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    "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Heart failure &#40;HF&#41; is a first-order healthcare problem&#46; The condition is associated with considerable morbidity and mortality and is the leading cause of hospitalizations for those older than 65 years in the western world&#46;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> In the context of this highly prevalent syndrome&#44; which mainly affects elderly patients&#44; the presence of associated comorbidities has considerable relevance&#46; On one hand&#44; the comorbidities have a high incidence rate and can be the cause or consequence of HF or merely a coincidence&#46; Moreover&#44; comorbidities can hinder the diagnosis of HF by masking or overlapping with some of its symptoms&#46; Comorbidities can also hinder the treatment of these patients<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> and have a significant repercussion on the prognosis&#46; Most comorbidities associated with HF lead to a poorer evolution&#44; with more hospitalizations&#44; resource consumption&#44; poorer quality of life and increased mortality&#46;<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2&#8211;4</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">Patients with HF typically present several associated comorbidities&#44; the absence of which is unusual&#46; This was made clear in a broad study performed on 122&#44;630 patients older than 65 years with HF&#46; Fifty-five percent of the patients had 4 or more comorbidities&#44; 40&#37; had 5 or more and only 4&#37; had none&#46;<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> In the last 2 decades&#44; the prevalence of these comorbidities has increased&#44; with the percentage of patients with 5 or more comorbidities increasing from 40&#37; at the end of the 1980s to almost 60&#37; by the end of the 2000&#46;<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> This increase coincided with the increase in age of patients with HF&#59; i&#46;e&#46;&#44; there has been a change in phenotype toward patients with HF at a more advanced age&#44; with more comorbidities and multiple medications&#46;<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">Another important issue is that the comorbidities are especially common in patients with HF who have admitted to internal medicine departments&#46; These are elderly patients&#44; predominantly women&#44; with an increased prevalence of hypertension&#44; diabetes&#44; obesity&#44; anemia&#44; chronic obstructive pulmonary disease &#40;COPD&#41; and renal failure&#46; In contrast&#44; more men&#44; younger individuals and those with more ischemic and valvular heart disease are admitted to cardiology departments&#44; as verified in an analysis of more than 27&#44;000 hospital discharges for HF performed in Spain&#46;<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">This article reviews the prevalence and prognostic impact of the main comorbidities associated with HF&#46;</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Prevalence of comorbidities in heart failure registries</span><p id="par0025" class="elsevierStylePara elsevierViewall">We have data on the prevalence of various comorbidities in the major registries<a class="elsevierStyleCrossRefs" href="#bib0040"><span class="elsevierStyleSup">8&#8211;18</span></a> that show a more realistic image of clinical practice than the data from clinical trials&#44; in which the presence of comorbidities is considered an exclusion criterion&#46; <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a> lists the prevalence of the various comorbidities in the large American&#44;<a class="elsevierStyleCrossRefs" href="#bib0050"><span class="elsevierStyleSup">10&#44;15&#44;18</span></a> Asian<a class="elsevierStyleCrossRefs" href="#bib0045"><span class="elsevierStyleSup">9&#44;14</span></a> and European<a class="elsevierStyleCrossRefs" href="#bib0060"><span class="elsevierStyleSup">12&#44;16&#44;17</span></a> registries&#44; including the RICA registry of the Spanish Society of Internal Medicine&#46;<a class="elsevierStyleCrossRefs" href="#bib0065"><span class="elsevierStyleSup">13&#44;19</span></a> In addition to the comorbidities typically recorded in the registries and clinical trials &#40;arterial hypertension &#91;AHT&#93;&#44; diabetes&#44; chronic kidney disease&#44; anemia&#44; COPD&#44; atrial fibrillation &#91;AF&#93;&#44; ischemic heart disease&#41;&#44; we should highlight others that are usually underdiagnosed but are important due to their prevalence and repercussion on the prognosis of HF&#44;<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> such as depressive syndrome&#44; sleep apnea&#44; cognitive impairment&#44; liver disease&#44; malnutrition&#44; osteoarticular disease and thyroid dysfunction&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0030" class="elsevierStylePara elsevierViewall">We can deduce that the high prevalence of comorbidity in patients with HF is due to their advanced age&#44; given that the majority of individuals aged 65 years or older have some comorbidity&#59; by the age of 85 years&#44; more than 90&#37; have some comorbidity&#46;<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">20</span></a> However&#44; it has been reported that patients with HF have more comorbidity than similarly aged controls&#46;<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">21</span></a> This phenomenon is due to several causes&#46; On one hand&#44; comorbidities act as a cause of HF&#59; on the other&#44; they can be a consequence of HF or even coincide&#59; however&#44; many of them contribute to the progression and perpetuation of HF&#46;<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a></p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Comorbidities as a cause of heart failure</span><p id="par0035" class="elsevierStylePara elsevierViewall">HF is a syndrome with multiple causes&#46; Some comorbidities constitute risk factors for developing HF&#46;<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">22</span></a> In fact&#44; patients with AHT&#44; diabetes&#44; obesity or atherosclerosis are included in stage A of the HF classification of the American Heart Association &#40;AHA&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">22</span></a> These risk factors can behave as etiologic agents&#59; for example&#44; AHT in HF with preserved left ventricular ejection fraction &#40;HFPEF&#41; or arteriosclerosis&#44; through ischemia&#44; in HF with reduced left ventricular ejection fraction &#40;HFREF&#41;&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">These risk factors for the onset of HF are also risk factors for developing chronic kidney disease&#44; whose main causes are diabetes and AHT&#46; Moreover&#44; renal failure can cause heart failure&#59; the so-called cardiorenal syndromes types 3 and 4&#46;<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">23</span></a> Similarly&#44; anemia associated with kidney disease can trigger or promote the development of HF&#46;<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">24</span></a></p><p id="par0045" class="elsevierStylePara elsevierViewall">Sleep apnea &#40;through hypoxia&#41;&#44; sympathetic activation&#44; pulmonary and systemic arterial hypertension and arrhythmias contribute to the development of HF&#46;<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">25</span></a> Moreover&#44; smoking&#44; which is a risk factor for HF&#44; can promote the development of COPD&#44; a disease that also increases the risk of HF&#46;<a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">26</span></a> These diseases &#40;COPD&#44; diabetes and obesity&#41; cause a systemic inflammatory state&#44; which intervenes in the genesis of HFPEF&#46; A review by Paulus and Tsch&#246;pe<a class="elsevierStyleCrossRef" href="#bib0135"><span class="elsevierStyleSup">27</span></a> proposed a systemic proinflammatory state generated or induced by comorbidities as a cause of the structural and functional myocardial disorders in patients with HFPEF&#46;</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Comorbidities as a consequence of heart failure</span><p id="par0050" class="elsevierStylePara elsevierViewall">Comorbidities can also be the consequence of HF&#44; through the congestion and hypoperfusion that HF causes&#46; In fact&#44; HF can cause renal failure &#40;cardiorenal syndromes types 1 and 2&#41;<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">23</span></a> and contributes to the presence of anemia by a dilutional mechanism<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">24</span></a> and to hepatic dysfunction&#46; Numerous comorbidities also contribute to the progression of HF&#44; thereby establishing a bidirectional relationship that perpetuates the disease&#46;<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2&#44;3&#44;25&#44;28</span></a></p><p id="par0055" class="elsevierStylePara elsevierViewall">Finally&#44; some comorbidities can also act as triggers of HF&#59; for example&#44; anemia&#44; atrial fibrillation with rapid ventricular response&#44; hyperthyroidism and infectious processes&#44; mainly of respiratory origin&#46;<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a></p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Comorbidity and prognosis</span><p id="par0060" class="elsevierStylePara elsevierViewall">Numerous comorbidities&#44; considered individually&#44; have been associated with a poorer prognosis for HF&#46;<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2&#44;21&#44;29</span></a></p><p id="par0065" class="elsevierStylePara elsevierViewall">Renal failure is one of the most relevant comorbidities due to its high prevalence&#44;<a class="elsevierStyleCrossRefs" href="#bib0150"><span class="elsevierStyleSup">30&#44;31</span></a> for being a cause and effect of HF&#44;<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">23</span></a> hindering its treatment<a class="elsevierStyleCrossRef" href="#bib0150"><span class="elsevierStyleSup">30</span></a> and for being an independent predictor of mortality&#44; as has been demonstrated by several studies<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">3&#44;31</span></a> and meta-analyses&#46;<a class="elsevierStyleCrossRefs" href="#bib0160"><span class="elsevierStyleSup">32&#44;33</span></a> Renal function impairment has been reported in up to 63&#37; of patients with HF&#44;<a class="elsevierStyleCrossRef" href="#bib0160"><span class="elsevierStyleSup">32</span></a> and the prevalence of chronic kidney disease in various HF registries varies from 20&#37;<a class="elsevierStyleCrossRefs" href="#bib0045"><span class="elsevierStyleSup">9&#44;18</span></a> to 50&#37;<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">15</span></a> or 59&#37;&#44;<a class="elsevierStyleCrossRef" href="#bib0170"><span class="elsevierStyleSup">34</span></a> depending on the diagnostic criteria employed&#46;</p><p id="par0070" class="elsevierStylePara elsevierViewall">Regarding its prognostic value&#44; a recent meta-analysis that included 57 studies on chronic kidney disease and 28 studies on acute renal function impairment showed that both conditions are associated with increased mortality&#44; both in acute HF and in chronic HF&#44; either HFPEF or HFREF&#46;<a class="elsevierStyleCrossRef" href="#bib0165"><span class="elsevierStyleSup">33</span></a></p><p id="par0075" class="elsevierStylePara elsevierViewall">In Spain&#44; the RICA registry has shown a very high prevalence of renal failure &#40;59&#46;5&#37;&#41;<a class="elsevierStyleCrossRef" href="#bib0170"><span class="elsevierStyleSup">34</span></a> in patients with HF&#44; both overall<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a> and specifically in HFPEF&#44;<a class="elsevierStyleCrossRef" href="#bib0175"><span class="elsevierStyleSup">35</span></a> and its association with a poorer prognosis&#44; with lower survival as the glomerular filtration rate decreases&#46;</p><p id="par0080" class="elsevierStylePara elsevierViewall">Anemia is another of the most common comorbidities&#46; In a meta-analysis of 34 studies that included 153&#44;180 patients with HF&#44; 37&#46;2&#37; of the patients had anemia&#46;<a class="elsevierStyleCrossRef" href="#bib0180"><span class="elsevierStyleSup">36</span></a> Nevertheless&#44; the prevalence of anemia among various registries varies from 15&#37;<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">16</span></a> and 53&#37;&#44;<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a> mainly due to the varying diagnostic criteria employed&#46; The frequency of anemia increases with the time of HF progression&#44; the NYHA functional class and the degree of renal function impairment&#46;<a class="elsevierStyleCrossRef" href="#bib0185"><span class="elsevierStyleSup">37</span></a> Anemia also constitutes a trigger for HF decompensation and is associated with a poorer quality of life and prognosis&#46; There is certain controversy as to the latter point&#46; A number of studies have shown that anemia acts as a factor for poor prognosis &#40;associated with more readmissions and all-cause mortality&#41;&#44; regardless of the ejection fraction&#46;<a class="elsevierStyleCrossRefs" href="#bib0180"><span class="elsevierStyleSup">36&#8211;38</span></a> However&#44; other authors have suggested that anemia is a mere marker of severity&#44; associated with other factors of poor prognosis such as a poorer NYHA functional class and chronic renal failure&#46;<a class="elsevierStyleCrossRef" href="#bib0185"><span class="elsevierStyleSup">37</span></a> In fact&#44; it has been reported that anemia loses its independent prognostic value in patients with advanced chronic kidney disease&#46;<a class="elsevierStyleCrossRef" href="#bib0195"><span class="elsevierStyleSup">39</span></a></p><p id="par0085" class="elsevierStylePara elsevierViewall">The GESAIC study&#44;<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">12</span></a> performed in Spain&#44; observed a prevalence of anemia of 52&#46;7&#37; in patients hospitalized for HF and greater mortality in this patient group&#44; although statistical significance was not reached when considering all-cause mortality&#46; The authors attributed this result to the short follow-up time &#40;1 year&#41; and to the inclusion of patients with initial HF&#44; although the results could also have been affected by the small sample size &#40;211 patients&#41;&#46; In this study&#44; however&#44; the patients with anemia and refractory HF did have greater mortality&#46;<a class="elsevierStyleCrossRef" href="#bib0200"><span class="elsevierStyleSup">40</span></a></p><p id="par0090" class="elsevierStylePara elsevierViewall">Iron deficiency is very common in patients with HF&#44; even in the absence of anemia&#46; Various studies have shown an improved capacity for exercise and quality of life with iron deficiency correction&#46;<a class="elsevierStyleCrossRef" href="#bib0205"><span class="elsevierStyleSup">41</span></a></p><p id="par0095" class="elsevierStylePara elsevierViewall">Diabetes is another very common comorbidity&#44; with a prevalence of 40&#37;&#44;<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a> which is very similar in all the large American registries &#40;ADHERE&#44;<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a> OPTIMIZE-HF<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">18</span></a> and GWTG-HF<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">15</span></a>&#41;&#46; In the RICA registry&#44;<a class="elsevierStyleCrossRef" href="#bib0210"><span class="elsevierStyleSup">42</span></a> the prevalence of diabetes is 45&#37;&#46;</p><p id="par0100" class="elsevierStylePara elsevierViewall">The presence of diabetes in patients with HF worsens the prognosis&#46; Increased mortality&#44;<a class="elsevierStyleCrossRef" href="#bib0215"><span class="elsevierStyleSup">43</span></a> longer hospital stays and more readmissions have been observed&#46;<a class="elsevierStyleCrossRef" href="#bib0220"><span class="elsevierStyleSup">44</span></a> The DIAMOND study showed lower long-term survival after hospital discharge for patients with diabetes and HF&#44; especially in women&#46;<a class="elsevierStyleCrossRef" href="#bib0225"><span class="elsevierStyleSup">45</span></a> Similar results were obtained in a subanalysis of the EVEREST study&#44; with greater cardiovascular mortality and more readmissions for patients with diabetes than for their nondiabetic counterparts&#46;<a class="elsevierStyleCrossRef" href="#bib0230"><span class="elsevierStyleSup">46</span></a> The RICA registry confirmed that diabetes is an independent predictor of readmission and all-cause mortality&#46;<a class="elsevierStyleCrossRef" href="#bib0210"><span class="elsevierStyleSup">42</span></a></p><p id="par0105" class="elsevierStylePara elsevierViewall">COPD is present in 10&#37;<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">14</span></a> to 31&#37;<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a> of patients with HF&#46; Results of observational studies<a class="elsevierStyleCrossRef" href="#bib0235"><span class="elsevierStyleSup">47</span></a> and subanalyses of clinical trials<a class="elsevierStyleCrossRef" href="#bib0240"><span class="elsevierStyleSup">48</span></a> have shown that the presence of COPD in patients with HF is associated with a poorer prognosis&#44; increased risk of death and hospitalization&#46;</p><p id="par0110" class="elsevierStylePara elsevierViewall">The VAlHeft<a class="elsevierStyleCrossRef" href="#bib0240"><span class="elsevierStyleSup">48</span></a> study observed an increase in noncardiovascular mortality and hospitalization for patients with HF and COPD compared with patients without COPD&#46; In an observational study with a 5-year follow-up&#44; Rusinaru et al&#46;<a class="elsevierStyleCrossRef" href="#bib0235"><span class="elsevierStyleSup">47</span></a> found that the presence of COPD in patients with HF behaves as an independent prognostic factor for mortality at 5 years&#46;</p><p id="par0115" class="elsevierStylePara elsevierViewall">Lung function assessed through spirometry has also been related to the prognosis of patients with HF&#46;<a class="elsevierStyleCrossRef" href="#bib0245"><span class="elsevierStyleSup">49</span></a> It has therefore been observed that forced expiratory volume in the first second &#40;FEV1&#41; constitutes an independent predictor of all-cause mortality in these patients&#46;<a class="elsevierStyleCrossRef" href="#bib0245"><span class="elsevierStyleSup">49</span></a></p><p id="par0120" class="elsevierStylePara elsevierViewall">Moreover&#44; HF also worsens the prognosis of patients with COPD&#46; In the ESMI study&#44;<a class="elsevierStyleCrossRef" href="#bib0250"><span class="elsevierStyleSup">50</span></a> which analyzed the comorbidities and short-term prognosis of patients hospitalized for COPD exacerbation&#44; HF was the most common comorbidity and was associated with greater mortality at 90 days&#46;<a class="elsevierStyleCrossRef" href="#bib0250"><span class="elsevierStyleSup">50</span></a></p><p id="par0125" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Respiratory sleep disorders &#40;sleep apnea&#41;</span> have been reported in 50&#37; to 75&#37;<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> of patients with HF&#44; although the disorders are often underdiagnosed&#46;<a class="elsevierStyleCrossRef" href="#bib0255"><span class="elsevierStyleSup">51</span></a> The presence of these disorders is also associated with a poorer prognosis&#59; specifically&#44; lower survival&#46;<a class="elsevierStyleCrossRefs" href="#bib0255"><span class="elsevierStyleSup">51&#8211;54</span></a> This lower survival has been reported in obstructive apnea<a class="elsevierStyleCrossRef" href="#bib0270"><span class="elsevierStyleSup">54</span></a> and regardless of the type of apnea&#46;<a class="elsevierStyleCrossRef" href="#bib0260"><span class="elsevierStyleSup">52</span></a> Additionally&#44; several studies have shown longer survival of patients with sleep apnea treated with nocturnal ventilation&#46;<a class="elsevierStyleCrossRefs" href="#bib0255"><span class="elsevierStyleSup">51&#8211;54</span></a></p><p id="par0130" class="elsevierStylePara elsevierViewall">The prevalence of <span class="elsevierStyleItalic">depression</span> is 2&#8211;3 times higher in patients with HF than in the general population<a class="elsevierStyleCrossRef" href="#bib0275"><span class="elsevierStyleSup">55</span></a> and varies between 9&#37; and 60&#37;&#44; with an average rate of 21&#46;5&#37; in a meta-analysis of 27 studies&#46;<a class="elsevierStyleCrossRef" href="#bib0280"><span class="elsevierStyleSup">56</span></a> Depression is often underdiagnosed and undertreated&#46;<a class="elsevierStyleCrossRef" href="#bib0275"><span class="elsevierStyleSup">55</span></a> Depression also worsens the prognosis when moderate or severe&#44; and it is associated with greater mortality&#44; more readmissions and greater consumption of healthcare resources&#46;<a class="elsevierStyleCrossRef" href="#bib0275"><span class="elsevierStyleSup">55</span></a> Depression also worsens quality of life&#44; which can be improved if the depressive disorder is treated&#46;<a class="elsevierStyleCrossRef" href="#bib0285"><span class="elsevierStyleSup">57</span></a> A meta-analysis of 8 cohort studies showed a 2-fold risk of death for patients with HF and with associated depressive symptoms or disorder &#40;RR&#44; 2&#46;1&#59; 95&#37; CI 1&#46;7&#8211;2&#46;6&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0280"><span class="elsevierStyleSup">56</span></a></p><p id="par0135" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Cognitive impairment</span> is more common in patients with HF than in the general populationl<a class="elsevierStyleCrossRef" href="#bib0290"><span class="elsevierStyleSup">58</span></a> and often remains underdiagnosed&#46; A prospective study of hospitalized patients older than 65 years&#44; which used the <span class="elsevierStyleItalic">Mini Mental</span> test for screening&#44; detected cognitive impairment in almost half of the patients &#40;46&#46;8&#37;&#41;&#44; which had only been previously diagnosed in 22&#46;7&#37; of the patients&#46;<a class="elsevierStyleCrossRef" href="#bib0295"><span class="elsevierStyleSup">59</span></a> The presence of cognitive impairment was also associated with a poorer prognosis&#44; a greater risk of readmission and death at 6 months&#46;<a class="elsevierStyleCrossRef" href="#bib0295"><span class="elsevierStyleSup">59</span></a> Lastly&#44; cognitive impairment hinders self-care and therapeutic compliance&#46;<a class="elsevierStyleCrossRef" href="#bib0300"><span class="elsevierStyleSup">60</span></a></p><p id="par0140" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Malnutrition</span> is another underdiagnosed condition&#44; with a high prevalence in HF &#40;25&#8211;60&#37;&#41;&#44;<a class="elsevierStyleCrossRef" href="#bib0305"><span class="elsevierStyleSup">61</span></a> and it is associated with greater mortality&#46;<a class="elsevierStyleCrossRefs" href="#bib0305"><span class="elsevierStyleSup">61&#44;62</span></a> Malnutrition can be present in patients with HF and normal weight and even with excess weight&#46; Gastelurrutia et al&#46;<a class="elsevierStyleCrossRef" href="#bib0315"><span class="elsevierStyleSup">63</span></a> found that 53&#37; and 22&#37; of patients with HF and normal weight and excess weight&#44; respectively&#44; were malnourished&#46; Therefore&#44; body mass index is not useful for assessing the nutritional state&#46;<a class="elsevierStyleCrossRef" href="#bib0315"><span class="elsevierStyleSup">63</span></a> In fact&#44; a number of authors have postulated that one explanation for the paradox of obesity in patients with HF &#40;i&#46;e&#46;&#44; the greater survival of patients with obesity&#41; is partly explained by the lower proportion of malnutrition among these patients&#46;<a class="elsevierStyleCrossRef" href="#bib0320"><span class="elsevierStyleSup">64</span></a></p><p id="par0145" class="elsevierStylePara elsevierViewall">Strictly speaking&#44; AF is the only cardiac comorbidity that will be mentioned&#46; AF often coexists with HF&#44; as either the cause or consequence of AF&#46; AF can also act as a trigger&#44; with one negatively affecting the other&#46;<a class="elsevierStyleCrossRef" href="#bib0325"><span class="elsevierStyleSup">65</span></a> The prevalence of AF varies between 30&#37; and 40&#37; in the various HF registries&#44;<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a> increasing with age and HF severity&#46;<a class="elsevierStyleCrossRef" href="#bib0330"><span class="elsevierStyleSup">66</span></a> AF increases the risk of stroke and the number of hospitalizations and is associated with a poorer quality of life&#46; Although there is no unanimous agreement&#44; numerous studies have associated AF with lower survival&#46;<a class="elsevierStyleCrossRefs" href="#bib0335"><span class="elsevierStyleSup">67&#44;68</span></a></p><p id="par0150" class="elsevierStylePara elsevierViewall">Patients with HF are usually elderly and present geriatric syndromes such as functional impairment&#44; sarcopenia&#44; reduced muscle strength&#44; slower gait and frailty&#44; which various studies have shown to be independent predictors of readmission and mortality&#46;<a class="elsevierStyleCrossRefs" href="#bib0345"><span class="elsevierStyleSup">69&#44;70</span></a></p><p id="par0155" class="elsevierStylePara elsevierViewall">The RICA registry analyzed the prognostic value of the <span class="elsevierStyleItalic">baseline functional status</span>&#44; as evaluated using the Barthel index&#44; and found a high prevalence of functional impairment&#44; with severe dependence for basic activities of daily life in 55&#46;9&#37; of the patients&#46;<a class="elsevierStyleCrossRef" href="#bib0355"><span class="elsevierStyleSup">71</span></a> The Barthel index prior to hospitalization was shown to be an independent predictor of short-term mortality&#46;<a class="elsevierStyleCrossRef" href="#bib0355"><span class="elsevierStyleSup">71</span></a></p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Associated comorbidities and prognosis</span><p id="par0160" class="elsevierStylePara elsevierViewall">Although the individual presence of the various comorbidities is associated with a poor prognosis&#44; the coexistence of several of them&#44; as one would expect&#44; determines an even poorer prognosis&#46; A direct relationship has been observed between the number of comorbidities and lower long-term survival&#44; both in outpatients<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">21</span></a> and hospitalized patients&#46;<a class="elsevierStyleCrossRef" href="#bib0360"><span class="elsevierStyleSup">72</span></a> A direct relationship has also been confirmed between the number of comorbidities and the risk of hospitalization&#44;<a class="elsevierStyleCrossRefs" href="#bib0025"><span class="elsevierStyleSup">5&#44;73</span></a> which entails poorer evolution&#44; increased mortality&#44; greater consumption of resources and higher healthcare costs&#46;<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a></p><p id="par0165" class="elsevierStylePara elsevierViewall">One of the most widely used instruments for assessing overall comorbidity is the Charlson comorbidity index&#46; Its prognostic value has been analyzed in Spain in the SEMI-IC study&#44;<a class="elsevierStyleCrossRef" href="#bib0370"><span class="elsevierStyleSup">74</span></a> which included 2127 patients from 51 hospitals&#46; The patients with the highest scores on the Charlson index &#40;&#8805;3 points&#41; had significantly more prior hospitalizations&#44; longer hospital stays and greater mortality&#46;<a class="elsevierStyleCrossRef" href="#bib0370"><span class="elsevierStyleSup">74</span></a> The RICA registry has also confirmed the prognostic value of the Charlson index as an independent predictor of mortality or readmission at 1 year&#46;<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">13</span></a></p><p id="par0170" class="elsevierStylePara elsevierViewall">The association of comorbidities in profiles or clusters has recently been reported&#44; which helps identify those patients with HF who have a greater risk of death&#44; longer stays and increased hospitalization costs&#46;<a class="elsevierStyleCrossRef" href="#bib0375"><span class="elsevierStyleSup">75</span></a> Four profiles have been differentiated&#58; &#40;1&#41; the &#8220;common&#8221; profile&#44; which has the lowest comorbidity and is related to a lower prevalence of cerebrovascular disease&#44; myocardial infarction&#44; peripheral vascular disorders&#44; depression&#44; kidney disease&#44; AHT and obesity when compared with the other profiles&#59; &#40;2&#41; the &#8220;lifestyle&#8221; profile&#44; which has a high rate of AHT&#44; uncomplicated diabetes&#44; chronic lung disorders and obesity&#59; &#40;3&#41; the &#8220;renal&#8221; profile&#44; with high rates of kidney disease&#44; diabetes with complications and electrolyte imbalances&#59; and &#40;4&#41; the &#8220;neurovascular&#8221; profile&#44; with a high prevalence of cerebrovascular disease&#44; myocardial infarction and peripheral vascular disease&#46; Compared with the common profile&#44; the 3 other profiles are associated with longer hospital stays and higher hospitalization costs&#46; Additionally&#44; the renal and neurovascular profiles are associated with greater mortality&#46;<a class="elsevierStyleCrossRef" href="#bib0375"><span class="elsevierStyleSup">75</span></a></p><p id="par0175" class="elsevierStylePara elsevierViewall">For patients with HF&#44; comorbidities are frequently the cause of hospital readmission&#46; In fact&#44; a number of series have observed that only a third or fewer of readmissions are due to HF per se<span class="elsevierStyleItalic">&#46;</span><a class="elsevierStyleCrossRef" href="#bib0380"><span class="elsevierStyleSup">76</span></a> This occurs more frequently in patients with HFPEF&#44;<a class="elsevierStyleCrossRef" href="#bib0365"><span class="elsevierStyleSup">73</span></a> in whom mortality is often linked to noncardiovascular diseases&#44; such as malignancies&#44; kidney disease and infections&#46;<a class="elsevierStyleCrossRef" href="#bib0385"><span class="elsevierStyleSup">77</span></a></p><p id="par0180" class="elsevierStylePara elsevierViewall">Given the importance of comorbidities in the morbidity and mortality of patients with HF&#44; our attention has recently been focused on the importance of providing overall care for patients with HF instead of restrictive care &#40;i&#46;e&#46;&#44; focusing entirely on the heart disease&#41;&#46;<a class="elsevierStyleCrossRefs" href="#bib0360"><span class="elsevierStyleSup">72&#44;78</span></a></p><p id="par0185" class="elsevierStylePara elsevierViewall">In short&#44; the HF profile in general and especially the type treated in internal medicine departments is that of an elderly patient&#44; with multiple comorbidities that impede their diagnosis and treatment&#44; complicating the evolution&#44; worsening the quality of life and resulting in a poorer prognosis &#40;more hospitalizations&#44; greater consumption of resources and higher mortality&#41;&#46;</p><p id="par0190" class="elsevierStylePara elsevierViewall">Given that the comorbidities frequently go unnoticed&#44; our approach should consist of an active search for them&#44; to identify them and treat them correctly&#44; as this can improve the evolution and quality of life of patients with HF&#46; It is therefore essential that we approach HF from an overall perspective that is not focused exclusively on the heart disease itself&#46;</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Conflict of interests</span><p id="par0195" class="elsevierStylePara elsevierViewall">The authors declare that they have no conflicts of interest&#46;</p></span></span>"
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        0 => array:2 [
          "identificador" => "sec0005"
          "titulo" => "Prevalence of comorbidities in heart failure registries"
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        1 => array:2 [
          "identificador" => "sec0010"
          "titulo" => "Comorbidities as a cause of heart failure"
        ]
        2 => array:2 [
          "identificador" => "sec0015"
          "titulo" => "Comorbidities as a consequence of heart failure"
        ]
        3 => array:2 [
          "identificador" => "sec0020"
          "titulo" => "Comorbidity and prognosis"
        ]
        4 => array:2 [
          "identificador" => "sec0025"
          "titulo" => "Associated comorbidities and prognosis"
        ]
        5 => array:2 [
          "identificador" => "sec0030"
          "titulo" => "Conflict of interests"
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          "titulo" => "References"
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    "fechaRecibido" => "2015-07-28"
    "fechaAceptado" => "2015-08-31"
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        "nota" => "<p class="elsevierStyleNotepara" id="npar0015">Please cite this article as&#58; Conde-Martel A&#44; Hern&#225;ndez-Meneses M&#46; Prevalencia y significado pron&#243;stico de la comorbilidad en la insuficiencia cardiaca&#46; Rev Clin Esp&#46; 2016&#59;216&#58;222&#8211;228&#46;</p>"
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          "leyenda" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">COPD&#44; chronic obstructive pulmonary disease&#46;</p>"
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                  \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="" valign="top" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">ADHERE<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a><br>&#40;US&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">OPTIMIZE-HF<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">18</span></a><br>&#40;US&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">GWTG-HF<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">15</span></a><br>&#40;US&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">EHFSII<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">16</span></a><br>&#40;Europe&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">ADHERE Asia-Pacific<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">OFICA<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">17</span></a><br>&#40;France&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">IN-HF Outcome<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">12</span></a><br>&#40;Italy&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">ATTEND<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">14</span></a><br>&#40;Japan&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">RICA<a class="elsevierStyleCrossRefs" href="#bib0065"><span class="elsevierStyleSup">13&#44;19</span></a><br>&#40;Spain&#41;&nbsp;\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">Patients&#44; <span class="elsevierStyleItalic">n</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">105&#44;388&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">48&#44;612&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">110&#44;621&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">3580&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">10&#44;171&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1658&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1855&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">4842&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">2051&nbsp;\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">Age &#40;years<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>SD&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">74<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>14&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">72<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>12&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">47&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">71&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">76&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">63&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">83&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">43&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">45&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">31&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">40&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">34&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">44&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">50&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">33&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#8211;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">53&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">18&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">18&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">15&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#8211;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#8211;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">39&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">45&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">19&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">21&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">30&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">38&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">38&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">40&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">53&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">50&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">54&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">50&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#8211;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#8211;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#8211;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#8211;&nbsp;\t\t\t\t\t\t\n
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                  """
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                      "titulo" => "Clinical epidemiology of heart failure"
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                            0 => "A&#46; Mosterd"
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                      "doi" => "10.1136/hrt.2003.025270"
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                      "titulo" => "Non-cardiac comorbidities in chronic heart failure"
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                            0 => "C&#46;C&#46; Lang"
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                    0 => array:2 [
                      "doi" => "10.1136/hrt.2005.068296"
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                      "titulo" => "Hospitalization epidemic in patients with heart failure&#58; risk factors&#44; risk prediction&#44; knowledge gaps&#44; and future directions"
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                    0 => array:2 [
                      "doi" => "10.1016/j.cardfail.2010.08.010"
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                        "tituloSerie" => "J Card Fail"
                        "fecha" => "2011"
                        "volumen" => "17"
                        "paginaInicial" => "54"
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                      "titulo" => "Noncardiac comorbidity increases preventable hospitalizations and mortality among Medicare beneficiaries with chronic heart failure"
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Symposium. Heart failure
Prevalence and prognostic meaning of comorbidity in heart failure
Prevalencia y significado pronóstico de la comorbilidad en la insuficiencia cardiaca
A. Conde-Martela,b,
Corresponding author
, M. Hernández-Menesesa
a Servicio de Medicina Interna. Hospital Universitario de Gran Canaria Dr. Negrín, Las Palmas, Spain
b Universidad de Las Palmas de Gran Canaria, Las Palmas, Spain
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    "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Heart failure &#40;HF&#41; is a first-order healthcare problem&#46; The condition is associated with considerable morbidity and mortality and is the leading cause of hospitalizations for those older than 65 years in the western world&#46;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> In the context of this highly prevalent syndrome&#44; which mainly affects elderly patients&#44; the presence of associated comorbidities has considerable relevance&#46; On one hand&#44; the comorbidities have a high incidence rate and can be the cause or consequence of HF or merely a coincidence&#46; Moreover&#44; comorbidities can hinder the diagnosis of HF by masking or overlapping with some of its symptoms&#46; Comorbidities can also hinder the treatment of these patients<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> and have a significant repercussion on the prognosis&#46; Most comorbidities associated with HF lead to a poorer evolution&#44; with more hospitalizations&#44; resource consumption&#44; poorer quality of life and increased mortality&#46;<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2&#8211;4</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">Patients with HF typically present several associated comorbidities&#44; the absence of which is unusual&#46; This was made clear in a broad study performed on 122&#44;630 patients older than 65 years with HF&#46; Fifty-five percent of the patients had 4 or more comorbidities&#44; 40&#37; had 5 or more and only 4&#37; had none&#46;<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> In the last 2 decades&#44; the prevalence of these comorbidities has increased&#44; with the percentage of patients with 5 or more comorbidities increasing from 40&#37; at the end of the 1980s to almost 60&#37; by the end of the 2000&#46;<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> This increase coincided with the increase in age of patients with HF&#59; i&#46;e&#46;&#44; there has been a change in phenotype toward patients with HF at a more advanced age&#44; with more comorbidities and multiple medications&#46;<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">Another important issue is that the comorbidities are especially common in patients with HF who have admitted to internal medicine departments&#46; These are elderly patients&#44; predominantly women&#44; with an increased prevalence of hypertension&#44; diabetes&#44; obesity&#44; anemia&#44; chronic obstructive pulmonary disease &#40;COPD&#41; and renal failure&#46; In contrast&#44; more men&#44; younger individuals and those with more ischemic and valvular heart disease are admitted to cardiology departments&#44; as verified in an analysis of more than 27&#44;000 hospital discharges for HF performed in Spain&#46;<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">This article reviews the prevalence and prognostic impact of the main comorbidities associated with HF&#46;</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Prevalence of comorbidities in heart failure registries</span><p id="par0025" class="elsevierStylePara elsevierViewall">We have data on the prevalence of various comorbidities in the major registries<a class="elsevierStyleCrossRefs" href="#bib0040"><span class="elsevierStyleSup">8&#8211;18</span></a> that show a more realistic image of clinical practice than the data from clinical trials&#44; in which the presence of comorbidities is considered an exclusion criterion&#46; <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a> lists the prevalence of the various comorbidities in the large American&#44;<a class="elsevierStyleCrossRefs" href="#bib0050"><span class="elsevierStyleSup">10&#44;15&#44;18</span></a> Asian<a class="elsevierStyleCrossRefs" href="#bib0045"><span class="elsevierStyleSup">9&#44;14</span></a> and European<a class="elsevierStyleCrossRefs" href="#bib0060"><span class="elsevierStyleSup">12&#44;16&#44;17</span></a> registries&#44; including the RICA registry of the Spanish Society of Internal Medicine&#46;<a class="elsevierStyleCrossRefs" href="#bib0065"><span class="elsevierStyleSup">13&#44;19</span></a> In addition to the comorbidities typically recorded in the registries and clinical trials &#40;arterial hypertension &#91;AHT&#93;&#44; diabetes&#44; chronic kidney disease&#44; anemia&#44; COPD&#44; atrial fibrillation &#91;AF&#93;&#44; ischemic heart disease&#41;&#44; we should highlight others that are usually underdiagnosed but are important due to their prevalence and repercussion on the prognosis of HF&#44;<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> such as depressive syndrome&#44; sleep apnea&#44; cognitive impairment&#44; liver disease&#44; malnutrition&#44; osteoarticular disease and thyroid dysfunction&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0030" class="elsevierStylePara elsevierViewall">We can deduce that the high prevalence of comorbidity in patients with HF is due to their advanced age&#44; given that the majority of individuals aged 65 years or older have some comorbidity&#59; by the age of 85 years&#44; more than 90&#37; have some comorbidity&#46;<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">20</span></a> However&#44; it has been reported that patients with HF have more comorbidity than similarly aged controls&#46;<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">21</span></a> This phenomenon is due to several causes&#46; On one hand&#44; comorbidities act as a cause of HF&#59; on the other&#44; they can be a consequence of HF or even coincide&#59; however&#44; many of them contribute to the progression and perpetuation of HF&#46;<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a></p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Comorbidities as a cause of heart failure</span><p id="par0035" class="elsevierStylePara elsevierViewall">HF is a syndrome with multiple causes&#46; Some comorbidities constitute risk factors for developing HF&#46;<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">22</span></a> In fact&#44; patients with AHT&#44; diabetes&#44; obesity or atherosclerosis are included in stage A of the HF classification of the American Heart Association &#40;AHA&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">22</span></a> These risk factors can behave as etiologic agents&#59; for example&#44; AHT in HF with preserved left ventricular ejection fraction &#40;HFPEF&#41; or arteriosclerosis&#44; through ischemia&#44; in HF with reduced left ventricular ejection fraction &#40;HFREF&#41;&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">These risk factors for the onset of HF are also risk factors for developing chronic kidney disease&#44; whose main causes are diabetes and AHT&#46; Moreover&#44; renal failure can cause heart failure&#59; the so-called cardiorenal syndromes types 3 and 4&#46;<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">23</span></a> Similarly&#44; anemia associated with kidney disease can trigger or promote the development of HF&#46;<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">24</span></a></p><p id="par0045" class="elsevierStylePara elsevierViewall">Sleep apnea &#40;through hypoxia&#41;&#44; sympathetic activation&#44; pulmonary and systemic arterial hypertension and arrhythmias contribute to the development of HF&#46;<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">25</span></a> Moreover&#44; smoking&#44; which is a risk factor for HF&#44; can promote the development of COPD&#44; a disease that also increases the risk of HF&#46;<a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">26</span></a> These diseases &#40;COPD&#44; diabetes and obesity&#41; cause a systemic inflammatory state&#44; which intervenes in the genesis of HFPEF&#46; A review by Paulus and Tsch&#246;pe<a class="elsevierStyleCrossRef" href="#bib0135"><span class="elsevierStyleSup">27</span></a> proposed a systemic proinflammatory state generated or induced by comorbidities as a cause of the structural and functional myocardial disorders in patients with HFPEF&#46;</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Comorbidities as a consequence of heart failure</span><p id="par0050" class="elsevierStylePara elsevierViewall">Comorbidities can also be the consequence of HF&#44; through the congestion and hypoperfusion that HF causes&#46; In fact&#44; HF can cause renal failure &#40;cardiorenal syndromes types 1 and 2&#41;<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">23</span></a> and contributes to the presence of anemia by a dilutional mechanism<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">24</span></a> and to hepatic dysfunction&#46; Numerous comorbidities also contribute to the progression of HF&#44; thereby establishing a bidirectional relationship that perpetuates the disease&#46;<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2&#44;3&#44;25&#44;28</span></a></p><p id="par0055" class="elsevierStylePara elsevierViewall">Finally&#44; some comorbidities can also act as triggers of HF&#59; for example&#44; anemia&#44; atrial fibrillation with rapid ventricular response&#44; hyperthyroidism and infectious processes&#44; mainly of respiratory origin&#46;<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a></p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Comorbidity and prognosis</span><p id="par0060" class="elsevierStylePara elsevierViewall">Numerous comorbidities&#44; considered individually&#44; have been associated with a poorer prognosis for HF&#46;<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2&#44;21&#44;29</span></a></p><p id="par0065" class="elsevierStylePara elsevierViewall">Renal failure is one of the most relevant comorbidities due to its high prevalence&#44;<a class="elsevierStyleCrossRefs" href="#bib0150"><span class="elsevierStyleSup">30&#44;31</span></a> for being a cause and effect of HF&#44;<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">23</span></a> hindering its treatment<a class="elsevierStyleCrossRef" href="#bib0150"><span class="elsevierStyleSup">30</span></a> and for being an independent predictor of mortality&#44; as has been demonstrated by several studies<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">3&#44;31</span></a> and meta-analyses&#46;<a class="elsevierStyleCrossRefs" href="#bib0160"><span class="elsevierStyleSup">32&#44;33</span></a> Renal function impairment has been reported in up to 63&#37; of patients with HF&#44;<a class="elsevierStyleCrossRef" href="#bib0160"><span class="elsevierStyleSup">32</span></a> and the prevalence of chronic kidney disease in various HF registries varies from 20&#37;<a class="elsevierStyleCrossRefs" href="#bib0045"><span class="elsevierStyleSup">9&#44;18</span></a> to 50&#37;<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">15</span></a> or 59&#37;&#44;<a class="elsevierStyleCrossRef" href="#bib0170"><span class="elsevierStyleSup">34</span></a> depending on the diagnostic criteria employed&#46;</p><p id="par0070" class="elsevierStylePara elsevierViewall">Regarding its prognostic value&#44; a recent meta-analysis that included 57 studies on chronic kidney disease and 28 studies on acute renal function impairment showed that both conditions are associated with increased mortality&#44; both in acute HF and in chronic HF&#44; either HFPEF or HFREF&#46;<a class="elsevierStyleCrossRef" href="#bib0165"><span class="elsevierStyleSup">33</span></a></p><p id="par0075" class="elsevierStylePara elsevierViewall">In Spain&#44; the RICA registry has shown a very high prevalence of renal failure &#40;59&#46;5&#37;&#41;<a class="elsevierStyleCrossRef" href="#bib0170"><span class="elsevierStyleSup">34</span></a> in patients with HF&#44; both overall<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a> and specifically in HFPEF&#44;<a class="elsevierStyleCrossRef" href="#bib0175"><span class="elsevierStyleSup">35</span></a> and its association with a poorer prognosis&#44; with lower survival as the glomerular filtration rate decreases&#46;</p><p id="par0080" class="elsevierStylePara elsevierViewall">Anemia is another of the most common comorbidities&#46; In a meta-analysis of 34 studies that included 153&#44;180 patients with HF&#44; 37&#46;2&#37; of the patients had anemia&#46;<a class="elsevierStyleCrossRef" href="#bib0180"><span class="elsevierStyleSup">36</span></a> Nevertheless&#44; the prevalence of anemia among various registries varies from 15&#37;<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">16</span></a> and 53&#37;&#44;<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a> mainly due to the varying diagnostic criteria employed&#46; The frequency of anemia increases with the time of HF progression&#44; the NYHA functional class and the degree of renal function impairment&#46;<a class="elsevierStyleCrossRef" href="#bib0185"><span class="elsevierStyleSup">37</span></a> Anemia also constitutes a trigger for HF decompensation and is associated with a poorer quality of life and prognosis&#46; There is certain controversy as to the latter point&#46; A number of studies have shown that anemia acts as a factor for poor prognosis &#40;associated with more readmissions and all-cause mortality&#41;&#44; regardless of the ejection fraction&#46;<a class="elsevierStyleCrossRefs" href="#bib0180"><span class="elsevierStyleSup">36&#8211;38</span></a> However&#44; other authors have suggested that anemia is a mere marker of severity&#44; associated with other factors of poor prognosis such as a poorer NYHA functional class and chronic renal failure&#46;<a class="elsevierStyleCrossRef" href="#bib0185"><span class="elsevierStyleSup">37</span></a> In fact&#44; it has been reported that anemia loses its independent prognostic value in patients with advanced chronic kidney disease&#46;<a class="elsevierStyleCrossRef" href="#bib0195"><span class="elsevierStyleSup">39</span></a></p><p id="par0085" class="elsevierStylePara elsevierViewall">The GESAIC study&#44;<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">12</span></a> performed in Spain&#44; observed a prevalence of anemia of 52&#46;7&#37; in patients hospitalized for HF and greater mortality in this patient group&#44; although statistical significance was not reached when considering all-cause mortality&#46; The authors attributed this result to the short follow-up time &#40;1 year&#41; and to the inclusion of patients with initial HF&#44; although the results could also have been affected by the small sample size &#40;211 patients&#41;&#46; In this study&#44; however&#44; the patients with anemia and refractory HF did have greater mortality&#46;<a class="elsevierStyleCrossRef" href="#bib0200"><span class="elsevierStyleSup">40</span></a></p><p id="par0090" class="elsevierStylePara elsevierViewall">Iron deficiency is very common in patients with HF&#44; even in the absence of anemia&#46; Various studies have shown an improved capacity for exercise and quality of life with iron deficiency correction&#46;<a class="elsevierStyleCrossRef" href="#bib0205"><span class="elsevierStyleSup">41</span></a></p><p id="par0095" class="elsevierStylePara elsevierViewall">Diabetes is another very common comorbidity&#44; with a prevalence of 40&#37;&#44;<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a> which is very similar in all the large American registries &#40;ADHERE&#44;<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a> OPTIMIZE-HF<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">18</span></a> and GWTG-HF<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">15</span></a>&#41;&#46; In the RICA registry&#44;<a class="elsevierStyleCrossRef" href="#bib0210"><span class="elsevierStyleSup">42</span></a> the prevalence of diabetes is 45&#37;&#46;</p><p id="par0100" class="elsevierStylePara elsevierViewall">The presence of diabetes in patients with HF worsens the prognosis&#46; Increased mortality&#44;<a class="elsevierStyleCrossRef" href="#bib0215"><span class="elsevierStyleSup">43</span></a> longer hospital stays and more readmissions have been observed&#46;<a class="elsevierStyleCrossRef" href="#bib0220"><span class="elsevierStyleSup">44</span></a> The DIAMOND study showed lower long-term survival after hospital discharge for patients with diabetes and HF&#44; especially in women&#46;<a class="elsevierStyleCrossRef" href="#bib0225"><span class="elsevierStyleSup">45</span></a> Similar results were obtained in a subanalysis of the EVEREST study&#44; with greater cardiovascular mortality and more readmissions for patients with diabetes than for their nondiabetic counterparts&#46;<a class="elsevierStyleCrossRef" href="#bib0230"><span class="elsevierStyleSup">46</span></a> The RICA registry confirmed that diabetes is an independent predictor of readmission and all-cause mortality&#46;<a class="elsevierStyleCrossRef" href="#bib0210"><span class="elsevierStyleSup">42</span></a></p><p id="par0105" class="elsevierStylePara elsevierViewall">COPD is present in 10&#37;<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">14</span></a> to 31&#37;<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a> of patients with HF&#46; Results of observational studies<a class="elsevierStyleCrossRef" href="#bib0235"><span class="elsevierStyleSup">47</span></a> and subanalyses of clinical trials<a class="elsevierStyleCrossRef" href="#bib0240"><span class="elsevierStyleSup">48</span></a> have shown that the presence of COPD in patients with HF is associated with a poorer prognosis&#44; increased risk of death and hospitalization&#46;</p><p id="par0110" class="elsevierStylePara elsevierViewall">The VAlHeft<a class="elsevierStyleCrossRef" href="#bib0240"><span class="elsevierStyleSup">48</span></a> study observed an increase in noncardiovascular mortality and hospitalization for patients with HF and COPD compared with patients without COPD&#46; In an observational study with a 5-year follow-up&#44; Rusinaru et al&#46;<a class="elsevierStyleCrossRef" href="#bib0235"><span class="elsevierStyleSup">47</span></a> found that the presence of COPD in patients with HF behaves as an independent prognostic factor for mortality at 5 years&#46;</p><p id="par0115" class="elsevierStylePara elsevierViewall">Lung function assessed through spirometry has also been related to the prognosis of patients with HF&#46;<a class="elsevierStyleCrossRef" href="#bib0245"><span class="elsevierStyleSup">49</span></a> It has therefore been observed that forced expiratory volume in the first second &#40;FEV1&#41; constitutes an independent predictor of all-cause mortality in these patients&#46;<a class="elsevierStyleCrossRef" href="#bib0245"><span class="elsevierStyleSup">49</span></a></p><p id="par0120" class="elsevierStylePara elsevierViewall">Moreover&#44; HF also worsens the prognosis of patients with COPD&#46; In the ESMI study&#44;<a class="elsevierStyleCrossRef" href="#bib0250"><span class="elsevierStyleSup">50</span></a> which analyzed the comorbidities and short-term prognosis of patients hospitalized for COPD exacerbation&#44; HF was the most common comorbidity and was associated with greater mortality at 90 days&#46;<a class="elsevierStyleCrossRef" href="#bib0250"><span class="elsevierStyleSup">50</span></a></p><p id="par0125" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Respiratory sleep disorders &#40;sleep apnea&#41;</span> have been reported in 50&#37; to 75&#37;<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> of patients with HF&#44; although the disorders are often underdiagnosed&#46;<a class="elsevierStyleCrossRef" href="#bib0255"><span class="elsevierStyleSup">51</span></a> The presence of these disorders is also associated with a poorer prognosis&#59; specifically&#44; lower survival&#46;<a class="elsevierStyleCrossRefs" href="#bib0255"><span class="elsevierStyleSup">51&#8211;54</span></a> This lower survival has been reported in obstructive apnea<a class="elsevierStyleCrossRef" href="#bib0270"><span class="elsevierStyleSup">54</span></a> and regardless of the type of apnea&#46;<a class="elsevierStyleCrossRef" href="#bib0260"><span class="elsevierStyleSup">52</span></a> Additionally&#44; several studies have shown longer survival of patients with sleep apnea treated with nocturnal ventilation&#46;<a class="elsevierStyleCrossRefs" href="#bib0255"><span class="elsevierStyleSup">51&#8211;54</span></a></p><p id="par0130" class="elsevierStylePara elsevierViewall">The prevalence of <span class="elsevierStyleItalic">depression</span> is 2&#8211;3 times higher in patients with HF than in the general population<a class="elsevierStyleCrossRef" href="#bib0275"><span class="elsevierStyleSup">55</span></a> and varies between 9&#37; and 60&#37;&#44; with an average rate of 21&#46;5&#37; in a meta-analysis of 27 studies&#46;<a class="elsevierStyleCrossRef" href="#bib0280"><span class="elsevierStyleSup">56</span></a> Depression is often underdiagnosed and undertreated&#46;<a class="elsevierStyleCrossRef" href="#bib0275"><span class="elsevierStyleSup">55</span></a> Depression also worsens the prognosis when moderate or severe&#44; and it is associated with greater mortality&#44; more readmissions and greater consumption of healthcare resources&#46;<a class="elsevierStyleCrossRef" href="#bib0275"><span class="elsevierStyleSup">55</span></a> Depression also worsens quality of life&#44; which can be improved if the depressive disorder is treated&#46;<a class="elsevierStyleCrossRef" href="#bib0285"><span class="elsevierStyleSup">57</span></a> A meta-analysis of 8 cohort studies showed a 2-fold risk of death for patients with HF and with associated depressive symptoms or disorder &#40;RR&#44; 2&#46;1&#59; 95&#37; CI 1&#46;7&#8211;2&#46;6&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0280"><span class="elsevierStyleSup">56</span></a></p><p id="par0135" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Cognitive impairment</span> is more common in patients with HF than in the general populationl<a class="elsevierStyleCrossRef" href="#bib0290"><span class="elsevierStyleSup">58</span></a> and often remains underdiagnosed&#46; A prospective study of hospitalized patients older than 65 years&#44; which used the <span class="elsevierStyleItalic">Mini Mental</span> test for screening&#44; detected cognitive impairment in almost half of the patients &#40;46&#46;8&#37;&#41;&#44; which had only been previously diagnosed in 22&#46;7&#37; of the patients&#46;<a class="elsevierStyleCrossRef" href="#bib0295"><span class="elsevierStyleSup">59</span></a> The presence of cognitive impairment was also associated with a poorer prognosis&#44; a greater risk of readmission and death at 6 months&#46;<a class="elsevierStyleCrossRef" href="#bib0295"><span class="elsevierStyleSup">59</span></a> Lastly&#44; cognitive impairment hinders self-care and therapeutic compliance&#46;<a class="elsevierStyleCrossRef" href="#bib0300"><span class="elsevierStyleSup">60</span></a></p><p id="par0140" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Malnutrition</span> is another underdiagnosed condition&#44; with a high prevalence in HF &#40;25&#8211;60&#37;&#41;&#44;<a class="elsevierStyleCrossRef" href="#bib0305"><span class="elsevierStyleSup">61</span></a> and it is associated with greater mortality&#46;<a class="elsevierStyleCrossRefs" href="#bib0305"><span class="elsevierStyleSup">61&#44;62</span></a> Malnutrition can be present in patients with HF and normal weight and even with excess weight&#46; Gastelurrutia et al&#46;<a class="elsevierStyleCrossRef" href="#bib0315"><span class="elsevierStyleSup">63</span></a> found that 53&#37; and 22&#37; of patients with HF and normal weight and excess weight&#44; respectively&#44; were malnourished&#46; Therefore&#44; body mass index is not useful for assessing the nutritional state&#46;<a class="elsevierStyleCrossRef" href="#bib0315"><span class="elsevierStyleSup">63</span></a> In fact&#44; a number of authors have postulated that one explanation for the paradox of obesity in patients with HF &#40;i&#46;e&#46;&#44; the greater survival of patients with obesity&#41; is partly explained by the lower proportion of malnutrition among these patients&#46;<a class="elsevierStyleCrossRef" href="#bib0320"><span class="elsevierStyleSup">64</span></a></p><p id="par0145" class="elsevierStylePara elsevierViewall">Strictly speaking&#44; AF is the only cardiac comorbidity that will be mentioned&#46; AF often coexists with HF&#44; as either the cause or consequence of AF&#46; AF can also act as a trigger&#44; with one negatively affecting the other&#46;<a class="elsevierStyleCrossRef" href="#bib0325"><span class="elsevierStyleSup">65</span></a> The prevalence of AF varies between 30&#37; and 40&#37; in the various HF registries&#44;<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a> increasing with age and HF severity&#46;<a class="elsevierStyleCrossRef" href="#bib0330"><span class="elsevierStyleSup">66</span></a> AF increases the risk of stroke and the number of hospitalizations and is associated with a poorer quality of life&#46; Although there is no unanimous agreement&#44; numerous studies have associated AF with lower survival&#46;<a class="elsevierStyleCrossRefs" href="#bib0335"><span class="elsevierStyleSup">67&#44;68</span></a></p><p id="par0150" class="elsevierStylePara elsevierViewall">Patients with HF are usually elderly and present geriatric syndromes such as functional impairment&#44; sarcopenia&#44; reduced muscle strength&#44; slower gait and frailty&#44; which various studies have shown to be independent predictors of readmission and mortality&#46;<a class="elsevierStyleCrossRefs" href="#bib0345"><span class="elsevierStyleSup">69&#44;70</span></a></p><p id="par0155" class="elsevierStylePara elsevierViewall">The RICA registry analyzed the prognostic value of the <span class="elsevierStyleItalic">baseline functional status</span>&#44; as evaluated using the Barthel index&#44; and found a high prevalence of functional impairment&#44; with severe dependence for basic activities of daily life in 55&#46;9&#37; of the patients&#46;<a class="elsevierStyleCrossRef" href="#bib0355"><span class="elsevierStyleSup">71</span></a> The Barthel index prior to hospitalization was shown to be an independent predictor of short-term mortality&#46;<a class="elsevierStyleCrossRef" href="#bib0355"><span class="elsevierStyleSup">71</span></a></p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Associated comorbidities and prognosis</span><p id="par0160" class="elsevierStylePara elsevierViewall">Although the individual presence of the various comorbidities is associated with a poor prognosis&#44; the coexistence of several of them&#44; as one would expect&#44; determines an even poorer prognosis&#46; A direct relationship has been observed between the number of comorbidities and lower long-term survival&#44; both in outpatients<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">21</span></a> and hospitalized patients&#46;<a class="elsevierStyleCrossRef" href="#bib0360"><span class="elsevierStyleSup">72</span></a> A direct relationship has also been confirmed between the number of comorbidities and the risk of hospitalization&#44;<a class="elsevierStyleCrossRefs" href="#bib0025"><span class="elsevierStyleSup">5&#44;73</span></a> which entails poorer evolution&#44; increased mortality&#44; greater consumption of resources and higher healthcare costs&#46;<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a></p><p id="par0165" class="elsevierStylePara elsevierViewall">One of the most widely used instruments for assessing overall comorbidity is the Charlson comorbidity index&#46; Its prognostic value has been analyzed in Spain in the SEMI-IC study&#44;<a class="elsevierStyleCrossRef" href="#bib0370"><span class="elsevierStyleSup">74</span></a> which included 2127 patients from 51 hospitals&#46; The patients with the highest scores on the Charlson index &#40;&#8805;3 points&#41; had significantly more prior hospitalizations&#44; longer hospital stays and greater mortality&#46;<a class="elsevierStyleCrossRef" href="#bib0370"><span class="elsevierStyleSup">74</span></a> The RICA registry has also confirmed the prognostic value of the Charlson index as an independent predictor of mortality or readmission at 1 year&#46;<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">13</span></a></p><p id="par0170" class="elsevierStylePara elsevierViewall">The association of comorbidities in profiles or clusters has recently been reported&#44; which helps identify those patients with HF who have a greater risk of death&#44; longer stays and increased hospitalization costs&#46;<a class="elsevierStyleCrossRef" href="#bib0375"><span class="elsevierStyleSup">75</span></a> Four profiles have been differentiated&#58; &#40;1&#41; the &#8220;common&#8221; profile&#44; which has the lowest comorbidity and is related to a lower prevalence of cerebrovascular disease&#44; myocardial infarction&#44; peripheral vascular disorders&#44; depression&#44; kidney disease&#44; AHT and obesity when compared with the other profiles&#59; &#40;2&#41; the &#8220;lifestyle&#8221; profile&#44; which has a high rate of AHT&#44; uncomplicated diabetes&#44; chronic lung disorders and obesity&#59; &#40;3&#41; the &#8220;renal&#8221; profile&#44; with high rates of kidney disease&#44; diabetes with complications and electrolyte imbalances&#59; and &#40;4&#41; the &#8220;neurovascular&#8221; profile&#44; with a high prevalence of cerebrovascular disease&#44; myocardial infarction and peripheral vascular disease&#46; Compared with the common profile&#44; the 3 other profiles are associated with longer hospital stays and higher hospitalization costs&#46; Additionally&#44; the renal and neurovascular profiles are associated with greater mortality&#46;<a class="elsevierStyleCrossRef" href="#bib0375"><span class="elsevierStyleSup">75</span></a></p><p id="par0175" class="elsevierStylePara elsevierViewall">For patients with HF&#44; comorbidities are frequently the cause of hospital readmission&#46; In fact&#44; a number of series have observed that only a third or fewer of readmissions are due to HF per se<span class="elsevierStyleItalic">&#46;</span><a class="elsevierStyleCrossRef" href="#bib0380"><span class="elsevierStyleSup">76</span></a> This occurs more frequently in patients with HFPEF&#44;<a class="elsevierStyleCrossRef" href="#bib0365"><span class="elsevierStyleSup">73</span></a> in whom mortality is often linked to noncardiovascular diseases&#44; such as malignancies&#44; kidney disease and infections&#46;<a class="elsevierStyleCrossRef" href="#bib0385"><span class="elsevierStyleSup">77</span></a></p><p id="par0180" class="elsevierStylePara elsevierViewall">Given the importance of comorbidities in the morbidity and mortality of patients with HF&#44; our attention has recently been focused on the importance of providing overall care for patients with HF instead of restrictive care &#40;i&#46;e&#46;&#44; focusing entirely on the heart disease&#41;&#46;<a class="elsevierStyleCrossRefs" href="#bib0360"><span class="elsevierStyleSup">72&#44;78</span></a></p><p id="par0185" class="elsevierStylePara elsevierViewall">In short&#44; the HF profile in general and especially the type treated in internal medicine departments is that of an elderly patient&#44; with multiple comorbidities that impede their diagnosis and treatment&#44; complicating the evolution&#44; worsening the quality of life and resulting in a poorer prognosis &#40;more hospitalizations&#44; greater consumption of resources and higher mortality&#41;&#46;</p><p id="par0190" class="elsevierStylePara elsevierViewall">Given that the comorbidities frequently go unnoticed&#44; our approach should consist of an active search for them&#44; to identify them and treat them correctly&#44; as this can improve the evolution and quality of life of patients with HF&#46; It is therefore essential that we approach HF from an overall perspective that is not focused exclusively on the heart disease itself&#46;</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Conflict of interests</span><p id="par0195" class="elsevierStylePara elsevierViewall">The authors declare that they have no conflicts of interest&#46;</p></span></span>"
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        0 => array:2 [
          "identificador" => "sec0005"
          "titulo" => "Prevalence of comorbidities in heart failure registries"
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        1 => array:2 [
          "identificador" => "sec0010"
          "titulo" => "Comorbidities as a cause of heart failure"
        ]
        2 => array:2 [
          "identificador" => "sec0015"
          "titulo" => "Comorbidities as a consequence of heart failure"
        ]
        3 => array:2 [
          "identificador" => "sec0020"
          "titulo" => "Comorbidity and prognosis"
        ]
        4 => array:2 [
          "identificador" => "sec0025"
          "titulo" => "Associated comorbidities and prognosis"
        ]
        5 => array:2 [
          "identificador" => "sec0030"
          "titulo" => "Conflict of interests"
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        6 => array:1 [
          "titulo" => "References"
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    "fechaRecibido" => "2015-07-28"
    "fechaAceptado" => "2015-08-31"
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        "nota" => "<p class="elsevierStyleNotepara" id="npar0015">Please cite this article as&#58; Conde-Martel A&#44; Hern&#225;ndez-Meneses M&#46; Prevalencia y significado pron&#243;stico de la comorbilidad en la insuficiencia cardiaca&#46; Rev Clin Esp&#46; 2016&#59;216&#58;222&#8211;228&#46;</p>"
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          "leyenda" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">COPD&#44; chronic obstructive pulmonary disease&#46;</p>"
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                  \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="" valign="top" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">ADHERE<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a><br>&#40;US&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">OPTIMIZE-HF<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">18</span></a><br>&#40;US&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">GWTG-HF<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">15</span></a><br>&#40;US&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">EHFSII<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">16</span></a><br>&#40;Europe&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">ADHERE Asia-Pacific<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">OFICA<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">17</span></a><br>&#40;France&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">IN-HF Outcome<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">12</span></a><br>&#40;Italy&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">ATTEND<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">14</span></a><br>&#40;Japan&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">RICA<a class="elsevierStyleCrossRefs" href="#bib0065"><span class="elsevierStyleSup">13&#44;19</span></a><br>&#40;Spain&#41;&nbsp;\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">Patients&#44; <span class="elsevierStyleItalic">n</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">105&#44;388&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">10&#44;171&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1658&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1855&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">4842&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">2051&nbsp;\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">Age &#40;years<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>SD&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">74<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>14&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">73<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>14&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">74&#40;62&#8211;83&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">70<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>13&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">67&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">79&#40;70&#8211;86&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">72<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>12&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#8211;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">39&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">45&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">19&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#8211;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">21&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">30&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">10&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">27&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">31&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">31&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">31&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">40&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">53&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">50&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">54&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">50&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#8211;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#8211;&nbsp;\t\t\t\t\t\t\n
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                            0 => "A&#46; Mosterd"
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                      "doi" => "10.1136/hrt.2003.025270"
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                      "titulo" => "Non-cardiac comorbidities in chronic heart failure"
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                            0 => "C&#46;C&#46; Lang"
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                      "doi" => "10.1136/hrt.2005.068296"
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                      "titulo" => "Hospitalization epidemic in patients with heart failure&#58; risk factors&#44; risk prediction&#44; knowledge gaps&#44; and future directions"
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                      "doi" => "10.1016/j.cardfail.2010.08.010"
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                        "tituloSerie" => "J Card Fail"
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                      "titulo" => "Noncardiac comorbidity increases preventable hospitalizations and mortality among Medicare beneficiaries with chronic heart failure"
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                      "titulo" => "Trends in comorbidity&#44; disability&#44; and polypharmacy in heart failure"
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                            3 => "H&#46;M&#46; Krumholz"
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                      "titulo" => "Analysis of 27&#44;248 hospital discharges for heart failure&#58; a study of an administrative database 1998&#8211;2002"
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                          "etal" => false
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                            3 => "J&#46;J&#46; Villar"
                            4 => "P&#46;M&#46; Martin"
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