardia sinusal&#59; ondas T negativas em V1&#8208;V4&#59; crit&#233;rios de voltagem para HVE&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">11&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Mulher&#44; caucasiana&#44; 24 anos&#59; atletismo&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Fisiol&#243;gico&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Bradicardia sinusal&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">12&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Homem&#44; caucasiano&#44; 18 anos&#59; <span class="elsevierStyleItalic">kickboxing</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Fisiol&#243;gico&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Arritmia sinusal&#59; repolariza&#231;&#227;o precoce&#59; crit&#233;rios de voltagem para HVE&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">13&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Homem&#44; caucasiano&#44; 31 anos&#59; t&#233;nis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Patol&#243;gico &#40;WPW&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Intervalo PR curto &#40;&#60;<span class="elsevierStyleHsp" style=""></span>120<span class="elsevierStyleHsp" style=""></span>ms&#41;&#59; onda delta&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">14&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Homem&#44; caucasiano&#44; 30 anos&#59; ciclismo&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Fisiol&#243;gico&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Bradicardia sinusal&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">15&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Homem&#44; caucasiano&#44; 19 anos&#59; futebol 11&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Fisiol&#243;gico&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Bradicardia sinusal&#59; repolariza&#231;&#227;o precoce&#59; crit&#233;rios de voltagem para HVE&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">16&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Homem&#44; caucasiano&#44; 22 anos&#59; atletismo&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Fisiol&#243;gico&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Bloqueio auriculoventricular do 2&#46;&#176; grau tipo 1&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">17&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Homem&#44; negro&#44; 25 anos&#59; futebol 11&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Patol&#243;gico &#40;MCH&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Ondas T negativas nas deriva&#231;&#245;es inferiores e em V3&#8208;V6&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">18&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Mulher&#44; caucasiana&#44; 30 anos&#59; ciclismo&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Patol&#243;gico &#40;MAVD&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">ESVs isoladas com padr&#227;o de BCRE e ondas T negativas nas deriva&#231;&#245;es inferiores&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">19&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Homem&#44; caucasiano&#44; 15 anos&#59; nata&#231;&#227;o&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Patol&#243;gico &#40;SQTL&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Intervalo QT prolongado &#40;QTc<span class="elsevierStyleHsp" style=""></span>&#62;<span class="elsevierStyleHsp" style=""></span>480<span class="elsevierStyleHsp" style=""></span>ms&#41;&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">20&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Homem&#44; caucasiano&#44; 16 anos&#59; <span class="elsevierStyleItalic">rugby</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Fisiol&#243;gico&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Bradicardia sinusal&#59; padr&#227;o <span class="elsevierStyleItalic">juvenile</span> &#40;ondas T negativas em V1&#8208;V3&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
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          "pt" => "<p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">Principais caracter&#237;sticas dos atletas e respetivos ECG inclu&#237;dos no estudo</p>"
        ]
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          "leyenda" => "<p id="spar0075" class="elsevierStyleSimplePara elsevierViewall">ECG&#58; eletrocardiograma&#59; ESC&#58; <span class="elsevierStyleItalic">European Society of Cardiology</span>&#46;</p>"
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              "tabla" => array:1 [
                0 => """
                  <table border="0" frame="\n
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                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td-with-role" title="table-head ; entry_with_role_rowhead " align="left" valign="top" scope="col">Caracter&#237;stica &#40;n&#47;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col">Total&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " colspan="3" align="center" valign="top" scope="col" style="border-bottom: 2px solid black">&#37; m&#233;dia de ECG corretamente interpretados</th></tr><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
                  \t\t\t\t</th><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
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Total&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">N&#227;o patol&#243;gicos&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Patol&#243;gicos&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  " colspan="5" align="left" valign="top"><span class="elsevierStyleItalic">&#193;rea principal de pr&#225;tica cl&#237;nica</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>Cardiologista&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">42 &#40;72&#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">74&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">79&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">67&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>Interno de cardiologia&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">16 &#40;27&#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">75&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">79&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">70&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>Cardiologia cl&#237;nica&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">41 &#40;70&#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">75&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">80&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">70&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>Outras &#225;reas da cardiologia&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">1 &#40;1&#44;9&#41;&nbsp;\t\t\t\t\t\t\n
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