The clinical profile of women with stable ischemic heart disease in Spain. More effort is needed in secondary prevention. SIRENA study

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Son necesarios más esfuerzos en prevención secundaria. Estudio SIRENA" ] ] "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" => 1021 "Ancho" => 1590 "Tamanyo" => 54145 ] ] "descripcion" => array:1 [ "en" => "Coronary arteries affected with significant lesions (≥50%). Abbreviations: DA, descending anterior; Cx, circumflex; RC, right coronary artery." ] ] ] "textoCompleto" => "BackgroundCardiovascular disease is the leading cause of death among Spanish women, as is the case for the rest of the Western world.<a class="elsevierStyleCrossRefs" href="#bib0190">1,2</a> Ischemic heart disease (IHD) is still the leading cause of cardiovascular death for both sexes, despite the fact that women develop it less frequently and at a later age than men.<a class="elsevierStyleCrossRefs" href="#bib0200">3–5</a>Assessing IHD in women is a difficult challenge for clinicians, due to the greater burden of symptoms, many of which are atypical, the higher rate of functional limitations and the lower prevalence of obstructive coronary artery disease when compared with men.<a class="elsevierStyleCrossRef" href="#bib0215">6</a> Women with IHD also have more adverse events than men with IHD, despite the lower rate of coronary angiographic disease and higher rate of preserved ventricular function.<a class="elsevierStyleCrossRef" href="#bib0220">7</a>Despite its severity in women, IHD is still considered “a man's disease”. However, there has been a shift in recent years on this issue, due to increased sensitivity and concern by practitioners. There are several IHD registries in Spain (PRIAMHO,<a class="elsevierStyleCrossRef" href="#bib0225">8</a> RESCATE II<a class="elsevierStyleCrossRef" href="#bib0230">9</a> and CIBAR<a class="elsevierStyleCrossRef" href="#bib0235">10</a>); however, most do not focus on chronic IHD nor are they exclusive to women. Scientific societies have recommended designing and implementing scientific studies in the field of IHD for women.<a class="elsevierStyleCrossRef" href="#bib0240">11</a>The objectives of the Observational Study on Stable Ischemic Heart Disease in Women (Estudio observacional sobre cardiopatía isquémica estable en la mujer, SIRENA) were to report the clinical profile of women with IHD treated in cardiology consultations, to determine the prevalence of cardiovascular risk factors (CRF) and to better understand the clinical management and treatment of these patients.Patients and methodsStudy designSIRENA is a Spanish, multicenter, cross-sectional study of consecutive cases, performed in standard clinical practice conditions, with no intervention whatsoever. The study was classified by the Spanish Agency of Medication and Health Products as an observational nonpostmarketing study.PatientsThe population consisted of women diagnosed with IHD in stable condition, followed-up in cardiology consultations, both hospital and outpatient. The inclusion criteria were women aged 18 years or older, diagnosed with IHD in any of its presentations (stable or acute events), who attended a cardiology consultation. Documented evidence of ischemia was not required nor was the presence of coronary lesions observed through functional and imaging tests. The exclusion criteria were participation in a clinical trial or any type of disorder that affected the patient's ability to provide written informed consent. All patients were consecutively recruited.ParticipantsForty-one researchers from all over Spain participated in the study. To make the sample as representative as possible, a stratification of the centers by geographical area was performed (one half for the upper peninsula, the other half for the lower peninsula and archipelagos). The recruitment was performed between December 2011 and August 2012.Statistical analysisThe qualitative variables are shown as frequencies and percentages. The quantitative variables are expressed as mean and standard deviation or median, depending on their distribution. The means and percentages are expressed with their corresponding 95% confidence intervals. We employed the SPSS statistical package 10.0.Ethical considerationsSIRENA was approved by the Research Ethics Committee of the Balearic Islands and was performed according to the ethical requirements of the 1975 Declaration of Helsinki and its subsequent amendments. The patients were informed, and all signed the written consent form.ResultsStudy populationThe study included 631 women, with a mean age of 68.5 years, 88.1% of whom were menopausal. The mean age at the start of menopause was 49±5.1 years. The mean age at symptom onset was 65.7±12 years. Ninety-seven of these women (15.4%) were premenopausal at the time.The most common presentation was acute coronary syndrome (ACS) in 424 cases (67.2%): 37% presented as ACS without ST-elevation and 30.2% as ST-elevation acute myocardial infarction (STEAMI). The other presentations were stable angina in 139 (22%) patients, anginal equivalent in 27 (4.3%), atypical chest pain in 21 (3.3%), cardiac syndrome X in 17 (2.7%) and vasospastic angina in 3 (0.5%). A total of 142 (74.3%) of the 191 women who presented acute myocardial infarction with ST-elevation underwent percutaneous coronary intervention, and 24.1% underwent fibrinolysis; 1.6% of the patients did not undergo coronary reperfusion therapy.Within the cases of stable angina, the most common presentation was class II of the Canadian Cardiovascular Society in 64% of the cases and class III in 25.9%.As shown in <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>, the patients had a high CRF burden. Of the cases of dyslipidemia, 53.7% had pure hypercholesterolemia, 1.3% had hypertriglyceridemia and 13% had mixed dyslipidemia. Ninety-four percent of the cases of diabetes were type 2. The most common cardiovascular comorbidities were atrial fibrillation and heart failure, which progressed with preserved ejection fractions in 50% of the cases.<elsevierMultimedia ident="tbl0005"></elsevierMultimedia>Clinical dataAt the time of inclusion, 69.7% of the patients were asymptomatic, 13.3% had Canadian Cardiovascular Society class I angina, 14.3% had class II and 2.7% had class III. The most common causes of hospitalization in the previous 6 months were ACS for 17.8% of the cases, coronary revascularization for 11.1%, heart failure for 7.5%, arrhythmias for 4.6% and noncardiovascular causes for 4.8%.The mean systolic blood pressure was 134.4±20.6mmHg, and the mean diastolic blood pressure was 74.7±11.1mmHg. Some 30.7% of the patients had uncontrolled blood pressure (≥140/90mmHg). The mean heart rate was 67.8±10.4bpm, and 8.1% of the patients were smokers.The mean body mass index (BMI) was 28.8±5.2, with 76.1% of the patients above 25 (25–29.9:39.6%; ≥30:36.5%), and 1% were underweight (<18.5). Seventy-one percent of the patients had central obesity, with a mean abdominal circumference of 95.4±14cm.Some 88.9% of the patients had sinus rhythm, 8.9% had atrial fibrillation and 2.2% had pacemaker rhythms.Blood analyses within the last 6 months were available for 552 women (87.5%). The mean hemoglobin level was 12.8±1.4g/dL. The lipid results were as follows (mg/dL): total cholesterol, 170.1±38.6; HDL cholesterol, 47.2±11.7; LDL cholesterol, 95.6±33; and triglycerides, 138.3±71.1. <a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a> provides a bar graph that shows the percentage of patients with poorly controlled lipid metabolism.<elsevierMultimedia ident="fig0005"></elsevierMultimedia>The mean glucose level was 119.3±41.8mg/dL, and the mean HbA1c level (available for 327 women) was 6.8%±1.5%. Of the 185 women with diabetes and available HbA1c levels, 49.2% were not well controlled (HbA1c>7%). We also detected 6.5% of women with newly diagnosed diabetes and fasting glucose levels >125mg/dL. The mean creatinine value was 0.9±0.4mg/dL.Clinical management<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a> shows the additional tests performed. Coronary angiography was performed on 557 patients, which found the anterior descending artery to be the most commonly affected with significant lesions (luminal stenosis ≥50%) (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>). It is worth noting that up to 10.2% of cases had no vessel that was significantly affected. Of these, 17 (29.8%) presented as cardiac syndrome X, 3 (5.3%) as vasospastic angina, 2 (3.5%) with atypical chest pain, 11 (19.3%) with stable angina and up to 24 (42.1%) in the form of ACS.<elsevierMultimedia ident="tbl0010"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia>The ejection fraction was measured in 617 women (97.8%), most through echocardiography, with a median value of 60% (range, 19–81%). <a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a> shows the cardiovascular drug treatment. Percutaneous coronary intervention was performed on 63.4% of the patients and more than once on 23.9% during the progression. Fourteen percent of the patients underwent coronary surgery. The anterior descending artery and left common trunk were addressed in 97.7% and 23.9% of the cases, respectively. A second surgery was not performed in any of the cases.<elsevierMultimedia ident="tbl0015"></elsevierMultimedia>DiscussionIn the SIRENA study, we determined the profile of Spanish woman with chronic IHD, calculated the prevalence of CRF and analyzed the clinical management and treatment of these patients.The mean age was higher than that of the women in the Euro Heart Survey of Stable Angina (62 years),<a class="elsevierStyleCrossRef" href="#bib0245">12</a> slightly higher than that of the recent CLARIFY registry on stable coronary artery disease<a class="elsevierStyleCrossRef" href="#bib0250">13</a> (which included 7002 women with a mean age of 66.5 years) and was the same as that of the women in the Galician CIBAR cohort<a class="elsevierStyleCrossRef" href="#bib0235">10</a> on chronic IHD. The fact that Spain has one of the lowest incidences of IHD in the world<a class="elsevierStyleCrossRefs" href="#bib0255">14,15</a> could be related to the later onset of IHD in women. It is worth noting that, despite the high mean age, almost a fifth of the women had their clinical presentation before 55 years of age. Moreover, SIRENA cannot provide us with comparative data on men, given that this study was designed exclusively to analyze women with IHD.The most common presentation of IHD was ACS, which differs from the more classical concept of an initial presentation in the form of stable angina, as found in the Framingham Study, and compared with men in whom AMI is more common.<a class="elsevierStyleCrossRefs" href="#bib0265">16,17</a> The high mean age and prevalence of CRF in our patients, especially after menopause,<a class="elsevierStyleCrossRef" href="#bib0275">18</a> as well as the progressive acquisition of male habits, such as smoking at an earlier age,<a class="elsevierStyleCrossRef" href="#bib0280">19</a> has surely contributed to this form of acute presentation.The most common cardiovascular comorbidities were AF and HF, which were more common than those observed in other studies on stable IHD.<a class="elsevierStyleCrossRefs" href="#bib0235">10–13</a> We believe that this finding is related to the higher mean age, greater prevalence of arterial hypertension (which is expected due to the predominance of postmenopausal women)<a class="elsevierStyleCrossRef" href="#bib0195">2</a> and the high prevalence of diabetes, including the 6.5% of cases of previously unknown diabetes (a finding not evaluated in other IHD studies). The advanced mean age and the anthropometry of these women undoubtedly play a relevant role in the high prevalence of diabetes.A considerable majority of our patients had a high body mass index, in keeping with previous studies,<a class="elsevierStyleCrossRef" href="#bib0250">13</a> and inadequate body fat distribution. However, the prevalence of obesity was less than that reported in the CIBAR study,<a class="elsevierStyleCrossRef" href="#bib0235">10</a> possibly due to geographical differences. There are variations in the geographical distribution of obesity, with a higher prevalence in the northwest and southeast communities and in the Canary Islands,<a class="elsevierStyleCrossRef" href="#bib0285">20</a> which would explain the lower results in SIRENA, which is a representative sample of the entire country. There was a worryingly high prevalence of overweight, obesity and abdominal obesity, known risk factors of IHD and for IHD mortality in women.<a class="elsevierStyleCrossRefs" href="#bib0290">21–23</a>We detected only a 5.4% rate of early menopause, which is associated with an increased risk of IHD and stroke,<a class="elsevierStyleCrossRef" href="#bib0305">24</a> as well as a shorter life expectancy.<a class="elsevierStyleCrossRef" href="#bib0310">25</a> Polycystic ovaries are also an established risk factor for IHD.<a class="elsevierStyleCrossRefs" href="#bib0315">26,27</a> However, this condition is not recorded in other registries of stable IHD. Despite the low rate observed, which could be due to lack of awareness by cardiologists, this information should be recorded when studying women with IHD.As has been published by other authors,<a class="elsevierStyleCrossRef" href="#bib0275">18</a> SIRENA revealed a high prevalence of CRF in women. Previous studies have also demonstrated poorer CRF control in women with chronic IHD.<a class="elsevierStyleCrossRef" href="#bib0325">28</a> We should therefore increase our efforts in secondary prevention.The most frequently performed ischemia examination in the SIRENA population was the stress test (ergometry). Various studies have observed that the test is performed less frequently for women than for men.<a class="elsevierStyleCrossRefs" href="#bib0330">29,30</a> More prognostic ergometries are performed than diagnostic. This situation would probably be reversed if it were men that were being treated. Ergometry is an essential test and should be the first test when studying IHD in men and women. However, the test is less sensitive and less specific in women due to their lower prevalence of coronary artery disease.Most of the patients underwent optimal medical therapy (antiplatelet agents, beta-blockers, hypolipidemic agents and renin–angiotensin–aldosterone system inhibitors), which was more than was found in other registries.<a class="elsevierStyleCrossRefs" href="#bib0235">10,12,13</a>In other studies, the female sex was a predictor of a lower use of coronary angiography as part of the study on stable angina.<a class="elsevierStyleCrossRefs" href="#bib0245">12,31,32</a> This is the case for various ACS registries, such as the Canadian ACS,<a class="elsevierStyleCrossRef" href="#bib0350">33</a> SWEDEHEART<a class="elsevierStyleCrossRef" href="#bib0355">34</a> and CRUSADE,<a class="elsevierStyleCrossRef" href="#bib0360">35</a> which have obvious Yentl syndrome or the “medical invisibility” of women in the study of cardiac disease, resulting in the underdiagnosis and undertreatment of this population.<a class="elsevierStyleCrossRef" href="#bib0365">36</a> Nevertheless, most of these women underwent coronary angiography, which is more than has occurred in other populations of stable IHD.<a class="elsevierStyleCrossRefs" href="#bib0235">10,12,13</a> The patients in SIRENA underwent percutaneous coronary intervention at more than twice the rate of other Spanish women with chronic IHD and also underwent more coronary surgery, despite having only slightly lower multivessel involvement.<a class="elsevierStyleCrossRef" href="#bib0235">10</a> The revascularization in SIRENA is the result of more interventional treatment and provides an overall idea of the management of IHD in Spain. In this respect, our data do not reflect Yentl syndrome,<a class="elsevierStyleCrossRef" href="#bib0365">36</a> with the caveat that this registry is exclusively on women.The cardiologist's mindset has probably changed due to the dissemination conducted by scientific societies in recent years. These results indicate that there are no differences in clinical management between sexes that were present beforehand.As pointed out in a recent editorial, the knowledge of IHD in women should be transferred to clinical practice, and policies of information, dissemination and sensitization should be developed on coronary artery disease in women.<a class="elsevierStyleCrossRef" href="#bib0370">37</a>This study has a number of limitations. SIRENA is not a comparative study with men, given that it was designed to determine the profile and clinical treatment of women with stable IHD. The sample is also relatively small, especially when compared with population registries.ConclusionsIn Spain, IHD in women mostly presents as ACS, which is treated invasively. There is a high prevalence of poorly controlled CRF, despite the fact that the majority of patients undergo optimal medical therapy. We believe that more healthcare policies need to be developed to control CRF through secondary prevention.FundingThis study was funded by a grant from the Clinical Cardiology Section of the Spanish Society of Cardiology and by an unconditional grant by Grupo Menarini España S.A. to the Spanish Society of Cardiology.Conflict of interestThe authors declare that they have no conflicts of interest." "textoCompletoSecciones" => array:1 [ "secciones" => array:13 [ 0 => array:3 [ "identificador" => "xres599575" "titulo" => "Abstract" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Objectives" ] 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" => "xpalclavsec613964" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres599576" "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" => "xpalclavsec613965" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Background" ] 5 => array:3 [ "identificador" => "sec0010" "titulo" => "Patients and methods" "secciones" => array:5 [ 0 => array:2 [ "identificador" => "sec0015" "titulo" => "Study design" ] 1 => array:2 [ "identificador" => "sec0020" "titulo" => "Patients" ] 2 => array:2 [ "identificador" => "sec0025" "titulo" => "Participants" ] 3 => array:2 [ "identificador" => "sec0030" "titulo" => "Statistical analysis" ] 4 => array:2 [ "identificador" => "sec0035" "titulo" => "Ethical considerations" ] ] ] 6 => array:3 [ "identificador" => "sec0040" "titulo" => "Results" "secciones" => array:3 [ 0 => array:2 [ "identificador" => "sec0045" "titulo" => "Study population" ] 1 => array:2 [ "identificador" => "sec0050" "titulo" => "Clinical data" ] 2 => array:2 [ "identificador" => "sec0055" "titulo" => "Clinical management" ] ] ] 7 => array:2 [ "identificador" => "sec0060" "titulo" => "Discussion" ] 8 => array:2 [ "identificador" => "sec0065" "titulo" => "Conclusions" ] 9 => array:2 [ "identificador" => "sec0070" "titulo" => "Funding" ] 10 => array:2 [ "identificador" => "sec0075" "titulo" => "Conflict of interest" ] 11 => array:2 [ "identificador" => "xack201981" "titulo" => "Acknowledgements" ] 12 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2015-06-03" "fechaAceptado" => "2015-09-23" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec613964" "palabras" => array:4 [ 0 => "Ischemic heart disease" 1 => "Risk factors" 2 => "Woman" 3 => "Prevalence" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec613965" "palabras" => array:4 [ 0 => "Cardiopatía isquémica" 1 => "Factores de riesgo" 2 => "Mujer" 3 => "Prevalencia" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:3 [ "titulo" => "Abstract" "resumen" => "ObjectivesCardiovascular diseases are the leading cause of death for women, especially ischemic heart disease, which is still considered a man's disease. In Spain, there are various registries on ischemic heart disease, although none are exclusively for women. The objectives of the SIRENA study were to describe the clinical profile of women with ischemic heart disease treated in cardiology consultations, to estimate its prevalence of cardiovascular risk factors and understand its clinical management. Patients and methodsA multicentre observational study was conducted with a sample of 631 women with stable ischemic heart disease, consecutively included during cardiology consultations. Forty-one researchers from all over Spain participated in the study. ResultsThe mean age was 68.5 years. The clinical presentation was in the form of acute coronary syndrome in up to 67.2% of the patients. The prevalence of cardiovascular risk factors was high (77.7% of the patients had hypertension, 40.7% had diabetes and 68% had dyslipidaemia), with 30.7% having uncontrolled hypertension, 78.4% having LDL-cholesterol levels higher than 70mg/dL and 49.2% having HbA1c levels greater than 7%. The considerable majority of the patients underwent optimal medical treatment with antiplatelet agents, beta-blockers, renin–angiotensin–aldosterone system blockers and hypolipidaemic agents. Coronary angiography was performed for 88.3% of the patients, and 63.4% underwent percutaneous coronary intervention. ConclusionsWomen with stable ischemic heart disease in Spain initially present some form of acute coronary syndrome and a high prevalence of inadequately controlled cardiovascular risk factors, despite undergoing optimal medical therapy. A high percentage of these women undergo coronary revascularisation. Increased efforts are required for secondary prevention in women with stable ischemic heart disease." "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Objectives" ] 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" => "ObjetivosLas enfermedades cardiovasculares son la primera causa de muerte en mujeres, particularmente la cardiopatía isquémica, que aún se sigue considerando una enfermedad de hombres. En España hay diversos registros sobre cardiopatía isquémica, aunque ninguno exclusivo de mujeres. Los objetivos de SIRENA fueron describir el perfil clínico de las mujeres con cardiopatía isquémica atendidas en las consultas de cardiología, estimar su prevalencia de factores de riesgo cardiovascular y conocer su manejo clínico y tratamiento. Pacientes y métodosEstudio multicéntrico, observacional, con una muestra de 631 mujeres con cardiopatía isquémica estable, incluidas consecutivamente en las consulta de cardiología. Participaron 41 investigadores de toda España. ResultadosLa edad media fue de 68,5 años. La presentación clínica fue en forma de síndrome coronario agudo hasta en un 67,2%. La prevalencia de factores de riesgo cardiovascular fue elevada (77,7% hipertensión, 40,7% diabetes y 68% dislipidemia), con un 30,7% de hipertensión no controlada, un 78,4% con cifras de colesterol-LDL superiores a 70mg/dL y un 49,2% con HbA1c superior al 7%. La gran mayoría de las pacientes recibían tratamiento médico óptimo con antiagregantes, betabloqueantes, bloqueadores del eje renina–angiotensina–aldosterona e hipolipidemiantes. Se realizó coronariografía en el 88,3% de los casos e intervencionismo coronario percutáneo en el 63,4%. ConclusionesLa mujer con cardiopatía isquémica estable en España tiene una presentación clínica inicial con alguna forma de síndrome coronario agudo y una elevada prevalencia de factores de riesgo cardiovascular inadecuadamente controlados, pese a recibir terapia médica óptima. Un elevado porcentaje se somete a revascularización coronaria. Son precisos más esfuerzos en la prevención secundaria de las mujeres con cardiopatía isquémica estable." "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:2 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "Please cite this article as: Gámez JM, Ripoll T, Barrios V, Anguita M, Pedreira M, Madariaga I, et al. Perfil clínico de la mujer con cardiopatía isquémica estable en España. Son necesarios más esfuerzos en prevención secundaria. Estudio SIRENA. Rev Clin Esp. 2016;216:1–7." ] 1 => array:3 [ "etiqueta" => "◊" "nota" => "See Appendix." "identificador" => "fn1" ] ] "apendice" => array:1 [ 0 => array:1 [ "seccion" => array:1 [ 0 => array:4 [ "apendice" => "Joan Alguersuari Cabiscol, Gonzalo Barón Esquivias, Ramón Bover Freire, Mercedes Camprubí, Santiago Cantabrana Miguel, Miguel Castillo Orive, Almudena Castro, Juan Cosín Sales, Alberto Cordero Fort, Carlos Culebras Cáceres, Regina Dalmau, Carlos Escobar Cervantes, Luis Escosa Royo, Lorenzo Fácila Rubio, Enrique Galve Basilio, José María García Acuña, Xavier García-Moll Marimón, José Javier Gómez Barrado, Juan José Gómez Doblas, María Gracia Aznárez, José Sergio Hevia Nava, Rafael Hidalgo, Ismael Laplaza Alastruey, Iñaki Lekuona Goya, Manuel Martínez-Sellés, Pilar Mazón Ramos, Gaspar Melis Riera, Nekane Murga Eizagaechevarría, Inés Otero Gómez, Francisco Ridocci Soriano, Francisco Ruiz Mateas, Francisco Torres Calvo, Joan Torres Marqués, Isabel María Ureña Montilla, Alfonso Varela Román." "etiqueta" => "Appendix A" "titulo" => "SIRENA study researchers (by alphabetical order)" "identificador" => "sec0080" ] ] ] ] "multimedia" => array:5 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1038 "Ancho" => 1649 "Tamanyo" => 98475 ] ] "descripcion" => array:1 [ "en" => "Patients with poor lipid metabolism control." ] ] 1 => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 1021 "Ancho" => 1590 "Tamanyo" => 54145 ] ] "descripcion" => array:1 [ "en" => "Coronary arteries affected with significant lesions (≥50%). Abbreviations: DA, descending anterior; Cx, circumflex; RC, right coronary artery." ] ] 2 => array:7 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "tabla" => array:3 [ "leyenda" => "Abbreviations: BMI, body mass index; COPD, chronic obstructive pulmonary disease; IHD, ischemic heart disease; PAD, peripheral arterial disease." "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Risk factors and comorbidities \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">Patients (%) \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">Patients, n \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">631 \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">Mean age, y \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">68.5 (12.2) \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">Premenopausal presentation \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">97 (15.4) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Active smoking \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">51 (8.1) \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">Exsmoker \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">131 (20.8) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Dyslipidemia \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">429 (68) \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">Arterial hypertension \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">490 (77.7) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Diabetes mellitus \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">257 (40.7) \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">Family history of early IHD \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">78 (12.4) \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">Early menopause \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">30 (5.4) \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 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">28.8 (5.2) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Atrial fibrillation \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">102 (16.2) \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">Heart failure \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">120 (19) \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">Thoracic aortic disease \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">6 (1) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Abdominal aortic disease \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2 (0.3) \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">Stroke \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">62 (9.8) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">COPD \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">40 (6.3) \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">Liver disease \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">11 (1.7) \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">Chronic kidney disease \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">84 (13.3) \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">PAD in lower limbs \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">43 (6.8) \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">PAD in carotid artery \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">25 (4) \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">Thyroid dysfunction \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">73 (11.6) \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">Polycystic ovaries \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">11 (1.7) \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">Anxiety-depressive syndrome \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">156 (24.7) \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab980914.png" ] ] ] "notaPie" => array:1 [ 0 => array:3 [ "identificador" => "tblfn0005" "etiqueta" => "a" "nota" => "<45 years for men and <55 years for women." ] ] ] "descripcion" => array:1 [ "en" => "Cardiovascular risk factors and comorbidity.<a class="elsevierStyleCrossRef" href="#tblfn0005">a</a>" ] ] 3 => array:7 [ "identificador" => "tbl0010" "etiqueta" => "Table 2" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "tabla" => array:2 [ "leyenda" => "Abbreviations: CT, computed axial tomography; MIBI, methoxyisobutylisonitrile." "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Additional tests \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">Patients (%) \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">Patients,n \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">631 \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">Echocardiogram \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">568 (90) \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">Ergometry \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">284 (45) \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">Diagnostic \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">(43.7) \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">Prognostic \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">(56.3) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="2" align="left" valign="top"></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Myocardial perfusion-MIBI \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">113 (17.9) \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">Pharmacological stress echocardiography \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">55 (8.7) \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">Coronary CT scan \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">16 (2.5) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="2" align="left" valign="top"></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Coronary angiography \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">557 (88.3) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="2" align="left" valign="top">Number of coronary vessels affected</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">None \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">57 (10.2) \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">1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">221 (39.7) \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">2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">143 (25.7) \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">3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">136 (24.4) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="2" align="left" valign="top">Trunk disease and no. of vessels</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">None \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">2 (4.3) \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">1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">7 (14.9) \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">2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">19 (40.4) \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">3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">19 (40.4) \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab980915.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Additional tests performed." ] ] 4 => array:7 [ "identificador" => "tbl0015" "etiqueta" => "Table 3" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "tabla" => array:2 [ "leyenda" => "Abbreviations: ACEI, angiotensin-converting enzyme inhibitor; ARB II, angiotensin II receptor blockers; ASA, acetylsalicylic acid; CA, calcium antagonists." "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Pharmacotherapy \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">Patients (%) \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">Patients, n \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">631 \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">Antiplatelets \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">584 (92.6) \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">AAS \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">550 (87.2) \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">Clopidogrel \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">226 (35.8) \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">Prasugrel \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">28 (4.4) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="2" align="left" valign="top"></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Beta-blockers \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">500 (79.2) \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">Nitrates \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">215 (34.1) \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">Dihydropyridine CAs \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">154 (24.4) \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">Nondihydropyridine CAs \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">46 (7.3) \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">Ranolazine \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">47 (7.5) \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">Ivabradine \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">37 (5.9) \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">Trimetazidine \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">8 (1.3) \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">Molsidomine \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0 (0) \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">Diuretics \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">250 (39.6) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Aldosterone inhibitors \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">77 (12.2) \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">Hypolipidemic agents \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">601 (95.3) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="2" align="left" valign="top"></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">ACEI or ARB II \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">495 (78.5) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">ACEI \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">256 (40.6) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">ARB II \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">246 (39.0) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="2" align="left" valign="top"></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Aliskiren \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2 (0.3) \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">Oral anticoagulants \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">95 (15.1) \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab980913.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Pharmacotherapy." ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:37 [ 0 => array:3 [ "identificador" => "bib0190" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Temas de actualidad en cardiología clínica y extrahospitalaria. 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          "en" => "<p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">Coronary arteries affected with significant lesions &#40;&#8805;50&#37;&#41;&#46; <span class="elsevierStyleItalic">Abbreviations</span>&#58; DA&#44; descending anterior&#59; Cx&#44; circumflex&#59; RC&#44; right coronary artery&#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">Cardiovascular disease is the leading cause of death among Spanish women&#44; as is the case for the rest of the Western world&#46;<a class="elsevierStyleCrossRefs" href="#bib0190"><span class="elsevierStyleSup">1&#44;2</span></a> Ischemic heart disease &#40;IHD&#41; is still the leading cause of cardiovascular death for both sexes&#44; despite the fact that women develop it less frequently and at a later age than men&#46;<a class="elsevierStyleCrossRefs" href="#bib0200"><span class="elsevierStyleSup">3&#8211;5</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">Assessing IHD in women is a difficult challenge for clinicians&#44; due to the greater burden of symptoms&#44; many of which are atypical&#44; the higher rate of functional limitations and the lower prevalence of obstructive coronary artery disease when compared with men&#46;<a class="elsevierStyleCrossRef" href="#bib0215"><span class="elsevierStyleSup">6</span></a> Women with IHD also have more adverse events than men with IHD&#44; despite the lower rate of coronary angiographic disease and higher rate of preserved ventricular function&#46;<a class="elsevierStyleCrossRef" href="#bib0220"><span class="elsevierStyleSup">7</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">Despite its severity in women&#44; IHD is still considered &#8220;a man&#39;s disease&#8221;&#46; However&#44; there has been a shift in recent years on this issue&#44; due to increased sensitivity and concern by practitioners&#46; There are several IHD registries in Spain &#40;PRIAMHO&#44;<a class="elsevierStyleCrossRef" href="#bib0225"><span class="elsevierStyleSup">8</span></a> RESCATE II<a class="elsevierStyleCrossRef" href="#bib0230"><span class="elsevierStyleSup">9</span></a> and CIBAR<a class="elsevierStyleCrossRef" href="#bib0235"><span class="elsevierStyleSup">10</span></a>&#41;&#59; however&#44; most do not focus on chronic IHD nor are they exclusive to women&#46; Scientific societies have recommended designing and implementing scientific studies in the field of IHD for women&#46;<a class="elsevierStyleCrossRef" href="#bib0240"><span class="elsevierStyleSup">11</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">The objectives of the Observational Study on Stable Ischemic Heart Disease in Women &#40;<span class="elsevierStyleItalic">Estudio observacional sobre cardiopat&#237;a isqu&#233;mica estable en la mujer</span>&#44; SIRENA&#41; were to report the clinical profile of women with IHD treated in cardiology consultations&#44; to determine the prevalence of cardiovascular risk factors &#40;CRF&#41; and to better understand the clinical management and treatment of these patients&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Patients and methods</span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Study design</span><p id="par0025" class="elsevierStylePara elsevierViewall">SIRENA is a Spanish&#44; multicenter&#44; cross-sectional study of consecutive cases&#44; performed in standard clinical practice conditions&#44; with no intervention whatsoever&#46; The study was classified by the Spanish Agency of Medication and Health Products as an observational nonpostmarketing study&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Patients</span><p id="par0030" class="elsevierStylePara elsevierViewall">The population consisted of women diagnosed with IHD in stable condition&#44; followed-up in cardiology consultations&#44; both hospital and outpatient&#46; The inclusion criteria were women aged 18 years or older&#44; diagnosed with IHD in any of its presentations &#40;stable or acute events&#41;&#44; who attended a cardiology consultation&#46; Documented evidence of ischemia was not required nor was the presence of coronary lesions observed through functional and imaging tests&#46; The exclusion criteria were participation in a clinical trial or any type of disorder that affected the patient&#39;s ability to provide written informed consent&#46; All patients were consecutively recruited&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Participants</span><p id="par0035" class="elsevierStylePara elsevierViewall">Forty-one researchers from all over Spain participated in the study&#46; To make the sample as representative as possible&#44; a stratification of the centers by geographical area was performed &#40;one half for the upper peninsula&#44; the other half for the lower peninsula and archipelagos&#41;&#46; The recruitment was performed between December 2011 and August 2012&#46;</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Statistical analysis</span><p id="par0040" class="elsevierStylePara elsevierViewall">The qualitative variables are shown as frequencies and percentages&#46; The quantitative variables are expressed as mean and standard deviation or median&#44; depending on their distribution&#46; The means and percentages are expressed with their corresponding 95&#37; confidence intervals&#46; We employed the SPSS statistical package 10&#46;0&#46;</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Ethical considerations</span><p id="par0045" class="elsevierStylePara elsevierViewall">SIRENA was approved by the Research Ethics Committee of the Balearic Islands and was performed according to the ethical requirements of the 1975 Declaration of Helsinki and its subsequent amendments&#46; The patients were informed&#44; and all signed the written consent form&#46;</p></span></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">Results</span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0105">Study population</span><p id="par0050" class="elsevierStylePara elsevierViewall">The study included 631 women&#44; with a mean age of 68&#46;5 years&#44; 88&#46;1&#37; of whom were menopausal&#46; The mean age at the start of menopause was 49<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>5&#46;1 years&#46; The mean age at symptom onset was 65&#46;7<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>12 years&#46; Ninety-seven of these women &#40;15&#46;4&#37;&#41; were premenopausal at the time&#46;</p><p id="par0055" class="elsevierStylePara elsevierViewall">The most common presentation was acute coronary syndrome &#40;ACS&#41; in 424 cases &#40;67&#46;2&#37;&#41;&#58; 37&#37; presented as ACS without ST-elevation and 30&#46;2&#37; as ST-elevation acute myocardial infarction &#40;STEAMI&#41;&#46; The other presentations were stable angina in 139 &#40;22&#37;&#41; patients&#44; anginal equivalent in 27 &#40;4&#46;3&#37;&#41;&#44; atypical chest pain in 21 &#40;3&#46;3&#37;&#41;&#44; cardiac syndrome X in 17 &#40;2&#46;7&#37;&#41; and vasospastic angina in 3 &#40;0&#46;5&#37;&#41;&#46; A total of 142 &#40;74&#46;3&#37;&#41; of the 191 women who presented acute myocardial infarction with ST-elevation underwent percutaneous coronary intervention&#44; and 24&#46;1&#37; underwent fibrinolysis&#59; 1&#46;6&#37; of the patients did not undergo coronary reperfusion therapy&#46;</p><p id="par0060" class="elsevierStylePara elsevierViewall">Within the cases of stable angina&#44; the most common presentation was class II of the Canadian Cardiovascular Society in 64&#37; of the cases and class III in 25&#46;9&#37;&#46;</p><p id="par0065" class="elsevierStylePara elsevierViewall">As shown in <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#44; the patients had a high CRF burden&#46; Of the cases of dyslipidemia&#44; 53&#46;7&#37; had pure hypercholesterolemia&#44; 1&#46;3&#37; had hypertriglyceridemia and 13&#37; had mixed dyslipidemia&#46; Ninety-four percent of the cases of diabetes were type 2&#46; The most common cardiovascular comorbidities were atrial fibrillation and heart failure&#44; which progressed with preserved ejection fractions in 50&#37; of the cases&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0110">Clinical data</span><p id="par0070" class="elsevierStylePara elsevierViewall">At the time of inclusion&#44; 69&#46;7&#37; of the patients were asymptomatic&#44; 13&#46;3&#37; had Canadian Cardiovascular Society class I angina&#44; 14&#46;3&#37; had class II and 2&#46;7&#37; had class III&#46; The most common causes of hospitalization in the previous 6 months were ACS for 17&#46;8&#37; of the cases&#44; coronary revascularization for 11&#46;1&#37;&#44; heart failure for 7&#46;5&#37;&#44; arrhythmias for 4&#46;6&#37; and noncardiovascular causes for 4&#46;8&#37;&#46;</p><p id="par0075" class="elsevierStylePara elsevierViewall">The mean systolic blood pressure was 134&#46;4<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>20&#46;6<span class="elsevierStyleHsp" style=""></span>mmHg&#44; and the mean diastolic blood pressure was 74&#46;7<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>11&#46;1<span class="elsevierStyleHsp" style=""></span>mmHg&#46; Some 30&#46;7&#37; of the patients had uncontrolled blood pressure &#40;&#8805;140&#47;90<span class="elsevierStyleHsp" style=""></span>mmHg&#41;&#46; The mean heart rate was 67&#46;8<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>10&#46;4<span class="elsevierStyleHsp" style=""></span>bpm&#44; and 8&#46;1&#37; of the patients were smokers&#46;</p><p id="par0080" class="elsevierStylePara elsevierViewall">The mean body mass index &#40;BMI&#41; was 28&#46;8<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>5&#46;2&#44; with 76&#46;1&#37; of the patients above 25 &#40;25&#8211;29&#46;9&#58;39&#46;6&#37;&#59; &#8805;30&#58;36&#46;5&#37;&#41;&#44; and 1&#37; were underweight &#40;&#60;18&#46;5&#41;&#46; Seventy-one percent of the patients had central obesity&#44; with a mean abdominal circumference of 95&#46;4<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>14<span class="elsevierStyleHsp" style=""></span>cm&#46;</p><p id="par0085" class="elsevierStylePara elsevierViewall">Some 88&#46;9&#37; of the patients had sinus rhythm&#44; 8&#46;9&#37; had atrial fibrillation and 2&#46;2&#37; had pacemaker rhythms&#46;</p><p id="par0090" class="elsevierStylePara elsevierViewall">Blood analyses within the last 6 months were available for 552 women &#40;87&#46;5&#37;&#41;&#46; The mean hemoglobin level was 12&#46;8<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>1&#46;4<span class="elsevierStyleHsp" style=""></span>g&#47;dL&#46; The lipid results were as follows &#40;mg&#47;dL&#41;&#58; total cholesterol&#44; 170&#46;1<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>38&#46;6&#59; HDL cholesterol&#44; 47&#46;2<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>11&#46;7&#59; LDL cholesterol&#44; 95&#46;6<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>33&#59; and triglycerides&#44; 138&#46;3<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>71&#46;1&#46; <a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a> provides a bar graph that shows the percentage of patients with poorly controlled lipid metabolism&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0095" class="elsevierStylePara elsevierViewall">The mean glucose level was 119&#46;3<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>41&#46;8<span class="elsevierStyleHsp" style=""></span>mg&#47;dL&#44; and the mean HbA1c level &#40;available for 327 women&#41; was 6&#46;8&#37;<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>1&#46;5&#37;&#46; Of the 185 women with diabetes and available HbA1c levels&#44; 49&#46;2&#37; were not well controlled &#40;HbA1c<span class="elsevierStyleHsp" style=""></span>&#62;<span class="elsevierStyleHsp" style=""></span>7&#37;&#41;&#46; We also detected 6&#46;5&#37; of women with newly diagnosed diabetes and fasting glucose levels &#62;125<span class="elsevierStyleHsp" style=""></span>mg&#47;dL&#46; The mean creatinine value was 0&#46;9<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>0&#46;4<span class="elsevierStyleHsp" style=""></span>mg&#47;dL&#46;</p></span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0115">Clinical management</span><p id="par0100" class="elsevierStylePara elsevierViewall"><a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a> shows the additional tests performed&#46; Coronary angiography was performed on 557 patients&#44; which found the anterior descending artery to be the most commonly affected with significant lesions &#40;luminal stenosis &#8805;50&#37;&#41; &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>&#41;&#46; It is worth noting that up to 10&#46;2&#37; of cases had no vessel that was significantly affected&#46; Of these&#44; 17 &#40;29&#46;8&#37;&#41; presented as cardiac syndrome X&#44; 3 &#40;5&#46;3&#37;&#41; as vasospastic angina&#44; 2 &#40;3&#46;5&#37;&#41; with atypical chest pain&#44; 11 &#40;19&#46;3&#37;&#41; with stable angina and up to 24 &#40;42&#46;1&#37;&#41; in the form of ACS&#46;</p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0105" class="elsevierStylePara elsevierViewall">The ejection fraction was measured in 617 women &#40;97&#46;8&#37;&#41;&#44; most through echocardiography&#44; with a median value of 60&#37; &#40;range&#44; 19&#8211;81&#37;&#41;&#46; <a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a> shows the cardiovascular drug treatment&#46; Percutaneous coronary intervention was performed on 63&#46;4&#37; of the patients and more than once on 23&#46;9&#37; during the progression&#46; Fourteen percent of the patients underwent coronary surgery&#46; The anterior descending artery and left common trunk were addressed in 97&#46;7&#37; and 23&#46;9&#37; of the cases&#44; respectively&#46; A second surgery was not performed in any of the cases&#46;</p><elsevierMultimedia ident="tbl0015"></elsevierMultimedia></span></span><span id="sec0060" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0120">Discussion</span><p id="par0110" class="elsevierStylePara elsevierViewall">In the SIRENA study&#44; we determined the profile of Spanish woman with chronic IHD&#44; calculated the prevalence of CRF and analyzed the clinical management and treatment of these patients&#46;</p><p id="par0115" class="elsevierStylePara elsevierViewall">The mean age was higher than that of the women in the Euro Heart Survey of Stable Angina &#40;62 years&#41;&#44;<a class="elsevierStyleCrossRef" href="#bib0245"><span class="elsevierStyleSup">12</span></a> slightly higher than that of the recent CLARIFY registry on stable coronary artery disease<a class="elsevierStyleCrossRef" href="#bib0250"><span class="elsevierStyleSup">13</span></a> &#40;which included 7002 women with a mean age of 66&#46;5 years&#41; and was the same as that of the women in the Galician CIBAR cohort<a class="elsevierStyleCrossRef" href="#bib0235"><span class="elsevierStyleSup">10</span></a> on chronic IHD&#46; The fact that Spain has one of the lowest incidences of IHD in the world<a class="elsevierStyleCrossRefs" href="#bib0255"><span class="elsevierStyleSup">14&#44;15</span></a> could be related to the later onset of IHD in women&#46; It is worth noting that&#44; despite the high mean age&#44; almost a fifth of the women had their clinical presentation before 55 years of age&#46; Moreover&#44; SIRENA cannot provide us with comparative data on men&#44; given that this study was designed exclusively to analyze women with IHD&#46;</p><p id="par0120" class="elsevierStylePara elsevierViewall">The most common presentation of IHD was ACS&#44; which differs from the more classical concept of an initial presentation in the form of stable angina&#44; as found in the Framingham Study&#44; and compared with men in whom AMI is more common&#46;<a class="elsevierStyleCrossRefs" href="#bib0265"><span class="elsevierStyleSup">16&#44;17</span></a> The high mean age and prevalence of CRF in our patients&#44; especially after menopause&#44;<a class="elsevierStyleCrossRef" href="#bib0275"><span class="elsevierStyleSup">18</span></a> as well as the progressive acquisition of male habits&#44; such as smoking at an earlier age&#44;<a class="elsevierStyleCrossRef" href="#bib0280"><span class="elsevierStyleSup">19</span></a> has surely contributed to this form of acute presentation&#46;</p><p id="par0125" class="elsevierStylePara elsevierViewall">The most common cardiovascular comorbidities were AF and HF&#44; which were more common than those observed in other studies on stable IHD&#46;<a class="elsevierStyleCrossRefs" href="#bib0235"><span class="elsevierStyleSup">10&#8211;13</span></a> We believe that this finding is related to the higher mean age&#44; greater prevalence of arterial hypertension &#40;which is expected due to the predominance of postmenopausal women&#41;<a class="elsevierStyleCrossRef" href="#bib0195"><span class="elsevierStyleSup">2</span></a> and the high prevalence of diabetes&#44; including the 6&#46;5&#37; of cases of previously unknown diabetes &#40;a finding not evaluated in other IHD studies&#41;&#46; The advanced mean age and the anthropometry of these women undoubtedly play a relevant role in the high prevalence of diabetes&#46;</p><p id="par0130" class="elsevierStylePara elsevierViewall">A considerable majority of our patients had a high body mass index&#44; in keeping with previous studies&#44;<a class="elsevierStyleCrossRef" href="#bib0250"><span class="elsevierStyleSup">13</span></a> and inadequate body fat distribution&#46; However&#44; the prevalence of obesity was less than that reported in the CIBAR study&#44;<a class="elsevierStyleCrossRef" href="#bib0235"><span class="elsevierStyleSup">10</span></a> possibly due to geographical differences&#46; There are variations in the geographical distribution of obesity&#44; with a higher prevalence in the northwest and southeast communities and in the Canary Islands&#44;<a class="elsevierStyleCrossRef" href="#bib0285"><span class="elsevierStyleSup">20</span></a> which would explain the lower results in SIRENA&#44; which is a representative sample of the entire country&#46; There was a worryingly high prevalence of overweight&#44; obesity and abdominal obesity&#44; known risk factors of IHD and for IHD mortality in women&#46;<a class="elsevierStyleCrossRefs" href="#bib0290"><span class="elsevierStyleSup">21&#8211;23</span></a></p><p id="par0135" class="elsevierStylePara elsevierViewall">We detected only a 5&#46;4&#37; rate of early menopause&#44; which is associated with an increased risk of IHD and stroke&#44;<a class="elsevierStyleCrossRef" href="#bib0305"><span class="elsevierStyleSup">24</span></a> as well as a shorter life expectancy&#46;<a class="elsevierStyleCrossRef" href="#bib0310"><span class="elsevierStyleSup">25</span></a> Polycystic ovaries are also an established risk factor for IHD&#46;<a class="elsevierStyleCrossRefs" href="#bib0315"><span class="elsevierStyleSup">26&#44;27</span></a> However&#44; this condition is not recorded in other registries of stable IHD&#46; Despite the low rate observed&#44; which could be due to lack of awareness by cardiologists&#44; this information should be recorded when studying women with IHD&#46;</p><p id="par0140" class="elsevierStylePara elsevierViewall">As has been published by other authors&#44;<a class="elsevierStyleCrossRef" href="#bib0275"><span class="elsevierStyleSup">18</span></a> SIRENA revealed a high prevalence of CRF in women&#46; Previous studies have also demonstrated poorer CRF control in women with chronic IHD&#46;<a class="elsevierStyleCrossRef" href="#bib0325"><span class="elsevierStyleSup">28</span></a> We should therefore increase our efforts in secondary prevention&#46;</p><p id="par0145" class="elsevierStylePara elsevierViewall">The most frequently performed ischemia examination in the SIRENA population was the stress test &#40;ergometry&#41;&#46; Various studies have observed that the test is performed less frequently for women than for men&#46;<a class="elsevierStyleCrossRefs" href="#bib0330"><span class="elsevierStyleSup">29&#44;30</span></a> More prognostic ergometries are performed than diagnostic&#46; This situation would probably be reversed if it were men that were being treated&#46; Ergometry is an essential test and should be the first test when studying IHD in men and women&#46; However&#44; the test is less sensitive and less specific in women due to their lower prevalence of coronary artery disease&#46;</p><p id="par0150" class="elsevierStylePara elsevierViewall">Most of the patients underwent optimal medical therapy &#40;antiplatelet agents&#44; beta-blockers&#44; hypolipidemic agents and renin&#8211;angiotensin&#8211;aldosterone system inhibitors&#41;&#44; which was more than was found in other registries&#46;<a class="elsevierStyleCrossRefs" href="#bib0235"><span class="elsevierStyleSup">10&#44;12&#44;13</span></a></p><p id="par0155" class="elsevierStylePara elsevierViewall">In other studies&#44; the female sex was a predictor of a lower use of coronary angiography as part of the study on stable angina&#46;<a class="elsevierStyleCrossRefs" href="#bib0245"><span class="elsevierStyleSup">12&#44;31&#44;32</span></a> This is the case for various ACS registries&#44; such as the Canadian ACS&#44;<a class="elsevierStyleCrossRef" href="#bib0350"><span class="elsevierStyleSup">33</span></a> SWEDEHEART<a class="elsevierStyleCrossRef" href="#bib0355"><span class="elsevierStyleSup">34</span></a> and CRUSADE&#44;<a class="elsevierStyleCrossRef" href="#bib0360"><span class="elsevierStyleSup">35</span></a> which have obvious Yentl syndrome or the &#8220;medical invisibility&#8221; of women in the study of cardiac disease&#44; resulting in the underdiagnosis and undertreatment of this population&#46;<a class="elsevierStyleCrossRef" href="#bib0365"><span class="elsevierStyleSup">36</span></a> Nevertheless&#44; most of these women underwent coronary angiography&#44; which is more than has occurred in other populations of stable IHD&#46;<a class="elsevierStyleCrossRefs" href="#bib0235"><span class="elsevierStyleSup">10&#44;12&#44;13</span></a> The patients in SIRENA underwent percutaneous coronary intervention at more than twice the rate of other Spanish women with chronic IHD and also underwent more coronary surgery&#44; despite having only slightly lower multivessel involvement&#46;<a class="elsevierStyleCrossRef" href="#bib0235"><span class="elsevierStyleSup">10</span></a> The revascularization in SIRENA is the result of more interventional treatment and provides an overall idea of the management of IHD in Spain&#46; In this respect&#44; our data do not reflect Yentl syndrome&#44;<a class="elsevierStyleCrossRef" href="#bib0365"><span class="elsevierStyleSup">36</span></a> with the caveat that this registry is exclusively on women&#46;</p><p id="par0160" class="elsevierStylePara elsevierViewall">The cardiologist&#39;s mindset has probably changed due to the dissemination conducted by scientific societies in recent years&#46; These results indicate that there are no differences in clinical management between sexes that were present beforehand&#46;</p><p id="par0165" class="elsevierStylePara elsevierViewall">As pointed out in a recent editorial&#44; the knowledge of IHD in women should be transferred to clinical practice&#44; and policies of information&#44; dissemination and sensitization should be developed on coronary artery disease in women&#46;<a class="elsevierStyleCrossRef" href="#bib0370"><span class="elsevierStyleSup">37</span></a></p><p id="par0170" class="elsevierStylePara elsevierViewall">This study has a number of limitations&#46; SIRENA is not a comparative study with men&#44; given that it was designed to determine the profile and clinical treatment of women with stable IHD&#46; The sample is also relatively small&#44; especially when compared with population registries&#46;</p></span><span id="sec0065" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0125">Conclusions</span><p id="par0175" class="elsevierStylePara elsevierViewall">In Spain&#44; IHD in women mostly presents as ACS&#44; which is treated invasively&#46; There is a high prevalence of poorly controlled CRF&#44; despite the fact that the majority of patients undergo optimal medical therapy&#46; We believe that more healthcare policies need to be developed to control CRF through secondary prevention&#46;</p></span><span id="sec0070" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0130">Funding</span><p id="par0180" class="elsevierStylePara elsevierViewall">This study was funded by a grant from the <span class="elsevierStyleGrantSponsor" id="gs1">Clinical Cardiology Section of the Spanish Society of Cardiology</span> and by an unconditional grant by <span class="elsevierStyleGrantSponsor" id="gs2">Grupo Menarini Espa&#241;a S&#46;A&#46;</span> to the Spanish Society of Cardiology&#46;</p></span><span id="sec0075" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0135">Conflict of interest</span><p id="par0185" class="elsevierStylePara elsevierViewall">The authors declare that they have no conflicts of interest&#46;</p></span></span>"
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    "fechaRecibido" => "2015-06-03"
    "fechaAceptado" => "2015-09-23"
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          "clase" => "keyword"
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            0 => "Ischemic heart disease"
            1 => "Risk factors"
            2 => "Woman"
            3 => "Prevalence"
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          "palabras" => array:4 [
            0 => "Cardiopat&#237;a isqu&#233;mica"
            1 => "Factores de riesgo"
            2 => "Mujer"
            3 => "Prevalencia"
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    "resumen" => array:2 [
      "en" => array:3 [
        "titulo" => "Abstract"
        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Objectives</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Cardiovascular diseases are the leading cause of death for women&#44; especially ischemic heart disease&#44; which is still considered a man&#39;s disease&#46; In Spain&#44; there are various registries on ischemic heart disease&#44; although none are exclusively for women&#46; The objectives of the SIRENA study were to describe the clinical profile of women with ischemic heart disease treated in cardiology consultations&#44; to estimate its prevalence of cardiovascular risk factors and understand its clinical management&#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 multicentre observational study was conducted with a sample of 631 women with stable ischemic heart disease&#44; consecutively included during cardiology consultations&#46; Forty-one researchers from all over Spain participated in the study&#46;</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Results</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">The mean age was 68&#46;5 years&#46; The clinical presentation was in the form of acute coronary syndrome in up to 67&#46;2&#37; of the patients&#46; The prevalence of cardiovascular risk factors was high &#40;77&#46;7&#37; of the patients had hypertension&#44; 40&#46;7&#37; had diabetes and 68&#37; had dyslipidaemia&#41;&#44; with 30&#46;7&#37; having uncontrolled hypertension&#44; 78&#46;4&#37; having LDL-cholesterol levels higher than 70<span class="elsevierStyleHsp" style=""></span>mg&#47;dL and 49&#46;2&#37; having HbA1c levels greater than 7&#37;&#46; The considerable majority of the patients underwent optimal medical treatment with antiplatelet agents&#44; beta-blockers&#44; renin&#8211;angiotensin&#8211;aldosterone system blockers and hypolipidaemic agents&#46; Coronary angiography was performed for 88&#46;3&#37; of the patients&#44; and 63&#46;4&#37; underwent percutaneous coronary intervention&#46;</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Conclusions</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Women with stable ischemic heart disease in Spain initially present some form of acute coronary syndrome and a high prevalence of inadequately controlled cardiovascular risk factors&#44; despite undergoing optimal medical therapy&#46; A high percentage of these women undergo coronary revascularisation&#46; Increased efforts are required for secondary prevention in women with stable ischemic heart disease&#46;</p></span>"
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            "identificador" => "abst0005"
            "titulo" => "Objectives"
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          1 => array:2 [
            "identificador" => "abst0010"
            "titulo" => "Patients and methods"
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          2 => array:2 [
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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">Las enfermedades cardiovasculares son la primera causa de muerte en mujeres&#44; particularmente la cardiopat&#237;a isqu&#233;mica&#44; que a&#250;n se sigue considerando una enfermedad de hombres&#46; En Espa&#241;a hay diversos registros sobre cardiopat&#237;a isqu&#233;mica&#44; aunque ninguno exclusivo de mujeres&#46; Los objetivos de SIRENA fueron describir el perfil cl&#237;nico de las mujeres con cardiopat&#237;a isqu&#233;mica atendidas en las consultas de cardiolog&#237;a&#44; estimar su prevalencia de factores de riesgo cardiovascular y conocer su manejo cl&#237;nico y tratamiento&#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">Estudio multic&#233;ntrico&#44; observacional&#44; con una muestra de 631 mujeres con cardiopat&#237;a isqu&#233;mica estable&#44; incluidas consecutivamente en las consulta de cardiolog&#237;a&#46; Participaron 41 investigadores de toda Espa&#241;a&#46;</p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Resultados</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">La edad media fue de 68&#44;5 a&#241;os&#46; La presentaci&#243;n cl&#237;nica fue en forma de s&#237;ndrome coronario agudo hasta en un 67&#44;2&#37;&#46; La prevalencia de factores de riesgo cardiovascular fue elevada &#40;77&#44;7&#37; hipertensi&#243;n&#44; 40&#44;7&#37; diabetes y 68&#37; dislipidemia&#41;&#44; con un 30&#44;7&#37; de hipertensi&#243;n no controlada&#44; un 78&#44;4&#37; con cifras de colesterol-LDL superiores a 70<span class="elsevierStyleHsp" style=""></span>mg&#47;dL y un 49&#44;2&#37; con HbA1c superior al 7&#37;&#46; La gran mayor&#237;a de las pacientes recib&#237;an tratamiento m&#233;dico &#243;ptimo con antiagregantes&#44; betabloqueantes&#44; bloqueadores del eje renina&#8211;angiotensina&#8211;aldosterona e hipolipidemiantes&#46; Se realiz&#243; coronariograf&#237;a en el 88&#44;3&#37; de los casos e intervencionismo coronario percut&#225;neo en el 63&#44;4&#37;&#46;</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Conclusiones</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">La mujer con cardiopat&#237;a isqu&#233;mica estable en Espa&#241;a tiene una presentaci&#243;n cl&#237;nica inicial con alguna forma de s&#237;ndrome coronario agudo y una elevada prevalencia de factores de riesgo cardiovascular inadecuadamente controlados&#44; pese a recibir terapia m&#233;dica &#243;ptima&#46; Un elevado porcentaje se somete a revascularizaci&#243;n coronaria&#46; Son precisos m&#225;s esfuerzos en la prevenci&#243;n secundaria de las mujeres con cardiopat&#237;a isqu&#233;mica estable&#46;</p></span>"
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        "etiqueta" => "&#9734;"
        "nota" => "<p class="elsevierStyleNotepara" id="npar0010">Please cite this article as&#58; G&#225;mez JM&#44; Ripoll T&#44; Barrios V&#44; Anguita M&#44; Pedreira M&#44; Madariaga I&#44; et al&#46; Perfil cl&#237;nico de la mujer con cardiopat&#237;a isqu&#233;mica estable en Espa&#241;a&#46; Son necesarios m&#225;s esfuerzos en prevenci&#243;n secundaria&#46; Estudio SIRENA&#46; Rev Clin Esp&#46; 2016&#59;216&#58;1&#8211;7&#46;</p>"
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        "nota" => "<p class="elsevierStyleNotepara" id="npar0015">See Appendix&#46;</p>"
        "identificador" => "fn1"
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      0 => array:1 [
        "seccion" => array:1 [
          0 => array:4 [
            "apendice" => "<p id="par0195" class="elsevierStylePara elsevierViewall">Joan Alguersuari Cabiscol&#44; Gonzalo Bar&#243;n Esquivias&#44; Ram&#243;n Bover Freire&#44; Mercedes Camprub&#237;&#44; Santiago Cantabrana Miguel&#44; Miguel Castillo Orive&#44; Almudena Castro&#44; Juan Cos&#237;n Sales&#44; Alberto Cordero Fort&#44; Carlos Culebras C&#225;ceres&#44; Regina Dalmau&#44; Carlos Escobar Cervantes&#44; Luis Escosa Royo&#44; Lorenzo F&#225;cila Rubio&#44; Enrique Galve Basilio&#44; Jos&#233; Mar&#237;a Garc&#237;a Acu&#241;a&#44; Xavier Garc&#237;a-Moll Marim&#243;n&#44; Jos&#233; Javier G&#243;mez Barrado&#44; Juan Jos&#233; G&#243;mez Doblas&#44; Mar&#237;a Gracia Azn&#225;rez&#44; Jos&#233; Sergio Hevia Nava&#44; Rafael Hidalgo&#44; Ismael Laplaza Alastruey&#44; I&#241;aki Lekuona Goya&#44; Manuel Mart&#237;nez-Sell&#233;s&#44; Pilar Maz&#243;n Ramos&#44; Gaspar Melis Riera&#44; Nekane Murga Eizagaechevarr&#237;a&#44; In&#233;s Otero G&#243;mez&#44; Francisco Ridocci Soriano&#44; Francisco Ruiz Mateas&#44; Francisco Torres Calvo&#44; Joan Torres Marqu&#233;s&#44; Isabel Mar&#237;a Ure&#241;a Montilla&#44; Alfonso Varela Rom&#225;n&#46;</p>"
            "etiqueta" => "Appendix A"
            "titulo" => "SIRENA study researchers &#40;by alphabetical order&#41;"
            "identificador" => "sec0080"
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        ]
      ]
    ]
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        "etiqueta" => "Figure 1"
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          "en" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Patients with poor lipid metabolism control&#46;</p>"
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        "etiqueta" => "Figure 2"
        "tipo" => "MULTIMEDIAFIGURA"
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          "en" => "<p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">Coronary arteries affected with significant lesions &#40;&#8805;50&#37;&#41;&#46; <span class="elsevierStyleItalic">Abbreviations</span>&#58; DA&#44; descending anterior&#59; Cx&#44; circumflex&#59; RC&#44; right coronary artery&#46;</p>"
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        "tabla" => array:3 [
          "leyenda" => "<p id="spar0060" class="elsevierStyleSimplePara elsevierViewall"><span class="elsevierStyleItalic">Abbreviations</span>&#58; BMI&#44; body mass index&#59; COPD&#44; chronic obstructive pulmonary disease&#59; IHD&#44; ischemic heart disease&#59; PAD&#44; peripheral arterial disease&#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="left" valign="top" scope="col" style="border-bottom: 2px solid black">Risk factors and comorbidities&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">Patients &#40;&#37;&#41;&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">Patients&#44; <span class="elsevierStyleItalic">n</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">631&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">Mean age&#44; <span class="elsevierStyleItalic">y</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">68&#46;5 &#40;12&#46;2&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Premenopausal presentation&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">97 &#40;15&#46;4&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Active smoking&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">51 &#40;8&#46;1&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Exsmoker&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">131 &#40;20&#46;8&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Dyslipidemia&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">429 &#40;68&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Arterial hypertension&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">490 &#40;77&#46;7&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Diabetes mellitus&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">257 &#40;40&#46;7&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Family history of early IHD&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">78 &#40;12&#46;4&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Early menopause&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">30 &#40;5&#46;4&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">BMI&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">28&#46;8 &#40;5&#46;2&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Atrial fibrillation&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">102 &#40;16&#46;2&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Heart failure&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">120 &#40;19&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Thoracic aortic disease&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">6 &#40;1&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Abdominal aortic disease&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">2 &#40;0&#46;3&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Stroke&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">62 &#40;9&#46;8&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">COPD&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">40 &#40;6&#46;3&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Liver disease&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">11 &#40;1&#46;7&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Chronic kidney disease&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">84 &#40;13&#46;3&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">PAD in lower limbs&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">43 &#40;6&#46;8&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">PAD in carotid artery&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">25 &#40;4&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Thyroid dysfunction&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">73 &#40;11&#46;6&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Polycystic ovaries&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">11 &#40;1&#46;7&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Anxiety-depressive syndrome&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">156 &#40;24&#46;7&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
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              "identificador" => "tblfn0005"
              "etiqueta" => "a"
              "nota" => "<p class="elsevierStyleNotepara" id="npar0005">&#60;45 years for men and &#60;55 years for women&#46;</p>"
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          "en" => "<p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">Cardiovascular risk factors and comorbidity&#46;<a class="elsevierStyleCrossRef" href="#tblfn0005"><span class="elsevierStyleSup">a</span></a></p>"
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        "etiqueta" => "Table 2"
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          "leyenda" => "<p id="spar0070" class="elsevierStyleSimplePara elsevierViewall"><span class="elsevierStyleItalic">Abbreviations</span>&#58; CT&#44; computed axial tomography&#59; MIBI&#44; methoxyisobutylisonitrile&#46;</p>"
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              "tabla" => array:1 [
                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Additional tests&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">Patients &#40;&#37;&#41;&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"><span class="elsevierStyleBold">Patients&#44;</span><span class="elsevierStyleItalic"><span class="elsevierStyleBold">n</span></span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">631&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="elsevierStyleBold">Echocardiogram</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">568 &#40;90&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleBold">Ergometry</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">284 &#40;45&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">Diagnostic</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#40;43&#46;7&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">Prognostic</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#40;56&#46;3&#41;&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="2" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></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="elsevierStyleBold">Myocardial perfusion-MIBI</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">113 &#40;17&#46;9&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleBold">Pharmacological stress echocardiography</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">55 &#40;8&#46;7&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleBold">Coronary CT scan</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">16 &#40;2&#46;5&#41;&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="2" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></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="elsevierStyleBold">Coronary angiography</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">557 &#40;88&#46;3&#41;&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="2" align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">Number of coronary vessels affected</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><span class="elsevierStyleHsp" style=""></span>None&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">57 &#40;10&#46;2&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">221 &#40;39&#46;7&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">143 &#40;25&#46;7&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">136 &#40;24&#46;4&#41;&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="2" align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">Trunk disease and no&#46; of vessels</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><span class="elsevierStyleHsp" style=""></span>None&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">2 &#40;4&#46;3&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">7 &#40;14&#46;9&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">19 &#40;40&#46;4&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">19 &#40;40&#46;4&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
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          "en" => "<p id="spar0065" class="elsevierStyleSimplePara elsevierViewall">Additional tests performed&#46;</p>"
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        "identificador" => "tbl0015"
        "etiqueta" => "Table 3"
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          "leyenda" => "<p id="spar0080" class="elsevierStyleSimplePara elsevierViewall"><span class="elsevierStyleItalic">Abbreviations</span>&#58; ACEI&#44; angiotensin-converting enzyme inhibitor&#59; ARB II&#44; angiotensin II receptor blockers&#59; ASA&#44; acetylsalicylic acid&#59; CA&#44; calcium antagonists&#46;</p>"
          "tablatextoimagen" => array:1 [
            0 => array:2 [
              "tabla" => array:1 [
                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Pharmacotherapy&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">Patients &#40;&#37;&#41;&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"><span class="elsevierStyleItalic">Patients&#44; n</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">631&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="elsevierStyleItalic">Antiplatelets</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">584 &#40;92&#46;6&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>AAS&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">550 &#40;87&#46;2&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Clopidogrel&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">226 &#40;35&#46;8&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Prasugrel&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">28 &#40;4&#46;4&#41;&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="2" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></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="elsevierStyleItalic">Beta-blockers</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">500 &#40;79&#46;2&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">Nitrates</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">215 &#40;34&#46;1&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">Dihydropyridine CAs</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">154 &#40;24&#46;4&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">Nondihydropyridine CAs</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">46 &#40;7&#46;3&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">Ranolazine</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">47 &#40;7&#46;5&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">Ivabradine</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">37 &#40;5&#46;9&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">Trimetazidine</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">8 &#40;1&#46;3&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">Molsidomine</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0 &#40;0&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">Diuretics</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">250 &#40;39&#46;6&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">Aldosterone inhibitors</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">77 &#40;12&#46;2&#41;&nbsp;\t\t\t\t\t\t\n
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