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a mortalidade por DCV tem vindo a diminuir ao longo dos anos&#44; mantendo&#8208;se&#44; no entanto&#44; como a principal causa de morte&#46; Em 2015&#44; representou 29&#44;7&#37; da mortalidade total&#46;<a class="elsevierStyleCrossRef" href="#bib0225"><span class="elsevierStyleSup">5</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">Dentro das doen&#231;as cardiovasculares&#44; a cardiopatia isqu&#233;mica &#233; a que apresenta maior mortalidade&#46;<a class="elsevierStyleCrossRef" href="#bib0205"><span class="elsevierStyleSup">1</span></a> Neste contexto&#44; as s&#237;ndromes coron&#225;rias agudas com eleva&#231;&#227;o do segmento ST &#40;SCAcEST&#41; assumem particular import&#226;ncia dada a elevada mortalidade que&#44; quer na fase aguda quer no seguimento&#44; podem provocar&#46; Relativamente &#224;s op&#231;&#245;es de tratamento dispon&#237;veis&#44; a interven&#231;&#227;o coron&#225;ria percut&#226;nea prim&#225;ria &#40;ICPp&#41;&#44; comparativamente com a tromb&#243;lise&#44; demonstrou ser mais eficaz na redu&#231;&#227;o da mortalidade e dos eventos card&#237;acos adversos e tamb&#233;m mais segura com a redu&#231;&#227;o das complica&#231;&#245;es hemorr&#225;gicas graves&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">Independentemente do m&#233;todo de reperfus&#227;o coron&#225;ria escolhido&#44; este deve ser concretizado o mais rapidamente poss&#237;vel&#46; O progn&#243;stico do doente depende do tamanho do enfarte e este depende do tempo desde o in&#237;cio dos sintomas at&#233; &#224; reperfus&#227;o do tecido mioc&#225;rdio&#46;<a class="elsevierStyleCrossRef" href="#bib0395"><span class="elsevierStyleSup">6</span></a> Uma r&#225;pida restaura&#231;&#227;o do fluxo coron&#225;rio permite diminuir o tamanho do enfarte e consequentemente melhorar a morbilidade e a mortalidade dos doentes&#46;<a class="elsevierStyleCrossRef" href="#bib0400"><span class="elsevierStyleSup">7</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">A maioria dos hospitais em Portugal n&#227;o tem laborat&#243;rio de hemodin&#226;mica&#44; o que obriga &#224; transfer&#234;ncia dos doentes com SCAcEST para um hospital de refer&#234;ncia com essa capacidade&#46; O impacto das transfer&#234;ncias inter&#8208;hospitalares e dos atrasos associados no progn&#243;stico dos doentes tem sido um foco de aten&#231;&#227;o a n&#237;vel europeu e t&#234;m sido feitos esfor&#231;os para que estes atrasos sejam reduzidos&#46;<a class="elsevierStyleCrossRefs" href="#bib0405"><span class="elsevierStyleSup">8&#44;9</span></a> A exist&#234;ncia de protocolos regionais bem definidos &#233; uma estrat&#233;gia v&#225;lida para aumentar a propor&#231;&#227;o de doentes tratados dentro dos limites de tempo adequados&#46;<a class="elsevierStyleCrossRefs" href="#bib0415"><span class="elsevierStyleSup">10&#44;11</span></a> No entanto&#44; muitas vezes&#44; a ida a um hospital sem laborat&#243;rio de hemodin&#226;mica e a consequente transfer&#234;ncia inter&#8208;hospitalar produzem um atraso substancial na reperfus&#227;o do mioc&#225;rdio&#44;<a class="elsevierStyleCrossRefs" href="#bib0425"><span class="elsevierStyleSup">12&#44;13</span></a> com poss&#237;vel aumento da morbilidade e mortalidade&#46; Idealmente&#44; todos os doentes com SCAcEST deveriam ser orientados pelos sistemas m&#233;dicos de emerg&#234;ncia para hospitais capazes de efetuar ICPp de forma imediata&#46; No entanto&#44; o que se verifica na pr&#225;tica &#233; que muitos doentes recorrem por meios pr&#243;prios a hospitais sem laborat&#243;rio de hemodin&#226;mica&#44; atrasando desta forma o in&#237;cio de um tratamento que indiscutivelmente diminui a mortalidade&#46;<a class="elsevierStyleCrossRefs" href="#bib0425"><span class="elsevierStyleSup">12&#44;13</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">A finalidade deste estudo passa pela objetiva&#231;&#227;o do atraso dos doentes sujeitos a transfer&#234;ncias inter&#8208;hospitalares relativamente aos doentes admitidos diretamente no Hospital de Braga e pelo estabelecimento da sua influ&#234;ncia na mortalidade&#44; obtendo&#8208;se uma base para discuss&#227;o e eventual implanta&#231;&#227;o de medidas que possam melhorar o progn&#243;stico de um doente com SCAcEST na regi&#227;o do Minho&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">M&#233;todos</span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Tipo de estudo</span><p id="par0030" class="elsevierStylePara elsevierViewall">Observacional&#44; longitudinal e retrospetivo&#44; com componente descritivo e anal&#237;tico&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Popula&#231;&#227;o em estudo</span><p id="par0035" class="elsevierStylePara elsevierViewall">Compreendeu 1369 doentes com o diagn&#243;stico de EAMcEST submetidos a ICPp com sucesso no Laborat&#243;rio de Hemodin&#226;mica e Cardiologia de Interven&#231;&#227;o do Hospital de Braga&#44; desde 1 de junho de 2011 a 31 de maio de 2016&#46; Ap&#243;s uma an&#225;lise inicial&#44; verificou&#8208;se que 115 doentes apresentavam enfartes evolu&#237;dos &#40;&#62; 12 horas desde o in&#237;cio dos sintomas&#41;&#44; pelo que foram exclu&#237;dos&#46; De forma a evitar a duplica&#231;&#227;o de resultados&#44; exclu&#237;ram&#8208;se 12 doentes com um novo epis&#243;dio de EAMcEST na janela temporal selecionada&#46; Em 20 doentes n&#227;o foi poss&#237;vel realizar o seguimento cl&#237;nico a um ano&#44; pelo que se obteve uma popula&#231;&#227;o final de 1222 doentes&#46; Posteriormente&#44; estes doentes foram divididos em dois grupos tendo em conta o tipo de admiss&#227;o no Hospital de Braga&#58; admiss&#227;o direta &#40;AD&#41; ou transfer&#234;ncia inter&#8208;hospitalar &#40;TI&#41;&#46; Foram inclu&#237;dos no grupo da admiss&#227;o direta os doentes que recorreram por meios pr&#243;prios ao Servi&#231;o de Urg&#234;ncia &#40;SU&#41; do HB e aqueles que foram transportados diretamente para o HB pelo Instituto Nacional de Emerg&#234;ncia M&#233;dica &#40;INEM&#41;&#46; No grupo da transfer&#234;ncia inter&#8208;hospitalar foram inclu&#237;dos os doentes que chegaram ao HB transferidos de hospitais regionais sem capacidade de realiza&#231;&#227;o de ICPp&#46; Deste modo&#44; 37&#44;0&#37; dos doentes pertenciam ao grupo de admiss&#227;o direta &#40;n &#61; 452&#41; e 63&#44;0&#37; ao grupo transfer&#234;ncia inter&#8208;hospitalar &#40;n &#61; 770&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0205"><span class="elsevierStyleSup">1</span></a></p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">M&#233;todo de recolha de dados e dados em estudo</span><p id="par0040" class="elsevierStylePara elsevierViewall">Para a realiza&#231;&#227;o do presente estudo foram recolhidos dados do processo cl&#237;nico do doente atrav&#233;s dos sistemas inform&#225;ticos Glintt&#174;&#44; SimmaCardio&#174; e Plataforma de Dados de Sa&#250;de&#174;&#44; os quais foram registados numa base de dados informatizada&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">Foram recolhidos os seguintes dados&#58;<ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005"><span class="elsevierStyleLabel">&#8208;</span><p id="par0050" class="elsevierStylePara elsevierViewall">Sociodemogr&#225;ficos&#44; nomeadamente idade&#44; g&#233;nero&#44; peso&#44; altura e &#237;ndice de massa corporal&#59;</p></li><li class="elsevierStyleListItem" id="lsti0010"><span class="elsevierStyleLabel">&#8208;</span><p id="par0055" class="elsevierStylePara elsevierViewall">Cl&#237;nicos&#44; como a hist&#243;ria de diabetes <span class="elsevierStyleItalic">mellitus</span>&#44; hipertens&#227;o arterial&#44; dislipidemia&#44; tabagismo atual ou pr&#233;vio&#44; insufici&#234;ncia renal cr&#243;nica &#40;IRC&#41;&#59; antecedentes pessoais de EAM&#44; ICP e cirurgia de revasculariza&#231;&#227;o do mioc&#225;rdio &#40;<span class="elsevierStyleItalic">Coronary Artery Bypass Grafting</span> &#91;CABG&#93;&#41;&#59; tipo de EAMcEST &#40;anterior <span class="elsevierStyleItalic">versus</span> inferior&#47;lateral&#47;posterior&#41; e classe de Killip que os doentes apresentaram &#224; admiss&#227;o e durante o internamento&#59;</p></li><li class="elsevierStyleListItem" id="lsti0015"><span class="elsevierStyleLabel">&#8208;</span><p id="par0060" class="elsevierStylePara elsevierViewall">Angiogr&#225;ficos&#44; como a presen&#231;a ou aus&#234;ncia de doen&#231;a multivaso&#59;</p></li><li class="elsevierStyleListItem" id="lsti0020"><span class="elsevierStyleLabel">&#8208;</span><p id="par0065" class="elsevierStylePara elsevierViewall">Ecogr&#225;ficos&#44; como a fra&#231;&#227;o de eje&#231;&#227;o do ventr&#237;culo esquerdo&#44; sendo considerada a &#250;ltima avalia&#231;&#227;o antes da alta do doente&#59;</p></li><li class="elsevierStyleListItem" id="lsti0025"><span class="elsevierStyleLabel">&#8208;</span><p id="par0070" class="elsevierStylePara elsevierViewall">Par&#226;metros temporais relativos ao percurso do doente&#44; como a hora do in&#237;cio dos sintomas&#44; hora do primeiro contacto m&#233;dico &#40;<span class="elsevierStyleItalic">First Medical Contact &#8211;</span> Primeiro Contacto M&#233;dico &#91;FMC&#93;&#41; e hora de reperfus&#227;o coron&#225;ria por ICPp&#46;</p></li></ul></p><p id="par0075" class="elsevierStylePara elsevierViewall">Com o objetivo de agrupar os indiv&#237;duos em estudo foi colhida informa&#231;&#227;o sobre o tipo de admiss&#227;o do doente no Hospital de Braga&#44; crit&#233;rio j&#225; definido anteriormente&#46;</p><p id="par0080" class="elsevierStylePara elsevierViewall">Para analisar o progn&#243;stico dos doentes em estudo foram recolhidos dados sobre a mortalidade intra&#8208;hospitalar&#44; a 30 dias&#44; a seis meses e a um ano&#46;</p></span></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">Defini&#231;&#245;es</span><p id="par0090" class="elsevierStylePara elsevierViewall">O primeiro contacto m&#233;dico foi definido como o primeiro contacto com um servi&#231;o de sa&#250;de &#40;incluindo os servi&#231;os de sa&#250;de prim&#225;rios&#41;&#46; No caso dos doentes assistidos primariamente pelo INEM foi registado o momento em que uma VMER ou uma SIV chegava ao local onde estava o doente&#46; A hora de reperfus&#227;o foi considerada o momento em que a guia de angioplastia atravessava a les&#227;o <span class="elsevierStyleItalic">culprit</span>&#46;</p><p id="par0095" class="elsevierStylePara elsevierViewall">Estabeleceram&#8208;se tr&#234;s intervalos de tempo&#44; de acordo com o percurso do doente at&#233; &#224; ICPp&#44; nomeadamente o tempo desde o in&#237;cio dos sintomas at&#233; ao primeiro contacto m&#233;dico&#44; o tempo desde o primeiro contacto m&#233;dico at&#233; &#224; reperfus&#227;o e o tempo desde o in&#237;cio dos sintomas at&#233; &#224; reperfus&#227;o&#46;</p><p id="par0100" class="elsevierStylePara elsevierViewall">Considerou&#8208;se enfarte evolu&#237;do sempre que o intervalo de tempo desde o in&#237;cio dos sintomas at&#233; &#224; reperfus&#227;o fosse superior a 12 horas&#46;</p><p id="par0105" class="elsevierStylePara elsevierViewall">Definiu&#8208;se como sucesso da ICPp a obten&#231;&#227;o no final do procedimento de um fluxo TIMI &#8805; 2 e uma estenose residual m&#237;nima &#60; 30&#37;&#46;</p><p id="par0110" class="elsevierStylePara elsevierViewall">O diagn&#243;stico de doen&#231;a multivaso foi realizado angiograficamente&#44; tendo em considera&#231;&#227;o a presen&#231;a de uma estenose superior a 50&#37; em pelo menos uma das art&#233;rias epic&#225;rdicas <span class="elsevierStyleItalic">major</span> para al&#233;m da art&#233;ria <span class="elsevierStyleItalic">culprit</span> &#40;art&#233;ria respons&#225;vel pelo enfarte&#41;&#46;</p><p id="par0115" class="elsevierStylePara elsevierViewall">A estratifica&#231;&#227;o dos doentes segundo a classifica&#231;&#227;o de Killip foi baseada no seu exame f&#237;sico e no desenvolvimento de insufici&#234;ncia card&#237;aca&#46; Uma classifica&#231;&#227;o classe Killip IV foi atribu&#237;da aos doentes em choque cardiog&#233;nico&#46;<a class="elsevierStyleCrossRefs" href="#bib0270"><span class="elsevierStyleSup">14&#44;15</span></a></p><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0105">An&#225;lise estat&#237;stica dos dados</span><p id="par0120" class="elsevierStylePara elsevierViewall">Para tratamento dos dados utilizou&#8208;se o programa <span class="elsevierStyleItalic">IBM Statistical Package for the Social Sciences</span>&#174; &#40;IBM SPSS&#41; vers&#227;o 23&#44;0&#46;</p><p id="par0125" class="elsevierStylePara elsevierViewall">As vari&#225;veis estudadas para a carateriza&#231;&#227;o dos doentes em estudo foram divididas em vari&#225;veis cont&#237;nuas e vari&#225;veis categ&#243;ricas&#46; Para a an&#225;lise das vari&#225;veis cont&#237;nuas avaliou&#8208;se em primeiro lugar a sua distribui&#231;&#227;o&#44; sendo que nas vari&#225;veis em que foi verificada uma distribui&#231;&#227;o normal aproximadamente sim&#233;trica os resultados foram apresentados como m&#233;dia &#40;<span class="elsevierStyleItalic">M</span>&#41; e desvio padr&#227;o &#40;<span class="elsevierStyleItalic">DP</span>&#41;&#44; enquanto que nas vari&#225;veis sem distribui&#231;&#227;o normal os resultados foram reportados como mediana &#40;<span class="elsevierStyleItalic">Mdn</span>&#41; e amplitude interquartil &#40;<span class="elsevierStyleItalic">AIQ</span>&#41;&#46; A avalia&#231;&#227;o da normalidade foi feita com o teste Kolmogorov&#8208;Smirnov<span class="elsevierStyleItalic">&#44;</span> considerando distribui&#231;&#227;o normal para valores de p &#62; 0&#44;05 e complementada com a an&#225;lise da assimetria &#40;<span class="elsevierStyleItalic">skewnes</span>s&#41; e o coeficiente de achatamento &#40;<span class="elsevierStyleItalic">kurtose</span>&#41;&#46;<a class="elsevierStyleCrossRefs" href="#bib0280"><span class="elsevierStyleSup">16&#44;17</span></a></p><p id="par0130" class="elsevierStylePara elsevierViewall">De modo a comparar as vari&#225;veis cont&#237;nuas entre os dois grupos de doentes aplicaram&#8208;se testes param&#233;tricos para as vari&#225;veis com distribui&#231;&#227;o normal e testes n&#227;o param&#233;tricos para as restantes&#46; O teste param&#233;trico utilizado foi o Teste T para amostras independentes&#44; ap&#243;s avalia&#231;&#227;o da homogeneidade de vari&#226;ncias&#44; utilizando&#8208;se para este fim o teste de Levene&#46;<a class="elsevierStyleCrossRef" href="#bib0290"><span class="elsevierStyleSup">18</span></a> Como medida de tamanho do efeito para este teste foi calculado o g de Hedges &#40;g&#41;&#44; teste mais utilizado para tamanhos amostrais diferentes&#44; correspondendo valores pr&#243;ximos de 0&#44;2&#44; 0&#44;5 e 0&#44;8 a um efeito pequeno&#44; moderado e grande&#44; respetivamente&#46;<a class="elsevierStyleCrossRefs" href="#bib0295"><span class="elsevierStyleSup">19&#44;20</span></a> O teste Mann&#8208;Whitney foi o teste n&#227;o param&#233;trico aplicado&#44; sendo reportado o valor de <span class="elsevierStyleItalic">r</span>&#44; calculado pela f&#243;rmula r &#61; Z&#47;&#40;&#8730;n&#41;&#44; representando valores pr&#243;ximos de 0&#44;1&#44; 0&#44;3 e 0&#44;5 um efeito pequeno&#44; m&#233;dio e grande&#44; respetivamente&#46;<a class="elsevierStyleCrossRef" href="#bib0300"><span class="elsevierStyleSup">20</span></a></p><p id="par0135" class="elsevierStylePara elsevierViewall">Na descri&#231;&#227;o das vari&#225;veis categ&#243;ricas foram calculadas as respetivas frequ&#234;ncias absolutas &#40;n&#41; e relativas &#40;&#37;&#41;&#46; A compara&#231;&#227;o das propor&#231;&#245;es entre os grupos em estudo foi feita atrav&#233;s do teste qui&#8208;quadrado &#40;&#967;<span class="elsevierStyleSup">2</span>&#41; ou teste exato de Fisher&#44; quando a percentagem das c&#233;lulas da tabela com frequ&#234;ncia esperada inferior a cinco se apresentava superior a 20&#37;&#46; Reportaram&#8208;se os valores da corre&#231;&#227;o de continuidade nas tabelas de conting&#234;ncia 2x2&#46;<a class="elsevierStyleCrossRef" href="#bib0290"><span class="elsevierStyleSup">18</span></a> Para avaliar o tamanho do efeito dos testes referidos foi analisado o coeficiente <span class="elsevierStyleItalic">phi</span> &#40;<span class="elsevierStyleItalic">&#966;&#41;</span> para tabelas 2x2&#44; com valores pr&#243;ximos de 0&#44;1&#44; 0&#44;3&#44; 0&#44;5 a corresponder a efeitos pequeno&#44; m&#233;dio e grande&#44; respetivamente&#46;<a class="elsevierStyleCrossRef" href="#bib0300"><span class="elsevierStyleSup">20</span></a></p><p id="par0140" class="elsevierStylePara elsevierViewall">Para avaliar a distribui&#231;&#227;o cumulativa da mortalidade a um ano dos doentes em fun&#231;&#227;o do tempo foram criados gr&#225;ficos para os tr&#234;s intervalos de tempo definidos &#40;sintomas&#8208;primeiro contacto m&#233;dico&#44; primeiro contacto m&#233;dico&#8208;reperfus&#227;o e sintomas&#8208;reperfus&#227;o&#41;&#46;</p><p id="par0145" class="elsevierStylePara elsevierViewall">A an&#225;lise da sobreviv&#234;ncia a um ano efetuou&#8208;se com o m&#233;todo de Kaplan&#8208;Meier&#44; comparando os grupos atrav&#233;s do teste <span class="elsevierStyleItalic">Log&#8208;rank&#46;</span></p><p id="par0150" class="elsevierStylePara elsevierViewall">Realizou&#8208;se uma an&#225;lise multivariada com a regress&#227;o de Cox&#44; ajustada para confundidores que se revelaram estatisticamente significativos na an&#225;lise univariada&#44; para determinar se o tipo de admiss&#227;o do doente constitu&#237;a um preditor independente de mortalidade a um ano&#46; Analisou&#8208;se o <span class="elsevierStyleItalic">Hazard Ratio &#40;HR&#41;</span> ajustado para confundidores&#44; em conjunto com um intervalo de confian&#231;a &#40;IC&#41; de 95&#37;&#46;<a class="elsevierStyleCrossRef" href="#bib0305"><span class="elsevierStyleSup">21</span></a></p><p id="par0155" class="elsevierStylePara elsevierViewall">A rela&#231;&#227;o entre o intervalo de tempo desde o primeiro contacto m&#233;dico at&#233; &#224; reperfus&#227;o e a mortalidade a um ano foi avaliada como uma fun&#231;&#227;o cont&#237;nua&#44; atrav&#233;s de uma regress&#227;o log&#237;stica univariada &#40;a mortalidade a um ano foi a vari&#225;vel dependente e o intervalo de tempo FMC&#8208;reperfus&#227;o &#91;em minutos&#93; a vari&#225;vel independente&#41;&#46;</p><p id="par0160" class="elsevierStylePara elsevierViewall">Em todas as an&#225;lises realizadas foram considerados estatisticamente significativos os resultados com valores de probabilidade <span class="elsevierStyleItalic">p</span> &#60; 0&#44;05&#44; com exce&#231;&#227;o do teste Kolmogorov&#8208;Smirnov e teste de Levene&#44; cujos pressupostos se consideraram cumpridos para valores de <span class="elsevierStyleItalic">p</span> &#62; 0&#44;05&#46;<a class="elsevierStyleCrossRef" href="#bib0290"><span class="elsevierStyleSup">18</span></a></p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0110">Confidencialidade e considera&#231;&#245;es &#233;ticas</span><p id="par0165" class="elsevierStylePara elsevierViewall">No decorrer deste estudo n&#227;o se aplicaram question&#225;rios aos doentes&#46; Assegurou&#8208;se a confidencialidade e o anonimato de todos os dados recolhidos atrav&#233;s da atribui&#231;&#227;o de um c&#243;digo numa base de dados informatizada&#46; Foi atribu&#237;do a cada doente do estudo um n&#250;mero identificativo &#40;c&#243;digo&#41;&#44; sendo que a correspond&#234;ncia entre o c&#243;digo e o participante do estudo foi registada num documento guardado somente pelo investigador principal&#46;</p><p id="par0170" class="elsevierStylePara elsevierViewall">Este estudo foi aprovado pela Comiss&#227;o de &#201;tica para a Sa&#250;de do Hospital de Braga &#40;CESHB&#41; e pela Subcomiss&#227;o de &#201;tica para as Ci&#234;ncias da Vida e da Sa&#250;de &#40;SECVS&#41; da Universidade do Minho &#8211; Escola de Medicina&#46;</p><p id="par0175" class="elsevierStylePara elsevierViewall">As Regras de Conduta &#201;tica e de Boas Pr&#225;ticas foram garantidas para que fossem cumpridos os preceitos da Declara&#231;&#227;o de Hels&#237;nquia &#40;com as emendas de T&#243;quio 1975&#44; Veneza 1983&#44; Hong&#8208;Kong 1989&#44; Somerset West 1996&#44; Edimburgo 2000&#44; Washington 2002&#44; T&#243;quio 2004&#44; Seul 2008 e Fortaleza 2013&#41;&#44; a Conven&#231;&#227;o sobre os Direitos do Homem e da Biomedicina&#44; as orienta&#231;&#245;es do <span class="elsevierStyleItalic">Council for International Organizations of Medical Sciences</span> e o Guia das Boas Pr&#225;ticas Cl&#237;nicas &#40;ICH&#44; GCP&#41;&#46;<a class="elsevierStyleCrossRefs" href="#bib0310"><span class="elsevierStyleSup">22&#8211;25</span></a></p></span></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0115">Resultados</span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0120">An&#225;lise descritiva e inferencial</span><p id="par0180" class="elsevierStylePara elsevierViewall">Caracter&#237;sticas basais dos grupos em estudo</p><p id="par0185" class="elsevierStylePara elsevierViewall">Na <a class="elsevierStyleCrossRef" href="#tbl0005">Tabela 1</a> s&#227;o apresentados os resultados da an&#225;lise &#224;s caracter&#237;sticas basais dos dois grupos em estudo&#44; admiss&#227;o direta e transfer&#234;ncia inter&#8208;hospitalar&#46; No que diz respeito &#224;s caracter&#237;sticas sociodemogr&#225;ficas dos doentes&#44; n&#227;o se observaram diferen&#231;as estatisticamente significativas&#46; No entanto&#44; &#233; relevante salientar que&#44; apesar de n&#227;o se ter demonstrada signific&#226;ncia estat&#237;stica na diferen&#231;a de idades entre os grupos em estudo &#40;M &#61; 62&#44;0&#44; DP &#61; 14 <span class="elsevierStyleItalic">versus</span> M &#61; 61&#44;0&#44; DP &#61; 13&#44;3&#58; t &#91;1220&#93; &#61; 1&#44;2&#44; p &#61; 0&#44;239&#44; g &#61; 0&#44;074&#41;&#44; numa an&#225;lise ao subgrupo dos doentes com idade igual ou superior a 75 anos constatou&#8208;se que os doentes da AD eram mais velhos &#40;M &#61; 82&#44;7&#44; DP &#61; 5&#44;3 <span class="elsevierStyleItalic">versus</span> M &#61; 80&#44;8&#44; DP &#61; 4&#44;6&#58; t &#91;183&#93; &#61; 2&#44;9&#44; p &#61; 0&#44;004&#44; g &#61; 0&#44;39<span class="elsevierStyleItalic">&#41;</span>&#46; Relativamente aos outros fatores de risco cardiovascular&#44; como obesidade&#44; diabetes <span class="elsevierStyleItalic">mellitus</span>&#44; hipertens&#227;o arterial&#44; dislipidemia&#44; tabagismo e insufici&#234;ncia renal cr&#243;nica&#44; os dois grupos n&#227;o diferiram de forma significativa&#46; Tamb&#233;m nos antecedentes de doen&#231;a coron&#225;ria e no tipo de enfarte com que os doentes se apresentaram n&#227;o se verificaram diferen&#231;as estatisticamente significativas&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0190" class="elsevierStylePara elsevierViewall">Quanto &#224; forma de apresenta&#231;&#227;o&#44; verificou&#8208;se que a propor&#231;&#227;o de doentes com classe de Killip IV &#40;choque cardiog&#233;nico&#41; &#224; admiss&#227;o era significativamente superior nos doentes com admiss&#227;o direta no HB em compara&#231;&#227;o com os doentes com transfer&#234;ncia inter&#8208;hospitalar &#40;5&#44;8&#37; <span class="elsevierStyleItalic">vs&#46;</span> 3&#44;2&#37;&#44; <span class="elsevierStyleItalic">X</span><span class="elsevierStyleSup"><span class="elsevierStyleItalic">2</span></span> &#91;1&#44; N &#61; 1&#46;222&#93; &#61; 5&#44;43&#44; p &#61; 0&#44;049&#44; &#966; <span class="elsevierStyleItalic">&#61;</span> 0&#44;079&#41;&#46; Tamb&#233;m a propor&#231;&#227;o de doentes que desenvolveram choque cardiog&#233;nico durante todo o per&#237;odo de internamento foi superior no grupo da admiss&#227;o direta &#40;10&#37; <span class="elsevierStyleItalic">vs&#46;</span> 5&#46;8&#37;&#44; <span class="elsevierStyleItalic">X</span><span class="elsevierStyleSup"><span class="elsevierStyleItalic">2</span></span> &#91;1&#44; N &#61; 1&#46;222&#93; &#61; 6&#44;47&#44; p &#61; 0&#44;011&#44; &#966; &#61; 0&#44;076&#41;&#46; <a class="elsevierStyleCrossRef" href="#fig0005">Figura 1</a></p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0195" class="elsevierStylePara elsevierViewall">No que concerne &#224;s caracter&#237;sticas angiogr&#225;ficas e ecocardiogr&#225;ficas n&#227;o se identificaram diferen&#231;as significativas entre os doentes&#46;</p><p id="par0200" class="elsevierStylePara elsevierViewall">A <a class="elsevierStyleCrossRef" href="#fig0010">Figura 2</a> mostra a distribui&#231;&#227;o cumulativa dos doentes em fun&#231;&#227;o do tempo para os tr&#234;s intervalos de tempo definidos &#40;sintomas&#8208;primeiro contacto m&#233;dico&#44; primeiro contacto m&#233;dico&#8208;reperfus&#227;o e sintomas&#8208;reperfus&#227;o&#41;&#46; A sua an&#225;lise permitiu constatar que o grupo de doentes da AD apresentou intervalos de tempo inferiores comparativamente aos doentes da TI&#44; nomeadamente&#58; quanto ao tempo desde o in&#237;cio dos sintomas at&#233; ao primeiro contacto m&#233;dico &#40;<span class="elsevierStyleItalic">Mdn</span> &#61; 76&#44;5&#44; <span class="elsevierStyleItalic">AIQ</span> &#91;40&#44;3&#8208;150&#93; <span class="elsevierStyleItalic">vs&#46; Mdn</span> &#61; 91&#44;0&#44; <span class="elsevierStyleItalic">AIQ</span> &#91;50&#8208;180&#93;&#44; <span class="elsevierStyleItalic">U</span> &#61; 155&#46;421&#44; <span class="elsevierStyleItalic">p</span> &#61; 0&#44;002&#44; <span class="elsevierStyleItalic">r</span> &#61; 0&#44;090&#41;&#44; desde o primeiro contacto m&#233;dico at&#233; &#224; reperfus&#227;o coron&#225;ria &#40;<span class="elsevierStyleItalic">Mdn</span> &#61; 87&#44;5&#44; <span class="elsevierStyleItalic">AIQ</span> &#91;69&#44;0&#8208;114&#93; <span class="elsevierStyleItalic">vs&#46; Mdn</span> &#61; 145&#44; <span class="elsevierStyleItalic">AIQ</span> &#91;115&#8208;199&#93;&#44; <span class="elsevierStyleItalic">U</span> &#61; 61&#46;915&#44; <span class="elsevierStyleItalic">p</span> &#60; 0&#44;001&#44; <span class="elsevierStyleItalic">r</span> &#61; 0&#44;54&#41; e&#44; consequentemente&#44; desde o in&#237;cio dos sintomas at&#233; &#224; reperfus&#227;o coron&#225;ria &#40;<span class="elsevierStyleItalic">Mdn</span> &#61; 177&#44; <span class="elsevierStyleItalic">AIQ</span> &#91;125&#8208;265&#93; <span class="elsevierStyleItalic">vs</span>&#46; <span class="elsevierStyleItalic">Mdn</span> &#61; 265&#44; <span class="elsevierStyleItalic">AIQ</span> &#91;188&#8208;400&#93;&#44; <span class="elsevierStyleItalic">U</span> &#61; 103&#46;233&#44; <span class="elsevierStyleItalic">p</span> &#60; 0&#44;001&#44; <span class="elsevierStyleItalic">r</span> &#61; 0&#44;34&#41;&#46;</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia></span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0125">Mortalidade durante o seguimento</span><p id="par0205" class="elsevierStylePara elsevierViewall">Como se pode observar na <a class="elsevierStyleCrossRef" href="#tbl0010">Tabela 2</a> no que diz respeito &#224; mortalidade ao fim de um ano&#44; n&#227;o se verificaram diferen&#231;as significativas entre os dois grupos &#40;11&#44;7&#37; <span class="elsevierStyleItalic">versus</span> 9&#44;2&#37; X<span class="elsevierStyleSup">2 &#91;</span>1&#44;N &#61; 1&#46;222&#93; &#61; 1&#44;70&#44; p &#61; 0&#44;193&#44; &#966; &#61; 0&#44;040&#41;&#46; Tamb&#233;m na mortalidade intra&#8208;hospitalar e na mortalidade ap&#243;s a alta os dois grupos n&#227;o diferiram significativamente&#46;</p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><p id="par0210" class="elsevierStylePara elsevierViewall">As curvas de Kaplan&#8208;Meier para a sobreviv&#234;ncia dos dois grupos&#44; apresentadas na <a class="elsevierStyleCrossRef" href="#fig0015">Figura 3</a>&#44; tamb&#233;m n&#227;o registaram diferen&#231;as significativas &#40;<span class="elsevierStyleItalic">Log&#8208;rank</span> p &#61; 0&#44;162&#41;&#46;</p><elsevierMultimedia ident="fig0015"></elsevierMultimedia><p id="par0215" class="elsevierStylePara elsevierViewall">O tipo de admiss&#227;o hospitalar n&#227;o demonstrou ser um preditor independente de mortalidade a um ano na an&#225;lise multivariada &#40;HR &#61; 0&#44;99&#44; IC 95&#37; &#91;0&#44;63&#8208;1&#44;55&#93;&#44; <span class="elsevierStyleItalic">p</span> &#61; 0&#44;946&#41;&#44; sendo esta &#250;ltima ajustada para confundidores que se revelaram significativos na an&#225;lise univariada &#40;<a class="elsevierStyleCrossRef" href="#fig0015">Figura 3</a>&#41;&#46; Por sua vez&#44; verificou&#8208;se que a idade &#40;HR &#61; 1&#44;09&#44; IC 95&#37; &#91;1&#44;07&#8208;1&#44;11&#93;&#44; <span class="elsevierStyleItalic">p</span> &#60; 0&#44;001&#41;&#44; a IRC &#40;HR &#61; 3&#44;05&#44; IC 95&#37; &#91;1&#44;38&#8208;6&#44;78&#93; <span class="elsevierStyleItalic">p</span> &#61; 0&#44;006&#41;&#44; a classe de Killip IV &#224; admiss&#227;o &#40;HR &#61;11&#44;2&#44; IC 95&#37; &#91;6&#44;35&#8208;19&#44;8&#93;&#44; <span class="elsevierStyleItalic">p</span> &#60; 0&#44;001&#41; e o intervalo de tempo sintomas&#8208;reperfus&#227;o &#40;HR &#61;1&#44;001&#44; IC 95&#37; &#91;1&#44;001&#8208;1&#44;003&#93;&#44; <span class="elsevierStyleItalic">p</span> &#61; 0&#44;034&#41; tiveram impacto na mortalidade dos doentes a um ano&#44; sendo preditores independentes&#46;</p><p id="par0220" class="elsevierStylePara elsevierViewall">Quando analisado como uma fun&#231;&#227;o cont&#237;nua atrav&#233;s de uma regress&#227;o log&#237;stica univariada&#44; o intervalo de tempo desde o primeiro contacto m&#233;dico at&#233; &#224; reperfus&#227;o na popula&#231;&#227;o em estudo correlacionou&#8208;se inversamente com a mortalidade a um ano &#40;<span class="elsevierStyleItalic">odds ratio</span> &#91;OR&#93;&#58;1&#44;003&#44; IC 95&#37; &#91;1&#44;002&#8208;1&#44;005&#93;&#44; p &#60; 0&#44;001&#41; &#40;<a class="elsevierStyleCrossRef" href="#fig0020">Figura 4</a>&#41;&#46; Al&#233;m disso&#44; a an&#225;lise da sua curva permitiu observar que o impacto na mortalidade aumentou de uma forma apenas ligeira durante os primeiros 210 minutos&#44; ao contr&#225;rio do que aconteceu da&#237; para a frente&#46;</p><elsevierMultimedia ident="fig0020"></elsevierMultimedia><p id="par0225" class="elsevierStylePara elsevierViewall">Relativamente &#224; rela&#231;&#227;o entre o choque cardiog&#233;nico e a mortalidade&#44; verificou&#8208;se que os doentes que desenvolveram choque cardiog&#233;nico durante o per&#237;odo de internamento apresentaram mortalidade superior a 60&#37; em ambos os grupos &#40;62&#44;2&#37; <span class="elsevierStyleItalic">versus</span> 64&#44;4&#37;&#44; X<span class="elsevierStyleSup">2</span> &#91;1&#44; N &#61; 90&#93; &#61; 0&#44; p &#62; 0&#44;999&#44; &#966; &#61; 0&#44;076&#41;&#46; Por outro lado&#44; observa&#8208;se que a mortalidade a um ano ocorreu em 52&#44;8&#37; dos doentes que estiveram em choque cardiog&#233;nico durante o internamento no grupo da admiss&#227;o direta e em 40&#44;8&#37; dos doentes do grupo da transfer&#234;ncia inter&#8208;hospitalar &#40;X<span class="elsevierStyleSup">2</span> &#91;1&#44;N &#61; 124&#93; &#61; 1&#44;31&#44; p &#61; 0&#44;253&#44; &#966; &#61; 0&#44;119&#41; &#40;<a class="elsevierStyleCrossRef" href="#fig0025">Figura 5</a>&#41;&#46;</p><elsevierMultimedia ident="fig0025"></elsevierMultimedia></span></span><span id="sec0060" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0130">Discuss&#227;o</span><p id="par0230" class="elsevierStylePara elsevierViewall">No presente estudo&#44; os resultados obtidos nos dois componentes do tempo total de isquemia &#40;in&#237;cio dos sintomas&#8208;primeiro contacto m&#233;dico e primeiro contacto m&#233;dico&#8208;reperfus&#227;o&#41; podem ser considerados&#44; de uma forma geral&#44; aceit&#225;veis&#46; Verificou&#8208;se que&#44; embora com diferen&#231;as estatisticamente significativas&#44; os doentes de ambos os grupos s&#227;o r&#225;pidos a recorrer ao sistema de sa&#250;de ap&#243;s o in&#237;cio dos sintomas&#44; apresentando uma mediana de 76&#44;5 minutos &#40;40&#44;3&#8208;150&#41; o grupo da admiss&#227;o direta e 910 minutos &#40;50&#8208;180&#41; o grupo da transfer&#234;ncia inter&#8208;hospitalar &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Figura 2</a>&#8208;A&#41;&#46; Estes resultados nas medianas n&#227;o escondem que&#44; sobretudo no &#250;ltimo quartil&#44; onde a demora &#233; superior a 150 minutos e 180 minutos respetivamente no grupo AD e no grupo TI&#44; haja uma parte significativa dos doentes a recorrer demasiado tarde ao sistema de sa&#250;de&#46; Este &#233; um ponto que urge melhorar&#44; o que &#233; poss&#237;vel fazer com a realiza&#231;&#227;o de extensas e repetidas campanhas de informa&#231;&#227;o dirigidas &#224; popula&#231;&#227;o&#44; que alertem sobre os sinais e sintomas do enfarte agudo do mioc&#225;rdio e sobre a atitude a ter nessa situa&#231;&#227;o&#46;<a class="elsevierStyleCrossRefs" href="#bib0405"><span class="elsevierStyleSup">8&#44;26</span></a></p><p id="par0235" class="elsevierStylePara elsevierViewall">Quanto ao intervalo de tempo que decorre entre o primeiro contacto m&#233;dico e a reperfus&#227;o&#44; o grupo da admiss&#227;o direta apresentou bons resultados com uma mediana de 87&#44;5 minutos &#40;69&#44;0&#8208;114&#41;&#46; Se considerarmos o tempo m&#225;ximo recomendado pelos <span class="elsevierStyleItalic">guidelines</span>&#44; que s&#227;o 120 minutos&#44; verificamos que 78&#44;8&#37; dos doentes foram tratados dentro deste limite temporal&#46; Por outro lado&#44; o grupo da transfer&#234;ncia inter&#8208;hospitalar apresentou uma mediana de 145 minutos &#40;115&#8208;199&#41; para o tempo entre o primeiro contacto m&#233;dico e a reperfus&#227;o e apenas 30&#44;9&#37; dos doentes foram tratados dentro do tempo m&#225;ximo de 120 minutos preconizados pelas recomenda&#231;&#245;es &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Figura 2</a>&#8208;B&#41;&#46; Comparativamente com os resultados obtidos no grupo da admiss&#227;o direta&#44; estes resultados s&#227;o modestos&#46; No entanto&#44; se considerarmos toda a log&#237;stica necess&#225;ria &#224; transfer&#234;ncia de um doente com EAMcEST&#44; percebemos que um adicional de 56&#44;5 minutos na mediana acaba por ser um resultado aceit&#225;vel&#44; relativamente ao que se tem publicado noutras s&#233;ries&#46;<a class="elsevierStyleCrossRefs" href="#bib0400"><span class="elsevierStyleSup">7&#44;27&#8208;30</span></a> Neste particular&#44; h&#225; v&#225;rios pontos pass&#237;veis de melhoria e que se poderiam traduzir numa diminui&#231;&#227;o do tempo de resposta do sistema de sa&#250;de ao doente com EAMcEST&#46; Os esfor&#231;os para melhorar este tempo devem centrar&#8208;se em dois momentos&#58; em primeiro lugar&#44; o tempo entre o primeiro contacto m&#233;dico e a reperfus&#227;o pode ser reduzido com um diagn&#243;stico mais r&#225;pido do EAMcEST&#44; associando&#8208;se a realiza&#231;&#227;o de ECG por t&#233;cnicos de cardiopneumologia &#224; triagem de Manchester em todos os doentes com dor tor&#225;cica ou epig&#225;strica&#46;<a class="elsevierStyleCrossRef" href="#bib0460"><span class="elsevierStyleSup">31</span></a> Em segundo lugar&#44; nos hospitais sem laborat&#243;rio de hemodin&#226;mica&#44; devem ser estabelecidos protocolos de transfer&#234;ncia dos doentes com a disponibiliza&#231;&#227;o imediata de ambul&#226;ncias medicalizadas &#40;pr&#243;prias ou do sistema de emerg&#234;ncia m&#233;dica nacional&#41;&#44; com m&#233;dico e enfermeiro&#44; capazes de transportar o doente diretamente para o laborat&#243;rio de hemodin&#226;mica em seguran&#231;a e sem mais demoras &#40;como as que acontecem atualmente com a chamada de uma ambul&#226;ncia&#44; disponibiliza&#231;&#227;o de profissionais a prestar servi&#231;o na urg&#234;ncia desses hospitais&#44; entre outras&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0415"><span class="elsevierStyleSup">10</span></a> Adicionalmente&#44; as j&#225; referidas campanhas &#224; popula&#231;&#227;o ensinariam aos doentes que&#44; perante os sinais e sintomas de enfarte&#44; devem ligar diretamente o 112 e desta forma contornar os hospitais sem laborat&#243;rio de hemodin&#226;mica com ganhos enormes em termos de tempo total de isquemia&#46;<a class="elsevierStyleCrossRefs" href="#bib0405"><span class="elsevierStyleSup">8&#44;26</span></a></p><p id="par0240" class="elsevierStylePara elsevierViewall">A soma do tempo gasto na transfer&#234;ncia inter&#8208;hospitalar ao tempo total de isquemia tornaria expect&#225;vel um aumento da mortalidade nesse grupo de doentes&#46; No entanto&#44; na popula&#231;&#227;o em estudo&#44; a transfer&#234;ncia inter&#8208;hospitalar n&#227;o teve impacto na mortalidade ao fim de um ano&#44; n&#227;o se tendo registado diferen&#231;as estaticamente significativas entre os grupos &#40;11&#44;7&#37; <span class="elsevierStyleItalic">versus</span> 9&#44;2&#37;&#44; p &#61; 0&#44;193&#41;&#46; Pensamos que a principal explica&#231;&#227;o para este facto reside nas importantes diferen&#231;as entre os dois grupos relativamente &#224; classe de Killip IV &#224; admiss&#227;o&#46; Efetivamente&#44; o grupo da admiss&#227;o direta apresentou quase o dobro da frequ&#234;ncia relativamente ao grupo da transfer&#234;ncia inter&#8208;hospitalar &#40;5&#44;8&#37; <span class="elsevierStyleItalic">versus</span> 3&#44;2&#37;&#44; p &#61; 0&#44;049&#41; &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">Tabela 1</a>&#41;&#46; Este &#233; um achado inesperado tendo em conta a aus&#234;ncia de diferen&#231;as nas caracter&#237;sticas basais das duas popula&#231;&#245;es&#46; Embora n&#227;o disponhamos de dados concretos em que nos possamos apoiar&#44; &#233; poss&#237;vel que esta diferen&#231;a tenha resultado de um grupo de doentes graves com EAMcEST que recorreu a hospitais sem laborat&#243;rio de hemodin&#226;mica e que entrou em choque e morreu&#44; antes da transfer&#234;ncia se efetuar ou mesmo durante a transfer&#234;ncia&#44; mas antes de chegarem ao laborat&#243;rio de hemodin&#226;mica&#46; Estes doentes&#44; n&#227;o sendo contabilizados&#44; podem ter constitu&#237;do uma forma de sele&#231;&#227;o positiva do grupo da transfer&#234;ncia inter&#8208;hospitalar&#44; pelo que a classe de Killip IV &#224; admiss&#227;o e a mortalidade poder&#227;o estar subestimadas neste grupo&#46;</p><p id="par0245" class="elsevierStylePara elsevierViewall">Um dado que suporta esta hip&#243;tese vem da an&#225;lise multivariada &#40;<a class="elsevierStyleCrossRef" href="#tbl0015">Tabela 3</a>&#41;&#44; em que se verificou que o principal preditor para a mortalidade a um ano foi exatamente a classe Killip IV &#224; admiss&#227;o &#40;HR &#61;11&#44;2&#44; IC 95&#37; &#91;6&#44;35&#8208;19&#44;8&#93;&#44; p &#60; 0&#44;001&#41;&#46; Outro dos preditores da mortalidade a um ano foi a idade e embora esta n&#227;o difira em termos globais nos dois grupos&#44; no subgrupo de doentes com idade &#8805; 75 anos essa diferen&#231;a assume significado estat&#237;stico&#44; sendo maior no grupo da admiss&#227;o direta &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">Tabela 1</a>&#41;&#46; Isto pode tamb&#233;m ajudar a explicar a aus&#234;ncia de diferen&#231;as na mortalidade ao fim de um ano nos dois grupos&#46;</p><elsevierMultimedia ident="tbl0015"></elsevierMultimedia><p id="par0250" class="elsevierStylePara elsevierViewall">Finalmente&#44; importa referir que o atraso no tratamento dos doentes com EAMcEST e a sua repercuss&#227;o na mortalidade tem sido objeto de estudo e alvo de an&#225;lise de muitos grupos&#47;programas de angioplastia prim&#225;ria com resultados contradit&#243;rios entre si&#46;<a class="elsevierStyleCrossRefs" href="#bib0420"><span class="elsevierStyleSup">10&#44;11&#44;27</span></a> Embora o conceito &#171;tempo &#233; mioc&#225;rdio&#187; seja muito importante e os <span class="elsevierStyleItalic">guidelines</span> atuais recomendem fortemente que o tempo que decorre entre o primeiro contacto m&#233;dico e a reperfus&#227;o seja inferior a 120 minutos&#44; os benef&#237;cios da ICPp para al&#233;m deste limite s&#227;o reais&#46;<a class="elsevierStyleCrossRefs" href="#bib0460"><span class="elsevierStyleSup">31&#8208;34</span></a> Por outro lado&#44; dados provenientes de institui&#231;&#245;es com alto volume de angioplastias prim&#225;rias e sistemas bem organizados de transporte dos doentes mostram que o atraso adicional devido &#224; transfer&#234;ncia inter&#8208;hospitalar pode ter efeitos m&#237;nimos no progn&#243;stico dos doentes&#46;<a class="elsevierStyleCrossRef" href="#bib0480"><span class="elsevierStyleSup">35</span></a> Dadas as especificidades geogr&#225;ficas e rodovi&#225;rias da regi&#227;o do Minho &#40;em que os hospitais referenciadores est&#227;o muito pr&#243;ximos do laborat&#243;rio de hemodin&#226;mica do Hospital de Braga e todos est&#227;o servidos por autoestradas&#41;&#44; os atrasos que se verificam na transfer&#234;ncia inter&#8208;hospitalar podem n&#227;o ser t&#227;o elevados como noutras regi&#245;es<a class="elsevierStyleCrossRef" href="#bib0425"><span class="elsevierStyleSup">12</span></a> e por isso n&#227;o terem tanto impacto na mortalidade global ao fim de um ano&#46; A corroborar esta ideia&#44; est&#225; a an&#225;lise do gr&#225;fico que avalia a rela&#231;&#227;o entre o intervalo de tempo desde o primeiro contacto m&#233;dico at&#233; &#224; reperfus&#227;o e a mortalidade a um ano &#40;<a class="elsevierStyleCrossRef" href="#fig0020">Figura 4</a>&#41;&#46; Aqui&#44; vemos que a mortalidade prevista aumentou de forma ligeira durante os primeiros 210 minutos e de forma mais significativa da&#237; para a frente&#46; Podemos assim pensar que o tempo adicional introduzido pela transfer&#234;ncia inter&#8208;hospitalar pode ter tido um impacto m&#237;nimo na mortalidade dos doentes que efetivamente chegaram ao laborat&#243;rio de hemodin&#226;mica para a realiza&#231;&#227;o de uma ICPp &#40;p &#60; 0&#44;5&#37; na mortalidade ao fim de um ano&#41;&#46;</p><p id="par0255" class="elsevierStylePara elsevierViewall">A an&#225;lise da rela&#231;&#227;o que se estabeleceu entre a mortalidade ao fim de um ano e a presen&#231;a da classe de Killip IV durante o internamento &#40;<a class="elsevierStyleCrossRef" href="#fig0025">Figura 5</a>&#41; permite verificar que mais de metade da mortalidade do grupo da AD ocorreu em doentes que estiveram em choque cardiog&#233;nico durante o internamento&#46; No grupo da transfer&#234;ncia inter&#8208;hospitalar esse valor foi mais baixo&#44; embora a diferen&#231;a n&#227;o tenha sido estatisticamente significativa &#40;52&#44;8 <span class="elsevierStyleItalic">vs&#46;</span> 40&#44;8&#37;&#44; p &#61; 0&#44;253&#41;&#46; Outro dado que surgiu da an&#225;lise dos resultados foi a elevada mortalidade dos doentes em choque&#44; que ultrapassou os 60&#37; em ambos os grupos &#40;62&#44;2&#37; <span class="elsevierStyleItalic">versus</span> 64&#44;4&#37;&#44; p &#62; 0&#44;999&#41; &#40;<a class="elsevierStyleCrossRef" href="#fig0025">Figura 5</a>&#41;&#46; Sendo valores dentro do que est&#225; descrito na literatura&#44; n&#227;o deixam de ser preocupantes&#46;<a class="elsevierStyleCrossRefs" href="#bib0380"><span class="elsevierStyleSup">36&#44;37</span></a> Neste grupo de doentes n&#227;o basta realizar uma ICPp com sucesso&#46; Trata&#8208;se de doentes muito inst&#225;veis&#44; que frequentemente pioram no imediato com a realiza&#231;&#227;o da ICPp e que requerem um acompanhamento muito apertado&#46; Dado o seu alt&#237;ssimo risco e disfun&#231;&#227;o multiorg&#226;nica que frequentemente apresentam&#44; necessitam de um conjunto de tratamentos &#40;como sistemas de suporte circulat&#243;rio&#44; ventila&#231;&#227;o mec&#226;nica&#44; t&#233;cnicas de substitui&#231;&#227;o renal&#44; entre outros&#41; e estrat&#233;gias terap&#234;uticas multidisciplinares&#44; que aplicadas precocemente&#44; poder&#227;o ajudar a diminuir esta elevada mortalidade&#46;<a class="elsevierStyleCrossRefs" href="#bib0425"><span class="elsevierStyleSup">12&#44;38</span></a></p><p id="par0260" class="elsevierStylePara elsevierViewall">Apesar de ser o estudo com maior n&#250;mero de doentes e abrangendo o maior espa&#231;o temporal publicado em Portugal no contexto de EAMcEST&#44; existem v&#225;rias limita&#231;&#245;es a serem consideradas na sua interpreta&#231;&#227;o&#46; Em primeiro lugar&#44; este foi um estudo observacional e retrospetivo realizado num &#250;nico laborat&#243;rio de hemodin&#226;mica e&#44; portanto&#44; tem as limita&#231;&#245;es e os vieses inerentes aos estudos retrospetivos unic&#234;ntricos&#46; Em segundo lugar&#44; n&#227;o foi poss&#237;vel obter mortalidade cardiovascular&#59; a mortalidade analisada &#233; a mortalidade total e n&#227;o se pode excluir que alguns dos doentes possam ter morrido de causas n&#227;o relacionadas com o EAMcEST&#46; Em terceiro lugar&#44; e como j&#225; referido&#44; a aus&#234;ncia de dados sobre os doentes admitidos nos hospitais referenciadores&#44; mas tamb&#233;m no HB&#44; que morreram antes de chegar ao laborat&#243;rio de hemodin&#226;mica dificulta a interpreta&#231;&#227;o dos dados relativos &#224; classe de Killip e &#224; mortalidade&#46; Por &#250;ltimo&#44; estes resultados foram obtidos na regi&#227;o do Minho e&#44; dadas as suas especificidades geogr&#225;ficas&#44; rodovi&#225;rias e sociodemogr&#225;ficas&#44; n&#227;o s&#227;o generaliz&#225;veis para o resto do pa&#237;s&#46;</p></span><span id="sec0065" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0135">Conclus&#227;o</span><p id="par0265" class="elsevierStylePara elsevierViewall">Pode&#8208;se dizer que o programa de angioplastia prim&#225;ria do Minho funcionou&#44; durante os cinco anos em an&#225;lise&#44; com resultados aceit&#225;veis do ponto de vista do tempo que os doentes demoram a ser tratados&#46;</p><p id="par0270" class="elsevierStylePara elsevierViewall">A maior parte dos doentes submetidos a angioplastia prim&#225;ria no laborat&#243;rio de hemodin&#226;mica do Hospital de Braga &#233; proveniente de outras institui&#231;&#245;es hospitalares da regi&#227;o&#46; Embora o tempo despendido na sua transfer&#234;ncia atrase de forma significativa o momento da reperfus&#227;o&#44; esse atraso n&#227;o foi suficiente para provocar aumento da mortalidade ao fim de um ano&#46; No entanto&#44; a diferen&#231;a estatisticamente significativa observada na percentagem de doentes que s&#227;o admitidos em Killip IV&#44; em dois grupos com caracter&#237;sticas basais t&#227;o semelhantes&#44; leva&#8208;nos a pensar que alguns doentes dos hospitais referenciadores poder&#227;o ter morrido antes da sua chegada ao laborat&#243;rio de hemodin&#226;mica e desta forma terem influenciado a mortalidade do grupo da transfer&#234;ncia inter&#8208;hospitalar&#46;</p><p id="par0275" class="elsevierStylePara elsevierViewall">S&#227;o ainda identificados os pontos menos positivos em todo o processo&#44; que decorre desde o in&#237;cio dos sintomas at&#233; &#224; reperfus&#227;o&#44; e abordadas as solu&#231;&#245;es que os podem contornar&#46;</p></span><span id="sec0070" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0140">Conflitos de interesse</span><p id="par0280" class="elsevierStylePara elsevierViewall">Os autores declaram n&#227;o haver conflitos de interesse&#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">Num programa de angioplastia prim&#225;ria&#44; a transfer&#234;ncia inter&#8208;hospitalar dos doentes com enfarte agudo do mioc&#225;rdio com eleva&#231;&#227;o do segmento ST &#40;EAMcEST&#41; pode aumentar o tempo de isquemia relativamente aos doentes que s&#227;o admitidos diretamente num laborat&#243;rio de hemodin&#226;mica&#46;</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Objetivo</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Avaliar o impacto da transfer&#234;ncia inter&#8208;hospitalar nos doentes submetidos a interven&#231;&#227;o coron&#225;ria percut&#226;nea prim&#225;ria &#40;ICPp&#41;&#44; no intervalo de tempo at&#233; &#224; reperfus&#227;o e na mortalidade a um ano&#46;</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">M&#233;todos</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Estudo observacional&#44; retrospetivo e longitudinal&#46; Foram divididos em dois grupos 1222 doentes com EAMcEST admitidos no Hospital de Braga &#40;HB&#41;&#44; entre junho&#47;2011 e maio&#47;2016&#44; tratados com sucesso nas primeiras 12 horas de evolu&#231;&#227;o dos sintomas&#44; consoante a admiss&#227;o&#58; direta ou transfer&#234;ncia inter&#8208;hospitalar&#46;</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Resultados</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Foram admitidos diretamente no HB 37&#44;0&#37; &#40;n &#61; 452&#41; e 63&#44;0&#37; &#40;n &#61; 770&#41; transferidos de outros hospitais&#46; Apesar do aumento nos intervalos de tempo &#40;em minutos&#41; at&#233; &#224; reperfus&#227;o nos doentes da transfer&#234;ncia inter&#8208;hospitalar &#40;in&#237;cio dos sintomas&#8208;primeiro contacto m&#233;dico&#41; &#40;Mdn &#61;76&#44;5&#44; AIQ &#40;40&#44;3&#8208;150&#41; versus Mdn &#61; 91&#44;0&#44; AIQ &#40;50&#8208;180&#41;&#44; p &#61; 0&#44;002&#41;&#44; primeiro contacto m&#233;dico&#8208;reperfus&#227;o &#40;Mdn &#61; 87&#44;5&#44; AIQ &#40;69&#44;0&#8208;114&#41; <span class="elsevierStyleItalic">versus</span> Mdn &#61; 145&#44; AIQ &#40;115&#8208;199&#41;&#44; p &#60; 0&#44;001&#41; e in&#237;cio dos sintomas&#8208;reperfus&#227;o &#40;Mdn &#61; 177&#44; AIQ &#91;125&#8208;265&#93; versus Mdn &#61; 265&#44; AIQ &#91;188&#8208;400&#93;&#44; p &#60; 0&#44;001&#41;&#44; a mortalidade a um ano n&#227;o diferiu significativamente entre os grupos &#40;53 &#91;11&#44;7&#37;&#93; versus 71 &#91;9&#44;2&#37;&#93;&#44; p &#61; 0&#44;193&#41;&#46; Na an&#225;lise multivariada&#44; a idade&#44; o tempo sintomas&#8208;reperfus&#227;o e sobretudo a classe Killip IV &#224; admiss&#227;o &#40;HR &#61; 11&#44;2&#44; IC95&#37; &#91;6&#44;35&#8208;19&#44;8&#93;&#44; p &#60; 0&#44;001&#41; revelaram&#8208;se os principais preditores independentes de mortalidade a um ano&#46;</p></span> <span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Conclus&#227;o</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">A transfer&#234;ncia inter&#8208;hospitalar dos doentes com EAMcEST aumentou de forma significativa o intervalo de tempo at&#233; &#224; realiza&#231;&#227;o da ICPp&#46; Relativamente &#224; mortalidade a um ano&#44; n&#227;o se detetaram diferen&#231;as entre grupos&#46; Isto pode estar relacionado com o facto de o grupo da admiss&#227;o direta ter o dobro de doentes em Killip IV&#46;</p></span>"
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        "resumen" => "<span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Introduction</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">In a primary percutaneous coronary intervention &#40;PCI&#41; program&#44; interhospital transfer of patients with ST&#8208;elevation myocardial infarction &#40;STEMI&#41; can increase ischemic time&#44; compared to patients who are admitted directly to a catheterization laboratory&#46;</p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Objectives</span><p id="spar0115" class="elsevierStyleSimplePara elsevierViewall">To assess the impact of interhospital transfer in patients with STEMI undergoing primary PCI&#44; in terms of time to reperfusion and one&#8208;year mortality&#46;</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Methods</span><p id="spar0120" class="elsevierStyleSimplePara elsevierViewall">This was an observational&#44; retrospective&#44; longitudinal study of patients with STEMI admitted to Hospital de Braga between June 2011 and May 2016&#44; who were treated successfully within 12 hours of symptom onset&#46; A total of 1222 patients were included and divided into two groups according to admission to Hospital de Braga&#58; direct or interhospital transfer&#46;</p></span> <span id="abst0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Results</span><p id="spar0125" class="elsevierStyleSimplePara elsevierViewall">In this study&#44; 37&#46;0&#37; &#40;n&#61;452&#41; of the population were admitted directly to Hospital de Braga and 63&#46;0&#37; &#40;n&#61;770&#41; were transferred from other hospitals&#46; Although timings &#40;in min&#41; until reperfusion were longer in interhospital transfer patients &#40;symptom onset&#8208;first medical contact &#40;median 76&#46;5&#44; IQR 40&#46;3&#8208;150 vs&#46; 91&#46;0&#44; IQR 50&#8208;180&#44; p&#61;0&#46;002&#41;&#44; first medical contact&#8208;reperfusion &#40;median 87&#46;5&#44; IQR 69&#46;0&#8208;114 vs&#46; 145&#44; IQR 115&#8208;199&#44; p&#60;0&#46;001&#41; and symptom onset&#8208;reperfusion &#40;median 177&#44; IQR 125&#8208;265 vs&#46; 265&#44; IQR 188&#8208;400&#44; p&#60;0&#46;001&#41;&#41;&#44; one&#8208;year mortality did not differ significantly between the groups &#40;53 &#91;11&#46;7&#37;&#93; vs&#46; 71 &#91;9&#46;2&#37;&#93;&#44; p&#61;0&#46;193&#41;&#46; In multivariate analysis&#44; age&#44; symptom onset&#8208;reperfusion time and especially Killip class IV at admission &#40;HR 11&#46;2&#44; 95&#37; CI 6&#46;35&#8208;19&#46;8&#44; p&#60;0&#46;001&#41; were the main independent predictors of one&#8208;year mortality&#46;</p></span> <span id="abst0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0060">Conclusion</span><p id="spar0130" class="elsevierStyleSimplePara elsevierViewall">Interhospital transfer of patients with STEMI increased the time before PCI&#46; No differences were detected between groups in one&#8208;year mortality&#46; This may be related to the fact that the direct admission group had twice as many patients in Killip class IV as the interhospital transfer group&#46;</p></span>"
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                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">TI &#40;n &#61; 770&#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">Teste estat&#237;stico&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" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="4" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Carater&#237;sticas cl&#237;nicas</span></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"><span class="elsevierStyleHsp" style=""></span>Idade&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">62&#44;0 &#40;14&#44;0&#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">61&#44;0 &#40;13&#44;3&#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">T &#40;1&#44;220&#41; &#61; 1&#44;18&#44; <span class="elsevierStyleItalic">p</span> &#61; 0&#44;239&#44; <span class="elsevierStyleItalic">g</span> &#61; 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"><span class="elsevierStyleHsp" style=""></span>Idade &#8805; 75 anos&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">96 &#40;21&#44;2&#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">141 &#40;18&#44;3&#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"><span class="elsevierStyleItalic">X</span><span class="elsevierStyleSup"><span class="elsevierStyleItalic">2</span></span> &#40;1&#44; N &#61; 1&#44;222&#41; &#61; 1&#44;38&#44; <span class="elsevierStyleItalic">p</span> &#61; 0&#44;240&#44; <span class="elsevierStyleItalic">&#966;</span> &#61; 0&#44;036&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"><span class="elsevierStyleHsp" style=""></span>Sexo masculino&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">365 &#40;80&#44;8&#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">588 &#40;76&#44;4&#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"><span class="elsevierStyleItalic">X</span><span class="elsevierStyleSup"><span class="elsevierStyleItalic">2</span></span> &#40;1&#44; N &#61; 1&#44;222&#41; &#61; 2&#44;95&#44; <span class="elsevierStyleItalic">p</span> &#61; 0&#44;086&#44; <span class="elsevierStyleItalic">&#966;</span> &#61; 0&#44;051&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"><span class="elsevierStyleHsp" style=""></span>Obesidade&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">81 &#40;18&#44;2&#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">129 &#40;16&#44;9&#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"><span class="elsevierStyleItalic">X</span><span class="elsevierStyleSup"><span class="elsevierStyleItalic">2</span></span> &#40;1&#44; N &#61; 1&#44;208&#41; &#61; 0&#44;24&#44; <span class="elsevierStyleItalic">p</span> &#61; 0&#44;621&#44; <span class="elsevierStyleItalic">&#966;</span> &#61; 0&#44;016&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"><span class="elsevierStyleHsp" style=""></span>Diabetes <span class="elsevierStyleItalic">mellitus</span>&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">85 &#40;20&#44;4&#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">165 &#40;22&#44;2&#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"><span class="elsevierStyleItalic">X</span><span class="elsevierStyleSup"><span class="elsevierStyleItalic">2</span></span> &#40;1&#44; N &#61; 1&#44;160&#41; &#61; 0&#44;38&#44; <span class="elsevierStyleItalic">p</span> &#61; 0&#44;536&#44; <span class="elsevierStyleItalic">&#966;</span> &#61; 0&#44;020&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"><span class="elsevierStyleHsp" style=""></span>Hipertens&#227;o arterial&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">227 &#40;50&#44;9&#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">395 &#40;51&#44;4&#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"><span class="elsevierStyleItalic">X</span><span class="elsevierStyleSup"><span class="elsevierStyleItalic">2</span></span> &#40;1&#44; N &#61; 1&#44;214&#41; &#61; 0&#44;01&#44; <span class="elsevierStyleItalic">p</span> &#61; 0&#44;904&#44; <span class="elsevierStyleItalic">&#966;</span> &#61; 0&#44;005&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"><span class="elsevierStyleHsp" style=""></span>Dislipidemia&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">210 &#40;47&#44;1&#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">343 &#40;44&#44;6&#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"><span class="elsevierStyleItalic">X</span><span class="elsevierStyleSup"><span class="elsevierStyleItalic">2</span></span> &#40;1&#44; N &#61; 1&#44;215&#41; &#61; 0&#44;61&#44; <span class="elsevierStyleItalic">p</span> &#61; &#8208;0&#44;437&#44; <span class="elsevierStyleItalic">&#966;</span> &#61; 0&#44;024&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"><span class="elsevierStyleHsp" style=""></span>Tabagismo &#40;atual ou pr&#233;vio&#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">241 &#40;56&#44;8&#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">384 &#40;51&#44;6&#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"><span class="elsevierStyleItalic">X</span><span class="elsevierStyleSup"><span class="elsevierStyleItalic">2</span></span> &#40;1&#44; N &#61; 1&#44;168&#41; &#61; 1&#44;22 <span class="elsevierStyleItalic">p</span> &#61; 0&#44;097&#44; <span class="elsevierStyleItalic">&#966;</span> &#61; 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"><span class="elsevierStyleHsp" style=""></span>Insufici&#234;ncia renal cr&#243;nica&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">9 &#40;2&#44;0&#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">11 &#40;1&#44;4&#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"><span class="elsevierStyleItalic">X</span><span class="elsevierStyleSup"><span class="elsevierStyleItalic">2</span></span> &#40;1&#44; N &#61; 1&#44;218&#41; &#61; 0&#44;29&#44; <span class="elsevierStyleItalic">p</span> &#61; 0&#44;593&#44; <span class="elsevierStyleItalic">&#966;</span> &#61; 0&#44;022&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="4" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="4" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Antecedentes</span></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"><span class="elsevierStyleHsp" style=""></span>EAM&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">30 &#40;6&#44;7&#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">54 &#40;7&#44;0&#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"><span class="elsevierStyleItalic">X</span><span class="elsevierStyleSup"><span class="elsevierStyleItalic">2</span></span> &#40;1&#44; N &#61; 1&#44;218&#41; &#61; 0&#44;01&#44; <span class="elsevierStyleItalic">p</span> &#61; 0&#44;913&#44; <span class="elsevierStyleItalic">&#966;</span> &#61; 0&#44;006&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"><span class="elsevierStyleHsp" style=""></span>ICP&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">25 &#40;5&#44;6&#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">37 &#40;4&#44;8&#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"><span class="elsevierStyleItalic">X</span><span class="elsevierStyleSup"><span class="elsevierStyleItalic">2</span></span> &#40;1&#44; N &#61; 1&#44;219&#41; &#61; 0&#44;20&#44; <span class="elsevierStyleItalic">p</span> &#61; 0&#44;653&#44; <span class="elsevierStyleItalic">&#966;</span> &#61; 0&#44;017&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"><span class="elsevierStyleHsp" style=""></span>CABG&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;0&#44;90&#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;0&#44;90&#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"><span class="elsevierStyleItalic">X</span><span class="elsevierStyleSup"><span class="elsevierStyleItalic">2</span></span> &#40;1&#44; N &#61; 1&#44;219&#41; &#61; 0&#44;00&#44; <span class="elsevierStyleItalic">p</span> &#62; 0&#44;999&#44;<a class="elsevierStyleCrossRef" href="#tblfn0005">&#42;</a><span class="elsevierStyleItalic">&#966;</span> &#61; 0&#44;001&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="4" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="4" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Apresenta&#231;&#227;o cl&#237;nica</span></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"><span class="elsevierStyleHsp" style=""></span>CK 4 na admiss&#227;o&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
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                  \t\t\t\t">45 &#40;5&#44;8&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
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                  \t\t\t\t  " colspan="4" align="left" valign="\n
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                  \t\t\t\t  " colspan="4" align="left" valign="\n
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                  \t\t\t\t">0&#44;63&#8208;1&#44;55&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
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                  \t\t\t\t">1&#44;09&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">1&#44;07&#8208;1&#44;11&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">1&#44;09&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  " align="left" valign="\n
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                  \t\t\t\t\ttable-entry\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">1&#44;38&#8208;6&#44;78&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;006&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
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                  \t\t\t\t  " align="left" valign="\n
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                  \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
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                  \t\t\t\t">0&#44;377&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
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                  \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&#44;16&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;68&#8208;2&#44;20&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;586&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">Hipertens&#227;o arterial&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;88&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&#8208;1&#44;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;592&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">Doen&#231;a multivaso&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
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&#44;08&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;70&#8208;1&#44;65&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;735&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">Classe Killip 4 na admiss&#227;o&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&#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">6&#44;35&#8208;19&#44;8&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">FEVE &#8804; 40&#37; no internamento&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">3&#44;02&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
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                  \t\t\t\t">1&#44;91&#8208;4&#44;76&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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