ABC | Volume 115, Nº2, August 2020

Short Editorial Pedrosa Distinct prognostic competence between models Arq Bras Cardiol. 2020; 115(2):226-228 (SYNTAX) were shown to have a good predictive capacity for death. However, only the anatomical model was able to predict recurrent non-fatal events. This demonstration that the scores commonly used in the clinical management of patients with ACS may have a predilection for different outcomes has not been described in the literature to date. Nevertheless, the interpretation of these results should consider the presence of a type β error in this analysis, because of the small number of patients with death events (19 deaths in 365 patients). The non-controlled confounding factors and the uncertainty introduced by a large difference in the third tertile were observed in both scores for the death event. The design of the present study (case series), with a retrospective data collection, represents a partial sample of the population of patients hospitalized for ACS, comprising a subpopulation submitted to coronary angiography, therefore not representing the real scenario of the ACS population treated in this hospital, but a selected subgroup with the best prognosis for which the attending physician indicated the performance of a coronary angiography. Data analysis was performed based on reports, and the imaging data were not obtained by reviewing the images and findings. Finally, a population in different post-ACS evolutionary stages was studied, as the coronary angiography exam was adopted as the reference. Likewise, we recognize that, despite their usefulness, risk scores tend to overestimate risk, 12 besides presenting limited power of discrimination between high and low risk individuals. They overestimate risk because they are sometimes derived from the general population, and sometimes from specific populations. There is a difficulty in stratifying risk by means of scores, since most events continue to occur in patients considered to be at low or intermediate risk. The limitations of risk scores result from the pathophysiology of ACS itself. Mendelian randomization studies, longitudinal cohort studies with young populations, in addition to autopsy studies, demonstrated that exposure to the risk of atherosclerosis occurs early, varies in intensity throughout life and includes genetic and environmental factors not taken into account in the scores. A single measure of risk factors in the adult individual with ACS fails to quantify the exposure to time- dependent risk. The risk of disease would be expressed more precisely, due to the cumulative exposure to all these risk determinants throughout life. 13 It is important to note that, in the dynamic process of establishing risk in the patient in which ACS is suspected and / or confirmed, clinical criteria are of paramount importance, managing to identify, without any other resource, the patients at highest risk for the occurrence of death or recurrent ischemic events. Continued clinical evaluation is always essential, whether due to abrupt complications that require rapid changes in conduct or the need for clinical criteria adjusted to the case. The formulation and updating of the evaluation of clinical variables that can predict the risk of adverse results at well- defined points in time are necessary, particularly in terms of cost-effectiveness. Using only clinical elements, we can define high-risk patients for major cardiac events, both in the short and long term, by the characteristics of their symptoms, their personal history and physical examination. Nevertheless, four variables always seem significant when trying to predict death after ACS. Clinical variables: age, renal dysfunction (expressed by serum creatinine), history of previous AMI, diabetes mellitus - which indicates a global physiological dysfunction characterized by elevated blood glucose - and the left ventricular dysfunction data. Therefore, in the presence of ACS, in most cases, it is the initial clinical suspicion that provides the offer of the best therapy as well as the prognosis. In the current socio- economic conditions, the evaluation at the patient’s arrival at the hospital is the one that ultimately has the greatest possibility of effectiveness along with the disease. Again, we emphasize that these “scores” should serve as guides, and not as ‘strings’ for our clinical judgment, with the latter being able to make use of the existing information to choose the best alternative for the patient. Such scores must be open to interpretations and treatment options that may be limited by financial resources. An early diagnosis together with good treatment and cardiac rehabilitation promote good patient recovery. In our context, changes in the organizational improvement, as well as in patient education, professionals in the emergency department, and coordination with agents in the public or private health system will result in a significant decrease in mortality due to ACS. 1. RothGA,HuffmanMD,MoranAE,FeiginV,MensahGA,etal.Globalandregional patterns in cardiovascular mortality from 1990 to 2013. Circulation. 2015; 132(17):1667-78. 2. Matos LN, Carvalho AC, Gonçalves Jr I, Barbosa A, Tarkieltaub E, Moreno AC, et al. Pharmaco-invasive therapy in STEMI patients in emerging countries, different from the developed world, could decreased mortality compared to usualtreatment. JAmCollCardiol.2013;61(10Suppl):E61-E76. 3. Bruyninckx R, Aertgeerts B, Bruyninckx P, Buntinx F. Signs and symptoms in diagnosing acute myocardial infarction and acute coronary syndrome: a diagnosticmeta-analysis.Br JGenPract.2008;58(547):e1-e8. 4. Varma C, Brecker S. Predictors of mortality in acute myocardial infarction. Lancet.2001;358 (9292):1473-4.Erratum in:Lancet.2002;359 (9312):1160. 5. Kanamasa K, Ishikawa K, Hayashi T, Hoshida S, Yamada Y, Kawarabayashi T, et al. South Osaka Acute Coronary Syndrome Study Group. Increased cardiac mortality in women compared with men in patients with acute myocardial infarction. Intern Med. 2004;43(10):911-8. 6. Murcia AM, Hennekens CH, Lamas GA, Jiménez-Navarro M, Rouleau JL, Flaker GC, et al. 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