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apesar de apresentar limita&#231;&#245;es&#44; tem sido o crit&#233;rio mais utilizado para identificar os doentes com dessincronia da contra&#231;&#227;o ventricular&#44; que poder&#227;o beneficiar da terap&#234;utica de ressincroniza&#231;&#227;o card&#237;aca<a class="elsevierStyleCrossRef" href="#bib0150"><span class="elsevierStyleSup">2</span></a>&#59; no entanto&#44; cerca de um ter&#231;o n&#227;o responde a esta terap&#234;utica<a class="elsevierStyleCrossRef" href="#bib0175"><span class="elsevierStyleSup">7</span></a>&#44; o que &#233; atribu&#237;do a fatores como a localiza&#231;&#227;o dos eletrocateteres&#44; as caracter&#237;sticas do mioc&#225;rdio &#40;presen&#231;a de fibrose e viabilidade nas zonas de contra&#231;&#227;o tardia&#41; e aus&#234;ncia de dessincronia mec&#226;nica&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">Alguns estudos sugeriram que outros m&#233;todos&#44; nomeadamente a ecocardiografia&#44; poderiam adicionar marcadores de dessincronia ventricular<a class="elsevierStyleCrossRef" href="#bib0180"><span class="elsevierStyleSup">8</span></a> especulando&#8208;se na altura em que este estudo foi iniciado&#44; que os par&#226;metros de ecocardiografia poderiam&#44; por si s&#243;&#44; identificar os candidatos a CRT&#46; A incerteza nesta &#225;rea traduziu&#8208;se em sucessivas revis&#245;es das recomenda&#231;&#245;es internacionais ao longo dos anos&#44; mantendo&#8208;se a procura de crit&#233;rios sens&#237;veis e espec&#237;ficos para sele&#231;&#227;o dos doentes que mais poder&#227;o beneficiar do CRT<a class="elsevierStyleCrossRef" href="#bib0185"><span class="elsevierStyleSup">9</span></a> e o debate quanto &#224; utilidade dos par&#226;metros ecocardiogr&#225;ficos nesta sele&#231;&#227;o&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">Decidimos assim&#44; atrav&#233;s de um estudo observacional&#44; colher dados da pr&#225;tica cl&#237;nica em Portugal e avaliar os resultados da utiliza&#231;&#227;o de dispositivos eletr&#243;nicos na terap&#234;utica dos doentes com IC e FEVE &#60; 35&#37;&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">M&#233;todos</span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Desenho do estudo</span><p id="par0030" class="elsevierStylePara elsevierViewall">O estudo S&#237;ncrone &#233; um registo observacional&#44; prospetivo&#44; multic&#234;ntrico&#44; conduzido em 16 centros nacionais&#46; Teve como promotor o Instituto Portugu&#234;s do Ritmo Card&#237;aco &#40;IPRC&#41;&#44; integrando o seu <span class="elsevierStyleItalic">steering&#8208;committee</span> elementos desta institui&#231;&#227;o assim como outros provenientes dos Grupos de Estudo de Ecocardiografia e da Insufici&#234;ncia Card&#237;aca da Sociedade Portuguesa de Cardiologia&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">Ap&#243;s a elabora&#231;&#227;o do protocolo foram convidados a participar os centros nacionais que reunissem capacidade&#44; meios t&#233;cnicos e recursos humanos dos tr&#234;s setores da cardiologia que lidam com esta patologia &#8211; &#225;rea da insufici&#234;ncia card&#237;aca&#44; para avalia&#231;&#227;o dos doentes do ponto de vista cl&#237;nico&#44; garantia de otimiza&#231;&#227;o da terap&#234;utica farmacol&#243;gica e referencia&#231;&#227;o de doentes&#59; &#225;rea da ecocardiografia&#44; na sele&#231;&#227;o dos doentes com FEVE &#60; 35&#37; e avalia&#231;&#227;o dos par&#226;metros que se poder&#227;o relacionar com dessincronia&#59; &#225;rea da arritmologia&#44; para avalia&#231;&#227;o dos doentes do ponto de vista do risco arr&#237;tmico e indica&#231;&#227;o para implanta&#231;&#227;o dos dispositivos <span class="elsevierStyleItalic">&#40;ver material suplementar on line 1&#41;</span>&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">Nos centros que aceitaram participar&#44; o protocolo do estudo foi submetido &#224; Comiss&#227;o de &#201;tica e ao Conselho de Administra&#231;&#227;o do respetivo hospital&#44; s&#243; se iniciando o recrutamento dos doentes ap&#243;s a aceita&#231;&#227;o por estas duas entidades&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">Todos os doentes forneceram por escrito o seu consentimento informado para participa&#231;&#227;o no estudo e utiliza&#231;&#227;o dos dados recolhidos para fins cient&#237;ficos&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Popula&#231;&#227;o e seguimento</span><p id="par0050" class="elsevierStylePara elsevierViewall">Eram eleg&#237;veis para o estudo doentes de ambos os sexos&#44; com idade igual ou superior a 18 anos&#44; com diagn&#243;stico de insufici&#234;ncia card&#237;aca e FEVE &#60; 35&#37;&#44; com indica&#231;&#227;o para implanta&#231;&#227;o de dispositivos de desfibrilha&#231;&#227;o e&#47;ou ressincroniza&#231;&#227;o&#46; Os dados foram introduzidos pelos investigadores de cada centro num registo informatizado&#44; acess&#237;vel atrav&#233;s da Internet&#44; tendo a base de dados sido centralizada no IPRC&#46; Foram definidos cinco momentos de avalia&#231;&#227;o dos doentes&#58; antes da implanta&#231;&#227;o do dispositivo&#44; na alta hospitalar e aos 3&#44; 6 e 12 meses &#40;&#177;1 m&#234;s&#41; de seguimento&#44; o qual foi realizado de acordo com a pr&#225;tica de cada centro&#44; tendo a dura&#231;&#227;o total de um ano&#46;</p><p id="par0055" class="elsevierStylePara elsevierViewall">Em cada avalia&#231;&#227;o estavam dispon&#237;veis para preenchimento&#44; dados demogr&#225;ficos&#44; cl&#237;nicos&#44; laboratoriais&#44; terap&#234;uticos&#44; radiol&#243;gicos&#44; ecocardiogr&#225;ficos&#44; arritmol&#243;gicos e eletrofisiol&#243;gicos&#46; Os par&#226;metros do ecocardiograma definidos para avalia&#231;&#227;o estavam de acordo com as recomenda&#231;&#245;es conjuntas da Sociedade Americana de Ecocardiografia e Associa&#231;&#227;o Europeia de Ecocardiografia&#44; incluindo os crit&#233;rios de dessincronia auriculoventricular&#44; interventricular e intraventricular<a class="elsevierStyleCrossRef" href="#bib0190"><span class="elsevierStyleSup">10</span></a><span class="elsevierStyleItalic">&#40;ver material suplementar on line 1&#41;</span>&#46;</p><p id="par0060" class="elsevierStylePara elsevierViewall">No desenho inicial do estudo estava previsto o recrutamento dos doentes durante um ano&#44; a partir da primeira inclus&#227;o em cada centro&#46; A constata&#231;&#227;o da dificuldade de alguns centros na inclus&#227;o de doentes levou ao alargamento desse per&#237;odo&#44; at&#233; ter sido decidido pelo <span class="elsevierStyleItalic">steering&#8208;committee</span> que o estudo terminaria ao ser atingido o n&#250;mero de 500 doentes inclu&#237;dos&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Objetivos do estudo</span><p id="par0065" class="elsevierStylePara elsevierViewall">Definiu&#8208;se como objetivo principal para o estudo S&#237;ncrone a determina&#231;&#227;o da taxa de mortalidade e reinternamento por qualquer causa at&#233; um ano ap&#243;s o procedimento&#46;</p><p id="par0070" class="elsevierStylePara elsevierViewall">Para objetivos secund&#225;rios consideraram&#8208;se&#58; a taxa de mortalidade e hospitaliza&#231;&#227;o por insufici&#234;ncia card&#237;aca&#44; a caracteriza&#231;&#227;o dos doentes sob o ponto de vista cl&#237;nico&#44; eletrofisiol&#243;gico e ecocardiogr&#225;fico&#44; a avalia&#231;&#227;o dos fatores preditores de resposta &#224; terap&#234;utica de ressincroniza&#231;&#227;o&#44; as complica&#231;&#245;es intra e extra&#8208;hospitalares e respetivos preditores e a avalia&#231;&#227;o da pr&#225;tica cl&#237;nica em Portugal no respeitante &#224; implanta&#231;&#227;o de CRT e CDI&#46;</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">An&#225;lise estat&#237;stica</span><p id="par0075" class="elsevierStylePara elsevierViewall">As vari&#225;veis cont&#237;nuas foram descritas pela m&#233;dia &#177; desvio&#8208;padr&#227;o &#40;DP&#41; e para a sua compara&#231;&#227;o foi efetuado o teste <span class="elsevierStyleItalic">t&#8208;student</span> &#40;ou o equivalente n&#227;o param&#233;trico&#44; teste de <span class="elsevierStyleItalic">Mann Whitney</span>&#41;&#59; o teste <span class="elsevierStyleItalic">Kolmogorov&#8208;Smirnov</span> foi utilizado para testar a distribui&#231;&#227;o normal das vari&#225;veis&#46;</p><p id="par0080" class="elsevierStylePara elsevierViewall">As vari&#225;veis categ&#243;ricas foram representadas em valor absoluto e em percentagem &#40;&#37;&#41; e a sua compara&#231;&#227;o realizada com o teste de Qui&#8208;quadrado e&#47;ou Teste Exato de Fisher&#46;</p><p id="par0085" class="elsevierStylePara elsevierViewall">Foram utilizados modelos de regress&#227;o log&#237;stica para estimar o <span class="elsevierStyleItalic">odds ratio</span> dos preditores dos resultados cl&#237;nicos&#44; com intervalo de confian&#231;a de 95&#37;&#59; as vari&#225;veis inclu&#237;das no modelo apresentaram p &#60; 0&#44;01 na an&#225;lise univariada&#46;</p><p id="par0090" class="elsevierStylePara elsevierViewall">As vari&#225;veis inclu&#237;das no modelo da an&#225;lise multivariada&#44; que avaliou a dessincronia como preditor de melhoria cl&#237;nica&#44; foram a diabetes <span class="elsevierStyleItalic">mellitus</span>&#44; dissincronia intraventricular e dura&#231;&#227;o do QRS &#40;p &#60; 0&#44;01 na an&#225;lise univariada&#41;&#46;</p><p id="par0095" class="elsevierStylePara elsevierViewall">Os valores p &#60; 0&#44;05 foram considerados estatisticamente significativos&#46; A an&#225;lise estat&#237;stica foi realizada com recurso ao <span class="elsevierStyleItalic">software</span> SPSS vers&#227;o 22&#46;0&#46;</p></span></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Resultados</span><p id="par0100" class="elsevierStylePara elsevierViewall">Entre Novembro de 2008 e Maio de 2014 foram introduzidos no registo 515 doentes&#46; Destes&#44; foram considerados 486 doentes para a avalia&#231;&#227;o basal&#44; tendo sido exclu&#237;dos 29&#44; que n&#227;o tinham a maioria das caracter&#237;sticas preenchidas no CRF &#40;<span class="elsevierStyleItalic">case report form</span>&#41;&#44; e 419 doentes no seguimento &#40;perda de 67 doentes nesta fase do estudo&#41; &#40;<a class="elsevierStyleCrossRef" href="#fig0005">figura 1</a>&#41;&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">Caracter&#237;sticas basais</span><p id="par0105" class="elsevierStylePara elsevierViewall">A <a class="elsevierStyleCrossRef" href="#tbl0005">tabela 1</a> reflete as caracter&#237;sticas cl&#237;nicas basais&#46; A idade m&#233;dia foi de 65&#177;12 anos&#59; 77&#37; eram homens e as principais etiologias da IC foram a isqu&#233;mica &#40;47&#37;&#41; e a miocardiopatia dilatada idiop&#225;tica &#40;28&#37;&#41;&#46; A terap&#234;utica farmacol&#243;gica para a IC encontrava&#8208;se otimizada&#44; correspondendo &#224; m&#225;xima tolerada pelo doente&#58; 76&#37; dos doentes estava medicado com inibidores da enzima de convers&#227;o da angiotensina ou antagonistas dos recetores da angiotensina II &#40;IECA&#47;ARA&#41;&#44; 77&#37; fazia um bloqueador beta&#8208;adren&#233;rgico e 34&#37; um antagonista da aldosterona &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">tabela 1</a>&#41;&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0110" class="elsevierStylePara elsevierViewall">Cerca de 14&#37; dos doentes tinha tido pelo menos um internamento hospitalar no &#250;ltimo ano e 22&#37; tinha documentado um epis&#243;dio de taquicardia&#47;fibrilha&#231;&#227;o ventricular pr&#233;via &#40;implanta&#231;&#227;o do dispositivo em contexto de preven&#231;&#227;o secund&#225;ria de morte s&#250;bita&#41;&#46;</p><p id="par0115" class="elsevierStylePara elsevierViewall">Dos doentes inclu&#237;dos na avalia&#231;&#227;o basal&#44; metade &#40;n &#61; 243&#41; implantou um CDI e a outra metade CRT&#8208;D &#40;n &#61; 208&#41; ou CRT&#8208;P &#40;n &#61; 35&#41;&#59; os que implantaram CDI&#44; tinham&#44; em compara&#231;&#227;o com o grupo com CRT&#8208;D&#47;CRT&#8208;P&#44; idade mais jovem&#44; predom&#237;nio do sexo masculino e menor propor&#231;&#227;o de comorbilidades&#44; como diabetes ou doen&#231;a renal cr&#243;nica&#46; A maior parte dos doentes que implantaram CDI &#40;85&#37;&#41; estava em classe I&#8208;II da <span class="elsevierStyleItalic">New York Heart Association</span> &#40;NYHA&#41;&#44; enquanto a maioria com CRT&#8208;D&#47;CRT&#8208;P &#40;91&#37;&#41; se encontrava em classe funcional II&#8208;III da NYHA&#46;</p><p id="par0120" class="elsevierStylePara elsevierViewall">Em m&#233;dia&#44; a FEVE era de 28&#44;7&#177;8&#44;5&#37;&#44; estando a fun&#231;&#227;o sist&#243;lica do ventr&#237;culo direito preservada na maioria dos casos&#46; Os doentes que implantaram CRT&#8208;D&#47;CRT&#8208;P tinham volumes ventriculares esquerdos maiores e fra&#231;&#227;o de eje&#231;&#227;o mais baixa &#40;<a class="elsevierStyleCrossRef" href="#tbl0010">tabela 2</a>&#41;&#46;</p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><p id="par0125" class="elsevierStylePara elsevierViewall">Nos doentes que implantaram ressincronizadores&#44; a dura&#231;&#227;o m&#233;dia do QRS foi de 160&#177;21ms&#44; sendo que 73&#37; tinha QRS &#8805; 150ms&#44; 89&#37; apresentavam um padr&#227;o de bloqueio completo de ramo esquerdo e 24&#37; &#40;n &#61; 58&#41; tinham fibrilha&#231;&#227;o auricular <span class="elsevierStyleItalic">&#40;ver material suplementar on line 2 e 3&#41;</span>&#46;</p></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0105">Resultados cl&#237;nicos</span><p id="par0130" class="elsevierStylePara elsevierViewall">A mortalidade global a um ano&#44; objetivo prim&#225;rio do estudo&#44; foi de 3&#44;6&#37; &#40;15 doentes&#41; e o reinternamento por todas as causas de 11&#37; &#40;46 doentes&#41; &#40;tabela 3&#41;&#46; A mortalidade de causa cardiovascular foi de 1&#44;9&#37; e a principal causa de reinternamento a um ano foi IC &#40;4&#44;5&#37;&#41;&#44; seguida de complica&#231;&#245;es relacionadas com o procedimento &#40;2&#44;6&#37;&#41; e arritmias &#40;1&#44;4&#37;&#41;&#46; Os doentes que implantaram CRT&#8208;D&#47;CRT&#8208;P apresentaram mortalidade cardiovascular mais elevada que os com CDI &#40;3&#44;4&#37; <span class="elsevierStyleItalic">versus</span> 0&#44;5&#37;&#44; p &#61; 0&#44;028&#41; e maior n&#250;mero de reinternamentos &#40;17&#37; <span class="elsevierStyleItalic">versus</span> 5&#44;6&#37;&#44; p &#60; 0&#44;001&#41;&#46; Verificou&#8208;se por fim uma tend&#234;ncia para maior mortalidade global nos doentes isqu&#233;micos &#40;5&#44;4&#37; <span class="elsevierStyleItalic">versus</span> 1&#44;9&#37;&#44; p &#61; 0&#44;05&#41; &#40;tabela 3&#41;&#46;</p><elsevierMultimedia ident="tbl0015"></elsevierMultimedia><p id="par0135" class="elsevierStylePara elsevierViewall">Os preditores independentes do <span class="elsevierStyleItalic">endpoint</span> composto &#171;mortalidade global ou reinternamento por causa cardiovascular&#187; foram a exist&#234;ncia de&#44; pelo menos&#44; um internamento no &#250;ltimo ano &#40;RR 5&#44;20&#59; IC 95&#37;&#44; 1&#44;99&#8208;13&#44;6&#59; p &#61; 0&#44;001&#41; e um &#237;ndice de massa corporal &#40;IMC&#41; mais elevado &#40;RR 1&#44;14&#59; IC 95&#37;&#44; 1&#44;02&#8208;1&#44;26&#59; p &#61; 0&#44;02&#41; &#40;figura 2&#41;&#46;</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0140" class="elsevierStylePara elsevierViewall">As complica&#231;&#245;es intra&#8208;hospitalares relacionadas com a implanta&#231;&#227;o do dispositivo foram raras &#40;4&#44;1&#37;&#59; n &#61; 17&#41;&#44; ocorrendo sobretudo nos doentes que implantaram CRT &#40;n &#61; 16&#41;&#44; sendo as principais a disse&#231;&#227;o do seio coron&#225;rio &#40;n &#61; 8&#41;&#44; hemorragias significativas &#40;n &#61; 5&#41; e desloca&#231;&#227;o de el&#233;trodos &#40;n &#61; 3&#41;&#46; No seguimento a um ano&#44; as complica&#231;&#245;es relacionadas com o dispositivo ocorreram em 8&#44;6&#37; dos doentes&#44; tendo&#8208;se destacado problemas relacionados com o posicionamento&#47;avaria de el&#233;trodos &#40;n &#61; 17&#41;&#44; estimula&#231;&#227;o do nervo fr&#233;nico &#40;n &#61; 7&#41; e infe&#231;&#227;o da loca &#40;n &#61; 4&#41;&#46; Os preditores destas complica&#231;&#245;es foram a utiliza&#231;&#227;o de dispositivos de ressincroniza&#231;&#227;o &#40;RR 3&#44;35&#59; IC 95&#37;&#44; 1&#44;26&#8208;8&#44;90&#59; p &#61; 0&#44;02&#41; e o sexo feminino &#40;RR 3&#44;35&#59; IC 95&#37;&#44; 1&#44;42&#8208;7&#44;93&#59; p &#61; 0&#44;01&#41;&#46;</p><p id="par0145" class="elsevierStylePara elsevierViewall">Dos doentes que implantaram desfibrilhadores &#40;CDI e CRT&#8208;D&#41;&#44; 71 tiveram choques &#40;18&#44;1&#37;&#41;&#44; na sua maioria apropriados &#40;77&#37;&#41;&#46;</p><p id="par0150" class="elsevierStylePara elsevierViewall">Os doentes submetidos a ressincroniza&#231;&#227;o apresentaram redu&#231;&#227;o significativa da dura&#231;&#227;o do QRS durante o seguimento &#40;QRS basal&#58; 160&#177;21<span class="elsevierStyleHsp" style=""></span>ms <span class="elsevierStyleItalic">versus</span> QRS seguimento&#58; 141&#177;24<span class="elsevierStyleHsp" style=""></span>ms&#44; p &#60; 0&#44;001&#41;&#44; assim como&#44; em 62&#37; dos doentes&#44; melhoria significativa da classe funcional de IC da NYHA &#40;figura 3&#41;&#46; N&#227;o houve diferen&#231;a significativa na percentagem de doentes que apresentaram melhoria da classe funcional de IC da NYHA&#44; de acordo com a dura&#231;&#227;o do QRS &#40;QRS&#8805; 150<span class="elsevierStyleHsp" style=""></span>ms&#58; 69&#37; <span class="elsevierStyleItalic">versus</span> QRS 130&#8208;149<span class="elsevierStyleHsp" style=""></span>ms&#58; 67&#37;&#44; p &#61; 0&#44;85&#41; <span class="elsevierStyleItalic">&#40;ver material suplementar on line 4&#41;</span>&#46;</p><elsevierMultimedia ident="fig0015"></elsevierMultimedia><p id="par0155" class="elsevierStylePara elsevierViewall">Nos doentes com avalia&#231;&#227;o basal completa por ecocardiograma &#40;n &#61; 82&#41;&#44; apenas a exist&#234;ncia de dessincronia intraventricular ecocardiogr&#225;fica foi um preditor de melhoria da classe funcional NYHA &#40;RR 5&#44;23&#59; IC 95&#37;&#44; 1&#44;13&#8208;24&#44;3&#59; p &#61; 0&#44;035&#41; <span class="elsevierStyleItalic">&#40;ver material suplementar on line 3 e 4&#41;</span>&#46;</p></span></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0110">Discuss&#227;o</span><p id="par0160" class="elsevierStylePara elsevierViewall">Apesar de no estudo S&#237;ncrone a inclus&#227;o dos doentes se ter estendido por v&#225;rios anos&#44; durante os quais se registaram avan&#231;os na abordagem deste tipo de doentes&#44; queremos salientar que os dados e conclus&#245;es deste estudo s&#227;o particularmente atuais&#46; Assim&#44; a terap&#234;utica farmacol&#243;gica prescrita estava genericamente de acordo com os padr&#245;es internacionais em uso e definidos pelas <span class="elsevierStyleItalic">guidelines</span> mais recentes<a class="elsevierStyleCrossRef" href="#bib0195"><span class="elsevierStyleSup">11</span></a>&#44; podendo ser considerada como a terap&#234;utica otimizada caso a caso &#40;76&#37; IECA&#47;ARA&#59; 77&#37; bloqueadores beta&#8208;adren&#233;rgicos&#59; 34&#37; antagonista aldosterona&#41;&#46; Tamb&#233;m as indica&#231;&#245;es para coloca&#231;&#227;o de dispositivos est&#227;o de acordo com os crit&#233;rios atuais&#44; sobretudo a op&#231;&#227;o na grande maioria dos casos pelo CRT&#8208;D<a class="elsevierStyleCrossRefs" href="#bib0170"><span class="elsevierStyleSup">6&#44;12&#44;13</span></a>&#46; A maioria dos doentes que implantou CRT tinha bloqueio completo de ramo esquerdo&#44; com QRS alargado&#44; de dura&#231;&#227;o &#8805; 130<span class="elsevierStyleHsp" style=""></span>ms &#40;87&#37;&#41;&#44; sugerindo que em Portugal&#44; seguimos indica&#231;&#245;es de classe I para estes dispositivos<a class="elsevierStyleCrossRef" href="#bib0195"><span class="elsevierStyleSup">11</span></a>&#46; Existe no entanto uma pequena percentagem de implanta&#231;&#245;es que correspondem a recomenda&#231;&#245;es de n&#237;vel II&#44; o que n&#227;o nos parece ser atribu&#237;vel a condicionamentos financeiros mas a defici&#234;ncias na organiza&#231;&#227;o dos cuidados de insufici&#234;ncia card&#237;aca&#44; na defini&#231;&#227;o dos fluxos dos doentes ou na sua referencia&#231;&#227;o<a class="elsevierStyleCrossRef" href="#bib0210"><span class="elsevierStyleSup">14</span></a>&#46; Torna&#8208;se assim necess&#225;ria maior colabora&#231;&#227;o entre as diversas &#225;reas de tratamento da insufici&#234;ncia card&#237;aca&#44; com a cria&#231;&#227;o de protocolos de referencia&#231;&#227;o e de equipas multidisciplinares entre os v&#225;rios n&#237;veis de cuidados de insufici&#234;ncia card&#237;aca em Portugal&#46;</p><p id="par0165" class="elsevierStylePara elsevierViewall">A qualidade do esquema de tratamento farmacol&#243;gico&#44; da indica&#231;&#227;o&#44; implanta&#231;&#227;o de dispositivos e seguimento dos doentes com insufici&#234;ncia card&#237;aca&#44; nos centros nacionais&#44; pode&#8208;se ter traduzido na baixa mortalidade encontrada &#40;apenas 3&#44;6&#37; no seguimento ao ano&#41; assim como no n&#250;mero de reinternamentos no mesmo per&#237;odo &#40;11&#37;&#41;&#46; O registo europeu de insufici&#234;ncia card&#237;aca&#44; <span class="elsevierStyleItalic">ESC&#8208;HF&#8208;LT &#40;European Society of Cardiology Heart Failure Long&#8208;Term&#41; Registry&#44;</span> mostrou taxas de mortalidade ao ano mais elevadas &#40;6&#44;4&#37;&#41; e mais hospitaliza&#231;&#245;es por IC ao ano &#40;9&#44;9&#37;&#41;&#44; numa popula&#231;&#227;o de doentes com IC cr&#243;nica seguidos em ambulat&#243;rio com FEVE m&#233;dia de 37 e 75&#37; em classe NYHA I&#8208;II<a class="elsevierStyleCrossRefs" href="#bib0215"><span class="elsevierStyleSup">15&#44;16</span></a>&#46; A menor mortalidade no nosso estudo poder&#225; estar em parte relacionada com a perda de seguimento de alguns dos doentes&#44; que poder&#227;o eventualmente ter falecido&#46; Por outro lado&#44; as popula&#231;&#245;es dos dois registos s&#227;o totalmente diferentes&#44; uma vez que a do nosso estudo incluiu apenas doentes com dispositivos e disfun&#231;&#227;o ventricular esquerda grave enquanto no <span class="elsevierStyleItalic">ESC&#8208;HF&#8208;LT Registry</span> foram inclu&#237;dos todos os tipos de IC cr&#243;nica e&#44; apesar do elevado n&#250;mero de doentes com FEVE deprimida&#44;&#160;a taxa de CRT e CDI foi inferior ao expet&#225;vel&#46; Verificando&#8208;se uma taxa de implanta&#231;&#227;o de CRT&#47;CDI muito menor que no nosso estudo&#44; &#233; coerente que o <span class="elsevierStyleItalic">ESC&#8208;HF&#8208;LT Registry</span>&#44; ao abordar uma popula&#231;&#227;o indiscriminada com IC&#44; apresente mortalidade e reinternamento significativamente superiores&#46;</p><p id="par0170" class="elsevierStylePara elsevierViewall">Como seria de esperar&#44; verificou&#8208;se tend&#234;ncia para maior mortalidade e n&#250;mero de reinternamentos nos doentes isqu&#233;micos relativamente aos n&#227;o&#8208;isqu&#233;micos&#46; Tamb&#233;m foi coerente que a ocorr&#234;ncia de internamento no &#250;ltimo ano identificasse os doentes mais graves&#44; tendo sido preditor independente de mortalidade e de reinternamento cardiovascular&#46; O outro preditor independente de morte ao ano&#44; o IMC&#44; questiona o debate sobre o fen&#243;meno do efeito paradoxal da obesidade na IC e no risco da mortalidade global e cardiovascular<a class="elsevierStyleCrossRefs" href="#bib0225"><span class="elsevierStyleSup">17&#8208;19</span></a>&#46;</p><p id="par0175" class="elsevierStylePara elsevierViewall">O procedimento mais complexo da implanta&#231;&#227;o dos CRT explica o maior n&#250;mero de complica&#231;&#245;es e de reinterven&#231;&#227;o nos doentes com ressincronizadores&#44; &#224; semelhan&#231;a de estudos anteriores<a class="elsevierStyleCrossRef" href="#bib0240"><span class="elsevierStyleSup">20</span></a>&#46; Para al&#233;m disso&#44; o sexo feminino foi tamb&#233;m um preditor de complica&#231;&#245;es relacionadas com o dispositivo&#44; atribu&#237;veis a raz&#245;es como a diferente anatomia e a menor superf&#237;cie corporal<a class="elsevierStyleCrossRefs" href="#bib0245"><span class="elsevierStyleSup">21&#44;22</span></a>&#46;</p><p id="par0180" class="elsevierStylePara elsevierViewall">Os resultados da implanta&#231;&#227;o de CRT podem ser considerados bons a n&#237;vel funcional&#44; tendo&#8208;se observado melhoria da classe da NYHA em 62&#37; dos doentes&#44; independentemente da etiologia isqu&#233;mica&#46; Estes resultados foram sobrepon&#237;veis a outros estudos que mostraram uma melhoria da classe NYHA entre 60&#8208;70&#37; com o uso de CRT quando comparado com o uso de terap&#234;utica m&#233;dica<a class="elsevierStyleCrossRefs" href="#bib0170"><span class="elsevierStyleSup">6&#44;23</span></a>&#46;</p><p id="par0185" class="elsevierStylePara elsevierViewall">Em contraste com os estudos aleatorizados publicados anteriormente<a class="elsevierStyleCrossRefs" href="#bib0260"><span class="elsevierStyleSup">24&#44;25</span></a>&#44; o S&#237;ncrone sugere que a ecocardiografia&#44; atrav&#233;s da avalia&#231;&#227;o da dessincronia intraventricular&#44; pode desempenhar algum papel como preditor da resposta dos doentes &#224; implanta&#231;&#227;o de CRT&#46; &#201; de notar que os nossos resultados se aplicam a uma popula&#231;&#227;o em que a maioria tem padr&#227;o de bloqueio de ramo esquerdo com complexos QRS muito alargados&#44; diferente&#44; portanto da do estudo <span class="elsevierStyleItalic">Echo&#8208;CRT</span><a class="elsevierStyleCrossRef" href="#bib0260"><span class="elsevierStyleSup">24</span></a>&#46; Por outro lado&#44; ao contr&#225;rio do verificado no estudo PROSPECT<a class="elsevierStyleCrossRef" href="#bib0265"><span class="elsevierStyleSup">25</span></a>&#44; em que a resposta ao CRT foi avaliada por um <span class="elsevierStyleItalic">score</span> cl&#237;nico e pela redu&#231;&#227;o do volume telesist&#243;lico do ventr&#237;culo esquerdo&#44; no S&#237;ncrone foi apenas utilizado como preditor de resposta a melhoria da classe funcional NYHA&#46; Este achado poder&#225; resultar de uma maior consciencializa&#231;&#227;o dos ecocardiografistas &#40;ap&#243;s os resultados do estudo PROSPECT&#41; para a necessidade de maior precis&#227;o nas medi&#231;&#245;es efetuadas e de uma mais rigorosa sele&#231;&#227;o dos par&#226;metros de dessincronia utilizados&#46;</p><p id="par0190" class="elsevierStylePara elsevierViewall">A corroborar este conceito&#44; v&#225;rios estudos recentes t&#234;m vindo a mostrar mais&#8208;valia da ecocardiografia como preditor de melhoria cl&#237;nica destes doentes<a class="elsevierStyleCrossRefs" href="#bib0270"><span class="elsevierStyleSup">26&#8208;28</span></a>&#46;</p><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0115">Limita&#231;&#245;es do estudo</span><p id="par0195" class="elsevierStylePara elsevierViewall">O estudo S&#237;ncrone apresenta diversas limita&#231;&#245;es&#44; nomeadamente o facto de ter sido puramente observacional&#44; n&#227;o interferindo nas pr&#225;ticas cl&#237;nicas dos diversos centros&#44; as quais podem n&#227;o ter sido uniformes&#44; com eventual influ&#234;ncia nos resultados finais&#46;</p><p id="par0200" class="elsevierStylePara elsevierViewall">A distribui&#231;&#227;o assim&#233;trica dos doentes inclu&#237;dos pelos diversos centros&#44; embora corresponda &#224; realidade nacional&#44; pode ter condicionado algum enviesamento dos resultados&#44; dado o predom&#237;nio de alguns centros&#46; O per&#237;odo de inclus&#227;o dos doentes foi prolongado em rela&#231;&#227;o ao estipulado inicialmente e houve perda do seguimento de 67 doentes&#44; o que constituiu uma limita&#231;&#227;o&#44; no entanto&#44; os resultados obtidos correspondem certamente a uma pr&#225;tica cl&#237;nica qualificada&#44; coerente com os avan&#231;os que se foram verificando na forma de abordar os doentes com insufici&#234;ncia card&#237;aca&#46;</p><p id="par0205" class="elsevierStylePara elsevierViewall">Temos de levar em conta que se trata de um registo com uma participa&#231;&#227;o volunt&#225;ria e n&#227;o remunerada dos Centros&#46;&#160;Foi sempre reiterado o comprometimento dos Centros e a maturidade demonstrada na participa&#231;&#227;o neste registo foi independente da sua dimens&#227;o&#46; Os dados devem ser analisados de uma forma global e mostram a import&#226;ncia dos sistemas implantados no tratamento de doentes com disfun&#231;&#227;o ventricular esquerda&#44; sendo concordantes com os de outros estudos multic&#234;ntricos&#46;</p><p id="par0210" class="elsevierStylePara elsevierViewall">Em rela&#231;&#227;o &#224; ecocardiografia&#44; o reduzido n&#250;mero de doentes com avalia&#231;&#227;o basal ecocardiogr&#225;fica completa e a simplicidade e subjetividade do <span class="elsevierStyleItalic">endpoint</span>&#44; constituem limita&#231;&#245;es do trabalho&#46;</p></span></span><span id="sec0060" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0120">Conclus&#245;es</span><p id="par0215" class="elsevierStylePara elsevierViewall">Sendo um estudo observacional&#44; os dados recolhidos pelo S&#237;ncrone permitem concluir que&#44; nos centros nacionais que tratam os doentes com insufici&#234;ncia card&#237;aca e FEVE diminu&#237;da com recurso a dispositivos eletr&#243;nicos implant&#225;veis&#44; quer a terap&#234;utica farmacol&#243;gica quer as indica&#231;&#245;es para a implanta&#231;&#227;o de dispositivos est&#227;o de acordo com os mais exigentes padr&#245;es internacionais&#44; refletidos nas recomenda&#231;&#245;es europeias&#44; destacando&#8208;se a op&#231;&#227;o na grande maioria dos casos pela utiliza&#231;&#227;o do CRT&#8208;D&#46;</p><p id="par0220" class="elsevierStylePara elsevierViewall">Tamb&#233;m os resultados das implanta&#231;&#245;es dos CRT podem ser considerados sobrepon&#237;veis aos da literatura internacional&#44; com melhoria significativa da classe funcional&#44; independentemente de a etiologia ser ou n&#227;o isqu&#233;mica&#46; Refletindo a qualidade do trabalho cl&#237;nico desses Centros&#44; observou&#8208;se uma mortalidade global inferior &#224; dos registos internacionais&#46;</p><p id="par0225" class="elsevierStylePara elsevierViewall">Por fim&#44; um dado interessante e controverso do estudo foi a observa&#231;&#227;o de que a presen&#231;a de dessincronia intraventricular no ecocardiograma foi preditor da resposta &#224; terap&#234;utica de ressincroniza&#231;&#227;o&#44; contrariando a tend&#234;ncia&#44; verificada ap&#243;s o estudo PROSPECT<a class="elsevierStyleCrossRef" href="#bib0265"><span class="elsevierStyleSup">25</span></a>&#44; para desvaloriza&#231;&#227;o deste m&#233;todo como meio de previs&#227;o da resposta dos doentes &#224; implanta&#231;&#227;o de ressincronizadores&#46;</p></span><span id="sec0065" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0125">Financiamento</span><p id="par0230" class="elsevierStylePara elsevierViewall">O estudo S&#237;ncrone beneficiou de uma bolsa de investiga&#231;&#227;o &#40;n&#227;o condicionada&#41; atribu&#237;da pela firma Boston Scientific Portugal &#8208; Dispositivos M&#233;dicos&#44; Lda&#46; que n&#227;o teve qualquer interfer&#234;ncia na defini&#231;&#227;o do protocolo do estudo&#44; na colheita e an&#225;lise dos dados ou na elabora&#231;&#227;o do manuscrito&#46;</p></span><span id="sec0070" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0130">Conflitos de interesse</span><p id="par0235" class="elsevierStylePara elsevierViewall">Os autores declaram n&#227;o ter existido qualquer conflito de interesses a n&#237;vel da sua participa&#231;&#227;o no estudo S&#237;ncrone&#46;</p></span></span>"
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        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Introdu&#231;&#227;o</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">O objetivo deste registo foi caracterizar a pr&#225;tica cl&#237;nica em Portugal no que respeita &#224; utiliza&#231;&#227;o de dispositivos eletr&#243;nicos na terap&#234;utica dos doentes com insufici&#234;ncia card&#237;aca &#40;IC&#41; e fra&#231;&#227;o de eje&#231;&#227;o ventricular esquerda &#40;FEVE&#41; diminu&#237;da&#46;</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">M&#233;todos</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">O estudo S&#237;ncrone &#233; um registo observacional&#44; multic&#234;ntrico e prospetivo que foi conduzido em 16 centros portugueses de 2006 a 2014&#46; Incluiu doentes adultos com diagn&#243;stico de IC&#44; FEVE<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>35&#37; e indica&#231;&#227;o para implanta&#231;&#227;o de dispositivos de desfibrilha&#231;&#227;o &#40;CDI&#41; e&#47;ou ressincroniza&#231;&#227;o &#40;CRT&#41;&#44; de acordo com as recomenda&#231;&#245;es da Sociedade Europeia de Cardiologia em vigor aquando do in&#237;cio do estudo&#46; Os doentes foram seguidos durante um ano&#44; de acordo com a pr&#225;tica de cada centro&#46;</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Resultados</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">No total&#44; foram inclu&#237;dos 486 doentes&#44; dos quais metade implantou CDI e a outra metade CRT&#8208;P ou CRT&#8208;D&#46; A idade m&#233;dia foi de 65<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>12 anos e as etiologias mais frequentes foram a isqu&#233;mica &#40;47&#37;&#41; e a miocardiopatia dilatada idiop&#225;tica &#40;28&#37;&#41;&#46; A mortalidade global ao ano foi 3&#44;6&#37; e a taxa de reinternamento 11&#37;&#44; sendo significativamente maior nos doentes que implantaram CRT&#8208;D&#47;CRT&#8208;P em rela&#231;&#227;o aos que implantaram CDI &#40;17&#37; <span class="elsevierStyleItalic">versus</span> 5&#44;6&#37; p<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#44;001&#41;&#46; Nos doentes submetidos a CRT observou&#8208;se redu&#231;&#227;o significativa da dura&#231;&#227;o do QRS &#40;160<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>21<span class="elsevierStyleHsp" style=""></span>ms <span class="elsevierStyleItalic">versus</span> 141<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>24<span class="elsevierStyleHsp" style=""></span>ms&#44; p<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#44;001&#41;&#44; bem como melhoria da classe funcional <span class="elsevierStyleItalic">New York Heart Association&#46;</span></p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Conclus&#227;o</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">O estudo S&#237;ncrone mostra que a utiliza&#231;&#227;o dos dispositivos implant&#225;veis na IC com FEVE diminu&#237;da est&#225; de acordo com as recomenda&#231;&#245;es internacionais&#44; tendo os doentes apresentado melhoria funcional e reduzida mortalidade ao ano&#46;</p></span>"
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        "resumen" => "<span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Introduction</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">The aim of this study was to document clinical practice in Portugal regarding the use of electronic cardiac devices in patients with heart failure &#40;HF&#41; and reduced left ventricular ejection fraction &#40;LVEF&#41;&#46;</p></span> <span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Methods</span><p id="spar0100" class="elsevierStyleSimplePara elsevierViewall">The S&#237;ncrone study was an observational prospective multicenter registry conducted in 16 centers in Portugal between 2006 and 2014&#46; It included adult patients with a diagnosis of HF&#44; LVEF &#60;35&#37; and indication for implantable cardioverter&#8208;defibrillator &#40;ICD&#41; and&#47;or cardiac resynchronization therapy &#40;CRT&#41; devices&#44; according to the recommendations of the European Society of Cardiology at the beginning of the study&#46; Patients were followed for one year according to the practice of each center&#46;</p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Results</span><p id="spar0105" class="elsevierStyleSimplePara elsevierViewall">A total of 486 patients were included in the registry&#44; half of whom received an ICD and the other half a CRT pacemaker &#40;CRT&#8208;P&#41; or CRT defibrillator &#40;CRT&#8208;D&#41;&#46; Mean age was 65&#177;12 years and the most frequent causes of HF were ischemic &#40;47&#37;&#41; and idiopathic dilated cardiomyopathy &#40;28&#37;&#41;&#46; Overall mortality at one year was 3&#46;6&#37; and the hospitalization rate was 11&#37;&#44; significantly higher in patients with CRT&#8208;P&#47;CRT&#8208;D than with ICD &#40;17&#37; vs&#46; 5&#46;6&#37;&#44; p&#60;0&#46;001&#41;&#46; Patients who received CRT&#8208;P&#47;CRT&#8208;D experienced significant reductions in QRS duration &#40;160&#177;21 vs&#46; 141&#177;24 ms&#44; p&#60;0&#46;001&#41; as well as improvement in New York Heart Association functional class&#46;</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Conclusion</span><p id="spar0110" class="elsevierStyleSimplePara elsevierViewall">The S&#237;ncrone study shows that the use of implantable devices in HF with reduced LVEF in Portugal is in accordance with international recommendations and that patients presented functional improvement and reduced one&#8208;year mortality&#46;</p></span>"
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          "pt" => "<p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">Preditores de mortalidade global ou reinternamento de causa cardiovascular</p> <p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">CRT&#58; terap&#234;utica de ressincroniza&#231;&#227;o card&#237;aca&#59; IC&#58; intervalo de confian&#231;a&#59; IMC&#58; &#237;ndice de massa corporal&#46;</p>"
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          "pt" => "<p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">Evolu&#231;&#227;o da classe funcional NYHA nos doentes submetidos a terap&#234;utica de ressincroniza&#231;&#227;o&#46;</p> <p id="spar0065" class="elsevierStyleSimplePara elsevierViewall">NYHA&#58; <span class="elsevierStyleItalic">New York Heart Association</span>&#46;</p>"
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          "leyenda" => "<p id="spar0075" class="elsevierStyleSimplePara elsevierViewall">CDI&#58; desfibrilhador cardioversor implant&#225;vel&#59; CRT&#58; terap&#234;utica de ressincroniza&#231;&#227;o card&#237;aca&#59; IECA&#47;ARA&#58; inibidores da enzima de convers&#227;o da angiotensina&#47;antoganistas do recetor da angiotensina II&#59; IMC&#58; &#237;ndice de massa corporal&#59; NYHA&#58; <span class="elsevierStyleItalic">New York Heart Association</span>&#59; TV&#47;FV&#58; taquicardia ventricular&#47;fibrilha&#231;&#227;o ventricular&#46;</p>"
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">27&#177;5&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t">27&#177;4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">0&#44;66&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " colspan="5" align="left" valign="\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">291 &#40;60&#37;&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">139 &#40;57&#37;&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">152 &#40;63&#37;&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">0&#44;23&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Diabetes&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">140 &#40;29&#37;&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">82 &#40;34&#37;&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">0&#44;01&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Dislipidemia&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">246 &#40;51&#37;&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">123 &#40;51&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">123 &#40;51&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t">1&#44;0&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " colspan="5" align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="\n
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                  \t\t\t\t  " colspan="5" align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleItalic">Etiologia da cardiopatia</span></td></tr><tr title="table-row"><td class="td-with-role" title="\n
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                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Isqu&#233;mica&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">229 &#40;47&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">144 &#40;59&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">85 &#40;35&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">&#60; 0&#44;001&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Dilatada Idiop&#225;tica&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">135 &#40;28&#37;&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">35 &#40;14&#37;&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">100 &#40;41&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t">&#60; 0&#44;001&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleItalic">Doen&#231;a Renal Cr&#243;nica</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">7 &#40;1&#44;7&#37;&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleItalic">n &#61;192</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="" valign="\n
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                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>IECA&#47;ARA&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Antiplaquetar&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Antiarr&#237;tmico&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">72 &#40;21&#37;&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">33 &#40;21&#37;&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">39 &#40;20&#37;&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">0&#44;87&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
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                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Dimens&#227;o telessist&#243;lica &#40;mm&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">53&#44;9&#177;13&#44;0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">51&#44;2&#177;13&#44;3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">55&#44;9&#177;12&#44;4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#44;01&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Volume telediast&#243;lico indexado &#40;ml&#47;m<span class="elsevierStyleSup">2</span>&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">103&#44;9&#177;32&#44;2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">94&#44;6&#177;20&#44;9&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">113&#44;9&#177;43&#44;4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#60; 0&#44;001&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Volume telessist&#243;lico indexado &#40;ml&#47;m<span class="elsevierStyleSup">2</span>&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">74&#44;1&#177;30&#44;5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">66&#44;5&#177;19&#44;7&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">78&#44;4&#177;33&#44;9&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#44;08&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Raz&#227;o E&#47;E&#8217;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">15&#44;7&#177;11&#44;0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">14&#44;8&#177;5&#44;2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">16&#44;2&#177;13&#44;2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#44;50&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Press&#227;o sist&#243;lica da art&#233;ria pulmonar &#40;mmHg&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">41&#44;6&#177;12&#44;0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">40&#44;7&#177;12&#44;2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">42&#44;1&#177;11&#44;9&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#44;55&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">TAPSE &#40;mm&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">18&#44;3&#177;4&#44;6&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">18&#44;2&#177;4&#44;6&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">18&#44;4&#177;4&#44;7&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#44;58&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
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                0 => """
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                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">N &#61; 419&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">CDI &#40;n &#61; 214&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">CRT &#40;n &#61; 205&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black"><span class="elsevierStyleItalic">p</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Isqu&#233;micos &#40;n &#61; 203&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">N&#227;o isqu&#233;micos&#40;n &#61; 216&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black"><span class="elsevierStyleItalic">p</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Mortalidade global&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">15 &#40;3&#44;6&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">5 &#40;2&#44;3&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">10 &#40;4&#44;9&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#44;162&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">11 &#40;5&#44;4&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">4 &#40;1&#44;9&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#44;050&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Mortalidade CV&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">8 &#40;1&#44;9&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1 &#40;0&#44;5&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">7 &#40;3&#44;4&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#44;028&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">6 &#40;3&#44;0&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2 &#40;0&#44;9&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#44;129&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Internamento global&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">46 &#40;11&#44;0&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">12 &#40;5&#44;6&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">34 &#40;17&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#60;0&#44;001&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">28 &#40;14&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">18 &#40;8&#44;3&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#44;074&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Internamento por IC&nbsp;\t\t\t\t\t\t\n
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