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1.
Clin Res Cardiol ; 109(12): 1511-1521, 2020 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-32676681

RESUMO

AIMS: To assess the impact of the lockdown due to coronavirus disease 2019 (COVID-19) on key quality indicators for the treatment of ST-segment elevation myocardial infarction (STEMI) patients. METHODS: Data were obtained from 41 hospitals participating in the prospective Feedback Intervention and Treatment Times in ST-Elevation Myocardial Infarction (FITT-STEMI) study, including 15,800 patients treated for acute STEMI from January 2017 to the end of March 2020. RESULTS: There was a 12.6% decrease in the total number of STEMI patients treated at the peak of the pandemic in March 2020 as compared to the mean number treated in the March months of the preceding years. This was accompanied by a significant difference among the modes of admission to hospitals (p = 0.017) with a particular decline in intra-hospital infarctions and transfer patients from other hospitals, while the proportion of patients transported by emergency medical service (EMS) remained stable. In EMS-transported patients, predefined quality indicators, such as percentages of pre-hospital ECGs (both 97%, 95% CI = - 2.2-2.7, p = 0.846), direct transports from the scene to the catheterization laboratory bypassing the emergency department (68% vs. 66%, 95% CI = - 4.9-7.9, p = 0.641), and contact-to-balloon-times of less than or equal to 90 min (58.3% vs. 57.8%, 95%CI = - 6.2-7.2, p = 0.879) were not significantly altered during the COVID-19 crisis, as was in-hospital mortality (9.2% vs. 8.5%, 95% CI = - 3.2-4.5, p = 0.739). CONCLUSIONS: Clinically important indicators for STEMI management were unaffected at the peak of COVID-19, suggesting that the pre-existing logistic structure in the regional STEMI networks preserved high-quality standards even when challenged by a threatening pandemic. CLINICAL TRIAL REGISTRATION: NCT00794001.


Assuntos
COVID-19 , Serviço Hospitalar de Cardiologia/tendências , Prestação Integrada de Cuidados de Saúde/tendências , Hospitalização/tendências , Avaliação de Processos e Resultados em Cuidados de Saúde/tendências , Intervenção Coronária Percutânea/tendências , Regionalização da Saúde/tendências , Infarto do Miocárdio com Supradesnível do Segmento ST/terapia , Idoso , COVID-19/epidemiologia , Estudos Transversais , Feminino , Alemanha/epidemiologia , Mortalidade Hospitalar/tendências , Humanos , Masculino , Pessoa de Meia-Idade , Intervenção Coronária Percutânea/mortalidade , Estudos Prospectivos , Indicadores de Qualidade em Assistência à Saúde/tendências , Sistema de Registros , Infarto do Miocárdio com Supradesnível do Segmento ST/diagnóstico , Infarto do Miocárdio com Supradesnível do Segmento ST/mortalidade , Fatores de Tempo , Tempo para o Tratamento/tendências , Resultado do Tratamento
2.
Pharmacol Res ; 158: 104883, 2020 08.
Artigo em Inglês | MEDLINE | ID: mdl-32446979

RESUMO

BACKGROUND: Xinyue capsule, a patented Chinese herbal medicine, has been used to manage coronary artery disease (CAD) for over a decade in China, but whether it can further reduce risk of cardiovascular events beyond conventional treatment is unknown. METHODS: In this multicenter, randomized, placebo-controlled trial, we randomly assigned patients with stable CAD who underwent percutaneous coronary intervention (PCI) within the preceding 3-12 months to receive Xinyue capsule (100 mg panax quinquefolius saponins, three times a day) or placebo for 24 weeks in addition to conventional treatment. The primary endpoint was a composite that included cardiac death, nonfatal myocardial infarction and urgent revascularization with either PCI or coronary artery bypass grafting. The secondary composite endpoints included stroke, re-hospitalization due to acute coronary syndrome (ACS), pulmonary embolism, peripheral vascular events and all-cause mortality. Quality of life was assessed using a 36-item Short-Form Health Survey (SF-36). RESULTS: A total of 1054 participants were included in the analyses. The median follow up was 1 year. The primary endpoint events occurred in 16 patients (3.02%) in the Xinyue group and 34 patients (6.49%) in the placebo group (hazard ratio [HR] 0.455, 95% confidence interval [CI] 0.25 to 0.825; P = 0.009). Secondary end-point events occurred in 5.47% of patients in the Xinyue group and 10.31% in the placebo group (HR 0.515, 95% CI 0.328 to 0.809; P = 0.004). SF-36 subscale scores at 12 months were significantly higher in the Xinyue group than placebo group for general health (P = 0.048) and vitality (P = 0.008). CONCLUSIONS: In patients with stable CAD after PCI within the preceding 3 to 12 months, Xinyue capsule added on conventional treatment reduced the incidence of primary composite endpoint (cardiac death, nonfatal myocardial infarction and urgent revascularization).


Assuntos
Doença da Artéria Coronariana/tratamento farmacológico , Doença da Artéria Coronariana/cirurgia , Medicamentos de Ervas Chinesas/uso terapêutico , Panax , Intervenção Coronária Percutânea/tendências , Saponinas/uso terapêutico , Idoso , Cápsulas , China/epidemiologia , Doença da Artéria Coronariana/epidemiologia , Método Duplo-Cego , Feminino , Seguimentos , Humanos , Masculino , Pessoa de Meia-Idade
3.
N Z Med J ; 133(1508): 29-42, 2020 01 17.
Artigo em Inglês | MEDLINE | ID: mdl-31945041

RESUMO

AIMS: Length of hospital stay (LOS) for acute coronary syndrome (ACS) has important clinical and cost implications. We report recent trends and predictors of ACS hospitalisation LOS in New Zealand. METHODS: Using routine national hospitalisation datasets, we calculated mean LOS for ACS admissions annually from 2006 to 2016, by demographics, ACS subtype and ACS procedures (coronary angiography, percutaneous coronary intervention (PCI) and coronary artery bypass grafting (CABG)). We also identified predictors of longer LOS. RESULTS: Among 185,962 ACS hospitalisations, mean LOS decreased from 7.8 to 6.7 days between 2006 and 2016 (adjusted decrease = -0.18 days/year). Decline in LOS was observed for all demographic subgroups by age, sex, ethnicity and deprivation quintile. While coronary angiography and PCI rates increased during this time, LOS declined for all management strategies. However, the adjusted rate of decline was greater for patients receiving coronary angiography without revascularisation (-0.24 days/year), PCI (-0.22 days/year) and CABG (0.33 days/year)-than those not receiving angiography (-0.14 days/year), P<0.001. A greater decline occurred for NSTEMI and STEMI (9.4 to 7.5 days and 7.8 to 6.2 days, respectively) than UA (5.4 to 4.9 days). Predictors of longer LOS in 2016 were older age, female, Maori or Pacific ethnicity, not receiving coronary angiography, initial presentation to a non-interventional hospital and CABG. CONCLUSIONS: Mean LOS for ACS hospitalisations declined between 2006 and 2016. The decline was greatest in the increasing proportion of patients who received a coronary angiogram. Further reductions in LOS may be achieved by implementation of nationally agreed pathways for adequate and timely access to coronary angiography.


Assuntos
Síndrome Coronariana Aguda/epidemiologia , Síndrome Coronariana Aguda/terapia , Hospitalização/estatística & dados numéricos , Tempo de Internação/economia , Síndrome Coronariana Aguda/diagnóstico por imagem , Síndrome Coronariana Aguda/mortalidade , Adulto , Fatores Etários , Idoso , Idoso de 80 Anos ou mais , Angiografia Coronária/métodos , Angiografia Coronária/tendências , Ponte de Artéria Coronária/métodos , Ponte de Artéria Coronária/tendências , Etnicidade/estatística & dados numéricos , Feminino , Hospitalização/tendências , Humanos , Tempo de Internação/tendências , Masculino , Pessoa de Meia-Idade , Nova Zelândia/epidemiologia , Infarto do Miocárdio sem Supradesnível do Segmento ST/epidemiologia , Infarto do Miocárdio sem Supradesnível do Segmento ST/fisiopatologia , Infarto do Miocárdio sem Supradesnível do Segmento ST/terapia , Intervenção Coronária Percutânea/métodos , Intervenção Coronária Percutânea/tendências , Infarto do Miocárdio com Supradesnível do Segmento ST/epidemiologia , Infarto do Miocárdio com Supradesnível do Segmento ST/fisiopatologia , Infarto do Miocárdio com Supradesnível do Segmento ST/terapia , Fatores Sexuais
4.
J Am Heart Assoc ; 8(24): e014906, 2019 12 17.
Artigo em Inglês | MEDLINE | ID: mdl-31813312

RESUMO

Background Patients undergoing percutaneous coronary intervention (PCI) are older with greater medical comorbidities and anatomical complexity than ever before, resulting in an increased frequency of nonemergent high-risk PCI (HR-PCI). We thus sought to evaluate the temporal trends in performance of HR-PCI and utilization of mechanical circulatory support in the largest integrated healthcare system in the United States. Methods and Results A cohort of high-risk adult patients that underwent nonemergent PCI in the Veterans Affairs Healthcare System between January 2008 and June 2018 were identified by objective clinical, hemodynamic, and anatomic criteria. Temporal trends in the performance of HR-PCI, utilization of mechanical circulatory support, and site-level variation were assessed. Of 111 548 patients assessed during the study period, 554 met 3 high-risk criteria whereas 4414 met at least 2 criteria for HR-PCI. There was a significant linear increase in the proportion of interventions that met 3 (P<0.001) or at least 2 (P<0.001) high-risk criteria over time, with rates approaching 1.9% and 11.2% in the last full calendar year analyzed. A minority of patients who met all high-risk criteria received PCI with mechanical support (15.7%) without a significant increase over time (P=0.193). However, there was significant site-level variation in the probability of performing HR-PCI (4.0-fold higher likelihood) and utilizing mechanical circulatory support (1.9-fold higher likelihood) between high and low utilization sites. Conclusions The proportion of cases categorized as HR-PCI has increased over time, with significant site-level variation in performance. The majority of HR-PCI cases did not utilize mechanical support, highlighting a discrepancy between current recommendations and clinical practice in an integrated healthcare system.


Assuntos
Circulação Assistida/estatística & dados numéricos , Doença da Artéria Coronariana/cirurgia , Intervenção Coronária Percutânea/tendências , Utilização de Procedimentos e Técnicas/estatística & dados numéricos , Saúde dos Veteranos , Idoso , Idoso de 80 Anos ou mais , Estudos de Coortes , Feminino , Instalações de Saúde/estatística & dados numéricos , Humanos , Masculino , Medição de Risco , Fatores de Tempo , Estados Unidos , United States Department of Veterans Affairs
5.
JACC Cardiovasc Interv ; 11(9): 879-888, 2018 05 14.
Artigo em Inglês | MEDLINE | ID: mdl-29747919

RESUMO

OBJECTIVES: The aim of this study was to evaluate temporal trends in characteristics and outcomes among patients referred for invasive coronary procedures within a national health care system for veterans. BACKGROUND: Coronary angiography and percutaneous coronary intervention remain instrumental diagnostic and therapeutic interventions for coronary artery disease. METHODS: All coronary angiographic studies and interventions performed in U.S. Department of Veterans Affairs cardiac catheterization laboratories for fiscal years 2009 through 2015 were identified. The demographic characteristics and management of these patients were stratified by time. Clinical outcomes including readmission (30-day) and mortality were assessed across years. RESULTS: From 2009 to 2015, 194,476 coronary angiographic examinations and 85,024 interventions were performed at Veterans Affairs facilities. The median numbers of angiographic studies (p = 0.81) and interventions (p = 0.22) remained constant over time. Patients undergoing these procedures were progressively older, with more comorbidities, as the proportion classified as having high Framingham risk significantly increased among those undergoing angiography (from 20% to 25%; p < 0.001) and intervention (from 24% to 32%; p < 0.001). Similarly, the median National Cardiovascular Data Registry CathPCI risk score increased for diagnostic (from 14 to 15; p = 0.005) and interventional (from 14 to 18; p = 0.002) procedures. Post-procedural medical management was unchanged over time, although there was increasing adoption of transradial access for diagnostic (from 6% to 36%; p < 0.001) and interventional (from 5% to 32%; p < 0.001) procedures. Complications and clinical outcomes also remained constant, with a trend toward a reduction in the adjusted hazard ratio for percutaneous coronary intervention mortality (hazard ratio: 0.983; 95% confidence interval: 0.967 to 1.000). CONCLUSIONS: Veterans undergoing invasive coronary procedures have had increasing medical complexity over time, without attendant increases in mortality among those receiving interventions. As the Department of Veterans Affairs moves toward a mix of integrated and community-based care, it will be important to account for these demographic shifts so that quality can be maintained.


Assuntos
Angiografia Coronária/tendências , Doença da Artéria Coronariana/terapia , Intervenção Coronária Percutânea/tendências , Idoso , Angiografia Coronária/efeitos adversos , Angiografia Coronária/mortalidade , Doença da Artéria Coronariana/diagnóstico por imagem , Doença da Artéria Coronariana/mortalidade , Bases de Dados Factuais , Prestação Integrada de Cuidados de Saúde/tendências , Feminino , Necessidades e Demandas de Serviços de Saúde/tendências , Humanos , Masculino , Pessoa de Meia-Idade , Readmissão do Paciente/tendências , Intervenção Coronária Percutânea/efeitos adversos , Intervenção Coronária Percutânea/instrumentação , Intervenção Coronária Percutânea/mortalidade , Valor Preditivo dos Testes , Sistema de Registros , Stents/tendências , Fatores de Tempo , Resultado do Tratamento , Estados Unidos/epidemiologia , United States Department of Veterans Affairs/tendências
6.
Am J Cardiovasc Drugs ; 18(3): 213-221, 2018 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-29322434

RESUMO

BACKGROUND: Evidence suggests that oxidative stress plays a principal role in myocardial damage following ischemia/reperfusion events. Recent studies have shown that the antioxidant properties of N-acetylcysteine (NAC) may have cardioprotective effects in high doses, but-to the best of our knowledge-few studies have assessed this. OBJECTIVES: Our objective was to investigate the impact of high-dose NAC on ischemia/reperfusion injury. METHODS: We conducted a randomized double-blind placebo-controlled trial in which 100 consecutive patients with ST-elevation myocardial infarction undergoing percutaneous coronary intervention (PCI) were randomly assigned to the case group (high-dose NAC 100 mg/kg bolus followed by intracoronary NAC 480 mg during PCI then intravenous NAC 10 mg/kg for 12 h) or the control group (5% dextrose). We measured differences in peak creatine kinase-myocardial band (CK-MB) concentration, highly sensitive troponin T (hs-TnT), thrombolysis in myocardial infarction (TIMI) flow, myocardial blush grade (MBG), and corrected thrombolysis in myocardial infarction frame count (cTFC). RESULTS: The peak CK-MB level was comparable between the two groups (P = 0.327), but patients receiving high-dose NAC demonstrated a significantly larger reduction in hs-TnT (P = 0.02). In total, 94% of the NAC group achieved TIMI flow grade 3 versus 80% of the control group (P = 0.03). No significant differences were observed between the two groups in terms of changes in the cTFC and MBG. CONCLUSIONS: In this study, NAC improved myocardial reperfusion markers and coronary blood flow, as revealed by differences in peak hs-TnT and TIMI flow grade 3 levels, respectively. Further studies with large samples are warranted to elucidate the role of NAC in this population. ClinicalTrials.gov identifier: NCT01741207, and the Iranian Registry of Clinical Trials (IRCT; http://irct.ir ) registration number: IRCT201301048698N8.


Assuntos
Acetilcisteína/administração & dosagem , Cardiotônicos/administração & dosagem , Traumatismo por Reperfusão Miocárdica/prevenção & controle , Intervenção Coronária Percutânea/efeitos adversos , Infarto do Miocárdio com Supradesnível do Segmento ST/terapia , Centros de Atenção Terciária , Idoso , Método Duplo-Cego , Feminino , Seguimentos , Humanos , Infusões Intravenosas , Injeções Intra-Arteriais , Irã (Geográfico)/epidemiologia , Masculino , Pessoa de Meia-Idade , Traumatismo por Reperfusão Miocárdica/diagnóstico por imagem , Intervenção Coronária Percutânea/tendências , Estudos Prospectivos , Infarto do Miocárdio com Supradesnível do Segmento ST/diagnóstico por imagem , Centros de Atenção Terciária/tendências
7.
J Am Heart Assoc ; 6(10)2017 Oct 11.
Artigo em Inglês | MEDLINE | ID: mdl-29021273

RESUMO

BACKGROUND: Patients with ST-elevation myocardial infarction (STEMI) with out-of-hospital cardiac arrest (OHCA) may benefit from direct transport to a percutaneous cardiac intervention (PCI) hospital but have previously been less likely to bypass local non-PCI hospitals to go to a PCI center. METHODS AND RESULTS: We reported time trends in emergency medical service transport and care of patients with STEMI with and without OHCA included from 171 PCI-capable hospitals in 16 US regions with participation in the Mission: Lifeline STEMI Accelerator program between July 1, 2012, and March 31, 2014. Time trends by quarter were assessed using logistic regression with generalized estimating equations to account for hospital clustering. Of 13 189 emergency medical service-transported patients, 88.7% (N=11 703; 10.5% OHCA) were taken directly to PCI hospitals. Among 1486 transfer-in patients, 21.7% had OHCA. Direct transport to a PCI center for OHCA increased from 74.7% (July 1, 2012) to 83.6% (March 31, 2014) (odds ratio per quarter, 1.07; 95% confidence interval, 1.02-1.14), versus 89.0% to 91.0% for patients without OHCA (odds ratio, 1.03; 95% confidence interval, 0.99-1.07; interaction P=0.23). The proportion with prehospital ECGs increased for patients taken directly to PCI centers (53.9%-61.9% for those with OHCA versus 73.9%-81.9% for those without OHCA; interaction P=0.12). Of 997 patients with OHCA taken directly to PCI hospitals and treated with primary PCI, first medical contact-to-device times within the guideline-recommended goal of ≤90 minutes were met for 34.5% on July 1, 2012, versus 41.8% on March 31, 2014 (51.6% and 56.1%, respectively, for 9352 counterparts without OHCA; interaction P=0.72). CONCLUSIONS: Direct transport to PCI hospitals increased for patients with STEMI with and without OHCA during the 2012 to 2014 Mission: Lifeline STEMI Accelerator program. Proportions with prehospital ECGs and timely reperfusion increased for patients taken directly to PCI hospitals.


Assuntos
Parada Cardíaca Extra-Hospitalar/terapia , Intervenção Coronária Percutânea/tendências , Avaliação de Processos em Cuidados de Saúde/normas , Melhoria de Qualidade/tendências , Indicadores de Qualidade em Assistência à Saúde/tendências , Infarto do Miocárdio com Supradesnível do Segmento ST/terapia , Tempo para o Tratamento/tendências , Transporte de Pacientes/tendências , Idoso , Prestação Integrada de Cuidados de Saúde/tendências , Eletrocardiografia/tendências , Feminino , Fidelidade a Diretrizes/tendências , Mortalidade Hospitalar/tendências , Humanos , Modelos Logísticos , Masculino , Pessoa de Meia-Idade , Parada Cardíaca Extra-Hospitalar/diagnóstico , Parada Cardíaca Extra-Hospitalar/mortalidade , Parada Cardíaca Extra-Hospitalar/fisiopatologia , Guias de Prática Clínica como Assunto , Valor Preditivo dos Testes , Infarto do Miocárdio com Supradesnível do Segmento ST/diagnóstico , Infarto do Miocárdio com Supradesnível do Segmento ST/mortalidade , Infarto do Miocárdio com Supradesnível do Segmento ST/fisiopatologia , Fatores de Tempo , Resultado do Tratamento , Estados Unidos
8.
J Am Heart Assoc ; 6(9)2017 Sep 12.
Artigo em Inglês | MEDLINE | ID: mdl-28899894

RESUMO

BACKGROUND: Little is known about facility-level variation in the use of revascularization procedures for the management of stable obstructive coronary artery disease. Furthermore, it is unknown if variation in the use of coronary revascularization is associated with use of other cardiovascular procedures. METHODS AND RESULTS: We evaluated all elective coronary angiograms performed in the Veterans Affairs system between September 1, 2007, and December 31, 2011, using the Clinical Assessment and Reporting Tool and identified patients with obstructive coronary artery disease. Patients were considered managed with revascularization if they received percutaneous coronary intervention (PCI) or coronary artery bypass grafting within 30 days of diagnosis. We calculated risk-adjusted facility-level rates of overall revascularization, PCI, and coronary artery bypass grafting. In addition, we determined the association between facility-level rates of revascularization and post-PCI stress testing. Among 15 650 patients at 51 Veterans Affairs sites who met inclusion criteria, the median rate of revascularization was 59.6% (interquartile range, 55.7%-66.7%). Across all facilities, risk-adjusted rates of overall revascularization varied from 41.5% to 88.1%, rate of PCI varied from 23.2% to 80.6%, and rate of coronary artery bypass graftingvariedfrom 7.5% to 36.5%. Of 6179 patients who underwent elective PCI, the median rate of stress testing in the 2 years after PCI was 33.7% (interquartile range, 30.7%-47.1%). There was no evidence of correlation between facility-level rate of revascularization and follow-up stress testing. CONCLUSIONS: Within the Veterans Affairs system, we observed large facility-level variation in rates of revascularization for obstructive coronary artery disease, with variation driven primarily by PCI. There was no association between facility-level use of revascularization and follow-up stress testing, suggesting use rates are specific to a particular procedure and not a marker of overall facility-level use.


Assuntos
Ponte de Artéria Coronária/tendências , Estenose Coronária/terapia , Prestação Integrada de Cuidados de Saúde/tendências , Disparidades em Assistência à Saúde/tendências , Intervenção Coronária Percutânea/tendências , Padrões de Prática Médica/tendências , Avaliação de Processos em Cuidados de Saúde/tendências , United States Department of Veterans Affairs , Idoso , Angiografia Coronária/tendências , Ponte de Artéria Coronária/estatística & dados numéricos , Estenose Coronária/diagnóstico por imagem , Ecocardiografia sob Estresse/tendências , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Intervenção Coronária Percutânea/estatística & dados numéricos , Valor Preditivo dos Testes , Avaliação de Programas e Projetos de Saúde , Fatores de Tempo , Resultado do Tratamento , Estados Unidos , Vasodilatadores/administração & dosagem
10.
J Am Heart Assoc ; 4(7)2015 Jul 10.
Artigo em Inglês | MEDLINE | ID: mdl-26163041

RESUMO

BACKGROUND: Early clopidogrel administration to patients with acute myocardial infarction (AMI) has been demonstrated to improve outcomes in a large Chinese trial. However, patterns of use of clopidogrel for patients with AMI in China are unknown. METHODS AND RESULTS: From a nationally representative sample of AMI patients from 2006 and 2011, we identified 11 944 eligible patients for clopidogrel therapy and measured early clopidogrel use, defined as initiation within 24 hours of hospital admission. Among the patients eligible for clopidogrel, the weighted rate of early clopidogrel therapy increased from 45.7% in 2006 to 79.8% in 2011 (P<0.001). In 2006 and 2011, there was significant variation in early clopidogrel use by region, ranging from 1.5% to 58.0% in 2006 (P<0.001) and 48.7% to 87.7% in 2011 (P<0.001). While early use of clopidogrel was uniformly high in urban hospitals in 2011 (median 89.3%; interquartile range: 80.1% to 94.5%), there was marked heterogeneity among rural hospitals (median 50.0%; interquartile range: 11.5% to 84.4%). Patients without reperfusion therapy and those admitted to rural hospitals were less likely to be treated with clopidogrel. CONCLUSIONS: Although the use of early clopidogrel therapy in patients with AMI has increased substantially in China, there is notable wide variation across hospitals, with much less adoption in rural hospitals. Quality improvement initiatives are needed to increase consistency of early clopidogrel use for patients with AMI. CLINICAL TRIAL REGISTRATION: URL: https://www.clinicaltrials.gov/. Unique identifier: NCT01624883.


Assuntos
Povo Asiático , Disparidades em Assistência à Saúde/tendências , Infarto do Miocárdio/tratamento farmacológico , Inibidores da Agregação Plaquetária/uso terapêutico , Padrões de Prática Médica/tendências , Ticlopidina/análogos & derivados , Idoso , China/epidemiologia , Clopidogrel , Esquema de Medicação , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Infarto do Miocárdio/diagnóstico , Infarto do Miocárdio/etnologia , Infarto do Miocárdio/mortalidade , Programas Nacionais de Saúde/tendências , Intervenção Coronária Percutânea/tendências , Inibidores da Agregação Plaquetária/efeitos adversos , Melhoria de Qualidade/tendências , Indicadores de Qualidade em Assistência à Saúde/tendências , Características de Residência , Estudos Retrospectivos , Fatores de Risco , Serviços de Saúde Rural/tendências , Ticlopidina/administração & dosagem , Ticlopidina/efeitos adversos , Fatores de Tempo , Resultado do Tratamento , Serviços Urbanos de Saúde/tendências
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