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    "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">In patients with acute coronary syndromes &#40;ACS&#41;&#44; early coronary angiography followed by revascularization when feasible&#44; has gained wide acceptance in clinical practice&#44; due to improvements in prognosis and reduced mortality&#46; In ST elevation acute myocardial infarction &#40;STEMI&#41;&#44; the main objective is to perform primary angioplasty in less than 60 minutes&#44; or less than 90 minutes&#44; depending on whether the patient is admitted to a hospital with or without on-site percutaneous coronary intervention &#40;PCI&#41; capabilities&#46; Studies have shown that STEMI patients admitted directly to hospitals with PCI capabilities have shorter door-to-balloon times and reduced mortality&#46; In a real world setting&#44; this requires a well-organized regional network with pre-hospital triage and expedited decision-making&#46;<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">1</span></a> In non-ST-elevation ACS &#40;NSTE-ACS&#41; an immediate &#40;&#60;2 h&#41; or early invasive &#40;&#60;24 h&#41; strategy is also recommended in very high or high risk patients&#44; precluding an immediate or same day transfer to a hospital with PCI capabilities&#46;<a class="elsevierStyleCrossRefs" href="#bib0055"><span class="elsevierStyleSup">2&#44;3</span></a> However&#44; in patients with NSTE-ACS&#44; transfer to a hospital with PCI capabilities is less well established as a marker for risk of adverse events&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">In the paper from Miranda H et al&#46;&#44;<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">4</span></a> the authors aim to compare the outcomes of patients admitted to hospitals with and without on-site capabilities&#44; included in the nationwide Portuguese Registry of Acute Coronary Syndromes &#40;ProACS&#41;&#46; During an eight-year period&#44; from October 2010 to December 2018&#44; 28 hospitals included 17 789 patients&#44; 7396 &#40;41&#46;5&#37;&#41; of whom were in non-PCI capable hospitals&#46; More than half of the patients&#44; 56&#46;7&#37;&#44; had NSTE-ACS&#44; and the remaining 43&#46;3&#37; had STEMI&#46; Overall&#44; patients admitted to PCI-capable hospitals had more prior history of cardiovascular disease and higher use of pre-hospital services triage&#44; probably reflecting tertiary center patient selection biases and&#47;or greater knowledge of symptoms and emergency protocols for chest pain&#46; The majority of STEMI patients had primary PCI&#44; with only 2&#46;1&#37; receiving fibrinolysis in PCI-capable hospitals and 12&#46;9&#37; in non-PCI-capable hospitals&#46; However&#44; door-to-balloon times were sub-optimal in most patients&#44; with a median time of 42 minutes in PCI-capable hospitals&#44; compared to 140 minutes in non-PCI hospitals&#46; In patients with NSTE-ACS&#44; more than 80&#37; had an invasive strategy and around 50&#37; had subsequent revascularization performed&#46; Interestingly&#44; patients admitted to non-PCI hospitals had statistically significant higher rates of an invasive strategy and revascularization by PCI &#40;86&#46;8&#37; and 82&#46;2&#37; for the former and 54&#46;6&#37; and 50&#46;4&#37; for the latter&#44; comparing non-PCI to PCI hospitals&#41;&#46; The authors do not report data on invasive strategy timing according to risk in NSTE-ACS&#44; but patients admitted to non-PCI hospitals underwent a coronary angiography a median of one day later than those admitted to PCI hospitals&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">The authors used a propensity score analysis for adjusting the differences between groups admitted to PCI and non-PCI capable hospitals&#46; Slight differences were observed in in-hospital pharmacological treatment&#44; which were probably due to chance and did not have a meaningful impact on the overall results&#46; When outcomes were compared between patients admitted to PCI and non-PCI-capable hospitals&#44; patients in the former group were more prone to present with heart failure&#44; cardiogenic shock or resuscitated cardiac arrest&#46; Only mechanical complications and sustained ventricular tachycardia &#40;VT&#41; were more frequent in patients presenting to non-PCI hospitals&#46; After adjustments for the propensity score&#44; STEMI patients had a lower rate of sustained VT and NSTE-ACS had a higher rate of heart failure during hospitalization in PCI hospitals&#46; But overall&#44; no differences were found between groups in in-hospital death&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">The study from Miranda et al&#46; reinforces the expected finding that door-to-balloon times are higher in STEMI patients admitted to non-PCI-capable hospitals&#46; Surprisingly&#44; the reported difference on reperfusion timings&#44; did not translate into lower in-hospital mortality&#44; probably due to the fact that STEMI patients in PCI-hospitals presented with a higher rate of heart failure&#44; cardiogenic shock and resuscitated cardiac arrest&#44; differences impossible to adjust even when using a propensity score analysis&#46;<a class="elsevierStyleCrossRefs" href="#bib0070"><span class="elsevierStyleSup">5&#44;6</span></a> On the other hand&#44; catherization laboratories are not available in every hospital and the study from Miranda et al&#46; reinforces that transferring STEMI patients for primary PCI is a feasible and safe option&#46;<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">2</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">In NSTE-ACS patients&#44; an early invasive strategy is increasingly pursued&#44; particularly in very high and high-risk patients&#46;<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">3</span></a> In the paper from Miranda H et al&#46;&#44; 84&#37; of patients had an invasive strategy and&#44; in the majority&#44; the coronary angiography was performed in the first 72 hours&#44; with more than 50&#37; of those in the first 24 hours&#46; This reflects a high compliance with the guidelines&#44; whether patients are admitted to non-PCI or PCI-capable hospitals&#46; More than 50&#37; of NSTE-ACS patients were revascularized and as expected there were no differences in in-hospital death rates&#46; Patients with NSTE-ACS admitted to non-PCI hospitals might derive a similar benefit when compared to patients in PCI hospitals&#44; and early referral and transfer has shown to be safe and effective&#44; as reinforced by the Miranda H et al study&#46;<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">7</span></a> Also worthy of merit is the fact that NSTE-ACS patients admitted to non-PCI hospitals were not under-treated as has been reported elsewhere&#44; which should be celebrated in this nationwide registry population&#46;<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">8</span></a></p><p id="par0030" class="elsevierStylePara elsevierViewall">The study by Miranda et al&#46; uses the largest and longest registry in Portugal&#44; the ProACS&#44; and derives some important findings&#46; The management of ACS patients in non-PCI hospitals compared to PCI-capable hospitals&#44; shows a similar use of guideline-driven therapies and similar in-hospital mortality&#46; In STEMI patients&#44; the transfer to PCI-capable hospitals is feasible&#44; but the reperfusion times need improvement&#44; whatever the admission hospital type&#46; This opportunity has already been identified for the pre-hospital and regional network management&#46;<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">1</span></a> In NSTE-ACS the use of an almost universal and early invasive strategy translates into lower rates of adverse outcomes and even non-PCI hospitals show high adherence to guideline-recommended therapies&#46; Whether treating ACS patients in PCI or non-PCI hospitals&#44; doctors should aim to implement guideline-recommended therapies that have shown to improve prognosis&#46;<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">9</span></a></p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Conflicts of interest</span><p id="par0035" class="elsevierStylePara elsevierViewall">The author has no conflicts of interest to declare&#46;</p></span></span>"
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Editorial comment
On-site percutaneous coronary intervention: Does it matter when treating patients with acute coronary syndromes?
Intervenção coronária percutânea on site: importante quando se tratam doentes com síndromes coronárias agudas?
José Ferreira Santos
Serviço de Cardiologia, Hospital da Luz, Setúbal, Portugal
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        "titulo" => "Interven&#231;&#227;o coron&#225;ria percut&#226;nea <span class="elsevierStyleItalic">on site</span>&#58; importante quando se tratam doentes com s&#237;ndromes coron&#225;rias agudas&#63;"
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    "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">In patients with acute coronary syndromes &#40;ACS&#41;&#44; early coronary angiography followed by revascularization when feasible&#44; has gained wide acceptance in clinical practice&#44; due to improvements in prognosis and reduced mortality&#46; In ST elevation acute myocardial infarction &#40;STEMI&#41;&#44; the main objective is to perform primary angioplasty in less than 60 minutes&#44; or less than 90 minutes&#44; depending on whether the patient is admitted to a hospital with or without on-site percutaneous coronary intervention &#40;PCI&#41; capabilities&#46; Studies have shown that STEMI patients admitted directly to hospitals with PCI capabilities have shorter door-to-balloon times and reduced mortality&#46; In a real world setting&#44; this requires a well-organized regional network with pre-hospital triage and expedited decision-making&#46;<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">1</span></a> In non-ST-elevation ACS &#40;NSTE-ACS&#41; an immediate &#40;&#60;2 h&#41; or early invasive &#40;&#60;24 h&#41; strategy is also recommended in very high or high risk patients&#44; precluding an immediate or same day transfer to a hospital with PCI capabilities&#46;<a class="elsevierStyleCrossRefs" href="#bib0055"><span class="elsevierStyleSup">2&#44;3</span></a> However&#44; in patients with NSTE-ACS&#44; transfer to a hospital with PCI capabilities is less well established as a marker for risk of adverse events&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">In the paper from Miranda H et al&#46;&#44;<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">4</span></a> the authors aim to compare the outcomes of patients admitted to hospitals with and without on-site capabilities&#44; included in the nationwide Portuguese Registry of Acute Coronary Syndromes &#40;ProACS&#41;&#46; During an eight-year period&#44; from October 2010 to December 2018&#44; 28 hospitals included 17 789 patients&#44; 7396 &#40;41&#46;5&#37;&#41; of whom were in non-PCI capable hospitals&#46; More than half of the patients&#44; 56&#46;7&#37;&#44; had NSTE-ACS&#44; and the remaining 43&#46;3&#37; had STEMI&#46; Overall&#44; patients admitted to PCI-capable hospitals had more prior history of cardiovascular disease and higher use of pre-hospital services triage&#44; probably reflecting tertiary center patient selection biases and&#47;or greater knowledge of symptoms and emergency protocols for chest pain&#46; The majority of STEMI patients had primary PCI&#44; with only 2&#46;1&#37; receiving fibrinolysis in PCI-capable hospitals and 12&#46;9&#37; in non-PCI-capable hospitals&#46; However&#44; door-to-balloon times were sub-optimal in most patients&#44; with a median time of 42 minutes in PCI-capable hospitals&#44; compared to 140 minutes in non-PCI hospitals&#46; In patients with NSTE-ACS&#44; more than 80&#37; had an invasive strategy and around 50&#37; had subsequent revascularization performed&#46; Interestingly&#44; patients admitted to non-PCI hospitals had statistically significant higher rates of an invasive strategy and revascularization by PCI &#40;86&#46;8&#37; and 82&#46;2&#37; for the former and 54&#46;6&#37; and 50&#46;4&#37; for the latter&#44; comparing non-PCI to PCI hospitals&#41;&#46; The authors do not report data on invasive strategy timing according to risk in NSTE-ACS&#44; but patients admitted to non-PCI hospitals underwent a coronary angiography a median of one day later than those admitted to PCI hospitals&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">The authors used a propensity score analysis for adjusting the differences between groups admitted to PCI and non-PCI capable hospitals&#46; Slight differences were observed in in-hospital pharmacological treatment&#44; which were probably due to chance and did not have a meaningful impact on the overall results&#46; When outcomes were compared between patients admitted to PCI and non-PCI-capable hospitals&#44; patients in the former group were more prone to present with heart failure&#44; cardiogenic shock or resuscitated cardiac arrest&#46; Only mechanical complications and sustained ventricular tachycardia &#40;VT&#41; were more frequent in patients presenting to non-PCI hospitals&#46; After adjustments for the propensity score&#44; STEMI patients had a lower rate of sustained VT and NSTE-ACS had a higher rate of heart failure during hospitalization in PCI hospitals&#46; But overall&#44; no differences were found between groups in in-hospital death&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">The study from Miranda et al&#46; reinforces the expected finding that door-to-balloon times are higher in STEMI patients admitted to non-PCI-capable hospitals&#46; Surprisingly&#44; the reported difference on reperfusion timings&#44; did not translate into lower in-hospital mortality&#44; probably due to the fact that STEMI patients in PCI-hospitals presented with a higher rate of heart failure&#44; cardiogenic shock and resuscitated cardiac arrest&#44; differences impossible to adjust even when using a propensity score analysis&#46;<a class="elsevierStyleCrossRefs" href="#bib0070"><span class="elsevierStyleSup">5&#44;6</span></a> On the other hand&#44; catherization laboratories are not available in every hospital and the study from Miranda et al&#46; reinforces that transferring STEMI patients for primary PCI is a feasible and safe option&#46;<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">2</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">In NSTE-ACS patients&#44; an early invasive strategy is increasingly pursued&#44; particularly in very high and high-risk patients&#46;<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">3</span></a> In the paper from Miranda H et al&#46;&#44; 84&#37; of patients had an invasive strategy and&#44; in the majority&#44; the coronary angiography was performed in the first 72 hours&#44; with more than 50&#37; of those in the first 24 hours&#46; This reflects a high compliance with the guidelines&#44; whether patients are admitted to non-PCI or PCI-capable hospitals&#46; More than 50&#37; of NSTE-ACS patients were revascularized and as expected there were no differences in in-hospital death rates&#46; Patients with NSTE-ACS admitted to non-PCI hospitals might derive a similar benefit when compared to patients in PCI hospitals&#44; and early referral and transfer has shown to be safe and effective&#44; as reinforced by the Miranda H et al study&#46;<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">7</span></a> Also worthy of merit is the fact that NSTE-ACS patients admitted to non-PCI hospitals were not under-treated as has been reported elsewhere&#44; which should be celebrated in this nationwide registry population&#46;<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">8</span></a></p><p id="par0030" class="elsevierStylePara elsevierViewall">The study by Miranda et al&#46; uses the largest and longest registry in Portugal&#44; the ProACS&#44; and derives some important findings&#46; The management of ACS patients in non-PCI hospitals compared to PCI-capable hospitals&#44; shows a similar use of guideline-driven therapies and similar in-hospital mortality&#46; In STEMI patients&#44; the transfer to PCI-capable hospitals is feasible&#44; but the reperfusion times need improvement&#44; whatever the admission hospital type&#46; This opportunity has already been identified for the pre-hospital and regional network management&#46;<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">1</span></a> In NSTE-ACS the use of an almost universal and early invasive strategy translates into lower rates of adverse outcomes and even non-PCI hospitals show high adherence to guideline-recommended therapies&#46; Whether treating ACS patients in PCI or non-PCI hospitals&#44; doctors should aim to implement guideline-recommended therapies that have shown to improve prognosis&#46;<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">9</span></a></p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Conflicts of interest</span><p id="par0035" class="elsevierStylePara elsevierViewall">The author has no conflicts of interest to declare&#46;</p></span></span>"
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