Special article
Residual congestion and clinical intuition in decompensated heart failure
La congestión residual y la intuición clínica en la insuficiencia cardiaca descompensada
J.I. Pérez Calvoa,b,c,
, J. Rubio Graciaa,c, C. Josa Laordena,c, J.L. Morales Rulld,e
Corresponding author
a Servicio de Medicina Interna, Hospital Clínico Universitario Lozano Blesa, Zaragoza, Spain
b Facultad de Medicina, Universidad de Zaragoza, Zaragoza, Spain
c Instituto de Investigación Sanitaria de Aragón, Zaragoza, Spain
d Servicio de Medicina Interna, Hospital Universitario Arnau de Vilanova, Lleida, Spain
e Instituto de Investigación Biomédica Dr. Pifarré, Lleida, Spain
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Pérez Calvo, J. Rubio Gracia, C. Josa Laorden, J.L. Morales Rull" "autores" => array:4 [ 0 => array:4 [ "nombre" => "J.I." "apellidos" => "Pérez Calvo" "email" => array:1 [ 0 => "jiperez@unizar.es" ] "referencia" => array:4 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] 2 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">c</span>" "identificador" => "aff0015" ] 3 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] 1 => array:3 [ "nombre" => "J." "apellidos" => "Rubio Gracia" "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">c</span>" "identificador" => "aff0015" ] ] ] 2 => array:3 [ "nombre" => "C." "apellidos" => "Josa Laorden" "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">c</span>" "identificador" => "aff0015" ] ] ] 3 => array:3 [ "nombre" => "J.L." "apellidos" => "Morales Rull" "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">d</span>" "identificador" => "aff0020" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">e</span>" "identificador" => "aff0025" ] ] ] ] "afiliaciones" => array:5 [ 0 => array:3 [ "entidad" => "Servicio de Medicina Interna, Hospital Clínico Universitario Lozano Blesa, Zaragoza, Spain" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Facultad de Medicina, Universidad de Zaragoza, Zaragoza, Spain" "etiqueta" => "b" "identificador" => "aff0010" ] 2 => array:3 [ "entidad" => "Instituto de Investigación Sanitaria de Aragón, Zaragoza, Spain" "etiqueta" => "c" "identificador" => "aff0015" ] 3 => array:3 [ "entidad" => "Servicio de Medicina Interna, Hospital Universitario Arnau de Vilanova, Lleida, Spain" "etiqueta" => "d" "identificador" => "aff0020" ] 4 => array:3 [ "entidad" => "Instituto de Investigación Biomédica Dr. Pifarré, Lleida, Spain" "etiqueta" => "e" "identificador" => "aff0025" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "La congestión residual y la intuición clínica en la insuficiencia cardiaca descompensada" ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Several matters relating to heart failure (HF) were discussed at the last congress held by the Spanish Society of Internal Medicine (SEMI, <span class="elsevierStyleItalic">Sociedad Española de Medicina Interna</span>). Remarkably, congestion has returned to the headlines and is raising clinical and scientific interest.</p><p id="par0010" class="elsevierStylePara elsevierViewall">The congestive signs that characterize HF syndrome were already recognized and described by Hippocrates in Ancient Greece in the 5th century B.C.<a class="elsevierStyleCrossRef" href="#bib0165"><span class="elsevierStyleSup">1</span></a> There is no doubt that the pathophysiology on which Hippocratic medicine was based was not the current one, given that, at that time, the syndrome was explained by an imbalance between the different humors. Objectively speaking, however, was this pathophysiological concept mistaken? To be more precise, was this concept more mistaken than the one that we currently use? The return of congestion to the forefront of interest among the medical community is likely to reflect a lack of understanding of its pathophysiological mechanisms and consequences.<a class="elsevierStyleCrossRefs" href="#bib0170"><span class="elsevierStyleSup">2,3</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">Etymologically, the term “congestion” derives from the Latin word “<span class="elsevierStyleItalic">con-gestus-tio</span>”, which refers to an excessive accumulation of fluid in certain parts of the body.</p><p id="par0020" class="elsevierStylePara elsevierViewall">Patients admitted to clinics due to a decompensated HF primarily exhibit symptoms and signs of congestion<a class="elsevierStyleCrossRef" href="#bib0180"><span class="elsevierStyleSup">4</span></a> (dyspnea, orthopnea, edema, hepatomegaly, jugular vein engorgement, etc.). The symptoms of congestion in cases of HF are a result of extracellular fluid retention secondary to increased ventricular filling pressure. The congestive manifestations, together with those derived from the associated hypoperfusion, define the decompensated HF syndrome and enable its quick classification into groups requiring varied therapeutic measures.<a class="elsevierStyleCrossRef" href="#bib0185"><span class="elsevierStyleSup">5</span></a> The fact that this ancient classification based on clinical aspects is included in the latest guidelines of the European Society of Cardiology<a class="elsevierStyleCrossRef" href="#bib0190"><span class="elsevierStyleSup">6</span></a> indicates its importance.<a class="elsevierStyleCrossRef" href="#bib0190"><span class="elsevierStyleSup">6</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">The detection of congestive symptoms and signs has limitations. On the one hand, its propedeutics requires training<a class="elsevierStyleCrossRef" href="#bib0195"><span class="elsevierStyleSup">7</span></a> and the acquisition of possibly numerous techniques,<a class="elsevierStyleCrossRef" href="#bib0200"><span class="elsevierStyleSup">8</span></a> thus implying a certain degree of variability in the actual data acquisition process. As is the case for many other diagnostic methods, clinical symptomatology is fairly unspecific, with a high negative predictive value but a low positive predictive value.<a class="elsevierStyleCrossRefs" href="#bib0180"><span class="elsevierStyleSup">4,9,10</span></a> In addition to clinical methods, the degree of congestion can be determined by ultrasonography (<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>).<a class="elsevierStyleCrossRef" href="#bib0180"><span class="elsevierStyleSup">4</span></a></p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0030" class="elsevierStylePara elsevierViewall">Although this is still just speculation, it is likely that systemic congestion<a class="elsevierStyleCrossRefs" href="#bib0215"><span class="elsevierStyleSup">11,12</span></a> or that of the splanchnic territory,<a class="elsevierStyleCrossRef" href="#bib0225"><span class="elsevierStyleSup">13</span></a> triggers inflammatory mechanisms<a class="elsevierStyleCrossRefs" href="#bib0230"><span class="elsevierStyleSup">14,15</span></a> that play a crucial role in the pathophysiology of decompensated heart failures.</p><p id="par0035" class="elsevierStylePara elsevierViewall">There is no doubt that congestive signs and symptoms are the herald of decompensated heart failures<a class="elsevierStyleCrossRef" href="#bib0180"><span class="elsevierStyleSup">4</span></a>; in fact, the fight against this congestion focuses the treatment on the patients’ hospital admission.<a class="elsevierStyleCrossRefs" href="#bib0180"><span class="elsevierStyleSup">4,16</span></a></p><p id="par0040" class="elsevierStylePara elsevierViewall">Given that the persistence of congestive signs at discharge is associated with an increased risk of re-hospitalization and mortality due to HF,<a class="elsevierStyleCrossRefs" href="#bib0245"><span class="elsevierStyleSup">17–20</span></a> complete decongestion could be the primary therapeutic aim in cases of decompensated HF. In light of the findings of recent studies,<a class="elsevierStyleCrossRefs" href="#bib0250"><span class="elsevierStyleSup">18,19</span></a> reaching a degree of decongestion that achieves symptomatic relief and allows patient discharge might still not be enough, given that there are substantial differences between decongestion that relieves symptoms and decongestion that improves the prognosis. The subtle degree of congestion that persists after the initial treatment, which is barely relevant from a symptomatologic point of view but has a negative effect on mortality, can be called “residual congestion”.</p><p id="par0045" class="elsevierStylePara elsevierViewall">Using a simple score system based on the presence of dyspnea, orthopnea, asthenia, crackles, edema, and jugular venous distention (<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>) applied to a cohort of 2061 patients with HF and a reduced left ventricular ejection fraction, Ambrosy<a class="elsevierStyleCrossRef" href="#bib0250"><span class="elsevierStyleSup">18</span></a> proved that the higher the score, the higher the mortality and the number of readmissions due to HF during the follow-up. In a subsequent study, Rubio et al.<a class="elsevierStyleCrossRef" href="#bib0255"><span class="elsevierStyleSup">19</span></a> proved that clinically inapparent residual congestion is very common at discharge and confirmed its poor prognosis using a simplified score (<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>) that solely included the degree of orthopnea, jugular venous distention and edema measured in a cohort of 1572 patients with HF and a reduced left ventricular ejection fraction. In this study,<a class="elsevierStyleCrossRef" href="#bib0255"><span class="elsevierStyleSup">19</span></a> only 23% of the patients showed no signs of congestion at discharge, while 48% and 29% had mild to severe symptoms of congestion that were associated with an increased rate of re-hospitalizations and mortality, respectively.</p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><p id="par0050" class="elsevierStylePara elsevierViewall">It is clear that the challenge in the immediate future will be to detect and combat residual congestion that resists the action of intensive diuretic therapy immediately on admission. To meet this challenge effectively and safely, we must first recognize it. These clinical scores can most likely be supplemented with the patients’ diuretic response<a class="elsevierStyleCrossRef" href="#bib0260"><span class="elsevierStyleSup">20</span></a>; biochemical parameters, such as their hematocrit<a class="elsevierStyleCrossRef" href="#bib0265"><span class="elsevierStyleSup">21</span></a>; and variations in natriuretic peptide (NP)<a class="elsevierStyleCrossRefs" href="#bib0270"><span class="elsevierStyleSup">22,23</span></a> concentration or carbohydrate antigen 125 (CA-125).<a class="elsevierStyleCrossRef" href="#bib0280"><span class="elsevierStyleSup">24</span></a> The usefulness and performance of ultrasonography<a class="elsevierStyleCrossRefs" href="#bib0285"><span class="elsevierStyleSup">25,26</span></a> procedures and of other noninvasive methods, such as bioelectrical impedance analysis, must also be analyzed.<a class="elsevierStyleCrossRefs" href="#bib0295"><span class="elsevierStyleSup">27,28</span></a></p><p id="par0055" class="elsevierStylePara elsevierViewall">There is little evidence about the role of congestion in the decision-making process at discharge and the perception of residual congestion, which is an emerging situation in daily clinical practice. To further delve into these two aspects, we prepared an anonymous 13-item survey that was distributed by e-mail to the members of the Heart Failure Group (<span class="elsevierStyleItalic">Grupo de Insuficiencia Cardíaca</span>, GIC) of SEMI, which was accessible from the 22nd of August to the 23rd of September 2018. The survey focused on determining how congestion was assessed and the importance that the respondents gave to the method used at two key points of the condition's progress: (1) on completion of an intensive diuretic treatment; i.e., when the congestive symptoms that motivated the admission are considered to be resolved and (2) when the decision to proceed with the discharge is made; i.e., when the congestion is considered to no longer exist or to be safely treatable on an outpatient basis (supplementary material).</p><p id="par0060" class="elsevierStylePara elsevierViewall">A total of 253 specialists, most of whom worked in internal medicine departments (247), completed the survey; their answers can be consulted in the GIC blog (<a href="http://cardioclinico.com/">http://cardioclinico.com</a>) and the supplementary material.</p><p id="par0065" class="elsevierStylePara elsevierViewall">The respondents based their identification of cases of congestion and the determination of its degree on its characteristic symptoms and signs (dyspnea, orthopnea, jugular venous distention and edema; over 50% for each), the NP concentration (43%), the ultrasound findings of the inferior vena cava (45%), the ultrasound findings of the lungs (43%) and the CA-125 levels (16%).</p><p id="par0070" class="elsevierStylePara elsevierViewall">A total of 247 respondents selected the answer concerning the early response of the congestion that allows for de-escalating the diuretic treatment and replacing the intravenous route with an oral one. Most of the respondents resorted once again to the assessment of the patients’ clinical symptoms (improved dyspnea [80%], reduced edema [78%] or weight [63%]) and a stable dose of oral diuretics (62%). Eighty-six percent of the participants reported that they based their assessment on diuretic efficacy, although this parameter was measured in several ways and was related to a reduction of the signs and symptoms of congestion in 86% of cases, followed by the NP concentration (24%), the serial lung ultrasound findings (8%) and those of an ultrasound of the inferior vena cava (5%).</p><p id="par0075" class="elsevierStylePara elsevierViewall">The respondents were openly asked whether “residual congestion” suggested anything to them and, if so, how they interpreted the term. Of the 247 respondents, 185 (75%) reported being aware this clinical situation, and their perception, although variable, was reasonably in line with what could be expected from a clinical point of view (individualized responses can be consulted in the blog).</p><p id="par0080" class="elsevierStylePara elsevierViewall">Discharge was primarily prompted by a reduction of the edema (72%), a functional class improvement (63%) and a stable dose of oral diuretics (62%), once again, based on eminently clinical criteria.</p><p id="par0085" class="elsevierStylePara elsevierViewall">Remarkably, most decisions made in relation to the assessment, monitoring and treatment of congestion in cases of decompensated heart failures are based on clinical perception, i.e. on symptomatologic aspects. Nevertheless, this is also logical if we consider that there are no quantitative tools available for its correct measurement and that awareness of the importance of congestion persisting in a latent state despite treatment is very recent.</p><p id="par0090" class="elsevierStylePara elsevierViewall">We should also note the use of complementary methods, such as assessing the NP concentration and the use of lung ultrasonography to evaluate the clinical progress of congestion. Although both methods have clearly been shown to be useful in diagnosing HF, especially in cases of decompensated heart failure,<a class="elsevierStyleCrossRefs" href="#bib0305"><span class="elsevierStyleSup">29,30</span></a> there is insufficient evidence of their reliability for serial use (e.g., in daily clinical practice) to determine the degree of congestion<a class="elsevierStyleCrossRefs" href="#bib0315"><span class="elsevierStyleSup">31,32</span></a>; therefore, their results should be interpreted with caution for decision making.</p><p id="par0095" class="elsevierStylePara elsevierViewall">This manuscript has methodological limitations. First, this study was based on an ad hoc survey. Second, despite being significant, the number of responses accounted for slightly less than half of the survey recipients. However, the purpose of the study was to analyze the subjective perception of internists accustomed to treating patients with decompensated heart failure, particularly regarding residual congestion, which has been understudied to date and therefore lacks strong evidence. The results of this survey prove that clinical intuition, an aspect that would barely reach a C recommendation score in the context of evidence-based medicine, is a powerful tool in daily clinical practice. This intuition involves the ability to detect a real problem for which there are still no answers and to reasonably face it following a consensual approach.</p><p id="par0100" class="elsevierStylePara elsevierViewall">The task before us is to determine the exact threshold of residual congestion that can provide relevant prognostic information in clinical practice, a threshold to be set between its detection using accessible but not very sensitive clinical methods and a sensitive but invasive heart catheterization.</p><p id="par0105" class="elsevierStylePara elsevierViewall">We must tackle this task cooperatively without delay, given that the use of intuition and possibilities are not alien to the HF group.</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Conflicts of interest</span><p id="par0110" class="elsevierStylePara elsevierViewall">The authors declare that they have no conflicts of interest with this article.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:7 [ 0 => array:3 [ "identificador" => "xres1225427" "titulo" => "Abstract" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0005" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec1139226" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres1225426" "titulo" => "Resumen" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0010" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec1139227" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Conflicts of interest" ] 5 => array:2 [ "identificador" => "xack419361" "titulo" => "Acknowledgments" ] 6 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2019-01-03" "fechaAceptado" => "2019-02-19" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec1139226" "palabras" => array:4 [ 0 => "Heart failure" 1 => "Congestion" 2 => "Residual congestion" 3 => "Diuretic therapy" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec1139227" "palabras" => array:4 [ 0 => "Insuficiencia cardiaca" 1 => "Congestión" 2 => "Congestión residual" 3 => "Terapia diurética" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:2 [ "titulo" => "Abstract" "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Congestive symptoms are the key to recognizing decompensated heart failure, whose treatment is based on reducing the congestion until a clinical situation has been reached that allows the patient to be discharged to continue outpatient treatment. The important aspect is not the degree of congestion at admission but rather the congestion that persists after energetic diuretic therapy. The persistence of congestive signs following an apparently correct and effective therapy has been called residual congestion and is associated with a poor prognosis. The tools for determining this condition are still rudimentary. Methods therefore need to be developed that enable a more accurate assessment.</p></span>" ] "es" => array:2 [ "titulo" => "Resumen" "resumen" => "<span id="abst0010" class="elsevierStyleSection elsevierViewall"><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Los síntomas congestivos son la clave para reconocer las descompensaciones de la insuficiencia cardiaca. Su tratamiento se basa en la reducción de la congestión hasta alcanzar una situación clínica que permita el alta del paciente para continuar el tratamiento ambulatoriamente. Lo importante, no obstante, no es el grado de congestión al ingreso, sino la que persiste después de un tratamiento diurético enérgico. A la persistencia de signos congestivos después de un tratamiento aparentemente correcto y eficaz, se le ha denominado «congestión residual» y se asocia con mal pronóstico. Las herramientas para su estimación son todavía rudimentarias, por lo que deben desarrollarse métodos que permitan una valoración más precisa.</p></span>" ] ] "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0010">Please cite this article as: Pérez Calvo JI, Rubio Gracia J, Josa Laorden C, Morales Rull JL. La congestión residual y la intuición clínica en la insuficiencia cardiaca descompensada. Rev Clin Esp. 2019;219:327–331.</p>" ] ] "apendice" => array:1 [ 0 => array:1 [ "seccion" => array:1 [ 0 => array:4 [ "apendice" => "<p id="par0125" class="elsevierStylePara elsevierViewall">The following are the supplementary data to this article:<elsevierMultimedia ident="upi0005"></elsevierMultimedia></p>" "etiqueta" => "Appendix A" "titulo" => "Supplementary data" "identificador" => "sec0015" ] ] ] ] "multimedia" => array:3 [ 0 => array:9 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "fuente" => "<span class="elsevierStyleItalic">Source</span>: Mullens et al.<a class="elsevierStyleCrossRef" href="#bib0180"><span class="elsevierStyleSup">4</span></a>" "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at1" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:2 [ "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Parameter \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Sensitivity \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Specificity \t\t\t\t\t\t\n \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Clinical methods<a class="elsevierStyleCrossRef" href="#tblfn0005"><span class="elsevierStyleSup">a</span></a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">13–94% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">10–90% \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Inspiratory collapse of the inferior vena cava (<50%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">12% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">27% \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">E-wave velocity<span class="elsevierStyleHsp" style=""></span>>50<span class="elsevierStyleHsp" style=""></span>cm/s \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">92% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">28% \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">E/e′ ratio<span class="elsevierStyleHsp" style=""></span>><span class="elsevierStyleHsp" style=""></span>12 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">66% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">55% \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Diffuse B-lines in the pulmonary ultrasound \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">86% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">40% \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab2092917.png" ] ] ] "notaPie" => array:1 [ 0 => array:3 [ "identificador" => "tblfn0005" "etiqueta" => "a" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Assessment of the presence and degree of jugular distension, hepatomegaly, edema, dyspnea and crackles.</p>" ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Performance of the various techniques for determining the degree of congestion.</p>" ] ] 1 => array:8 [ "identificador" => "tbl0010" "etiqueta" => "Table 2" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at2" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:1 [ "tablatextoimagen" => array:2 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " colspan="5" align="center" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Ambrosy score<a class="elsevierStyleCrossRef" href="#bib0250"><span class="elsevierStyleSup">18</span></a></th></tr><tr title="table-row"><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Signs/symptoms \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">0 \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">1 \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">2 \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">3 \t\t\t\t\t\t\n \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Dyspnea \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Absent \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Minimal \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Frequent \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Continuous \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Orthopnea \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Absent \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Minimal \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Frequent \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Continuous \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Asthenia \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Absent \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Minimal \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Frequent \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Continuous \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Jugular venous distention (cm H<span class="elsevierStyleInf">2</span>O) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><6 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">6–9 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">10–15 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">>15 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Pulmonary crackles \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Absent \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">In base \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><50% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">>50% \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Leg edema \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Absent \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Mild \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Moderate \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Pronounced \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab2092916.png" ] ] 1 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " colspan="5" align="center" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Rubio score<a class="elsevierStyleCrossRef" href="#bib0255"><span class="elsevierStyleSup">19</span></a></th></tr><tr title="table-row"><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">0 \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">1 \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">2 \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">3 \t\t\t\t\t\t\n \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Orthopnea \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Absent \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1-Pillow \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2-Pillow \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">>30 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Edema \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Absent \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Mild \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Moderate \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Pronounced \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Jugular venous distention (cm H<span class="elsevierStyleInf">2</span>O) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><6 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">6–10 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">>10 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">– \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab2092915.png" ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Congestion assessment using clinical scores.</p>" ] ] 2 => array:5 [ "identificador" => "upi0005" "tipo" => "MULTIMEDIAECOMPONENTE" "mostrarFloat" => false "mostrarDisplay" => true "Ecomponente" => array:2 [ "fichero" => "mmc1.pdf" "ficheroTamanyo" => 337899 ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0015" "bibliografiaReferencia" => array:32 [ 0 => array:3 [ "identificador" => "bib0165" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "The “modern” view of heart failure. How did we get there?" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:1 [ 0 => "A.M. Katz" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1161/CIRCHEARTFAILURE.108.772756" "Revista" => array:6 [ "tituloSerie" => "Circ Heart Fail" "fecha" => "2008" "volumen" => "1" "paginaInicial" => "63" "paginaFinal" => "71" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/19808272" "web" => "Medline" ] ] ] ] ] ] ] ] 1 => array:3 [ "identificador" => "bib0170" "etiqueta" => "2" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Daño orgánico y síndrome cardiorrenal en la insuficiencia cardiaca aguda" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "J. Casado Cerrada" 1 => "J.I. 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| 2023 March | 5 | 4 | 9 |
| 2020 September | 0 | 1 | 1 |
| 2020 February | 1 | 2 | 3 |
