High-sensitivity troponin T and the risk of recurrent readmissions after hospitalization for acute heart failure

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TnT-Q: cuartiles de troponina T." ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "D. Escribano, E. Santas, G. Miñana, A. Mollar, S. García-Blas, E. Valero, A. Payá, F.J. Chorro, J. Sanchis, J. Núñez" "autores" => array:10 [ 0 => array:2 [ "nombre" => "D." "apellidos" => "Escribano" ] 1 => array:2 [ "nombre" => "E." "apellidos" => "Santas" ] 2 => array:2 [ "nombre" => "G." "apellidos" => "Miñana" ] 3 => array:2 [ "nombre" => "A." "apellidos" => "Mollar" ] 4 => array:2 [ "nombre" => "S." "apellidos" => "García-Blas" ] 5 => array:2 [ "nombre" => "E." "apellidos" => "Valero" ] 6 => array:2 [ "nombre" => "A." "apellidos" => "Payá" ] 7 => array:2 [ "nombre" => "F.J." "apellidos" => "Chorro" ] 8 => array:2 [ "nombre" => "J." "apellidos" => "Sanchis" ] 9 => array:2 [ "nombre" => "J." 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Escribano, E. Santas, G. Miñana, A. Mollar, S. García-Blas, E. Valero, A. Payá, F.J. Chorro, J. Sanchis, J. Núñez" "autores" => array:10 [ 0 => array:2 [ "nombre" => "D." "apellidos" => "Escribano" ] 1 => array:2 [ "nombre" => "E." "apellidos" => "Santas" ] 2 => array:2 [ "nombre" => "G." "apellidos" => "Miñana" ] 3 => array:2 [ "nombre" => "A." "apellidos" => "Mollar" ] 4 => array:2 [ "nombre" => "S." "apellidos" => "García-Blas" ] 5 => array:2 [ "nombre" => "E." "apellidos" => "Valero" ] 6 => array:2 [ "nombre" => "A." "apellidos" => "Payá" ] 7 => array:2 [ "nombre" => "F.J." "apellidos" => "Chorro" ] 8 => array:2 [ "nombre" => "J." "apellidos" => "Sanchis" ] 9 => array:4 [ "nombre" => "J." "apellidos" => "Núñez" "email" => array:1 [ 0 => "yulnunez@gmail.com" ] "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "*" "identificador" => "cor0005" ] ] ] ] "afiliaciones" => array:1 [ 0 => array:2 [ "entidad" => "Servicio de Cardiología, Hospital Clínico Universitario de Valencia, INCLIVA, Universitat de Valencia, Valencia, Spain" "identificador" => "aff0005" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Troponina T de alta sensibilidad y riesgo de hospitalizaciones recurrentes tras un ingreso por insuficiencia cardíaca aguda" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 953 "Ancho" => 2741 "Tamanyo" => 106049 ] ] "descripcion" => array:1 [ "en" => "Incidence of recurrent hospitalizations according to hs-TnT values. (A) All-cause hospitalizations. (B) Hospitalizations for heart failure. Abbreviations: hs-TnT, high-sensitivity troponin T; TnT-Q, troponin T quartiles." ] ] ] "textoCompleto" => "BackgroundHeart failure (HF) is a syndrome characterized by repeated episodes of clinical decompensation that result in a high rate of readmissions.<a class="elsevierStyleCrossRefs" href="#bib0175">1,2</a> After an episode of acute HF (AHF), approximately 50% of patients are readmitted within 6 months of being discharged.<a class="elsevierStyleCrossRef" href="#bib0185">3</a> Readmissions for HF are associated with disease progression, higher mortality and increased healthcare costs.<a class="elsevierStyleCrossRefs" href="#bib0190">4–6</a> Our understanding of the factors related to the risk of readmission for these patients is still limited. Traditionally, the predictive models developed for HF have assessed the risk to the onset of the first event, ignoring subsequent readmissions that occur during the natural history of a patient with HF. Various authors have supported the implementation of statistical methodologies that help assess all hospitalizations for patients with HF, thereby achieving a more realistic vision of the burden of readmission-related morbidity.<a class="elsevierStyleCrossRef" href="#bib0205">7</a>High-sensitivity troponin is a widely available biomarker of myocardial damage and is mainly used for diagnosing acute myocardial infarction (AMI).<a class="elsevierStyleCrossRef" href="#bib0210">8</a> High-sensitivity troponin levels are also increased in a significant number of patients with AHF, even in the absence of signs or symptoms of myocardial ischemia.<a class="elsevierStyleCrossRef" href="#bib0215">9</a> The increase in high-sensitivity troponin T (hs-TnT) levels is associated with an increased risk of first readmission and mortality in the follow-up of these patients.<a class="elsevierStyleCrossRefs" href="#bib0220">10–18</a> However, we have no data on its value in predicting recurrent hospitalizations over the entire follow-up. The aim of our study was to assess the association between hs-TnT values at admission of patients with AHF and the subsequent risk of readmissions during the follow-up.MethodsStudy protocol and groupWe prospectively included a consecutive cohort of 645 patients hospitalized with the diagnosis of AHF in the Department of Cardiology of University Clinic Hospital of Valencia between the January 1, 2012 and March 1, 2014. AHF was defined according to the clinical practice guidelines.<a class="elsevierStyleCrossRef" href="#bib0265">19</a> The study included patients with de novo HF and those with acute decompensation of chronic HF. We excluded patients with AMI.<a class="elsevierStyleCrossRef" href="#bib0210">8</a> The patients’ clinical care during the hospitalization was individualized, at the discretion of the responsible physician, who could request additional pertinent examinations for the diagnosis of the acute ischemic etiology based on their clinical suspicion. Thus, we excluded from this analysis 24 patients whose final diagnosis at discharge was AMI, leaving a final study sample of 621 patients. Over the course of the index hospitalization, many clinical, demographic and biochemical variables were assessed, as well as echocardiographic parameters, 12-lead electrocardiograms and treatments.Measurement of hs-TnTThe blood measurement of hs-TnT values was performed during the first medical contact in the emergency department during the index episode, using the available in vitro immunologic test (Elecsys Troponin T hs STAT Cobas® of Roche Diagnostic GmbH), with a double monoclonal antibody sandwich technique (sensitivity, 0.1ng/mL). The hs-TnT results were available to the clinicians responsible for the patient.Follow-up and study objectivesThe primary study endpoint was the number of readmissions during the follow-up. We assessed the risk of readmission both for all causes and specifically for AHF. All episodes of unscheduled hospital readmissions after the discharge from the index episode were recorded. The researchers responsible for judging the events were unaware of the hs-TnT values. The patients’ follow-up was conducted to the last date in which the patient's vital status was certified.The study was conducted according to the principles of the Declaration of Helsinki and was approved by our center's ethics committee.Statistical analysisThe continuous variables are expressed as means±standard deviation or medians (interquartile range [IQR]). The rates of the categorical variables are expressed as percentages. The patients’ baseline characteristics are represented according to the quartiles of the hs-TnT values. We determined the cumulative incidence rates of hospital readmissions according to the hs-TnT quartiles (TnT-Q). The independent association between the logarithmic transformation of the hs-TnT values (log-hs-TnT) or the TnT-Q with the readmissions was assessed using multivariate binomial regression (Nbreg), and its risk estimates are expressed as incident rate ratios (IRR). Death was included as an additional hospitalization in the Nbreg model but only if it occurred outside a hospitalization, as has recently been suggested in the literature.<a class="elsevierStyleCrossRefs" href="#bib0270">20,21</a>The final multivariate model included the following covariates: age, previous hospitalizations for HF, ischemic etiology, history of chronic obstructive pulmonary disease, left ventricular ejection fraction (LVEF) <35%, systolic blood pressure at admission, hemoglobin, urea, natriuretic peptide NT-proBNP and treatment with beta blockers.We considered a value of p<.05 statistically significant for all analyses. We employed the statistical software STATA 14 for the calculations (StataCorp, College Station, TX, USA).ResultsBaseline patient characteristicsThe sample's mean age was 73.6±10.8 years, 54.6% were men, and 52% had an LVEF ≥50%. The median hs-TnT level was 35.5pg/mL (IQR, 22–67), and 90% of the patients had values that were considered high (≥14pg/mL). The median NT-proBNP level was 3795pg/mL (IQR, 2111–7464). In terms of renal function, the mean serum creatinine level and estimated glomerular filtration rate were 1.21±0.56mg/dL and 65.6±26.4mL/min/1.73m2, respectively, such that 270 patients (43.4%) presented a glomerular filtration rate <60mL/min/1.73m2. The sample's baseline characteristics, represented according to the hs-TnT quartiles at admission, are listed in <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>. The patients with high hs-TnT values were older and had a higher prevalence of arterial hypertension, chronic ischemic heart disease, left ventricular systolic dysfunction and renal failure, as well as higher NT-proBNP values.<elsevierMultimedia ident="tbl0005"></elsevierMultimedia>Mortality rate and recurrent hospitalizationsAfter a median follow-up of 1.2 years (IQR, 0.4–2.4), a total of 153 deaths (24.6%) were recorded, as well as 698 readmissions for all causes in 303 patients (48.8%) and 286 readmissions for HF in 163 patients (26.3%). Of the deaths, 109 had a cardiovascular cause and 56 were due to HF. The distribution of the number of hospitalizations for all causes was as follows: 1 hospitalization, 134 (21.6%); 2, 76 (12.2%); 3, 31 (5); 4, 29 (4.7%); and ≥5, 33 (5.3%). For the number of readmissions for HF, the distribution was as follows: 1, 101 (16.3%); 2, 28 (4.5%); 3, 19 (3.1%); 4, 9 (1.5%); and ≥5, 6 (1%).hs-TnT and recurrent hospitalizationsThe cumulative incidence rate for all-cause admissions (per 10 person-years of follow-up) increased stepwise and significantly from the lower to the higher hs-TnT quartile (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>A). This finding (and even with a difference of greater magnitude) was observed for the AHF readmissions (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>B), as well as for total mortality (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>). High hs-TnT values were also associated with the risk of cardiovascular death (log-rank test; p<.001) and with HF (log-rank test; p=001). In the multivariate analysis, these differences remained significant, such that log-hs-TnT was directly and independently associated with an increased risk of readmissions, both for all causes and for HF (IRR, 1.16; 95% CI 1.01–1.36; p=.029 and IRR, 1.23; 95% CI 1.04–1.46; p=018; respectively).<elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia>By assessing the risk of readmission for all causes attributable to TnT-Q, with regard to those patients belonging to the lower quartile (≤22pg/mL), we observed a progressive increase in the risk from TnT-Q2 to TnT-Q4, although of moderate magnitude (<a class="elsevierStyleCrossRef" href="#fig0015">Fig. 3</a>A). When we analyzed the association between TnT-Q and the risk of readmission specifically for HF, we observed an increased intensity of this association, with a striking increase in the risk for those patients belonging to TnT-Q3 and TnT-Q4 (<a class="elsevierStyleCrossRef" href="#fig0015">Fig. 3</a>B).<elsevierMultimedia ident="fig0015"></elsevierMultimedia>In terms of readmissions for all causes, there were no differences in the prognostic value of hs-TnT between patients with HF and depressed systolic function (LVEF <50%) and those with preserved function (LVEF ≥50%) (p=110 for the interaction). However, when assessing the risk of readmissions for HF, we did observe a significant interaction between LVEF and hs-TnT (p=029 for the interaction). The association between hs-TnT values and readmissions for HF was more significant for the patient subgroup with depressed systolic function (IRR, 1.61, 95% CI, 1.21–2.17; p=001) than for those with preserved systolic function (IRR, 1.09; 95% CI 0.89–1.33; p=400).DiscussionThe present study confirms that patients with AHF have high hs-TnT values, which are associated with an increased risk of mortality, and broadens our understanding of the value of this biomarker as a predictor of morbidity. In particular, the study shows that hs-TnT values, determined during the admission of unselected patients with AHF, are directly and independently associated with the risk of recurrent hospitalizations during follow-up.It is well known that, after hospitalization for HF, the rate of subsequent readmissions continuous to be high.<a class="elsevierStyleCrossRefs" href="#bib0175">1–3</a> The natural history of a patient with HF is characterized by numerous episodes of decompensation, which frequently cause recurrent hospitalizations, which in turn result in a significant loss of quality of life, increased consumption of healthcare resources and lower survival.<a class="elsevierStyleCrossRefs" href="#bib0190">4–6</a> The prognostic effect of a certain clinical profile or therapeutic strategy has classically been evaluated as the time until the first event, largely ignoring the adverse events that subsequently occur in the outcomes of patients with HF. To more accurately profile the burden of HF-associated morbidity, we consider (as have other authors) that the assessment of the natural history of a patient with HF should include all adverse episodes of rehospitalization during the follow-up.<a class="elsevierStyleCrossRefs" href="#bib0205">7,22</a> Although the experience in implementing this methodology is still scarce, it has been employed in the post hoc analysis of various clinical trials on HF (e.g., the Candesartan in Heart Failure-Assessment of Reduction in Mortality and Morbidity trial<a class="elsevierStyleCrossRef" href="#bib0270">20</a>; the Controlled Rosuvastatin Multinational Trial in Heart Failure<a class="elsevierStyleCrossRef" href="#bib0275">21</a>; the Systolic Heart failure treatment with the If inhibitor Ivabradine Trial<a class="elsevierStyleCrossRef" href="#bib0285">23</a>; and Eplerenone in Mild Patients Hospitalization and Survival Study in Heart Failure trial<a class="elsevierStyleCrossRef" href="#bib0290">24</a>) and is defined as a primary assessment criterion in studies that are currently underway such as the Efficacy and Safety of LCZ696 Compared to Valsartan, on Morbidity and Mortality in Heart Failure Patients With Preserved Ejection Fraction trial.<a class="elsevierStyleCrossRef" href="#bib0295">25</a>Troponin is a biomarker of myocardial damage that has been classically employed for the diagnosis of AMI and the prognostic stratification of patients with acute ischemic heart disease.<a class="elsevierStyleCrossRef" href="#bib0210">8</a> However, high troponin levels are commonly observed in patients with AHF and in patients with chronic HF.<a class="elsevierStyleCrossRef" href="#bib0215">9</a> This situation is even most frequent when high-sensitivity reagents are employed, such as hs-TnT. For example, in the Efficacy and Safety of Relaxin for the Treatment of Acute Heart Failure (RELAX-AHF) study, 90% of the included patients showed hs-TnT values above the reference 99 percentile,<a class="elsevierStyleCrossRef" href="#bib0230">12</a> a result that was comparable to our study.The mechanisms responsible for the increase in troponin levels in patients with HF are controversial and include subendocardial ischemia and the consequent cell necrosis, cytokine-mediated cardiomyocyte damage and oxidative stress.<a class="elsevierStyleCrossRefs" href="#bib0215">9,26–28</a> An interesting pathophysiological hypothesis holds that the increase in troponin levels in HF reflects the phenomena of cardiac contractile protein proteolysis, which could be triggered by parietal stress, oxidative stress, neurohormonal activation or microvascular ischemia, all of which are phenomena that are typically present in HF.<a class="elsevierStyleCrossRef" href="#bib0315">29</a> The phenomena of apoptosis have been reported in patients with HF, but it has not been clearly established that the phenomena provoke the release of troponin.<a class="elsevierStyleCrossRef" href="#bib0320">30</a> In short, the pathophysiological mechanisms involved in the increase in hs-TnT levels in AHF are still largely unknown. Additional experimental studies would likely be necessary to better understand the underlying mechanisms responsible for the presence of high troponin levels in HF.Although there is considerable heterogeneity among the various studies that have evaluated the prognostic role of troponin in HF (for the various reagents evaluated, the timing of their measurement and the clinical profile of the analyzed population), there is broad consensus that high troponin levels are associated with an increased risk of mortality for patients with AHF.<a class="elsevierStyleCrossRefs" href="#bib0220">10–18</a> For example, a recent analysis of the RELAX-AHF study showed that both the baseline values and the changes in hs-TnT during the index hospitalization for AHF were associated with an increased risk of cardiovascular mortality at 180 days.<a class="elsevierStyleCrossRef" href="#bib0230">12</a> Our results support and broaden the available evidence, showing that hs-TnT levels are independently associated not only with mortality during follow-up but also with the burden of morbidity and readmissions. Although several studies have already shown an association between the risk of a first readmission (assessed as the time to the first event) and troponin levels,<a class="elsevierStyleCrossRefs" href="#bib0220">10,13,14,17,18</a> our study is the first to support the close association between plasma hs-TnT concentrations and the risk of repeated hospitalizations after an episode of AHF. This association was significant both for all-cause readmissions and for HF decompensation and was mainly observed in the patient subgroup with depressed systolic function.Although not an objective assessed in this study, troponin can have an additional prognostic value to other HF biomarkers. In this series, the prognostic value of hs-TnT was independent of NT-proBNP levels. Vorovich et al. assessed the usefulness of a panel of 9 biomarkers as predictors of readmission for cardiac causes in more than 1500 patients with stable HF, obtaining the most significant association for BNP and TnI.<a class="elsevierStyleCrossRef" href="#bib0325">31</a> Tentzeris et al. obtained similar data in terms of the combined use of copeptin and TnT for predicting mortality and readmission for patients with chronic HF.<a class="elsevierStyleCrossRef" href="#bib0330">32</a> In 107 patients with AHF, Pascual-Figal et al. showed that hs-TnT, NT-proBNP and ST-2 provide independent prognostic information for mortality and that the joint use of the 3 biomarkers helps optimize risk stratification in HF.<a class="elsevierStyleCrossRef" href="#bib0250">16</a>In this series, we found a high prevalence of patients with renal failure (43.4%). There is controversy about the accuracy and interpretation of hs-TnT levels for diagnosing AMI in patients with kidney disease, a situation in which the biomarker's cutoff points could be higher than for the general population.<a class="elsevierStyleCrossRef" href="#bib0335">33</a> For patients with renal failure, however, the prognostic value of troponin does not appear to be affected by the use of high-sensitivity reagents. In previous studies, hs-TnT maintained its prognostic value, and high values of the biomarker were predictors of HF progression and mortality in broad series of patients with chronic kidney disease.<a class="elsevierStyleCrossRef" href="#bib0340">34</a>Study limitationsThe main study limitations are related to its single-center nature. In addition, although patients with a final diagnosis of AMI were excluded from the analysis (as per the clinical practice guidelines<a class="elsevierStyleCrossRefs" href="#bib0210">8,19</a>), a systematic search was not conducted of the acute ischemic etiology in all patients with high hs-TnT levels. Rather, the search depended on the clinical suspicion of acute coronary syndrome by the physician responsible for the patient during the index hospitalization. This clinical variability in patient care inherent in a study performed in the context of daily clinical practice precludes our safely ruling out the presence of patients with acute coronary syndrome. A serial reading of hs-TnT levels in all included patients was not conducted, which prevents us from knowing the most optimal moment for their measurement or whether the serial measurements of the biomarker could have an additional predictive value.Future perspectivesThe data suggest that measuring hs-TnT levels should be incorporated into the available tools for the risk stratification of patients with AHF. In addition to the already known value of hs-TnT levels as a predictor of mortality, this study confirmed its usefulness in predicting recurrent hospitalizations during these patients’ follow-up. Future studies should clarify whether measures such as treatment intensification, the search for new therapeutic strategies and a closer follow-up of patients with increased hs-TnT levels will have an effect on improving the prognosis.FundingThis study was funded in part by grants from the Carlos III Health Institute and from FEDER, Cardiovascular Research network, Program 7 (RD12/0042/0010) and PIE15/00013.Conflicts of interestThe authors declare that they have no conflicts of interest." "textoCompletoSecciones" => array:1 [ "secciones" => array:13 [ 0 => array:3 [ "identificador" => "xres806056" "titulo" => "Abstract" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Objectives" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Methods" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Results" ] 3 => array:2 [ "identificador" => "abst0020" "titulo" => "Conclusions" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec804156" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres806055" "titulo" => "Resumen" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0025" "titulo" => "Objetivos" ] 1 => array:2 [ "identificador" => "abst0030" "titulo" => "Métodos" ] 2 => array:2 [ "identificador" => "abst0035" "titulo" => "Resultados" ] 3 => array:2 [ "identificador" => "abst0040" "titulo" => "Conclusiones" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec804157" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Background" ] 5 => array:3 [ "identificador" => "sec0010" "titulo" => "Methods" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "sec0015" "titulo" => "Study protocol and group" ] 1 => array:2 [ "identificador" => "sec0020" "titulo" => "Measurement of hs-TnT" ] 2 => array:2 [ "identificador" => "sec0025" "titulo" => "Follow-up and study objectives" ] 3 => array:2 [ "identificador" => "sec0030" "titulo" => "Statistical analysis" ] ] ] 6 => array:3 [ "identificador" => "sec0035" "titulo" => "Results" "secciones" => array:3 [ 0 => array:2 [ "identificador" => "sec0040" "titulo" => "Baseline patient characteristics" ] 1 => array:2 [ "identificador" => "sec0045" "titulo" => "Mortality rate and recurrent hospitalizations" ] 2 => array:2 [ "identificador" => "sec0050" "titulo" => "hs-TnT and recurrent hospitalizations" ] ] ] 7 => array:2 [ "identificador" => "sec0055" "titulo" => "Discussion" ] 8 => array:2 [ "identificador" => "sec0060" "titulo" => "Study limitations" ] 9 => array:2 [ "identificador" => "sec0065" "titulo" => "Future perspectives" ] 10 => array:2 [ "identificador" => "sec0070" "titulo" => "Funding" ] 11 => array:2 [ "identificador" => "sec0075" "titulo" => "Conflicts of interest" ] 12 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2016-05-02" "fechaAceptado" => "2016-10-18" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec804156" "palabras" => array:3 [ 0 => "Ultrasensitive troponin" 1 => "Heart failure" 2 => "Recurrent readmissions" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec804157" "palabras" => array:3 [ 0 => "Troponina ultrasensible" 1 => "Insuficiencia cardíaca" 2 => "Hospitalizaciones recurrentes" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:3 [ "titulo" => "Abstract" "resumen" => "ObjectivesHigh-sensitivity troponin is a biomarker of myocardial damage and is associated with a greater risk of mortality and disease progression in patients with acute heart failure (AHF). However, its relationship with the risk of future readmissions is less known. The aim of this study was to assess the association between ultrasensitive troponin T (TnT-us) values in patients with AHF and the risk of recurrent readmissions in the follow-up. MethodsWe prospectively included a cohort of 621 consecutive patients with AHF, excluding those patients with acute coronary syndrome. We measured the TnT-us levels obtained during the first medical contact in the emergency department. The risk of cumulative readmissions was assessed using negative binomial regression. ResultsThe mean age of the participants was 73.6±10.8 years, 54.6% were men, and 52% had a left ventricular systolic function ≥50%. The median TnT-us level was 35.5pg/mL (interquartile range [IQR], 22–67). After a median follow-up of 1.2 years (IQR, 0.4–2.4), a total of 153 deaths (24.6%) were recorded, as well as 689 readmissions for all causes in 303 patients (48.8%) and 286 readmissions for HF in 163 patients (26.3%). In the multivariate analysis, the high TnT-us values were associated with an increased risk of readmission, both for all causes and for HF (incidence rate ratio [IRR], 1.16; 95% CI, 1.02–1.36; p=.029 and IRR, 1.23; 95% CI, 1.04–1.46; p=.018, respectively). ConclusionsFor patients with AHF, the increase in TnT-us levels was independently associated with a risk of recurrent readmissions during the follow-up." "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Objectives" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Methods" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Results" ] 3 => array:2 [ "identificador" => "abst0020" "titulo" => "Conclusions" ] ] ] "es" => array:3 [ "titulo" => "Resumen" "resumen" => "ObjetivosLa troponina de alta sensibilidad es un biomarcador de daño miocárdico que se asocia a un mayor riesgo de mortalidad y progresión de la enfermedad en pacientes con insuficiencia cardíaca aguda (ICA). Sin embargo, su relación con el riesgo de futuras rehospitalizaciones es menos conocido. El objetivo de este estudio fue evaluar la asociación entre los valores de troponina T ultrasensible (TnT-us) en pacientes con ICA y el riesgo de hospitalizaciones recurrentes en el seguimiento. MétodosSe incluyó prospectivamente una cohorte de 621 pacientes consecutivos con ICA, excluyéndose pacientes con síndrome coronario agudo. Se determinó la TnT-us obtenida en el primer contacto médico en urgencias. El riesgo de reingresos acumulados se evaluó mediante regresión binomial negativa. ResultadosLa edad media de los sujetos fue de 73.6±10,8 años, el 54,6% eran varones y el 52% tenían una función sistólica ventricular izquierda ≥50%. La mediana de TnT-us fue de 35,5pg/ml (rango intercuartílico [RI]=22–67). Tras una mediana de seguimiento de 1,2 años (RI= 0,4–2,4) se registraron 153 muertes (24,6%), 689 reingresos por todas las causas en 303 pacientes (48,8%), y 286 reingresos por IC en 163 pacientes (26,3%). En el análisis multivariante, los valores elevados de TnT-us se asociaron con un aumento del riesgo de reingreso, tanto por todas las causas como por IC (cociente de las tasas de incidencia [IRR] =1,16; intervalo de confianza del 95%, 1,02-1,36; p=0,029; IRR=1,23; intervalo de confianza del 95%, 1,04-1,46; p= 0,018, respectivamente). ConclusionesEn pacientes con ICA, el aumento de los valores de TnT-us se asoció de manera independiente con el riesgo de hospitalizaciones recurrentes durante el seguimiento." "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0025" "titulo" => "Objetivos" ] 1 => array:2 [ "identificador" => "abst0030" "titulo" => "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: Escribano D, Santas E, Miñana G, Mollar A, García-Blas S, Valero E, et al. Troponina T de alta sensibilidad y riesgo de hospitalizaciones recurrentes tras un ingreso por insuficiencia cardíaca aguda. Rev Clin Esp. 2017;217:63–70." ] ] "multimedia" => array:4 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 953 "Ancho" => 2741 "Tamanyo" => 106049 ] ] "descripcion" => array:1 [ "en" => "Incidence of recurrent hospitalizations according to hs-TnT values. (A) All-cause hospitalizations. (B) Hospitalizations for heart failure. Abbreviations: hs-TnT, high-sensitivity troponin T; TnT-Q, troponin T quartiles." ] ] 1 => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 1009 "Ancho" => 1618 "Tamanyo" => 75886 ] ] "descripcion" => array:1 [ "en" => "Kaplan–Meier mortality curves according to hs-TnT quartiles. Abbreviation: hs-TnT, high-sensitivity troponin T." ] ] 2 => array:7 [ "identificador" => "fig0015" "etiqueta" => "Figure 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 1397 "Ancho" => 1561 "Tamanyo" => 90395 ] ] "descripcion" => array:1 [ "en" => "Risk of recurrent hospitalizations according to the hs-TnT quartiles. (A) All-cause hospitalizations. (B) Hospitalizations for heart failure. Abbreviation: IRR, incident rate ratio." ] ] 3 => array:8 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at1" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:3 [ "leyenda" => "Values for continuous variables are expressed as mean±standard deviation.Abbreviations: ACEI, angiotensin-converting enzyme inhibitors; ARB, angiotensin-receptor blockers; COPD, chronic obstructive pulmonary disease; DBP, diastolic blood pressure; GFR, glomerular filtration rate; HF, heart failure; hs-TnT-us, high-sensitivity troponin T; LA, left atrium; LVEDD, left ventricular end-diastolic diameter; LVEF, left ventricular ejection fraction; NT-proBNP, fraction amino-terminal fragment of the brain natriuretic peptide; SBP, systolic blood pressure; TAPSE, tricuspid annular plane systolic excursion." "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-with-role" title="table-head ; entry_with_role_rowhead " align="left" valign="top" scope="col">Variables \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " colspan="4" align="left" valign="top" scope="col" style="border-bottom: 2px solid black">hs-TnT, pg/mL</th><th class="td" title="table-head " align="left" valign="top" scope="col">p-Value \t\t\t\t\t\t\n \t\t\t\t</th></tr><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">Q1 (≤22) (n=155) \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">Q2 (22–35.4) (n=155) \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">Q3 (35.5–67) (n=156) \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">Q4 (>67) (n=155) \t\t\t\t\t\t\n \t\t\t\t</th><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></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry " colspan="6" align="left" valign="top">Medical history and demographic characteristics</td></tr><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">72±10 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">74±10 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">74±12 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">75±11 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">.006 \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">65 (41.9) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">91 (58.7) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">97 (61.2) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">86 (55.5) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">.014 \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">First hospitalization for HF, n (%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">111 (71.6) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">94 (60.6) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">108 (69.3) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">103 (66.4) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">.684 \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">113 (72.9) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">127 (81.9) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">137 (87.8) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">136 (87.7) \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">Diabetes mellitus, n (%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">62 (40) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">74 (47.7) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">81 (51.9) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">80 (51.6) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">.121 \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">62 (40) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">74 (47.7) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">81 (51.9) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">80 (51.6) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">.030 \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">Active smoking, n (%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">18 (11.6) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">24 (15.5) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">22 (14.1) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">23 (14.8) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">.506 \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">Ischemic heart disease, n (%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">44 (28.4) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">62 (40.0) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">58 (37.2) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">72 (46.4) \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><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">COPD, n (%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">28 (18.1) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">33 (21.3) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">39 (25) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">36 (23) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">.196 \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">Prior stroke, n (%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">13 (8.4) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">18 (11.6) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">14 (9.0) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">17 (10.1) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">.636 \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">Peripheral artery disease, n (%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">13 (8.4) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">17 (11.0) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">19 (12.2) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">19 (12.3) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">.253 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="6" align="left" valign="top"></td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="6" align="left" valign="top">Vital signs</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Heart rate, bpm \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">102.9±30.7 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">97.5±28.7 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">94.4±26 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">97.6±28.2 \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">SBP, mmHg \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">144.6±28.7 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">148.9±36.3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">153.5±33.4 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">149.1±35.8 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">.148 \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">DBP, mmHg \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">83.5±17.3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">82.5±20.5 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">82.9±21 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">81.1±20.5 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">.079 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="6" align="left" valign="top"></td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="6" align="left" valign="top">Electrocardiogram</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">QRS >120ms, n (%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">37 (23.9) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">63 (40.6) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">56 (35.9) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">48 (30.9) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">.327 \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">Atrial fibrillation, n (%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">87 (56.1) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">58 (37.4) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">54 (34.6) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">51 (32.9) \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" title="table-entry " colspan="6" align="left" valign="top"></td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="6" align="left" valign="top">Laboratory</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Hemoglobin, g/dL \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">12.5±1.9 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">12.8±2.0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">12.3±2.3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">12.5±2.1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">.507 \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">Leukocytes, mm3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">9257±3637 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">9648±3810 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">9672±3422 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">11,610±4226 \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">Sodium, mEq/L \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">138.2±3.8 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">137.8±10.6 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">138.5±4.6 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">137.5±4.5 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">.099 \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">NT-proBNP, pg/mL<a class="elsevierStyleCrossRef" href="#tblfn0005">a</a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">2321 (3578) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">3795 (4531) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">4274 (5375) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">5029 (8439) \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">Creatinine at admission, mg/dL \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">0.98±0.33 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">1.12±0.38 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">1.30±0.59 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">1.43±0.72 \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">Urea, mg/dL \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">44.9±16.6 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">52.0±22.8 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">56.9±28.0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">66.9±38.7 \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">GFR, mL/min/1.73m2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">74.8±24.2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">67.6±22.3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">62.7±28.1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">57.3±27.6 \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" title="table-entry " colspan="6" align="left" valign="top"></td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="6" align="left" valign="top">Echocardiogram</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">LVEF, % \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">52.9±14.5 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">43.9±15.3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">48.2±15.8 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">48.0±15.2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">.053 \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">LVEF <35%, n (%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">21 (13.6) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">50 (32.3) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">39 (25) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">38 (24.5) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">.094 \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">LA, mm \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">43.0±8 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">43.3±10 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">43.8±8 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">42.5±7 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">.987 \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">LVEDD, mm \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">53.6±8 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">58.2±10 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">56.3±10 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">55.5±10 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">.352 \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">TAPSE, mm \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">18±3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">17±2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">16±3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">15±3 \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" title="table-entry " colspan="6" align="left" valign="top"></td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="6" align="left" valign="top">Treatment at discharge</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Beta blockers, n (%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">129 (83.2) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">122 (78.7) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">133 (85.3) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">119 (76.8) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">.365 \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">ACEI, n (%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">64 (41.3) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">69 (44.5) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">52 (33.3) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">59 (38.1) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">.234 \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">ARB, n (%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">50 (32.3) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">43 (27.2) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">53 (33.9) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">46 (29.7) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">.929 \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">Aldosterone antagonists, n (%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">41 (26.4) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">71 (45.8) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">56 (35.9) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">65 (41.9) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">.036 \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1352707.png" ] ] ] "notaPie" => array:1 [ 0 => array:3 [ "identificador" => "tblfn0005" "etiqueta" => "a" "nota" => "Value expressed as median (interquartile range)." ] ] ] "descripcion" => array:1 [ "en" => "Baseline characteristics according to the hs-TnT quartiles." ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:34 [ 0 => array:3 [ "identificador" => "bib0175" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Epidemiology of heart failure in Spain over the last 20 years" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "I. 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High-sensitivity troponin T and the risk of recurrent readmissions after hospitalization for acute heart failure

Troponina T de alta sensibilidad y riesgo de hospitalizaciones recurrentes tras un ingreso por insuficiencia cardíaca aguda

D. Escribano, E. Santas, G. Miñana, A. Mollar, S. García-Blas, E. Valero, A. Payá, F.J. Chorro, J. Sanchis, J. Núñez

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yulnunez@gmail.com

Corresponding author.

Servicio de Cardiología, Hospital Clínico Universitario de Valencia, INCLIVA, Universitat de Valencia, Valencia, Spain

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          "en" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Incidence of recurrent hospitalizations according to hs-TnT values&#46; &#40;A&#41; All-cause hospitalizations&#46; &#40;B&#41; Hospitalizations for heart failure&#46; Abbreviations&#58; hs-TnT&#44; high-sensitivity troponin T&#59; TnT-Q&#44; troponin T quartiles&#46;</p>"
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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">Heart failure &#40;HF&#41; is a syndrome characterized by repeated episodes of clinical decompensation that result in a high rate of readmissions&#46;<a class="elsevierStyleCrossRefs" href="#bib0175"><span class="elsevierStyleSup">1&#44;2</span></a> After an episode of acute HF &#40;AHF&#41;&#44; approximately 50&#37; of patients are readmitted within 6 months of being discharged&#46;<a class="elsevierStyleCrossRef" href="#bib0185"><span class="elsevierStyleSup">3</span></a> Readmissions for HF are associated with disease progression&#44; higher mortality and increased healthcare costs&#46;<a class="elsevierStyleCrossRefs" href="#bib0190"><span class="elsevierStyleSup">4&#8211;6</span></a> Our understanding of the factors related to the risk of readmission for these patients is still limited&#46; Traditionally&#44; the predictive models developed for HF have assessed the risk to the onset of the first event&#44; ignoring subsequent readmissions that occur during the natural history of a patient with HF&#46; Various authors have supported the implementation of statistical methodologies that help assess all hospitalizations for patients with HF&#44; thereby achieving a more realistic vision of the burden of readmission-related morbidity&#46;<a class="elsevierStyleCrossRef" href="#bib0205"><span class="elsevierStyleSup">7</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">High-sensitivity troponin is a widely available biomarker of myocardial damage and is mainly used for diagnosing acute myocardial infarction &#40;AMI&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0210"><span class="elsevierStyleSup">8</span></a> High-sensitivity troponin levels are also increased in a significant number of patients with AHF&#44; even in the absence of signs or symptoms of myocardial ischemia&#46;<a class="elsevierStyleCrossRef" href="#bib0215"><span class="elsevierStyleSup">9</span></a> The increase in high-sensitivity troponin T &#40;hs-TnT&#41; levels is associated with an increased risk of first readmission and mortality in the follow-up of these patients&#46;<a class="elsevierStyleCrossRefs" href="#bib0220"><span class="elsevierStyleSup">10&#8211;18</span></a> However&#44; we have no data on its value in predicting recurrent hospitalizations over the entire follow-up&#46; The aim of our study was to assess the association between hs-TnT values at admission of patients with AHF and the subsequent risk of readmissions during the follow-up&#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">Study protocol and group</span><p id="par0015" class="elsevierStylePara elsevierViewall">We prospectively included a consecutive cohort of 645 patients hospitalized with the diagnosis of AHF in the Department of Cardiology of University Clinic Hospital of Valencia between the January 1&#44; 2012 and March 1&#44; 2014&#46; AHF was defined according to the clinical practice guidelines&#46;<a class="elsevierStyleCrossRef" href="#bib0265"><span class="elsevierStyleSup">19</span></a> The study included patients with de novo HF and those with acute decompensation of chronic HF&#46; We excluded patients with AMI&#46;<a class="elsevierStyleCrossRef" href="#bib0210"><span class="elsevierStyleSup">8</span></a> The patients&#8217; clinical care during the hospitalization was individualized&#44; at the discretion of the responsible physician&#44; who could request additional pertinent examinations for the diagnosis of the acute ischemic etiology based on their clinical suspicion&#46; Thus&#44; we excluded from this analysis 24 patients whose final diagnosis at discharge was AMI&#44; leaving a final study sample of 621 patients&#46; Over the course of the index hospitalization&#44; many clinical&#44; demographic and biochemical variables were assessed&#44; as well as echocardiographic parameters&#44; 12-lead electrocardiograms and treatments&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Measurement of hs-TnT</span><p id="par0020" class="elsevierStylePara elsevierViewall">The blood measurement of hs-TnT values was performed during the first medical contact in the emergency department during the index episode&#44; using the available in vitro immunologic test &#40;Elecsys Troponin T hs STAT Cobas<span class="elsevierStyleSup">&#174;</span> of Roche Diagnostic GmbH&#41;&#44; with a double monoclonal antibody sandwich technique &#40;sensitivity&#44; 0&#46;1<span class="elsevierStyleHsp" style=""></span>ng&#47;mL&#41;&#46; The hs-TnT results were available to the clinicians responsible for the patient&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Follow-up and study objectives</span><p id="par0025" class="elsevierStylePara elsevierViewall">The primary study endpoint was the number of readmissions during the follow-up&#46; We assessed the risk of readmission both for all causes and specifically for AHF&#46; All episodes of unscheduled hospital readmissions after the discharge from the index episode were recorded&#46; The researchers responsible for judging the events were unaware of the hs-TnT values&#46; The patients&#8217; follow-up was conducted to the last date in which the patient&#39;s vital status was certified&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">The study was conducted according to the principles of the Declaration of Helsinki and was approved by our center&#39;s ethics committee&#46;</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Statistical analysis</span><p id="par0035" class="elsevierStylePara elsevierViewall">The continuous variables are expressed as means<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>standard deviation or medians &#40;interquartile range &#91;IQR&#93;&#41;&#46; The rates of the categorical variables are expressed as percentages&#46; The patients&#8217; baseline characteristics are represented according to the quartiles of the hs-TnT values&#46; We determined the cumulative incidence rates of hospital readmissions according to the hs-TnT quartiles &#40;TnT-Q&#41;&#46; The independent association between the logarithmic transformation of the hs-TnT values &#40;log-hs-TnT&#41; or the TnT-Q with the readmissions was assessed using multivariate binomial regression &#40;Nbreg&#41;&#44; and its risk estimates are expressed as incident rate ratios &#40;IRR&#41;&#46; Death was included as an additional hospitalization in the Nbreg model but only if it occurred outside a hospitalization&#44; as has recently been suggested in the literature&#46;<a class="elsevierStyleCrossRefs" href="#bib0270"><span class="elsevierStyleSup">20&#44;21</span></a></p><p id="par0040" class="elsevierStylePara elsevierViewall">The final multivariate model included the following covariates&#58; age&#44; previous hospitalizations for HF&#44; ischemic etiology&#44; history of chronic obstructive pulmonary disease&#44; left ventricular ejection fraction &#40;LVEF&#41; &#60;35&#37;&#44; systolic blood pressure at admission&#44; hemoglobin&#44; urea&#44; natriuretic peptide NT-proBNP and treatment with beta blockers&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">We considered a value of <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>&#46;05 statistically significant for all analyses&#46; We employed the statistical software STATA 14 for the calculations &#40;StataCorp&#44; College Station&#44; TX&#44; USA&#41;&#46;</p></span></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Results</span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">Baseline patient characteristics</span><p id="par0050" class="elsevierStylePara elsevierViewall">The sample&#39;s mean age was 73&#46;6<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>10&#46;8 years&#44; 54&#46;6&#37; were men&#44; and 52&#37; had an LVEF &#8805;50&#37;&#46; The median hs-TnT level was 35&#46;5<span class="elsevierStyleHsp" style=""></span>pg&#47;mL &#40;IQR&#44; 22&#8211;67&#41;&#44; and 90&#37; of the patients had values that were considered high &#40;&#8805;14<span class="elsevierStyleHsp" style=""></span>pg&#47;mL&#41;&#46; The median NT-proBNP level was 3795<span class="elsevierStyleHsp" style=""></span>pg&#47;mL &#40;IQR&#44; 2111&#8211;7464&#41;&#46; In terms of renal function&#44; the mean serum creatinine level and estimated glomerular filtration rate were 1&#46;21<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>0&#46;56<span class="elsevierStyleHsp" style=""></span>mg&#47;dL and 65&#46;6<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>26&#46;4<span class="elsevierStyleHsp" style=""></span>mL&#47;min&#47;1&#46;73<span class="elsevierStyleHsp" style=""></span>m<span class="elsevierStyleSup">2</span>&#44; respectively&#44; such that 270 patients &#40;43&#46;4&#37;&#41; presented a glomerular filtration rate &#60;60<span class="elsevierStyleHsp" style=""></span>mL&#47;min&#47;1&#46;73<span class="elsevierStyleHsp" style=""></span>m<span class="elsevierStyleSup">2</span>&#46; The sample&#39;s baseline characteristics&#44; represented according to the hs-TnT quartiles at admission&#44; are listed in <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#46; The patients with high hs-TnT values were older and had a higher prevalence of arterial hypertension&#44; chronic ischemic heart disease&#44; left ventricular systolic dysfunction and renal failure&#44; as well as higher NT-proBNP values&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0105">Mortality rate and recurrent hospitalizations</span><p id="par0055" class="elsevierStylePara elsevierViewall">After a median follow-up of 1&#46;2 years &#40;IQR&#44; 0&#46;4&#8211;2&#46;4&#41;&#44; a total of 153 deaths &#40;24&#46;6&#37;&#41; were recorded&#44; as well as 698 readmissions for all causes in 303 patients &#40;48&#46;8&#37;&#41; and 286 readmissions for HF in 163 patients &#40;26&#46;3&#37;&#41;&#46; Of the deaths&#44; 109 had a cardiovascular cause and 56 were due to HF&#46; The distribution of the number of hospitalizations for all causes was as follows&#58; 1 hospitalization&#44; 134 &#40;21&#46;6&#37;&#41;&#59; 2&#44; 76 &#40;12&#46;2&#37;&#41;&#59; 3&#44; 31 &#40;5&#41;&#59; 4&#44; 29 &#40;4&#46;7&#37;&#41;&#59; and &#8805;5&#44; 33 &#40;5&#46;3&#37;&#41;&#46; For the number of readmissions for HF&#44; the distribution was as follows&#58; 1&#44; 101 &#40;16&#46;3&#37;&#41;&#59; 2&#44; 28 &#40;4&#46;5&#37;&#41;&#59; 3&#44; 19 &#40;3&#46;1&#37;&#41;&#59; 4&#44; 9 &#40;1&#46;5&#37;&#41;&#59; and &#8805;5&#44; 6 &#40;1&#37;&#41;&#46;</p></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0110">hs-TnT and recurrent hospitalizations</span><p id="par0060" class="elsevierStylePara elsevierViewall">The cumulative incidence rate for all-cause admissions &#40;per 10 person-years of follow-up&#41; increased stepwise and significantly from the lower to the higher hs-TnT quartile &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>A&#41;&#46; This finding &#40;and even with a difference of greater magnitude&#41; was observed for the AHF readmissions &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>B&#41;&#44; as well as for total mortality &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>&#41;&#46; High hs-TnT values were also associated with the risk of cardiovascular death &#40;log-rank test&#59; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>&#46;001&#41; and with HF &#40;log-rank test&#59; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>001&#41;&#46; In the multivariate analysis&#44; these differences remained significant&#44; such that log-hs-TnT was directly and independently associated with an increased risk of readmissions&#44; both for all causes and for HF &#40;IRR&#44; 1&#46;16&#59; 95&#37; CI 1&#46;01&#8211;1&#46;36&#59; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>&#46;029 and IRR&#44; 1&#46;23&#59; 95&#37; CI 1&#46;04&#8211;1&#46;46&#59; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>018&#59; respectively&#41;&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0065" class="elsevierStylePara elsevierViewall">By assessing the risk of readmission for all causes attributable to TnT-Q&#44; with regard to those patients belonging to the lower quartile &#40;&#8804;22<span class="elsevierStyleHsp" style=""></span>pg&#47;mL&#41;&#44; we observed a progressive increase in the risk from TnT-Q2 to TnT-Q4&#44; although of moderate magnitude &#40;<a class="elsevierStyleCrossRef" href="#fig0015">Fig&#46; 3</a>A&#41;&#46; When we analyzed the association between TnT-Q and the risk of readmission specifically for HF&#44; we observed an increased intensity of this association&#44; with a striking increase in the risk for those patients belonging to TnT-Q3 and TnT-Q4 &#40;<a class="elsevierStyleCrossRef" href="#fig0015">Fig&#46; 3</a>B&#41;&#46;</p><elsevierMultimedia ident="fig0015"></elsevierMultimedia><p id="par0070" class="elsevierStylePara elsevierViewall">In terms of readmissions for all causes&#44; there were no differences in the prognostic value of hs-TnT between patients with HF and depressed systolic function &#40;LVEF &#60;50&#37;&#41; and those with preserved function &#40;LVEF &#8805;50&#37;&#41; &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>110 for the interaction&#41;&#46; However&#44; when assessing the risk of readmissions for HF&#44; we did observe a significant interaction between LVEF and hs-TnT &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>029 for the interaction&#41;&#46; The association between hs-TnT values and readmissions for HF was more significant for the patient subgroup with depressed systolic function &#40;IRR&#44; 1&#46;61&#44; 95&#37; CI&#44; 1&#46;21&#8211;2&#46;17&#59; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>001&#41; than for those with preserved systolic function &#40;IRR&#44; 1&#46;09&#59; 95&#37; CI 0&#46;89&#8211;1&#46;33&#59; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>400&#41;&#46;</p></span></span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0115">Discussion</span><p id="par0075" class="elsevierStylePara elsevierViewall">The present study confirms that patients with AHF have high hs-TnT values&#44; which are associated with an increased risk of mortality&#44; and broadens our understanding of the value of this biomarker as a predictor of morbidity&#46; In particular&#44; the study shows that hs-TnT values&#44; determined during the admission of unselected patients with AHF&#44; are directly and independently associated with the risk of recurrent hospitalizations during follow-up&#46;</p><p id="par0080" class="elsevierStylePara elsevierViewall">It is well known that&#44; after hospitalization for HF&#44; the rate of subsequent readmissions continuous to be high&#46;<a class="elsevierStyleCrossRefs" href="#bib0175"><span class="elsevierStyleSup">1&#8211;3</span></a> The natural history of a patient with HF is characterized by numerous episodes of decompensation&#44; which frequently cause recurrent hospitalizations&#44; which in turn result in a significant loss of quality of life&#44; increased consumption of healthcare resources and lower survival&#46;<a class="elsevierStyleCrossRefs" href="#bib0190"><span class="elsevierStyleSup">4&#8211;6</span></a> The prognostic effect of a certain clinical profile or therapeutic strategy has classically been evaluated as the time until the first event&#44; largely ignoring the adverse events that subsequently occur in the outcomes of patients with HF&#46; To more accurately profile the burden of HF-associated morbidity&#44; we consider &#40;as have other authors&#41; that the assessment of the natural history of a patient with HF should include all adverse episodes of rehospitalization during the follow-up&#46;<a class="elsevierStyleCrossRefs" href="#bib0205"><span class="elsevierStyleSup">7&#44;22</span></a> Although the experience in implementing this methodology is still scarce&#44; it has been employed in the post hoc analysis of various clinical trials on HF &#40;e&#46;g&#46;&#44; the Candesartan in Heart Failure-Assessment of Reduction in Mortality and Morbidity trial<a class="elsevierStyleCrossRef" href="#bib0270"><span class="elsevierStyleSup">20</span></a>&#59; the Controlled Rosuvastatin Multinational Trial in Heart Failure<a class="elsevierStyleCrossRef" href="#bib0275"><span class="elsevierStyleSup">21</span></a>&#59; the Systolic Heart failure treatment with the If inhibitor Ivabradine Trial<a class="elsevierStyleCrossRef" href="#bib0285"><span class="elsevierStyleSup">23</span></a>&#59; and Eplerenone in Mild Patients Hospitalization and Survival Study in Heart Failure trial<a class="elsevierStyleCrossRef" href="#bib0290"><span class="elsevierStyleSup">24</span></a>&#41; and is defined as a primary assessment criterion in studies that are currently underway such as the Efficacy and Safety of LCZ696 Compared to Valsartan&#44; on Morbidity and Mortality in Heart Failure Patients With Preserved Ejection Fraction trial&#46;<a class="elsevierStyleCrossRef" href="#bib0295"><span class="elsevierStyleSup">25</span></a></p><p id="par0085" class="elsevierStylePara elsevierViewall">Troponin is a biomarker of myocardial damage that has been classically employed for the diagnosis of AMI and the prognostic stratification of patients with acute ischemic heart disease&#46;<a class="elsevierStyleCrossRef" href="#bib0210"><span class="elsevierStyleSup">8</span></a> However&#44; high troponin levels are commonly observed in patients with AHF and in patients with chronic HF&#46;<a class="elsevierStyleCrossRef" href="#bib0215"><span class="elsevierStyleSup">9</span></a> This situation is even most frequent when high-sensitivity reagents are employed&#44; such as hs-TnT&#46; For example&#44; in the Efficacy and Safety of Relaxin for the Treatment of Acute Heart Failure &#40;RELAX-AHF&#41; study&#44; 90&#37; of the included patients showed hs-TnT values above the reference 99 percentile&#44;<a class="elsevierStyleCrossRef" href="#bib0230"><span class="elsevierStyleSup">12</span></a> a result that was comparable to our study&#46;</p><p id="par0090" class="elsevierStylePara elsevierViewall">The mechanisms responsible for the increase in troponin levels in patients with HF are controversial and include subendocardial ischemia and the consequent cell necrosis&#44; cytokine-mediated cardiomyocyte damage and oxidative stress&#46;<a class="elsevierStyleCrossRefs" href="#bib0215"><span class="elsevierStyleSup">9&#44;26&#8211;28</span></a> An interesting pathophysiological hypothesis holds that the increase in troponin levels in HF reflects the phenomena of cardiac contractile protein proteolysis&#44; which could be triggered by parietal stress&#44; oxidative stress&#44; neurohormonal activation or microvascular ischemia&#44; all of which are phenomena that are typically present in HF&#46;<a class="elsevierStyleCrossRef" href="#bib0315"><span class="elsevierStyleSup">29</span></a> The phenomena of apoptosis have been reported in patients with HF&#44; but it has not been clearly established that the phenomena provoke the release of troponin&#46;<a class="elsevierStyleCrossRef" href="#bib0320"><span class="elsevierStyleSup">30</span></a> In short&#44; the pathophysiological mechanisms involved in the increase in hs-TnT levels in AHF are still largely unknown&#46; Additional experimental studies would likely be necessary to better understand the underlying mechanisms responsible for the presence of high troponin levels in HF&#46;</p><p id="par0095" class="elsevierStylePara elsevierViewall">Although there is considerable heterogeneity among the various studies that have evaluated the prognostic role of troponin in HF &#40;for the various reagents evaluated&#44; the timing of their measurement and the clinical profile of the analyzed population&#41;&#44; there is broad consensus that high troponin levels are associated with an increased risk of mortality for patients with AHF&#46;<a class="elsevierStyleCrossRefs" href="#bib0220"><span class="elsevierStyleSup">10&#8211;18</span></a> For example&#44; a recent analysis of the RELAX-AHF study showed that both the baseline values and the changes in hs-TnT during the index hospitalization for AHF were associated with an increased risk of cardiovascular mortality at 180 days&#46;<a class="elsevierStyleCrossRef" href="#bib0230"><span class="elsevierStyleSup">12</span></a> Our results support and broaden the available evidence&#44; showing that hs-TnT levels are independently associated not only with mortality during follow-up but also with the burden of morbidity and readmissions&#46; Although several studies have already shown an association between the risk of a first readmission &#40;assessed as the time to the first event&#41; and troponin levels&#44;<a class="elsevierStyleCrossRefs" href="#bib0220"><span class="elsevierStyleSup">10&#44;13&#44;14&#44;17&#44;18</span></a> our study is the first to support the close association between plasma hs-TnT concentrations and the risk of repeated hospitalizations after an episode of AHF&#46; This association was significant both for all-cause readmissions and for HF decompensation and was mainly observed in the patient subgroup with depressed systolic function&#46;</p><p id="par0100" class="elsevierStylePara elsevierViewall">Although not an objective assessed in this study&#44; troponin can have an additional prognostic value to other HF biomarkers&#46; In this series&#44; the prognostic value of hs-TnT was independent of NT-proBNP levels&#46; Vorovich et al&#46; assessed the usefulness of a panel of 9 biomarkers as predictors of readmission for cardiac causes in more than 1500 patients with stable HF&#44; obtaining the most significant association for BNP and TnI&#46;<a class="elsevierStyleCrossRef" href="#bib0325"><span class="elsevierStyleSup">31</span></a> Tentzeris et al&#46; obtained similar data in terms of the combined use of copeptin and TnT for predicting mortality and readmission for patients with chronic HF&#46;<a class="elsevierStyleCrossRef" href="#bib0330"><span class="elsevierStyleSup">32</span></a> In 107 patients with AHF&#44; Pascual-Figal et al&#46; showed that hs-TnT&#44; NT-proBNP and ST-2 provide independent prognostic information for mortality and that the joint use of the 3 biomarkers helps optimize risk stratification in HF&#46;<a class="elsevierStyleCrossRef" href="#bib0250"><span class="elsevierStyleSup">16</span></a></p><p id="par0105" class="elsevierStylePara elsevierViewall">In this series&#44; we found a high prevalence of patients with renal failure &#40;43&#46;4&#37;&#41;&#46; There is controversy about the accuracy and interpretation of hs-TnT levels for diagnosing AMI in patients with kidney disease&#44; a situation in which the biomarker&#39;s cutoff points could be higher than for the general population&#46;<a class="elsevierStyleCrossRef" href="#bib0335"><span class="elsevierStyleSup">33</span></a> For patients with renal failure&#44; however&#44; the prognostic value of troponin does not appear to be affected by the use of high-sensitivity reagents&#46; In previous studies&#44; hs-TnT maintained its prognostic value&#44; and high values of the biomarker were predictors of HF progression and mortality in broad series of patients with chronic kidney disease&#46;<a class="elsevierStyleCrossRef" href="#bib0340"><span class="elsevierStyleSup">34</span></a></p></span><span id="sec0060" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0120">Study limitations</span><p id="par0110" class="elsevierStylePara elsevierViewall">The main study limitations are related to its single-center nature&#46; In addition&#44; although patients with a final diagnosis of AMI were excluded from the analysis &#40;as per the clinical practice guidelines<a class="elsevierStyleCrossRefs" href="#bib0210"><span class="elsevierStyleSup">8&#44;19</span></a>&#41;&#44; a systematic search was not conducted of the acute ischemic etiology in all patients with high hs-TnT levels&#46; Rather&#44; the search depended on the clinical suspicion of acute coronary syndrome by the physician responsible for the patient during the index hospitalization&#46; This clinical variability in patient care inherent in a study performed in the context of daily clinical practice precludes our safely ruling out the presence of patients with acute coronary syndrome&#46; A serial reading of hs-TnT levels in all included patients was not conducted&#44; which prevents us from knowing the most optimal moment for their measurement or whether the serial measurements of the biomarker could have an additional predictive value&#46;</p></span><span id="sec0065" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0125">Future perspectives</span><p id="par0115" class="elsevierStylePara elsevierViewall">The data suggest that measuring hs-TnT levels should be incorporated into the available tools for the risk stratification of patients with AHF&#46; In addition to the already known value of hs-TnT levels as a predictor of mortality&#44; this study confirmed its usefulness in predicting recurrent hospitalizations during these patients&#8217; follow-up&#46; Future studies should clarify whether measures such as treatment intensification&#44; the search for new therapeutic strategies and a closer follow-up of patients with increased hs-TnT levels will have an effect on improving the prognosis&#46;</p></span><span id="sec0070" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0130">Funding</span><p id="par0120" class="elsevierStylePara elsevierViewall">This study was funded in part by grants from the Carlos III Health Institute and from <span class="elsevierStyleGrantSponsor" id="gs1">FEDER</span>&#44; Cardiovascular Research network&#44; Program 7 &#40;RD12&#47;0042&#47;0010&#41; and PIE15&#47;00013&#46;</p></span><span id="sec0075" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0135">Conflicts of interest</span><p id="par0125" class="elsevierStylePara elsevierViewall">The authors declare that they have no conflicts of interest&#46;</p></span></span>"
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          "titulo" => "Background"
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              "identificador" => "sec0015"
              "titulo" => "Study protocol and group"
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              "identificador" => "sec0020"
              "titulo" => "Measurement of hs-TnT"
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              "titulo" => "Follow-up and study objectives"
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              "titulo" => "Baseline patient characteristics"
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              "titulo" => "Mortality rate and recurrent hospitalizations"
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              "titulo" => "hs-TnT and recurrent hospitalizations"
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            0 => "Ultrasensitive troponin"
            1 => "Heart failure"
            2 => "Recurrent readmissions"
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            0 => "Troponina ultrasensible"
            1 => "Insuficiencia card&#237;aca"
            2 => "Hospitalizaciones recurrentes"
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        "titulo" => "Abstract"
        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Objectives</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">High-sensitivity troponin is a biomarker of myocardial damage and is associated with a greater risk of mortality and disease progression in patients with acute heart failure &#40;AHF&#41;&#46; However&#44; its relationship with the risk of future readmissions is less known&#46; The aim of this study was to assess the association between ultrasensitive troponin T &#40;TnT-us&#41; values in patients with AHF and the risk of recurrent readmissions in the follow-up&#46;</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Methods</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">We prospectively included a cohort of 621 consecutive patients with AHF&#44; excluding those patients with acute coronary syndrome&#46; We measured the TnT-us levels obtained during the first medical contact in the emergency department&#46; The risk of cumulative readmissions was assessed using negative binomial regression&#46;</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Results</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">The mean age of the participants was 73&#46;6<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>10&#46;8 years&#44; 54&#46;6&#37; were men&#44; and 52&#37; had a left ventricular systolic function &#8805;50&#37;&#46; The median TnT-us level was 35&#46;5<span class="elsevierStyleHsp" style=""></span>pg&#47;mL &#40;interquartile range &#91;IQR&#93;&#44; 22&#8211;67&#41;&#46; After a median follow-up of 1&#46;2 years &#40;IQR&#44; 0&#46;4&#8211;2&#46;4&#41;&#44; a total of 153 deaths &#40;24&#46;6&#37;&#41; were recorded&#44; as well as 689 readmissions for all causes in 303 patients &#40;48&#46;8&#37;&#41; and 286 readmissions for HF in 163 patients &#40;26&#46;3&#37;&#41;&#46; In the multivariate analysis&#44; the high TnT-us values were associated with an increased risk of readmission&#44; both for all causes and for HF &#40;incidence rate ratio &#91;IRR&#93;&#44; 1&#46;16&#59; 95&#37; CI&#44; 1&#46;02&#8211;1&#46;36&#59; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>&#46;029 and IRR&#44; 1&#46;23&#59; 95&#37; CI&#44; 1&#46;04&#8211;1&#46;46&#59; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>&#46;018&#44; respectively&#41;&#46;</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Conclusions</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">For patients with AHF&#44; the increase in TnT-us levels was independently associated with a risk of recurrent readmissions during the follow-up&#46;</p></span>"
        "secciones" => array:4 [
          0 => array:2 [
            "identificador" => "abst0005"
            "titulo" => "Objectives"
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          1 => array:2 [
            "identificador" => "abst0010"
            "titulo" => "Methods"
          ]
          2 => array:2 [
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        "resumen" => "<span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Objetivos</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">La troponina de alta sensibilidad es un biomarcador de da&#241;o mioc&#225;rdico que se asocia a un mayor riesgo de mortalidad y progresi&#243;n de la enfermedad en pacientes con insuficiencia card&#237;aca aguda &#40;ICA&#41;&#46; Sin embargo&#44; su relaci&#243;n con el riesgo de futuras rehospitalizaciones es menos conocido&#46; El objetivo de este estudio fue evaluar la asociaci&#243;n entre los valores de troponina T ultrasensible &#40;TnT-us&#41; en pacientes con ICA y el riesgo de hospitalizaciones recurrentes en el seguimiento&#46;</p></span> <span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">M&#233;todos</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Se incluy&#243; prospectivamente una cohorte de 621 pacientes consecutivos con ICA&#44; excluy&#233;ndose pacientes con s&#237;ndrome coronario agudo&#46; Se determin&#243; la TnT-us obtenida en el primer contacto m&#233;dico en urgencias&#46; El riesgo de reingresos acumulados se evalu&#243; mediante regresi&#243;n binomial negativa&#46;</p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Resultados</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">La edad media de los sujetos fue de 73&#46;6<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>10&#44;8 a&#241;os&#44; el 54&#44;6&#37; eran varones y el 52&#37; ten&#237;an una funci&#243;n sist&#243;lica ventricular izquierda &#8805;50&#37;&#46; La mediana de TnT-us fue de 35&#44;5<span class="elsevierStyleHsp" style=""></span>pg&#47;ml &#40;rango intercuart&#237;lico &#91;RI&#93;<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>22&#8211;67&#41;&#46; Tras una mediana de seguimiento de 1&#44;2 a&#241;os &#40;RI&#61; 0&#44;4&#8211;2&#44;4&#41; se registraron 153 muertes &#40;24&#44;6&#37;&#41;&#44; 689 reingresos por todas las causas en 303 pacientes &#40;48&#44;8&#37;&#41;&#44; y 286 reingresos por IC en 163 pacientes &#40;26&#44;3&#37;&#41;&#46; En el an&#225;lisis multivariante&#44; los valores elevados de TnT-us se asociaron con un aumento del riesgo de reingreso&#44; tanto por todas las causas como por IC &#40;cociente de las tasas de incidencia &#91;IRR&#93; &#61;1&#44;16&#59; intervalo de confianza del 95&#37;&#44; 1&#44;02-1&#44;36&#59; p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;029&#59; IRR<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>1&#44;23&#59; intervalo de confianza del 95&#37;&#44; 1&#44;04-1&#44;46&#59; p&#61; 0&#44;018&#44; respectivamente&#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 con ICA&#44; el aumento de los valores de TnT-us se asoci&#243; de manera independiente con el riesgo de hospitalizaciones recurrentes durante el seguimiento&#46;</p></span>"
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        "etiqueta" => "&#9734;"
        "nota" => "<p class="elsevierStyleNotepara" id="npar0010">Please cite this article as&#58; Escribano D&#44; Santas E&#44; Mi&#241;ana G&#44; Mollar A&#44; Garc&#237;a-Blas S&#44; Valero E&#44; et al&#46; Troponina T de alta sensibilidad y riesgo de hospitalizaciones recurrentes tras un ingreso por insuficiencia card&#237;aca aguda&#46; Rev Clin Esp&#46; 2017&#59;217&#58;63&#8211;70&#46;</p>"
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          "en" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Incidence of recurrent hospitalizations according to hs-TnT values&#46; &#40;A&#41; All-cause hospitalizations&#46; &#40;B&#41; Hospitalizations for heart failure&#46; Abbreviations&#58; hs-TnT&#44; high-sensitivity troponin T&#59; TnT-Q&#44; troponin T quartiles&#46;</p>"
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        "etiqueta" => "Figure 2"
        "tipo" => "MULTIMEDIAFIGURA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
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          0 => array:4 [
            "imagen" => "gr2.jpeg"
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          "en" => "<p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">Kaplan&#8211;Meier mortality curves according to hs-TnT quartiles&#46; Abbreviation&#58; hs-TnT&#44; high-sensitivity troponin T&#46;</p>"
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      2 => array:7 [
        "identificador" => "fig0015"
        "etiqueta" => "Figure 3"
        "tipo" => "MULTIMEDIAFIGURA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "figura" => array:1 [
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          "en" => "<p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">Risk of recurrent hospitalizations according to the hs-TnT quartiles&#46; &#40;A&#41; All-cause hospitalizations&#46; &#40;B&#41; Hospitalizations for heart failure&#46; Abbreviation&#58; IRR&#44; incident rate ratio&#46;</p>"
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        "etiqueta" => "Table 1"
        "tipo" => "MULTIMEDIATABLA"
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        "detalles" => array:1 [
          0 => array:3 [
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          "leyenda" => "<p id="spar0065" class="elsevierStyleSimplePara elsevierViewall">Values for continuous variables are expressed as mean<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>standard deviation&#46;</p><p id="spar0070" class="elsevierStyleSimplePara elsevierViewall">Abbreviations&#58; ACEI&#44; angiotensin-converting enzyme inhibitors&#59; ARB&#44; angiotensin-receptor blockers&#59; COPD&#44; chronic obstructive pulmonary disease&#59; DBP&#44; diastolic blood pressure&#59; GFR&#44; glomerular filtration rate&#59; HF&#44; heart failure&#59; hs-TnT-us&#44; high-sensitivity troponin T&#59; LA&#44; left atrium&#59; LVEDD&#44; left ventricular end-diastolic diameter&#59; LVEF&#44; left ventricular ejection fraction&#59; NT-proBNP&#44; fraction amino-terminal fragment of the brain natriuretic peptide&#59; SBP&#44; systolic blood pressure&#59; TAPSE&#44; tricuspid annular plane systolic excursion&#46;</p>"
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                  <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-with-role" title="table-head ; entry_with_role_rowhead " align="left" valign="top" scope="col">Variables&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " colspan="4" align="left" valign="top" scope="col" style="border-bottom: 2px solid black">hs-TnT&#44; pg&#47;mL</th><th class="td" title="table-head  " align="left" valign="top" scope="col"><span class="elsevierStyleItalic">p</span>-Value&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr><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">Q1<br>&#40;&#8804;22&#41;<br>&#40;<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>155&#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">Q2<br>&#40;22&#8211;35&#46;4&#41;<br>&#40;<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>155&#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">Q3<br>&#40;35&#46;5&#8211;67&#41;<br>&#40;<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>156&#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">Q4<br>&#40;&#62;67&#41;<br>&#40;<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>155&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><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></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry  " colspan="6" align="left" valign="top"><span class="elsevierStyleItalic">Medical history and demographic characteristics</span></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>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">72<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="left" valign="top">74<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="left" valign="top">74<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">75<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;006&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"><span class="elsevierStyleHsp" style=""></span>Male sex&#44; <span class="elsevierStyleItalic">n</span> &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">65 &#40;41&#46;9&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">91 &#40;58&#46;7&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">97 &#40;61&#46;2&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">86 &#40;55&#46;5&#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;014&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"><span class="elsevierStyleHsp" style=""></span>First hospitalization for HF&#44; <span class="elsevierStyleItalic">n</span> &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">111 &#40;71&#46;6&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">94 &#40;60&#46;6&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">108 &#40;69&#46;3&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">103 &#40;66&#46;4&#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;684&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"><span class="elsevierStyleHsp" style=""></span>Hypertension&#44; <span class="elsevierStyleItalic">n</span> &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">113 &#40;72&#46;9&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">127 &#40;81&#46;9&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">137 &#40;87&#46;8&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">136 &#40;87&#46;7&#41;&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"><span class="elsevierStyleHsp" style=""></span>Diabetes mellitus&#44; <span class="elsevierStyleItalic">n</span> &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">62 &#40;40&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">74 &#40;47&#46;7&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">81 &#40;51&#46;9&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">80 &#40;51&#46;6&#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;121&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"><span class="elsevierStyleHsp" style=""></span>Dyslipidemia&#44; <span class="elsevierStyleItalic">n</span> &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">62 &#40;40&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">74 &#40;47&#46;7&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">81 &#40;51&#46;9&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">80 &#40;51&#46;6&#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;030&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"><span class="elsevierStyleHsp" style=""></span>Active smoking&#44; <span class="elsevierStyleItalic">n</span> &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">18 &#40;11&#46;6&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">24 &#40;15&#46;5&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">22 &#40;14&#46;1&#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;14&#46;8&#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;506&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"><span class="elsevierStyleHsp" style=""></span>Ischemic heart disease&#44; <span class="elsevierStyleItalic">n</span> &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">44 &#40;28&#46;4&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">62 &#40;40&#46;0&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">58 &#40;37&#46;2&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">72 &#40;46&#46;4&#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;003&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"><span class="elsevierStyleHsp" style=""></span>COPD&#44; <span class="elsevierStyleItalic">n</span> &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">28 &#40;18&#46;1&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">33 &#40;21&#46;3&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">39 &#40;25&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">36 &#40;23&#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;196&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"><span class="elsevierStyleHsp" style=""></span>Prior stroke&#44; <span class="elsevierStyleItalic">n</span> &#40;&#37;&#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;8&#46;4&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">18 &#40;11&#46;6&#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;9&#46;0&#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;10&#46;1&#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;636&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"><span class="elsevierStyleHsp" style=""></span>Peripheral artery disease&#44; <span class="elsevierStyleItalic">n</span> &#40;&#37;&#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;8&#46;4&#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;11&#46;0&#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;12&#46;2&#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;12&#46;3&#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;253&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="6" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="6" align="left" valign="top"><span class="elsevierStyleItalic">Vital signs</span></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Heart rate&#44; bpm&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">102&#46;9<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>30&#46;7&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">97&#46;5<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>28&#46;7&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">94&#46;4<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>26&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">97&#46;6<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>28&#46;2&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"><span class="elsevierStyleHsp" style=""></span>SBP&#44; mmHg&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">144&#46;6<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>28&#46;7&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">148&#46;9<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>36&#46;3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">153&#46;5<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>33&#46;4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">149&#46;1<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>35&#46;8&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#46;148&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"><span class="elsevierStyleHsp" style=""></span>DBP&#44; mmHg&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">83&#46;5<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>17&#46;3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">82&#46;5<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>20&#46;5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">82&#46;9<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>21&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">81&#46;1<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>20&#46;5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#46;079&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="6" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="6" align="left" valign="top"><span class="elsevierStyleItalic">Electrocardiogram</span></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>QRS &#62;120<span class="elsevierStyleHsp" style=""></span>ms&#44; <span class="elsevierStyleItalic">n</span> &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">37 &#40;23&#46;9&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">63 &#40;40&#46;6&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">56 &#40;35&#46;9&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">48 &#40;30&#46;9&#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;327&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"><span class="elsevierStyleHsp" style=""></span>Atrial fibrillation&#44; <span class="elsevierStyleItalic">n</span> &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">87 &#40;56&#46;1&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">58 &#40;37&#46;4&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">54 &#40;34&#46;6&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">51 &#40;32&#46;9&#41;&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" title="table-entry  " colspan="6" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="6" align="left" valign="top"><span class="elsevierStyleItalic">Laboratory</span></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Hemoglobin&#44; g&#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">12&#46;5<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>1&#46;9&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">12&#46;8<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>2&#46;0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">12&#46;3<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>2&#46;3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">12&#46;5<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>2&#46;1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#46;507&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"><span class="elsevierStyleHsp" style=""></span>Leukocytes&#44; mm<span class="elsevierStyleSup">3</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">9257<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>3637&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">9648<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>3810&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">9672<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>3422&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">11&#44;610<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>4226&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"><span class="elsevierStyleHsp" style=""></span>Sodium&#44; mEq&#47;L&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">138&#46;2<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>3&#46;8&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">137&#46;8<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>10&#46;6&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">138&#46;5<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>4&#46;6&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">137&#46;5<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>4&#46;5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#46;099&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"><span class="elsevierStyleHsp" style=""></span>NT-proBNP&#44; pg&#47;mL<a class="elsevierStyleCrossRef" href="#tblfn0005"><span class="elsevierStyleSup">a</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">2321 &#40;3578&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">3795 &#40;4531&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">4274 &#40;5375&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">5029 &#40;8439&#41;&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"><span class="elsevierStyleHsp" style=""></span>Creatinine at admission&#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;98<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>0&#46;33&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">1&#46;12<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>0&#46;38&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">1&#46;30<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>0&#46;59&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">1&#46;43<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>0&#46;72&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"><span class="elsevierStyleHsp" style=""></span>Urea&#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">44&#46;9<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>16&#46;6&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">52&#46;0<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>22&#46;8&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">56&#46;9<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>28&#46;0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">66&#46;9<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>38&#46;7&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"><span class="elsevierStyleHsp" style=""></span>GFR&#44; mL&#47;min&#47;1&#46;73<span class="elsevierStyleHsp" style=""></span>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">74&#46;8<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>24&#46;2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">67&#46;6<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>22&#46;3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">62&#46;7<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>28&#46;1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">57&#46;3<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>27&#46;6&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" title="table-entry  " colspan="6" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="6" align="left" valign="top"><span class="elsevierStyleItalic">Echocardiogram</span></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>LVEF&#44; &#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">52&#46;9<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>14&#46;5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">43&#46;9<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>15&#46;3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">48&#46;2<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>15&#46;8&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">48&#46;0<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>15&#46;2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#46;053&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"><span class="elsevierStyleHsp" style=""></span>LVEF &#60;35&#37;&#44; <span class="elsevierStyleItalic">n</span> &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">21 &#40;13&#46;6&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">50 &#40;32&#46;3&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">39 &#40;25&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">38 &#40;24&#46;5&#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;094&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"><span class="elsevierStyleHsp" style=""></span>LA&#44; mm&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">43&#46;0<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>8&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">43&#46;3<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="left" valign="top">43&#46;8<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>8&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">42&#46;5<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="char" valign="top">&#46;987&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"><span class="elsevierStyleHsp" style=""></span>LVEDD&#44; mm&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">53&#46;6<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>8&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">58&#46;2<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="left" valign="top">56&#46;3<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="left" valign="top">55&#46;5<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;352&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"><span class="elsevierStyleHsp" style=""></span>TAPSE&#44; mm&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">18<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">17<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">16<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">15<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>3&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" title="table-entry  " colspan="6" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="6" align="left" valign="top"><span class="elsevierStyleItalic">Treatment at discharge</span></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Beta blockers&#44; <span class="elsevierStyleItalic">n</span> &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">129 &#40;83&#46;2&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">122 &#40;78&#46;7&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">133 &#40;85&#46;3&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">119 &#40;76&#46;8&#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;365&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"><span class="elsevierStyleHsp" style=""></span>ACEI&#44; <span class="elsevierStyleItalic">n</span> &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">64 &#40;41&#46;3&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">69 &#40;44&#46;5&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">52 &#40;33&#46;3&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">59 &#40;38&#46;1&#41;&nbsp;\t\t\t\t\t\t\n
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Article information

ISSN: 22548874
Original language: English

DOI:10.1016/j.rceng.2016.12.002

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