Choosing Wisely Brazil: top 5 low-value practices that should be avoided in musculoskeletal physical therapy.

BACKGROUND: The Choosing Wisely initiative aims to promote discussions among healthcare professionals and patients about low-value, or potentially harmful, health practices. OBJECTIVES: To describe the process of development of the Brazilian Choosing Wisely list for musculoskeletal physical therapy. METHODS: The Brazilian Choosing Wisely list was developed in accordance with the recommendations of the American Board of Internal Medicine. A three-step procedure was used. First, an expert panel was selected, and a modified Delphi approach was used to obtain a list of evidence-based statements. Second, members of the research team performed content analysis. Third, a national survey was conducted to present selected statements to a sample of physical therapists. Participants were invited to vote considering the level of importance of selected statements for physical therapists and patients. RESULTS: The expert panel comprised 17 physical therapists. The median age of the expert panel was 33 [interquartile range (IQR) 29 to 37; range 26 to 60] years and the median length of professional experience was 12 (IQR 10 to 18) years. A list of eight recommendations was presented to a national sample composed of 1127 physical therapists. The median length of professional experience of the national sample was 10 (IQR 5 to 15) years. Based on the number of votes, the five most important recommendations were included in the Brazilian Choosing Wisely list for musculoskeletal physical therapy. Descriptive and frequency analysis were used to report the results. CONCLUSION: The Brazilian Choosing Wisely list for musculoskeletal physical therapy provides an opportunity for physical therapists, patients, society and policy makers to collaboratively discuss tests and treatments that are unnecessary or potentially harmful.

Inappropriate screening of obstructive coronary artery disease during pre-anesthesia assessment of candidates for non-cardiac surgery.

Preoperative evaluation in elective surgeries has been associated with successful surgical treatment. However, there is no solid scientific evidence that screening for coronary artery disease (CAD) reduces surgical risk. The aims of this study were to describe the frequency of inappropriate investigation of obstructive CAD induced by pre-anesthetic assessment in individuals without cardiovascular symptoms (candidates for low- to intermediate-risk surgeries) and to evaluate predictors of this conduct. We performed a retrospective evaluation of medical records of anesthesiology services from patients undergoing pre-anesthesia assessment between May 2015 and May 2016, including those with functional capacity ≥4 metabolic equivalents without a diagnosis of heart disease. A total of 778 medical records (47±16 years of age, 62.6% female) were studied. A private hospital performed 50.1% of the surgeries and 60.4% were of intermediate risk. Only 2.7% (95%CI: 1.7-4.1%) were screened for CAD, and 91% of these requests were mediated by cardiology consultations performed during pre-anesthetic testing visits. Factors associated with screening for CAD were hypertension, diabetes, moderate systemic disease (ASA III), cardiac consultation, previous diagnosis of CAD, and admission to a private hospital. Independent predictors were private hospitals (OR: 3.9; 95%CI: 1.3-11.0), ASA III (OR: 5.3; 95%CI: 1.7-16.2), and hypertension (OR: 3.8; 95%CI: 1.5-9.8). The frequency of inappropriate requests for CAD screening in asymptomatic individuals without untreated systemic diseases was low in pre-anesthetic visits. Although infrequent, screening for CAD is more common in the private setting, in patients with poorer health status, and is usually prescribed during cardiology consultation.

Inappropriate screening of obstructive coronary artery disease during pre-anesthesia assessment of candidates for non-cardiac surgery

Preoperative evaluation in elective surgeries has been associated with successful surgical treatment. However, there is no solid scientific evidence that screening for coronary artery disease (CAD) reduces surgical risk. The aims of this study were to describe the frequency of inappropriate investigation of obstructive CAD induced by pre-anesthetic assessment in individuals without cardiovascular symptoms (candidates for low- to intermediate-risk surgeries) and to evaluate predictors of this conduct. We performed a retrospective evaluation of medical records of anesthesiology services from patients undergoing pre-anesthesia assessment between May 2015 and May 2016, including those with functional capacity ≥4 metabolic equivalents without a diagnosis of heart disease. A total of 778 medical records (47±16 years of age, 62.6% female) were studied. A private hospital performed 50.1% of the surgeries and 60.4% were of intermediate risk. Only 2.7% (95%CI: 1.7-4.1%) were screened for CAD, and 91% of these requests were mediated by cardiology consultations performed during pre-anesthetic testing visits. Factors associated with screening for CAD were hypertension, diabetes, moderate systemic disease (ASA III), cardiac consultation, previous diagnosis of CAD, and admission to a private hospital. Independent predictors were private hospitals (OR: 3.9; 95%CI: 1.3-11.0), ASA III (OR: 5.3; 95%CI: 1.7-16.2), and hypertension (OR: 3.8; 95%CI: 1.5-9.8). The frequency of inappropriate requests for CAD screening in asymptomatic individuals without untreated systemic diseases was low in pre-anesthetic visits. Although infrequent, screening for CAD is more common in the private setting, in patients with poorer health status, and is usually prescribed during cardiology consultation.

Low prevalence of relevant findings in inappropriate echocardiograms and discordant perceptions between cardiologists and patients.

Complementary examinations are "inadequate" whenever the likelihood of benefits from their indication is lower than the negative results. The low benefit is a result of poor performance in detecting relevant changes that lead to improved behavior. However, inadequate examinations are prevalent and little is known about patients' notions of the usefulness of such indications. The aim of this study was to describe relevant findings in inappropriate echocardiograms and to assess the level of agreement between patients and cardiologists regarding their usefulness. Adults without known cardiovascular disease who were referred for echocardiogram by inappropriate criteria according to the American College of Cardiology were selected. Relevant findings were defined by any change in the degree of moderate to severe, according to the American Society of Echocardiography. We tested the level of agreement between the patients who underwent echocardiographic examination and the physicians who requested the exam through a standard questionnaire. Five hundred patients were included, with average age of 52±17 years (47% males). Only 17 patients had any relevant changes (3.4%, 95%CI=2 to 5.4%). The most frequent alterations included valve changes in 8 and diastolic dysfunction grade II in 6 patients. Eighty-seven examinations were performed to determine the level of agreement between patients and cardiologists. For the question "Is this test really necessary?", 92% of patients responded positively, compared with 5% of cardiologists (Kappa negative 0.04; P=0.01). The frequency of relevant findings was low in inadequate echocardiograms and patients and cardiologists had a different perception regarding its usefulness.

Low prevalence of relevant findings in inappropriate echocardiograms and discordant perceptions between cardiologists and patients

Complementary examinations are "inadequate" whenever the likelihood of benefits from their indication is lower than the negative results. The low benefit is a result of poor performance in detecting relevant changes that lead to improved behavior. However, inadequate examinations are prevalent and little is known about patients' notions of the usefulness of such indications. The aim of this study was to describe relevant findings in inappropriate echocardiograms and to assess the level of agreement between patients and cardiologists regarding their usefulness. Adults without known cardiovascular disease who were referred for echocardiogram by inappropriate criteria according to the American College of Cardiology were selected. Relevant findings were defined by any change in the degree of moderate to severe, according to the American Society of Echocardiography. We tested the level of agreement between the patients who underwent echocardiographic examination and the physicians who requested the exam through a standard questionnaire. Five hundred patients were included, with average age of 52±17 years (47% males). Only 17 patients had any relevant changes (3.4%, 95%CI=2 to 5.4%). The most frequent alterations included valve changes in 8 and diastolic dysfunction grade II in 6 patients. Eighty-seven examinations were performed to determine the level of agreement between patients and cardiologists. For the question "Is this test really necessary?", 92% of patients responded positively, compared with 5% of cardiologists (Kappa negative 0.04; P=0.01). The frequency of relevant findings was low in inadequate echocardiograms and patients and cardiologists had a different perception regarding its usefulness.

Predictive value of ophthalmic artery Doppler velocimetry in relation to development of pre-eclampsia.

OBJECTIVE: To test the hypothesis that ophthalmic artery Doppler velocimetry is predictive of the development of pre-eclampsia (PE). METHODS: This was a prospective cohort study that included pregnant women in the second trimester who had risk factors for PE. Seven ophthalmic artery Doppler parameters, in addition to uterine artery (UtA) Doppler and clinical variables, were investigated for their prognostic value with respect to PE. RESULTS: A total of 347 women were recruited, of whom 40 developed PE. A comparison of the mean ophthalmic artery Doppler parameter values between women with and those without PE showed statistically significant differences in several parameters: peak systolic velocity, end-diastolic velocity, mean velocity, peak mesodiastolic velocity (PMDV) and peak ratio. After adjusting for confounding variables, only PMDV remained statistically significant (P < 0.001), with an area under the receiver-operating characteristics curve (AUC) of 0.73. The best cut-off for predicting PE was a PMDV of > 22.11 cm/s, with sensitivity of 70%, specificity of 75%, positive likelihood ratio of 2.8, negative likelihood ratio of 0.4, positive predictive value of 28% and negative predictive value of 95%. The AUC increased from 0.72 to 0.78 when the PMDV was incorporated into a prediction model based on clinical variables, demonstrating that this marker increased the discriminatory capability of the model. The performance of ophthalmic artery Doppler was similar to that of UtA Doppler for predicting PE. Additionally, the AUC increased significantly from 0.82 to 0.88 when the PMDV was incorporated into the model containing clinical variables and UtA Doppler indices. CONCLUSION: A high ophthalmic artery PMDV in the second trimester of pregnancy is an independent predictor of PE that increases the discriminatory ability of clinical markers, as well as of models that include clinical variables and UtA Doppler indices.

Safety and efficacy of angioplasty with intracoronary stenting in patients with unstable coronary syndromes. Comparison with stable coronary syndromes.

OBJECTIVE: To assess safety and efficacy of coronary angioplasty with stent implantation in unstable coronary syndromes. METHODS: Retrospective analysis of in-hospital and late evolution of 74 patients with unstable coronary syndromes (unstable angina or infarction without elevation of the ST segment) undergoing coronary angioplasty with stent placement. These 74 patients were compared with 31 patients with stable coronary syndromes (stable angina or stable silent ischemia) undergoing the same procedure. RESULTS: No death and no need for revascularization of the culprit artery occurred in the in-hospital phase. The incidences of acute non-Q-wave myocardial infarction were 1.4% and 3.2% (p = 0.6) in the unstable and stable coronary syndrome groups, respectively. In the late follow-up (11.2 +/- 7.5 months), the incidences of these events combined were 5.7% in the unstable coronary syndrome group and 6.9% (p = 0.8) in the stable coronary syndrome group. In the multivariate analysis, the only variable with a tendency to significance as an event predictor was diabetes mellitus (p = 0.07; OR = 5.2; 95% CI = 0.9-29.9). CONCLUSION: The in-hospital and late evolutions of patients with unstable coronary syndrome undergoing angioplasty with intracoronary stent implantation are similar to those of the stable coronary syndrome group, suggesting that this procedure is safe and efficacious when performed in unstable coronary syndrome patients.

Phytophilous Chironomidae (Diptera) and other macroinvertebrates in the ox-bow Infernão Lake (Jataí Ecological Station, Luiz Antônio, SP, Brazil)

Infernão Lake, located within the Jataí Ecological Station in Luiz Antônio Municipal district (São Paulo State, Brazil), is one of the most typical ox-bow lake of the Mogi-Guaçu River, and it presents, as the main feature, its great quantity of aquatic macrophytes, whose intensive development, in the last years practically covered the whole mirror of water. With the purpose to point out the composition and to establish the relative participation of the phytophilic zoocoenosis that inhabits the different macrophytes of that lake, a collection program of the main vegetation stands was established. The collections, were carried out randomly, during dry season (1994), in stands of Salvinia auriculata, Utricularia sp., Cabomba piauhyensis, Eichhornia azurea and Scirpus cubensis being used specific methodology for each vegetable type. The analysis of the different macrophytes showed the presence of 4,130 macroinvertebrates of 28 families, in which Chironomidae (Diptera) and Naididae (Oligochaeta) were the most representative, contributing on the average with 51 percent and 25 percent of the total fauna. Asheum, Beardius, Chironomus, Goeldichironomus, Parachironomus and Polypedilum were the most abundant Chironomidae genera. Species of the genus Dero (Dero) and D. (Aulophorus) represented the most typical Naididae of the phytofauna. With clear faunistic gradient from the shore to the center of the lake, the taxocoenosis indicated low similarity (PSc < 50 percent), evidencing its own characteristics of each biotope. On the contrary, there was a high similarity (PSc > 60 percent) among the associated communities on different vegetables, when grouped into feeding guilds, with expressive participation, in most of the macrophytes, of the collector-gatherers category, except on S. auriculata, whose predators (> 50 percent) and collector-filterers (> 20 percent) dominance turned that zoocoenosis distinct from the others

Phytophilous chironomidae (Diptera) and other macroinvertebrates in the ox-bow Infernão Lake (Jatai Ecological Station, Luiz Antonio, SP, Brazil).

Infernão Lake, located within the Jataí Ecological Station in Luiz Ant nio Municipal district (São Paulo State, Brazil), is one of the most typical ox-bow lake of the Mogi-Guaçu River, and it presents, as the main feature, its great quantity of aquatic macrophytes, whose intensive development, in the last years practically covered the whole mirror of water. With the purpose to point out the composition and to establish the relative participation of the phytophilic zoocoenosis that inhabits the different macrophytes of that lake, a collection program of the main vegetation stands was established. The collections, were carried out randomly, during dry season (1994), in stands of Salvinia auriculata, Utricularia sp., Cabomba piauhyensis, Eichhornia azurea and Scirpus cubensis being used specific methodology for each vegetable type. The analysis of the different macrophytes showed the presence of 4,130 macroinvertebrates of 28 families, in which Chironomidae (Diptera) and Naididae (Oligochaeta) were the most representative, contributing on the average with 51% and 25% of the total fauna. Asheum, Beardius, Chironomus, Goeldichironomus, Parachironomus and Polypedilum were the most abundant Chironomidae genera. Species of the genus Dero (Dero) and D. (Aulophorus) represented the most typical Naididac of the phytofauna. With clear faunistic gradient from the shore to the center of the lake, the taxocoenosis indicated low similarity (PSc < 50%), evidencing its own characteristics of each biotope. On the contrary, there was a high similarity (PSc > 60%) among the associated communities on different vegetables, when grouped into feeding guilds, with expressive participation, in most of the macrophytes, of the collector-gatherers category, except on S. auriculata, whose predators (> 50%) and collector-filterers (> 20%) dominance turned that zoocoenosis distinct from the others.

[The Internet as a solution facilitating the identification of patients with a suspected acute myocardial infarct]. / A Internet como solução facilitadora da identificação de doentes com suspeita de enfarte agudo do miocárdio.

The current steps for diagnosing heart disease are very time consuming, delaying the correct identification of the problem, therefore, delaying the right treatment. In this study we have developed an experimental method using e-mail in order to identify patients with "rule out myocardial" condition and reduce the time lag for thrombolysis or coronary angioplasty in this clinical setting. Three different locations linked to the Internet by ISDN lines were used. Each line was connected with a computer. A pager and a dedicated phone line were also used. The following steps were performed for each situation: filling out of a questionnaire, ECG recording, questionnaire mailing and ECG by e-mail as attachment, pager warning that an urgent cardiology consultation was requested, including the doctor and patient's phone number, time to open the message and reply by e-mail, phone call for additional comments. A total of 24 attempts of interactive communication were performed. In 22 of those, an answer was obtained in less than 30 minutes. Two failures were recorded. One was due to a delay in the pager message, which did not arrive within the first hour; the second was due to a computer break down. This report shows that it is possible to establish a fast communication between the out patient clinic and the hospital (less than 30 minutes in most cases) at a very low cost and in a simple manner.

Intravascular magnetic resonance imaging of aortic atherosclerotic plaque composition.

Magnetic resonance imaging (MRI) may be an excellent tool to define atherosclerotic plaque composition, but surface MRI (SMRI) suffers from a low signal-to-noise ratio and low resolution of arterial images. Intravascular MRI (IVMRI) represents a potential solution for acquiring high-quality in vivo images of atherosclerotic plaques. Isolated segments of 11 thoracic human aortas obtained at autopsy were imaged by IVMRI using an intravascular receiver catheter coil designed and built at our institution. Images obtained by IVMRI were compared with corresponding images obtained by SMRI and with histopathological aortic cross sections. The intensity of intimal thickness and plaque components was graded by IVMRI and histopathology using a score of 1 for mild, 2 for moderate, and 3 for severe intensity. IVMRI had an agreement of 75% with histopathology in fibrous cap grading (37.5% expected, kappa = 0.60, P < 0.001) and of 74% in necrotic core grading (39% expected, kappa = 0.57, P < 0.001). Intraplaque calcification was correctly graded by IVMRI in six of the eight plaques in which histopathology recognized calcium. The analysis of intimal thickness showed 80% agreement between IVMRI and histopathology (52% expected, kappa = 0.59, P < 0.001). IVMRI image features were similar to those of SMRI. In addition, IVMRI accurately determined atherosclerotic plaque size in comparison with histopathology and SMRI (slope = 1.25 cm2, r = 0.99, P < 0.001 for luminal area by IVMRI vs histopathology; slope = 0.97 cm2, r = 0.996, P < 0.001 for luminal area by IVMRI vs SMRI). IVMRI has the potential to provide important prognostic information in patients with atherosclerosis because of its ability to accurately assess both plaque composition and size.

High resolution intravascular MRI and MRS by using a catheter receiver coil.

Potentially important diagnostic information about atherosclerosis can be obtained by using magnetic resonance imaging and spectroscopy techniques. Because critical vessels such as the aorta, coronary arteries, and renal arteries are not near the surface of the body, surface coils are not adequate to increase the data quality to desired levels. A few catheter MR receiver coil designs have been proposed for imaging the walls of large blood vessels such as the aorta. These coils have limited longitudinal coverage and they are too thick to be placed into small vessels. A flexible, long and narrow receiver coil that can be placed on the tip of a catheter and will enable multi-slice high resolution imaging of small vessels has been developed. The authors describe the theory of the coil design technique, derive formulae for the signal-to-noise ratio characteristics of the coil, and show examples of high resolution cross-sectional images from isolated human aortas acquired by using this catheter coil. In addition, high resolution in vivo rabbit aorta images were obtained as well as a set of spatially resolved chemical shift spectra from a dog circumflex coronary artery.

[The role of low-molecular-weight heparin in unstable angina, acute myocardial infarction and post-elective percutaneous transluminal coronary angioplasty]. / O papel da heparina de baixo peso molecular na angina instável, infarto agudo do miocárdio e pós-angioplastia percutânea transluminal coronária eletiva.

PURPOSE: To evaluate the clinical efficacy and safety of subcutaneous (SC) low molecular weight heparin (LMWH) compared to intravenous (IV) non fractioned heparin (NFH) in unstable angina, acute myocardial infarction and post-percutaneous transluminal coronary angioplasty. METHODS: From September/92 to April/94, 314 patients were randomized in two groups. Group I-- 154 patients treated with SC LMWH, using in the 1st phase SC LMWH with a dosage of 160 UaXa IC/kg/day (group IA--92 patients), and in the 2nd, a dosage of 320 UaXa IC/kg/day (group IB--62 patients). Group II--160 patients treated with IV NFH 100UI/kg (bolus), followed by 1000UI/h with adjusted dosage by activated partial thromboplastin time. RESULTS: There was not a statistically significant difference among the three groups in relation to cardiac events, hemorrhagic complications and deaths. CONCLUSION: The clinical efficacy and safety of SC LMWH in patients with unstable angina, acute myocardial infarction and post-percutaneous transluminal coronary angioplasty were similar to IV NFH with the dosages used in this study.

[Doppler echocardiography in the diagnosis of mechanic complications of acute myocardial infarction]. / Ecocardiografia/Doppler no diagnóstico das complicações mecânicas do enfarte agudo do miocárdio.

OBJECTIVES: To evaluate the ability of bedside emergency Doppler/Echocardiographic (ECOCG/DP) studies in the diagnosis of mechanic complications during acute myocardial infarction (AMI). DESIGN: Retrospective analysis of 44 fatal AMI cases, studied by ECOCG/DP and with diagnostic confirmation by surgery and/or necropsy. SETTING: Patients (pts) with AMI admitted to an Intensive Care Unit of a tertiary Hospital (UCIM), Hospital de Santa Maria. PATIENTS: 44 fatal AMI cases were analysed (24 men and 20 women; mean age +/- SD: 72 +/- 9 years) and were divided in two groups according to Killip classification in Group 1 (III/IV): 35 pts and Group 2 (I/II): 9 pts. METHODS: ECOCG/DP was performed in a routine basis at admission, using all standard views and by subcostal view when in an emergency scenario. RESULTS: In 20 pts with bad left ventricular function (LVF) (Group 1) at admission, ECOCG/DP monitoring showed that death was due to worsening of LVF, which was confirmed by necropsy. In the other 15 pts of this group, ECOCG/DP documented the clinical diagnosis of cardiac rupture (free wall: 4 pts; papillary muscle: 4 pts; interventricular septum: 7 pts) which was confirmed by surgery and/or necropsy. In the 9 pts of Group 2, ECOCG/DP disclosed, at admission, good LVF in all. In 5 pts there was a sudden worsening clinical status, and ECOCG/DP showed a severe pericardial effusion with right chambers collapse, highly suggestive of free wall rupture also confirmed at necropsy. In the other 4 pts, ECOCG/DP showed aggravation of wall motion abnormalities and of LVF without rupture, once again in agreement with necropsy. Five clinical cases are presented for illustration of this issue. CONCLUSION: In the 44 fatal AMI cases of our study there was complete agreement between the ECOCG/DP and necropsy studies. In AMI patients, ECOCG/DP monitoring can in a routine basis, evaluate wall motion abnormalities and LVF. In an emergency setting ECOCG/DP can diagnose all the mechanic complications with a great certainty.

[Thrombolysis in acute myocardial infarction in the aged. A greater risk of cardiac rupture?]. / Trombólise no enfarte agudo do miocárdio no idoso. Um risco acrescido de ruptura cardíaca?

OBJECTIVE: To evaluate age group and i.v. thrombolytic therapy (TT) influences on cardiac rupture complicating acute myocardial infarction (AMI). CONCEPTION: Retrospective analysis of patients (pts) admitted during 1988-89 to an Intensive Care Unit of a Terciary Hospital (UCIM) with AMI. POPULATION: 430 pts were admitted with AMI. During this period 89 pts were submitted to TT (25% age greater than or equal to 65 years). Eighty four pts died during hospital stay and 42 had autopsy study (50%). Only 7 of nonautopsied pts died of undetermined cause. Dead pts had age m +/- SD 72 +/- 11 years old (yo) (37% female, 63% male and 74% age greater than or equal to 65 yo). RESULTS: Nineteen pts died of cardiac rupture (CR) (23%). CR prevalence was 1.4% (3/218) in pts less than 65 yo and 7.5% (16/212) in pts greater than or equal to 65 yo (p less than 0.01). CR prevalence in pts submitted to TT (4.5%) 4/89, was similar to pts not submitted to TT (4.4%) 15/341 (n.s.). Pts less than 65 yo had nonsignificant differences in CR wether submitted or not to TT (0% vs 2%). Elderly pts (greater than or equal to 65 yo) CR prevalence was 18% (4/22) in those submitted to TT vs 6% (12/190) in those not submitted to TT (p less than 0.05). CONCLUSIONS: Thrombolytic therapy may carry an additional risk for cardiac rupture in elderly patients (greater than or equal to 65 yo).

[Thrombolysis in acute myocardial infarct. Experience at Santa Maria's Hospital]. / Trombólise no enfarte agudo do miocárdio Experiência no Hospital de Santa Maria.

OBJECTIVES: To evaluate the experience with i.v. streptokinase (SK) in the treatment of acute myocardial infarction (AMI) in two cardiac care units. Conception: Retrospective analysis of patients (pts) admitted either to UCIM or UTIC-AC with the diagnosis of AMI receiving SK. PATIENTS: 77 pts were treated, although one of them was later proved to be a false positive diagnosis of AMI. Of the other 76, there were 63 men and 13 women with age 55 +/- 12 (mean age +/- SD) years (limits of 20 and 82 years). AMIs were anterior in 42% of the pts, inferior in 51%, anterior and inferior in 4% and non Q wave in 1%; Killip classes (cl) were: cl I in 64%, cl II in 26%, cl III in 5% an cl IV in 5%. The time interval from the beginning of acute symptoms to the arrival at the hospital was 2.8 +/- 1.2 hours (1 to 15) and from that moment to administration of SK was 1.6 +/- 1.4 h. The whole interval to the administration of SK was 4.4 +/- 2.5 h. RESULTS: The 3 criteria of reperfusion (pain relief, ST changes resolution and less than 18 h maximum CK rise) were present in 36% of the pts, 2 of the criteria in 21%, and 41% of the pts had only one or no criteria. The time interval to the administration of SK in these 3 groups was 3.3 +/- 1.3 h, 4.8 +/- 3.1 h and 5.0 +/- 2.5 h respectively. Non fatal complications occurred in 16% of the pts (major bleeding in 2.6%, minor bleeding in 99% and minor anafilaxy in 4%. Mortality was 11.8% (9 pts). Two thirds of the deaths were due to cardiac rupture. In hospital residual ischemia was present in 9% (7 pts). CONCLUSION: Treatment of AMI with i.v. SK proved to be a safe and easy to apply therapeutic option, carrying a low morbidity and mortality, lower than that normally observed in our hospital with the conventional approach of AMI before the era of thrombolysis.