Impact of smoking cessation on estimated cardiovascular risk in Spanish type 2 diabetes mellitus patients: The DIABETES study

Luque-Ramírez, M.; Sanz de Burgoa, V.

doi:10.1016/j.rceng.2018.04.012

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Gutiérrez Guisado, J. Trujillo-Santos, J.I. Arcelus, L. Bertoletti, C. Fernandez-Capitán, R. Valle, J.A. Hernandez-Hermoso, A. Erice Calvo-Sotelo, J.A. Nieto, M. Monreal" "autores" => array:11 [ 0 => array:2 [ "nombre" => "J." "apellidos" => "Gutiérrez Guisado" ] 1 => array:2 [ "nombre" => "J." "apellidos" => "Trujillo-Santos" ] 2 => array:2 [ "nombre" => "J.I." "apellidos" => "Arcelus" ] 3 => array:2 [ "nombre" => "L." "apellidos" => "Bertoletti" ] 4 => array:2 [ "nombre" => "C." "apellidos" => "Fernandez-Capitán" ] 5 => array:2 [ "nombre" => "R." "apellidos" => "Valle" ] 6 => array:2 [ "nombre" => "J.A." "apellidos" => "Hernandez-Hermoso" ] 7 => array:2 [ "nombre" => "A." "apellidos" => "Erice Calvo-Sotelo" ] 8 => array:2 [ "nombre" => "J.A." "apellidos" => "Nieto" ] 9 => array:2 [ "nombre" => "M." 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Luque-Ramírez, V. Sanz de Burgoa" "autores" => array:3 [ 0 => array:3 [ "nombre" => "M." "apellidos" => "Luque-Ramírez" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "a" "identificador" => "aff0005" ] ] ] 1 => array:4 [ "nombre" => "V." "apellidos" => "Sanz de Burgoa" "email" => array:1 [ 0 => "veronica.sanz.de.burgoa@pfizer.com" ] "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "b" "identificador" => "aff0010" ] 1 => array:2 [ "etiqueta" => "*" "identificador" => "cor0005" ] ] ] 2 => array:1 [ "colaborador" => "on behalf of the participants of the DIABETES study" ] ] "afiliaciones" => array:2 [ 0 => array:3 [ "entidad" => "Grupo de Investigación en Diabetes, Obesidad y Reproducción Humana, Universidad de Alcalá, Hospital Universitario Ramón y Cajal, Instituto Ramón y Cajal de Investigación Sanitaria (IRYCIS), Centro de Investigación Biomédica en Red Diabetes y Enfermedades Metabólicas Asociadas (CIBERDEM), Madrid, Spain" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Departamento Médico, Pfizer S.L.U., Madrid, Spain" "etiqueta" => "b" "identificador" => "aff0010" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Impacto de la cesación tabáquica en el riesgo cardiovascular estimado de pacientes con diabetes mellitus tipo 2: El estudio DIABETES" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 4125 "Ancho" => 1492 "Tamanyo" => 234013 ] ] "descripcion" => array:1 [ "en" => "(A) Estimated risk of coronary heart disease at 10 years according to the UKPDS risk engine as a function of smoking status. The data were analyzed with a one-way general linear model, introducing age as a covariate. Current smokers are represented by black circles and ex-smokers by white circles. *p<.05 for smoking status. (B) Influence of blood glucose control upon the estimated risk of coronary heart disease as a function of smoking status. The data were analyzed with a two-way general linear model, introducing age as a covariate. Current smokers are represented by black circles and ex-smokers by white circles. *p<.05 for smoking status. †p<.05 for blood glucose control status. ‡p<.05 for the interaction between smoking status and blood glucose control. (C) Influence of age and gender upon estimated relative risk reduction of coronary heart disease among ex-smokers versus smokers. Data are shown as means. Estimated risk of coronary heart disease in current smokers is represented by black circles. Arrowheads represent estimated relative risk reduction of ex-smokers vs. current smokers." ] ] ] "textoCompleto" => "BackgroundMany smoking-related deaths are due to cardiovascular diseases such as coronary heart disease (CHD), stroke and peripheral arterial disease.<a class="elsevierStyleCrossRef" href="#bib0150">1</a> In Spain, 24% of the population older than 15 years smokes, and 20% claim to be ex-smokers.<a class="elsevierStyleCrossRef" href="#bib0155">2</a>Current smokers have an increased risk of developing type 2 diabetes mellitus (DM2)<a class="elsevierStyleCrossRef" href="#bib0160">3</a> and the chronic macrovascular complications of diabetes. Smoking is a major risk factor for cardiovascular morbidity and CHD in patients with DM2.<a class="elsevierStyleCrossRef" href="#bib0165">4</a> However, the prevalence of smoking among men and women with diabetes in Spain is approximately 27% and 35%, respectively.<a class="elsevierStyleCrossRef" href="#bib0170">5</a> Smoking cessation (SC) in this high-risk population could be one of the best approaches for proper disease management.Information provided by cardiovascular risk scales can be useful in primary care, both for diagnosis and treatment. However, the accuracy of most current scales in predicting risk among patients with DM2 is a subject of debate. To solve this problem, the United Kingdom Prospective Diabetes Study (UKPDS) Risk Engine was published in 2001, which included, among other factors, blood glucose control and the duration of the patient's diabetes.<a class="elsevierStyleCrossRef" href="#bib0175">6</a>This study assesses the cardiovascular risk according to the UKPDS risk engine in a representative sample of patients with DM2, comparing the clinical characteristics of smokers versus those of ex-smokers.MethodsObjectivesOur primary objective was to assess and compare, using the UKPDS risk engine, the CHD risk of patients with DM2 who were either current or former smokers. The secondary objective was to compare these results with those obtained with the Registre Gironí del Cor (REGICOR) and Framingham scales.Study designA total of 156 Spanish diabetes specialists participated in this nationwide, cross-sectional, observational, epidemiological, multicenter study, which employed a stratified, multistage probability sample without replacement. The sampling frame was all health regions of the 17 Spanish autonomous communities, similar to other studies sponsored by Pfizer Spain.<a class="elsevierStyleCrossRef" href="#bib0180">7</a> The number of clinics was proportional to the population of each region.Patients and methodsThe study was conducted from February to December 2012. To ensure similarity in terms of sex and age range, each investigator included 8 patients with DM2<a class="elsevierStyleCrossRef" href="#bib0185">8</a> (4 current smokers and 4 ex-smokers) who visited their office for any reason. The inclusion criteria were (a) patients of either sex, (b) an age of 18 years or older and c) current smokers (daily consumers of at least 1 cigarette/day for the last month) or former smokers (at least 10 years since quitting). The exclusion criteria were (a) former smoker for fewer than 10 years, (b) a history of cardiovascular events or known nephropathy (secondary cardiovascular disease prevention) and (c) unwillingness to participate in the study. All included participants provided their informed written consent. The study was approved by the ethics committees of all the centers involved and by the Spanish Ministry of Health. The following data were recorded: (a) demographic data (province and area [rural, intermediary or urban]); (b) anthropometric variables, including height, weight and waist circumference; (c) blood pressure measured in the consultation<a class="elsevierStyleCrossRef" href="#bib0190">9</a>; (d) the last metabolic blood profile including HbA1c and lipid levels; (e) DM2 state according to the American Diabetes Association (ADA) classification; and (f) current smoking status, age when patient started smoking, duration of smoking cessation (ex-smokers) and packs/year (current smokers).The data were collected during a single visit, and there was no follow-up. All gathered data were based on the information provided by the participants and on the data contained in the case histories. All participants continued to undergo their usual diabetic treatment indicated by their physicians.Using the participants’ clinical data, the CHD risk at 10 years was estimated with the UKPDS equation<a class="elsevierStyleCrossRef" href="#bib0175">6</a> using Microsoft Excel's implementation of the UKPDS Risk Engine v2.0 provided by the University of Oxford.<a class="elsevierStyleCrossRef" href="#bib0195">10</a>This equation includes the age at diagnosis, sex, ethnicity, DM2 duration (years), HbA1c level, smoking status, systolic blood pressure (SBP) and total and high-density lipoprotein (HDL)-cholesterol. To assess the influence of the population used for the development of risk scales and their suitability for patients with diabetes, we also calculated the risks based on the Framingham equation calibrated for the Spanish population aged 35–74 years (REGICOR),<a class="elsevierStyleCrossRef" href="#bib0200">11</a> using the online risk calculator (v2.1, April 2012), and on the updated (2008) Framingham risk equation<a class="elsevierStyleCrossRef" href="#bib0205">12</a> using the Microsoft Excel worksheet designed by the University of Edinburgh.<a class="elsevierStyleCrossRef" href="#bib0210">13</a> The REGICOR scale includes sex, age, presence of DM2, smoking status, total cholesterol level, SBP and diastolic blood pressure (DBP), adjusting the total result according to HDL-cholesterol levels. The Framingham scale is based on age, sex, smoking status (smoker/nonsmoker), diabetes status, SBP, total cholesterol and HDL-cholesterol. Long-term former smokers with diabetes show small differences in tobacco-related cardiovascular deaths when compared with nonsmokers. These differences are even smaller in terms of CHD,<a class="elsevierStyleCrossRef" href="#bib0215">14</a> with a significant risk reduction observed after 10 years of smoking cessation. Accordingly, our ex-smokers were coded as nonsmokers in the REGICOR and Framingham risk scales.Statistical analysisThe results are expressed as mean±standard deviation (SD), mean (95% confidence interval [95%CI]) or counts (percentage), unless stated otherwise. Nominal variables were analyzed with the chi-squared test or Fisher's exact test as appropriate. We performed a z transformation of the continuous variables, expressing the deviation from the mean as SD. We then used univariate one-way general linear models (GLMs) to evaluate the differences in the continuous variables between current and ex-smokers based on a single analysis. Given that there were differences between the two types of smokers using the t test, age was introduced as a covariate in the analysis of other variables. The effect of the risk scales, duration of diabetes, blood glucose control and smoking status on the estimated CHD at 10 years was analyzed using a two-way GLM, introducing age as a covariate. Significant differences among the risk scales were then analyzed by applying the Bonferroni correction. The relative risk reduction (RRR), regarded as the estimated reduction of coronary heart event risk between former and current smokers, was calculated as follows: [(current smokers estimated event rate−former smokers estimated event rate)/former smokers estimated event rate]×100. The number needed to treat (NNT) was calculated as follows: [1/(current smokers estimated event rate−former smokers estimated event rate)]. The SPSS statistical package (version 17.0)<a class="elsevierStyleCrossRef" href="#bib0220">15</a> was employed throughout the analysis. Statistical significance was considered for p<.05.ResultsStudy population characteristicsA total of 1062 patients with DM2 were initially included, 172 of whom were subsequently excluded (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>), resulting in 890 patients ultimately analyzed. The patients were distributed to 2 separate groups according to smoking habit: 444 current smokers and 446 ex-smokers. Ninety-five percent (95%) and 96% of the active and ex-smokers were 35 years of age or older, respectively. The smokers had a lower body mass index (BMI) than ex-smokers despite having similar waist circumferences. Obesity (BMI ≥30kg/m2) was also lower in the current smokers (current vs. ex-smokers: 165 [37%] and 190 [43%]; chi-squared, 7.9, p=.019). The mean HbA1c and triglyceride levels were higher in the current smokers (<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a><a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>).<elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="tbl0005"></elsevierMultimedia>Estimated risk of coronary heart disease according to the UKPDS risk engineThe likelihood of CHD at 10 years according to the UKPDS risk engine was significantly greater for the smokers (25.4%; 95% CI 23.6–27.2) than for the ex-smokers (20.8%; 95% CI 19.3–22.4), after adjusting for age (F, 850.2; p<.001) (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>A). The RRR of the former smokers versus the current smokers was 22% at 10 years. The estimated NNT to avoid a coronary event at 10 years was 22 individuals. Smokers also had a greater mean predicted risk of a fatal coronary event at 10 years (17.9%; 95% CI 16.3–19.5) than the ex-smokers (15.4%; 95% CI 14.0–16.9) (F, 875.2; p<.001, adjusted for age) (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>A). The RRR of the ex-smokers for a fatal coronary event at 10 years was 15% compared with the current smokers. The estimated NNT was 43 individuals. The risk of CHD at 10 years (UKPDS risk ≥20%) was lower for the former smokers (178, 40%) than for the current smokers (223, 50%) (odds ratio [OR], 1.5; 95% CI 1.2–2]; chi-squared, 9.6; p=.002), as was the risk for a fatal coronary event (114 [26%] vs. 140 [32%], respectively; OR, 1.3; 95% CI 1.0–1.8; chi-squared, 3.9; p=.049). The RRR was similar for those patients diagnosed with diabetes 10 or more years ago (36.7% [95% CI 33.6–39.8] vs. 28.7% [95% CI 26.2–31.3] for the current smokers vs. ex-smokers, respectively; RRR, 28%) and for those participants who had been diagnosed with diabetes within the past 10 years (17.2% [95% CI 15.6–18.8] vs. 13.4% [95% CI 12.0–14.8] for the current smokers vs. former smokers, respectively; RRR, 29%). In addition, the patients with poor blood glucose control (HbA1c >7%) benefited more from smoking cessation (RRR of ex-smokers vs. current smokers, 24%) than those individuals with HbA1c ≤7% (RRR of ex-smokers vs. smokers, 10%) (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>B). As for the influence of age and sex (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>C), we detected a higher RRR of predicted CHD risk in the former smokers versus current smokers, regardless of the age in men and in women under 60 years of age (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>B).<elsevierMultimedia ident="fig0010"></elsevierMultimedia>Comparison of the UKPDS, REGICOR and Framingham risk scalesThe study included patients between 35 and 75 years of age (<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>). There were statistically significant differences among the 3 risk scales in predicting CHD risk at 10 years. The patients showed the highest estimated risk when assessed by the UKPDS risk engine, while the lowest values were observed with the REGICOR scale. Nonetheless, all equations showed a reduced estimated CHD risk at 10 years in former smokers compared with current smokers. According to the UKPDS risk engine, however, this higher risk only applies to men. The number of patients presenting a very high CHD risk (UKPDS and Framingham score ≥20% or REGICOR score ≥10%), considering all patients as a whole (current smokers vs. ex-smokers) was 207 (51%) versus 142 (37%) for the UKPDS risk engine (OR, 1.8; 95% CI 1.4–2.4]; chi-squared, 17.7; p<.001); 235 (58%) versus 101 (26%) for the Framingham scale (OR, 4.0; 95% CI 2.9–5.4]; chi-squared, 84.3; p<.001) and 198 (49%) versus 91 (23%) for the REGICOR scale (OR, 3.2; 95% CI 2.3–4.3]; chi-squared, 56.6; p<.001).<elsevierMultimedia ident="tbl0010"></elsevierMultimedia>DiscussionThis study is the first to offer a comprehensive evaluation of predicted CHD in current vs. ex-smokers DM2 Spanish patients. Our results support the beneficial effect of smoking cessation in the primary prevention of CHD, as recommended by current clinical guidelines.<a class="elsevierStyleCrossRef" href="#bib0225">16</a>Our results show consistent risk reduction in young and older men and in young women. Smoking is strongly associated with an increase in coronary events among women with DM2, although this association is weaker in women over 60 years of age. CHD is unusual in premenopausal women, and women are usually approximately 10 years older than their male counterparts at the onset of CHD. The women in our study older than 60 years presented higher SBP values and a longer duration of diabetes (data not shown). Nonetheless, smoking cessation was associated with a lower risk of CHD among postmenopausal women with diabetes in our study.<a class="elsevierStyleCrossRef" href="#bib0230">17</a>We also observed a significant interaction between smoking status and blood glucose control in terms of predicted CHD risk, suggesting that the estimated benefit of smoking cessation might be greater among patients with poorer metabolic control. Individuals with diabetes who smoke have poorer blood glucose control than ex-smokers. Individuals with diabetes but no known cardiovascular disease can have better outcomes after improving glucose control than those undergoing secondary prevention.<a class="elsevierStyleCrossRef" href="#bib0235">18</a> Although the potential synergy among smoking, poor metabolic control and cardiovascular outcomes has not been well studied, our results suggest that smoking cessation is crucial for these patients, which is consistent with the results from patients with HbA1c levels >7%, who also had a higher BMI, larger waist circumference, higher SBP and DBP values and a poorer lipid profile compared with patients with better blood glucose control (data not shown). Smoking cessation is associated with weight gain, although long-term ex-smokers with diabetes show no significant weight differences compared with smokers.<a class="elsevierStyleCrossRef" href="#bib0240">19</a> While this short-term weight gain might weaken the cardiovascular benefits, the reduction in cardiovascular disease outcomes in ex-smokers with diabetes is similar to that seen in those without diabetes.<a class="elsevierStyleCrossRef" href="#bib0240">19</a>Cardiovascular risk scales use major risk factors to predict the likelihood of a cardiovascular event over a defined period. There are several concerns, especially for individuals with diabetes. Cardiovascular disease risk estimates depend highly on the studied population, and the risk might therefore not be extrapolatable to other populations.<a class="elsevierStyleCrossRef" href="#bib0245">20</a> The Framingham risk scale for the Spanish population overestimates the risk of CHD and is inferior to the REGICOR scale for Spain and Southern European countries.<a class="elsevierStyleCrossRefs" href="#bib0250">21,22</a> Although most absolute risk scales include DM2 as a dichotomous variable, several factors (e.g., age at diagnosis, duration of diabetes and blood glucose control) that have an established contribution to cardiovascular disease risk among patients with diabetes<a class="elsevierStyleCrossRef" href="#bib0260">23</a> are not included in these scales. Among the few existing diabetes-specific prediction models,<a class="elsevierStyleCrossRef" href="#bib0265">24</a> the UKPDS risk engine is recommended for calculating cardiovascular risk in patients with DM2 by the International Diabetes Federation and by the National Collaborating Centre for Chronic Conditions. Most validation studies of the UKPDS risk engine have shown moderate to poor calibration, with an overestimation of CHD risk.<a class="elsevierStyleCrossRefs" href="#bib0265">24,25</a>The available data on Spanish patients with DM2 are poor. The Validation of the Coronary Risk Tables in the South of Europe (VERIFICA) study<a class="elsevierStyleCrossRef" href="#bib0275">26</a> validated the calibrated version of the Framingham risk scale from the REGICOR study but did not consider either blood glucose control or the duration of the diabetes. It is well known that cardiovascular risk scales based on Anglo-Saxon populations, such as the UKPDS and Framingham equations, overestimate the actual risk for patients from Mediterranean countries.<a class="elsevierStyleCrossRefs" href="#bib0280">27,28</a> Risk scales adapted to the Spanish population, such as the REGICOR, might underestimate this risk in patients with diabetes.<a class="elsevierStyleCrossRef" href="#bib0280">27</a>Smoking cessation counseling by clinicians is an effective and cost-effective intervention.<a class="elsevierStyleCrossRef" href="#bib0290">29</a> Unfortunately, screening for smoking status and routine counseling on smoking cessation are often overlooked. To narrow the gap between the clinical guidelines and standard clinical practice, the calculated patient cardiovascular risk profile should improve screening performance and smoking cessation management by physicians.The study's limitations are as follows: (a) the Framingham and REGICOR risk scales include smoking status as a dichotomous variable (smoker vs. nonsmoker). Our study therefore only included (in addition to current smokers) long-term former smokers who could be considered nonsmokers in terms of cardiovascular events.<a class="elsevierStyleCrossRef" href="#bib0205">12</a> Smoking cessation for patients with DM2 is associated with a rapid decrease in cardiovascular risk, showing no statistically significant differences versus nonsmokers in terms of CHD and myocardial infarction relative risk<a class="elsevierStyleCrossRef" href="#bib0245">20</a>; (b) there were small but statistically significant differences in terms of age among the study subgroups; (c) the risk scales do not include the number of cigarettes smoked per day as an independent risk factor for smokers, although there is a well-known dose-dependent correlation with CHD; (d) our results come from a low incidence at baseline population and cannot therefore be extrapolated to other high-risk countries.In conclusion, smoking cessation for patients with DM2 is accompanied by a significant decrease in the estimated risk of CHD and fatal coronary events at 10 years. This decrease is even greater for patients with poorer blood glucose control and is attenuated in women over 60 years of age. Our findings underscore the importance of smoking cessation interventions for patients with diabetes.FundingThe present study was funded by Pfizer S.L.U., Madrid (Spain).Conflicts of InterestMLR declares that they have no conflicts of interest. VSB is employed by Pfizer S.L.U." "textoCompletoSecciones" => array:1 [ "secciones" => array:12 [ 0 => array:3 [ "identificador" => "xres1100548" "titulo" => "Abstract" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Aims" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Patients and methods" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Results" ] 3 => array:2 [ "identificador" => "abst0020" "titulo" => "Conclusions" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec1041550" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres1100547" "titulo" => "Resumen" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0025" "titulo" => "Objetivos" ] 1 => array:2 [ "identificador" => "abst0030" "titulo" => "Pacientes y métodos" ] 2 => array:2 [ "identificador" => "abst0035" "titulo" => "Resultados" ] 3 => array:2 [ "identificador" => "abst0040" "titulo" => "Conclusiones" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec1041549" "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" => "Objectives" ] 1 => array:2 [ "identificador" => "sec0020" "titulo" => "Study design" ] 2 => array:2 [ "identificador" => "sec0025" "titulo" => "Patients and methods" ] 3 => array:2 [ "identificador" => "sec0030" "titulo" => "Statistical analysis" ] ] ] 6 => array:3 [ "identificador" => "sec0035" "titulo" => "Results" "secciones" => array:3 [ 0 => array:2 [ "identificador" => "sec0040" "titulo" => "Study population characteristics" ] 1 => array:2 [ "identificador" => "sec0045" "titulo" => "Estimated risk of coronary heart disease according to the UKPDS risk engine" ] 2 => array:2 [ "identificador" => "sec0050" "titulo" => "Comparison of the UKPDS, REGICOR and Framingham risk scales" ] ] ] 7 => array:2 [ "identificador" => "sec0055" "titulo" => "Discussion" ] 8 => array:2 [ "identificador" => "sec0060" "titulo" => "Funding" ] 9 => array:2 [ "identificador" => "sec0065" "titulo" => "Conflicts of Interest" ] 10 => array:2 [ "identificador" => "xack373870" "titulo" => "Acknowledgements" ] 11 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2018-03-02" "fechaAceptado" => "2018-04-17" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec1041550" "palabras" => array:4 [ 0 => "Type 2 diabetes mellitus" 1 => "Smoking" 2 => "Smoking cessation" 3 => "Cardiovascular risk score" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec1041549" "palabras" => array:4 [ 0 => "Diabetes mellitus tipo 2" 1 => "Fumar" 2 => "Cesación tabáquica" 3 => "Escala de riesgo cardiovascular" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:3 [ "titulo" => "Abstract" "resumen" => "AimsTo assess the cardiovascular risk according to the UKPDS risk engine; Framingham function and score comparing clinical characteristics of diabetes mellitus type 2 (DM2) patients according to their habits status. Patients and methodsA descriptive analysis was performed. A total of 890 Spanish patients with DM2 (444 smokers and 446 former-smokers) were included in a cross-sectional, observational, epidemiological multicenter nationwide study. Coronary heart disease risk at 10 years was calculated using the UKPDS risk score in both patient subgroups. Results were also compared with the Spanish calibrated (REGICOR) and updated Framingham risk scores. ResultsThe estimated likelihood of coronary heart disease risk at 10 years according to the UKPDS score was significantly greater in smokers compared with former-smokers. This increased risk was greater in subjects with poorer blood glucose control, and was attenuated in women ≥60 years-old. The Framingham and UKPDS scores conferred a greater estimated risk than the REGICOR equation in Spanish diabetics. ConclusionsQuitting smoke in patients with DM2 is accompanied by a significant decrease in the estimated risk of coronary events as assessed by UKPDS. Our findings support the importance of quitting smoking among diabetic patients in order to reduce cardiovascular risk." "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Aims" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Patients and methods" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Results" ] 3 => array:2 [ "identificador" => "abst0020" "titulo" => "Conclusions" ] ] ] "es" => array:3 [ "titulo" => "Resumen" "resumen" => "ObjetivosEvaluar el riesgo cardiovascular con la herramienta UKPDS risk engine, la función y escala Framingham y comparar las características clínicas de pacientes con diabetes mellitus tipo 2 (DM2) en base a sus hábitos. Pacientes y métodosSe llevó a cabo un análisis descriptivo. Se incluyó a un total de 890 pacientes con DM2 (444 fumadores y 446 no fumadores) en un estudio transversal, observacional, epidemiológico, multicéntrico y a nivel nacional. Se calculó el riesgo de enfermedad coronaria a 10 años utilizando, para ello, la puntuación UKPDS en ambas cohortes. Los resultados se compararon también con las puntuaciones calibradas para España (REGICOR) y la escala de riesgo de Framingham. ResultadosLa probabilidad estimada de enfermedad coronaria a los 10 años según la herramienta UKPDS fue ostensiblemente superior en los fumadores que en los no fumadores. Este aumento del riesgo fue mayor en sujetos con un peor control de la glucosa en sangre, y disminuye en mujeres de 60 o más años de edad. Tanto Framingham como UKPDS confieren un riesgo estimado mayor que REGICOR a los diabéticos españoles. ConclusionesDejar de fumar en pacientes con DM2 implica un descenso significativo del riesgo estimado de eventos coronarios según la herramienta UKPDS. Nuestros descubrimientos avalan lo importante que es dejar de fumar en pacientes diabéticos a la hora de reducir el riesgo cardiovascular." "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0025" "titulo" => "Objetivos" ] 1 => array:2 [ "identificador" => "abst0030" "titulo" => "Pacientes y métodos" ] 2 => array:2 [ "identificador" => "abst0035" "titulo" => "Resultados" ] 3 => array:2 [ "identificador" => "abst0040" "titulo" => "Conclusiones" ] ] ] ] "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "Please cite this article as: Luque-Ramírez M, Sanz de Burgoa V, en nombre de los participantes del estudio DIABETES. Impacto de la cesación tabáquica en el riesgo cardiovascular estimado de pacientes con diabetes mellitus tipo 2: El estudio DIABETES. Rev Clín Esp. 2018;218:391–398." ] ] "multimedia" => array:4 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 2604 "Ancho" => 2098 "Tamanyo" => 211950 ] ] "descripcion" => array:1 [ "en" => "Flow of patients included in the study." ] ] 1 => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 4125 "Ancho" => 1492 "Tamanyo" => 234013 ] ] "descripcion" => array:1 [ "en" => "(A) Estimated risk of coronary heart disease at 10 years according to the UKPDS risk engine as a function of smoking status. The data were analyzed with a one-way general linear model, introducing age as a covariate. Current smokers are represented by black circles and ex-smokers by white circles. *p<.05 for smoking status. (B) Influence of blood glucose control upon the estimated risk of coronary heart disease as a function of smoking status. The data were analyzed with a two-way general linear model, introducing age as a covariate. Current smokers are represented by black circles and ex-smokers by white circles. *p<.05 for smoking status. †p<.05 for blood glucose control status. ‡p<.05 for the interaction between smoking status and blood glucose control. (C) Influence of age and gender upon estimated relative risk reduction of coronary heart disease among ex-smokers versus smokers. Data are shown as means. Estimated risk of coronary heart disease in current smokers is represented by black circles. Arrowheads represent estimated relative risk reduction of ex-smokers vs. current smokers." ] ] 2 => array:8 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at1" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:2 [ "leyenda" => "The results are expressed as means±SD or raw values (percentage). The effects of the study subgroup on the continues variables were analyzed with an age-adjusted unidirectional GLM. For the nominal variables, we used the chi-squared test or Fisher's exact test, as appropriate.Abbreviations: BMC, body mass index; DM2, type 2 diabetes mellitus; F, female; GLM, general linear model; HDL, high-density lipoprotein; LDL, low-density lipoprotein; M, male; 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="table-head " align="" valign="top" scope="col" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Smokers (n=444) \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Ex-smokers (n=446) \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">p \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Age, years \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">56±11 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">59±12 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top"><.001 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Sex (M/F), n (%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">320 (72)/124 (78) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">299 (67)/147 (33) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">.103 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Race (white), n (%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">428 (96) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">429 (96) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">.870 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Smoking duration, years \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">29±13 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">20±11 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top"><.001 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Packs/year \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">26±21 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">20±16 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top"><.0001 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">BMI, kg/m2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">29±5 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">30±6 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">.004 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Waist circumference, cm \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">101±14 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">104±17 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">.155 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Systolic blood pressure, mm Hg \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">136±16 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">137±18 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">.267 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Diastolic blood pressure, mm Hg \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">80±10 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">79±10 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">.132 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Duration of DM2, years \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">9±7 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">10±7 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">.877 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">HbA1c, levels, % \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">7.5±2.9 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">7.3±3.2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">.005 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Total cholesterol, mg/dL \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">203±43 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">200±42 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">.292 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">HDL-cholesterol, mg/dL \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">47±13 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">48±13 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">.021 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">LDL-cholesterol, mg/dL \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">123±37 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">121±37 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">.441 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Triglycerides, mg/dL \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">175±104 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">161±87 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">.021 \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1883000.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Clinical characteristics of the population. Smokers compared with ex-smokers." ] ] 3 => array:8 [ "identificador" => "tbl0010" "etiqueta" => "Table 2" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at2" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:3 [ "leyenda" => "The results are expressed as means and with a 95% confidence interval (95% CI). The effects of the risk scales and smoking in coronary disease estimated at 10 years were analyzed using a general bidirectional age-adjusted linear model (GLM). The significant differences between the risk scales were analyzed by applying Bonferroni's correction." "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " align="" valign="top" scope="col"> \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " colspan="2" align="center" valign="top" scope="col" style="border-bottom: 2px solid black">REGICOR</th><th class="td" title="table-head " colspan="2" align="center" valign="top" scope="col" style="border-bottom: 2px solid black">UKPDS</th><th class="td" title="table-head " colspan="2" align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Framingham</th><th class="td" title="table-head " colspan="2" align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Comparison between scales</th></tr><tr title="table-row"><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Ager range (35–74 years) \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Mean \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">IC 95% \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Mean \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">IC 95% \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Mean \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">95% CI \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">F \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">p \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry " colspan="9" align="left" valign="top">All patients</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Smokers (n=403) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">11.10 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">10.40–11.80 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">24.98 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">23.24–26.72 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">22.63 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">21.60–23.64 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " rowspan="2" align="char" valign="top">404.4<a class="elsevierStyleCrossRefs" href="#tblfn0005">a,b,c</a></td><td class="td" title="table-entry " rowspan="2" align="char" valign="top"><.001</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Ex-smokers (n=389) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">7.51 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">7.01–8.01 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">19.28 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">17.79–20.77 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">15.91 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">15.03–16.79 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Relative risk reduction, % \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " colspan="2" align="center" valign="top">50</td><td class="td" title="table-entry " colspan="2" align="center" valign="top">30</td><td class="td" title="table-entry " colspan="2" align="center" valign="top">42</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="9" align="left" valign="top"></td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="9" align="left" valign="top">Men</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Smokers (n=289) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">12.10 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">11.30–13.08 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">29.93 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">27.86–32.00 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">24.46 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">23.24–25.68 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " rowspan="2" align="char" valign="top">264.3<a class="elsevierStyleCrossRefs" href="#tblfn0005">a,b,c</a></td><td class="td" title="table-entry " rowspan="2" align="char" valign="top"><.001</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Ex-smokers (n=267) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">7.70 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">7.05–8.35 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">22.64 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">20.69–24.59 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">17.02 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">15.89–18.15 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Relative risk reduction, % \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " colspan="2" align="center" valign="top">54</td><td class="td" title="table-entry " colspan="2" align="center" valign="top">32</td><td class="td" title="table-entry " colspan="2" align="center" valign="top">46</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="9" align="left" valign="top"></td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="9" align="left" valign="top">Women</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Smokers (n=114) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">8.32 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">7.48–9.16 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">12.43 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">10,75–14,11 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">17,97 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">16,41–19.53 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">104.4<a class="elsevierStyleCrossRefs" href="#tblfn0005">a,b,c</a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top"><.001 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Ex-smokers (n=122) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">7.08 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">6.35–7.81 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">11.93 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">10.42–13.44 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">13,50 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">12.30–14.70 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Relative risk reduction, % \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " colspan="2" align="center" valign="top">19</td><td class="td" title="table-entry " colspan="2" align="center" valign="top">0</td><td class="td" title="table-entry " colspan="2" align="center" valign="top">32</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1883001.png" ] ] ] "notaPie" => array:3 [ 0 => array:3 [ "identificador" => "tblfn0005" "etiqueta" => "a" "nota" => "p<.05 for UKPDS vs. REGICOR." ] 1 => array:3 [ "identificador" => "tblfn0010" "etiqueta" => "b" "nota" => "p<.05 for UKPDS vs. Framingham." ] 2 => array:3 [ "identificador" => "tblfn0015" "etiqueta" => "c" "nota" => "p<.05 for REGICOR vs. Framingham." ] ] ] "descripcion" => array:1 [ "en" => "Comparison of the estimated risk of coronary disease at 10 years (%) according to the cardiovascular risk scales." ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0015" "bibliografiaReferencia" => array:29 [ 0 => array:3 [ "identificador" => "bib0150" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Smoking-attributable deaths in Spain, 2006" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "J.R. 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    "titulo" => "Impact of smoking cessation on estimated cardiovascular risk in Spanish type 2 diabetes mellitus patients&#58; The DIABETES study"
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          "en" => "<p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">&#40;A&#41; Estimated risk of coronary heart disease at 10 years according to the UKPDS risk engine as a function of smoking status&#46; The data were analyzed with a one-way general linear model&#44; introducing age as a covariate&#46; Current smokers are represented by black circles and ex-smokers by white circles&#46; &#42;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>&#46;05 for smoking status&#46; &#40;B&#41; Influence of blood glucose control upon the estimated risk of coronary heart disease as a function of smoking status&#46; The data were analyzed with a two-way general linear model&#44; introducing age as a covariate&#46; Current smokers are represented by black circles and ex-smokers by white circles&#46; &#42;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>&#46;05 for smoking status&#46; <span class="elsevierStyleSup">&#8224;</span><span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>&#46;05 for blood glucose control status&#46; <span class="elsevierStyleSup">&#8225;</span><span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>&#46;05 for the interaction between smoking status and blood glucose control&#46; &#40;C&#41; Influence of age and gender upon estimated relative risk reduction of coronary heart disease among ex-smokers versus smokers&#46; Data are shown as means&#46; Estimated risk of coronary heart disease in current smokers is represented by black circles&#46; Arrowheads represent estimated relative risk reduction of ex-smokers vs&#46; current smokers&#46;</p>"
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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Background</span><p id="par0005" class="elsevierStylePara elsevierViewall">Many smoking-related deaths are due to cardiovascular diseases such as coronary heart disease &#40;CHD&#41;&#44; stroke and peripheral arterial disease&#46;<a class="elsevierStyleCrossRef" href="#bib0150"><span class="elsevierStyleSup">1</span></a> In Spain&#44; 24&#37; of the population older than 15 years smokes&#44; and 20&#37; claim to be ex-smokers&#46;<a class="elsevierStyleCrossRef" href="#bib0155"><span class="elsevierStyleSup">2</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">Current smokers have an increased risk of developing type 2 diabetes mellitus &#40;DM2&#41;<a class="elsevierStyleCrossRef" href="#bib0160"><span class="elsevierStyleSup">3</span></a> and the chronic macrovascular complications of diabetes&#46; Smoking is a major risk factor for cardiovascular morbidity and CHD in patients with DM2&#46;<a class="elsevierStyleCrossRef" href="#bib0165"><span class="elsevierStyleSup">4</span></a> However&#44; the prevalence of smoking among men and women with diabetes in Spain is approximately 27&#37; and 35&#37;&#44; respectively&#46;<a class="elsevierStyleCrossRef" href="#bib0170"><span class="elsevierStyleSup">5</span></a> Smoking cessation &#40;SC&#41; in this high-risk population could be one of the best approaches for proper disease management&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">Information provided by cardiovascular risk scales can be useful in primary care&#44; both for diagnosis and treatment&#46; However&#44; the accuracy of most current scales in predicting risk among patients with DM2 is a subject of debate&#46; To solve this problem&#44; the United Kingdom Prospective Diabetes Study &#40;UKPDS&#41; Risk Engine was published in 2001&#44; which included&#44; among other factors&#44; blood glucose control and the duration of the patient&#39;s diabetes&#46;<a class="elsevierStyleCrossRef" href="#bib0175"><span class="elsevierStyleSup">6</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">This study assesses the cardiovascular risk according to the UKPDS risk engine in a representative sample of patients with DM2&#44; comparing the clinical characteristics of smokers versus those of ex-smokers&#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">Objectives</span><p id="par0025" class="elsevierStylePara elsevierViewall">Our primary objective was to assess and compare&#44; using the UKPDS risk engine&#44; the CHD risk of patients with DM2 who were either current or former smokers&#46; The secondary objective was to compare these results with those obtained with the <span class="elsevierStyleItalic">Registre Giron&#237; del Cor</span> &#40;REGICOR&#41; and Framingham scales&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Study design</span><p id="par0030" class="elsevierStylePara elsevierViewall">A total of 156 Spanish diabetes specialists participated in this nationwide&#44; cross-sectional&#44; observational&#44; epidemiological&#44; multicenter study&#44; which employed a stratified&#44; multistage probability sample without replacement&#46; The sampling frame was all health regions of the 17 Spanish autonomous communities&#44; similar to other studies sponsored by Pfizer Spain&#46;<a class="elsevierStyleCrossRef" href="#bib0180"><span class="elsevierStyleSup">7</span></a> The number of clinics was proportional to the population of each region&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Patients and methods</span><p id="par0035" class="elsevierStylePara elsevierViewall">The study was conducted from February to December 2012&#46; To ensure similarity in terms of sex and age range&#44; each investigator included 8 patients with DM2<a class="elsevierStyleCrossRef" href="#bib0185"><span class="elsevierStyleSup">8</span></a> &#40;4 current smokers and 4 ex-smokers&#41; who visited their office for any reason&#46; The inclusion criteria were &#40;a&#41; patients of either sex&#44; &#40;b&#41; an age of 18 years or older and c&#41; current smokers &#40;daily consumers of at least 1 cigarette&#47;day for the last month&#41; or former smokers &#40;at least 10 years since quitting&#41;&#46; The exclusion criteria were &#40;a&#41; former smoker for fewer than 10 years&#44; &#40;b&#41; a history of cardiovascular events or known nephropathy &#40;secondary cardiovascular disease prevention&#41; and &#40;c&#41; unwillingness to participate in the study&#46; All included participants provided their informed written consent&#46; The study was approved by the ethics committees of all the centers involved and by the Spanish Ministry of Health&#46; The following data were recorded&#58; &#40;a&#41; demographic data &#40;province and area &#91;rural&#44; intermediary or urban&#93;&#41;&#59; &#40;b&#41; anthropometric variables&#44; including height&#44; weight and waist circumference&#59; &#40;c&#41; blood pressure measured in the consultation<a class="elsevierStyleCrossRef" href="#bib0190"><span class="elsevierStyleSup">9</span></a>&#59; &#40;d&#41; the last metabolic blood profile including HbA<span class="elsevierStyleInf">1c</span> and lipid levels&#59; &#40;e&#41; DM2 state according to the American Diabetes Association &#40;ADA&#41; classification&#59; and &#40;f&#41; current smoking status&#44; age when patient started smoking&#44; duration of smoking cessation &#40;ex-smokers&#41; and packs&#47;year &#40;current smokers&#41;&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">The data were collected during a single visit&#44; and there was no follow-up&#46; All gathered data were based on the information provided by the participants and on the data contained in the case histories&#46; All participants continued to undergo their usual diabetic treatment indicated by their physicians&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">Using the participants&#8217; clinical data&#44; the CHD risk at 10 years was estimated with the UKPDS equation<a class="elsevierStyleCrossRef" href="#bib0175"><span class="elsevierStyleSup">6</span></a> using Microsoft Excel&#39;s implementation of the UKPDS Risk Engine v2&#46;0 provided by the University of Oxford&#46;<a class="elsevierStyleCrossRef" href="#bib0195"><span class="elsevierStyleSup">10</span></a></p><p id="par0050" class="elsevierStylePara elsevierViewall">This equation includes the age at diagnosis&#44; sex&#44; ethnicity&#44; DM2 duration &#40;years&#41;&#44; HbA<span class="elsevierStyleInf">1c</span> level&#44; smoking status&#44; systolic blood pressure &#40;SBP&#41; and total and high-density lipoprotein &#40;HDL&#41;-cholesterol&#46; To assess the influence of the population used for the development of risk scales and their suitability for patients with diabetes&#44; we also calculated the risks based on the Framingham equation calibrated for the Spanish population aged 35&#8211;74 years &#40;REGICOR&#41;&#44;<a class="elsevierStyleCrossRef" href="#bib0200"><span class="elsevierStyleSup">11</span></a> using the online risk calculator &#40;v2&#46;1&#44; April 2012&#41;&#44; and on the updated &#40;2008&#41; Framingham risk equation<a class="elsevierStyleCrossRef" href="#bib0205"><span class="elsevierStyleSup">12</span></a> using the Microsoft Excel worksheet designed by the University of Edinburgh&#46;<a class="elsevierStyleCrossRef" href="#bib0210"><span class="elsevierStyleSup">13</span></a> The REGICOR scale includes sex&#44; age&#44; presence of DM2&#44; smoking status&#44; total cholesterol level&#44; SBP and diastolic blood pressure &#40;DBP&#41;&#44; adjusting the total result according to HDL-cholesterol levels&#46; The Framingham scale is based on age&#44; sex&#44; smoking status &#40;smoker&#47;nonsmoker&#41;&#44; diabetes status&#44; SBP&#44; total cholesterol and HDL-cholesterol&#46; Long-term former smokers with diabetes show small differences in tobacco-related cardiovascular deaths when compared with nonsmokers&#46; These differences are even smaller in terms of CHD&#44;<a class="elsevierStyleCrossRef" href="#bib0215"><span class="elsevierStyleSup">14</span></a> with a significant risk reduction observed after 10 years of smoking cessation&#46; Accordingly&#44; our ex-smokers were coded as nonsmokers in the REGICOR and Framingham risk scales&#46;</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Statistical analysis</span><p id="par0055" class="elsevierStylePara elsevierViewall">The results are expressed as mean<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>standard deviation &#40;SD&#41;&#44; mean &#40;95&#37; confidence interval &#91;95&#37;CI&#93;&#41; or counts &#40;percentage&#41;&#44; unless stated otherwise&#46; Nominal variables were analyzed with the chi-squared test or Fisher&#39;s exact test as appropriate&#46; We performed a <span class="elsevierStyleItalic">z</span> transformation of the continuous variables&#44; expressing the deviation from the mean as SD&#46; We then used univariate one-way general linear models &#40;GLMs&#41; to evaluate the differences in the continuous variables between current and ex-smokers based on a single analysis&#46; Given that there were differences between the two types of smokers using the <span class="elsevierStyleItalic">t</span> test&#44; age was introduced as a covariate in the analysis of other variables&#46; The effect of the risk scales&#44; duration of diabetes&#44; blood glucose control and smoking status on the estimated CHD at 10 years was analyzed using a two-way GLM&#44; introducing age as a covariate&#46; Significant differences among the risk scales were then analyzed by applying the Bonferroni correction&#46; The relative risk reduction &#40;RRR&#41;&#44; regarded as the estimated reduction of coronary heart event risk between former and current smokers&#44; was calculated as follows&#58; &#91;&#40;current smokers estimated event rate<span class="elsevierStyleHsp" style=""></span>&#8722;<span class="elsevierStyleHsp" style=""></span>former smokers estimated event rate&#41;&#47;former smokers estimated event rate&#93;<span class="elsevierStyleHsp" style=""></span>&#215;<span class="elsevierStyleHsp" style=""></span>100&#46; The number needed to treat &#40;NNT&#41; was calculated as follows&#58; &#91;1&#47;&#40;current smokers estimated event rate<span class="elsevierStyleHsp" style=""></span>&#8722;<span class="elsevierStyleHsp" style=""></span>former smokers estimated event rate&#41;&#93;&#46; The SPSS statistical package &#40;version 17&#46;0&#41;<a class="elsevierStyleCrossRef" href="#bib0220"><span class="elsevierStyleSup">15</span></a> was employed throughout the analysis&#46; Statistical significance was considered for <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>&#46;05&#46;</p></span></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Results</span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">Study population characteristics</span><p id="par0060" class="elsevierStylePara elsevierViewall">A total of 1062 patients with DM2 were initially included&#44; 172 of whom were subsequently excluded &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;&#44; resulting in 890 patients ultimately analyzed&#46; The patients were distributed to 2 separate groups according to smoking habit&#58; 444 current smokers and 446 ex-smokers&#46; Ninety-five percent &#40;95&#37;&#41; and 96&#37; of the active and ex-smokers were 35 years of age or older&#44; respectively&#46; The smokers had a lower body mass index &#40;BMI&#41; than ex-smokers despite having similar waist circumferences&#46; Obesity &#40;BMI &#8805;30<span class="elsevierStyleHsp" style=""></span>kg&#47;m<span class="elsevierStyleSup">2</span>&#41; was also lower in the current smokers &#40;current vs&#46; ex-smokers&#58; 165 &#91;37&#37;&#93; and 190 &#91;43&#37;&#93;&#59; chi-squared&#44; 7&#46;9&#44; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>&#46;019&#41;&#46; The mean HbA<span class="elsevierStyleInf">1c</span> and triglyceride levels were higher in the current smokers &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a><a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#41;&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="tbl0005"></elsevierMultimedia></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0105">Estimated risk of coronary heart disease according to the UKPDS risk engine</span><p id="par0065" class="elsevierStylePara elsevierViewall">The likelihood of CHD at 10 years according to the UKPDS risk engine was significantly greater for the smokers &#40;25&#46;4&#37;&#59; 95&#37; CI 23&#46;6&#8211;27&#46;2&#41; than for the ex-smokers &#40;20&#46;8&#37;&#59; 95&#37; CI 19&#46;3&#8211;22&#46;4&#41;&#44; after adjusting for age &#40;<span class="elsevierStyleItalic">F</span>&#44; 850&#46;2&#59; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>&#46;001&#41; &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>A&#41;&#46; The RRR of the former smokers versus the current smokers was 22&#37; at 10 years&#46; The estimated NNT to avoid a coronary event at 10 years was 22 individuals&#46; Smokers also had a greater mean predicted risk of a fatal coronary event at 10 years &#40;17&#46;9&#37;&#59; 95&#37; CI 16&#46;3&#8211;19&#46;5&#41; than the ex-smokers &#40;15&#46;4&#37;&#59; 95&#37; CI 14&#46;0&#8211;16&#46;9&#41; &#40;<span class="elsevierStyleItalic">F</span>&#44; 875&#46;2&#59; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>&#46;001&#44; adjusted for age&#41; &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>A&#41;&#46; The RRR of the ex-smokers for a fatal coronary event at 10 years was 15&#37; compared with the current smokers&#46; The estimated NNT was 43 individuals&#46; The risk of CHD at 10 years &#40;UKPDS risk &#8805;20&#37;&#41; was lower for the former smokers &#40;178&#44; 40&#37;&#41; than for the current smokers &#40;223&#44; 50&#37;&#41; &#40;odds ratio &#91;OR&#93;&#44; 1&#46;5&#59; 95&#37; CI 1&#46;2&#8211;2&#93;&#59; chi-squared&#44; 9&#46;6&#59; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>&#46;002&#41;&#44; as was the risk for a fatal coronary event &#40;114 &#91;26&#37;&#93; vs&#46; 140 &#91;32&#37;&#93;&#44; respectively&#59; OR&#44; 1&#46;3&#59; 95&#37; CI 1&#46;0&#8211;1&#46;8&#59; chi-squared&#44; 3&#46;9&#59; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>&#46;049&#41;&#46; The RRR was similar for those patients diagnosed with diabetes 10 or more years ago &#40;36&#46;7&#37; &#91;95&#37; CI 33&#46;6&#8211;39&#46;8&#93; vs&#46; 28&#46;7&#37; &#91;95&#37; CI 26&#46;2&#8211;31&#46;3&#93; for the current smokers vs&#46; ex-smokers&#44; respectively&#59; RRR&#44; 28&#37;&#41; and for those participants who had been diagnosed with diabetes within the past 10 years &#40;17&#46;2&#37; &#91;95&#37; CI 15&#46;6&#8211;18&#46;8&#93; vs&#46; 13&#46;4&#37; &#91;95&#37; CI 12&#46;0&#8211;14&#46;8&#93; for the current smokers vs&#46; former smokers&#44; respectively&#59; RRR&#44; 29&#37;&#41;&#46; In addition&#44; the patients with poor blood glucose control &#40;HbA<span class="elsevierStyleInf">1c</span> &#62;7&#37;&#41; benefited more from smoking cessation &#40;RRR of ex-smokers vs&#46; current smokers&#44; 24&#37;&#41; than those individuals with HbA<span class="elsevierStyleInf">1c</span> &#8804;7&#37; &#40;RRR of ex-smokers vs&#46; smokers&#44; 10&#37;&#41; &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>B&#41;&#46; As for the influence of age and sex &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>C&#41;&#44; we detected a higher RRR of predicted CHD risk in the former smokers versus current smokers&#44; regardless of the age in men and in women under 60 years of age &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>B&#41;&#46;</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0110">Comparison of the UKPDS&#44; REGICOR and Framingham risk scales</span><p id="par0070" class="elsevierStylePara elsevierViewall">The study included patients between 35 and 75 years of age &#40;<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>&#41;&#46; There were statistically significant differences among the 3 risk scales in predicting CHD risk at 10 years&#46; The patients showed the highest estimated risk when assessed by the UKPDS risk engine&#44; while the lowest values were observed with the REGICOR scale&#46; Nonetheless&#44; all equations showed a reduced estimated CHD risk at 10 years in former smokers compared with current smokers&#46; According to the UKPDS risk engine&#44; however&#44; this higher risk only applies to men&#46; The number of patients presenting a very high CHD risk &#40;UKPDS and Framingham score &#8805;20&#37; or REGICOR score &#8805;10&#37;&#41;&#44; considering all patients as a whole &#40;current smokers vs&#46; ex-smokers&#41; was 207 &#40;51&#37;&#41; versus 142 &#40;37&#37;&#41; for the UKPDS risk engine &#40;OR&#44; 1&#46;8&#59; 95&#37; CI 1&#46;4&#8211;2&#46;4&#93;&#59; chi-squared&#44; 17&#46;7&#59; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>&#46;001&#41;&#59; 235 &#40;58&#37;&#41; versus 101 &#40;26&#37;&#41; for the Framingham scale &#40;OR&#44; 4&#46;0&#59; 95&#37; CI 2&#46;9&#8211;5&#46;4&#93;&#59; chi-squared&#44; 84&#46;3&#59; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>&#46;001&#41; and 198 &#40;49&#37;&#41; versus 91 &#40;23&#37;&#41; for the REGICOR scale &#40;OR&#44; 3&#46;2&#59; 95&#37; CI 2&#46;3&#8211;4&#46;3&#93;&#59; chi-squared&#44; 56&#46;6&#59; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>&#46;001&#41;&#46;</p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia></span></span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0115">Discussion</span><p id="par0075" class="elsevierStylePara elsevierViewall">This study is the first to offer a comprehensive evaluation of predicted CHD in current vs&#46; ex-smokers DM2 Spanish patients&#46; Our results support the beneficial effect of smoking cessation in the primary prevention of CHD&#44; as recommended by current clinical guidelines&#46;<a class="elsevierStyleCrossRef" href="#bib0225"><span class="elsevierStyleSup">16</span></a></p><p id="par0080" class="elsevierStylePara elsevierViewall">Our results show consistent risk reduction in young and older men and in young women&#46; Smoking is strongly associated with an increase in coronary events among women with DM2&#44; although this association is weaker in women over 60 years of age&#46; CHD is unusual in premenopausal women&#44; and women are usually approximately 10 years older than their male counterparts at the onset of CHD&#46; The women in our study older than 60 years presented higher SBP values and a longer duration of diabetes &#40;data not shown&#41;&#46; Nonetheless&#44; smoking cessation was associated with a lower risk of CHD among postmenopausal women with diabetes in our study&#46;<a class="elsevierStyleCrossRef" href="#bib0230"><span class="elsevierStyleSup">17</span></a></p><p id="par0085" class="elsevierStylePara elsevierViewall">We also observed a significant interaction between smoking status and blood glucose control in terms of predicted CHD risk&#44; suggesting that the estimated benefit of smoking cessation might be greater among patients with poorer metabolic control&#46; Individuals with diabetes who smoke have poorer blood glucose control than ex-smokers&#46; Individuals with diabetes but no known cardiovascular disease can have better outcomes after improving glucose control than those undergoing secondary prevention&#46;<a class="elsevierStyleCrossRef" href="#bib0235"><span class="elsevierStyleSup">18</span></a> Although the potential synergy among smoking&#44; poor metabolic control and cardiovascular outcomes has not been well studied&#44; our results suggest that smoking cessation is crucial for these patients&#44; which is consistent with the results from patients with HbA<span class="elsevierStyleInf">1c</span> levels &#62;7&#37;&#44; who also had a higher BMI&#44; larger waist circumference&#44; higher SBP and DBP values and a poorer lipid profile compared with patients with better blood glucose control &#40;data not shown&#41;&#46; Smoking cessation is associated with weight gain&#44; although long-term ex-smokers with diabetes show no significant weight differences compared with smokers&#46;<a class="elsevierStyleCrossRef" href="#bib0240"><span class="elsevierStyleSup">19</span></a> While this short-term weight gain might weaken the cardiovascular benefits&#44; the reduction in cardiovascular disease outcomes in ex-smokers with diabetes is similar to that seen in those without diabetes&#46;<a class="elsevierStyleCrossRef" href="#bib0240"><span class="elsevierStyleSup">19</span></a></p><p id="par0090" class="elsevierStylePara elsevierViewall">Cardiovascular risk scales use major risk factors to predict the likelihood of a cardiovascular event over a defined period&#46; There are several concerns&#44; especially for individuals with diabetes&#46; Cardiovascular disease risk estimates depend highly on the studied population&#44; and the risk might therefore not be extrapolatable to other populations&#46;<a class="elsevierStyleCrossRef" href="#bib0245"><span class="elsevierStyleSup">20</span></a> The Framingham risk scale for the Spanish population overestimates the risk of CHD and is inferior to the REGICOR scale for Spain and Southern European countries&#46;<a class="elsevierStyleCrossRefs" href="#bib0250"><span class="elsevierStyleSup">21&#44;22</span></a> Although most absolute risk scales include DM2 as a dichotomous variable&#44; several factors &#40;e&#46;g&#46;&#44; age at diagnosis&#44; duration of diabetes and blood glucose control&#41; that have an established contribution to cardiovascular disease risk among patients with diabetes<a class="elsevierStyleCrossRef" href="#bib0260"><span class="elsevierStyleSup">23</span></a> are not included in these scales&#46; Among the few existing diabetes-specific prediction models&#44;<a class="elsevierStyleCrossRef" href="#bib0265"><span class="elsevierStyleSup">24</span></a> the UKPDS risk engine is recommended for calculating cardiovascular risk in patients with DM2 by the International Diabetes Federation and by the National Collaborating Centre for Chronic Conditions&#46; Most validation studies of the UKPDS risk engine have shown moderate to poor calibration&#44; with an overestimation of CHD risk&#46;<a class="elsevierStyleCrossRefs" href="#bib0265"><span class="elsevierStyleSup">24&#44;25</span></a></p><p id="par0095" class="elsevierStylePara elsevierViewall">The available data on Spanish patients with DM2 are poor&#46; The Validation of the Coronary Risk Tables in the South of Europe &#40;VERIFICA&#41; study<a class="elsevierStyleCrossRef" href="#bib0275"><span class="elsevierStyleSup">26</span></a> validated the calibrated version of the Framingham risk scale from the REGICOR study but did not consider either blood glucose control or the duration of the diabetes&#46; It is well known that cardiovascular risk scales based on Anglo-Saxon populations&#44; such as the UKPDS and Framingham equations&#44; overestimate the actual risk for patients from Mediterranean countries&#46;<a class="elsevierStyleCrossRefs" href="#bib0280"><span class="elsevierStyleSup">27&#44;28</span></a> Risk scales adapted to the Spanish population&#44; such as the REGICOR&#44; might underestimate this risk in patients with diabetes&#46;<a class="elsevierStyleCrossRef" href="#bib0280"><span class="elsevierStyleSup">27</span></a></p><p id="par0100" class="elsevierStylePara elsevierViewall">Smoking cessation counseling by clinicians is an effective and cost-effective intervention&#46;<a class="elsevierStyleCrossRef" href="#bib0290"><span class="elsevierStyleSup">29</span></a> Unfortunately&#44; screening for smoking status and routine counseling on smoking cessation are often overlooked&#46; To narrow the gap between the clinical guidelines and standard clinical practice&#44; the calculated patient cardiovascular risk profile should improve screening performance and smoking cessation management by physicians&#46;</p><p id="par0105" class="elsevierStylePara elsevierViewall">The study&#39;s limitations are as follows&#58; &#40;a&#41; the Framingham and REGICOR risk scales include smoking status as a dichotomous variable &#40;smoker vs&#46; nonsmoker&#41;&#46; Our study therefore only included &#40;in addition to current smokers&#41; long-term former smokers who could be considered nonsmokers in terms of cardiovascular events&#46;<a class="elsevierStyleCrossRef" href="#bib0205"><span class="elsevierStyleSup">12</span></a> Smoking cessation for patients with DM2 is associated with a rapid decrease in cardiovascular risk&#44; showing no statistically significant differences versus nonsmokers in terms of CHD and myocardial infarction relative risk<a class="elsevierStyleCrossRef" href="#bib0245"><span class="elsevierStyleSup">20</span></a>&#59; &#40;b&#41; there were small but statistically significant differences in terms of age among the study subgroups&#59; &#40;c&#41; the risk scales do not include the number of cigarettes smoked per day as an independent risk factor for smokers&#44; although there is a well-known dose-dependent correlation with CHD&#59; &#40;d&#41; our results come from a low incidence at baseline population and cannot therefore be extrapolated to other high-risk countries&#46;</p><p id="par0110" class="elsevierStylePara elsevierViewall">In conclusion&#44; smoking cessation for patients with DM2 is accompanied by a significant decrease in the estimated risk of CHD and fatal coronary events at 10 years&#46; This decrease is even greater for patients with poorer blood glucose control and is attenuated in women over 60 years of age&#46; Our findings underscore the importance of smoking cessation interventions for patients with diabetes&#46;</p></span><span id="sec0060" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0120">Funding</span><p id="par0115" class="elsevierStylePara elsevierViewall">The present study was funded by Pfizer S&#46;L&#46;U&#46;&#44; Madrid &#40;Spain&#41;&#46;</p></span><span id="sec0065" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0125">Conflicts of Interest</span><p id="par0120" class="elsevierStylePara elsevierViewall">MLR declares that they have no conflicts of interest&#46; VSB is employed by Pfizer S&#46;L&#46;U&#46;</p></span></span>"
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              "titulo" => "Estimated risk of coronary heart disease according to the UKPDS risk engine"
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              "titulo" => "Comparison of the UKPDS&#44; REGICOR and Framingham risk scales"
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    "fechaRecibido" => "2018-03-02"
    "fechaAceptado" => "2018-04-17"
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            0 => "Type 2 diabetes mellitus"
            1 => "Smoking"
            2 => "Smoking cessation"
            3 => "Cardiovascular risk score"
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          "palabras" => array:4 [
            0 => "Diabetes mellitus tipo 2"
            1 => "Fumar"
            2 => "Cesaci&#243;n tab&#225;quica"
            3 => "Escala de riesgo cardiovascular"
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    "resumen" => array:2 [
      "en" => array:3 [
        "titulo" => "Abstract"
        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Aims</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">To assess the cardiovascular risk according to the UKPDS risk engine&#59; Framingham function and score comparing clinical characteristics of diabetes mellitus type 2 &#40;DM2&#41; patients according to their habits status&#46;</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Patients and methods</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">A descriptive analysis was performed&#46; A total of 890 Spanish patients with DM2 &#40;444 smokers and 446 former-smokers&#41; were included in a cross-sectional&#44; observational&#44; epidemiological multicenter nationwide study&#46; Coronary heart disease risk at 10 years was calculated using the UKPDS risk score in both patient subgroups&#46; Results were also compared with the Spanish calibrated &#40;REGICOR&#41; and updated Framingham risk scores&#46;</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Results</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">The estimated likelihood of coronary heart disease risk at 10 years according to the UKPDS score was significantly greater in smokers compared with former-smokers&#46; This increased risk was greater in subjects with poorer blood glucose control&#44; and was attenuated in women &#8805;60 years-old&#46; The Framingham and UKPDS scores conferred a greater estimated risk than the REGICOR equation in Spanish diabetics&#46;</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Conclusions</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Quitting smoke in patients with DM2 is accompanied by a significant decrease in the estimated risk of coronary events as assessed by UKPDS&#46; Our findings support the importance of quitting smoking among diabetic patients in order to reduce cardiovascular risk&#46;</p></span>"
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          0 => array:2 [
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          1 => array:2 [
            "identificador" => "abst0010"
            "titulo" => "Patients and methods"
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            "titulo" => "Results"
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        "resumen" => "<span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Objetivos</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Evaluar el riesgo cardiovascular con la herramienta <span class="elsevierStyleItalic">UKPDS risk engine</span>&#44; la funci&#243;n y escala Framingham y comparar las caracter&#237;sticas cl&#237;nicas de pacientes con diabetes mellitus tipo 2 &#40;DM2&#41; en base a sus h&#225;bitos&#46;</p></span> <span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Pacientes y m&#233;todos</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Se llev&#243; a cabo un an&#225;lisis descriptivo&#46; Se incluy&#243; a un total de 890 pacientes con DM2 &#40;444 fumadores y 446 no fumadores&#41; en un estudio transversal&#44; observacional&#44; epidemiol&#243;gico&#44; multic&#233;ntrico y a nivel nacional&#46; Se calcul&#243; el riesgo de enfermedad coronaria a 10 a&#241;os utilizando&#44; para ello&#44; la puntuaci&#243;n UKPDS en ambas cohortes&#46; Los resultados se compararon tambi&#233;n con las puntuaciones calibradas para Espa&#241;a &#40;REGICOR&#41; y la escala de riesgo de Framingham&#46;</p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Resultados</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">La probabilidad estimada de enfermedad coronaria a los 10 a&#241;os seg&#250;n la herramienta UKPDS fue ostensiblemente superior en los fumadores que en los no fumadores&#46; Este aumento del riesgo fue mayor en sujetos con un peor control de la glucosa en sangre&#44; y disminuye en mujeres de 60 o m&#225;s a&#241;os de edad&#46; Tanto Framingham como UKPDS confieren un riesgo estimado mayor que REGICOR a los diab&#233;ticos espa&#241;oles&#46;</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Conclusiones</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">Dejar de fumar en pacientes con DM2 implica un descenso significativo del riesgo estimado de eventos coronarios seg&#250;n la herramienta UKPDS&#46; Nuestros descubrimientos avalan lo importante que es dejar de fumar en pacientes diab&#233;ticos a la hora de reducir el riesgo cardiovascular&#46;</p></span>"
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        "nota" => "<p class="elsevierStyleNotepara" id="npar0020">Please cite this article as&#58; Luque-Ram&#237;rez M&#44; Sanz de Burgoa V&#44; en nombre de los participantes del estudio DIABETES&#46; Impacto de la cesaci&#243;n tab&#225;quica en el riesgo cardiovascular estimado de pacientes con diabetes mellitus tipo 2&#58; El estudio DIABETES&#46; Rev Cl&#237;n Esp&#46; 2018&#59;218&#58;391&#8211;398&#46;</p>"
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          "en" => "<p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">&#40;A&#41; Estimated risk of coronary heart disease at 10 years according to the UKPDS risk engine as a function of smoking status&#46; The data were analyzed with a one-way general linear model&#44; introducing age as a covariate&#46; Current smokers are represented by black circles and ex-smokers by white circles&#46; &#42;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>&#46;05 for smoking status&#46; &#40;B&#41; Influence of blood glucose control upon the estimated risk of coronary heart disease as a function of smoking status&#46; The data were analyzed with a two-way general linear model&#44; introducing age as a covariate&#46; Current smokers are represented by black circles and ex-smokers by white circles&#46; &#42;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>&#46;05 for smoking status&#46; <span class="elsevierStyleSup">&#8224;</span><span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>&#46;05 for blood glucose control status&#46; <span class="elsevierStyleSup">&#8225;</span><span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>&#46;05 for the interaction between smoking status and blood glucose control&#46; &#40;C&#41; Influence of age and gender upon estimated relative risk reduction of coronary heart disease among ex-smokers versus smokers&#46; Data are shown as means&#46; Estimated risk of coronary heart disease in current smokers is represented by black circles&#46; Arrowheads represent estimated relative risk reduction of ex-smokers vs&#46; current smokers&#46;</p>"
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          "leyenda" => "<p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">The results are expressed as means<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>SD or raw values &#40;percentage&#41;&#46; The effects of the study subgroup on the continues variables were analyzed with an age-adjusted unidirectional GLM&#46; For the nominal variables&#44; we used the chi-squared test or Fisher&#39;s exact test&#44; as appropriate&#46;</p><p id="spar0065" class="elsevierStyleSimplePara elsevierViewall">Abbreviations&#58; BMC&#44; body mass index&#59; DM2&#44; type 2 diabetes mellitus&#59; F&#44; female&#59; GLM&#44; general linear model&#59; HDL&#44; high-density lipoprotein&#59; LDL&#44; low-density lipoprotein&#59; M&#44; male&#59; SD&#44; standard deviation&#46;</p>"
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                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Smokers &#40;<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>444&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Ex-smokers &#40;<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>446&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black"><span class="elsevierStyleItalic">p</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Age&#44; years&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">56<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>11&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">59<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>12&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#60;&#46;001&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Sex &#40;M&#47;F&#41;&#44; <span class="elsevierStyleItalic">n</span> &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">320 &#40;72&#41;&#47;124 &#40;78&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">299 &#40;67&#41;&#47;147 &#40;33&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#46;103&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Race &#40;white&#41;&#44; <span class="elsevierStyleItalic">n</span> &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">428 &#40;96&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">429 &#40;96&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#46;870&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Smoking duration&#44; years&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">29<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>13&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">20<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>11&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#60;&#46;001&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Packs&#47;year&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">26<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>21&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">20<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>16&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#60;&#46;0001&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">BMI&#44; kg&#47;m<span class="elsevierStyleSup">2</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">29<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">30<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>6&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#46;004&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Waist circumference&#44; cm&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">101<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>14&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">104<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>17&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#46;155&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Systolic blood pressure&#44; mm Hg&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">136<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>16&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">137<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>18&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#46;267&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Diastolic blood pressure&#44; mm Hg&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">80<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>10&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">79<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>10&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#46;132&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Duration of DM2&#44; years&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">9<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>7&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">10<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>7&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#46;877&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">HbA<span class="elsevierStyleInf">1c</span>&#44; levels&#44; &#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">7&#46;5<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>2&#46;9&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">7&#46;3<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>3&#46;2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#46;005&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Total cholesterol&#44; mg&#47;dL&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">203<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>43&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">200<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>42&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#46;292&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">HDL-cholesterol&#44; mg&#47;dL&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">47<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>13&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">48<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>13&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#46;021&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">LDL-cholesterol&#44; mg&#47;dL&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">123<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>37&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">121<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>37&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#46;441&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Triglycerides&#44; mg&#47;dL&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">175<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>104&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">161<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>87&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#46;021&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
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          "leyenda" => "<p id="spar0075" class="elsevierStyleSimplePara elsevierViewall">The results are expressed as means and with a 95&#37; confidence interval &#40;95&#37; CI&#41;&#46; The effects of the risk scales and smoking in coronary disease estimated at 10 years were analyzed using a general bidirectional age-adjusted linear model &#40;GLM&#41;&#46; The significant differences between the risk scales were analyzed by applying Bonferroni&#39;s correction&#46;</p>"
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                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " align="" valign="top" scope="col">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " colspan="2" align="center" valign="top" scope="col" style="border-bottom: 2px solid black">REGICOR</th><th class="td" title="table-head  " colspan="2" align="center" valign="top" scope="col" style="border-bottom: 2px solid black">UKPDS</th><th class="td" title="table-head  " colspan="2" align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Framingham</th><th class="td" title="table-head  " colspan="2" align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Comparison between scales</th></tr><tr title="table-row"><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Ager range &#40;35&#8211;74 years&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Mean&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">IC 95&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Mean&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">IC 95&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Mean&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">95&#37; CI&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black"><span class="elsevierStyleItalic">F</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black"><span class="elsevierStyleItalic">p</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry  " colspan="9" align="left" valign="top"><span class="elsevierStyleItalic">All patients</span></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Smokers &#40;<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>403&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">11&#46;10&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">10&#46;40&#8211;11&#46;80&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">24&#46;98&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">23&#46;24&#8211;26&#46;72&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">22&#46;63&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">21&#46;60&#8211;23&#46;64&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " rowspan="2" align="char" valign="top">404&#46;4<a class="elsevierStyleCrossRefs" href="#tblfn0005"><span class="elsevierStyleSup">a&#44;b&#44;c</span></a></td><td class="td" title="table-entry  " rowspan="2" align="char" valign="top">&#60;&#46;001</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Ex-smokers &#40;<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>389&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">7&#46;51&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">7&#46;01&#8211;8&#46;01&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">19&#46;28&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">17&#46;79&#8211;20&#46;77&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">15&#46;91&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">15&#46;03&#8211;16&#46;79&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Relative risk reduction&#44; &#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " colspan="2" align="center" valign="top">50</td><td class="td" title="table-entry  " colspan="2" align="center" valign="top">30</td><td class="td" title="table-entry  " colspan="2" align="center" valign="top">42</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="9" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="9" align="left" valign="top"><span class="elsevierStyleItalic">Men</span></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Smokers &#40;<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>289&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">12&#46;10&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">11&#46;30&#8211;13&#46;08&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">29&#46;93&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">27&#46;86&#8211;32&#46;00&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">23&#46;24&#8211;25&#46;68&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " rowspan="2" align="char" valign="top">264&#46;3<a class="elsevierStyleCrossRefs" href="#tblfn0005"><span class="elsevierStyleSup">a&#44;b&#44;c</span></a></td><td class="td" title="table-entry  " rowspan="2" align="char" valign="top">&#60;&#46;001</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Ex-smokers &#40;<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>267&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">7&#46;05&#8211;8&#46;35&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">7&#46;48&#8211;9&#46;16&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Ex-smokers &#40;<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>122&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">6&#46;35&#8211;7&#46;81&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">11&#46;93&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">10&#46;42&#8211;13&#46;44&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">13&#44;50&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">12&#46;30&#8211;14&#46;70&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Relative risk reduction&#44; &#37;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
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        "texto" => "<p id="par0125" class="elsevierStylePara elsevierViewall">The authors would like to thank all the diabetes specialists and patients for their collaboration in this study&#46; The authors would also like to thank Luz Samaniego and Marina Azc&#225;rate for their technical assistance&#46;</p>"
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