This study compared two techniques for hemostasis after transradial catheterization: 1) minimum pressure technique, where the hemostatic wristband was deflated to the lowest pressure maintaining hemostasis without monitoring patency, and 2) patent hemostasis technique, where patency was monitored every 15 minutes. The study found: 1) Early radial artery occlusion occurred in 1.8% of patients using minimum pressure technique and 1.9% using patent hemostasis technique, with no significant difference. 2) No major bleeding events occurred in either group. Hematoma rates were also similar between groups. 3) Minimum pressure technique may be as effective as patent hemostasis technique in preventing radial artery

1. ORIGINAL RESEARCH
Vol. 32, No. 4, April 2020 147
The use of transradial access (TRA) for coronary cath-
eterization has increased over the years, worldwide.1
The radial artery is nowadays utilized by default for
percutaneous coronary procedures at many centers, due to the
reduced rates of vascular and bleeding complications and easier
postprocedural management.2,3
The use of TRA also improves
patient comfort, saves costs, and has an equivalent procedural
success rate when compared with the femoral approach.4,5
AlthoughTRA is widely accepted by cardiologists and pa-
tients, some problems still exist. One of the major limitations
is the development of postprocedural radial artery occlusion
(RAO), ranging from 1%-12%.6,7
The benign nature of such
an event has been constantly emphasized because of the dual
blood supply to the hand from the palmar arch. Mostly, the
occurrence of RAO is asymptomatic, and symptomatic RAO
requiring medical attention is very rare, but hand ischemia
caused by RAO has been described.8,9
The most important
aspect is that once the artery is occluded, it cannot be used as
the access site for future catheterization, as a conduit for by-
pass surgery, or for fistula formation in hemodialysis patients.
The use of smaller-caliber catheters, adequate dose of
heparin administration, immediate sheath removal after pro-
cedure, patent hemostasis technique, and short duration of
compressive bandage are the key elements to reduce the risk
of RAO.10-13
Notably, the presence of radial pulse does not
exclude RAO due to presence of collateral circulation;it can
be more accurately defined by absence of antegrade flow in
vascular Doppler ultrasound.14
Indeed patent hemostatic compression, bleeding control
while maintaining radial arterial flow, appears to be the sin-
gle most important factor in reducing RAO. Maintaining
patent hemostasis has been shown to be feasible, with min-
imal conversion to manual compression immediately after
diagnostic catheterization. But ideally, control of patency is
required each 15 minutes.15
We therefore sought to evaluate whether using a “min-
imum pressure” technique in hemostatic wristband, that
is, applying the same principle of “patent hemostasis” but
without controlling patency, has the same efficacy in pre-
venting RAO.
Comparison of Minimum Pressure and Patent
Hemostasis on Radial Artery Occlusion After
Transradial Catheterization
Roberto L. da Silva, MD1,2,3
; Pedro B. de Andrade, MD, PhD4
; Alexandre A.C.Abizaid, MD, PhD1
;
Paulo F.R. Britto, MD2
; Filippe B. Filippini, MD2
; Renata M.M.Viana, MD1
; Amanda G.M. Sousa, MD, PhD1
;
Fausto Feres, MD, PhD1
; José R. Costa Jr, MD, PhD1
ABSTRACT: Objectives. The aim of this study was to compare two hemostatic techniques, minimum pressure technique and
patent hemostasis, on radial artery occlusion (RAO) after transradial catheterization. Background. RAO is an infrequent com-
plication of transradial procedures. One of the strategies used to reduce this complication is the patent hemostasis technique.
Use of minimum pressure in hemostatic wristband, without monitoring patency, might have the same efficacy for preventing
RAO. Methods. This is a multicenter study encompassing patients submitted to transradial catheterization. After pneumatic
wristband application, the band was deflated to the lowest allowable volume while preserving hemostasis. Radial artery
patency was subsequently evaluated. The group with no return of plethysmographic curve was labeled “minimum pressure,”
and the group in which the signal returned was labeled “patent hemostasis.” RAO was verified by Doppler evaluation within
the first 24 hours of the procedure. Results. A total of 1082 patients were enrolled, with mean age of 61.4 ± 10.4 years. The
majority (61.0%) were male and 34.5% had diabetes. Patent hemostasis was achieved in only 213 cases (20%). Early RAO
occurred in 16 patients (1.8%) in the minimum pressure group and in 4 patients (1.9%) in the patent hemostasis group (P=.97).
No major bleeding was observed among the entire cohort. EASY scale for hematoma grade was similar between the cohorts
(EASY grades 1-3: 7.0% in the minimum pressure group vs 7.5% in the patent hemostasis group; P=.96). Conclusion. Checking
radial patency during hemostatic compression may not be necessary after the procedure when adopting a mild and short
hemostatic compression.
J INVASIVE CARDIOL 2020;32(4):147-152. Epub 2020 March 11.
KEY WORDS: hemostasis, radial artery occlusion, transradial catheterization
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2. Minimum Pressure Hemostasis on RAO Da SILVA, et al.
148 The Journal of Invasive Cardiology®
Methods
This is a prospective, multicenter, non-randomized, ob-
servational study encompassing patients submitted to diag-
nostic and/or therapeutic percutaneous coronary procedure
by radial access. All adult patients undergoing transradial
catheterization at three centers between August 2017 and
December 2018 were considered for inclusion. With an
all-comers design, eligible patients were ≥18 years old with
a clinical indication for coronary angiography (ad hoc angio-
plasty was allowed) or percutaneous coronary intervention
(PCI) if the following prerequisites are met: (1) choice of
the operator to use the transradial access route; and (2) use
of 5 or 6 Fr sheath size. Baseline patency of the palmar arch,
by Allen test or Barbeau test, was not obligatory. Exclusion
criteria were: (1) primary angioplasty due to acute myocar-
dial infarction; (2) intubation; (3) complications during pro-
cedure (cardiac arrest, pulmonary edema, cardiogenic shock,
and stroke); (4) prior inclusion in this trial; (5) known allergy
or intolerance to nitrates; (6) medication with continuous
intravenous nitrates or any nitrates within the last hour; and
(7) use within 24 hours prior to randomization of phos-
phodiesterase inhibitors. The study protocol was presented
to the institutional medical ethics committees of all partici-
pating hospitals to comply with local standards. All patients
provided written informed consent.
Outcome definitions. The primary outcome was the inci-
dence of early RAO, confirmed by the absence of antegrade
flow in vascular duplex ultrasound, up to 24 hours after
catheterization. The secondary outcomes were: (1) late RAO,
wherein all patients with early occlusion were scanned for
recanalization, by the presence of antegrade flow in vascu-
lar duplex ultrasound, 30 days after catheterization; and (2)
presence of local hematoma or major bleeding.
Study definitions. A radial puncture attempt was defined
as any skin puncture with positive blood draw through the
needle.A local hematoma was classified according to the EASY
scale: grade 1, ≤5 cm diameter; grade 2, ≤10 cm diameter;
grade 3,>10 cm but not above the elbow;grade 4,extending
above the elbow;and grade 5,anywhere with ischemic threat
of the hand.16
Major bleeding was graded according to the
Bleeding Academic Research Consortium definitions: type
3a, bleeding with hemoglobin drop ≥ 3 g/dL and < 5 g/dL,
or packed red blood cell transfusion; type 3b, bleeding with
hemoglobin drop ≥5 g/dL, cardiac tamponade, bleeding re-
quiring surgical intervention, or bleeding requiring intrave-
nous inotropic drugs; type 3c, intracranial hemorrhage, with
subcategories confirmed by autopsy, imaging examinations
or lumbar puncture; intraocular bleeding with vision im-
pairment);or type 5 bleeding (type 5a,possibly fatal bleeding
and type 5b, definitive fatal bleeding).17
Transradial procedure. Local anesthesia was adminis-
tered with a subcutaneous injection of 1% lidocaine after
skin preparation. Radial artery access was obtained using
either anterior or counterpuncture technique based on the
operator’s preference, using a 21 gauge bare needle or 20/22
gauge sheath-covered needle, after which a 5 Fr or 6 Fr hy-
drophilic sheath was inserted over a guidewire.Then, the pa-
tient received heparin (5000 U) through the radial sheath as
an intra-arterial bolus.Additional heparin was given in cases
of PCI (total 100 IU/kg). No routine intravenous sedation
was given.The use of additional medication, either vasodila-
tors or analgesics, was left to the operator’s discretion.Tran-
sradial coronary angiography and/or PCI were performed
according to standard techniques,at the operator’s discretion.
Radial spasm was detected by patient report of pain in the
forearm, and measured using a numeric scale applied at the
end of the procedure.The scale varied from 0 to 10 (0 cor-
responding to “no pain” and 10 to “worst possible pain”).
Operators reported the presence of spasm according to the
difficulty perceived during manipulation or withdrawal of
the introducer sheath or catheter.
Arterial hemostasis. A pneumatic compression device
designed to assist hemostasis of the radial artery was applied
immediately after the procedure according to the following
protocol. The sheath was initially pulled by approximately
2-4 cm.Three to 5 mL of blood were aspirated through the
sheath to remove any residual thrombus. The device was
applied to the patient, with the green marker (located in
the center of the larger balloon) positioned exactly at the
puncture hole to aid in the location, visualization, and con-
trol of possible bleeding. The balloon was inflated with a
proper syringe, injecting 15 mL of air, and then the sheath
was removed, noticing the absence of active bleeding. In the
presence of bleeding, up to 3 mL of additional air was inject-
ed to obtain complete hemostasis. Formerly, the device was
deflated to the lowest allowable volume (minimum, 7 mL)
while preserving hemostasis. If bleeding occurred, sufficient
air amount was reintroduced from the bleeding point (up to
1 mL in most cases) to achieve hemostasis. Unlike traditional
compression, no fixed amount of air was reinserted from
the bleeding point during wristband application, character-
izing the least necessary pressure to hemostasis, which is one
of the basics principles of patent hemostasis. Radial artery
patency was subsequently evaluated by plethysmography
and pulse oximetry evaluation, with the sensor placed over
the thumb or index finger, and transient occlusion (manual
pressure) of the ulnar artery. The group with no return of
plethysmographic curve (lack of signal) observed was labeled
the “minimum pressure” technique, and the one in which
the signal returned was labeled the “patent hemostasis” tech-
nique, according to the other basic principle to verify the
patency. No subsequent confirmation of patency was done
during hemostasis. One hour post diagnostic procedure or 2
hours post intervention, three mL of air was removed every
15 minutes, until complete deflation. If bleeding occurred
during any stage of device removal,the volume of air needed
for complete hemostasis was injected, restarting the deflation
process 60 minutes later.When all the air was removed, the
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3. Vol. 32, No. 4, April 2020 149
Minimum Pressure Hemostasis on RAO Da SILVA, et al.
device was removed and the access site was covered with a
simple light dressing, which did not encircle the entire wrist.
Evaluation of radial patency. Radial artery patency
was evaluated by vascular duplex Doppler ultrasound, using
a 6-13 MHz vascular transducer with M-turbo ultrasound
scanner (Fujifilm SonoSite) or a 7.5 MHz vascular trans-
ducer with PowerVision 6000 ultrasound scanner (Toshiba),
performed in all patients within 24 hours of the removal of
the compression band. RAO was defined by absence of an-
terograde flow.The physician who performed the ultrasound
scan was blinded to the technique of hemostasis applied. In
order to evaluate recanalization, every patient with con-
firmed RAO was further evaluated 30 days later to reassess
patency with a new duplex scan examination.
Statistical analysis. The primary analysis of the study
was a comparison between minimum pressure technique
and patent hemostasis technique to decrease early RAO.
Continuous variables were described as mean ± standard
deviation and compared using Student’s t -test for normally
distributed variables or assessed using Mann-Whitney test
when not normally distributed. Normality was tested us-
ing Shapiro-Wilk test. Categorical variables were expressed
as frequency (percentage of the group) and were compared
with the Chi-square or Fisher’s exact tests. A multivariate
logistic regression model, including variables with P<.10 in
the univariate analysis, was used to identify the indepen-
dent predictors of RAO. In the analysis of the primary and
secondary endpoints, a two-tailed P-value of <.05 was con-
sidered statistically significant. All analyses were performed
using SPSS, version 22 (SPSS, Inc).
Results
A total of 1082 patients underwent
transradial catheterization and were
enrolled between August 2017 and
December 2018. Mean patient age
was 61.4 ± 10.4 years. The majori-
ty (61.0%) were male and 34.5% had
diabetes. In 213 cases (20%), the eval-
uation of anterograde flow by pleth-
ysmography indicated patency of the
radial artery after applying the hemo-
static wristband; these patients consti-
tuted the patent hemostasis group.The
other 869 cases (80%) constituted the
minimum pressure group, and had no
demonstration of flow during hemo-
static compression.
There were few differences in base-
line clinical characteristics between
the groups.Age was lower (61.08 years
vs 62.68 years; P=.04), radial artery
diameter was bigger (2.8 mm vs 2.4
mm; P<.001), and acute coronary syn-
dromes were more frequent (60.9% vs
28.6%; P<.001) in the minimum pressure group vs the pat-
ent hemostasis group, respectively. Procedural characteristics
were similar between groups, but the minimum pressure
group had longer procedures (21.6 vs 18.2 minutes;P<.001),
anterior technique to radial artery puncture was used more
frequently (71.9% vs 45.5%; P<.001), and more catheters
were used to complete the procedures (2.0 vs 1.6; P<.001)
compared with the patent hemostasis group. Diagnostic cor-
onary angiography was the predominant procedure (74.9%),
although PCI was more commonly performed in the patent
hemostasis group (34.8% vs 22.8% in the minimum pressure
group; P=.01) (Tables 1 and 2).
The incidence of the primary outcome of early RAO
occurred in 16 patients (1.8%) in the minimum pressure
group and 4 patients (1.9%) in the patent hemostasis group
(P=.97; odds ratio [OR], 1.02; 95% confidence interval [CI],
0.33-3.08). No major bleeding was observed among the en-
tire cohort. EASY scale hematoma grades 1-3 were similar
between the cohorts (7.0% for the minimum pressure group
vs 7.5% for the patent hemostasis group; P=.96) (Table 3).
None of the patients with RAO experienced any signs and/
or symptoms of hand ischemia requiring specific treatment.
Three patients in the minimum pressure group and no pa-
tients in the patent hemostasis group showed re-establish-
ment of flow at 30-day Doppler assessment.
In the univariate model, several variables were predictors
of RAO (with P<.10), including a single clinical character-
istic (younger age) and multiple procedure variables (number
of puncture attempts, longer procedure time, higher radia-
tion used, spasm classified by operator and by patient use of
Table 1. Baseline clinical characteristics.
Minimum
Pressure
(n = 869)
Patent
Hemostasis
(n = 213)
All
Patients
(n = 1082)
P-
Value
Age (years) 61.08 ± 10.47 62.68 ± 9.95 61.39 .04
Sex (male) 60.1% 64.8% 61.0% .21
Weight (kg) 76.61 ± 15.71 77.73 ± 14.82 76.83 .33
Height (cm) 164.21 ± 9.22 165.45 ± 8.50 164.45 .06
Body mass index (kg/m2
) 28.37 ± 5.10 28.35 ± 4.77 28.36 ± 5.04 .96
Right handed 95.5% 96.2% 95.7% .62
Hypertension 74.3% 78.9% 75.2% .17
Diabetes mellitus 33.5% 38.5% 34.5% .17
Smoker 23.2% 21.1% 22.8% .50
Dyslipidemia 58.3% 61.5% 59.0% .40
Prior radial catheterization 22.1% 28.1% 23.3% .06
Clinical <.001
Stable 39.1% 71.4% 45.5%
Acute coronary syndrome 60.9% 28.6% 54.5%
Data presented as mean ± standard deviation or percentage.
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4. Minimum Pressure Hemostasis on RAO Da SILVA, et al.
150 The Journal of Invasive Cardiology®
the pain score).After multivariable adjustment with backward
deletion, only age <60 years (OR, 2.87; 95% CI, 1.07-7.64;
P=.03) and pain score >4 (OR, 5.16; 95% CI, 1.82-14.62;
P<.01) remained as independent predictors of RAO.
Discussion
Among patients undergoing transradial catheterization,
patent hemostasis, as characterized by demonstration of ra-
dial artery flow by an oximetric test or other similar test,
was found to be present in the minority of patients us-
ing standard hemostatic protocols, even with pneumatic
wristband application.18
To improve the patent hemostasis
rates, some protocols require repeated
assessment of radial artery patency or a
specified deflation of the band 15 min-
utes post placement.15,18,19
However, those
adjustments increase labor to the nursing
staff and require more frequent workflow
interruptions for the frequent plethys-
mographic evaluation of 15 minutes after
radial artery flow and, if necessary, adapta-
tion of the hemostatic device, reflecting a
possible important limitation in its routine
use.Without evaluation after the outset of
compression, we obtained demonstration
of flow in only one-fifth of the study pop-
ulation, demonstrating that re-evaluation
of flow would be mandatory to apply the
patent hemostasis technique in all patients.
We found that the balloon of the com-
pression band could be safely deflated to
the minimum pressure possible in all pa-
tients, without compromising safety or
increasing bleeding complications. This
specific adjustment in the wristband ap-
plication, coupled with a short compres-
sion time, seems to be equally efficient in
obtaining very low rates of RAO, as com-
pared with standard patent hemostasis, which required more
attention to patency during the entire hemostasis process.
The minimum pressure technique diverges from the pat-
ent hemostasis technique regarding the attention to patency
during wristband application and throughout the process.
This technique may help patient comfort and simplify the
nursing team’s work.
This study did not measure the pneumatic band com-
pression pressure, as used in another study,20
and instead used
a substitute that was easier to apply: minimum air volume
that allowed hemostasis.The lowest quantity of air to main-
tain hemostasis is the equivalent of the minimum pressure
needed for safe compression. Unlike traditional (occlusive)
hemostasis, the amount of air was the least necessary to stop
bleeding, rather than a fixed amount of air.As expected, the
rate of local hematoma around the puncture site and arm
was low. No other vascular complications were detected.
It was presumed that a thrombotic process causes RAO
afterTRA. Sheath insertion and catheter manipulation caus-
es local trauma and endothelial injury, allowing subsequent
thrombus formation. Studies with optical coherence tomog-
raphy and intravascular ultrasound confirmed that hypothe-
sis and have demonstrated postprocedural thrombus gener-
ation and considerable vessel trauma, including dissections,
ruptures, and thickening of the intima. In small radial arter-
ies, these lesions lead to formation of thrombus, producing
occlusion.21,22
Therefore, RAO after TRA appears to be an
intricate interaction of trauma, anticoagulation, and flow.
Table 3. Study outcomes.
Minimum
Pressure
Patent
Hemostasis
P-
Value
Early RAO 1.8% 1.9% .97
Late RAO 1.5% 1.9% .33
Pulse present 97.4% 98.6% .29
EASY scale .96
1 3.9% 4.2%
2 2.2% 2.3%
3 0.9% 0.9%
4-5 0.0% 0.0%
Data presented as percentages.
RAO = radial artery occlusion.
Table 2. Procedural characteristics.
Minimum
Pressure
(n = 869)
Patent
Hemostasis
(n = 213)
All
Patients
(n = 1082)
P-
Value
Radial size (mm) 2.79 ± 0.71 2.44 ± 0.63 2.74 <.001
Puncture attempts (n) 1.31 ± 0.66 1.28 ± 0.73 1.30 .60
Anterior puncture 71.9% 45.5% 66.7% <.001
6 Fr sheath size 44.5% 42.3% 44.1% .59
Procedure .01
Diagnostic 77.2% 65.3% 74.9%
Ad hoc PCI 16.2% 9.4% 14.9%
PCI 6.6% 25.4% 10.3%
Catheter (n) 1.96 ± 0.88 1.56 ± 0.82 1.88 <.001
Time (min) 21.65 ± 18.44 18.17 ± 16.62 20.96 .01
Radiation (µG) 594.23 ± 526.67 650.80 ± 485.03 605.38 .14
Spasm (operator) 6.3% 16.4% 8.3% <.001
Pain score 2.58 ± 2.81 2.30 ± 2.70 2.52 ± 2.80 .17
Precath nitroglycerin 49.7% 50.2% .89
Postcath nitroglycerin 50.1% 50.2% .96
Data presented as mean ± standard deviation or percentage.
PCI = percutaneous coronary intervention; precath = precatheterization use of nitroglycerin;
postcath = postcatheterization use of nitroglycerin.
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5. Vol. 32, No. 4, April 2020 151
Minimum Pressure Hemostasis on RAO Da SILVA, et al.
The wristband’s compressive pressure and duration of ap-
plication have a direct effect on hemostasis; indeed, duration
of hemostasis was one of the strongest predictors of RAO.23
This is probably related with flow impairment during com-
pression.In our study,we opted for a short compression time
(60 minutes), knowing that ultra-short radial compression
time was not associated with beneficial reduction in RAO
rates.24
The short compression time could help to explain
our low RAO incidence.
RAO was assessed up to 24 hours using Doppler ultraso-
nography in all patients.At this stage, this approach must be
considered the gold-standard technique to characterize both
the thrombotic obstruction and the lack of anterograde flow.
It is also known that the detection of RAO by the absence
of radial pulse underestimates the true incidence, as com-
pared with ultrasound assessment.25
Furthermore, in contrast
to Barbeau’s test, duplex scan allows a full appraisal of other
vascular complications. One study has used both Doppler
ultrasonography and pulse oximetry to measure RAO, with
some difference in results.26
The best moment to evaluate RAO is not yet established.
Studies have shown that incidence of RAO decreases over
time as compared with the first day, when the RAO inci-
dence is highest.7,19
Besides, many of our patients were dis-
charged on the same day. Even in this worst scenario for
RAO evaluation, both techniques used in our study popula-
tion provided very low RAO rates.
Prior trials have shown that a significant proportion of
patients (roughly 50%) will have spontaneous recanalization
of radial artery posterior evaluations.15,27,28
Despite this fact,
we found a late recanalization rate of only 15%.
Multiple prior studies have shown that a dosage of 5000
IU is superior to any lower doses of unfractionated heparin in
preventing RAO, without increasing the risk of bleeding.29-31
Rather than calculated doses of heparin based on the patients’
weights, we opted for a fixed dose of 5000 IU in most cases,
and used higher and weight-based doses in cases of angioplas-
ty.Anticoagulation of all patients could help to reduce RAO
rates in cases in which patent hemostasis was not obtained.
Study limitations. The present study has several im-
portant limitations. Primarily, there was no possibility of
randomization, since groups were separated after the ap-
plication of the wristband, when patency was checked and
no further evaluation of patency during compression was
planned. Although this was a non-randomized trial, clini-
cal and procedural characteristics were well balanced in the
two cohorts; however, a few differences between the groups
could have produced some bias in the results. In order to re-
duce bias, the physician who assessed the Doppler scans was
blinded to the study allocation. Additionally, this protocol
cannot be interpreted as a true “patent hemostasis” protocol
because maintenance of radial artery flow during hemosta-
sis, as verified by digital plethysmography, was not verified
further during the compression time, and fluctuation in the
patient’s arterial pressure could promote a change in the
patency status, although most protocols do not re-evaluate
the patency after a positive test, just as we did. Changes in
hemodynamic status may lead to loss of patency or establish-
ment of patency at a later time during compression. Finally,
our study only included patients accessed with 5 or 6 Fr
sheaths, so our findings should not be extrapolated to proce-
dures with larger sheaths.
Conclusion
In the present study, the use of minimum pressure and
patent hemostasis techniques resulted in very low RAO
rates and comparable efficacy in preventing RAO. Both
techniques are safe, with low incidence of hematoma for-
mation. Most important, our results indicate that checking
radial patency during hemostatic compression may not be
necessary after the procedure when adopting a mild and
short hemostatic compression.
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From the 1
Department of Interventional Cardiology, Instituto Dante Pazzanese de
Cardiolgia, São Paulo, SP, Brazil; 2
Department of Interventional Cardiology, Insti-
tuto de Cardiologia de Santa Catarina, São José, SC, Brazil; 3
Department of Inter-
ventional Cardiology, Hospital Universitário Prof. Polydoro Ernani de São Thiago,
Florianópolis, SC, Brazil; and 4
the Department of Interventional Cardiology, Santa
Casa de Marília, Marília, SP, Brazil.
Disclosure: The authors have completed and returned the ICMJE Form for Disclo-
sure of Potential Conflicts of Interest. The authors report no conflicts of interest
regarding the content herein.
Manuscript submitted September 15, 2019, provisional acceptance given Septem-
ber 24, 2019, final version accepted October 2, 2019.
Address for correspondence: Roberto Léo da Silva, MD, Instituto de Cardiologia de
Santa Catarina, Rua Adolfo Donato da Silva, s/n. Praia Comprida, São José, Santa
Catarina. CEP 88103-901. Email: roberto.leo@ufsc.br
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