Editorial
Acute myocardial infarction in the Brazilian Unified Health System: a bridge too far for reperfusion?
Infarto agudo do miocárdio no Sistema Único de Saúde: uma ponte longe demais para a reperfusão?
Luiz Alberto Piva e Mattosa,
, Dinaldo Cavalcanti Oliveirab
Corresponding author
pivmattos@uol.com.br
Corresponding author. Rua Engenheiro Oscar Americano, 840, Morumbi, CEP: 05673-050, São Paulo, SP, Brasil.
Corresponding author. Rua Engenheiro Oscar Americano, 840, Morumbi, CEP: 05673-050, São Paulo, SP, Brasil.
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Rua Engenheiro Oscar Americano, 840, Morumbi, CEP: 05673-050, São Paulo, SP, Brasil." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Infarto agudo do miocárdio no Sistema Único de Saúde: uma ponte longe demais para a reperfusão?" ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">A little over 30 years have passed since the first report on the use of coronary balloon angioplasty or, as it is currently called, primary percutaneous coronary intervention (PCI), for the treatment of patients with acute myocardial infarction, which is now called acute coronary syndrome with ST-segment elevation.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">This therapy started in parallel and had the same objectives of pharmacological coronary reperfusion (performed through intracoronary and, subsequently, intravenous administration of fibrinolytics): rapid and complete recovery of the anterograde coronary flow in the occluded epicardial coronary artery; reduction of the underlying coronary stenosis promoting the acute event; and coronary microcirculation preservation.<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> These principles are the weapons used to overcome muscular necrosis and its malevolent and severe consequences, which quickly appear after acute coronary vessel occlusion.<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">The first controlled and randomized trials comparing both methods, primary PCI vs. fibrinolytics, were published in 1993. Since then, a wave of positive, effective, restorative reperfusion of the coronary flow lost in acute occlusion has been definitively established, being largely favorable to the use of primary PCI.<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">The advent of the so-called “modern antiplatelet therapy”, which started with intravenous administration of glycoprotein IIb/IIIa inhibitors and progressed to the synthesis and use of the oral inhibitors of P2Y12 platelet receptors, has provided the much-needed systemic safety to the interventional procedure, a catalyst of strong coagulation vectors, and, as a final pillar of primary PCI consolidation, the mechanical anchoring of the ruptured atherothrombotic plaque, through coronary stent implantation.<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">Within a 20-year period, the interventionist method, feared and discredited at an initial moment, has become a unanimity in contemporary cardiology practice, reigning over the world's medical guidelines as the method of choice to treat ST-elevation myocardial infarction, with Class I and Level of Evidence A recommendation – the highest possible.<a class="elsevierStyleCrossRefs" href="#bib0025"><span class="elsevierStyleSup">5–7</span></a></p><p id="par0030" class="elsevierStylePara elsevierViewall">Thus, a strong pressure has been placed on hospital medical services on a worldwide scale. Hemodynamic and cardiovascular intervention services, previously accustomed to closing their activities after business hours, were turned upside down in their logistics, being forced to operate in the so-called eternal cycle, open 24<span class="elsevierStyleHsp" style=""></span>hours during the 7 days of the week, without ever closing.<a class="elsevierStyleCrossRefs" href="#bib0025"><span class="elsevierStyleSup">5–7</span></a></p><p id="par0035" class="elsevierStylePara elsevierViewall">Primary PCI has brought results that can be considered unique in the history of modern cardiology. The impact of reduced mortality, together with these patients’ rapid rehabilitation to work and social life, demonstrated the best feature of this procedure: the unequivocal ability to save lives, removing even the most resistant critics from their conservative trenches (for every 100 patients undergoing primary PCI vs. fibrinolysis, 5 deaths, 5 reinfarctions, and 1 stroke are prevented).<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a></p><p id="par0040" class="elsevierStylePara elsevierViewall">However, how can this benefit be offered to the entire population, in broadest sense? From the rural dweller, away from the tertiary centers, to the urban patient, trapped in chaotic traffic jams, and in all the different healthcare management systems?</p><p id="par0045" class="elsevierStylePara elsevierViewall">As demonstrated by Araújo et al.,<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a> primary PCI requires hospitals with a tertiary structure, equipped with dedicated radiology equipment, structured coronary units, an ample and always available array of percutaneous devices (the coronary anatomy will only be known in an emergency and will be always different from one patient to another), promptly available cardiac surgery and – most importantly – the dedicated “HR factor” (Human Resources), with qualified interventionists, trained in the approach of this acute and risky scenario, and a trained and experienced multidisciplinary team, in addition to treatment and access protocols that have been validated, implemented, and proven to be effective, available 24/7!<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">3,5–7</span></a> Phew! A bridge too far?</p><p id="par0050" class="elsevierStylePara elsevierViewall">Araujo et al.,<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a> located in the extreme south of Brazil, have shown that it is indeed possible and have demonstrated their results in their consecutive cohort. It is interesting to observe the incidence of cases in one of the largest federal hospitals in the Southern region of Brazil - approximately 80 per year; six, on average, per month; a little more than one per week.</p><p id="par0055" class="elsevierStylePara elsevierViewall">Given the number of infarctions reported to the Brazilian Unified Health System (SUS, acronym in Portuguese), approximately 50,000 cases/year, these numbers can be considered low, showing that the bridge remains too far; that is, it is not possible to treat as many patients as we should, since, for the most part, the distance and the multiple difficulties in the diagnosis of myocardial infarction result in a delay that removes the patients from the window of the best therapeutic opportunity: treatment at most within the initial 12<span class="elsevierStyleHsp" style=""></span>hours, and in an ideal world, in the first 6<span class="elsevierStyleHsp" style=""></span>hours of symptom onset. From the number of primary PCIs reported to SUS, it can be estimated that 12% of infarctions treated under the public healthcare system undergo primary PCI.<a class="elsevierStyleCrossRefs" href="#bib0050"><span class="elsevierStyleSup">10,11</span></a></p><p id="par0060" class="elsevierStylePara elsevierViewall">The therapeutic strategy of primary PCI requires understanding of the severity and intensity of myocardial infarction symptoms, as well as the search for professional help as soon as possible. In this sense, SUS users are far from having this awareness, partly because of those who should educate them.<a class="elsevierStyleCrossRefs" href="#bib0060"><span class="elsevierStyleSup">12,13</span></a></p><p id="par0065" class="elsevierStylePara elsevierViewall">Additionally, it should be mentioned that the availability of hospitals with established PCI programs is far from ideal because of the number of inhabitants, and that effective and organized transfer programs for this type of reperfusion are still a dream in our country.<a class="elsevierStyleCrossRefs" href="#bib0050"><span class="elsevierStyleSup">10–13</span></a></p><p id="par0070" class="elsevierStylePara elsevierViewall">In turn, data from primary PCIs are available in the SUS electronic database, starting in 2004; in the last 10 years, the increment in the number of procedures was remarkable, exceeding 300%.<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">11</span></a></p><p id="par0075" class="elsevierStylePara elsevierViewall">Comparing the findings of Araujo et al. with SUS numbers is an interesting task that illustrates the effort of colleagues to build a reperfusion bridge for these acutely infarcted individuals (<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>).<a class="elsevierStyleCrossRefs" href="#bib0045"><span class="elsevierStyleSup">9–11</span></a></p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0080" class="elsevierStylePara elsevierViewall">The mean mortality observed in the study by Araújo et al. was 9.9%, or approximately one-quarter higher than the Southern regional average in the year 2015. The authors discuss this finding, focusing on the delay in transferring these infarcted patients, considered higher than the ideal (transfer time of 4.4 ± 2.5<span class="elsevierStyleHsp" style=""></span>hours and door-to-balloon time of 68 ± 34<span class="elsevierStyleHsp" style=""></span>minutes) – the latter being very good, below the desired 90<span class="elsevierStyleHsp" style=""></span>minutes.</p><p id="par0085" class="elsevierStylePara elsevierViewall">In addition to the delay in transfer, the patient's delay in seeking care is a contributing factor to the increase in the time of ischemia, which determines worsening of results and prognosis.<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a></p><p id="par0090" class="elsevierStylePara elsevierViewall">In the study by Araujo et al., Killip IV was observed in 11.6% of cases on admission, and cardiovascular events at 30 days were observed in 18.3%. These results, among other factors, may be justified by the delay in opening the artery.<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">14</span></a></p><p id="par0095" class="elsevierStylePara elsevierViewall">The patients were referred from other health units 74% of the and in 29.3% they were transferred by the Emergency Medical Services (SAMU, acronym in Portuguese), that is, a bridge needs to be built for patients to arrive quickly, considering that a specialized structure to receive them will be waiting.</p><p id="par0100" class="elsevierStylePara elsevierViewall">The increase in the delay will result in a reduction of the benefits and may lead to increased procedural difficulty in reestablishing normal anterograde coronary flow, but the advent of adjuvant techniques and potent anticoagulant and antiplatelet pharmacology may help to increase PCI performance in scenarios of greater thrombotic adversity.<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a></p><p id="par0105" class="elsevierStylePara elsevierViewall">Other justifications and suggestions can be listed: delayed start of antiplatelet therapy (in the primary center, not only upon arriving at the tertiary center) and analysis of the interventionist profile, since it is a university hospital (physicians in training vs. physicians with established experience).</p><p id="par0110" class="elsevierStylePara elsevierViewall">Is the bridge still too far? Yes, it will always be; while we do not reach a higher percentage of infarcted individuals being submitted to primary PCI, we will need strong, unwavering and committed healthcare management performance.</p><p id="par0115" class="elsevierStylePara elsevierViewall">In a country of bold inequalities, with abysmal socioeconomic gradients of continental extension, with heterogeneous public management, thrice divided in its powers, often claudicating, oscillating, and subject to political-partisan rather than technical influences, only the persistence of a united, interested, and apt group of physicians can achieve significant advances, thus building not an unstable platform, but a perennial bridge, lined with solid concrete, to pave the reperfusion for the many more that will need it.</p><p id="par0120" class="elsevierStylePara elsevierViewall">Or else, all we shall have left to say, as one high official told British field marshal Montgomery, which inspired a great film, filled with Hollywood stars: “I think we may be going a bridge too far...”</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Conflicts of interest</span><p id="par0125" class="elsevierStylePara elsevierViewall">The authors declare no conflicts of interest.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:2 [ 0 => array:2 [ "identificador" => "sec0005" "titulo" => "Conflicts of interest" ] 1 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "multimedia" => array:1 [ 0 => array:8 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at1" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:1 [ "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Region \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">2012 \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">2013 \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">2014 \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">2015 \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Total number of procedures \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="center" valign="top">5,867 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="center" valign="top">6,093 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="center" valign="top">7,135 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="center" valign="top">8,524 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">North, (%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="center" valign="top">5.76 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="center" valign="top">8.78 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="center" valign="top">7.04 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="center" valign="top">6.88 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Northeast, (%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="center" valign="top">7.1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="center" valign="top">7.17 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="center" valign="top">7.15 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="center" valign="top">8.06 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Southeast, (%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="center" valign="top">6.57 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="center" valign="top">7.83 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="center" valign="top">7.89 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="center" valign="top">7.43 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">South, (%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="center" valign="top">7.17 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="center" valign="top">6.13 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="center" valign="top">6.95 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="center" valign="top">7.01 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Midwest, (%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="center" valign="top">6.72 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="center" valign="top">14.48 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="center" valign="top">9.55 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="center" valign="top">9.03 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Mean mortality, (%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="center" valign="top">6.87 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="center" valign="top">7.33 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="center" valign="top">7.44 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="center" valign="top">7.43 \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1628390.png" ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Primary percutaneous coronary intervention. 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| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 October | 11 | 0 | 11 |
| 2024 September | 18 | 2 | 20 |
| 2024 August | 25 | 3 | 28 |
| 2024 July | 17 | 2 | 19 |
| 2024 June | 12 | 5 | 17 |
| 2024 May | 13 | 5 | 18 |
| 2024 April | 23 | 2 | 25 |
| 2024 March | 19 | 5 | 24 |
| 2024 February | 25 | 6 | 31 |
| 2024 January | 8 | 4 | 12 |
| 2023 December | 21 | 2 | 23 |
| 2023 November | 23 | 7 | 30 |
| 2023 October | 21 | 7 | 28 |
| 2023 September | 13 | 3 | 16 |
| 2023 August | 14 | 4 | 18 |
| 2023 July | 13 | 6 | 19 |
| 2023 June | 10 | 5 | 15 |
| 2023 May | 13 | 4 | 17 |
| 2023 April | 23 | 0 | 23 |
| 2023 March | 9 | 2 | 11 |
| 2023 February | 17 | 5 | 22 |
| 2023 January | 13 | 6 | 19 |
| 2022 December | 16 | 7 | 23 |
| 2022 November | 13 | 10 | 23 |
| 2022 October | 22 | 7 | 29 |
| 2022 September | 14 | 16 | 30 |
| 2022 August | 14 | 12 | 26 |
| 2022 July | 15 | 13 | 28 |
| 2022 June | 9 | 9 | 18 |
| 2022 May | 12 | 11 | 23 |
| 2022 April | 14 | 8 | 22 |
| 2022 March | 21 | 9 | 30 |
| 2022 February | 14 | 5 | 19 |
| 2022 January | 12 | 16 | 28 |
| 2021 December | 11 | 9 | 20 |
| 2021 November | 18 | 5 | 23 |
| 2021 October | 15 | 9 | 24 |
| 2021 September | 12 | 12 | 24 |
| 2021 August | 8 | 4 | 12 |
| 2021 July | 11 | 6 | 17 |
| 2021 June | 23 | 11 | 34 |
| 2021 May | 16 | 7 | 23 |
| 2021 April | 31 | 12 | 43 |
| 2021 March | 29 | 14 | 43 |
| 2021 February | 11 | 9 | 20 |
| 2021 January | 18 | 7 | 25 |
| 2020 December | 20 | 9 | 29 |
| 2020 November | 15 | 6 | 21 |
| 2020 October | 10 | 7 | 17 |
| 2020 September | 17 | 11 | 28 |
| 2020 August | 18 | 5 | 23 |
| 2020 July | 15 | 9 | 24 |
| 2020 June | 12 | 9 | 21 |
| 2020 May | 8 | 7 | 15 |
| 2020 April | 8 | 1 | 9 |
| 2020 March | 7 | 2 | 9 |
| 2020 February | 7 | 3 | 10 |
| 2020 January | 4 | 1 | 5 |
| 2019 December | 12 | 3 | 15 |
| 2019 November | 5 | 4 | 9 |
| 2019 October | 9 | 4 | 13 |
| 2019 September | 8 | 5 | 13 |
| 2019 August | 1 | 4 | 5 |
| 2019 July | 8 | 5 | 13 |
| 2019 June | 16 | 3 | 19 |
| 2019 May | 21 | 22 | 43 |
| 2019 April | 1 | 0 | 1 |
| 2018 October | 1 | 0 | 1 |
| 2018 September | 13 | 6 | 19 |
| 2018 August | 43 | 15 | 58 |
| 2018 July | 43 | 19 | 62 |
| 2018 June | 74 | 17 | 91 |
| 2018 May | 47 | 20 | 67 |
| 2018 April | 76 | 13 | 89 |
| 2018 March | 155 | 19 | 174 |
| 2018 February | 63 | 16 | 79 |
| 2018 January | 34 | 14 | 48 |
| 2017 December | 29 | 16 | 45 |
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