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the use of fibrinolysis has decreased steadily and is nowadays rare&#44; while PCI has been used in more cases from 2007 onward&#46; However&#44; this progress has not been accompanied by significant improvements in time delays in recent years&#44; and there is considerable room for improvement&#44; both through more campaigns aimed at the prehospital stage and by improving referral after first medical contact&#46;<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">5</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">Stent for Life &#40;SFL&#41;&#44; founded in 2008 as a joint initiative of the European Society of Cardiology&#44; the European Association for Percutaneous Cardiovascular Interventions and EuroPCR in collaboration with EUCOMED&#44; aimed to increase the use of primary angioplasty for STEMI reperfusion therapy and to improve qualitative parameters&#44; in order to reduce mortality&#46;<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">6</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">Portugal participated in SFL from 2011&#44; and a national program was implemented to increase patient access to PCI and to improve its quality&#44; particularly by reducing the time between symptom onset and PCI&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">The SFL Portugal Task Force set out an action plan with three main aims&#58; to launch a national campaign to raise public awareness of the symptoms of STEMI and of the actions to be taken to ensure timely and appropriate treatment&#59; to cooperate with the emergency medical system &#40;EMS&#41; in order to improve patient routing&#44; by enabling direct admission to a hospital with PCI facilities and transfer from hospitals without such facilities to a PCI-capable hospital&#59; and to improve hospital performance in the treatment of STEMI by PCI&#46;<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">7</span></a></p><p id="par0030" class="elsevierStylePara elsevierViewall">To monitor the implementation of the initiative&#44; SFL carried out snapshot surveys during a one-month period in six consecutive years&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">This issue of the <span class="elsevierStyleItalic">Journal</span> sees the publication of an article based on these surveys by Cal&#233; et al&#46;&#44;<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">8</span></a> which evaluates performance indicators in high-risk populations &#40;elderly&#44; female and diabetic patients&#41;&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">There were no differences in the way elderly patients requested medical assistance after symptom onset compared to younger patients &#40;age &#60;75 years&#41;&#44; but older patients had longer patient and system delays&#44; resulting in greater delay to reperfusion treatment&#46; As a result&#44; elderly patients were less compliant with the times recommended by the European guidelines<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">2</span></a>&#58; only 32&#46;2&#37; of these patients presented first medical contact to electrocardiogram &#40;ECG&#41; time &#8804;10 min&#59; 43&#46;6&#37; presented door-to-balloon time &#8804;60 min&#59; 11&#46;3&#37; presented system delay &#8804;90 min&#59; and 2&#46;9&#37; presented treatment delay &#8804;120 min&#46; Multivariate analysis after adjustment of the variable &#8216;age&#8217; for gender and presence of diabetes showed that age was an independent predictor of patient delay longer than the median and of system delay &#62;90 min&#46; Patient and system delays did not decrease significantly over the study period&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">The authors draw attention to the fact that in elderly patients it is more likely that the clinical picture will be atypical and that the first ECG will be delayed&#44; leading to delays in diagnosis and time to reperfusion&#46; This reveals the importance of the need to perform an early ECG&#44; even in patients who do not present typical STEMI symptoms&#44; regardless of their classification on the Manchester triage system&#46; Other reasons for system delay are comorbidities&#44; presentation at a hospital without PCI capability&#44; and delay in inter-hospital transfer&#46;</p><p id="par0050" class="elsevierStylePara elsevierViewall">Women had longer system and treatment delays than men&#44; but after adjustment for age and presence of diabetes&#44; the variable &#8216;women&#8217; was not a predictor of system delay &#62;90 min&#46; The authors draw attention to the need for educational campaigns emphasizing that cardiovascular disease&#44; specifically STEMI&#44; is the leading cause of death in women&#46;</p><p id="par0055" class="elsevierStylePara elsevierViewall">Diabetic patients more often called the EMS number 112 than non-diabetic patients&#44; but the percentage of patients transferred to a hospital with PCI capability by the EMS was not significantly higher in diabetic patients&#46; This may be related to a higher probability of prehospital system error in medical triage of diabetic patients with STEMI&#44; possibly due to difficulties in interpreting symptoms&#46; However&#44; in multivariate analysis the presence of diabetes did not increase the risk of patient delay longer than the median or of system delay &#62;90 min&#46;</p><p id="par0060" class="elsevierStylePara elsevierViewall">The authors identify three risk groups &#40;elderly&#44; female and diabetic patients&#41; in whom myocardial infarction is more difficult to diagnose&#44; since the forms of presentation are often atypical&#46; Thus&#44; in addition to comprehensive and ongoing population campaigns on the need to call 112 even with less typical symptoms&#44; medical personnel at both prehospital and hospital admission stages need to be more aware of the need to perform an early ECG in these circumstances&#46; If there is an ECG diagnosis of STEMI&#44; and the patient is in the reperfusion window&#44; immediate transfer for PCI should be considered&#46;</p><p id="par0065" class="elsevierStylePara elsevierViewall">Thus&#44; if the groups with greater delays and greater risk of cardiovascular events are treated faster&#44; the quality of reperfusion in Portugal can be improved&#44; with consequent reduction in cardiovascular mortality&#46;</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Conflicts of interest</span><p id="par0070" class="elsevierStylePara elsevierViewall">The author has no conflicts of interest to declare&#46;</p></span></span>"
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Time to reperfusion in high-risk patients with myocardial infarction
Tempo até à reperfusão em doentes de alto risco com enfarte agudo do miocárdio
Jorge Mimoso
Serviço de Cardiologia, Centro Hospitalar e Universitário do Algarve, Faro, Portugal
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    "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Primary percutaneous coronary intervention &#40;PCI&#41; is the preferred reperfusion therapy for ST-segment elevation myocardial infarction &#40;STEMI&#41;&#44; reducing mortality&#44; reinfarction&#44; and stroke compared to thrombolytic therapy&#46;<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">1</span></a> This is true if performed expeditiously by an experienced team in centers with a high volume of PCI procedures&#46;<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">2</span></a> Therefore&#44; it is important to organize STEMI networks to reduce time delays and improve prognosis&#46;<a class="elsevierStyleCrossRefs" href="#bib0055"><span class="elsevierStyleSup">3&#44;4</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">In the Portuguese Registry of Acute Coronary Syndromes &#40;ProACS&#41;&#44; the use of fibrinolysis has decreased steadily and is nowadays rare&#44; while PCI has been used in more cases from 2007 onward&#46; However&#44; this progress has not been accompanied by significant improvements in time delays in recent years&#44; and there is considerable room for improvement&#44; both through more campaigns aimed at the prehospital stage and by improving referral after first medical contact&#46;<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">5</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">Stent for Life &#40;SFL&#41;&#44; founded in 2008 as a joint initiative of the European Society of Cardiology&#44; the European Association for Percutaneous Cardiovascular Interventions and EuroPCR in collaboration with EUCOMED&#44; aimed to increase the use of primary angioplasty for STEMI reperfusion therapy and to improve qualitative parameters&#44; in order to reduce mortality&#46;<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">6</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">Portugal participated in SFL from 2011&#44; and a national program was implemented to increase patient access to PCI and to improve its quality&#44; particularly by reducing the time between symptom onset and PCI&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">The SFL Portugal Task Force set out an action plan with three main aims&#58; to launch a national campaign to raise public awareness of the symptoms of STEMI and of the actions to be taken to ensure timely and appropriate treatment&#59; to cooperate with the emergency medical system &#40;EMS&#41; in order to improve patient routing&#44; by enabling direct admission to a hospital with PCI facilities and transfer from hospitals without such facilities to a PCI-capable hospital&#59; and to improve hospital performance in the treatment of STEMI by PCI&#46;<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">7</span></a></p><p id="par0030" class="elsevierStylePara elsevierViewall">To monitor the implementation of the initiative&#44; SFL carried out snapshot surveys during a one-month period in six consecutive years&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">This issue of the <span class="elsevierStyleItalic">Journal</span> sees the publication of an article based on these surveys by Cal&#233; et al&#46;&#44;<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">8</span></a> which evaluates performance indicators in high-risk populations &#40;elderly&#44; female and diabetic patients&#41;&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">There were no differences in the way elderly patients requested medical assistance after symptom onset compared to younger patients &#40;age &#60;75 years&#41;&#44; but older patients had longer patient and system delays&#44; resulting in greater delay to reperfusion treatment&#46; As a result&#44; elderly patients were less compliant with the times recommended by the European guidelines<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">2</span></a>&#58; only 32&#46;2&#37; of these patients presented first medical contact to electrocardiogram &#40;ECG&#41; time &#8804;10 min&#59; 43&#46;6&#37; presented door-to-balloon time &#8804;60 min&#59; 11&#46;3&#37; presented system delay &#8804;90 min&#59; and 2&#46;9&#37; presented treatment delay &#8804;120 min&#46; Multivariate analysis after adjustment of the variable &#8216;age&#8217; for gender and presence of diabetes showed that age was an independent predictor of patient delay longer than the median and of system delay &#62;90 min&#46; Patient and system delays did not decrease significantly over the study period&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">The authors draw attention to the fact that in elderly patients it is more likely that the clinical picture will be atypical and that the first ECG will be delayed&#44; leading to delays in diagnosis and time to reperfusion&#46; This reveals the importance of the need to perform an early ECG&#44; even in patients who do not present typical STEMI symptoms&#44; regardless of their classification on the Manchester triage system&#46; Other reasons for system delay are comorbidities&#44; presentation at a hospital without PCI capability&#44; and delay in inter-hospital transfer&#46;</p><p id="par0050" class="elsevierStylePara elsevierViewall">Women had longer system and treatment delays than men&#44; but after adjustment for age and presence of diabetes&#44; the variable &#8216;women&#8217; was not a predictor of system delay &#62;90 min&#46; The authors draw attention to the need for educational campaigns emphasizing that cardiovascular disease&#44; specifically STEMI&#44; is the leading cause of death in women&#46;</p><p id="par0055" class="elsevierStylePara elsevierViewall">Diabetic patients more often called the EMS number 112 than non-diabetic patients&#44; but the percentage of patients transferred to a hospital with PCI capability by the EMS was not significantly higher in diabetic patients&#46; This may be related to a higher probability of prehospital system error in medical triage of diabetic patients with STEMI&#44; possibly due to difficulties in interpreting symptoms&#46; However&#44; in multivariate analysis the presence of diabetes did not increase the risk of patient delay longer than the median or of system delay &#62;90 min&#46;</p><p id="par0060" class="elsevierStylePara elsevierViewall">The authors identify three risk groups &#40;elderly&#44; female and diabetic patients&#41; in whom myocardial infarction is more difficult to diagnose&#44; since the forms of presentation are often atypical&#46; Thus&#44; in addition to comprehensive and ongoing population campaigns on the need to call 112 even with less typical symptoms&#44; medical personnel at both prehospital and hospital admission stages need to be more aware of the need to perform an early ECG in these circumstances&#46; If there is an ECG diagnosis of STEMI&#44; and the patient is in the reperfusion window&#44; immediate transfer for PCI should be considered&#46;</p><p id="par0065" class="elsevierStylePara elsevierViewall">Thus&#44; if the groups with greater delays and greater risk of cardiovascular events are treated faster&#44; the quality of reperfusion in Portugal can be improved&#44; with consequent reduction in cardiovascular mortality&#46;</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Conflicts of interest</span><p id="par0070" class="elsevierStylePara elsevierViewall">The author has no conflicts of interest to declare&#46;</p></span></span>"
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Informação do artigo
ISSN: 08702551
Idioma original: Inglês
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2021 Julho 17 19 36
2021 Junho 32 30 62
2021 Maio 29 30 59
2021 Abril 71 57 128
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2021 Fevereiro 24 21 45
2021 Janeiro 50 22 72
2020 Dezembro 28 5 33
2020 Novembro 11 23 34
2020 Outubro 25 16 41
2020 Setembro 17 8 25
2020 Agosto 30 9 39
2020 Julho 20 9 29
2020 Junho 27 8 35
2020 Maio 30 10 40
2020 Abril 29 13 42
2020 Maro 34 15 49
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2019 Dezembro 35 16 51
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