Letter to the Editor
Cangrelor as antiplatelet bridging therapy in non-cardiac surgery after percutaneous coronary intervention – First-time use in Portugal
Cangrelor como terapêutica antiplaquetária de bridging na cirurgia não cardíaca após intervenção coronária percutânea – Primeira utilização em Portugal
Inês Fialhoa,
, João B. Augustoa,b, Susana Fevereiroc, Miguel B. Santosa, Sérgio Bravo Baptistad, David Roquea
Autor para correspondência
a Cardiology Department, Hospital Professor Doutor Fernando Fonseca, Amadora, Portugal
b Institute of Cardiovascular Science, University College London, UK
c Transfusion Medicine Department, Hospital de Santa Cruz, Centro Hospitalar Lisboa Ocidental, Carnaxide, Portugal
d University Clinic of Cardiology, Faculty of Medicine at University of Lisbon, Lisboa, Portugal
Lido
3510
Vezesque se leu este artigo
1326
Total PDF
2184
Total HTML
Compartilhar estatísticas
array:24 [ "pii" => "S087025512200035X" "issn" => "08702551" "doi" => "10.1016/j.repc.2021.08.006" "estado" => "S300" "fechaPublicacion" => "2022-06-01" "aid" => "1903" "copyright" => "Sociedade Portuguesa de Cardiologia" "copyrightAnyo" => "2022" "documento" => "simple-article" "crossmark" => 1 "licencia" => "http://creativecommons.org/licenses/by-nc-nd/4.0/" "subdocumento" => "cor" "cita" => "Rev Port Cardiol. 2022;41:515-7" "abierto" => array:3 [ "ES" => true "ES2" => true "LATM" => true ] "gratuito" => true "lecturas" => array:1 [ "total" => 0 ] "itemSiguiente" => array:19 [ "pii" => "S0870255122000373" "issn" => "08702551" "doi" => "10.1016/j.repc.2021.08.007" "estado" => "S300" "fechaPublicacion" => "2022-06-01" "aid" => "1904" "copyright" => "Sociedade Portuguesa de Cardiologia" "documento" => "simple-article" "crossmark" => 1 "licencia" => "http://creativecommons.org/licenses/by-nc-nd/4.0/" "subdocumento" => "cor" "cita" => "Rev Port Cardiol. 2022;41:519-20" "abierto" => array:3 [ "ES" => true "ES2" => true "LATM" => true ] "gratuito" => true "lecturas" => array:1 [ "total" => 0 ] "en" => array:10 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Letter to the Editor</span>" "titulo" => "Relationship between arterial stiffness parameters and cardiovascular responses to maximal exercise testing in Parkinson's disease patients" "tienePdf" => "en" "tieneTextoCompleto" => "en" "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "519" "paginaFinal" => "520" ] ] "titulosAlternativos" => array:1 [ "pt" => array:1 [ "titulo" => "Relação entre parâmetros da rigidez arterial e resposta cardiovascular em prova de esforço máximo em pacientes com doença de Parkinson" ] ] "contieneTextoCompleto" => array:1 [ "en" => true ] "contienePdf" => array:1 [ "en" => true ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "Hélcio Kanegusuku, Marilia Almeida Correia, Paulo Longano, Erika Okamoto, Maria Elisa Pimentel Piemonte, Gabriel Grizzo Cucato, Raphael Mendes Ritti-Dias" "autores" => array:7 [ 0 => array:2 [ "nombre" => "Hélcio" "apellidos" => "Kanegusuku" ] 1 => array:2 [ "nombre" => "Marilia Almeida" "apellidos" => "Correia" ] 2 => array:2 [ "nombre" => "Paulo" "apellidos" => "Longano" ] 3 => array:2 [ "nombre" => "Erika" "apellidos" => "Okamoto" ] 4 => array:2 [ "nombre" => "Maria Elisa Pimentel" "apellidos" => "Piemonte" ] 5 => array:2 [ "nombre" => "Gabriel Grizzo" "apellidos" => "Cucato" ] 6 => array:2 [ "nombre" => "Raphael Mendes" "apellidos" => "Ritti-Dias" ] ] ] ] ] "idiomaDefecto" => "en" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0870255122000373?idApp=UINPBA00004E" "url" => "/08702551/0000004100000006/v3_202206160259/S0870255122000373/v3_202206160259/en/main.assets" ] "itemAnterior" => array:18 [ "pii" => "S0870255122001627" "issn" => "08702551" "doi" => "10.1016/j.repc.2022.04.006" "estado" => "S300" "fechaPublicacion" => "2022-06-01" "aid" => "1942" "documento" => "simple-article" "crossmark" => 1 "licencia" => "http://creativecommons.org/licenses/by-nc-nd/4.0/" "subdocumento" => "dis" "cita" => "Rev Port Cardiol. 2022;41:513-4" "abierto" => array:3 [ "ES" => true "ES2" => true "LATM" => true ] "gratuito" => true "lecturas" => array:1 [ "total" => 0 ] "en" => array:10 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Editorial comment</span>" "titulo" => "When an affliction doesn’t come alone" "tienePdf" => "en" "tieneTextoCompleto" => "en" "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "513" "paginaFinal" => "514" ] ] "titulosAlternativos" => array:1 [ "pt" => array:1 [ "titulo" => "Quando um mal não vem só" ] ] "contieneTextoCompleto" => array:1 [ "en" => true ] "contienePdf" => array:1 [ "en" => true ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "Alberto Mello e Silva" "autores" => array:1 [ 0 => array:2 [ "nombre" => "Alberto" "apellidos" => "Mello e Silva" ] ] ] ] ] "idiomaDefecto" => "en" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0870255122001627?idApp=UINPBA00004E" "url" => "/08702551/0000004100000006/v3_202206160259/S0870255122001627/v3_202206160259/en/main.assets" ] "en" => array:14 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Letter to the Editor</span>" "titulo" => "Cangrelor as antiplatelet bridging therapy in non-cardiac surgery after percutaneous coronary intervention – First-time use in Portugal" "tieneTextoCompleto" => true "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "515" "paginaFinal" => "517" ] ] "autores" => array:1 [ 0 => array:4 [ "autoresLista" => "Inês Fialho, João B. Augusto, Susana Fevereiro, Miguel B. Santos, Sérgio Bravo Baptista, David Roque" "autores" => array:6 [ 0 => array:4 [ "nombre" => "Inês" "apellidos" => "Fialho" "email" => array:1 [ 0 => "inesscfialho@gmail.com" ] "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] 1 => array:3 [ "nombre" => "João B." "apellidos" => "Augusto" "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] 2 => array:3 [ "nombre" => "Susana" "apellidos" => "Fevereiro" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">c</span>" "identificador" => "aff0015" ] ] ] 3 => array:3 [ "nombre" => "Miguel B." "apellidos" => "Santos" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 4 => array:3 [ "nombre" => "Sérgio Bravo" "apellidos" => "Baptista" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">d</span>" "identificador" => "aff0020" ] ] ] 5 => array:3 [ "nombre" => "David" "apellidos" => "Roque" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] ] "afiliaciones" => array:4 [ 0 => array:3 [ "entidad" => "Cardiology Department, Hospital Professor Doutor Fernando Fonseca, Amadora, Portugal" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Institute of Cardiovascular Science, University College London, UK" "etiqueta" => "b" "identificador" => "aff0010" ] 2 => array:3 [ "entidad" => "Transfusion Medicine Department, Hospital de Santa Cruz, Centro Hospitalar Lisboa Ocidental, Carnaxide, Portugal" "etiqueta" => "c" "identificador" => "aff0015" ] 3 => array:3 [ "entidad" => "University Clinic of Cardiology, Faculty of Medicine at University of Lisbon, Lisboa, Portugal" "etiqueta" => "d" "identificador" => "aff0020" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "pt" => array:1 [ "titulo" => "Cangrelor como terapêutica antiplaquetária de <span class="elsevierStyleItalic">bridging</span> na cirurgia não cardíaca após intervenção coronária percutânea – Primeira utilização em Portugal" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 1604 "Ancho" => 2167 "Tamanyo" => 137662 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">ADP-TEM test results for evaluation of adenosine diphosphate receptor-mediated platelet aggregation. The repreented values are the area under the curve (AUC) of each test, a measure of the overall platelet aggregation. Reference values of AUC ADP-TEM for citrated samples are 56-139 Ω*min (the lower the value, the better the inhibition). AUC: area under the curve.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Cangrelor is an intravenous adenosine triphosphate analog that reversibly blocks P2Y12 receptor-mediated platelet activation.<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">1</span></a> It has a quick onset of action and a short plasma half-life, enabling complete platelet function recovery within 60 minutes of stopping the infusion.<a class="elsevierStyleCrossRefs" href="#bib0040"><span class="elsevierStyleSup">2,3</span></a> Cangrelor is approved for co-administration with aspirin to reduce thrombotic events in patients with coronary artery disease, undergoing percutaneous coronary intervention (PCI), who have not received an oral P2Y12 inhibitor (P2Y12i) prior to the procedure and in whom oral P2Y12is are not feasible.<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">4</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">Stented patients who need urgent surgery are likely to experience an early suspension of dual antiplatelet therapy (DAPT), increasing the risk of stent thrombosis, or postponement of surgery due to bleeding risk concerns.<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">1</span></a> An effective and safe antiplatelet bridging therapy is of particular relevance in this setting.</p><p id="par0015" class="elsevierStylePara elsevierViewall">A 79-year-old man with rectal cancer under neoadjuvant chemotherapy suffered a non-ST-segment elevation myocardial infarction. Coronary angiography showed severe and complex osteal disease of the circumflex artery that was treated with a drug-eluting stent. The patient was considered to be at high thrombotic risk and DAPT with aspirin and ticagrelor was recommended for at least 12 months. Optimal timing for his rectal surgery was defined as 30 days after PCI. The high thrombotic risk associated with early suspension of P2Y12i was considered prohibitive. To avoid further delay in cancer surgery and worsening of the patient's prognosis, a special authorization for the off-label use of cangrelor as an antiplatelet bridging therapy was conceded by the Portuguese National Authority of Medicines and Health Products.</p><p id="par0020" class="elsevierStylePara elsevierViewall">The patient was admitted to the cardiology ward 30 days after PCI for antiplatelet bridging therapy (<a class="elsevierStyleCrossRef" href="#fig0005">Figure 1</a>). Ticagrelor was stopped five days before surgery and cangrelor infusion was started 48 hours later (day -3), at a dose of 0.75 mcg/kg/min, without bolus. Cangrelor infusion was performed for three days and stopped two hours before surgery. Aspirin therapy was not suspended. We used the ROTEM®-Platelet platform (TEM International GmbH, Munich, Germany) to measure platelet function at four points, based on impedance aggregometry (IPA): Test 1, 12 hours after ticagrelor suspension (day -5); Test 2, immediately before starting cangrelor (day -3); Test 3, 24 hours after starting cangrelor (day -2); and Test 4, one hour before surgery (day 0). IPA results showed effective antiplatelet inhibition until surgery (<a class="elsevierStyleCrossRef" href="#fig0010">Figure 2</a>). The patient underwent a laparoscopic rectal resection, without acute bleeding complications. Six hours after surgery, cangrelor was restarted and subsequently stopped on the first morning post-surgery, when oral drug administration became possible. Ticagrelor was resumed, as a loading dose, immediately after cangrelor suspension. During the postoperative period, there were no bleeding or thrombotic complications.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0025" class="elsevierStylePara elsevierViewall">The use of cangrelor in this setting is supported by the BRIDGE trial,<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">5</span></a> which showed a higher rate of platelet inhibition, without increasing major bleeding, in patients previously treated with oral P2Y12i awaiting cardiac surgery. Cangrelor bridging therapy should be started three days before surgery, maintained for two to seven days, and suspended one to six hours before surgery.<a class="elsevierStyleCrossRefs" href="#bib0035"><span class="elsevierStyleSup">1,2</span></a></p><p id="par0030" class="elsevierStylePara elsevierViewall">Although glycoprotein (GP) IIb/IIIa inhibitors have also been used as a bridging therapy, their safety and efficacy in this setting have not been clearly established.<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">6</span></a> They act in the final pathway of platelet aggregation, blocking the platelet response to all agonists.<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">6</span></a> They present disadvantages compared to cangrelor. Their plasma half-life is longer and they should be stopped four to six hours before surgery.<a class="elsevierStyleCrossRefs" href="#bib0035"><span class="elsevierStyleSup">1,6</span></a> The ideal bridging dose has not yet been determined, so the recommendation is to use the same dose as in PCI, without a loading dose.<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">1</span></a> Therapy should not exceed 72 hours to reduce bleeding risk.<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">1</span></a></p><p id="par0035" class="elsevierStylePara elsevierViewall">We report the first use of cangrelor as antiplatelet bridging therapy in Portugal. The absence of thrombotic or bleeding complications and the documentation of good platelet inhibition throughout bridging therapy suggest this strategy is safe and effective.</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Funding</span><p id="par0040" class="elsevierStylePara elsevierViewall">The authors have no funding</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Conflicts of interest</span><p id="par0045" class="elsevierStylePara elsevierViewall">Dr. Baptista reports receiving investigational grants from <span class="elsevierStyleGrantSponsor" id="gs1">AstraZeneca</span>.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:3 [ 0 => array:2 [ "identificador" => "sec0005" "titulo" => "Funding" ] 1 => array:2 [ "identificador" => "sec0010" "titulo" => "Conflicts of interest" ] 2 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "multimedia" => array:2 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1244 "Ancho" => 2508 "Tamanyo" => 246687 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Chronogram of antiplatelet bridging therapy with cangrelor and ticagrelor.</p>" ] ] 1 => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 1604 "Ancho" => 2167 "Tamanyo" => 137662 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">ADP-TEM test results for evaluation of adenosine diphosphate receptor-mediated platelet aggregation. The repreented values are the area under the curve (AUC) of each test, a measure of the overall platelet aggregation. Reference values of AUC ADP-TEM for citrated samples are 56-139 Ω*min (the lower the value, the better the inhibition). AUC: area under the curve.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0015" "bibliografiaReferencia" => array:6 [ 0 => array:3 [ "identificador" => "bib0035" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Management of antiplatelet therapy in patients with coronary artery disease requiring cardiac and noncardiac surgery" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "D. Capodanno" 1 => "D.J. Angiolillo" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1161/CIRCULATIONAHA.113.003675" "Revista" => array:6 [ "tituloSerie" => "Circulation" "fecha" => "2013" "volumen" => "128" "paginaInicial" => "2785" "paginaFinal" => "2798" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/24366588" "web" => "Medline" ] ] ] ] ] ] ] ] 1 => array:3 [ "identificador" => "bib0040" "etiqueta" => "2" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "International expert consensus on switching platelet P2Y <span class="elsevierStyleInf">12</span> receptor-inhibiting therapies" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:3 [ 0 => "D.J. Angiolillo" 1 => "F. Rollini" 2 => "R.F. Storey" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1161/CIRCULATIONAHA.117.031164" "Revista" => array:6 [ "tituloSerie" => "Circulation" "fecha" => "2017" "volumen" => "136" "paginaInicial" => "1955" "paginaFinal" => "1975" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/29084738" "web" => "Medline" ] ] ] ] ] ] ] ] 2 => array:3 [ "identificador" => "bib0045" "etiqueta" => "3" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Effect of platelet inhibition with cangrelor during PCI on ischemic events" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:3 [ 0 => "D.L. Bhatt" 1 => "G.W. Stone" 2 => "K.W. Mahaffey" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1056/NEJMoa1300815" "Revista" => array:6 [ "tituloSerie" => "N Engl J Med" "fecha" => "2013" "volumen" => "368" "paginaInicial" => "1303" "paginaFinal" => "1313" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/23473369" "web" => "Medline" ] ] ] ] ] ] ] ] 3 => array:3 [ "identificador" => "bib0050" "etiqueta" => "4" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Kangrexal - summary of product characteristics" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:1 [ 0 => "European Medicines Agency" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Libro" => array:1 [ "fecha" => "2015" ] ] ] ] ] ] 4 => array:3 [ "identificador" => "bib0055" "etiqueta" => "5" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Bridging antiplatelet therapy with cangrelor in patients undergoing cardiac surgery: a randomized controlled trial" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:3 [ 0 => "D.J. Angiolillo" 1 => "M.S. Firstenberg" 2 => "M.J. Price" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1001/jama.2011.2002" "Revista" => array:7 [ "tituloSerie" => "JAMA" "fecha" => "2012" "volumen" => "307" "paginaInicial" => "265" "paginaFinal" => "274" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/22253393" "web" => "Medline" ] ] "itemHostRev" => array:3 [ "pii" => "S003960601930114X" "estado" => "S300" "issn" => "00396060" ] ] ] ] ] ] ] 5 => array:3 [ "identificador" => "bib0060" "etiqueta" => "6" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Use of intravenous antiplatelet agents (cangrelor and GPIIb/IIIa inhibitors) in the modern era" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:3 [ 0 => "R. Chaudhary" 1 => "U. Tantry" 2 => "K. Bliden" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Libro" => array:1 [ "fecha" => "2018" ] ] ] ] ] ] ] ] ] ] ] "idiomaDefecto" => "en" "url" => "/08702551/0000004100000006/v3_202206160259/S087025512200035X/v3_202206160259/en/main.assets" "Apartado" => array:4 [ "identificador" => "93625" "tipo" => "SECCION" "en" => array:2 [ "titulo" => "Letters to the Editor" "idiomaDefecto" => true ] "idiomaDefecto" => "en" ] "PDF" => "https://static.elsevier.es/multimedia/08702551/0000004100000006/v3_202206160259/S087025512200035X/v3_202206160259/en/main.pdf?idApp=UINPBA00004E&text.app=https://revportcardiol.org/" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S087025512200035X?idApp=UINPBA00004E" ]
| Ano/Mês | Html | Total | |
|---|---|---|---|
| 2024 Novembro | 13 | 8 | 21 |
| 2024 Outubro | 70 | 42 | 112 |
| 2024 Setembro | 112 | 50 | 162 |
| 2024 Agosto | 71 | 61 | 132 |
| 2024 Julho | 66 | 47 | 113 |
| 2024 Junho | 64 | 33 | 97 |
| 2024 Maio | 71 | 37 | 108 |
| 2024 Abril | 60 | 50 | 110 |
| 2024 Maro | 83 | 30 | 113 |
| 2024 Fevereiro | 41 | 36 | 77 |
| 2024 Janeiro | 64 | 45 | 109 |
| 2023 Dezembro | 52 | 40 | 92 |
| 2023 Novembro | 69 | 53 | 122 |
| 2023 Outubro | 63 | 37 | 100 |
| 2023 Setembro | 49 | 35 | 84 |
| 2023 Agosto | 53 | 35 | 88 |
| 2023 Julho | 64 | 55 | 119 |
| 2023 Junho | 59 | 36 | 95 |
| 2023 Maio | 52 | 38 | 90 |
| 2023 Abril | 43 | 24 | 67 |
| 2023 Maro | 64 | 23 | 87 |
| 2023 Fevereiro | 58 | 33 | 91 |
| 2023 Janeiro | 40 | 23 | 63 |
| 2022 Dezembro | 55 | 24 | 79 |
| 2022 Novembro | 73 | 41 | 114 |
| 2022 Outubro | 74 | 44 | 118 |
| 2022 Setembro | 85 | 59 | 144 |
| 2022 Agosto | 123 | 43 | 166 |
| 2022 Julho | 93 | 49 | 142 |
| 2022 Junho | 147 | 80 | 227 |
| 2022 Maio | 44 | 29 | 73 |
| 2022 Abril | 57 | 39 | 96 |
| 2022 Maro | 52 | 47 | 99 |
Mostrar tudo
