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As vantagens dessa t&#233;cnica consistem no n&#227;o uso de adenosina e na eventual obten&#231;&#227;o de resultados de forma mais r&#225;pida do que o FFR<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a>&#46; V&#225;rios resultados apontam para uma elevada concord&#226;ncia entre os resultados do iFR e os resultados do FFR<a class="elsevierStyleCrossRefs" href="#bib0035"><span class="elsevierStyleSup">7&#44;8</span></a>&#46; Recentemente&#44; foram publicados os resultados de dois ensaios cl&#237;nicos aleatorizados multic&#234;ntricos que apoiam a n&#227;o inferioridade &#40;relativamente a <span class="elsevierStyleItalic">outcomes</span>&#41; do iFR relativamente ao FFR na decis&#227;o de proceder &#224; angioplastia&#44; com um <span class="elsevierStyleItalic">cut&#8208;off</span> de iFR de &#8804; 0&#44;89 para proceder &#224; angioplastia&#46; Outros estudos abordaram o uso de uma estrat&#233;gia &#171;h&#237;brida&#187;<a class="elsevierStyleCrossRefs" href="#bib0045"><span class="elsevierStyleSup">9&#44;10</span></a>&#44; em que se procede &#224; angioplastia com valores de iFR &#60; 0&#44;86&#44; a abordagem conservadora com valores &#62; 0&#44;93 e a medi&#231;&#227;o por FFR nos casos com valores interm&#233;dios<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a>&#46; N&#227;o obstante&#44; n&#227;o &#233; consensual o uso isolado do iFR&#44; nem t&#227;o pouco a estrat&#233;gia de interpreta&#231;&#227;o de resultados dela<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">11</span></a>&#46; O FFR &#233; ainda considerado a t&#233;cnica padr&#227;o na avalia&#231;&#227;o funcional de les&#245;es coron&#225;rias&#44; nomeadamente nas recomenda&#231;&#245;es internacionais<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#44;11</span></a>&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">Desse modo&#44; importa analisar os resultados de um registo sobre o uso dessas duas t&#233;cnicas&#44; nomeadamente&#58; &#40;1&#41; analisar a acuidade diagn&#243;stica do iFR tendo como refer&#234;ncia o FFR&#59; &#40;2&#41; determinar a influ&#234;ncia que o uso <span class="elsevierStyleItalic">a priori</span> do iFR teve na decis&#227;o de execu&#231;&#227;o de FFR de acordo com o crit&#233;rio do operador&#59; &#40;3&#41; analisar o grau de concord&#226;ncia entre as duas t&#233;cnicas&#59; &#40;4&#41; analisar o efeito do uso de iFR na dose&#47;tempo de radia&#231;&#227;o e tempo de procedimento&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Material e m&#233;todos</span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Caracter&#237;sticas do estudo&#44; crit&#233;rios de inclus&#227;o e de exclus&#227;o</span><p id="par0240" class="elsevierStylePara elsevierViewall">Registo unic&#234;ntrico de todos os doentes submetidos a coronariografia com avalia&#231;&#227;o funcional com FFR e&#47;ou iFR de les&#245;es coron&#225;rias durante cinco anos &#40;2012&#8208;2016&#41;&#46; A decis&#227;o de efetuar uma&#44; outra ou ambas as t&#233;cnicas ficou ao crit&#233;rio do operador&#44; bem como a decis&#227;o de proceder &#224; revasculariza&#231;&#227;o ou terap&#234;utica m&#233;dica&#46; Exclu&#237;ram&#8208;se os doentes inclu&#237;dos em ensaios cl&#237;nicos no &#226;mbito dessas t&#233;cnicas&#44; uma vez que eram sujeitos a protocolos pr&#243;prios&#44; n&#227;o dependentes da decis&#227;o do operador&#46; Registaram&#8208;se prospetivamente os dados demogr&#225;ficos&#44; cl&#237;nicos e as caracter&#237;sticas do procedimento&#44; nomeadamente as medi&#231;&#245;es de FFR e iFR efetuadas e os respetivos resultados&#46; A an&#225;lise efetuada neste artigo tem uma configura&#231;&#227;o retrospetiva&#44; dado que se focou predominantemente no subgrupo submetido a ambas as medi&#231;&#245;es&#44; o registo n&#227;o foi criado especificamente com o prop&#243;sito de comparar os dois grupos&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Procedimento de medi&#231;&#227;o de FFR e iFR</span><p id="par0245" class="elsevierStylePara elsevierViewall">O FFR foi determinado ap&#243;s hiperemia m&#225;xima alcan&#231;ada por administra&#231;&#227;o de adenosina em veia central &#40;140<span class="elsevierStyleHsp" style=""></span>&#956;g&#47;kg&#47;min&#41;&#44; com os sistemas St&#46; Jude Medical &#40;atual Abbot&#41; ou Volcano &#40;atual Philips Volcano&#41;&#46; Nos casos em que se fez medi&#231;&#227;o de iFR apenas ou de iFR e FFR&#44; foi sempre usado o sistema Volcano &#40;material e consola&#41;&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">An&#225;lise estat&#237;stica</span><p id="par0250" class="elsevierStylePara elsevierViewall">Para identifica&#231;&#227;o do valor de iFR com melhor acuidade diagn&#243;stica tendo como refer&#234;ncia o FFR usou&#8208;se an&#225;lise de <span class="elsevierStyleItalic">Receiver Operating Characteristic</span> &#40;ROC&#41; <span class="elsevierStyleItalic">Curve&#46;</span> A an&#225;lise efetuada teve como refer&#234;ncia o valor de FFR &#8804; 0&#44;80 e tamb&#233;m o valor &#60; 0&#44;75&#46; Usaram&#8208;se a an&#225;lise de Bland&#8208;Altman e a de correla&#231;&#227;o de Pearson para comparar os valores de iFR com os valores de FFR&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">Procedeu&#8208;se igualmente &#224; aferi&#231;&#227;o dos resultados de iFR de acordo com a estrat&#233;gia &#171;h&#237;brida&#187;<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a>&#58; para efeitos de an&#225;lise&#44; considerou&#8208;se como inconclusivo um valor de iFR entre 0&#44;86 e 0&#44;93&#59; positivo um valor &#60; 0&#44;86 &#40;i&#46;e&#46; isquemia e portanto a favor de proceder &#224; angioplastia&#41;&#59; negativo um valor &#62; 0&#44;93 &#40;i&#46;e&#46;&#44; sem isquemia e portanto a favor de protelar angioplastia&#41;&#46; Procedeu&#8208;se tamb&#233;m &#224; mesma avalia&#231;&#227;o com o uso como <span class="elsevierStyleItalic">cut&#8208;off</span> para positividade de um valor &#8804; 0&#44;89 de acordo com dois ensaios cl&#237;nicos aleatorizados recentemente publicados<a class="elsevierStyleCrossRefs" href="#bib0045"><span class="elsevierStyleSup">9&#44;12</span></a>&#46; Em ambas as an&#225;lises&#44; usou&#8208;se como valor de refer&#234;ncia de FFR um <span class="elsevierStyleItalic">cut&#8208;off</span> &#8804; 0&#44;80&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">Por &#250;ltimo&#44; procedeu&#8208;se &#224; an&#225;lise do efeito do iFR na dose&#47;tempo de radia&#231;&#227;o&#44; tempo de procedimento e uso de adenosina&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">Para compara&#231;&#227;o de vari&#225;veis param&#233;tricas quantitativas usou&#8208;se o teste <span class="elsevierStyleItalic">t</span> de Student e para vari&#225;veis param&#233;tricas qualitativas o teste de qui&#8208;quadrado&#46; As vari&#225;veis s&#227;o apresentadas sob a forma de m&#233;dia<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>desvio padr&#227;o &#40;DP&#41;&#46;</p></span></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Resultados</span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">Caracter&#237;sticas da popula&#231;&#227;o e procedimento</span><p id="par0255" class="elsevierStylePara elsevierViewall">Durante cinco anos foi efetuada avalia&#231;&#227;o funcional em les&#245;es coron&#225;rias moderadas em 326 doentes &#40;idade m&#233;dia de 67<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>11 anos&#44; 68&#44;7&#37; homens&#41;&#46;</p><p id="par0055" class="elsevierStylePara elsevierViewall">Executaram&#8208;se medi&#231;&#245;es em 402 les&#245;es&#46; Procederam&#8208;se a 376 avalia&#231;&#245;es &#40;93&#44;5&#37;&#41; de FFR e a 180 &#40;44&#44;8&#37;&#41; de iFR&#46; Em 222 casos &#40;55&#44;2&#37;&#41; a avalia&#231;&#227;o funcional foi efetuada somente por FFR e em 26 casos &#40;6&#44;5&#37;&#41; somente por iFR &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Figura 1</a>&#41;&#46; N&#227;o houve complica&#231;&#227;o decorrente do uso de adenosina&#46; Na <a class="elsevierStyleCrossRef" href="#tbl0005">Tabela 1</a> encontram&#8208;se resumidas as principais caracter&#237;sticas demogr&#225;ficas e cl&#237;nicas dos doentes na popula&#231;&#227;o global e consoante se tenha empregue apenas FFR&#44; iFR ou ambas as t&#233;cnicas &#40;por doente&#41;&#46; Verificou&#8208;se maior preval&#234;ncia de dislipidemia no grupo aferido apenas por iFR relativamente ao grupo em que apenas se fez FFR&#46; Observou&#8208;se maior preval&#234;ncia de hist&#243;ria pr&#233;via de enfarte &#40;quase a atingir significado estat&#237;stico&#44; p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;05&#41; e de ICP pr&#233;via &#40;p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;034&#41; no grupo submetido apenas a FFR <span class="elsevierStyleItalic">versus</span> o grupo em que ambas as t&#233;cnicas foram empregues&#46; N&#227;o se observaram outras diferen&#231;as entre os grupos&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0060" class="elsevierStylePara elsevierViewall">As medi&#231;&#245;es efetuadas no &#226;mbito de s&#237;ndrome coron&#225;ria aguda sem supradesnivelamento de ST referem&#8208;se a les&#245;es n&#227;o <span class="elsevierStyleItalic">culprit</span>&#44; foram efetuadas 48&#8208;72 horas ap&#243;s o quadro cl&#237;nico inicial&#46; Fizeram&#8208;se seis medi&#231;&#245;es de les&#245;es n&#227;o <span class="elsevierStyleItalic">culprit</span> no &#226;mbito de enfarte agudo do mioc&#225;rdio com supradesnivelamento de segmento ST&#44; todas na fase aguda&#46; Quatro dessas medi&#231;&#245;es foram feitas com ambas as t&#233;cnicas e duas com FFR apenas&#44; foi seguido para decis&#227;o o resultado do FFR&#46; Das quatro medi&#231;&#245;es de iFR&#44; tr&#234;s les&#245;es tinham um valor de 0&#44;9 &#40;dois casos com FFR positivo e um com FFR negativo&#41; e a outra les&#227;o um valor de 0&#44;88 &#40;com FFR de 0&#44;81&#41;&#46;</p><p id="par0065" class="elsevierStylePara elsevierViewall">Na <a class="elsevierStyleCrossRef" href="#tbl0010">Tabela 2</a> encontra&#8208;se a distribui&#231;&#227;o anat&#243;mica das les&#245;es avaliadas&#46;</p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0105">Acuidade diagn&#243;stica do iFR e FFR</span><p id="par0260" class="elsevierStylePara elsevierViewall">O iFR m&#233;dio foi de 0&#44;90<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>0&#44;1&#44; foi de &#62; 0&#44;93 em 60 casos &#40;33&#44;3&#37; do total de medi&#231;&#245;es de iFR&#41; e &#60; 0&#44;86 em 21 casos &#40;11&#44;7&#37; do total de medi&#231;&#245;es de iFR&#41;&#46; No subgrupo em que apenas se efetuou iFR todos os valores eram &#60; 0&#44;86 ou maiores do que 0&#44;93&#44; pelo que o c&#225;lculo de m&#233;dia e desvio padr&#227;o n&#227;o representa a sua distribui&#231;&#227;o &#40;&#250;nico subgrupo sem distribui&#231;&#227;o normal&#41;&#46; Nos casos que ambas as t&#233;cnicas foram usadas o valor m&#233;dio de iFR foi de 0&#44;9<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>0&#44;05&#46; O valor m&#233;dio de FFR na popula&#231;&#227;o global foi de 0&#44;82<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>0&#44;08&#44; n&#227;o se verificaram diferen&#231;as estatisticamente significativas entre o valor m&#233;dio de FFR nos casos em que apenas se executou essa t&#233;cnica &#40;0&#44;81<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>0&#44;09&#41; <span class="elsevierStyleItalic">versus</span> os casos em que ambas as t&#233;cnicas foram usadas &#40;0&#44;82<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>0&#44;07&#41;&#46; Na <a class="elsevierStyleCrossRef" href="#fig0010">Figura 2</a> encontra&#8208;se a distribui&#231;&#227;o dos valores de iFR e FFR globais&#46;</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0075" class="elsevierStylePara elsevierViewall">Verificaram&#8208;se uma correla&#231;&#227;o significativa &#40;moderada&#41; entre os valores de iFR e FFR &#40;R<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;504&#59; p &#60; 0&#44;001&#41; &#40;<a class="elsevierStyleCrossRef" href="#fig0015">Figura 3</a>&#41;&#44; como representado no gr&#225;fico de dispers&#227;o&#44; e boa concord&#226;ncia por an&#225;lise de Bland&#8208;Altman &#40;m&#233;dia de diferen&#231;a entre iFR e FFR 0&#44;085<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>0&#44;062 &#8211; <a class="elsevierStyleCrossRef" href="#fig0020">Figura 4</a>&#41;&#46;</p><elsevierMultimedia ident="fig0015"></elsevierMultimedia><elsevierMultimedia ident="fig0020"></elsevierMultimedia><p id="par0080" class="elsevierStylePara elsevierViewall">A acuidade diagn&#243;stica do iFR&#44; quer se aplique um <span class="elsevierStyleItalic">cut&#8208;off</span> de FFR como refer&#234;ncia de &#8804; 0&#44;80 ou de &#60; 0&#44;75&#44; respetivamente&#44; exibiu uma &#225;rea sob a curva &#40;AUC&#41; de 0&#44;73 &#40;IC95&#37; 0&#44;65&#8208;0&#44;81&#41; e 0&#44;72 &#40;IC95&#37; 0&#44;60&#8208;0&#44;84&#41; &#8211; vide <a class="elsevierStyleCrossRef" href="#fig0025">Figura 5</a>&#46;</p><elsevierMultimedia ident="fig0025"></elsevierMultimedia><p id="par0085" class="elsevierStylePara elsevierViewall">Verificou&#8208;se ainda que o valor de <span class="elsevierStyleItalic">cut&#8208;off</span> &#243;timo de iFR foi &#8804; 0&#44;91 quer para FFR &#8804; 0&#44;80 &#91;sensibilidade 55&#37;&#44; especificidade 79&#37;&#44; valor preditivo positivo &#40;VPP&#41; 52&#37;&#44; valor preditivo negativo &#40;VPN&#41; 81&#37;&#93;&#44; quer para FFR &#60; 0&#44;75 &#40;sensibilidade 47&#37;&#44; especificidade 89&#37;&#44; VPP 19&#37;&#44; VPN 97&#37;&#93;&#46;</p><p id="par0090" class="elsevierStylePara elsevierViewall">Adicionalmente&#44; verificou&#8208;se que para um FFR &#8804; 0&#44;80&#44; o intervalo de valor de iFR com uma sensibilidade e especificidade &#62; 90&#37; foi de 0&#44;88&#8211;0&#44;94&#59; para um FFR &#8804; 0&#44;75&#44; o intervalo de valor de iFR com uma sensibilidade e especificidade &#62; 90&#37; foi de 0&#44;87&#8211;0&#44;95&#46;</p></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0110">Impacto do resultado do iFR na decis&#227;o de proceder &#224; FFR e concord&#226;ncia de resultados</span><p id="par0265" class="elsevierStylePara elsevierViewall">Verificou&#8208;se que um resultado de iFR entre 0&#44;86 e 0&#44;93 se associou fortemente &#224; decis&#227;o de executar FFR &#40;X<span class="elsevierStyleSup">2</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>30&#44;1&#59; p &#60; 0&#44;001&#41; &#8211; tal ocorreu em 93 de 94 casos&#46; Nos casos em que o iFR n&#227;o se encontrou nesse intervalo&#44; optou&#8208;se por avaliar a les&#227;o por FFR em 55 &#40;69&#44;1&#37;&#41; dos casos&#46; N&#227;o se verificou diferen&#231;a na decis&#227;o de proceder a FFR nesse subgrupo entre os casos em que o resultado do iFR era &#60; 0&#44;86 <span class="elsevierStyleItalic">versus</span> &#62; 0&#44;93 &#40;71&#44;4&#37; <span class="elsevierStyleItalic">versus</span> 68&#37;&#59; p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;792&#41;&#46; Nesses casos&#44; verificou&#8208;se uma concord&#226;ncia estatisticamente significativa de 87&#44;3&#37; entre o resultado de iFR e FFR &#40;X<span class="elsevierStyleSup">2</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>22&#44;43&#59; p &#60; 0&#44;001&#41;&#46; N&#227;o obstante&#44; observou&#8208;se discord&#226;ncia dos dois m&#233;todos em quatro de 13 &#40;30&#44;8&#37;&#41; casos de iFR positivo com FFR negativo e tr&#234;s em 42 &#40;7&#44;1&#37;&#41; casos em que o iFR foi negativo e o FFR positivo&#44; essa diferen&#231;a foi estatisticamente significativa &#40;p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;026 &#8211; <a class="elsevierStyleCrossRef" href="#fig0030">Figura 6</a>&#41;&#46;</p><elsevierMultimedia ident="fig0030"></elsevierMultimedia><p id="par0100" class="elsevierStylePara elsevierViewall">Os casos de discrep&#226;ncia encontram&#8208;se detalhados na <a class="elsevierStyleCrossRef" href="#tbl0015">Tabela 3</a>&#46; Quatro casos ocorreram em medi&#231;&#245;es na descendente anterior &#40;num total de 25 medi&#231;&#245;es nesse vaso &#8211; 16&#37;&#41;&#44; duas em medi&#231;&#245;es na coron&#225;ria direita &#40;num total de 14 medi&#231;&#245;es nesse vaso &#8211; 14&#37;&#41; e uma em medi&#231;&#245;es na circunflexa &#40;num total de 15 medi&#231;&#245;es nesse vaso &#8211; 6&#44;7&#37;&#41;&#46; Apenas foi feita uma medi&#231;&#227;o com ambas as t&#233;cnicas no tronco comum&#44; n&#227;o se observou discord&#226;ncia&#46; Como &#233; vis&#237;vel&#44; nos casos de iFR negativo e FFR positivo&#44; os operadores optaram por seguir a indica&#231;&#227;o do FFR quando esse foi claramente inferior a 0&#44;80&#46; No caso 3&#44; a presen&#231;a de um valor lim&#237;trofe levou o operador a deferir interven&#231;&#227;o&#46; Nos casos em que o iFR foi positivo&#44; os operadores seguiram a indica&#231;&#227;o do FFR&#46;</p><elsevierMultimedia ident="tbl0015"></elsevierMultimedia></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0115">Concord&#226;ncia de resultados segundo o <span class="elsevierStyleItalic">cut&#8208;off</span> de iFR de 0&#44;89</span><p id="par0270" class="elsevierStylePara elsevierViewall">Com o uso desse <span class="elsevierStyleItalic">cut&#8208;off</span>&#44; 56 les&#245;es &#40;36&#44;4&#37;&#41; exibiram resultado positivo &#40;&#8804; 0&#44;89&#41; e 98 &#40;73&#44;6&#37;&#41; negativo &#40;&#62; 0&#44;89&#41;&#46; Observou&#8208;se uma concord&#226;ncia estatisticamente significativa de 72&#44;1&#37; &#40;p &#60; 0&#44;001&#41; entre as duas t&#233;cnicas&#46; N&#227;o se verificaram diferen&#231;as estatisticamente significativas entre os casos de iFR positivo com FFR negativo &#40;20 em 43 casos &#8211; 46&#44;5&#37;&#41; ou negativo &#40;23 em 43 casos &#8211; 53&#44;5&#37;&#41;&#46;</p></span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0120">Resultado da avalia&#231;&#227;o e decis&#227;o de tratamento</span><p id="par0275" class="elsevierStylePara elsevierViewall">A decis&#227;o de avan&#231;ar para revasculariza&#231;&#227;o foi tomada por cada operador para cada doente individual&#46;</p><p id="par0115" class="elsevierStylePara elsevierViewall">Nos 26 casos em que apenas se efetuou iFR&#44; todos os valores se encontravam fora da zona cinzenta &#40;sete casos &#60; 0&#44;86 e os restantes &#62; 0&#44;93&#41; e a decis&#227;o de revasculariza&#231;&#227;o foi tomada em concord&#226;ncia com o resultado do iFR&#46;</p><p id="par0120" class="elsevierStylePara elsevierViewall">Nos casos em que apenas se efetuou FFR&#44; a decis&#227;o de tratamento foi feita de acordo com o resultado de FFR &#40;<span class="elsevierStyleItalic">cut&#8208;off</span> de 0&#44;80&#41; em 97&#44;7&#37; dos casos&#46; Nos restantes casos &#40;2&#44;3&#37;&#41; o operador atuou em disson&#226;ncia consoante os restantes dados adicionais de que dispunha &#40;caracter&#237;sticas da les&#227;o&#44; sintomas e resultados de testes n&#227;o invasivos de isquemia&#41;&#46;</p><p id="par0125" class="elsevierStylePara elsevierViewall">Nos casos em que se efetuaram ambas as t&#233;cnicas&#44; os operadores seguiram os resultados sempre que existiu concord&#226;ncia entre as duas t&#233;cnicas&#46; Os casos em que existiu discord&#226;ncia foram j&#225; abordados &#40;<a class="elsevierStyleCrossRef" href="#tbl0015">tabela 3</a>&#41;&#46;</p></span><span id="sec0060" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0125">Efeito da estrat&#233;gia usada no tempo de procedimento&#44; fluoroscopia e radia&#231;&#227;o</span><p id="par0280" class="elsevierStylePara elsevierViewall">Relativamente &#224; dose&#47;tempo de radia&#231;&#227;o&#44; tempo de procedimento&#44; n&#227;o se verificaram diferen&#231;as estatisticamente significativas entre os doentes que fizeram apenas iFR <span class="elsevierStyleItalic">versus</span> apenas FFR&#44; nem entre os grupos que efetuaram iFR mais FFR e aqueles que apenas foram submetidos a uma das t&#233;cnicas &#40;<a class="elsevierStyleCrossRef" href="#tbl0020">Tabela 4</a>&#41;&#46;</p><elsevierMultimedia ident="tbl0020"></elsevierMultimedia></span><span id="sec0065" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0130">Impacto no uso de adenosina</span><p id="par0285" class="elsevierStylePara elsevierViewall">Considerando apenas os doentes submetidos a iFR &#40;num total de 147&#44; isoladamente ou no &#226;mbito do uso de ambas as t&#233;cnicas&#41;&#44; verificou&#8208;se que o n&#250;mero de doentes em que todas as les&#245;es aferidas &#40;uma ou mais&#41; tinham um valor de iFR conclusivo &#40;fora do intervalo 0&#44;86&#8211;0&#44;93&#41; de 55 &#40;37&#44;4&#37;&#41;&#46; Desse modo&#44; seguindo a premissa da estrat&#233;gia h&#237;brida&#44; teria sido evitado o uso da adenosina nesses doentes&#46;</p></span></span><span id="sec0070" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0135">Discuss&#227;o</span><span id="sec0075" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0140">Desempenho do iFR considerando o FFR como <span class="elsevierStyleItalic">gold standard</span></span><p id="par0290" class="elsevierStylePara elsevierViewall">Neste registo&#44; o iFR exibiu uma acuidade diagn&#243;stica e concord&#226;ncia com o FFR razo&#225;veis&#44; todavia com algumas diferen&#231;as relativamente aos estudos previamente publicados&#46; O <span class="elsevierStyleItalic">cut&#8208;off</span> ideal nesta amostra foi ligeiramente superior ao publicado noutros estudos &#40;0&#44;91 <span class="elsevierStyleItalic">versus</span> 0&#44;89<a class="elsevierStyleCrossRefs" href="#bib0035"><span class="elsevierStyleSup">7&#44;13</span></a>&#41;&#44; qualquer que fosse o valor de FFR usado como padr&#227;o&#46; Adicionalmente&#44; a acuidade diagn&#243;stica foi inferior &#224; publicada noutros estudos&#44; cuja AUC variou entre 0&#44;86 e 0&#44;90<a class="elsevierStyleCrossRefs" href="#bib0035"><span class="elsevierStyleSup">7&#44;13&#44;14</span></a>&#44; mas superior &#224;quela observada no estudo VERIFY<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">15</span></a>&#46; Tamb&#233;m a correla&#231;&#227;o entre os resultados iFR e o FFR foi inferior aos previamente publicados &#40;0&#44;504 <span class="elsevierStyleItalic">versus</span> 0&#44;81 no estudo ADVISE II<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a>&#41;&#46; Esses resultados poder&#227;o refletir um efeito de dimens&#227;o de amostra&#44; inferior &#224; dos estudos publicados&#44; e tamb&#233;m um eventual vi&#233;s de sele&#231;&#227;o decorrente do estudo se tratar de um registo&#46; Os operadores poder&#227;o ter optado pela estrat&#233;gia de empregar ambas as medi&#231;&#245;es em casos particularmente lim&#237;trofres&#44; como se pode observar pelo facto de os valores m&#233;dios de iFR serem muito pr&#243;ximos dos valores de diagn&#243;stico empregues no DEFINE&#8208;FLAIR<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a> e no iFR SWEDEHEART<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">12</span></a> &#40;0&#44;89&#41;&#46; &#201; de destacar&#44; em particular&#44; que nos casos em que o operador come&#231;a por efetuar iFR e posteriormente opta por confirmar o resultado por FFR o valor n&#227;o s&#243; era lim&#237;trofe como o desvio padr&#227;o muito pequeno &#40;0&#44;05&#41;&#46;</p></span><span id="sec0080" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0145">Concord&#226;ncia entre iFR&#47;FFR e implica&#231;&#245;es pr&#225;ticas para o quotidiano</span><p id="par0295" class="elsevierStylePara elsevierViewall">Quando aplicado o racional da estrat&#233;gia h&#237;brida<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a>&#44; o iFR exibiu uma elevada concord&#226;ncia dentro dos intervalos diagn&#243;sticos &#40;&#60; 0&#44;86 e &#62; 0&#44;93&#41;&#46; Esse resultado foi similar a outros previamente publicados&#44; embora ligeiramente inferior &#8211; 87&#37; <span class="elsevierStyleItalic">versus</span> 91&#44;6&#37;<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a>&#46; Quando aplicado o <span class="elsevierStyleItalic">cut&#8208;off</span> de 0&#44;89&#44; o grau de concord&#226;ncia foi tamb&#233;m inferior ao previamente publicado &#40;72&#44;1&#37; <span class="elsevierStyleItalic">versus</span> 82&#44;5&#37;<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a>&#41;&#44; fruto de esse n&#227;o ter sido o <span class="elsevierStyleItalic">cut&#8208;off</span> ideal com melhor acuidade diagn&#243;stica nesta amostra &#40;o que limita a valoriza&#231;&#227;o desse resultado em particular&#41; e das limita&#231;&#245;es supracitadas&#46;</p><p id="par0150" class="elsevierStylePara elsevierViewall">N&#227;o obstante os bons resultados da estrat&#233;gia h&#237;brida neste registo&#44; o grau de discrep&#226;ncia entre as duas t&#233;cnicas n&#227;o &#233; negligenci&#225;vel&#46; Em caso de discrep&#226;ncia entre o resultado de iFR e FFR&#44; os operadores seguiram tendencialmente as recomenda&#231;&#245;es internacionais ent&#227;o vigentes<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a>&#44; usaram o FFR como <span class="elsevierStyleItalic">gold standard</span>&#46; &#201; relevante salientar que&#44; em caso de discord&#226;ncia&#44; predominaram os casos em que o iFR era positivo e o FFR negativo&#44; dados que v&#227;o no sentido de outros estudos publicados<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a>&#46; Assim&#44; sobretudo em casos lim&#237;trofes&#44; poder&#225; ser&#225; particularmente relevante o operador considerar proceder a FFR&#44; nomeadamente em casos de iFR positivo&#46;</p><p id="par0155" class="elsevierStylePara elsevierViewall">A recente publica&#231;&#227;o dos resultados do DEFINE&#8208;FLAIR<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a> e do iFR&#8208;SWEDEHEART<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a> traz&#44; pela primeira vez&#44; um n&#237;vel elevado de evid&#234;ncia a favor da tomada de decis&#245;es baseadas apenas com um valor de iFR &#8804; 0&#44;89&#46; E apesar da recente apresenta&#231;&#227;o do estudo FUTURE<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">16</span></a>&#44; a experi&#234;ncia acumulada com o FFR e a extensa literatura publicada relativamente a essa t&#233;cnica n&#227;o podem ser ignoradas&#46; Assim&#44; se existem agora ensaios cl&#237;nicos aleatorizados multic&#234;ntricos de grande dimens&#227;o a favor do uso de ambas as t&#233;cnicas&#44; imp&#245;em&#8208;se duas quest&#245;es essenciais&#58; &#40;1&#41; o que fazer se os resultados do FFR e do iFR forem discordantes&#63; &#40;2&#41; Dever&#225; ser usada apenas uma das t&#233;cnicas e&#44; se sim&#44; deve uma delas ser usada preferencialmente&#63;</p><p id="par0160" class="elsevierStylePara elsevierViewall">Como n&#227;o existe uma resposta definitiva e consensual a essas quest&#245;es&#44; importa tecer algumas considera&#231;&#245;es no sentido de tomar a melhor decis&#227;o poss&#237;vel em cada caso&#46;</p><p id="par0165" class="elsevierStylePara elsevierViewall">Em primeiro lugar&#44; o operador deve certificar&#8208;se de que a execu&#231;&#227;o da t&#233;cnica foi apropriada&#44; i&#46;e&#46;&#44; que o posicionamento&#44; calibre e tipo de cateter s&#227;o os adequados &#40;evitam&#8208;se assim fen&#243;menos de atenua&#231;&#227;o&#47;distor&#231;&#227;o de curvas de press&#227;o&#41; e que a calibra&#231;&#227;o das press&#245;es foi adequada &#40;garante&#8208;se a sobreposi&#231;&#227;o temporal e quantitativa integral das curvas&#44; sincronizada com o eletrocardiograma&#41;&#46; Embora ambos as t&#233;cnicas sejam influenciadas por esses fatores&#44; uma execu&#231;&#227;o incorreta pode falsear desequilibradamente uma das medi&#231;&#245;es relativamente &#224; outra&#46; Por exemplo&#44; no caso da medi&#231;&#227;o do iFR&#44; uma sincroniza&#231;&#227;o desadequada com o eletrocardiograma pode levar a uma medi&#231;&#227;o temporalmente imprecisa do Pd&#47;Pa&#44; incorporam&#8208;se valores n&#227;o diast&#243;licos ou parcialmente diast&#243;licos na medi&#231;&#227;o do iFR&#46; Deve ainda ser tida em considera&#231;&#227;o a possibilidade de descalibra&#231;&#227;o do sistema &#40;<span class="elsevierStyleItalic">pressure drift</span>&#41;&#44; deve idealmente o operador confirmar a sobreposi&#231;&#227;o de curvas antes de concluir o procedimento&#44; reposicionar o fio proximalmente&#46; Por &#250;ltimo&#44; &#233; de referir que a medi&#231;&#227;o de iFR &#233; ainda exclusiva do sistema Volcano Philips &#40;e todos os casos de iFR foram feitos com esse sistema e respetivo fio&#8208;guia&#41;&#44; pelo que tentativas de medi&#231;&#227;o com outros sistemas s&#227;o ainda <span class="elsevierStyleItalic">off&#8208;label</span>&#46; Neste registo&#44; &#233; relevante salientar que o centro e todos os seus operadores estavam j&#225; amplamente versados no uso de FFR&#44; pelo que os autores entendem que a ocorr&#234;ncia de imperfei&#231;&#245;es na t&#233;cnica ter&#225; sido baixa&#46; N&#227;o obstante&#44; sobretudo na fase de implanta&#231;&#227;o do iFR&#44; n&#227;o &#233; poss&#237;vel excluir em absoluto a ocorr&#234;ncia de imperfei&#231;&#245;es&#46; A confirma&#231;&#227;o da aus&#234;ncia de <span class="elsevierStyleItalic">pressure drift</span>&#44; embora pr&#225;tica corrente no centro&#44; n&#227;o foi registada&#46; Do mesmo modo&#44; embora n&#227;o se aceitassem medi&#231;&#245;es cujo tra&#231;ado electrocardiogr&#225;fico fosse sub&#243;timo e tenha sido raro o uso da t&#233;cnica em doentes com fibrilha&#231;&#227;o&#47;<span class="elsevierStyleItalic">flutter</span> auricular &#40;nenhum dos doentes em quem se observou discord&#226;ncia tinha esse ritmo&#41;&#44; n&#227;o &#233; poss&#237;vel excluir em absoluto que o ritmo possa ter influenciado os resultados&#46;</p><p id="par0170" class="elsevierStylePara elsevierViewall">Excluindo falhas na execu&#231;&#227;o da t&#233;cnica&#44; &#233; necess&#225;rio fazer uma reflex&#227;o sobre a fisiologia do que se est&#225; a medir&#46; Sendo o FFR uma medi&#231;&#227;o dependente de hiperemia m&#225;xima&#44; a resposta observada pode ser influenciada pelo f&#225;rmaco usado &#40;alguns centros usam vasodilatadores que n&#227;o a adenosina&#41; e a via de administra&#231;&#227;o<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">17</span></a>&#44; pelo efeito vasodilatador do pr&#243;prio contraste<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">18</span></a>&#44; pela presen&#231;a de disfun&#231;&#227;o microcirculat&#243;ria concomitante<a class="elsevierStyleCrossRefs" href="#bib0095"><span class="elsevierStyleSup">19&#44;20</span></a> e pelo efeito vasodilatador sist&#233;mico da adenosina&#46; &#201; tamb&#233;m sabido que a pr&#243;pria resposta&#44; quer na micro e macro circula&#231;&#227;o coron&#225;ria&#44; quer sist&#233;mica&#44; pode exibir variabilidade interindividual &#40;nomeadamente em casos de s&#237;ndrome coron&#225;ria aguda&#41;&#46; Por &#250;ltimo&#44; importa ainda referir que o valor de FFR em <span class="elsevierStyleItalic">steady&#8208;state</span> muitas vezes n&#227;o corresponde ao nadir&#44; deve ser usado o primeiro<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">21</span></a>&#46; Neste registo&#44; o valor considerado correspondeu ao valor <span class="elsevierStyleItalic">steady&#8208;state</span>&#46; Nos casos de discord&#226;ncia segundo a estrat&#233;gia h&#237;brida&#44; ocorreram cinco casos em contexto de angina est&#225;vel e dois de s&#237;ndrome coron&#225;ria aguda&#44; ambos casos de angina inst&#225;vel&#44; pelo que o contexto cl&#237;nico provavelmente teve pouca influ&#234;ncia nos casos de discord&#226;ncia&#46;</p><p id="par0175" class="elsevierStylePara elsevierViewall">Importa tamb&#233;m ter em considera&#231;&#227;o as limita&#231;&#245;es que norteiam o uso do iFR&#46; Embora o iFR n&#227;o esteja&#44; teoricamente&#44; limitado pelos fen&#243;menos de hiperemia&#44; alguns autores refutam essa premissa e alegam adicionalmente que a acuidade diagn&#243;stica desse &#237;ndice &#233; inferior &#224; publicada noutros estudos<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">15</span></a>&#46; Adicionalmente&#44; &#233; necess&#225;rio ter em considera&#231;&#227;o que os ensaios aleatorizados recentemente publicados t&#234;m alguma escassez de eventos e que foram estudos de n&#227;o inferioridade&#44; cuja margem era relativamente elevada&#44; como os pr&#243;prios autores reconhecem<a class="elsevierStyleCrossRefs" href="#bib0045"><span class="elsevierStyleSup">9&#44;10</span></a>&#46;</p><p id="par0180" class="elsevierStylePara elsevierViewall">Por &#250;ltimo&#44; alguns autores sugerem que a discrep&#226;ncia entre os dois m&#233;todos &#233; mais acentuada em les&#245;es que envolvam a descendente anterior<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">22</span></a>&#44; particularmente no segmento proximal<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">23</span></a>&#46; Os resultados do presente registo&#44; em virtude do reduzido n&#250;mero de casos de discrep&#226;ncia por vaso&#44; n&#227;o permitem tirar conclus&#245;es a respeito do impacto do vaso&#47;segmento envolvido&#46; Com efeito&#44; mesmo na descendente anterior&#44; existiram apenas quatro casos de discrep&#226;ncia e a percentagem de discord&#226;ncia nesse vaso e na coron&#225;ria direita foi id&#234;ntica&#46;</p><p id="par0185" class="elsevierStylePara elsevierViewall">Desse modo&#44; os resultados deste registo&#44; incorporados na literatura dispon&#237;vel at&#233; &#224; data&#44; sugerem que o iFR e o FFR s&#227;o&#44; acima de tudo&#44; m&#233;todos complementares na avalia&#231;&#227;o de les&#245;es coron&#225;rias&#44; n&#227;o s&#227;o mutuamente exclusivos&#46; A avalia&#231;&#227;o inicial apenas por iFR parece ser a estrat&#233;gia mais &#243;bvia pela sua simplicidade e rapidez de execu&#231;&#227;o&#46; Todavia&#44; as limita&#231;&#245;es dos estudos supracitados aconselham prud&#234;ncia&#44; pelo que os operadores devem&#44; em caso de d&#250;vida&#44; considerar proceder &#224; medi&#231;&#227;o de FFR tamb&#233;m&#46; A concord&#226;ncia dos dois &#237;ndices ser&#225; um indicador substancial na tomada de decis&#227;o de intervir ou n&#227;o&#46; Em caso de discrep&#226;ncia&#44; &#233; essencial tentar compreender o motivo dela&#44; a fim de decidir se um dos resultados ter&#225;&#44; para uma les&#227;o e doente individual&#44; maior validade&#46; Caso n&#227;o seja claro qual o motivo da discrep&#226;ncia&#44; n&#227;o deve ser descurado o uso adicional de m&#233;todos de imagem invasivos e&#47;n&#227;o invasivos na tomada da decis&#227;o final&#44; sobretudo tendo em considera&#231;&#227;o que&#44; at&#233; &#224; data&#44; essas t&#233;cnica est&#227;o validadas essencialmente para a doen&#231;a coron&#225;ria est&#225;vel&#46;</p></span><span id="sec0085" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0150">Impacto do iFR no tempo de procedimento&#44; fluroscopia e dose de radia&#231;&#227;o</span><p id="par0300" class="elsevierStylePara elsevierViewall">Para al&#233;m do n&#227;o uso de adenosina&#44; uma das vantagens te&#243;ricas do FFR &#233; a eventual redu&#231;&#227;o do tempo do procedimento&#46; N&#227;o obstante&#44; existe grande escassez de dados publicados sobre o impacto do uso de iFR nesse par&#226;metro&#46; Apesar de no estudo DEFINE&#8208;FLAIR<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a> se verificar uma redu&#231;&#227;o significativa de quatro minutos e 30 segundos com o uso do iFR&#44; essa redu&#231;&#227;o n&#227;o foi significativa no iFR&#8208;SWEDEHEART<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a>&#46; &#192; semelhan&#231;a desse &#250;ltimo&#44; nos resultados deste registo&#44; a t&#233;cnica n&#227;o exibiu impacto nesse nem noutros fatores &#40;dose de radia&#231;&#227;o e tempo de fluoroscopia&#41;&#46; Esse facto tamb&#233;m poderia ser explicado pela presen&#231;a de diferen&#231;as significativas entre os doentes estudados&#44; no sentido de que o operador poderia ter optado por uma t&#233;cnica mais simples em casos mais graves&#46; N&#227;o obstante&#44; quase n&#227;o se observaram diferen&#231;as estatisticamente significativas entre os grupos e aquelas observadas foram pequenas&#44; com significado estat&#237;stico pouco forte&#44; diferen&#231;as absolutas e relativas pequenas e pouca relev&#226;ncia cl&#237;nica&#44; n&#227;o parece ter existido rela&#231;&#227;o com as escolhas dos operadores&#46; Adicionalmente&#44; foram muito poucos os doentes que s&#243; fizeram iFR&#44; o que tamb&#233;m limita compara&#231;&#245;es entre grupos&#46; Tamb&#233;m &#233; preciso ter em considera&#231;&#227;o que em cada um desses grupos se aferiu por vezes mais do que uma les&#227;o&#44; o que pode contribuir para as diferen&#231;as num&#233;ricas entre grupos&#44; ainda que sem significado estat&#237;stico&#46; Por &#250;ltimo&#44; a salientar que a aparente discrep&#226;ncia entre a dose de radia&#231;&#227;o e o tempo de procedimento &#40;i&#46;e&#46; entre grupos&#44; verificou&#8208;se que ao aumento de tempo de fluroscopia n&#227;o se associou aumento da dose de radia&#231;&#227;o&#44; embora essa diferen&#231;a seja apenas num&#233;rica&#44; e n&#227;o estat&#237;stica&#41; decorre do uso de <span class="elsevierStyleItalic">frame rates</span> diferentes entre operadores&#44; pelo que para um mesmo tempo de fluoroscopia nem sempre se verificou a mesma dose de radia&#231;&#227;o&#46; Por esse motivo se optou pela apresenta&#231;&#227;o de ambos os dados&#46;</p></span><span id="sec0090" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0155">Impacto no uso de adenosina</span><p id="par0305" class="elsevierStylePara elsevierViewall">No presente registo o uso do iFR ficou a crit&#233;rio dos operadores&#46; Nesse sentido&#44; e sobretudo na fase inicial da t&#233;cnica&#44; era comum o uso das duas t&#233;cnicas&#46; Desse modo&#44; a taxa de uso de adenosina foi muito elevada&#46; Conforme explicitado nos resultados&#44; caso fosse seguida a premissa da estrat&#233;gia h&#237;brida&#44; teria sido poss&#237;vel evitar o uso de adenosina em quase 40&#37; dos doentes&#46; Esse valor &#233;&#44; ainda assim&#44; inferior ao verificado noutros estudos&#44; nomeadamente o ADVISE II<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a> &#40;65&#44;1&#37; de evic&#231;&#227;o de adenosina&#41;&#46; A diferen&#231;a desses n&#250;meros prende&#8208;se com o car&#225;cter observacional do estudo&#44; que condicionou a aus&#234;ncia de um crit&#233;rio uniforme para a sele&#231;&#227;o das t&#233;cnicas&#44; e&#44; como j&#225; mencionado&#44; e com um poss&#237;vel vi&#233;s de sele&#231;&#227;o para casos com valores de iFR tendencialmente lim&#237;trofes&#46;</p></span><span id="sec0095" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0160">Limita&#231;&#245;es</span><p id="par0310" class="elsevierStylePara elsevierViewall">As discrep&#226;ncias entre os resultados deste estudo de outros publicados poder&#227;o ser&#44; em parte&#44; consequ&#234;ncia das caracter&#237;sticas do estudo&#46; Com efeito&#44; este foi um registo&#44; e n&#227;o um ensaio cl&#237;nico aleatorizado&#46; Desse modo&#44; a decis&#227;o de proceder &#224; iFR ou FFR ficou inteiramente ao crit&#233;rio do operador&#46; Adicionalmente&#44; um registo n&#227;o tem o mesmo rigor metodol&#243;gico de um ensaio cl&#237;nico&#44; &#233; poss&#237;vel que alguns resultados finais possam ter sido em parte afetados por imperfei&#231;&#245;es t&#233;cnicas&#44; especialmente durante a fase inicial de implanta&#231;&#227;o da t&#233;cnica do iFR&#44; tal como previamente mencionado&#46;</p><p id="par1240" class="elsevierStylePara elsevierViewall">Por &#250;ltimo&#44; a an&#225;lise efetuada com o <span class="elsevierStyleItalic">cut&#8208;off</span> de 0&#44;89 proposto no DEFINE&#8208;FLAIR e iFR&#8208;SWEDEHEART<a class="elsevierStyleCrossRefs" href="#bib0045"><span class="elsevierStyleSup">9&#44;10</span></a> encontra&#8208;se limitada pelo facto de n&#227;o ter sido esse o <span class="elsevierStyleItalic">cut&#8208;off</span> com melhor acuidade diagn&#243;stica neste estudo&#44; pela dimens&#227;o da amostra e por eventual vi&#233;s de sele&#231;&#227;o&#44; conforme referido&#46;</p><p id="par0210" class="elsevierStylePara elsevierViewall">Por &#250;ltimo&#44; foram inclu&#237;dos doentes com s&#237;ndrome coron&#225;ria aguda&#44; n&#227;o &#233; poss&#237;vel excluir que esses possam ter influenciado os resultados&#46; Todavia&#44; as medi&#231;&#245;es efetuadas no &#226;mbito de s&#237;ndrome coron&#225;ria aguda sem supradesnivelamento de ST ocorreram 48&#8208;72 horas ap&#243;s o quadro inicial&#44; conforme efetuado noutros estudos de refer&#234;ncia<a class="elsevierStyleCrossRefs" href="#bib0045"><span class="elsevierStyleSup">9&#44;12</span></a>&#44; reduziu&#8208;se assim a probabilidade de interfer&#234;ncia nos resultados&#46; Foram efetuadas seis medi&#231;&#245;es no &#226;mbito da fase aguda do enfarte agudo do mioc&#225;rdio com supradesnivelamento de ST&#46; Embora existam muito recentemente dados publicados com n&#237;vel de evid&#234;ncia m&#225;xima &#40;ensaio aleatorizado&#41; sobre o uso de FFR nesse contexto<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">24</span></a>&#44; o seu uso ainda n&#227;o &#233; consensual &#40;&#224; &#233;poca do registo a evid&#234;ncia era observacional e a premissa te&#243;rica&#41; e o uso de iFR nesse contexto &#233; <span class="elsevierStyleItalic">off&#8208;label</span>&#46; N&#227;o obstante&#44; &#40;1&#41; os resultados de iFR obtidos foram sempre lim&#237;trofes&#44; &#40;2&#41; n&#227;o constitu&#237;ram casos de discord&#226;ncia segundo a estrat&#233;gia h&#237;brida&#44; &#40;3&#41; foram absoluta e relativamente muito pequenos no contexto da amostra total e &#40;4&#41; foi sempre seguida a premissa do FFR&#44; evitou&#8208;se o tratamento de les&#245;es sem indica&#231;&#227;o para interven&#231;&#227;o &#40;uma vez que nesse contexto a tend&#234;ncia do FFR &#233; subestimar a gravidade de les&#227;o&#41;&#46; Desse modo&#44; os autores n&#227;o creem que os casos de s&#237;ndrome coron&#225;ria aguda tenham influenciado de forma importante os resultados&#46;</p></span></span><span id="sec0100" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0165">Conclus&#227;o</span><p id="par0315" class="elsevierStylePara elsevierViewall">O iFR apresentou uma acuidade diagn&#243;stica e concord&#226;ncia com o FFR razo&#225;veis&#44; todavia inferiores ao descrito na maioria dos estudos&#46; Os valores com melhor acuidade diagn&#243;stica foram similares aos descritos na literatura&#44; embora ligeiramente superiores&#46; O uso de um <span class="elsevierStyleItalic">cut&#8208;off</span> de FFR de &#60; 0&#44;75 em detrimento de &#8804; 0&#44;80 teve um impacto negativo&#44; mas muito pequeno&#44; no desempenho diagn&#243;stico do iFR&#46;</p><p id="par0220" class="elsevierStylePara elsevierViewall">Aplicando a estrat&#233;gia h&#237;brida&#44; o iFR foi frequentemente inconclusivo&#46; Nos casos conclusivos&#44; verificou&#8208;se boa concord&#226;ncia entre os resultados de iFR e FFR&#46; Todavia&#44; existiu uma percentagem relevante de casos de discord&#226;ncia&#44; particularmente nas avalia&#231;&#245;es classificadas como positivas por iFR e negativas por FFR&#46;</p><p id="par0225" class="elsevierStylePara elsevierViewall">O uso de iFR n&#227;o teve impacto significativo na dose&#47;tempo de radia&#231;&#227;o e tempo de procedimento&#44; mas poderia ter resultado numa redu&#231;&#227;o muito significativa do uso de adenosina caso se aplique a premissa da estrat&#233;gia h&#237;brida&#46;</p><p id="par0230" class="elsevierStylePara elsevierViewall">Apesar da simplicidade de execu&#231;&#227;o e utilidade do iFR&#44; os resultados deste registo sugerem que devem ser interpretados de forma prudente&#44; n&#227;o excluir sistematicamente o uso do FFR&#46; No entanto&#44; ser&#225; bom referir que ambas as metodologias podem ter zonas &#171;cinzentas&#187; &#40;i&#46;e&#46; de interpreta&#231;&#227;o n&#227;o inequ&#237;voca&#41; n&#227;o desprez&#237;veis&#44; pelo que o uso de outros m&#233;todos invasivos ou n&#227;o invasivos para a avalia&#231;&#227;o da doen&#231;a coron&#225;ria deve ser sempre considerado&#46;</p></span><span id="sec0105" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0170">Conflitos de interesse</span><p id="par0320" class="elsevierStylePara elsevierViewall">Os autores declaram n&#227;o haver conflitos de interesse&#46;</p></span></span>"
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              "titulo" => "Procedimento de medi&#231;&#227;o de FFR e iFR"
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              "titulo" => "Caracter&#237;sticas da popula&#231;&#227;o e procedimento"
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              "titulo" => "Acuidade diagn&#243;stica do iFR e FFR"
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              "identificador" => "sec0045"
              "titulo" => "Impacto do resultado do iFR na decis&#227;o de proceder &#224; FFR e concord&#226;ncia de resultados"
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              "identificador" => "sec0050"
              "titulo" => "Concord&#226;ncia de resultados segundo o cut&#8208;off de iFR de 0&#44;89"
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              "titulo" => "Resultado da avalia&#231;&#227;o e decis&#227;o de tratamento"
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              "titulo" => "Desempenho do iFR considerando o FFR como gold standard"
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              "titulo" => "Impacto do iFR no tempo de procedimento&#44; fluroscopia e dose de radia&#231;&#227;o"
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              "identificador" => "sec0090"
              "titulo" => "Impacto no uso de adenosina"
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            2 => "Avalia&#231;&#227;o funcional invasiva de les&#245;es coron&#225;rias"
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            2 => "EAM"
            3 => "EAMcSST"
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            5 => "FFR"
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    "resumen" => array:2 [
      "pt" => array:3 [
        "titulo" => "Resumo"
        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Introdu&#231;&#227;o e objetivos</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">A avalia&#231;&#227;o de les&#245;es coron&#225;rias pelo <span class="elsevierStyleItalic">instantaneous wave free ratio</span> &#40;iFR&#41; tem gerado debate&#46; Pretendeu&#8208;se analisar o desempenho diagn&#243;stico do iFR e o seu impacto na decis&#227;o de usar o <span class="elsevierStyleItalic">fractional flow reserve</span> &#40;FFR&#41; e nas caracter&#237;sticas do procedimento&#46;</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">M&#233;todos</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Registo unic&#234;ntrico de doentes submetidos a avalia&#231;&#227;o funcional de les&#245;es coron&#225;rias&#46; O desempenho do iFR foi aferido com o FFR como refer&#234;ncia&#46; Valores de iFR<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#44;86 e &#62; 0&#44;93 foram considerados positivos e negativos&#44; respetivamente&#46;</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Resultados</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Avaliaram&#8208;se 402 les&#245;es&#44; em 154 casos com ambas as t&#233;cnicas&#44; em 222 apenas com FFR e 26 apenas com iFR&#46; Com um limiar de FFR &#8804; 0&#44;80&#44; a &#225;rea sob a curva foi de 0&#44;73 &#40;95&#37; IC 0&#44;65&#8208;0&#44;81&#41; &#8211; valor &#243;timo de iFR &#8804; 0&#44;91&#46; Efetuou&#8208;se FFR em 93 de 94 les&#245;es inconclusivas por iFR e em 69&#44;1&#37; dos restantes casos aferidos com iFR&#46; O iFR e o FFR foram concordantes em 87&#37; dos casos &#40;X<span class="elsevierStyleSup">2</span><span class="elsevierStyleHsp" style=""></span>&#61;22&#44;43&#59; p<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#44;001&#41;&#46; N&#227;o obstante&#44; verificaram&#8208;se quatro em 13 casos &#40;30&#44;7&#37;&#41; de iFR positivo e FFR negativo e tr&#234;s em 42 casos &#40;7&#44;1&#37;&#41; de iFR negativo e FFR positivo&#46; Essa diferen&#231;a foi estatisticamente significativa &#40;p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;026&#41;&#46; O iFR n&#227;o teve impacto na dura&#231;&#227;o&#44; dose&#47;tempo de radia&#231;&#227;o do procedimento&#46;</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Conclus&#245;es</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">O desempenho diagn&#243;stico do iFR foi razo&#225;vel&#46; Os operadores habitualmente efetuaram FFR apesar de valores conclusivos de iFR&#46; Verificou&#8208;se elevada concord&#226;ncia&#44; mas com uma propor&#231;&#227;o n&#227;o negligenci&#225;vel de les&#245;es classificadas como isqu&#233;micas por iFR e n&#227;o isqu&#233;micas por FFR&#46; O iFR n&#227;o teve impacto nas caracter&#237;sticas do procedimento&#46;</p></span>"
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            "identificador" => "abst0005"
            "titulo" => "Introdu&#231;&#227;o e objetivos"
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          1 => array:2 [
            "identificador" => "abst0010"
            "titulo" => "M&#233;todos"
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        "titulo" => "Abstract"
        "resumen" => "<span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Introduction and Objective</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Assessment of coronary lesions by the instantaneous wave free ratio &#40;iFR&#41; has generated significant debate&#46; We aimed to assess the diagnostic performance of iFR and its impact on the decision to use fractional flow reserve &#40;FFR&#41; and on procedural characteristics&#46;</p></span> <span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Methods</span><p id="spar0105" class="elsevierStyleSimplePara elsevierViewall">In this single&#8208;center registry of patients undergoing functional assessment of coronary lesions&#44; FFR was used as a reference for assessing the diagnostic performance of iFR&#46; An iFR value &#60;0&#46;86 was considered positive and a value &#62;0&#46;93 was considered negative&#46;</p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Results</span><p id="spar0110" class="elsevierStyleSimplePara elsevierViewall">Functional testing was undertaken of 402 lesions&#44; of which 154 were assessed with both techniques&#44; 222 with FFR only&#44; and 26 with iFR only&#46; Using a cut&#8208;off of &#8804;0&#46;80 for iFR&#44; the area under the curve was 0&#46;73 &#40;95&#37; CI 0&#46;65&#8208;0&#46;81&#41;&#44; with an optimal value of &#8804;0&#46;91&#46; FFR was undertaken in 93 out of 94 lesions with an inconclusive iFR and was performed in 69&#46;1&#37; of the remaining iFR&#8208;tested lesions&#46; Concordance between iFR and FFR was 87&#37; &#40;chi&#8208;square&#61;22&#46;43&#59; p&#60;0&#46;001&#41;&#46; Notwithstanding&#44; there were four out of 13 cases &#40;30&#46;7&#37;&#41; of positive iFR with negative FFR and three out of 42 &#40;7&#46;1&#37;&#41; cases of negative iFR and positive FFR&#46; This difference was significant &#40;p&#61;0&#46;026&#41;&#46; iFR had no impact on procedure time&#44; fluoroscopy time or radiation dose&#46;</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Conclusion</span><p id="spar0115" class="elsevierStyleSimplePara elsevierViewall">iFR had a reasonable diagnostic performance&#46; Operators often chose to perform FFR despite conclusive iFR results&#46; iFR and FFR were highly concordant&#44; but a non&#8208;negligible proportion of lesions classified as ischemic by iFR were classified as non&#8208;ischemic by FFR&#46; iFR had no impact on procedural characteristics&#46;</p></span>"
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          "pt" => "<p id="spar0065" class="elsevierStyleSimplePara elsevierViewall">Curvas ROC de iFR considera como refer&#234;ncia diferentes valores de FFR &#40;&#8804; 0&#44;80 e &#60; 0&#44;75&#41;&#46;</p>"
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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">&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">Global M&#233;dia<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>DP ou n &#40;&#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">iFR apenas&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">FFR apenas&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">H&#237;brida&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">p para iFR apenas <span class="elsevierStyleItalic">vs</span> FFR apenas&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">p para iFR apenas <span class="elsevierStyleItalic">vs</span> h&#237;brida&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">p para FFR apenas <span class="elsevierStyleItalic">vs</span> h&#237;brida&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</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">9 &#40;2&#44;8&#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" style="border-bottom: 2px solid black">179 &#40;54&#44;9&#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" style="border-bottom: 2px solid black">138 &#40;42&#44;3&#41;&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="" 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></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry  " colspan="8" align="left" valign="top"><span class="elsevierStyleItalic">Caracter&#237;sticas demogr&#225;ficas</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>Idade &#40;anos&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">67&#44;0<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>10&#44;7&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">68<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>8&#44;1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">66&#44;8<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>10&#44;1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">67&#44;3<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>11&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">NS&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">NS&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">NS&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>Sexo masculino&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">224 &#40;68&#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">8&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">127&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">89&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">NS&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">NS&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">NS&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="8" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="8" align="left" valign="top"><span class="elsevierStyleItalic">Antecedentes pessoais</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>Hipertens&#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">271 &#40;83&#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">7&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">150&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">114&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">NS&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">NS&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">NS&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>Dislipidemia&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">243 &#40;74&#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">7&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">136&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">100&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">0&#44;034&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">NS&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">NS&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>Diabetes&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">109 &#40;33&#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">4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">66&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">39&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">NS&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">NS&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">NS&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>Tabagismo&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">121 &#40;37&#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">4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">63&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">54&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">NS&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">NS&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">NS&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>EAM pr&#233;vio&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">77 &#40;23&#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">2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">35&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">40&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">NS&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">NS&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">0&#44;05&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>ICP pr&#233;via&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">117 &#40;35&#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">4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">54&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">59&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">NS&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">NS&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">0&#44;02&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>CRM pr&#233;via&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;4&#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">0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " 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">7&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">NS&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">NS&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">NS&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="8" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="8" align="left" valign="top"><span class="elsevierStyleItalic">FEj ventricular esquerda</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>Normal&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">168 &#40;71&#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">6&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">90&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">73&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">NS&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">NS&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">NS&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>Ligeiramente deprimida&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">23 &#40;9&#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">0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " 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">10&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">NS&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">NS&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">NS&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>Moderadamente deprimida&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">29 &#40;12&#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">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " 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">13&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">NS&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">NS&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">NS&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>Gravemente deprimida&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">16 &#40;6&#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">0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " 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">8&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">NS&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">NS&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">NS&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>Disfun&#231;&#227;o renal &#40;TFGe &#60; 60 mL&#47;min&#47;1&#44;73m<span class="elsevierStyleSup">2</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">72 &#40;22&#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">3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">35&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">34&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">NS&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">NS&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">NS&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>Doen&#231;a multivaso&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">64 &#40;19&#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">2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">32&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">30&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">NS&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">NS&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">NS&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="8" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="8" align="left" valign="top"><span class="elsevierStyleItalic">Apresenta&#231;&#227;o 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>Angina est&#225;vel&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">231 &#40;70&#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">8&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">132&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">91&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">NS&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">NS&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">NS&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 inst&#225;vel&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;8&#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">0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " 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">16&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">NS&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">NS&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">NS&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>EAMcSST&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">6 &#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="left" valign="top">0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " 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">4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">NS&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">NS&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">NS&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>EAMsSST&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;18&#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">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">33&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">27&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">NS&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">NS&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">NS&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="8" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="8" align="left" valign="top"><span class="elsevierStyleItalic">Ritmo</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>Sinusal&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;93&#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">8&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">166&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">129&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">NS&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">NS&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">NS&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>Fibrilha&#231;&#227;o auricular&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">8 &#40;2&#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">0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " 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">3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">NS&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">NS&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">NS&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>Pacing&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">14 &#40;4&#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">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " 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">6&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">NS&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">NS&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">NS&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
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          "pt" => "<p id="spar0075" class="elsevierStyleSimplePara elsevierViewall">Caracter&#237;sticas basais da popula&#231;&#227;o &#40;n<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>326&#41;</p>"
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                0 => """
                  <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
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">n &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Descendente anterior&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">242 &#40;60&#44;2&#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"><span class="elsevierStyleHsp" style=""></span>Circunflexa&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">73 &#40;18&#44;2&#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"><span class="elsevierStyleHsp" style=""></span>Coron&#225;ria direita&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Ramo interm&#233;dio&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;0&#44;7&#41;&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="2" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="2" align="left" valign="top"><span class="elsevierStyleItalic">Tipo de les&#227;o</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>A&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">128 &#40;31&#44;8&#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"><span class="elsevierStyleHsp" style=""></span>B1&#47;B2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">98 &#40;24&#44;4&#41; &#47; 132 &#40;32&#44;8&#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"><span class="elsevierStyleHsp" style=""></span>C&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;10&#44;9&#41;&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="2" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="2" align="left" valign="top"><span class="elsevierStyleItalic">Grau de estenose</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>30&#8208;49&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">41 &#40;10&#44;2&#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"><span class="elsevierStyleHsp" style=""></span>50&#8208;69&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">271 &#40;67&#44;4&#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"><span class="elsevierStyleHsp" style=""></span>70&#8208;89&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">88 &#40;21&#44;9&#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"><span class="elsevierStyleHsp" style=""></span>&#8805; 90&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">2 &#40;0&#44;4&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
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                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">1&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">AE&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">CD&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">70&#8208;89&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">B1&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">ICP&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">AE&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">CD&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">70&#8208;89&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">B2&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">0&#44;79&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">TMO&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">AE&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">DA&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">A&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">0&#44;84&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">TMO&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">AE&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">DA&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">50&#8208;69&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">C&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">0&#44;78&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">0&#44;82&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">TMO&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">AE&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">DA&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">50&#8208;69&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">C&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">TMO&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">Cx&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">B1&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">0&#44;97&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">TMO&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">AI&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">DA&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">50&#8208;69&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">A&nbsp;\t\t\t\t\t\t\n
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          "pt" => "<p id="spar0100" class="elsevierStyleSimplePara elsevierViewall">Caracter&#237;sticas globais do procedimento de acordo com a estrat&#233;gia efetuada &#40;n<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>402&#41;</p>"
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            0 => array:3 [
              "identificador" => "bib0005"
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                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "2014 ESC&#47;EACTS Guidelines on myocardial revascularization&#58; The Task Force on Myocardial Revascularization of the European Society of Cardiology &#40;ESC&#41; and the European Association for Cardio&#8208;Thoracic Surgery &#40;EACTS&#41; Developed with the special contribution of the European Association of Percutaneous Cardiovascular Interventions &#40;EAPCI&#41;"
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                        0 => array:2 [
                          "etal" => true
                          "autores" => array:3 [
                            0 => "S&#46; Windecker"
                            1 => "P&#46; Kolh"
                            2 => "F&#46; Alfonso"
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                    0 => array:2 [
                      "doi" => "10.1093/eurheartj/ehu278"
                      "Revista" => array:6 [
                        "tituloSerie" => "Eur Heart J&#46;"
                        "fecha" => "2014"
                        "volumen" => "35"
                        "paginaInicial" => "2541"
                        "paginaFinal" => "2619"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/25173339"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
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                ]
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              "identificador" => "bib0010"
              "etiqueta" => "2"
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                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Fractional Flow Reserve versus Angiography for Guiding Percutaneous Coronary Intervention"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:3 [
                            0 => "P&#46;A&#46;L&#46; Tonino"
                            1 => "B&#46; De Bruyne"
                            2 => "N&#46;H&#46;J&#46; Pijls"
                          ]
                        ]
                      ]
                    ]
                  ]
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                    0 => array:2 [
                      "doi" => "10.1056/NEJMoa1611310"
                      "Revista" => array:6 [
                        "tituloSerie" => "N Engl J Med&#46; Massachusetts Medical Society&#59;"
                        "fecha" => "2009"
                        "volumen" => "360"
                        "paginaInicial" => "213"
                        "paginaFinal" => "224"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/27717299"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
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                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Fractional Flow Reserve&#8211;Guided PCI versus Medical Therapy in Stable Coronary Disease"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:3 [
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                            1 => "N&#46;H&#46;J&#46; Pijls"
                            2 => "B&#46; Kalesan"
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                        ]
                      ]
                    ]
                  ]
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                    0 => array:2 [
                      "doi" => "10.1056/NEJMoa1611310"
                      "Revista" => array:6 [
                        "tituloSerie" => "N Engl J Med&#46; Massachusetts Medical Society&#59;"
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