Hemodynamic profile of Spanish adults with Down syndrome

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Abbreviations: AHT, arterial hypertension; CKD, chronic kidney disease; DM2, type 2 diabetes mellitus; GOLD, Global Initiative for Chronic Obstructive Lung Disease; HF, heart failure; IHD, ischemic heart disease; PAD, peripheral artery disease; SAHS, sleep apnea-hypopnea syndrome. The size of every node is proportional to the prevalence of each represented comorbidity. The width of the nexuses is proportional to the square of the phi coefficient. Blue represents an increase in the likelihood of the joint onset of 2 comorbidities in a patient, while the red lines represent a reduction in the likelihood of the joint onset of the 2 comorbidities (RRij < 1). Only statistically significant associations between 2 diseases are represented." ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "J.M. Figueira Gonçalves, M.A. García Bello, M.D. Martín Martínez, I. García-Talavera, J. Mesa Fumero, S. García Hernández, N. Bethencourt Martín, D. Díaz Pérez, A. 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Roy-Vallejo, E. Alonso, J.M. Galván-Román, P. Ibañez, F. Moldenhauer, C. Suárez Fernández, D. Real de Asúa" "autores" => array:7 [ 0 => array:4 [ "nombre" => "E." "apellidos" => "Roy-Vallejo" "email" => array:1 [ 0 => "eroyvallejo@gmail.com" ] "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "*" "identificador" => "cor0005" ] ] ] 1 => array:2 [ "nombre" => "E." "apellidos" => "Alonso" ] 2 => array:2 [ "nombre" => "J.M." "apellidos" => "Galván-Román" ] 3 => array:2 [ "nombre" => "P." "apellidos" => "Ibañez" ] 4 => array:2 [ "nombre" => "F." "apellidos" => "Moldenhauer" ] 5 => array:2 [ "nombre" => "C." "apellidos" => "Suárez Fernández" ] 6 => array:2 [ "nombre" => "D." "apellidos" => "Real de Asúa" ] ] "afiliaciones" => array:1 [ 0 => array:2 [ "entidad" => "Unidad de Atención a Adultos con síndrome de Down, Servicio de Medicina Interna, Hospital Universitario de La Princesa, Madrid, Spain" "identificador" => "aff0005" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Perfil hemodinámico de los adultos españoles con síndrome de Down" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:8 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1120 "Ancho" => 2249 "Tamanyo" => 99116 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0035" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "Hemodynamic state of adults with Down syndrome and its modulators (print in color). Abscissa axis: hemodynamic state and its modulators; ordinate axis: percentage of patients in each category. Red, hyper; green, normal; blue, hypo." ] ] ] "textoCompleto" => "BackgroundAtherosclerotic cardiovascular disease, the main cause of morbidity and mortality worldwide, is closely related to the aging of the population and to numerous cardiovascular risk factors, primary of which is arterial hypertension (AHT).<a class="elsevierStyleCrossRefs" href="#bib0005">1,2</a> However, the paradigmatic relation between aging, AHT and atherosclerotic cardiovascular events is not found in all patient populations. Due to a gradual increase in life expectancy in recent decades,<a class="elsevierStyleCrossRefs" href="#bib0015">3,4</a> it has been observed that adults with Down syndrome (DS) have a different cardiovascular risk profile than that of the general population.<a class="elsevierStyleCrossRef" href="#bib0025">5</a> Despite a high prevalence of some cardiovascular risk factors such as weight disorder and physical inactivity,<a class="elsevierStyleCrossRefs" href="#bib0030">6,7</a> the prevalence of AHT and atherosclerotic cardiovascular events in this population is incidental,<a class="elsevierStyleCrossRef" href="#bib0040">8</a> which has led to the consideration of trisomy 21 as a model free of atherogenesis.<a class="elsevierStyleCrossRefs" href="#bib0045">9,10</a>Discovering the mechanisms that regulate the blood pressure (BP) and hemodynamic state of individuals with DS could not only be beneficial for these patients but could also have relevant implications for the general population. For adults with DS, this discovery could represent a change in the intensity of the current diagnostic and therapeutic management of cardiovascular comorbidities, which would depart from that recommended in the current international guidelines for the general population. Characterizing the molecular pathways underlying this phenotype could also open a new frontier of novel therapeutic pathways for controlling AHT. As a first step towards these overall goals, the present study’s main objective was to characterize the clinical and hemodynamic phenotype of a cohort of adults with DS by studying their BP pattern and to report their hemodynamic state and main modulators of this state through thoracic bioimpedance of the heart beat.MethodsStudy design and populationWe conducted a cross-sectional study on patients with DS selected consecutively from the Care for Adults with Down Syndrome Unit of the Department of Internal Medicine of the University Hospital de La Princesa (Madrid, Spain) between June and November 2018. The established inclusion criteria were the confirmation (by medical history or karyotype) of trisomy 21 and an age older than 18 years. The following exclusion criteria were considered: uncontrolled hypothyroidism or hyperthyroidism, atrial fibrillation, complete right bundle branch block in the electrocardiogram and a body mass index (BMI)>35kg/m2 (given the poor reliability of the study using thoracic electrical bioimpedance under these circumstances), as well as sensory disability, severe functional impairment and the inability to provide consent.Determinations and variablesWe recorded the following variables:<ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005">•Demographic: sex and date of birth</li><li class="elsevierStyleListItem" id="lsti0010">•Anthropometric: weight (kg), height (cm), body mass index (kg/m2) and waist circumference (cm). Weight was measured on a calibrated scale, rounding the reading to the nearest 0.1kg. Height was measured using a stadiometer, rounding the reading to the nearest centimeter. Waist circumference was measured at the mid-height between the upper portion of the iliac crest and the lower costal margin.</li><li class="elsevierStyleListItem" id="lsti0015">•Comorbidities (diagnosed before participating in the study): diabetes mellitus,<a class="elsevierStyleCrossRef" href="#bib0055">11</a> dyslipidemia,<a class="elsevierStyleCrossRef" href="#bib0060">12</a> family history of premature cardiovascular disease,<a class="elsevierStyleCrossRef" href="#bib0065">13</a> chronic kidney disease,<a class="elsevierStyleCrossRef" href="#bib0070">14</a> thyroid disease, sleep apnea-hypopnea syndrome (SAHS),<a class="elsevierStyleCrossRef" href="#bib0075">15</a> history of congenital heart disease and/or need for surgical correction and Charlson index.<a class="elsevierStyleCrossRef" href="#bib0080">16</a></li><li class="elsevierStyleListItem" id="lsti0020">•Clinical variables recorded during the study:<ul class="elsevierStyleList" id="lis0010"><li class="elsevierStyleListItem" id="lsti0025">○Blood pressure and heart rate, both measured in the doctor's office with a validated oscillometric device (OMRON M6 Comfort or OMRON 711 models, OMRON Healthcare, Vernon Hills, IL, USA) in conditions recommended by the European Society of Hypertension/European Society of Cardiology.<a class="elsevierStyleCrossRef" href="#bib0065">13</a></li><li class="elsevierStyleListItem" id="lsti0030">○Electrocardiographic data: All participants underwent an electrocardiogram to detect the presence of left ventricular hypertrophy according to the Sokolow-Lyon<a class="elsevierStyleCrossRef" href="#bib0085">17</a> and Cornell indices,<a class="elsevierStyleCrossRef" href="#bib0090">18</a> as well as signs of ischemia.<a class="elsevierStyleCrossRef" href="#bib0095">19</a></li><li class="elsevierStyleListItem" id="lsti0035">○Outpatient blood pressure monitoring (OBPM), performed with WatchBP O3® devices (Microlife AG, Wildnau, Switzerland) according to the recommendations of the European Society of Hypertension/European Society of Cardiology.<a class="elsevierStyleCrossRef" href="#bib0065">13</a></li><li class="elsevierStyleListItem" id="lsti0040">○The participants’ hemodynamic state was measured with beat-to-beat thoracic bioimpedance (Hemodynamic and oxygen transport management [HOTMAN®] system; Hemo Sapiens Inc., San Ramon, CA, USA) after at least 5min of rest. Using the method described by Sramek,<a class="elsevierStyleCrossRef" href="#bib0100">20</a> we measured the following primary variables: cardiac index (bpm/m2), stroke index (SI, mL/beat/m2), mean blood pressure (mmHg), stroke systemic vascular resistance index (dyn.sec.cm−5.m2=F), left stroke work index (g.m/m2) and inotropic state index (sec-). The device also helps establish an assessment of the following variables: blood volume, inotropism, vasoactivity and chronotropism. According to the parameters established by Fadl Elmula et al.,<a class="elsevierStyleCrossRef" href="#bib0105">21</a> we considered hypervolemia when the blood volume was>20 %, hyperinotropism when the inotropism was>20 % and vasoconstriction when the vasoactivity was>34 %.<a class="elsevierStyleCrossRef" href="#bib0105">21</a> We considered normotensive those patients with a mean arterial pressure (MAP) between 70 and 105mmHg, hypotensive those with MAP<70mmHg and hypertensive those with MAP>105mmHg. In terms of SI, we considered normodynamic those patients with an SI of 35–65mL/m2, hypodynamic those with an SI<35mL/m2 and hyperdynamic those with an SI>65mL/m2.</li></ul></li><li class="elsevierStyleListItem" id="lsti0045">•Laboratory variables: For the present study, we employed any blood extraction performed for clinical purposes between the 3 months before and after the study assessment. This technique was performed under standardized conditions, after at least 8h of fasting. The following biochemical measurements were performed in a Roche/Hitachi® modular-D analyzer: glucose (mg/dL), urea (mg/dL), creatinine (mg/dL), estimated glomerular filtration rate (measured by the Chronic Kidney Disease Epidemiology Collaboration equation) (mL/min/1.73m2), sodium (mEq/L), potassium (mEq/L), bilirubin (mg/dL), glutamic oxaloacetic transaminase (U/L), glutamic pyruvic transaminase (U/L), gamma-glutamyl transferase (U/L), total cholesterol (mg/dL), high-density lipoprotein cholesterol (mg/dL), low-density lipoprotein cholesterol (mg/dL), triglycerides (mg/dL), glycated hemoglobin (%) and thyroid-stimulating hormone (mUI/mL).</li></ul>Statistical analysisThe study participants’ clinical and demographic characteristics were analyzed using the calculation of the mean and standard deviation (SD) for the quantitative variables and proportions for the qualitative variables. For the analysis of qualitative variables, we employed the chi-squared test with Yates correction or Fisher's exact test as necessary. We analyzed the quantitative variables using Student's t-test or ANOVA, with Bonferroni correction, as necessary. All tests were considered bilateral. The results with p<.05 were considered statistically significant. The statistical analysis was performed with the SPSS program v 21.0 (IBM Corporation, Armonk, NY).Ethical considerationsThe study was conducted in accordance with the principles of the Declaration of Helsinki (1996) in the Fortaleza version (Brazil, 2013) and with the current guidelines on good clinical practices and was approved by our center’s research ethics committee. All data were treated with the upmost confidentiality, in accordance with current legislation.ResultsThe initial study population consisted of 36 adults with DS. Six participants were excluded for a BMI>35kg/m2, 1 was excluded for uncontrolled hypothyroidism, and 3 were excluded for being unable to perform the study with the HOTMAN® system. The final sample consisted of 26 patients (50 % male). The participants’ mean age was 45±11 years, with no difference between the sexes. The mean BMI was 28.5±2.9. Two patients (7.7 %) had normal weight, 17 (65.4 %) had excess weight, and 7 (26.9 %) had obesity. The mean BP in the doctor's office was 109/69±11/9mmHg, and the mean heart rate was 60±12bpm. The prevalence of other relevant comorbidities is shown in <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>.<elsevierMultimedia ident="tbl0005"></elsevierMultimedia>The results of the laboratory measurements are summarized in <a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>. Despite the prevalence of excess weight and obesity in the sample, none of the participants met the criteria for metabolic syndrome.<a class="elsevierStyleCrossRef" href="#bib0060">12</a> None of the participants presented electrocardiographic signs of left ventricular hypertrophy or myocardial ischemia.<elsevierMultimedia ident="tbl0010"></elsevierMultimedia>Using the HOTMAN® system, 96 % (n=25) of the study participants had normal blood pressure, and 65.4 % (n=17) were normodynamic. In terms of the modulators of the hemodynamic state, 46.1 % of the participants (n=12) had hypochronotropism, and 53.8 % (n=14) had hypervolemia. One of the adults with DS had hypertension, according to the criteria employed in this technique<a class="elsevierStyleCrossRef" href="#bib0100">20</a>; however, this diagnosis was not confirmed by OBPM. The mean values for the hemodynamic study parameters measured with the HOTMAN® system are shown in <a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a>, and the representation of the hemodynamic state of the patient group is shown in <a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>.<elsevierMultimedia ident="tbl0015"></elsevierMultimedia><elsevierMultimedia ident="fig0005"></elsevierMultimedia>Although OBPM was offered to all participants, it was performed and provided quality readings for only 12 participants who agreed to it (46.2 %). None of the individuals with DS who underwent OBPM met the diagnostic criteria for AHT. In terms of the measures reported at 24h, the mean systolic blood pressure (SBP) was 105±11mmHg, the mean diastolic blood pressure (DBP) was 67±11mmHg, and the mean arterial pressure (MAP) was 80±11mmHg. The mean heart rate was 61±6bpm. As a measure of variability, we employed the median of the standard deviations for SBP, MAP and heart rate at 24h, which were 22mmHg (interquartile range [IQR], 19mmHg), 22mmHg (IQR, 18mmHg) and 11bpm (IQR, 1.8bpm), respectively. <a class="elsevierStyleCrossRef" href="#tbl0020">Table 4</a> summarizes the results of the BP measures during the diurnal, nocturnal and 24-h periods. Ten participants with DS showed a dipper circadian blood pressure pattern, while 2 patients showed a non-dipper pattern. None of the participants had a riser circadian pattern.<elsevierMultimedia ident="tbl0020"></elsevierMultimedia>Lastly, we compared the hemodynamic parameters of the participants who underwent OBPM with those of the rest of the sample. When comparing the OBPM group versus the non-OBPM group, we observed statistically significant differences in sex distribution (9 males [75 %] vs. 4 males [29 %], respectively; p=.02), hypothyroidism (5 [42 %] vs. 13 [93 %]; p=.01), inotropic stroke index (1.25 [SD, 0.37] vs. 0.94sec−2 [SD, 0.33]; p=.03), hyperinotropism (4 [33 %] vs. 0 [0 %]; p=.03) and normal blood volume (10 [83 %] vs. 2 [14.3 %]; p=.001).DiscussionThe first relevant result of our study was the absence of patients with DS who met the diagnostic criteria for AHT, either through causal BP detection in the doctor's office or through OBPM. Secondly, it is worth noting the predominant hemodynamic profile in our sample, which consisted of normal pressure and normal dynamism, with hypervolemia, hypochronotropism, normal inotropism and normal or reduced vascular resistances as the main modulators.The only participant who met the criteria of AHT through bioimpedance presented a mean BP of 140/67mmHg with the HOTMAN® system. This value was interpreted as diagnostic of AHT due to an SBP over the limit. Nevertheless, the casual measurement in the doctor's office and OBPM observed only normal measures during the observation period. As this was the only measurement, we interpret this discrepancy as possibly attributable to an alert reaction or nervousness during the performance of the test, which, despite being non-invasive, involves the use of cables in an unknown environment, both potential sources of stress for a participant with intellectual disability.The findings reported in this study are consistent with the current paradigm of a special cardiovascular protection and normal pressure in the population of adults with DS. Despite a high prevalence of weight disorders and physical inactivity in the adult population with DS, these individuals do not seem to develop AHT.<a class="elsevierStyleCrossRefs" href="#bib0025">5,22,23</a> The diagnosis of AHT in all previous series was established retrospectively by analyzing the discharge reports or by casual BP measurement in the doctor's office. The present study added a detailed vascular study using OBPM and HOTMAN®, which helps consolidate the initial observations.Secondly, in light of these results, we postulate that the primary hemodynamic disorder of adults with DS appears to be hypochronotropism, a hypothesis consistent with previous studies that have indicated a sympathetic dysregulation in adults with DS. It has therefore been observed that individuals with DS have a lower baseline heart rate than individuals without DS.<a class="elsevierStyleCrossRef" href="#bib0120">24</a> It has also been shown that these individuals have poorer BP and heart rate adaptation to exercise.<a class="elsevierStyleCrossRefs" href="#bib0125">25,26</a> Sympathetic dysregulation has also been postulated as a mechanism to explain the increased prevalence of neurally mediated syncope observed in this population. Furthermore, a recent study by Patel et al. showed that individuals with DS have lower sympathetic innervation of some organs and that this disorder is mediated by RCAN1, a gene located in chromosome 21 and whose products cause neural growth factor inhibition.<a class="elsevierStyleCrossRef" href="#bib0135">27</a>In this context of hypochronotropism, the observed hypervolemia reflects a compensatory mechanism for this primary disorder. Vascular resistances can also be expected to increase in an attempt to maintain vascular tone. However, the resistances were inadequately normal or low in 85 % of our study participants. We therefore suspect that another of the primary mechanisms underlying the absence of AHT in adults with DS directly points to the renin-angiotensin-aldosterone system (RAAS). We have found no studies that have systematically evaluated RAAS function in the population with DS. However, indirect data from cell models indicate that the RCAN1 gene located on chromosome 21 governs the effects of angiotensin II, reducing the cardiac hypertrophy that depends on this molecule.<a class="elsevierStyleCrossRef" href="#bib0140">28</a> Similarly, the DYRK1A gene, also overexpressed in DS, has been recently linked to a reduction in neprilysin levels in the fibroblasts of individuals with DS.<a class="elsevierStyleCrossRef" href="#bib0145">29</a> Given the possibility that constitutive overexpression of RCAN1 and DYRK1A in individuals with DS directly affects RAAS regulation, a differential study of the molecular characterization of this axis in individuals with DS compared with the population without DS could be an essential step in clarifying the mechanisms underlying its cardiovascular protection.Our study’s strengths include the novelty of using bioimpedance to perform the vascular study of individuals with DS, which has not been previously performed. Our study’s fundamental limitation was its cross-sectional design and low number of recruited participants, which reflect the complexity of clinical practice and the care for individuals with disability, thereby limiting the potential for generalizing the results. However, the standard deviations observed in our study were low. We would therefore expect that a larger sample size would not necessarily result in a significant change in the current results. Similarly, the lack of a control group is another significant limitation. We have therefore planned to incorporate individuals without DS (mostly siblings) in future studies. It is difficult to interpret the clinical relevance of the clinical differences observed between the OBPM and non-OBPM subgroups. First, we observed no differences between sexes in the analysis of the hemodynamic study in the full sample. Despite a different rate of hypothyroidism as a relevant antecedent between the groups, all study patients were properly treated with levothyroxine, as shown by the thyroid-stimulating hormone results. We also observed no significant differences in terms of BP in the doctor's office. The results of the OBPM might therefore be extrapolatable to the rest of the sample.ConclusionsDespite the progressive aging of the population with DS, AHT is a comorbidity virtually absent in adults with DS. These individuals have a hemodynamic condition dominated by hypochronotropism and hypervolemia, maintaining normal and even reduced vascular resistances. The regulation of both chronotropism and vascular resistances is postulated as the main mechanism for hypotension or normal pressure constitutive of this population.FundingThis project was funded by the Spanish Society of Internal Medicine (2017 Dr. Prof. Miguel Vilardell prize for clinical research), by the Jerôme Lejeune Foundation (Cycle2017B/Project #1711) and the Society of Internal Medicine of Madrid and Castilla La Mancha (2018 grant to the best research project).Conflicts of interestThe authors declare that they have no conflicts of interest." "textoCompletoSecciones" => array:1 [ "secciones" => array:13 [ 0 => array:3 [ "identificador" => "xres1346215" "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" => "xpalclavsec1238676" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres1346214" "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" => "xpalclavsec1238675" "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 design and population" ] 1 => array:2 [ "identificador" => "sec0020" "titulo" => "Determinations and variables" ] 2 => array:2 [ "identificador" => "sec0025" "titulo" => "Statistical analysis" ] 3 => array:2 [ "identificador" => "sec0030" "titulo" => "Ethical considerations" ] ] ] 6 => array:2 [ "identificador" => "sec0035" "titulo" => "Results" ] 7 => array:2 [ "identificador" => "sec0040" "titulo" => "Discussion" ] 8 => array:2 [ "identificador" => "sec0045" "titulo" => "Conclusions" ] 9 => array:2 [ "identificador" => "sec0050" "titulo" => "Funding" ] 10 => array:2 [ "identificador" => "sec0055" "titulo" => "Conflicts of interest" ] 11 => array:2 [ "identificador" => "xack466151" "titulo" => "Acknowledgements" ] 12 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2019-07-18" "fechaAceptado" => "2019-09-05" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec1238676" "palabras" => array:3 [ 0 => "Down syndrome" 1 => "Arterial hypertension" 2 => "Cardiovascular risk" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec1238675" "palabras" => array:3 [ 0 => "Síndrome de Down" 1 => "Hipertensión arterial" 2 => "Riesgo cardiovascular" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:3 [ "titulo" => "Abstract" "resumen" => "ObjectivesAlthough the reasons are unknown, the prevalence of arterial hypertension and atherosclerotic cardiovascular events in the adult population with Down syndrome (SD) is anecdotal. To better understand this finding, we evaluated the haemodynamic characteristics of a cohort of adults with SD. MethodsWe conducted a cross-sectional study of adults with SD recruited consecutively from the outpatient clinics of an internal medicine department between June and November 2018. We collected demographic, clinical and laboratory variables and employed a thoracic bioimpedance device (HOTMAN® System) for the haemodynamic measures. Outpatient blood pressure monitoring (OBPM) was conducted on a subgroup of participants. ResultsTwenty-six participants (mean age, 45±11 years) participated in the study (50 % men). The sample’s mean blood pressure (BP) was 109/69±11/9mm Hg, with a mean heart rate of 60±12 bpm. None of the participants had hypertension. The predominant haemodynamic profile consisted of normal dynamism (65 %), normal BP (96 %), hypochronotropism (46 %), normal inotropism (50 %) and hypervolaemia (54 %), with normal peripheral vascular resistance values (58 %). Twelve participants underwent OBPM (46 %). The mean 24-h systolic BP, diastolic BP, mean BP and mean heart rate were 105±11mm Hg, 67±11mm Hg, 80±11mm Hg and 61±6 bpm, respectively. ConclusionsThe most common haemodynamic profile observed in adults with SD consisted of hypochronotropism and hypervolaemia, with normal values for peripheral vascular resistance and optimal mean BP values. There were no participants with hypertension in our sample." "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" => "ObjetivosSi bien se desconocen los motivos, la prevalencia de hipertensión arterial y de eventos cardiovasculares ateroscleróticos en la población adulta con síndrome de Down (SD) es anecdótica. Para entender mejor este hallazgo evaluamos las características hemodinámicas de una cohorte de adultos con SD. MétodosEstudio transversal en adultos con SD reclutados de modo consecutivo de las consultas externas del servicio de M. Interna entre junio y noviembre 2018. Se recogieron variables demográficas, clínicas y analíticas. Se utilizó un dispositivo de bioimpedancia torácica (HOTMAN® System) para las medidas hemodinámicas. Se realizó una monitorización ambulatoria de presión arterial (MAPA) en un subgrupo de sujetos. ResultadosVeintiséis sujetos de edad media 45±11 años participaron en el estudio (50% varones). La presión arterial (PA) media en la muestra fue de 109/69±11/9mmHg, con una frecuencia cardiaca media de 60±12 lpm. Ningún sujeto era hipertenso. El perfil hemodinámico predominante consistió en normodinamismo (65%), normotensión (96%), hipocronotropismo (46%), normoinotropismo (50%) ehipervolemia (54%), con valores normales de resistencias vasculares periféricas (58%). Se realizó una MAPA a 12 sujetos (46%). Los valores medios en 24h de PA sistólica fueron 105±11mmHg, PA diastólica 67±11mmHg, PA media 80±11mmHg y frecuencia cardiaca media 61±6 lpm. ConclusionesEl perfil hemodinámico más frecuentemente observado en adultos con SD consistió en hipocronotropismo e hjpervolemia, con valores normales de resistencias vasculares periféricas y valores medios óptimos de PA. No identificamos ningún sujeto hipertenso en nuestra muestra." "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: Roy-Vallejo E, Alonso E, Galván-Román JM, Ibañez P, Moldenhauer F, Suárez Fernández C, et al. Perfil hemodinámico de los adultos españoles con síndrome de Down. Rev Clin Esp. 2020;220:275–281." ] ] "multimedia" => array:5 [ 0 => array:8 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1120 "Ancho" => 2249 "Tamanyo" => 99116 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0035" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "Hemodynamic state of adults with Down syndrome and its modulators (print in color). Abscissa axis: hemodynamic state and its modulators; ordinate axis: percentage of patients in each category. Red, hyper; green, normal; blue, hypo." ] ] 1 => array:8 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0040" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:3 [ "leyenda" => "Abbreviations: CVD, cardiovascular disease; DBP, diastolic blood pressure; DS, Down syndrome; eGFR, estimated glomerular filtration rate; HR, heart rate; SAHS, sleep apnea-hypopnea syndrome; SBP, systolic blood pressure; SD, standard deviation." "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="\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">Patient characteristics \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">Adults with DS (n=26) Mean (SD) \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">Age, years \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">45±11 \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">Sex, males \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">13 (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">Weight, kg \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">64.3±8.3 \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">Height, cm \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">150±8 \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">BMI, kg/m<a class="elsevierStyleCrossRef" href="#bib0010">2</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="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">28.5±2.9 \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">Abdominal circumference, cm \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">91±10 \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">Arterial hypertension \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">0 \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">Diabetes mellitus \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 (4 %) \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">Dyslipidemia \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 (4 %) \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">Family history of premature CVD \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">0 \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">Chronic kidney disease (eGFR<60ml/min/1.73m2) \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 (4 %) \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">Congenital heart disease \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 (4 %) \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">Hypothyroidism \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">18 (69 %) \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">SAHS \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 (23 %) \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">Charlson index<a class="elsevierStyleCrossRef" href="#tblfn0005">a</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="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0 (1) \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">SBP in doctor's office, mmHg \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">109.2±11 \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">DBP in doctor's office, mmHg \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">68.9±9 \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">HR in doctor's office, bpm \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">59.6±12 \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab2309642.png" ] ] ] "notaPie" => array:1 [ 0 => array:3 [ "identificador" => "tblfn0005" "etiqueta" => "a" "nota" => "Value expressed as median (interquartile range)." ] ] ] "descripcion" => array:1 [ "en" => "Clinical characteristics of adults with Down syndrome." ] ] 2 => array:8 [ "identificador" => "tbl0010" "etiqueta" => "Table 2" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0045" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:2 [ "leyenda" => "Abbreviations: DS, Down syndrome; eGFR, estimated glomerular filtration rate; SD, standard deviation." "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="\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">Laboratory Analysis \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">Adults with DS (n=26) Mean (SD) \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">Glucose, mg/dL \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">91.7±11.7 \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">Urea, mg/dL \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">38.9±14.4 \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">Creatinine, mg/dL \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">1.0±0.2 \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">eGFR CKD-EPI (mL/min/1.73m<a class="elsevierStyleCrossRef" href="#bib0010">2</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="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">87.8±19.8 \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">Sodium, mEq/L \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">141±1.8 \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">Potassium, mEq/L \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">4.4±0.2 \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">Bilirubin, mg/dL \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">0.5±0.2 \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">GOT, U/L \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">22±4 \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">GPT, U/L \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">21.4±10 \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">GGT, U/L \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">19.9±11 \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">Total cholesterol, mg/dL \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">193±34 \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">HDL, mg/dL \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">55±11.5 \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">LDL, mg/dL \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">125±24 \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">Triglycerides, mg/dL \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">86±24 \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">HbA1c, % \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">5.4±0.4 \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">TSH, mUI/mL \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">3±2 \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab2309645.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Baseline laboratory analysis for the adults with Down syndrome." ] ] 3 => array:8 [ "identificador" => "tbl0015" "etiqueta" => "Table 3" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0050" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:3 [ "leyenda" => "Abbreviations: DS, Down syndrome; ISI, inotropic state index; LSWI, left stroke work index; MAP, mean arterial pressure; SSVRI, stroke systemic vascular resistance index." "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">Measured variables \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">Adults with SD (n=26) \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">Reference values<a class="elsevierStyleCrossRef" href="#tblfn0010">a</a> \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">Cardiac index, L/min/m<a class="elsevierStyleCrossRef" href="#bib0010">2</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="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">3.3±1.2 \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">2.8–4.2 \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">Stroke index, mL/stroke/m2 \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">55±18.8 \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">35–65 \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">MAP, mmHg \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">84±8 \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">70–105 \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">SSVRI, dyn.sec.cm−5.m2)<a class="elsevierStyleCrossRef" href="#tblfn0015">b</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="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">123.5 (62.8) \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">101–186 \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">LSWI, g.m/m2 \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">60.1±19.4 \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">39.8–73.5 \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">ISI, sec−2 \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">1.1±0.4 \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">0.9–1.41 \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab2309643.png" ] ] ] "notaPie" => array:2 [ 0 => array:3 [ "identificador" => "tblfn0010" "etiqueta" => "a" "nota" => "Reference values established by the manufacturer." ] 1 => array:3 [ "identificador" => "tblfn0015" "etiqueta" => "b" "nota" => "Result expressed as median (interquartile range)." ] ] ] "descripcion" => array:1 [ "en" => "Study hemodynamic data using HOTMAN of the adults with Down syndrome." ] ] 4 => array:8 [ "identificador" => "tbl0020" "etiqueta" => "Table 4" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0055" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:2 [ "leyenda" => "Abbreviations: DBP, diastolic blood pressure; HR, heart rate; MAP, mean arterial pressure; SBP, systolic blood pressure." "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"> \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">24-h period \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">Diurnal period \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">Nocturnal period \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">SBP, mmHg \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">105±11 \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">116±17 \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">96±9 \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">DBP, mmHg \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">67±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="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">75±17 \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">59±8 \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">MAP, mmHg \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">80±11 \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">89±17 \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">71±8 \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">HR, bpm \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">61±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">65±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">58±7 \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab2309644.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Arterial pressure readings by outpatient blood pressure monitoring in the adults with Down syndrome." ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:29 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Global and Regional Causes of Death: Patterns and Trends, 2000–15" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:5 [ 0 => "C. 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Hemodynamic profile of Spanish adults with Down syndrome

Perfil hemodinámico de los adultos españoles con síndrome de Down

E. Roy-Vallejo

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eroyvallejo@gmail.com

Corresponding author.

, E. Alonso, J.M. Galván-Román, P. Ibañez, F. Moldenhauer, C. Suárez Fernández, D. Real de Asúa

Unidad de Atención a Adultos con síndrome de Down, Servicio de Medicina Interna, Hospital Universitario de La Princesa, Madrid, Spain

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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Background</span><p id="par0005" class="elsevierStylePara elsevierViewall">Atherosclerotic cardiovascular disease&#44; the main cause of morbidity and mortality worldwide&#44; is closely related to the aging of the population and to numerous cardiovascular risk factors&#44; primary of which is arterial hypertension &#40;AHT&#41;&#46;<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#44;2</span></a> However&#44; the paradigmatic relation between aging&#44; AHT and atherosclerotic cardiovascular events is not found in all patient populations&#46; Due to a gradual increase in life expectancy in recent decades&#44;<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">3&#44;4</span></a> it has been observed that adults with Down syndrome &#40;DS&#41; have a different cardiovascular risk profile than that of the general population&#46;<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> Despite a high prevalence of some cardiovascular risk factors such as weight disorder and physical inactivity&#44;<a class="elsevierStyleCrossRefs" href="#bib0030"><span class="elsevierStyleSup">6&#44;7</span></a> the prevalence of AHT and atherosclerotic cardiovascular events in this population is incidental&#44;<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a> which has led to the consideration of trisomy 21 as a model free of atherogenesis&#46;<a class="elsevierStyleCrossRefs" href="#bib0045"><span class="elsevierStyleSup">9&#44;10</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">Discovering the mechanisms that regulate the blood pressure &#40;BP&#41; and hemodynamic state of individuals with DS could not only be beneficial for these patients but could also have relevant implications for the general population&#46; For adults with DS&#44; this discovery could represent a change in the intensity of the current diagnostic and therapeutic management of cardiovascular comorbidities&#44; which would depart from that recommended in the current international guidelines for the general population&#46; Characterizing the molecular pathways underlying this phenotype could also open a new frontier of novel therapeutic pathways for controlling AHT&#46; As a first step towards these overall goals&#44; the present study&#8217;s main objective was to characterize the clinical and hemodynamic phenotype of a cohort of adults with DS by studying their BP pattern and to report their hemodynamic state and main modulators of this state through thoracic bioimpedance of the heart beat&#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 design and population</span><p id="par0015" class="elsevierStylePara elsevierViewall">We conducted a cross-sectional study on patients with DS selected consecutively from the Care for Adults with Down Syndrome Unit of the Department of Internal Medicine of the University Hospital de La Princesa &#40;Madrid&#44; Spain&#41; between June and November 2018&#46; The established inclusion criteria were the confirmation &#40;by medical history or karyotype&#41; of trisomy 21 and an age older than 18 years&#46; The following exclusion criteria were considered&#58; uncontrolled hypothyroidism or hyperthyroidism&#44; atrial fibrillation&#44; complete right bundle branch block in the electrocardiogram and a body mass index &#40;BMI&#41;<span class="elsevierStyleHsp" style=""></span>&#62;35<span class="elsevierStyleHsp" style=""></span>kg&#47;m<span class="elsevierStyleSup">2</span> &#40;given the poor reliability of the study using thoracic electrical bioimpedance under these circumstances&#41;&#44; as well as sensory disability&#44; severe functional impairment and the inability to provide consent&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Determinations and variables</span><p id="par0020" class="elsevierStylePara elsevierViewall">We recorded the following variables&#58;<ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005"><span class="elsevierStyleLabel">&#8226;</span><p id="par0025" class="elsevierStylePara elsevierViewall">Demographic&#58; sex and date of birth</p></li><li class="elsevierStyleListItem" id="lsti0010"><span class="elsevierStyleLabel">&#8226;</span><p id="par0030" class="elsevierStylePara elsevierViewall">Anthropometric&#58; weight &#40;kg&#41;&#44; height &#40;cm&#41;&#44; body mass index &#40;kg&#47;m<span class="elsevierStyleSup">2</span>&#41; and waist circumference &#40;cm&#41;&#46; Weight was measured on a calibrated scale&#44; rounding the reading to the nearest 0&#46;1<span class="elsevierStyleHsp" style=""></span>kg&#46; Height was measured using a stadiometer&#44; rounding the reading to the nearest centimeter&#46; Waist circumference was measured at the mid-height between the upper portion of the iliac crest and the lower costal margin&#46;</p></li><li class="elsevierStyleListItem" id="lsti0015"><span class="elsevierStyleLabel">&#8226;</span><p id="par0035" class="elsevierStylePara elsevierViewall">Comorbidities &#40;diagnosed before participating in the study&#41;&#58; diabetes mellitus&#44;<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">11</span></a> dyslipidemia&#44;<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">12</span></a> family history of premature cardiovascular disease&#44;<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">13</span></a> chronic kidney disease&#44;<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">14</span></a> thyroid disease&#44; sleep apnea-hypopnea syndrome &#40;SAHS&#41;&#44;<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">15</span></a> history of congenital heart disease and&#47;or need for surgical correction and Charlson index&#46;<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">16</span></a></p></li><li class="elsevierStyleListItem" id="lsti0020"><span class="elsevierStyleLabel">&#8226;</span><p id="par0040" class="elsevierStylePara elsevierViewall">Clinical variables recorded during the study&#58;<ul class="elsevierStyleList" id="lis0010"><li class="elsevierStyleListItem" id="lsti0025"><span class="elsevierStyleLabel">&#9675;</span><p id="par0045" class="elsevierStylePara elsevierViewall">Blood pressure and heart rate&#44; both measured in the doctor&#39;s office with a validated oscillometric device &#40;OMRON M6 Comfort or OMRON 711 models&#44; OMRON Healthcare&#44; Vernon Hills&#44; IL&#44; USA&#41; in conditions recommended by the European Society of Hypertension&#47;European Society of Cardiology&#46;<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">13</span></a></p></li><li class="elsevierStyleListItem" id="lsti0030"><span class="elsevierStyleLabel">&#9675;</span><p id="par0050" class="elsevierStylePara elsevierViewall">Electrocardiographic data&#58; All participants underwent an electrocardiogram to detect the presence of left ventricular hypertrophy according to the Sokolow-Lyon<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">17</span></a> and Cornell indices&#44;<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">18</span></a> as well as signs of ischemia&#46;<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">19</span></a></p></li><li class="elsevierStyleListItem" id="lsti0035"><span class="elsevierStyleLabel">&#9675;</span><p id="par0055" class="elsevierStylePara elsevierViewall">Outpatient blood pressure monitoring &#40;OBPM&#41;&#44; performed with WatchBP O3&#174; devices &#40;Microlife AG&#44; Wildnau&#44; Switzerland&#41; according to the recommendations of the European Society of Hypertension&#47;European Society of Cardiology&#46;<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">13</span></a></p></li><li class="elsevierStyleListItem" id="lsti0040"><span class="elsevierStyleLabel">&#9675;</span><p id="par0060" class="elsevierStylePara elsevierViewall">The participants&#8217; hemodynamic state was measured with beat-to-beat thoracic bioimpedance &#40;Hemodynamic and oxygen transport management &#91;HOTMAN&#174;&#93; system&#59; Hemo Sapiens Inc&#46;&#44; San Ramon&#44; CA&#44; USA&#41; after at least 5<span class="elsevierStyleHsp" style=""></span>min of rest&#46; Using the method described by Sramek&#44;<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">20</span></a> we measured the following primary variables&#58; cardiac index &#40;bpm&#47;m<span class="elsevierStyleSup">2</span>&#41;&#44; stroke index &#40;SI&#44; mL&#47;beat&#47;m<span class="elsevierStyleSup">2</span>&#41;&#44; mean blood pressure &#40;mm<span class="elsevierStyleHsp" style=""></span>Hg&#41;&#44; stroke systemic vascular resistance index &#40;dyn&#46;sec&#46;<span class="elsevierStyleHsp" style=""></span>cm<span class="elsevierStyleSup">&#8722;5</span>&#46;<span class="elsevierStyleHsp" style=""></span>m<span class="elsevierStyleSup">2</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>F&#41;&#44; left stroke work index &#40;g&#46;m&#47;m<span class="elsevierStyleSup">2</span>&#41; and inotropic state index &#40;sec-&#41;&#46; The device also helps establish an assessment of the following variables&#58; blood volume&#44; inotropism&#44; vasoactivity and chronotropism&#46; According to the parameters established by Fadl Elmula et al&#46;&#44;<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">21</span></a> we considered hypervolemia when the blood volume was<span class="elsevierStyleHsp" style=""></span>&#62;20 &#37;&#44; hyperinotropism when the inotropism was<span class="elsevierStyleHsp" style=""></span>&#62;20 &#37; and vasoconstriction when the vasoactivity was<span class="elsevierStyleHsp" style=""></span>&#62;34 &#37;&#46;<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">21</span></a> We considered normotensive those patients with a mean arterial pressure &#40;MAP&#41; between 70 and 105<span class="elsevierStyleHsp" style=""></span>mm<span class="elsevierStyleHsp" style=""></span>Hg&#44; hypotensive those with MAP<span class="elsevierStyleHsp" style=""></span>&#60;70<span class="elsevierStyleHsp" style=""></span>mm<span class="elsevierStyleHsp" style=""></span>Hg and hypertensive those with MAP<span class="elsevierStyleHsp" style=""></span>&#62;105<span class="elsevierStyleHsp" style=""></span>mm<span class="elsevierStyleHsp" style=""></span>Hg&#46; In terms of SI&#44; we considered normodynamic those patients with an SI of 35&#8211;65<span class="elsevierStyleHsp" style=""></span>mL&#47;m<span class="elsevierStyleSup">2</span>&#44; hypodynamic those with an SI<span class="elsevierStyleHsp" style=""></span>&#60;35<span class="elsevierStyleHsp" style=""></span>mL&#47;m<span class="elsevierStyleSup">2</span> and hyperdynamic those with an SI<span class="elsevierStyleHsp" style=""></span>&#62;65<span class="elsevierStyleHsp" style=""></span>mL&#47;m<span class="elsevierStyleSup">2</span>&#46;</p></li></ul></p></li><li class="elsevierStyleListItem" id="lsti0045"><span class="elsevierStyleLabel">&#8226;</span><p id="par0065" class="elsevierStylePara elsevierViewall">Laboratory variables&#58; For the present study&#44; we employed any blood extraction performed for clinical purposes between the 3 months before and after the study assessment&#46; This technique was performed under standardized conditions&#44; after at least 8<span class="elsevierStyleHsp" style=""></span>h of fasting&#46; The following biochemical measurements were performed in a Roche&#47;Hitachi&#174; modular-D analyzer&#58; glucose &#40;mg&#47;dL&#41;&#44; urea &#40;mg&#47;dL&#41;&#44; creatinine &#40;mg&#47;dL&#41;&#44; estimated glomerular filtration rate &#40;measured by the Chronic Kidney Disease Epidemiology Collaboration equation&#41; &#40;mL&#47;min&#47;1&#46;73<span class="elsevierStyleHsp" style=""></span>m<span class="elsevierStyleSup">2</span>&#41;&#44; sodium &#40;mEq&#47;L&#41;&#44; potassium &#40;mEq&#47;L&#41;&#44; bilirubin &#40;mg&#47;dL&#41;&#44; glutamic oxaloacetic transaminase &#40;U&#47;L&#41;&#44; glutamic pyruvic transaminase &#40;U&#47;L&#41;&#44; gamma-glutamyl transferase &#40;U&#47;L&#41;&#44; total cholesterol &#40;mg&#47;dL&#41;&#44; high-density lipoprotein cholesterol &#40;mg&#47;dL&#41;&#44; low-density lipoprotein cholesterol &#40;mg&#47;dL&#41;&#44; triglycerides &#40;mg&#47;dL&#41;&#44; glycated hemoglobin &#40;&#37;&#41; and thyroid-stimulating hormone &#40;mUI&#47;mL&#41;&#46;</p></li></ul></p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Statistical analysis</span><p id="par0070" class="elsevierStylePara elsevierViewall">The study participants&#8217; clinical and demographic characteristics were analyzed using the calculation of the mean and standard deviation &#40;SD&#41; for the quantitative variables and proportions for the qualitative variables&#46; For the analysis of qualitative variables&#44; we employed the chi-squared test with Yates correction or Fisher&#39;s exact test as necessary&#46; We analyzed the quantitative variables using Student&#39;s <span class="elsevierStyleItalic">t</span>-test or ANOVA&#44; with Bonferroni correction&#44; as necessary&#46; All tests were considered bilateral&#46; The results with p<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>&#46;05 were considered statistically significant&#46; The statistical analysis was performed with the SPSS program v 21&#46;0 &#40;IBM Corporation&#44; Armonk&#44; NY&#41;&#46;</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Ethical considerations</span><p id="par0075" class="elsevierStylePara elsevierViewall">The study was conducted in accordance with the principles of the Declaration of Helsinki &#40;1996&#41; in the Fortaleza version &#40;Brazil&#44; 2013&#41; and with the current guidelines on good clinical practices and was approved by our center&#8217;s research ethics committee&#46; All data were treated with the upmost confidentiality&#44; in accordance with current legislation&#46;</p></span></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Results</span><p id="par0080" class="elsevierStylePara elsevierViewall">The initial study population consisted of 36 adults with DS&#46; Six participants were excluded for a BMI<span class="elsevierStyleHsp" style=""></span>&#62;<span class="elsevierStyleHsp" style=""></span>35<span class="elsevierStyleHsp" style=""></span>kg&#47;m<span class="elsevierStyleSup">2</span>&#44; 1 was excluded for uncontrolled hypothyroidism&#44; and 3 were excluded for being unable to perform the study with the HOTMAN&#174; system&#46; The final sample consisted of 26 patients &#40;50 &#37; male&#41;&#46; The participants&#8217; mean age was 45<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>11 years&#44; with no difference between the sexes&#46; The mean BMI was 28&#46;5<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>2&#46;9&#46; Two patients &#40;7&#46;7 &#37;&#41; had normal weight&#44; 17 &#40;65&#46;4 &#37;&#41; had excess weight&#44; and 7 &#40;26&#46;9 &#37;&#41; had obesity&#46; The mean BP in the doctor&#39;s office was 109&#47;69<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>11&#47;9<span class="elsevierStyleHsp" style=""></span>mm<span class="elsevierStyleHsp" style=""></span>Hg&#44; and the mean heart rate was 60<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>12<span class="elsevierStyleHsp" style=""></span>bpm&#46; The prevalence of other relevant comorbidities is shown in <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0085" class="elsevierStylePara elsevierViewall">The results of the laboratory measurements are summarized in <a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>&#46; Despite the prevalence of excess weight and obesity in the sample&#44; none of the participants met the criteria for metabolic syndrome&#46;<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">12</span></a> None of the participants presented electrocardiographic signs of left ventricular hypertrophy or myocardial ischemia&#46;</p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><p id="par0090" class="elsevierStylePara elsevierViewall">Using the HOTMAN&#174; system&#44; 96 &#37; &#40;n<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>25&#41; of the study participants had normal blood pressure&#44; and 65&#46;4 &#37; &#40;n<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>17&#41; were normodynamic&#46; In terms of the modulators of the hemodynamic state&#44; 46&#46;1 &#37; of the participants &#40;n<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>12&#41; had hypochronotropism&#44; and 53&#46;8 &#37; &#40;n<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>14&#41; had hypervolemia&#46; One of the adults with DS had hypertension&#44; according to the criteria employed in this technique<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">20</span></a>&#59; however&#44; this diagnosis was not confirmed by OBPM&#46; The mean values for the hemodynamic study parameters measured with the HOTMAN&#174; system are shown in <a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a>&#44; and the representation of the hemodynamic state of the patient group is shown in <a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#46;</p><elsevierMultimedia ident="tbl0015"></elsevierMultimedia><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0095" class="elsevierStylePara elsevierViewall">Although OBPM was offered to all participants&#44; it was performed and provided quality readings for only 12 participants who agreed to it &#40;46&#46;2 &#37;&#41;&#46; None of the individuals with DS who underwent OBPM met the diagnostic criteria for AHT&#46; In terms of the measures reported at 24<span class="elsevierStyleHsp" style=""></span>h&#44; the mean systolic blood pressure &#40;SBP&#41; was 105<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>11<span class="elsevierStyleHsp" style=""></span>mm<span class="elsevierStyleHsp" style=""></span>Hg&#44; the mean diastolic blood pressure &#40;DBP&#41; was 67<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>11<span class="elsevierStyleHsp" style=""></span>mm<span class="elsevierStyleHsp" style=""></span>Hg&#44; and the mean arterial pressure &#40;MAP&#41; was 80<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>11<span class="elsevierStyleHsp" style=""></span>mm<span class="elsevierStyleHsp" style=""></span>Hg&#46; The mean heart rate was 61<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>6<span class="elsevierStyleHsp" style=""></span>bpm&#46; As a measure of variability&#44; we employed the median of the standard deviations for SBP&#44; MAP and heart rate at 24<span class="elsevierStyleHsp" style=""></span>h&#44; which were 22<span class="elsevierStyleHsp" style=""></span>mm<span class="elsevierStyleHsp" style=""></span>Hg &#40;interquartile range &#91;IQR&#93;&#44; 19<span class="elsevierStyleHsp" style=""></span>mm<span class="elsevierStyleHsp" style=""></span>Hg&#41;&#44; 22<span class="elsevierStyleHsp" style=""></span>mm<span class="elsevierStyleHsp" style=""></span>Hg &#40;IQR&#44; 18<span class="elsevierStyleHsp" style=""></span>mm<span class="elsevierStyleHsp" style=""></span>Hg&#41; and 11<span class="elsevierStyleHsp" style=""></span>bpm &#40;IQR&#44; 1&#46;8<span class="elsevierStyleHsp" style=""></span>bpm&#41;&#44; respectively&#46; <a class="elsevierStyleCrossRef" href="#tbl0020">Table 4</a> summarizes the results of the BP measures during the diurnal&#44; nocturnal and 24-h periods&#46; Ten participants with DS showed a dipper circadian blood pressure pattern&#44; while 2 patients showed a non-dipper pattern&#46; None of the participants had a riser circadian pattern&#46;</p><elsevierMultimedia ident="tbl0020"></elsevierMultimedia><p id="par0100" class="elsevierStylePara elsevierViewall">Lastly&#44; we compared the hemodynamic parameters of the participants who underwent OBPM with those of the rest of the sample&#46; When comparing the OBPM group versus the non-OBPM group&#44; we observed statistically significant differences in sex distribution &#40;9 males &#91;75 &#37;&#93; vs&#46; 4 males &#91;29 &#37;&#93;&#44; respectively&#59; p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>&#46;02&#41;&#44; hypothyroidism &#40;5 &#91;42 &#37;&#93; vs&#46; 13 &#91;93 &#37;&#93;&#59; p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>&#46;01&#41;&#44; inotropic stroke index &#40;1&#46;25 &#91;SD&#44; 0&#46;37&#93; vs&#46; 0&#46;94<span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>sec<span class="elsevierStyleSup">&#8722;2</span> &#91;SD&#44; 0&#46;33&#93;&#59; p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>&#46;03&#41;&#44; hyperinotropism &#40;4 &#91;33 &#37;&#93; vs&#46; 0 &#91;0 &#37;&#93;&#59; p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>&#46;03&#41; and normal blood volume &#40;10 &#91;83 &#37;&#93; vs&#46; 2 &#91;14&#46;3 &#37;&#93;&#59; p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>&#46;001&#41;&#46;</p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">Discussion</span><p id="par0105" class="elsevierStylePara elsevierViewall">The first relevant result of our study was the absence of patients with DS who met the diagnostic criteria for AHT&#44; either through causal BP detection in the doctor&#39;s office or through OBPM&#46; Secondly&#44; it is worth noting the predominant hemodynamic profile in our sample&#44; which consisted of normal pressure and normal dynamism&#44; with hypervolemia&#44; hypochronotropism&#44; normal inotropism and normal or reduced vascular resistances as the main modulators&#46;</p><p id="par0110" class="elsevierStylePara elsevierViewall">The only participant who met the criteria of AHT through bioimpedance presented a mean BP of 140&#47;67<span class="elsevierStyleHsp" style=""></span>mm<span class="elsevierStyleHsp" style=""></span>Hg with the HOTMAN&#174; system&#46; This value was interpreted as diagnostic of AHT due to an SBP over the limit&#46; Nevertheless&#44; the casual measurement in the doctor&#39;s office and OBPM observed only normal measures during the observation period&#46; As this was the only measurement&#44; we interpret this discrepancy as possibly attributable to an alert reaction or nervousness during the performance of the test&#44; which&#44; despite being non-invasive&#44; involves the use of cables in an unknown environment&#44; both potential sources of stress for a participant with intellectual disability&#46;</p><p id="par0115" class="elsevierStylePara elsevierViewall">The findings reported in this study are consistent with the current paradigm of a special cardiovascular protection and normal pressure in the population of adults with DS&#46; Despite a high prevalence of weight disorders and physical inactivity in the adult population with DS&#44; these individuals do not seem to develop AHT&#46;<a class="elsevierStyleCrossRefs" href="#bib0025"><span class="elsevierStyleSup">5&#44;22&#44;23</span></a> The diagnosis of AHT in all previous series was established retrospectively by analyzing the discharge reports or by casual BP measurement in the doctor&#39;s office&#46; The present study added a detailed vascular study using OBPM and HOTMAN&#174;&#44; which helps consolidate the initial observations&#46;</p><p id="par0120" class="elsevierStylePara elsevierViewall">Secondly&#44; in light of these results&#44; we postulate that the primary hemodynamic disorder of adults with DS appears to be hypochronotropism&#44; a hypothesis consistent with previous studies that have indicated a sympathetic dysregulation in adults with DS&#46; It has therefore been observed that individuals with DS have a lower baseline heart rate than individuals without DS&#46;<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">24</span></a> It has also been shown that these individuals have poorer BP and heart rate adaptation to exercise&#46;<a class="elsevierStyleCrossRefs" href="#bib0125"><span class="elsevierStyleSup">25&#44;26</span></a> Sympathetic dysregulation has also been postulated as a mechanism to explain the increased prevalence of neurally mediated syncope observed in this population&#46; Furthermore&#44; a recent study by Patel et al&#46; showed that individuals with DS have lower sympathetic innervation of some organs and that this disorder is mediated by RCAN1&#44; a gene located in chromosome 21 and whose products cause neural growth factor inhibition&#46;<a class="elsevierStyleCrossRef" href="#bib0135"><span class="elsevierStyleSup">27</span></a></p><p id="par0125" class="elsevierStylePara elsevierViewall">In this context of hypochronotropism&#44; the observed hypervolemia reflects a compensatory mechanism for this primary disorder&#46; Vascular resistances can also be expected to increase in an attempt to maintain vascular tone&#46; However&#44; the resistances were inadequately normal or low in 85 &#37; of our study participants&#46; We therefore suspect that another of the primary mechanisms underlying the absence of AHT in adults with DS directly points to the renin-angiotensin-aldosterone system &#40;RAAS&#41;&#46; We have found no studies that have systematically evaluated RAAS function in the population with DS&#46; However&#44; indirect data from cell models indicate that the RCAN1 gene located on chromosome 21 governs the effects of angiotensin <span class="elsevierStyleSmallCaps">II</span>&#44; reducing the cardiac hypertrophy that depends on this molecule&#46;<a class="elsevierStyleCrossRef" href="#bib0140"><span class="elsevierStyleSup">28</span></a> Similarly&#44; the DYRK1A gene&#44; also overexpressed in DS&#44; has been recently linked to a reduction in neprilysin levels in the fibroblasts of individuals with DS&#46;<a class="elsevierStyleCrossRef" href="#bib0145"><span class="elsevierStyleSup">29</span></a> Given the possibility that constitutive overexpression of RCAN1 and DYRK1A in individuals with DS directly affects RAAS regulation&#44; a differential study of the molecular characterization of this axis in individuals with DS compared with the population without DS could be an essential step in clarifying the mechanisms underlying its cardiovascular protection&#46;</p><p id="par0130" class="elsevierStylePara elsevierViewall">Our study&#8217;s strengths include the novelty of using bioimpedance to perform the vascular study of individuals with DS&#44; which has not been previously performed&#46; Our study&#8217;s fundamental limitation was its cross-sectional design and low number of recruited participants&#44; which reflect the complexity of clinical practice and the care for individuals with disability&#44; thereby limiting the potential for generalizing the results&#46; However&#44; the standard deviations observed in our study were low&#46; We would therefore expect that a larger sample size would not necessarily result in a significant change in the current results&#46; Similarly&#44; the lack of a control group is another significant limitation&#46; We have therefore planned to incorporate individuals without DS &#40;mostly siblings&#41; in future studies&#46; It is difficult to interpret the clinical relevance of the clinical differences observed between the OBPM and non-OBPM subgroups&#46; First&#44; we observed no differences between sexes in the analysis of the hemodynamic study in the full sample&#46; Despite a different rate of hypothyroidism as a relevant antecedent between the groups&#44; all study patients were properly treated with levothyroxine&#44; as shown by the thyroid-stimulating hormone results&#46; We also observed no significant differences in terms of BP in the doctor&#39;s office&#46; The results of the OBPM might therefore be extrapolatable to the rest of the sample&#46;</p></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0105">Conclusions</span><p id="par0135" class="elsevierStylePara elsevierViewall">Despite the progressive aging of the population with DS&#44; AHT is a comorbidity virtually absent in adults with DS&#46; These individuals have a hemodynamic condition dominated by hypochronotropism and hypervolemia&#44; maintaining normal and even reduced vascular resistances&#46; The regulation of both chronotropism and vascular resistances is postulated as the main mechanism for hypotension or normal pressure constitutive of this population&#46;</p></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0110">Funding</span><p id="par0140" class="elsevierStylePara elsevierViewall">This project was funded by the <span class="elsevierStyleGrantSponsor" id="gs0005">Spanish Society of Internal Medicine</span> &#40;2017 Dr&#46; Prof&#46; Miguel Vilardell prize for clinical research&#41;&#44; by the <span class="elsevierStyleGrantSponsor" id="gs0010">Jer&#244;me Lejeune Foundation</span> &#40;Cycle2017B&#47;Project &#35;1711&#41; and the <span class="elsevierStyleGrantSponsor" id="gs0015">Society of Internal Medicine of Madrid and Castilla La Mancha</span> &#40;2018 grant to the best research project&#41;&#46;</p></span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0115">Conflicts of interest</span><p id="par0145" class="elsevierStylePara elsevierViewall">The authors declare that they have no conflicts of interest&#46;</p></span></span>"
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    "fechaRecibido" => "2019-07-18"
    "fechaAceptado" => "2019-09-05"
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            1 => "Arterial hypertension"
            2 => "Cardiovascular risk"
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            0 => "S&#237;ndrome de Down"
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        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Objectives</span><p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">Although the reasons are unknown&#44; the prevalence of arterial hypertension and atherosclerotic cardiovascular events in the adult population with Down syndrome &#40;SD&#41; is anecdotal&#46; To better understand this finding&#44; we evaluated the haemodynamic characteristics of a cohort of adults with SD&#46;</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Methods</span><p id="spar0065" class="elsevierStyleSimplePara elsevierViewall">We conducted a cross-sectional study of adults with SD recruited consecutively from the outpatient clinics of an internal medicine department between June and November 2018&#46; We collected demographic&#44; clinical and laboratory variables and employed a thoracic bioimpedance device &#40;HOTMAN&#174; System&#41; for the haemodynamic measures&#46; Outpatient blood pressure monitoring &#40;OBPM&#41; was conducted on a subgroup of participants&#46;</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Results</span><p id="spar0070" class="elsevierStyleSimplePara elsevierViewall">Twenty-six participants &#40;mean age&#44; 45<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>11 years&#41; participated in the study &#40;50 &#37; men&#41;&#46; The sample&#8217;s mean blood pressure &#40;BP&#41; was 109&#47;69<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>11&#47;9<span class="elsevierStyleHsp" style=""></span>mm Hg&#44; with a mean heart rate of 60<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>12 bpm&#46; None of the participants had hypertension&#46; The predominant haemodynamic profile consisted of normal dynamism &#40;65 &#37;&#41;&#44; normal BP &#40;96 &#37;&#41;&#44; hypochronotropism &#40;46 &#37;&#41;&#44; normal inotropism &#40;50 &#37;&#41; and hypervolaemia &#40;54 &#37;&#41;&#44; with normal peripheral vascular resistance values &#40;58 &#37;&#41;&#46; Twelve participants underwent OBPM &#40;46 &#37;&#41;&#46; The mean 24-h systolic BP&#44; diastolic BP&#44; mean BP and mean heart rate were 105<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>11<span class="elsevierStyleHsp" style=""></span>mm Hg&#44; 67<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>11<span class="elsevierStyleHsp" style=""></span>mm Hg&#44; 80<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>11<span class="elsevierStyleHsp" style=""></span>mm Hg and 61<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>6 bpm&#44; respectively&#46;</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Conclusions</span><p id="spar0075" class="elsevierStyleSimplePara elsevierViewall">The most common haemodynamic profile observed in adults with SD consisted of hypochronotropism and hypervolaemia&#44; with normal values for peripheral vascular resistance and optimal mean BP values&#46; There were no participants with hypertension in our sample&#46;</p></span>"
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            "titulo" => "Methods"
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        "resumen" => "<span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Objetivos</span><p id="spar0080" class="elsevierStyleSimplePara elsevierViewall">Si bien se desconocen los motivos&#44; la prevalencia de hipertensi&#243;n arterial <span class="elsevierStyleBold">y</span> de eventos cardiovasculares ateroscler&#243;ticos en la poblaci&#243;n adulta con s&#237;ndrome de Down &#40;SD&#41; es anecd&#243;tica&#46; Para entender mejor este hallazgo evaluamos las caracter&#237;sticas hemodin&#225;micas de una cohorte de adultos con SD&#46;</p></span> <span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">M&#233;todos</span><p id="spar0085" class="elsevierStyleSimplePara elsevierViewall">Estudio transversal en adultos con SD reclutados de modo consecutivo de las consultas externas del servicio de M&#46; Interna entre junio y noviembre 2018&#46; Se recogieron variables demogr&#225;ficas&#44; cl&#237;nicas y anal&#237;ticas&#46; Se utiliz&#243; un dispositivo de bioimpedancia tor&#225;cica &#40;HOTMAN&#174; System&#41; para las medidas hemodin&#225;micas&#46; Se realiz&#243; una monitorizaci&#243;n ambulatoria de presi&#243;n arterial &#40;MAPA&#41; en un subgrupo de sujetos&#46;</p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Resultados</span><p id="spar0090" class="elsevierStyleSimplePara elsevierViewall">Veintis&#233;is sujetos de edad media 45<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>11 a&#241;os participaron en el estudio &#40;50&#37; varones&#41;&#46; La presi&#243;n arterial &#40;PA&#41; media en la muestra fue de 109&#47;69<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>11&#47;9<span class="elsevierStyleHsp" style=""></span>mmHg&#44; con una frecuencia cardiaca media de 60<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>12 lpm&#46; Ning&#250;n sujeto era hipertenso&#46; El perfil hemodin&#225;mico predominante consisti&#243; en normodinamismo &#40;65&#37;&#41;&#44; normotensi&#243;n &#40;96&#37;&#41;&#44; hipocronotropismo &#40;46&#37;&#41;&#44; normoinotropismo &#40;50&#37;&#41; ehipervolemia &#40;54&#37;&#41;&#44; con valores normales de resistencias vasculares perif&#233;ricas &#40;58&#37;&#41;&#46; Se realiz&#243; una MAPA a 12 sujetos &#40;46&#37;&#41;&#46; Los valores medios en 24<span class="elsevierStyleHsp" style=""></span>h de PA sist&#243;lica fueron 105<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>11<span class="elsevierStyleHsp" style=""></span>mmHg&#44; PA diast&#243;lica 67<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>11<span class="elsevierStyleHsp" style=""></span>mmHg&#44; PA media 80<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>11<span class="elsevierStyleHsp" style=""></span>mmHg y frecuencia cardiaca media 61<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>6 lpm&#46;</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Conclusiones</span><p id="spar0095" class="elsevierStyleSimplePara elsevierViewall">El perfil hemodin&#225;mico m&#225;s frecuentemente observado en adultos con SD consisti&#243; en hipocronotropismo e hjpervolemia&#44; con valores normales de resistencias vasculares perif&#233;ricas y valores medios &#243;ptimos de PA&#46; No identificamos ning&#250;n sujeto hipertenso en nuestra muestra&#46;</p></span>"
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        "nota" => "<p class="elsevierStyleNotepara" id="npar0020">Please cite this article as&#58; Roy-Vallejo E&#44; Alonso E&#44; Galv&#225;n-Rom&#225;n JM&#44; Iba&#241;ez P&#44; Moldenhauer F&#44; Su&#225;rez Fern&#225;ndez C&#44; et al&#46; Perfil hemodin&#225;mico de los adultos espa&#241;oles con s&#237;ndrome de Down&#46; Rev Clin Esp&#46; 2020&#59;220&#58;275&#8211;281&#46;</p>"
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          "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Hemodynamic state of adults with Down syndrome and its modulators &#40;print in color&#41;&#46;</p> <p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Abscissa axis&#58; hemodynamic state and its modulators&#59; ordinate axis&#58; percentage of patients in each category&#46;</p> <p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Red&#44; hyper&#59; green&#44; normal&#59; blue&#44; hypo&#46;</p>"
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          "leyenda" => "<p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Abbreviations&#58; CVD&#44; cardiovascular disease&#59; DBP&#44; diastolic blood pressure&#59; DS&#44; Down syndrome&#59; eGFR&#44; estimated glomerular filtration rate&#59; HR&#44; heart rate&#59; SAHS&#44; sleep apnea-hypopnea syndrome&#59; SBP&#44; systolic blood pressure&#59; SD&#44; standard deviation&#46;</p>"
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                  <table border="0" frame="\n
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Adults with DS &#40;n<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>26&#41; Mean &#40;SD&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">Sex&#44; males&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">13 &#40;50 &#37;&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">Weight&#44; kg&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">64&#46;3<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>8&#46;3&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">BMI&#44; kg&#47;m<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">28&#46;5<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>2&#46;9&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">Abdominal circumference&#44; cm&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">91<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>10&nbsp;\t\t\t\t\t\t\n
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                  \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">0&nbsp;\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">Diabetes mellitus&nbsp;\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 &#40;4 &#37;&#41;&nbsp;\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">Dyslipidemia&nbsp;\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 &#40;4 &#37;&#41;&nbsp;\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">Family history of premature CVD&nbsp;\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">0&nbsp;\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">Chronic kidney disease &#40;eGFR<span class="elsevierStyleHsp" style=""></span>&#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>&#41;&nbsp;\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 &#40;4 &#37;&#41;&nbsp;\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">Congenital heart disease&nbsp;\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 &#40;4 &#37;&#41;&nbsp;\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">Hypothyroidism&nbsp;\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">18 &#40;69 &#37;&#41;&nbsp;\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">SAHS&nbsp;\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 &#40;23 &#37;&#41;&nbsp;\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">Charlson index<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="\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">0 &#40;1&#41;&nbsp;\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">SBP in doctor&#39;s office&#44; mm<span class="elsevierStyleHsp" style=""></span>Hg&nbsp;\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">109&#46;2<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></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">DBP in doctor&#39;s office&#44; mm<span class="elsevierStyleHsp" style=""></span>Hg&nbsp;\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">68&#46;9<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>9&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></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">HR in doctor&#39;s office&#44; bpm&nbsp;\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">59&#46;6<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></tr></tbody></table>
                  """
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          "leyenda" => "<p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Abbreviations&#58; DS&#44; Down syndrome&#59; eGFR&#44; estimated glomerular filtration rate&#59; SD&#44; standard deviation&#46;</p>"
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              "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">Laboratory Analysis&nbsp;\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">Adults with DS &#40;n<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>26&#41; Mean &#40;SD&#41;&nbsp;\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">Glucose&#44; mg&#47;dL&nbsp;\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">91&#46;7<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>11&#46;7&nbsp;\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">Urea&#44; mg&#47;dL&nbsp;\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">38&#46;9<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>14&#46;4&nbsp;\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">Creatinine&#44; mg&#47;dL&nbsp;\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&#46;0<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>0&#46;2&nbsp;\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">eGFR CKD-EPI &#40;mL&#47;min&#47;1&#46;73<span class="elsevierStyleHsp" style=""></span>m<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a>&#41;&nbsp;\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">87&#46;8<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>19&#46;8&nbsp;\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">Sodium&#44; mEq&#47;L&nbsp;\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">141<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>1&#46;8&nbsp;\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">Potassium&#44; mEq&#47;L&nbsp;\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">4&#46;4<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>0&#46;2&nbsp;\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">Bilirubin&#44; mg&#47;dL&nbsp;\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">0&#46;5<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>0&#46;2&nbsp;\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">GOT&#44; U&#47;L&nbsp;\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">22<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></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">GPT&#44; U&#47;L&nbsp;\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">21&#46;4<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></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">GGT&#44; U&#47;L&nbsp;\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">19&#46;9<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></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">Total cholesterol&#44; mg&#47;dL&nbsp;\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">193<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>34&nbsp;\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">HDL&#44; mg&#47;dL&nbsp;\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">55<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>11&#46;5&nbsp;\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">LDL&#44; mg&#47;dL&nbsp;\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">125<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>24&nbsp;\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">Triglycerides&#44; mg&#47;dL&nbsp;\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">86<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>24&nbsp;\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">HbA1c&#44; &#37;&nbsp;\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">5&#46;4<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>0&#46;4&nbsp;\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">TSH&#44; mUI&#47;mL&nbsp;\t\t\t\t\t\t\n
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          "leyenda" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Abbreviations&#58; DS&#44; Down syndrome&#59; ISI&#44; inotropic state index&#59; LSWI&#44; left stroke work index&#59; MAP&#44; mean arterial pressure&#59; SSVRI&#44; stroke systemic vascular resistance index&#46;</p>"
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                  \t\t\t\t">MAP&#44; mm<span class="elsevierStyleHsp" style=""></span>Hg&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">84<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>8&nbsp;\t\t\t\t\t\t\n
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      "titulo" => "References"
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        0 => array:2 [
          "identificador" => "bibs0005"
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                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Global and Regional Causes of Death&#58; Patterns and Trends&#44; 2000&#8211;15"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:5 [
                            0 => "C&#46; Mathers"
                            1 => "G&#46; Stevens"
                            2 => "D&#46; Hogan"
                            3 => "W&#46;R&#46; Mahanani"
                            4 => "J&#46; Ho"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1596/978-1-4648-0527-1/pt2.ch4"
                      "LibroEditado" => array:4 [
                        "editores" => "D&#46;T&#46;Jamison, H&#46;Gelband, S&#46;Horton, P&#46;Jha, R&#46;Laxminarayan, C&#46;N&#46;Mock"
                        "titulo" => "Disease Control Priorities&#58; Improving Health and Reducing Poverty"
                        "edicion" => "3rd ed&#46;"
                        "serieFecha" => "2017"
                      ]
                    ]
                  ]
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                  "contribucion" => array:1 [
                    0 => array:1 [
                      "titulo" => "Global&#44; regional&#44; and national age-sex-specific mortality for 282 causes of death in 195 countries and territories&#44; 1980&#8211;2017&#58; a systematic analysis for the Global Burden of Disease Study 2017"
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1016/S0140-6736(18)32203-7D"
                      "Revista" => array:6 [
                        "tituloSerie" => "Lancet Lond Engl&#46;"
                        "fecha" => "2018"
                        "volumen" => "392"
                        "numero" => "10159"
                        "paginaInicial" => "1736"
                        "paginaFinal" => "1788"
                      ]
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                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Mortality associated with Down&#8217;s syndrome in the USA from 1983 to 1997&#58; a population-based study"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:3 [
                            0 => "Q&#46; Yang"
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        "texto" => "<p id="par0150" class="elsevierStylePara elsevierViewall">The authors would like to thank Jes&#250;s Coronado Hinojosa for his support to the Adults with Down Syndrome Unit of the University Hospital de La Princesa and to its research program&#46; We would also like to thank Patricia Carles for her assistance in preparing this manuscript&#46;</p>"
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Article information

ISSN: 22548874
Original language: English

DOI:10.1016/j.rceng.2019.09.005

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