Pulse wave velocity of the leg minus that of the arm measured with a custom device correlates to the coronary calcium quantification

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Rico Martín, J.M. de Nicolás Jiménez, S.L. Moyano Calvente, M.V. Mogollón Jiménez, J. Vega Fernández, J.F. Calderón García, M.A. Bacaicoa Lopez de Sabando, M. Tardio, J.F. Sánchez Muñoz-Torrero" "autores" => array:9 [ 0 => array:3 [ "nombre" => "S." "apellidos" => "Rico Martín" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "a" "identificador" => "aff0005" ] ] ] 1 => array:3 [ "nombre" => "J.M." "apellidos" => "de Nicolás Jiménez" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "b" "identificador" => "aff0010" ] ] ] 2 => array:3 [ "nombre" => "S.L." "apellidos" => "Moyano Calvente" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "c" "identificador" => "aff0015" ] ] ] 3 => array:3 [ "nombre" => "M.V." "apellidos" => "Mogollón Jiménez" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "d" "identificador" => "aff0020" ] ] ] 4 => array:3 [ "nombre" => "J." 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"apellidos" => "Sánchez Muñoz-Torrero" "email" => array:1 [ 0 => "juanf.sanchezm@gmail.com" ] "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "g" "identificador" => "aff0035" ] 1 => array:2 [ "etiqueta" => "*" "identificador" => "cor0005" ] ] ] ] "afiliaciones" => array:7 [ 0 => array:3 [ "entidad" => "Facultad de Enfermería y Terapia Ocupacional, Universidad de Extremadura, Cáceres, Spain" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Centro de Salud Jaraicejo, Jaraicejo, Cáceres, Spain" "etiqueta" => "b" "identificador" => "aff0010" ] 2 => array:3 [ "entidad" => "Servicio de Radiología, Hospital San Pedro de Alcántara, Cáceres, Spain" "etiqueta" => "c" "identificador" => "aff0015" ] 3 => array:3 [ "entidad" => "Servicio de Cardiología, Hospital San Pedro de Alcántara, Cáceres, Spain" "etiqueta" => "d" "identificador" => "aff0020" ] 4 => array:3 [ "entidad" => "Centro de Salud Manuel Encinas, Cáceres, Spain" "etiqueta" => "e" "identificador" => "aff0025" ] 5 => array:3 [ "entidad" => "Escuela de Ingenería Industrial. Universidad de Extremadura, Badajoz, Spain" "etiqueta" => "f" "identificador" => "aff0030" ] 6 => array:3 [ "entidad" => "Servicio de Medicina Interna, Hospital San Pedro de Alcántara, Cáceres, Spain" "etiqueta" => "g" "identificador" => "aff0035" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "La velocidad de onda de pulso de la pierna menos brazo medida con un dispositivo propio se correlaciona con la cuantificación de calcio coronario" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0010" "etiqueta" => "Fig. 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 1558 "Ancho" => 1633 "Tamanyo" => 132087 ] ] "descripcion" => array:1 [ "en" => "Area under the curve for predicting a CCQ >100 for IMT. Abbreviations: CCQ, coronary calcium quantification; cfPWV, carotid-femoral pulse wave velocity measured with COMPLIOR; IMT, intima-media thickness in common carotid artery; l-a PWV, difference in maximum pulse wave velocity in the legs minus the maximum PWV in the arms measured with abiPWV." ] ] ] "textoCompleto" => "BackgroundDetecting silent coronary artery disease is a challenge because half of all initial coronary events, including sudden death, occur in previously asymptomatic individuals.<a class="elsevierStyleCrossRef" href="#bib0140">1</a> Risk scales are the most widely used tool for identifying the most vulnerable of patients. However, their predictive value is modest (C-statistic, approx. 0.70–0.75),<a class="elsevierStyleCrossRef" href="#bib0145">2</a> because most vascular events happen in individuals classified as low to moderate risk.<a class="elsevierStyleCrossRef" href="#bib0150">3</a> The availability of methods that objectively assess the magnitude of the arteriosclerosis could be of considerable usefulness in preventing cardiovascular disease.<a class="elsevierStyleCrossRefs" href="#bib0155">4,5</a> Coronary calcium quantification (CCQ) with multidetector computed tomography can assess calcium deposits in coronary arteries and helps complete the anatomical study of the coronary tree so as to detect stenosis.<a class="elsevierStyleCrossRefs" href="#bib0165">6,7</a> CCQ is indicated for asymptomatic patients with intermediate vascular risk because it improves the stratification of cardiovascular risk and directs treatment.<a class="elsevierStyleCrossRef" href="#bib0175">8</a> However, the cost of the test and the exposure to radiation limit its use.<a class="elsevierStyleCrossRef" href="#bib0180">9</a> Other methods that have been proven useful in the early detection of atherosclerosis are the measurement of the intima-media thickness (IMT) with high-resolution carotid ultrasonography,<a class="elsevierStyleCrossRef" href="#bib0185">10</a> the ankle-brachial index<a class="elsevierStyleCrossRef" href="#bib0190">11</a> and large artery stiffness measured by pulse wave velocity (PWV).<a class="elsevierStyleCrossRefs" href="#bib0195">12,13</a> Both carotid IMT and carotid-femoral PWV (cfPWV) have shown a good correlation with CCQ.<a class="elsevierStyleCrossRefs" href="#bib0205">14,15</a>The study of PWV is recognized by the European Society of Hypertension and the European Society of Cardiology as tools for quantifying organ vascular damage.<a class="elsevierStyleCrossRef" href="#bib0215">16</a> The aorta is the most widely used vessel for studying arterial stiffness, which is calculated by measuring the cfPWV, considered the gold standard.<a class="elsevierStyleCrossRef" href="#bib0220">17</a> However, the cost of the equipment, the difficulty in locating the pulses, the discomfort for some patients when exposing the inguinal area and the time needed to perform the examination limit its routine use outside the hospital setting.<a class="elsevierStyleCrossRef" href="#bib0225">18</a> As a result, other simpler devices have been developed that measure the PWV in peripheral arteries.<a class="elsevierStyleCrossRef" href="#bib0230">19</a> In Europe and Australia, the cfPWV is frequently used. The new devices are more widely used in Asian countries.Our group has developed a device called the ankle brachial index pulse wave velocity (abiPWV),<a class="elsevierStyleCrossRef" href="#bib0235">20</a> which, using the oscillometric method, easily and accurately measures the PWV in the arms and legs separately. As a result, the abiPWV helps compare the PWVs of the legs and arms and explore the usefulness of different PWV indices between the legs and arms (sum, difference and ratio) in the assessment of arterial stiffness. The proposed indices have not been previously investigated or compared with other PWV-based techniques.The aim of our study was to determine the PWV index between the legs and arms measured with abiPWV that best correlates with CCQ. We also compared this association with the association between cfPWV and CCQ and between carotid IMT and CCQ.MethodsDesign and populationA cross-sectional descriptive study was conducted in Hospital San Pedro de Alcántara of Caceres, Spain, with 81 consecutive patients who underwent a CCQ study to assess ischemic heart disease due to the presence of nonspecific chest symptoms and who were considered at low risk after performing a stress test. The recruitment was performed between March 2013 and April 2014. We excluded patients with a history of cardiovascular disease and those who presented atrial fibrillation, other rhythm disorders or any conduction block. The study was designed according to the Declaration of Helsinki, and the protocol was approved by the local ethics committee.The following data were collected: age, sex, history of smoking and the presence of cardiovascular risk factors. We also measured the patients’ weight, height, blood pressure and blood glucose levels, creatinine, total cholesterol, LDL cholesterol, HDL cholesterol and triglycerides. The patients were classified into 2 groups according to whether their CCQ score was more than or less than 100. The CCQ cutoff above 100 is considered predictive of future cardiovascular events, while a score below 100 identifies patients with a low atherosclerotic burden.<a class="elsevierStyleCrossRef" href="#bib0240">21</a>Coronary calcium quantification by computed tomographyThe measurement of coronary calcium was performed with a computed tomography apparatus with 64 detectors (LightSpeed VCT 64-Slice CT, General Electrics Healthcare), with the following acquisition protocol: detector coverage of 20mm, thickness of 2.5mm at 8 images per rotation, rotation time of 0.4s, ECG synchronization, 380mA, 120kV. The acquired images were processed in an Advantage Workstation 4.4 (GE Medical Systems, UK) by the Smartscore 4.0 program to identify the presence of regional and overall calcification of the coronary arteries, using the AJ 130 calculation method, which uses the conventional Agatston/Janowitz technique,<a class="elsevierStyleCrossRef" href="#bib0245">22</a> with a threshold of 130HU adjusted to the thickness of the appropriate slice of the image.Measurement of arterial stiffnessThe examination was performed early in the morning, with the patient in fasting conditions and after lying in supine decubitus for 20min in a peaceful setting. All examinations were conducted at least 12h after taking any vasoactive drug. The measurement of cfPWV was performed with the Complior® device (Artech Medical, Pantin, France), following the manufacturer's recommendations.<a class="elsevierStyleCrossRef" href="#bib0220">17</a> The measurement of PWV with the abiPWV device was conducted according to the previously described technique.<a class="elsevierStyleCrossRef" href="#bib0235">20</a> Briefly, 4 cuffs are fitted, 2 on the arms next to the elbow flexure and 2 on the legs, close to the ankles. The apparatus functions entirely automatically, inflating the cuffs and recording the pulse waves using an incorporated oscillometric sensor. To measure the time, we took as reference the output of the heart pulse wave (R-wave peak in lead I of an electrocardiograph incorporated in the system) to its arrival at each limb (start of the pulse wave in the cuff recorder). The distance traveled was measured with the patient standing with arms outstretched at a 90° angle and with the legs together. We used an inextensible tape measure from the suprasternal notch to the midpoint of each cuff. The PWV in each limb was referenced automatically by the abiPWV in meters per second (m/s). To calculate the indices, we considered (a) arm PWV, the lower of the 2 arms; (b) leg PWV, the fasted of the 2 legs; (c) sum of PWVs from all limbs; (d) l-a PWV, highest leg PWV minus the lowest arm PWV; and ratio, highest leg PWV divided by the lowest arm PWV.Measurement of carotid intima-media thicknessCarotid ultrasonography was performed with the patient in supine decubitus and the neck slightly hyperextended, following the recommendations of the Mannheim Consensus.<a class="elsevierStyleCrossRef" href="#bib0250">23</a> We used a LOGIQ S7® ultrasound system (General Electrics Healthcare, UK), with a linear 8-MHz probe. The IMT was measured automatically with the equipment's specific software. To do this, a 1-cm plaque-free segment of the posterior wall of the common carotid artery was taken, 1cm away from the carotid bulb. As an IMT value, we considered the mean of 5 measurements in each carotid, 2 anterior, 2 posterior and one intermediate.Statistical analysisContinuous variables are expressed as means±standard deviation, and categorical variables are expressed as percentages. To determine whether there was a normal distribution, we used the Kolmogorov–Smirnov test. Variables were compared with Student's t-test for normal distributions or the Mann–Whitney U test otherwise. The chi-squared test was used for the categorical variables. The relationship between the various parameters was analyzed with the Pearson correlation coefficient. For the analysis of the area under the curve (AUC), we used 100 as the CCQ cutoff value. A p value <.05 was considered statistically significant. The data were analyzed using the IBM® statistical program SPSS® Statistics version 22.ResultsWe included 81 patients (43% of whom were women) with a mean age of 61±11 years. The main clinical characteristics according to CCQ are shown in <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>. The mean age of the patients with a CCQ <100 and that of those with a CCQ >100 was 58±11 and 65±9 years (p=.007), respectively. There was a larger proportion of men in the CCC group >100 group (63% vs. 33%, p=.011). In the CCQ >100 group, dyslipidemia was more common (70% vs. 44%, p=.028) and triglyceride levels were higher (152±31mg/dL vs. 112±46mg/dL; p=.026). There were no significant differences in the other analyzed variables.<elsevierMultimedia ident="tbl0005"></elsevierMultimedia><a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a> shows the correlations observed between CCQ and the indices obtained with abiPWV. The correlation of the sum of leg and arm PWVs to the CCQ score was 0.241 (p=.032), and the l-a PWV ratio was 0.263 (p=.019). The leg minus the arm PWV, however, had the best correlation to CCQ (r=0.401; p<.001).<elsevierMultimedia ident="tbl0010"></elsevierMultimedia><a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a> shows, using dispersion diagrams, the correlations between CCQ and IMT (r=0.366), the cfPWV measured with COMPLIOR (r=0.385) and the l-a PWV measured with abiPWV (r=0.40, p<.001 for all correlations).<elsevierMultimedia ident="fig0005"></elsevierMultimedia><a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a> shows the AUC of the analyzed variables for a CCQ >100, considered a measure of significant coronary arteriosclerosis. The AUC was 0.758 for IMT (95% confidence interval [95% CI] 0.641–0.875; p<.001), 0.636 for cfPWV with COMPLIOR (95% CI 0.499–0.733; p=.058) and 0.721 for l-a PWV with abiPWV (95% CI 0.605–0.837; p=.002).<elsevierMultimedia ident="fig0010"></elsevierMultimedia>The comparison of the IMT, cfPWV (COMPLIOR) and l-a PWV (abiPWV) values according to the presence or absence of significant coronary arteriosclerosis gave the following results for CCQ values <100 and >100, respectively (mean±standard deviation): (a) IMT of 0.67±0.11mm vs. 0.81±0.18mm (p=.002); (b) cfPWV of 9.53±1.74m/s vs. 10.54±1.93m/s (p=.043); and (c) l-a PWV of 2.50±0.77m/s vs. 3.02±0.62m/s (p=.003) (<a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a>).<elsevierMultimedia ident="tbl0015"></elsevierMultimedia>DiscussionThe results of this study show that l-a PWV measured with the abiPWV device maintains a good correlation with CCQ. This association is comparable to that of other methods that quantify arteriosclerosis, including the measurement of carotid IMT and cfPWV. L-a PWV can be useful in improving the stratification of vascular risk and helping identify hidden coronary artery disease in patients with no prior history of ischemic heart disease, stroke or peripheral arterial disease.PWV is a measure of arterial stiffness associated with vascular damage and has predictive power for future cardiovascular events. PWV in the aorta is considered the reference test, which is measured by simultaneously locating the pulse wave in the carotid and femoral arteries (cfPWV).<a class="elsevierStyleCrossRefs" href="#bib0215">16,24</a> Due to a number of drawbacks in this test and to simplify the technique, new devices have been introduced that measure the PWV in peripheral arteries.<a class="elsevierStyleCrossRef" href="#bib0260">25</a> These devices have demonstrated an efficacy comparable to those that measure cfPWV, and their measurements are considered an acceptable marker of vascular risk.<a class="elsevierStyleCrossRefs" href="#bib0225">18,26</a> In this study, we compared the association among various PWV indices between the extremities with the presence of significant coronary arteriosclerosis. Among the indices researched, the l-a PWV was the most closely associated with CCQ. PWV measurements employed in clinical practice are performed in the aorta and legs due to their greater involvement in arteriosclerosis. Although fixed PWV values have been proposed to indicate a high vascular risk, arterial stiffness is highly influenced by age and sex. As a result, the values should be normalized for these variables. A potential advantage of l-a PWV is that when comparing the leg arteries with the less diseased ones of the arm of the same patient, which are likely subjected to physiological aging, these adjustments can be avoided. Finally, the results of this study show that the AUC of the l-a PWV measured with abiPWV for predicting silent coronary artery disease was greater than 0.7, indicating that this index could behave as an acceptable marker of vascular risk. The l-a PWV measured with abiPWV could supplement the information provided by other techniques to reveal vascular damage in other arterial territories, including the carotid IMT and the cfPWV, which have also shown their correlation to CCQ. Of these methods, abiPWV is postulated as the most simple to perform, as well as being operator independent.The relationship between arterial stiffness and arteriosclerosis is not well-established.<a class="elsevierStyleCrossRef" href="#bib0210">15</a> Stiffness is the predominant consequence of changes in the tunica media, which progresses faster in the great arteries. Given that the increase in media thickness can be seen before the reduction in the lumen diameter and the development of stenosis,<a class="elsevierStyleCrossRef" href="#bib0270">27</a> the presence of arterial stiffness enables us to perform an early diagnosis. Although all arterial territories share the same risk factors, the factors affect each patient differently and determine their clinical presentation. The relationship between coronary arteriosclerosis and other arteries is not linear, thus the correlation between l-a PWV and CCQ is not consistent. However, this does not detract from its clinical usefulness.One of the limitations of this study is the small number of patients recruited from a single center. This is also a cross-sectional study, which only allows us to speculate on the pathophysiological mechanisms underlying the association between measures of arterial stiffness and between carotid IMT and CCQ. We attempted to minimize the influence of vasoactive drugs on the PWV measurements. To this end, patients must not have taken antihypertensive drugs in the 12h prior to implementing the test. Although we cannot confirm that we eliminated these potential interferences, we believe that unlike the strict research conducted in hemodynamics laboratories, the conditions of this study could approximate those of daily clinical practice.In conclusion, for patients with no symptoms of vascular disease, the l-a PWV measured with the abiPWV device shows good correlation with CCQ. This association is comparable to that between carotid IMT and CCQ and between cfPWV and CCQ. PWV measurements performed with abiPWV are easy, require no previous training and can be performed in any office. The abiPWV device can help improve the stratification of patients with moderate vascular risk.FundingCarlos III Health Institute: FIS 12/0013. Development Program for Intensifying Healthcare Research. 2015. FUNDESALUD. Ministry of Health and Social Policy, Government of Extremadura.Conflicts of interestJ. Vega Fernández, M. Tardio Fernández and J.F. Sánchez Muñoz-Torrero are co-inventors of the abiPWV device. Registered patent: ES 2 400 134 B2.The other authors declare that they have no conflicts of interest." "textoCompletoSecciones" => array:1 [ "secciones" => array:11 [ 0 => array:3 [ "identificador" => "xres632646" "titulo" => "Abstract" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Objective" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Material and methods" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Results" ] 3 => array:2 [ "identificador" => "abst0020" "titulo" => "Conclusions" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec645355" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres632645" "titulo" => "Resumen" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0025" "titulo" => "Objetivo" ] 1 => array:2 [ "identificador" => "abst0030" "titulo" => "Material y métodos" ] 2 => array:2 [ "identificador" => "abst0035" "titulo" => "Resultados" ] 3 => array:2 [ "identificador" => "abst0040" "titulo" => "Conclusiones" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec645354" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Background" ] 5 => array:3 [ "identificador" => "sec0010" "titulo" => "Methods" "secciones" => array:5 [ 0 => array:2 [ "identificador" => "sec0015" "titulo" => "Design and population" ] 1 => array:2 [ "identificador" => "sec0020" "titulo" => "Coronary calcium quantification by computed tomography" ] 2 => array:2 [ "identificador" => "sec0025" "titulo" => "Measurement of arterial stiffness" ] 3 => array:2 [ "identificador" => "sec0030" "titulo" => "Measurement of carotid intima-media thickness" ] 4 => array:2 [ "identificador" => "sec0035" "titulo" => "Statistical analysis" ] ] ] 6 => array:2 [ "identificador" => "sec0040" "titulo" => "Results" ] 7 => array:2 [ "identificador" => "sec0045" "titulo" => "Discussion" ] 8 => array:2 [ "identificador" => "sec0050" "titulo" => "Funding" ] 9 => array:2 [ "identificador" => "sec0055" "titulo" => "Conflicts of interest" ] 10 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2015-10-06" "fechaAceptado" => "2016-01-17" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec645355" "palabras" => array:4 [ 0 => "Pulse wave velocity" 1 => "Coronary calcium quantification" 2 => "Cardiovascular risk" 3 => "Intima-media thickness" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec645354" "palabras" => array:4 [ 0 => "Velocidad de onda de pulso" 1 => "Cuantificación de calcio coronario" 2 => "Riesgo cardiovascular" 3 => "Grosos de íntima media" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:3 [ "titulo" => "Abstract" "resumen" => "ObjectiveThe pulse wave velocity (PWV) in the great arteries is an indicator of vascular risk. Our objective was to identify the PWV index between the arms and legs that best correlates with the coronary calcium quantification (CCQ) and to compare it with other methods. Material and methodsEight-one patients without vascular disease underwent the following measurements: CCQ; carotid intima-media thickness (IMT); carotid-femoral PWV (cfPWV), using COMPLIOR; and PWV in the arms and legs, with our own device (abiPWV, ankle brachial index PWV). ResultsThe difference in PWVs between the leg and arm (l-a PWV) measured with abiPWV was the index that best correlated with CCQ (r=0.401, p<.001). The correlation between IMT and CCQ and between CF-PWV and CCQ were r=0.366, p=.001; and r=0.385, p=.001, respectively. For a CCQ score higher than 100 as a marker of significant coronary arteriosclerosis, the areas under the curve for l-a PWV, IMT and cfPWV were 0.721 (p=.002), 0.758 (p<.001) and 0.636 (p=.058), respectively. ConclusionsFor patients without vascular disease, the l-a PWV measured with abiPWV appears to be the index that best correlates with the CCQ. This association is comparable to that between IMT and CCQ and between cfPWV and CCQ. The abiPWV is an easy-to-use device that can help improve vascular risk stratification." "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Objective" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Material and methods" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Results" ] 3 => array:2 [ "identificador" => "abst0020" "titulo" => "Conclusions" ] ] ] "es" => array:3 [ "titulo" => "Resumen" "resumen" => "ObjetivoLa medida de la velocidad de onda de pulso (VOP) en las grandes arterias es un indicador de riesgo vascular. Nuestro objetivo fue identificar el índice de VOP entre brazos y piernas que mejor se correlaciona con la cuantificación del calcio coronario (CCC) y compararlo con otros métodos. Material y métodosA 81 pacientes sin enfermedad vascular, a los que se les había determinado la CCC, se les midió el grosor íntima-media carotídeo (GIM), la VOP carótido-femoral (VOP cf) con COMPLIOR y la VOP en brazos y piernas con un dispositivo propio (VOPITB: VOP índice tobillo brazo). ResultadosLa VOP de pierna menos brazo (VOP P-B) determinado con VOPITB fue el índice mejor correlacionado con la CCC (r=0,401, p<0,001). Las correlaciones del GIM y VOP cf con la CCC fueron: r=0,366, p=0,001 y r=0,385, p=0,001, respectivamente. Con referencia a una puntuación de la CCC mayor de 100 como marcador de arterosclerosis coronaria significativa, las áreas bajo la curva fueron para VOP P-B de 0,721 (p=0,002), GIM: 0,758 (p<0,001) y VOP cf: 0,636 (p=0,058). ConclusionesEn pacientes sin enfermedad vascular la VOP P-B medida con VOPITB parece ser el índice que mejor correlaciona con la CCC. Esta asociación es comparable con la que mantienen el GIM y la VOP cf con la CCC. VOPITB es un dispositivo fácil de manejar que puede contribuir a mejorar la estratificación del riesgo vascular." "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0025" "titulo" => "Objetivo" ] 1 => array:2 [ "identificador" => "abst0030" "titulo" => "Material y métodos" ] 2 => array:2 [ "identificador" => "abst0035" "titulo" => "Resultados" ] 3 => array:2 [ "identificador" => "abst0040" "titulo" => "Conclusiones" ] ] ] ] "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "Please cite this article as: Rico Martín S, de Nicolás Jiménez JM, Moyano Calvente SL, Mogollón Jiménez MV, Vega Fernández J, Calderón García JF, et al. La velocidad de onda de pulso de la pierna menos brazo medida con un dispositivo propio se correlaciona con la cuantificación de calcio coronario. Rev Clin Esp. 2016;216:191–197." ] ] "multimedia" => array:5 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 2755 "Ancho" => 3382 "Tamanyo" => 261930 ] ] "descripcion" => array:1 [ "en" => "Relationship between IMT, cfPWV (COMPLIOR) and l-a PWV (abiPWV) and coronary calcium quantification. Abbreviations: cfPWV, carotid-femoral pulse wave velocity measured with COMPLIOR; IMT, intima-media thickness in common carotid artery; l-a PWV, difference in maximum pulse wave velocity in the leg and minimum PWV in the arms measured with abiPWV; r, Pearson correlation coefficient for coronary calcium quantification." ] ] 1 => array:7 [ "identificador" => "fig0010" "etiqueta" => "Fig. 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 1558 "Ancho" => 1633 "Tamanyo" => 132087 ] ] "descripcion" => array:1 [ "en" => "Area under the curve for predicting a CCQ >100 for IMT. Abbreviations: CCQ, coronary calcium quantification; cfPWV, carotid-femoral pulse wave velocity measured with COMPLIOR; IMT, intima-media thickness in common carotid artery; l-a PWV, difference in maximum pulse wave velocity in the legs minus the maximum PWV in the arms measured with abiPWV." ] ] 2 => array:7 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "tabla" => array:2 [ "leyenda" => "Abbreviations: BMI, body mass index; c, cholesterol; CCQ, coronary calcium quantification; BP, blood pressure.The data are expressed as numbers (percentages) or mean±standard deviation." "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \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"> \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">Total (n=81) \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">CCQ<100 (n=54) \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">CCQ>100 (n=27) \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">p \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">Age, years \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">61±11 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">58±11 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">65±9 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">.007 \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">Male sex, n (%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">35 (43) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">18 (33) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">17 (63) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">.011 \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">History of tobacco use, n (%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">36 (44) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">23 (43) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">13 (48) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">.635 \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">Diabetes, n (%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">16 (19) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">9 (17) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">7 (25) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">.324 \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">Hypertension, n (%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">52 (64) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">33 (61) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">19 (70) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">.413 \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">Dyslipidemia, n (%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">43 (53) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">24 (44) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">19 (70) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">.028 \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">Obesity, n (%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">44 (54) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">30 (56) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">14 (52) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">.752 \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">Systolic BP, mm Hg \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">133±16 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">133±18 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">133±12 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">.955 \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">Diastolic BP, mm Hg \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">77±12 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">78±13 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">76±9 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">.460 \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">Pulse pressure \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">56±14 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">56±16 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">58±11 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">.518 \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">BMI, kg/m2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">32±6 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">32±7 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">32±4 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">.997 \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">Abdominal circumference, cm \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">101±13 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">100±14 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">104±10 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">.195 \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">Glucose, mg/dL \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">108±32 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">103±25 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">118±43 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">.051 \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">Creatinine, mg/dL \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">0.88±0.26 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">0.85±0.19 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">0.96±0.37 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">.317 \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">Total cholesterol, mg/dL \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">191±33 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">190±32 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">194±35 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">.653 \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">HDL-c, mg/dL \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">56±16 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">58±16 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">51±15 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">.078 \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">LDL-c, mg/dL \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">112±30 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">110±29 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">113±30 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">.406 \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">Triglycerides, mg/dL \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">125±60 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">112±46 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">152± 31 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">.026 \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1037731.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Clinical characteristics of the patients according to the coronary calcium quantification." ] ] 3 => array:7 [ "identificador" => "tbl0010" "etiqueta" => "Table 2" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "tabla" => array:2 [ "leyenda" => "Abbreviations: PWV, pulse wave velocity; r, Pearson correlation coefficient for the coronary calcium quantification measurement." "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \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="left" valign="top" scope="col" style="border-bottom: 2px solid black">Maximum PWV \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">r \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">p \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">Sum of leg and arm \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.241 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">.032 \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">Difference between leg and arm \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.401 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top"><.001 \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">Ratio of leg to arm \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.263 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">.019 \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1037733.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Correlation of maximum pulse wave velocity indices between arms and legs (measured with ankle brachial index pulse wave velocity device) with coronary calcium quantification." ] ] 4 => array:7 [ "identificador" => "tbl0015" "etiqueta" => "Table 3" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "tabla" => array:2 [ "leyenda" => "The data are expressed as means±standard deviation.Abbreviations: CCQ, coronary calcium quantification; IMT, intima-media thickness (in the common carotid artery); cfPWV, carotid-femoral pulse wave velocity measured with COMPLIOR; L-A PWV, difference in pulse wave velocities between the maximum of the leg and the minimum of the arm measured with abiPWV; abiPWV, ankle-brachial index pulse wave velocity device." "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \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"> \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">CCQ<100 (n=54) \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">CCQ>100 (n=27) \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">p \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">Intima-media thickness, mm \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.67±0.11 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.81±0.18 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">.002 \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">cfPWV COMPLIOR, m/s \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">9.53±1.74 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">10.45±1.93 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">.043 \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">L-A PWV abiPWV difference (m/s) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2.50±0.77 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">3.02±0.62 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">.003 \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1037732.png" ] ] ] ] "descripcion" => array:1 [ "en" => "comparison of intima-media thickness and pulse wave velocities according to the coronary calcium quantification." ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:27 [ 0 => array:3 [ "identificador" => "bib0140" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Anatomic features of victims of sudden death. 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Pulse wave velocity of the leg minus that of the arm measured with a custom device correlates to the coronary calcium quantification

La velocidad de onda de pulso de la pierna menos brazo medida con un dispositivo propio se correlaciona con la cuantificación de calcio coronario

S. Rico Martína, J.M. de Nicolás Jiménezb, S.L. Moyano Calventec, M.V. Mogollón Jiménezd, J. Vega Fernándezd, J.F. Calderón Garcíaa, M.A. Bacaicoa Lopez de Sabandoe, M. Tardiof, J.F. Sánchez Muñoz-Torrerog,

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juanf.sanchezm@gmail.com

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a Facultad de Enfermería y Terapia Ocupacional, Universidad de Extremadura, Cáceres, Spain

b Centro de Salud Jaraicejo, Jaraicejo, Cáceres, Spain

c Servicio de Radiología, Hospital San Pedro de Alcántara, Cáceres, Spain

d Servicio de Cardiología, Hospital San Pedro de Alcántara, Cáceres, Spain

e Centro de Salud Manuel Encinas, Cáceres, Spain

f Escuela de Ingenería Industrial. Universidad de Extremadura, Badajoz, Spain

g Servicio de Medicina Interna, Hospital San Pedro de Alcántara, Cáceres, Spain

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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Background</span><p id="par0005" class="elsevierStylePara elsevierViewall">Detecting silent coronary artery disease is a challenge because half of all initial coronary events&#44; including sudden death&#44; occur in previously asymptomatic individuals&#46;<a class="elsevierStyleCrossRef" href="#bib0140"><span class="elsevierStyleSup">1</span></a> Risk scales are the most widely used tool for identifying the most vulnerable of patients&#46; However&#44; their predictive value is modest &#40;C-statistic&#44; approx&#46; 0&#46;70&#8211;0&#46;75&#41;&#44;<a class="elsevierStyleCrossRef" href="#bib0145"><span class="elsevierStyleSup">2</span></a> because most vascular events happen in individuals classified as low to moderate risk&#46;<a class="elsevierStyleCrossRef" href="#bib0150"><span class="elsevierStyleSup">3</span></a> The availability of methods that objectively assess the magnitude of the arteriosclerosis could be of considerable usefulness in preventing cardiovascular disease&#46;<a class="elsevierStyleCrossRefs" href="#bib0155"><span class="elsevierStyleSup">4&#44;5</span></a> Coronary calcium quantification &#40;CCQ&#41; with multidetector computed tomography can assess calcium deposits in coronary arteries and helps complete the anatomical study of the coronary tree so as to detect stenosis&#46;<a class="elsevierStyleCrossRefs" href="#bib0165"><span class="elsevierStyleSup">6&#44;7</span></a> CCQ is indicated for asymptomatic patients with intermediate vascular risk because it improves the stratification of cardiovascular risk and directs treatment&#46;<a class="elsevierStyleCrossRef" href="#bib0175"><span class="elsevierStyleSup">8</span></a> However&#44; the cost of the test and the exposure to radiation limit its use&#46;<a class="elsevierStyleCrossRef" href="#bib0180"><span class="elsevierStyleSup">9</span></a> Other methods that have been proven useful in the early detection of atherosclerosis are the measurement of the intima-media thickness &#40;IMT&#41; with high-resolution carotid ultrasonography&#44;<a class="elsevierStyleCrossRef" href="#bib0185"><span class="elsevierStyleSup">10</span></a> the ankle-brachial index<a class="elsevierStyleCrossRef" href="#bib0190"><span class="elsevierStyleSup">11</span></a> and large artery stiffness measured by pulse wave velocity &#40;PWV&#41;&#46;<a class="elsevierStyleCrossRefs" href="#bib0195"><span class="elsevierStyleSup">12&#44;13</span></a> Both carotid IMT and carotid-femoral PWV &#40;cfPWV&#41; have shown a good correlation with CCQ&#46;<a class="elsevierStyleCrossRefs" href="#bib0205"><span class="elsevierStyleSup">14&#44;15</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">The study of PWV is recognized by the European Society of Hypertension and the European Society of Cardiology as tools for quantifying organ vascular damage&#46;<a class="elsevierStyleCrossRef" href="#bib0215"><span class="elsevierStyleSup">16</span></a> The aorta is the most widely used vessel for studying arterial stiffness&#44; which is calculated by measuring the cfPWV&#44; considered the gold standard&#46;<a class="elsevierStyleCrossRef" href="#bib0220"><span class="elsevierStyleSup">17</span></a> However&#44; the cost of the equipment&#44; the difficulty in locating the pulses&#44; the discomfort for some patients when exposing the inguinal area and the time needed to perform the examination limit its routine use outside the hospital setting&#46;<a class="elsevierStyleCrossRef" href="#bib0225"><span class="elsevierStyleSup">18</span></a> As a result&#44; other simpler devices have been developed that measure the PWV in peripheral arteries&#46;<a class="elsevierStyleCrossRef" href="#bib0230"><span class="elsevierStyleSup">19</span></a> In Europe and Australia&#44; the cfPWV is frequently used&#46; The new devices are more widely used in Asian countries&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">Our group has developed a device called the ankle brachial index pulse wave velocity &#40;abiPWV&#41;&#44;<a class="elsevierStyleCrossRef" href="#bib0235"><span class="elsevierStyleSup">20</span></a> which&#44; using the oscillometric method&#44; easily and accurately measures the PWV in the arms and legs separately&#46; As a result&#44; the abiPWV helps compare the PWVs of the legs and arms and explore the usefulness of different PWV indices between the legs and arms &#40;sum&#44; difference and ratio&#41; in the assessment of arterial stiffness&#46; The proposed indices have not been previously investigated or compared with other PWV-based techniques&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">The aim of our study was to determine the PWV index between the legs and arms measured with abiPWV that best correlates with CCQ&#46; We also compared this association with the association between cfPWV and CCQ and between carotid IMT and CCQ&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Methods</span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Design and population</span><p id="par0025" class="elsevierStylePara elsevierViewall">A cross-sectional descriptive study was conducted in Hospital San Pedro de Alc&#225;ntara of Caceres&#44; Spain&#44; with 81 consecutive patients who underwent a CCQ study to assess ischemic heart disease due to the presence of nonspecific chest symptoms and who were considered at low risk after performing a stress test&#46; The recruitment was performed between March 2013 and April 2014&#46; We excluded patients with a history of cardiovascular disease and those who presented atrial fibrillation&#44; other rhythm disorders or any conduction block&#46; The study was designed according to the Declaration of Helsinki&#44; and the protocol was approved by the local ethics committee&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">The following data were collected&#58; age&#44; sex&#44; history of smoking and the presence of cardiovascular risk factors&#46; We also measured the patients&#8217; weight&#44; height&#44; blood pressure and blood glucose levels&#44; creatinine&#44; total cholesterol&#44; LDL cholesterol&#44; HDL cholesterol and triglycerides&#46; The patients were classified into 2 groups according to whether their CCQ score was more than or less than 100&#46; The CCQ cutoff above 100 is considered predictive of future cardiovascular events&#44; while a score below 100 identifies patients with a low atherosclerotic burden&#46;<a class="elsevierStyleCrossRef" href="#bib0240"><span class="elsevierStyleSup">21</span></a></p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Coronary calcium quantification by computed tomography</span><p id="par0035" class="elsevierStylePara elsevierViewall">The measurement of coronary calcium was performed with a computed tomography apparatus with 64 detectors &#40;LightSpeed VCT 64-Slice CT&#44; General Electrics Healthcare&#41;&#44; with the following acquisition protocol&#58; detector coverage of 20<span class="elsevierStyleHsp" style=""></span>mm&#44; thickness of 2&#46;5<span class="elsevierStyleHsp" style=""></span>mm at 8 images per rotation&#44; rotation time of 0&#46;4<span class="elsevierStyleHsp" style=""></span>s&#44; ECG synchronization&#44; 380<span class="elsevierStyleHsp" style=""></span>mA&#44; 120<span class="elsevierStyleHsp" style=""></span>kV&#46; The acquired images were processed in an Advantage Workstation 4&#46;4 &#40;GE Medical Systems&#44; UK&#41; by the Smartscore 4&#46;0 program to identify the presence of regional and overall calcification of the coronary arteries&#44; using the AJ 130 calculation method&#44; which uses the conventional Agatston&#47;Janowitz technique&#44;<a class="elsevierStyleCrossRef" href="#bib0245"><span class="elsevierStyleSup">22</span></a> with a threshold of 130<span class="elsevierStyleHsp" style=""></span>HU adjusted to the thickness of the appropriate slice of the image&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Measurement of arterial stiffness</span><p id="par0040" class="elsevierStylePara elsevierViewall">The examination was performed early in the morning&#44; with the patient in fasting conditions and after lying in supine decubitus for 20<span class="elsevierStyleHsp" style=""></span>min in a peaceful setting&#46; All examinations were conducted at least 12<span class="elsevierStyleHsp" style=""></span>h after taking any vasoactive drug&#46; The measurement of cfPWV was performed with the Complior<span class="elsevierStyleSup">&#174;</span> device &#40;Artech Medical&#44; Pantin&#44; France&#41;&#44; following the manufacturer&#39;s recommendations&#46;<a class="elsevierStyleCrossRef" href="#bib0220"><span class="elsevierStyleSup">17</span></a> The measurement of PWV with the abiPWV device was conducted according to the previously described technique&#46;<a class="elsevierStyleCrossRef" href="#bib0235"><span class="elsevierStyleSup">20</span></a> Briefly&#44; 4 cuffs are fitted&#44; 2 on the arms next to the elbow flexure and 2 on the legs&#44; close to the ankles&#46; The apparatus functions entirely automatically&#44; inflating the cuffs and recording the pulse waves using an incorporated oscillometric sensor&#46; To measure the time&#44; we took as reference the output of the heart pulse wave &#40;R-wave peak in lead I of an electrocardiograph incorporated in the system&#41; to its arrival at each limb &#40;start of the pulse wave in the cuff recorder&#41;&#46; The distance traveled was measured with the patient standing with arms outstretched at a 90&#176; angle and with the legs together&#46; We used an inextensible tape measure from the suprasternal notch to the midpoint of each cuff&#46; The PWV in each limb was referenced automatically by the abiPWV in meters per second &#40;m&#47;s&#41;&#46; To calculate the indices&#44; we considered &#40;a&#41; arm PWV&#44; the lower of the 2 arms&#59; &#40;b&#41; leg PWV&#44; the fasted of the 2 legs&#59; &#40;c&#41; sum of PWVs from all limbs&#59; &#40;d&#41; l-a PWV&#44; highest leg PWV minus the lowest arm PWV&#59; and ratio&#44; highest leg PWV divided by the lowest arm PWV&#46;</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Measurement of carotid intima-media thickness</span><p id="par0045" class="elsevierStylePara elsevierViewall">Carotid ultrasonography was performed with the patient in supine decubitus and the neck slightly hyperextended&#44; following the recommendations of the Mannheim Consensus&#46;<a class="elsevierStyleCrossRef" href="#bib0250"><span class="elsevierStyleSup">23</span></a> We used a LOGIQ S7<span class="elsevierStyleSup">&#174;</span> ultrasound system &#40;General Electrics Healthcare&#44; UK&#41;&#44; with a linear 8-MHz probe&#46; The IMT was measured automatically with the equipment&#39;s specific software&#46; To do this&#44; a 1-cm plaque-free segment of the posterior wall of the common carotid artery was taken&#44; 1<span class="elsevierStyleHsp" style=""></span>cm away from the carotid bulb&#46; As an IMT value&#44; we considered the mean of 5 measurements in each carotid&#44; 2 anterior&#44; 2 posterior and one intermediate&#46;</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Statistical analysis</span><p id="par0050" class="elsevierStylePara elsevierViewall">Continuous variables are expressed as means<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>standard deviation&#44; and categorical variables are expressed as percentages&#46; To determine whether there was a normal distribution&#44; we used the Kolmogorov&#8211;Smirnov test&#46; Variables were compared with Student&#39;s <span class="elsevierStyleItalic">t</span>-test for normal distributions or the Mann&#8211;Whitney <span class="elsevierStyleItalic">U</span> test otherwise&#46; The chi-squared test was used for the categorical variables&#46; The relationship between the various parameters was analyzed with the Pearson correlation coefficient&#46; For the analysis of the area under the curve &#40;AUC&#41;&#44; we used 100 as the CCQ cutoff value&#46; A <span class="elsevierStyleItalic">p</span> value &#60;&#46;05 was considered statistically significant&#46; The data were analyzed using the IBM<span class="elsevierStyleSup">&#174;</span> statistical program SPSS<span class="elsevierStyleSup">&#174;</span> Statistics version 22&#46;</p></span></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">Results</span><p id="par0055" class="elsevierStylePara elsevierViewall">We included 81 patients &#40;43&#37; of whom were women&#41; with a mean age of 61<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>11 years&#46; The main clinical characteristics according to CCQ are shown in <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#46; The mean age of the patients with a CCQ &#60;100 and that of those with a CCQ &#62;100 was 58<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>11 and 65<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>9 years &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>&#46;007&#41;&#44; respectively&#46; There was a larger proportion of men in the CCC group &#62;100 group &#40;63&#37; vs&#46; 33&#37;&#44; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>&#46;011&#41;&#46; In the CCQ &#62;100 group&#44; dyslipidemia was more common &#40;70&#37; vs&#46; 44&#37;&#44; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>&#46;028&#41; and triglyceride levels were higher &#40;152<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>31<span class="elsevierStyleHsp" style=""></span>mg&#47;dL vs&#46; 112<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>46<span class="elsevierStyleHsp" style=""></span>mg&#47;dL&#59; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>&#46;026&#41;&#46; There were no significant differences in the other analyzed variables&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0060" class="elsevierStylePara elsevierViewall"><a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a> shows the correlations observed between CCQ and the indices obtained with abiPWV&#46; The correlation of the sum of leg and arm PWVs to the CCQ score was 0&#46;241 &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>&#46;032&#41;&#44; and the l-a PWV ratio was 0&#46;263 &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>&#46;019&#41;&#46; The leg minus the arm PWV&#44; however&#44; had the best correlation to CCQ &#40;<span class="elsevierStyleItalic">r</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;401&#59; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>&#46;001&#41;&#46;</p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><p id="par0065" class="elsevierStylePara elsevierViewall"><a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a> shows&#44; using dispersion diagrams&#44; the correlations between CCQ and IMT &#40;<span class="elsevierStyleItalic">r</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;366&#41;&#44; the cfPWV measured with COMPLIOR &#40;<span class="elsevierStyleItalic">r</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;385&#41; and the l-a PWV measured with abiPWV &#40;<span class="elsevierStyleItalic">r</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;40&#44; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>&#46;001 for all correlations&#41;&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0070" class="elsevierStylePara elsevierViewall"><a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a> shows the AUC of the analyzed variables for a CCQ &#62;100&#44; considered a measure of significant coronary arteriosclerosis&#46; The AUC was 0&#46;758 for IMT &#40;95&#37; confidence interval &#91;95&#37; CI&#93; 0&#46;641&#8211;0&#46;875&#59; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>&#46;001&#41;&#44; 0&#46;636 for cfPWV with COMPLIOR &#40;95&#37; CI 0&#46;499&#8211;0&#46;733&#59; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>&#46;058&#41; and 0&#46;721 for l-a PWV with abiPWV &#40;95&#37; CI 0&#46;605&#8211;0&#46;837&#59; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>&#46;002&#41;&#46;</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0075" class="elsevierStylePara elsevierViewall">The comparison of the IMT&#44; cfPWV &#40;COMPLIOR&#41; and l-a PWV &#40;abiPWV&#41; values according to the presence or absence of significant coronary arteriosclerosis gave the following results for CCQ values &#60;100 and &#62;100&#44; respectively &#40;mean<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>standard deviation&#41;&#58; &#40;a&#41; IMT of 0&#46;67<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>0&#46;11<span class="elsevierStyleHsp" style=""></span>mm vs&#46; 0&#46;81<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>0&#46;18<span class="elsevierStyleHsp" style=""></span>mm &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>&#46;002&#41;&#59; &#40;b&#41; cfPWV of 9&#46;53<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>1&#46;74<span class="elsevierStyleHsp" style=""></span>m&#47;s vs&#46; 10&#46;54<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>1&#46;93<span class="elsevierStyleHsp" style=""></span>m&#47;s &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>&#46;043&#41;&#59; and &#40;c&#41; l-a PWV of 2&#46;50<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>0&#46;77<span class="elsevierStyleHsp" style=""></span>m&#47;s vs&#46; 3&#46;02<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>0&#46;62<span class="elsevierStyleHsp" style=""></span>m&#47;s &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>&#46;003&#41; &#40;<a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a>&#41;&#46;</p><elsevierMultimedia ident="tbl0015"></elsevierMultimedia></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0105">Discussion</span><p id="par0080" class="elsevierStylePara elsevierViewall">The results of this study show that l-a PWV measured with the abiPWV device maintains a good correlation with CCQ&#46; This association is comparable to that of other methods that quantify arteriosclerosis&#44; including the measurement of carotid IMT and cfPWV&#46; L-a PWV can be useful in improving the stratification of vascular risk and helping identify hidden coronary artery disease in patients with no prior history of ischemic heart disease&#44; stroke or peripheral arterial disease&#46;</p><p id="par0085" class="elsevierStylePara elsevierViewall">PWV is a measure of arterial stiffness associated with vascular damage and has predictive power for future cardiovascular events&#46; PWV in the aorta is considered the reference test&#44; which is measured by simultaneously locating the pulse wave in the carotid and femoral arteries &#40;cfPWV&#41;&#46;<a class="elsevierStyleCrossRefs" href="#bib0215"><span class="elsevierStyleSup">16&#44;24</span></a> Due to a number of drawbacks in this test and to simplify the technique&#44; new devices have been introduced that measure the PWV in peripheral arteries&#46;<a class="elsevierStyleCrossRef" href="#bib0260"><span class="elsevierStyleSup">25</span></a> These devices have demonstrated an efficacy comparable to those that measure cfPWV&#44; and their measurements are considered an acceptable marker of vascular risk&#46;<a class="elsevierStyleCrossRefs" href="#bib0225"><span class="elsevierStyleSup">18&#44;26</span></a> In this study&#44; we compared the association among various PWV indices between the extremities with the presence of significant coronary arteriosclerosis&#46; Among the indices researched&#44; the l-a PWV was the most closely associated with CCQ&#46; PWV measurements employed in clinical practice are performed in the aorta and legs due to their greater involvement in arteriosclerosis&#46; Although fixed PWV values have been proposed to indicate a high vascular risk&#44; arterial stiffness is highly influenced by age and sex&#46; As a result&#44; the values should be normalized for these variables&#46; A potential advantage of l-a PWV is that when comparing the leg arteries with the less diseased ones of the arm of the same patient&#44; which are likely subjected to physiological aging&#44; these adjustments can be avoided&#46; Finally&#44; the results of this study show that the AUC of the l-a PWV measured with abiPWV for predicting silent coronary artery disease was greater than 0&#46;7&#44; indicating that this index could behave as an acceptable marker of vascular risk&#46; The l-a PWV measured with abiPWV could supplement the information provided by other techniques to reveal vascular damage in other arterial territories&#44; including the carotid IMT and the cfPWV&#44; which have also shown their correlation to CCQ&#46; Of these methods&#44; abiPWV is postulated as the most simple to perform&#44; as well as being operator independent&#46;</p><p id="par0090" class="elsevierStylePara elsevierViewall">The relationship between arterial stiffness and arteriosclerosis is not well-established&#46;<a class="elsevierStyleCrossRef" href="#bib0210"><span class="elsevierStyleSup">15</span></a> Stiffness is the predominant consequence of changes in the tunica media&#44; which progresses faster in the great arteries&#46; Given that the increase in media thickness can be seen before the reduction in the lumen diameter and the development of stenosis&#44;<a class="elsevierStyleCrossRef" href="#bib0270"><span class="elsevierStyleSup">27</span></a> the presence of arterial stiffness enables us to perform an early diagnosis&#46; Although all arterial territories share the same risk factors&#44; the factors affect each patient differently and determine their clinical presentation&#46; The relationship between coronary arteriosclerosis and other arteries is not linear&#44; thus the correlation between l-a PWV and CCQ is not consistent&#46; However&#44; this does not detract from its clinical usefulness&#46;</p><p id="par0095" class="elsevierStylePara elsevierViewall">One of the limitations of this study is the small number of patients recruited from a single center&#46; This is also a cross-sectional study&#44; which only allows us to speculate on the pathophysiological mechanisms underlying the association between measures of arterial stiffness and between carotid IMT and CCQ&#46; We attempted to minimize the influence of vasoactive drugs on the PWV measurements&#46; To this end&#44; patients must not have taken antihypertensive drugs in the 12<span class="elsevierStyleHsp" style=""></span>h prior to implementing the test&#46; Although we cannot confirm that we eliminated these potential interferences&#44; we believe that unlike the strict research conducted in hemodynamics laboratories&#44; the conditions of this study could approximate those of daily clinical practice&#46;</p><p id="par0100" class="elsevierStylePara elsevierViewall">In conclusion&#44; for patients with no symptoms of vascular disease&#44; the l-a PWV measured with the abiPWV device shows good correlation with CCQ&#46; This association is comparable to that between carotid IMT and CCQ and between cfPWV and CCQ&#46; PWV measurements performed with abiPWV are easy&#44; require no previous training and can be performed in any office&#46; The abiPWV device can help improve the stratification of patients with moderate vascular risk&#46;</p></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0110">Funding</span><p id="par0105" class="elsevierStylePara elsevierViewall">Carlos III Health Institute&#58; FIS 12&#47;0013&#46; Development Program for Intensifying Healthcare Research&#46; 2015&#46; FUNDESALUD&#46; Ministry of Health and Social Policy&#44; Government of Extremadura&#46;</p></span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0115">Conflicts of interest</span><p id="par0110" class="elsevierStylePara elsevierViewall">J&#46; Vega Fern&#225;ndez&#44; M&#46; Tardio Fern&#225;ndez and J&#46;F&#46; S&#225;nchez Mu&#241;oz-Torrero are co-inventors of the abiPWV device&#46; Registered patent&#58; ES 2 400 134 B2&#46;</p><p id="par0115" class="elsevierStylePara elsevierViewall">The other authors declare that they have no conflicts of interest&#46;</p></span></span>"
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              "identificador" => "sec0025"
              "titulo" => "Measurement of arterial stiffness"
            ]
            3 => array:2 [
              "identificador" => "sec0030"
              "titulo" => "Measurement of carotid intima-media thickness"
            ]
            4 => array:2 [
              "identificador" => "sec0035"
              "titulo" => "Statistical analysis"
            ]
          ]
        ]
        6 => array:2 [
          "identificador" => "sec0040"
          "titulo" => "Results"
        ]
        7 => array:2 [
          "identificador" => "sec0045"
          "titulo" => "Discussion"
        ]
        8 => array:2 [
          "identificador" => "sec0050"
          "titulo" => "Funding"
        ]
        9 => array:2 [
          "identificador" => "sec0055"
          "titulo" => "Conflicts of interest"
        ]
        10 => array:1 [
          "titulo" => "References"
        ]
      ]
    ]
    "pdfFichero" => "main.pdf"
    "tienePdf" => true
    "fechaRecibido" => "2015-10-06"
    "fechaAceptado" => "2016-01-17"
    "PalabrasClave" => array:2 [
      "en" => array:1 [
        0 => array:4 [
          "clase" => "keyword"
          "titulo" => "Keywords"
          "identificador" => "xpalclavsec645355"
          "palabras" => array:4 [
            0 => "Pulse wave velocity"
            1 => "Coronary calcium quantification"
            2 => "Cardiovascular risk"
            3 => "Intima-media thickness"
          ]
        ]
      ]
      "es" => array:1 [
        0 => array:4 [
          "clase" => "keyword"
          "titulo" => "Palabras clave"
          "identificador" => "xpalclavsec645354"
          "palabras" => array:4 [
            0 => "Velocidad de onda de pulso"
            1 => "Cuantificaci&#243;n de calcio coronario"
            2 => "Riesgo cardiovascular"
            3 => "Grosos de &#237;ntima media"
          ]
        ]
      ]
    ]
    "tieneResumen" => true
    "resumen" => array:2 [
      "en" => array:3 [
        "titulo" => "Abstract"
        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Objective</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">The pulse wave velocity &#40;PWV&#41; in the great arteries is an indicator of vascular risk&#46; Our objective was to identify the PWV index between the arms and legs that best correlates with the coronary calcium quantification &#40;CCQ&#41; and to compare it with other methods&#46;</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Material and methods</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Eight-one patients without vascular disease underwent the following measurements&#58; CCQ&#59; carotid intima-media thickness &#40;IMT&#41;&#59; carotid-femoral PWV &#40;cfPWV&#41;&#44; using COMPLIOR&#59; and PWV in the arms and legs&#44; with our own device &#40;abiPWV&#44; ankle brachial index PWV&#41;&#46;</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Results</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">The difference in PWVs between the leg and arm &#40;l-a PWV&#41; measured with abiPWV was the index that best correlated with CCQ &#40;<span class="elsevierStyleItalic">r</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;401&#44; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>&#46;001&#41;&#46; The correlation between IMT and CCQ and between CF-PWV and CCQ were <span class="elsevierStyleItalic">r</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;366&#44; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>&#46;001&#59; and <span class="elsevierStyleItalic">r</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;385&#44; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>&#46;001&#44; respectively&#46; For a CCQ score higher than 100 as a marker of significant coronary arteriosclerosis&#44; the areas under the curve for l-a PWV&#44; IMT and cfPWV were 0&#46;721 &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>&#46;002&#41;&#44; 0&#46;758 &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>&#46;001&#41; and 0&#46;636 &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>&#46;058&#41;&#44; respectively&#46;</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Conclusions</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">For patients without vascular disease&#44; the l-a PWV measured with abiPWV appears to be the index that best correlates with the CCQ&#46; This association is comparable to that between IMT and CCQ and between cfPWV and CCQ&#46; The abiPWV is an easy-to-use device that can help improve vascular risk stratification&#46;</p></span>"
        "secciones" => array:4 [
          0 => array:2 [
            "identificador" => "abst0005"
            "titulo" => "Objective"
          ]
          1 => array:2 [
            "identificador" => "abst0010"
            "titulo" => "Material and methods"
          ]
          2 => array:2 [
            "identificador" => "abst0015"
            "titulo" => "Results"
          ]
          3 => array:2 [
            "identificador" => "abst0020"
            "titulo" => "Conclusions"
          ]
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      "es" => array:3 [
        "titulo" => "Resumen"
        "resumen" => "<span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Objetivo</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">La medida de la velocidad de onda de pulso &#40;VOP&#41; en las grandes arterias es un indicador de riesgo vascular&#46; Nuestro objetivo fue identificar el &#237;ndice de VOP entre brazos y piernas que mejor se correlaciona con la cuantificaci&#243;n del calcio coronario &#40;CCC&#41; y compararlo con otros m&#233;todos&#46;</p></span> <span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Material y m&#233;todos</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">A 81 pacientes sin enfermedad vascular&#44; a los que se les hab&#237;a determinado la CCC&#44; se les midi&#243; el grosor &#237;ntima-media carot&#237;deo &#40;GIM&#41;&#44; la VOP car&#243;tido-femoral &#40;VOP cf&#41; con COMPLIOR y la VOP en brazos y piernas con un dispositivo propio &#40;VOPITB&#58; VOP &#237;ndice tobillo brazo&#41;&#46;</p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Resultados</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">La VOP de pierna menos brazo &#40;VOP P-B&#41; determinado con VOPITB fue el &#237;ndice mejor correlacionado con la CCC &#40;r<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;401&#44; p<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#44;001&#41;&#46; Las correlaciones del GIM y VOP cf con la CCC fueron&#58; r<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;366&#44; p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;001 y r<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;385&#44; p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;001&#44; respectivamente&#46; Con referencia a una puntuaci&#243;n de la CCC mayor de 100 como marcador de arterosclerosis coronaria significativa&#44; las &#225;reas bajo la curva fueron para VOP P-B de 0&#44;721 &#40;p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;002&#41;&#44; GIM&#58; 0&#44;758 &#40;p<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#44;001&#41; y VOP cf&#58; 0&#44;636 &#40;p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;058&#41;&#46;</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Conclusiones</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">En pacientes sin enfermedad vascular la VOP P-B medida con VOPITB parece ser el &#237;ndice que mejor correlaciona con la CCC&#46; Esta asociaci&#243;n es comparable con la que mantienen el GIM y la VOP cf con la CCC&#46; VOPITB es un dispositivo f&#225;cil de manejar que puede contribuir a mejorar la estratificaci&#243;n del riesgo vascular&#46;</p></span>"
        "secciones" => array:4 [
          0 => array:2 [
            "identificador" => "abst0025"
            "titulo" => "Objetivo"
          ]
          1 => array:2 [
            "identificador" => "abst0030"
            "titulo" => "Material y m&#233;todos"
          ]
          2 => array:2 [
            "identificador" => "abst0035"
            "titulo" => "Resultados"
          ]
          3 => array:2 [
            "identificador" => "abst0040"
            "titulo" => "Conclusiones"
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    ]
    "NotaPie" => array:1 [
      0 => array:2 [
        "etiqueta" => "&#9734;"
        "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as&#58; Rico Mart&#237;n S&#44; de Nicol&#225;s Jim&#233;nez JM&#44; Moyano Calvente SL&#44; Mogoll&#243;n Jim&#233;nez MV&#44; Vega Fern&#225;ndez J&#44; Calder&#243;n Garc&#237;a JF&#44; et al&#46; La velocidad de onda de pulso de la pierna menos brazo medida con un dispositivo propio se correlaciona con la cuantificaci&#243;n de calcio coronario&#46; Rev Clin Esp&#46; 2016&#59;216&#58;191&#8211;197&#46;</p>"
      ]
    ]
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      0 => array:7 [
        "identificador" => "fig0005"
        "etiqueta" => "Fig&#46; 1"
        "tipo" => "MULTIMEDIAFIGURA"
        "mostrarFloat" => true
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        "figura" => array:1 [
          0 => array:4 [
            "imagen" => "gr1.jpeg"
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        "descripcion" => array:1 [
          "en" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Relationship between IMT&#44; cfPWV &#40;COMPLIOR&#41; and l-a PWV &#40;abiPWV&#41; and coronary calcium quantification&#46;</p> <p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">Abbreviations&#58; cfPWV&#44; carotid-femoral pulse wave velocity measured with COMPLIOR&#59; IMT&#44; intima-media thickness in common carotid artery&#59; l-a PWV&#44; difference in maximum pulse wave velocity in the leg and minimum PWV in the arms measured with abiPWV&#59; <span class="elsevierStyleItalic">r</span>&#44; Pearson correlation coefficient for coronary calcium quantification&#46;</p>"
        ]
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      1 => array:7 [
        "identificador" => "fig0010"
        "etiqueta" => "Fig&#46; 2"
        "tipo" => "MULTIMEDIAFIGURA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "figura" => array:1 [
          0 => array:4 [
            "imagen" => "gr2.jpeg"
            "Alto" => 1558
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        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">Area under the curve for predicting a CCQ &#62;100 for IMT&#46;</p> <p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">Abbreviations&#58; CCQ&#44; coronary calcium quantification&#59; cfPWV&#44; carotid-femoral pulse wave velocity measured with COMPLIOR&#59; IMT&#44; intima-media thickness in common carotid artery&#59; l-a PWV&#44; difference in maximum pulse wave velocity in the legs minus the maximum PWV in the arms measured with abiPWV&#46;</p>"
        ]
      ]
      2 => array:7 [
        "identificador" => "tbl0005"
        "etiqueta" => "Table 1"
        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "tabla" => array:2 [
          "leyenda" => "<p id="spar0070" class="elsevierStyleSimplePara elsevierViewall">Abbreviations&#58; BMI&#44; body mass index&#59; c&#44; cholesterol&#59; CCQ&#44; coronary calcium quantification&#59; BP&#44; blood pressure&#46;</p><p id="spar0075" class="elsevierStyleSimplePara elsevierViewall">The data are expressed as numbers &#40;percentages&#41; or mean<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>standard deviation&#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">Total &#40;<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>81&#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">CCQ<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>100 &#40;<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>54&#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">CCQ<span class="elsevierStyleHsp" style=""></span>&#62;<span class="elsevierStyleHsp" style=""></span>100 &#40;<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>27&#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"><span class="elsevierStyleItalic">p</span>&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">Age&#44; years&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">61<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>11&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">58<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>11&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">65<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>9&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#46;007&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">18 &#40;33&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">17 &#40;63&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#46;011&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">36 &#40;44&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">23 &#40;43&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">13 &#40;48&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#46;635&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">Diabetes&#44; <span class="elsevierStyleItalic">n</span> &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">9 &#40;17&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">7 &#40;25&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#46;324&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">Hypertension&#44; <span class="elsevierStyleItalic">n</span> &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">33 &#40;61&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">19 &#40;70&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#46;413&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">Dyslipidemia&#44; <span class="elsevierStyleItalic">n</span> &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">24 &#40;44&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">19 &#40;70&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#46;028&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">Obesity&#44; <span class="elsevierStyleItalic">n</span> &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">30 &#40;56&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">14 &#40;52&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#46;752&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">Systolic BP&#44; mm Hg&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">133<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>16&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">133<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>18&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">133<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>12&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#46;955&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">Diastolic BP&#44; mm Hg&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">77<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>12&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">78<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="left" valign="top">76<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>9&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#46;460&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">Pulse pressure&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">56<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="left" valign="top">56<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>16&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">58<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>11&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#46;518&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">BMI&#44; kg&#47;m<span class="elsevierStyleSup">2</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">32<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>6&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">32<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>7&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">32<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#46;997&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">Abdominal circumference&#44; cm&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">101<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="left" valign="top">100<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="left" valign="top">104<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>10&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#46;195&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">Glucose&#44; mg&#47;dL&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">108<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>32&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">103<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>25&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">118<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>43&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#46;051&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">Creatinine&#44; mg&#47;dL&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">0&#46;88<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>0&#46;26&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">0&#46;85<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>0&#46;19&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">0&#46;96<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>0&#46;37&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#46;317&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">Total cholesterol&#44; mg&#47;dL&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">191<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>33&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">190<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>32&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">194<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>35&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#46;653&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">HDL-c&#44; mg&#47;dL&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">56<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>16&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">58<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>16&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">51<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>15&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#46;078&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">LDL-c&#44; mg&#47;dL&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">112<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>30&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">110<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>29&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">113<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>30&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#46;406&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">Triglycerides&#44; mg&#47;dL&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">125<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>60&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">112<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>46&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">152&#177; 31&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#46;026&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
              ]
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                0 => "xTab1037731.png"
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          "en" => "<p id="spar0065" class="elsevierStyleSimplePara elsevierViewall">Clinical characteristics of the patients according to the coronary calcium quantification&#46;</p>"
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      3 => array:7 [
        "identificador" => "tbl0010"
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        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "tabla" => array:2 [
          "leyenda" => "<p id="spar0085" class="elsevierStyleSimplePara elsevierViewall">Abbreviations&#58; PWV&#44; pulse wave velocity&#59; <span class="elsevierStyleItalic">r</span>&#44; Pearson correlation coefficient for the coronary calcium quantification measurement&#46;</p>"
          "tablatextoimagen" => array:1 [
            0 => array:2 [
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                0 => """
                  <table border="0" frame="\n
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                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Maximum PWV&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"><span class="elsevierStyleItalic">r</span>&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"><span class="elsevierStyleItalic">p</span>&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">Sum of leg and arm&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;241&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#46;032&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">Difference between leg and arm&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;401&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#60;&#46;001&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">Ratio of leg to arm&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;263&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#46;019&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
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                0 => "xTab1037733.png"
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          "en" => "<p id="spar0080" class="elsevierStyleSimplePara elsevierViewall">Correlation of maximum pulse wave velocity indices between arms and legs &#40;measured with ankle brachial index pulse wave velocity device&#41; with coronary calcium quantification&#46;</p>"
        ]
      ]
      4 => array:7 [
        "identificador" => "tbl0015"
        "etiqueta" => "Table 3"
        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "tabla" => array:2 [
          "leyenda" => "<p id="spar0095" class="elsevierStyleSimplePara elsevierViewall">The data are expressed as means<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>standard deviation&#46;</p><p id="spar0100" class="elsevierStyleSimplePara elsevierViewall">Abbreviations&#58; CCQ&#44; coronary calcium quantification&#59; IMT&#44; intima-media thickness &#40;in the common carotid artery&#41;&#59; cfPWV&#44; carotid-femoral pulse wave velocity measured with COMPLIOR&#59; L-A PWV&#44; difference in pulse wave velocities between the maximum of the leg and the minimum of the arm measured with abiPWV&#59; abiPWV&#44; ankle-brachial index pulse wave velocity device&#46;</p>"
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                0 => """
                  <table border="0" frame="\n
                  \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">CCQ<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>100 &#40;<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>54&#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">CCQ<span class="elsevierStyleHsp" style=""></span>&#62;<span class="elsevierStyleHsp" style=""></span>100 &#40;<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>27&#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"><span class="elsevierStyleItalic">p</span>&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">Intima-media thickness&#44; mm&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;67<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>0&#46;11&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;81<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>0&#46;18&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#46;002&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">cfPWV COMPLIOR&#44; m&#47;s&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">9&#46;53<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>1&#46;74&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">10&#46;45<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>1&#46;93&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#46;043&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">L-A PWV abiPWV difference &#40;m&#47;s&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">2&#46;50<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>0&#46;77&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">3&#46;02<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>0&#46;62&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#46;003&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
              ]
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                0 => "xTab1037732.png"
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        "descripcion" => array:1 [
          "en" => "<p id="spar0090" class="elsevierStyleSimplePara elsevierViewall">comparison of intima-media thickness and pulse wave velocities according to the coronary calcium quantification&#46;</p>"
        ]
      ]
    ]
    "bibliografia" => array:2 [
      "titulo" => "References"
      "seccion" => array:1 [
        0 => array:2 [
          "identificador" => "bibs0005"
          "bibliografiaReferencia" => array:27 [
            0 => array:3 [
              "identificador" => "bib0140"
              "etiqueta" => "1"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Anatomic features of victims of sudden death&#46; Coronary artery pathology"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:1 [
                            0 => "M&#46;J&#46; Davies"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "Circulation"
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                        "volumen" => "85"
                        "numero" => "I &#40;Suppl&#46;&#41;"
                        "paginaInicial" => "19"
                        "paginaFinal" => "24"
                      ]
                    ]
                  ]
                ]
              ]
            ]
            1 => array:3 [
              "identificador" => "bib0145"
              "etiqueta" => "2"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Comparison of the Framingham and Reynolds risk scores for global cardiovascular risk prediction in the multiethnic women&#39;s health initiative"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [
                            0 => "N&#46;R&#46; Cook"
                            1 => "N&#46;P&#46; Paynter"
                            2 => "C&#46;B&#46; Eaton"
                            3 => "J&#46;E&#46; Manson"
                            4 => "L&#46;W&#46; Martin"
                            5 => "J&#46;G&#46; Robinson"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1161/CIRCULATIONAHA.111.075929"
                      "Revista" => array:6 [
                        "tituloSerie" => "Circulation"
                        "fecha" => "2012"
                        "volumen" => "125"
                        "paginaInicial" => "1748"
                        "paginaFinal" => "1756"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/22399535"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            2 => array:3 [
              "identificador" => "bib0150"
              "etiqueta" => "3"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Prevalence and progression of subclinical atherosclerosis in younger adults with low short-term but high lifetime estimated risk for cardiovascular disease&#58; the coronary artery risk development in young adults study and multi-ethnic study of atherosclerosis"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [
                            0 => "J&#46;D&#46; Berry"
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Article information

ISSN: 22548874
Original language: English

DOI:10.1016/j.rceng.2016.01.003

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