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          "es" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Diagrama de inclusi&#243;n y clasificaci&#243;n de los pacientes con insuficiencia cardiaca aguda seg&#250;n tuviesen o no el diagn&#243;stico previo de enfermedad pulmonar obstructiva cr&#243;nica&#46;</p>"
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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Introducci&#243;n</span><p id="par0005" class="elsevierStylePara elsevierViewall">La insuficiencia cardiaca aguda &#40;ICA&#41; es una entidad compleja que ha recibido escasa atenci&#243;n en cuanto a la concordancia entre las concepciones actuales de manejo descritas en las gu&#237;as<a class="elsevierStyleCrossRef" href="#bib0245"><span class="elsevierStyleSup">1</span></a> y las pautas reales de tratamiento&#46; En consecuencia&#44; las gu&#237;as de manejo describen habitualmente la evoluci&#243;n natural y el tratamiento desde la perspectiva de una &#250;nica enfermedad<a class="elsevierStyleCrossRefs" href="#bib0245"><span class="elsevierStyleSup">1&#8211;3</span></a>&#46; Adem&#225;s&#44; los registros de ICA<a class="elsevierStyleCrossRefs" href="#bib0260"><span class="elsevierStyleSup">4&#44;5</span></a> han descrito habitualmente el uso de agentes cardiovasculares sin informar del uso de farmacoterapias no cardiacas&#46; Sin embargo&#44; los pacientes con ICA en los servicios de urgencias hospitalarios &#40;SUH&#41; en la pr&#225;ctica real son complejos&#44; y su tratamiento puede superar las categor&#237;as tradicionales debido a la incertidumbre diagn&#243;stica o a la coexistencia de diferentes enfermedades cr&#243;nicas o agudas<a class="elsevierStyleCrossRefs" href="#bib0485"><span class="elsevierStyleSup">6&#44;7</span></a>&#46; En los &#250;ltimos a&#241;os se ha prestado cada vez m&#225;s atenci&#243;n a comprender la superposici&#243;n de las enfermedades cardiacas y pulmonares&#46; Se ha demostrado que las enfermedades pulmonares y cardiacas cr&#243;nicas est&#225;n estrechamente relacionadas&#44; ya que la obstrucci&#243;n cr&#243;nica del flujo a&#233;reo puede alterar el llenado ventricular izquierdo&#44; el volumen sist&#243;lico y el gasto cardiaco<a class="elsevierStyleCrossRef" href="#bib0485"><span class="elsevierStyleSup">6</span></a>&#46; Adem&#225;s&#44; la extensi&#243;n de la enfermedad arterial pulmonar predice tanto la funci&#243;n ventricular derecha como las exacerbaciones de la enfermedad pulmonar obstructiva cr&#243;nica &#40;EPOC&#41;<a class="elsevierStyleCrossRef" href="#bib0275"><span class="elsevierStyleSup">7</span></a>&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">En este sentido&#44; la EPOC presenta un progresivo aumento de su prevalencia y la OMS considera que ser&#225; la tercera causa de mortalidad en el mundo para el 2030<a class="elsevierStyleCrossRef" href="#bib0280"><span class="elsevierStyleSup">8</span></a>&#46; Un gran porcentaje de los pacientes con EPOC experimentan concomitantemente insuficiencia cardiaca &#40;IC&#41;&#44; probablemente en parte debido a que comparten el consumo de tabaco como factor de riesgo com&#250;n<a class="elsevierStyleCrossRefs" href="#bib0285"><span class="elsevierStyleSup">9&#44;10</span></a>&#46; La prevalencia estimada de EPOC en los individuos con IC se encuentra entre el 20 y 32&#37; de los casos<a class="elsevierStyleCrossRef" href="#bib0295"><span class="elsevierStyleSup">11</span></a>&#44; y la coexistencia de estas enfermedades les confiere un mayor riesgo de morbimortalidad a largo plazo<a class="elsevierStyleCrossRefs" href="#bib0290"><span class="elsevierStyleSup">10&#44;12</span></a> Sin embargo&#44; el efecto que tiene la EPOC en el pron&#243;stico a corto plazo de las descompensaciones de los pacientes con IC es mucho menos conocido&#46; Uno de los obst&#225;culos m&#225;s grandes es que la descompensaci&#243;n tanto de la EPOC como de la IC se manifiesta como disnea en el paciente<a class="elsevierStyleCrossRefs" href="#bib0305"><span class="elsevierStyleSup">13&#44;14</span></a>&#44; y es por tanto muy importante distinguir ambas enfermedades a la hora de tratar al paciente&#46; Sin embargo&#44; hay pocos estudios prospectivos y ensayos cl&#237;nicos aleatorizados que aborden el tratamiento combinado de los pacientes con EPOC e IC en fase cr&#243;nica&#44; y menos a&#250;n estudios que eval&#250;en en pacientes con ICA<a class="elsevierStyleCrossRefs" href="#bib0290"><span class="elsevierStyleSup">10&#44;15&#8211;17</span></a> el tratamiento concomitante con terapias respiratorias agudas &#40;beta-2-agonistas inhalados o nebulizados&#44; anticolin&#233;rgicos&#44; corticoides sist&#233;micos o antibi&#243;ticos&#41; que reciben en los SUH&#46; Este tratamiento concomitante puede ser frecuente en la pr&#225;ctica habitual&#44; ya que los s&#237;ntomas y signos de la ICA suelen ser inespec&#237;ficos<a class="elsevierStyleCrossRef" href="#bib0310"><span class="elsevierStyleSup">14</span></a> y coinciden con afecciones respiratorias agudas y cr&#243;nicas comunes que tambi&#233;n se presentan con frecuencia<a class="elsevierStyleCrossRef" href="#bib0300"><span class="elsevierStyleSup">12</span></a>&#46; Adem&#225;s&#44; no existen hallazgos patognom&#243;nicos ni pruebas diagn&#243;sticas que diferencien la ICA de las afecciones respiratorias agudas comunes&#44; lo que puede contribuir con frecuencia a la incertidumbre en el diagn&#243;stico<a class="elsevierStyleCrossRef" href="#bib0285"><span class="elsevierStyleSup">9</span></a>&#46; El objetivo de este estudio es analizar si los pacientes con IC y EPOC presentan diferencias cl&#237;nicas y de manejo terap&#233;utico en urgencias cuando desarrollan un episodio de ICA y analizar la mortalidad precoz durante dicha descompensaci&#243;n&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">M&#233;todo</span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Dise&#241;o del estudio</span><p id="par0015" class="elsevierStylePara elsevierViewall">El presente estudio es un an&#225;lisis secundario del Registro EAHFE <span class="elsevierStyleItalic">&#40;Epidemiology of Acute Heart Failure in Emergency departments&#41;</span>&#44; el cual es un registro multic&#233;ntrico&#44; multiprop&#243;sito&#44; anal&#237;tico no intervencionista&#44; con seguimiento prospectivo y que incluye de forma consecutiva a los pacientes que acuden por episodio de ICA al SUH&#46; Hasta la fecha se han realizado 8 fases de reclutamiento &#40;en los a&#241;os 2007&#44; 2009&#44; 2011&#44; 2014&#44; 2016&#44; 2018&#44; 2019 y 2022&#41; en un total de 53 SUH espa&#241;oles y contiene 24&#46;248 episodios &#250;nicos de ICA&#46; Los detalles y caracter&#237;sticas de estos pacientes ya han sido previamente publicados<a class="elsevierStyleCrossRefs" href="#bib0260"><span class="elsevierStyleSup">4&#44;18</span></a>&#46; La inclusi&#243;n de pacientes con ICA en el registro EAHFE se basa en el cumplimiento de los criterios cl&#237;nicos de Framingham<a class="elsevierStyleCrossRef" href="#bib0335"><span class="elsevierStyleSup">19</span></a> y confirmaci&#243;n con p&#233;ptidos natriur&#233;ticos o ecocardiograf&#237;a<a class="elsevierStyleCrossRefs" href="#bib0245"><span class="elsevierStyleSup">1&#8211;3</span></a>&#46; El &#250;nico criterio de exclusi&#243;n para ser incluido en el Registro EAHFE es la presencia concomitante de un s&#237;ndrome coronario agudo con elevaci&#243;n del segmento ST e ICA&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">En este estudio se consideraron elegibles todos los pacientes del Registro EAHFE en los cuales se dispon&#237;a de informaci&#243;n del antecedente de EPOC como comorbilidad y del estado vital del paciente tras el episodio agudo &#40;dado de alta vivo o fallecido en urgencias o el hospital&#41;&#46; El diagn&#243;stico de EPOC fue cl&#237;nico y se aceptaba que este exist&#237;a si as&#237; lo relataba el paciente o sus acompa&#241;antes o bien figuraba entre los antecedentes del paciente en la historia cl&#237;nica previa del hospital o de su centro de salud&#46; El estado vital tras el episodio de descompensaci&#243;n se comprob&#243; por la consulta de la historia cl&#237;nica del hospital donde el paciente hab&#237;a sido atendido&#46; Adem&#225;s&#44; el estudio limit&#243; la inclusi&#243;n de pacientes a las fases 3 a 8 del Registro EAHFE&#44; pues en las hojas de recogida de datos figuraban todas las variables independientes que se relatan m&#225;s adelante&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Variables independientes</span><p id="par0025" class="elsevierStylePara elsevierViewall">Se recogieron 19 variables independientes relacionadas con la situaci&#243;n basal del paciente&#58; 2 referentes a datos demogr&#225;ficos &#40;edad&#44; sexo&#41;&#44; 14 comorbilidades &#40;hipertensi&#243;n arterial&#44; dislipidemia&#44; diabetes mellitus&#44; cardiopat&#237;a isqu&#233;mica&#44; episodios previos de ICA&#44; enfermedad renal cr&#243;nica&#44; enfermedad cerebrovascular&#44; fibrilaci&#243;n auricular&#44; valvulopat&#237;a&#44; arteriopat&#237;a perif&#233;rica&#44; EPOC&#44; demencia&#44; neoplasia&#44; cirrosis hep&#225;tica&#41; y 3 de situaci&#243;n funcional &#40;clase funcional de la <span class="elsevierStyleItalic">New York Heart Association</span> &#91;NYHA&#93;&#44; clasificaci&#243;n seg&#250;n la fracci&#243;n de eyecci&#243;n del ventr&#237;culo izquierdo &#91;FEVI&#93; e &#237;ndice de Barthel&#41;&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">En relaci&#243;n con el episodio de descompensaci&#243;n&#44; se recogieron 6 potenciales desencadenantes del episodio &#40;infecci&#243;n&#44; taquiarritmia&#44; anemia&#44; crisis hipertensiva&#44; transgresi&#243;n diet&#233;tico-terap&#233;utica&#44; s&#237;ndrome coronario agudo&#41;&#44; 4 constantes vitales a la llegada a urgencias &#40;presi&#243;n arterial sist&#243;lica&#44; frecuencia cardiaca y respiratoria&#44; pulsioximetr&#237;a&#41;&#44; 4 resultados anal&#237;ticos &#40;creatinina&#44; potasio&#44; NT-proBNP&#44; troponina&#41; y un dato del ECG &#40;hipertrofia ventricular izquierda&#44; siguiendo los criterios de Sokolof&#41;&#46; Se calcul&#243; la gravedad del episodio de descompensaci&#243;n mediante la estratificaci&#243;n del riesgo de los pacientes con la escala MEESSI-AHF <span class="elsevierStyleItalic">&#40;Multiple Estimation of risk based on the Emergency department Spanish Score in Acute Heart Failure&#41;</span>&#44; la cual utiliza 13 variables basales y del episodio para estimar el riesgo de fallecer durante los 30 d&#237;as siguientes a la consulta en urgencias<a class="elsevierStyleCrossRefs" href="#bib0340"><span class="elsevierStyleSup">20&#8211;22</span></a>&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">En relaci&#243;n con el manejo de la descompensaci&#243;n en urgencias&#44; se recogieron 13 tratamientos administrados en urgencias&#44; consistentes en oxigenoterapia&#44; ventilaci&#243;n no invasiva&#44; ventilaci&#243;n invasiva&#44; diur&#233;ticos endovenosos&#44; nitratos endovenosos&#44; inotr&#243;pico o vasopresores endovenosos&#44; morfina subcut&#225;nea o endovenosa&#44; amiodarona&#44; digoxina&#44; morfina&#44; beta-agonistas nebulizados&#44; anticolin&#233;rgicos nebulizados&#44; corticoides sist&#233;micos&#44; antibi&#243;ticos&#41;&#46; Adem&#225;s&#44; se consign&#243; si el paciente precis&#243; hospitalizaci&#243;n&#44; y si dicha hospitalizaci&#243;n fue en una unidad de cuidados intensivos &#40;UCI&#41;&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Variables de resultado</span><p id="par0040" class="elsevierStylePara elsevierViewall">Las variables de resultado que se analizaron fueron la mortalidad &#40;por cualquier causa&#41; intrahospitalaria &#40;independientemente de que se produjese en urgencias o durante la hospitalizaci&#243;n&#41; y a 30 d&#237;as &#40;los cuales se contaron a partir de la consulta del paciente en urgencias&#41;&#46; Para determinar la mortalidad a 30 d&#237;as&#44; se revis&#243; su historia cl&#237;nica electr&#243;nica &#40;del hospital y ambulatoria&#41; en los pacientes dados de alta vivos del evento &#237;ndice y&#44; en caso necesario&#44; se contact&#243; telef&#243;nicamente con el paciente o sus familiares&#46;</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">An&#225;lisis estad&#237;stico</span><p id="par0045" class="elsevierStylePara elsevierViewall">Las variables categ&#243;ricas fueron descritas mediante frecuencias y porcentajes&#46; Las continuas con la mediana y rango intercuartil &#40;RIC&#41;&#46; El an&#225;lisis de distribuci&#243;n de las variables categ&#243;ricas se realiz&#243; con el test de ji-cuadrado&#44; y el de las continuas mediante el test no param&#233;trico de la suma de rangos de Mann-Whitney&#46;</p><p id="par0050" class="elsevierStylePara elsevierViewall">Se investig&#243; si exist&#237;a relaci&#243;n entre la existencia de EPOC y mortalidad mediante modelos de regresi&#243;n log&#237;stica&#44; y el riesgo se expres&#243; como <span class="elsevierStyleItalic">odds ratio</span> &#40;OR&#41; con su intervalo de confianza del 95&#37; &#40;IC 95&#37;&#41;&#46; Esto se hizo de forma bivariable &#40;OR crudas&#41; y mediante un modelo multivariable &#40;m&#233;todo introducir&#41; en el que se incluyeron todas las variables basales&#44; del episodio de descompensaci&#243;n y de manejo en urgencias consideradas en el presente estudio&#46; Para dicho modelo multivariado&#44; se realiz&#243; imputaci&#243;n simple de los valores ausentes en las variables introducidas&#44; utilizando la moda o la mediana seg&#250;n la variable fuese cualitativa o cuantitativa&#46;</p><p id="par0055" class="elsevierStylePara elsevierViewall">En todas las comparaciones&#44; se acept&#243; que las diferencias eran estad&#237;sticamente significativas si el valor de p era inferior a 0&#44;05&#44; o si el IC 95&#37; de la OR exclu&#237;a el valor 1&#46; El an&#225;lisis estad&#237;stico se realiz&#243; con el programa SPSS versi&#243;n 29&#46;0 para Windows &#40;IBM Corp&#46; Released 2016&#46; IBM SPSS Statistics for Windows&#44; Version 24&#46;0&#46; Armonk&#44; NY&#44; EE&#46;UU&#46;&#41;&#46;</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Aspectos &#233;ticos</span><p id="par0060" class="elsevierStylePara elsevierViewall">Se siguieron los principios &#233;ticos de la Declaraci&#243;n de Helsinki sobre investigaci&#243;n en humanos&#44; y se solicit&#243; el consentimiento informado a todos los pacientes para participar en el estudio&#46; El protocolo fue aprobado por los Comit&#233;s de &#201;tica e Investigaci&#243;n Cl&#237;nica del Hospital Universitario Central de Asturias &#40;protocolos 69&#47;2011&#44; 166&#47;2013&#44; 160&#47;2015&#44; 205&#47;2017&#44; 015&#47;2022&#41; y del Hospital Cl&#237;nic de Barcelona &#40;2018&#47;0233&#41; como comit&#233;s principales y por los del resto de los centros participantes&#46;</p></span></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">Resultados</span><p id="par0065" class="elsevierStylePara elsevierViewall">Los pacientes recogidos en los registros EAHFE 3 a 8 &#40;del a&#241;o 2012 al 2022&#41; fueron 21&#46;817&#44; de los cuales se analizaron 21&#46;694 pacientes con ICA&#44; ya que se excluyeron 109 pacientes por no recogerse la existencia de diagn&#243;stico previo de EPOC y 14 por desconocerse su estado vital &#40;<a class="elsevierStyleCrossRef" href="#fig0005">fig&#46; 1</a>&#41;&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0070" class="elsevierStylePara elsevierViewall">De los pacientes incluidos&#44; la mediana de edad fue de 83 a&#241;os &#40;RIC&#58; 76-88&#41;&#44; el 56&#37; eran mujeres y 4&#46;942 &#40;23&#37;&#41; ten&#237;an el diagn&#243;stico previo de EPOC&#46; Estos pacientes con EPOC eran m&#225;s j&#243;venes que los pacientes sin EPOC &#40;82 frente a 84 a&#241;os&#44; p<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#44;001&#41;&#44; eran m&#225;s frecuentemente varones &#40;63&#44;9 frente a 38&#44;4&#37;&#44; p<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#44;001&#41;&#44; con m&#225;s comorbilidades &#40;con excepci&#243;n de valvulopat&#237;a y demencia&#44; m&#225;s frecuentes en pacientes no EPOC&#41;&#44; peor clase funcional de la NYHA &#40;28&#44;7&#37; con grado III-IV frente a 22&#44;5&#37;&#41; y mejor capacidad funcional global &#40;&#237;ndice de Barthel menor de 60 puntos&#58; 16&#44;4&#37; frente a 19&#44;9&#37;&#41; &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">tabla 1</a>&#41;&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0075" class="elsevierStylePara elsevierViewall">En relaci&#243;n con las caracter&#237;sticas de la descompensaci&#243;n de la IC en los pacientes EPOC &#40;<a class="elsevierStyleCrossRef" href="#tbl0010">tabla 2</a>&#41;&#44; esta estuvo m&#225;s frecuentemente desencadenada por una infecci&#243;n &#40;49&#44;1 frente a 36&#37;&#44; p<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#44;001&#41; y menos frecuentemente por taquiarritmia &#40;11&#44;7 frente a 16&#37;&#44; p<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#44;001&#41;&#44; crisis hipertensiva o s&#237;ndrome coronario agudo&#46; Aunque hubo m&#250;ltiples diferencias en los hallazgos cl&#237;nicos en urgencias &#40;principalmente mayor presencia de disnea de reposo &#40;48&#44;1 frente a 42&#44;4&#37;&#44; p<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#44;001&#41;&#44; menor saturaci&#243;n de ox&#237;geno &#40;93&#37;&#44; RIC 89-96 frente a 94&#37;&#44; RIC 91-97&#41; y mayor frecuencia respiratoria en los pacientes con EPOC&#44; la gravedad estimada mediante la Escala MEESSI-AHF fue similar en ambos grupos &#40;riesgo alto y muy alto&#58; 19&#44;8 frente a 20&#44;5&#37;&#44; p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;41&#41;&#46;</p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><p id="par0080" class="elsevierStylePara elsevierViewall">Los tratamientos administrados en urgencias se recogen en la <a class="elsevierStyleCrossRef" href="#tbl0015">tabla 3</a>&#46; Los pacientes con EPOC recibieron m&#225;s oxigenoterapia&#44; ventilaci&#243;n no invasiva &#40;VNI&#44; 9 frente a 6&#37;&#44; p<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#44;001&#41;&#44; broncodilatadores&#44; beta-agonistas nebulizados &#40;41 frente a 17&#44;6&#37;&#44; p<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#44;001&#41;&#44; anticolin&#233;rgicos nebulizados &#40;31&#44;3 frente a 20&#44;8&#37;&#44; p<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#44;001&#41;&#44; corticoides sist&#233;micos &#40;30&#44;6 frente a 14&#44;4&#37;&#44; p<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#44;001&#41; y antibi&#243;ticos &#40;48&#44;6 frente a 22&#44;8&#37;&#44; p<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#44;001&#41;&#46; En cambio&#44; recibieron con menor frecuencia nitroglicerina endovenosa&#46; De forma remarcable&#44; la frecuencia de uso de f&#225;rmacos relacionados con la ICA &#40;diur&#233;ticos&#44; vasoconstrictores e inotropos&#44; digoxina&#44; amiodarona&#44; morfina&#41; fue similar en ambos grupos&#46; La hospitalizaci&#243;n fue m&#225;s frecuente en los pacientes con ICA y coexistencia de EPOC &#40;77&#44;0 frente a 73&#44;7&#37;&#44; p<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#44;001&#41;&#46;</p><elsevierMultimedia ident="tbl0015"></elsevierMultimedia><p id="par0085" class="elsevierStylePara elsevierViewall">La mortalidad intrahospitalaria &#40;<a class="elsevierStyleCrossRef" href="#tbl0020">tabla 4</a>&#41; en pacientes con y sin EPOC fue del 8&#44;1&#37; y del 7&#44;5&#37;&#44; respectivamente&#44; sin diferencias significativas entre ambos grupos &#40;OR<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>1&#44;088&#44; IC 95&#37;<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;968-1&#44;224&#41;&#46; Por otro lado&#44; la mortalidad a 30 d&#237;as fue del 11&#44;0&#37; y del 10&#44;0&#37;&#44; y esta mayor mortalidad cruda entre los pacientes con EPOC result&#243; estad&#237;sticamente significativa &#40;OR<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>1&#44;111&#44; IC 95&#37;<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>1&#44;002-1&#44;231&#41;&#46; Sin embargo&#44; tras ajustar por las caracter&#237;sticas cl&#237;nicas&#44; del episodio de descompensaci&#243;n y del manejo en urgencias&#44; no se observaron diferencias significativas para ninguna de estas dos variables de resultado a corto plazo&#44; con unas OR que descendieron a 1&#44;040 &#40;0&#44;905-1&#44;195&#41; y de 1&#44;080 &#40;0&#44;957-1&#44;219&#41;&#44; respectivamente&#44; en el modelo con ajuste total&#46; El an&#225;lisis de la mortalidad a 30 d&#237;as en los modelos de ajuste parcial muestra que las diferencias de presentaci&#243;n cl&#237;nica y del manejo de la descompensaci&#243;n de la ICA corrigen de forma m&#225;s ostensible este incremento de mortalidad cruda que las diferencias en las caracter&#237;sticas basales entre los pacientes con y sin EPOC &#40;<a class="elsevierStyleCrossRef" href="#tbl0020">tabla 4</a>&#41;&#46;</p><elsevierMultimedia ident="tbl0020"></elsevierMultimedia></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0105">Discusi&#243;n</span><p id="par0090" class="elsevierStylePara elsevierViewall">Este estudio aporta 7 hallazgos relevantes en los pacientes con EPOC e ICA&#46; Primero&#44; son m&#225;s j&#243;venes&#44; m&#225;s frecuentemente varones y con m&#225;s comorbilidades&#44; principalmente de car&#225;cter cardiovascular&#46; En segundo lugar&#44; tienen una clase funcional de la NYHA m&#225;s avanzada&#46; Tercero&#44; el factor precipitante de la ICA involucrado m&#225;s com&#250;n son las infecciones&#46; Cuarto&#44; la gravedad del episodio de ICA fue similar en ambos grupos&#46; Quinto&#44; en el manejo terap&#233;utico destaca un mayor uso de VNI&#44; beta-2 agonistas y anticolin&#233;rgicos inhalados-nebulizados&#44; corticoides y antibi&#243;ticos&#46; Sexto&#44; la administraci&#243;n de beta-2 agonistas y anticolin&#233;rgicos inhalados-nebulizados&#44; en pacientes sin EPOC ocurre con frecuencia&#46; S&#233;ptimo&#44; el ingreso hospitalario es mayor en pacientes con EPOC&#44; pero la mortalidad a corto plazo es similar en ambos grupos&#46;</p><p id="par0095" class="elsevierStylePara elsevierViewall">Entre los factores relacionados con el paciente&#44; cabe destacar que la EPOC confiere una peor clase funcional a los pacientes con IC&#44; con mayor grado de disnea basal &#40;28&#44;7&#37; con clase funcional NYHA III-IV frente a 22&#44;5&#37; en IC sin EPOC&#41;&#46; Estos resultados se encuentran en la misma l&#237;nea que los obtenidos por Jacob et al<span class="elsevierStyleItalic">&#46;</span><a class="elsevierStyleCrossRef" href="#bib0320"><span class="elsevierStyleSup">16</span></a>&#44; donde en una poblaci&#243;n de 8089 pacientes con ICA atendidos en urgencias&#44; evidenciaron que un 29&#37; de los pacientes con IC y EPOC ten&#237;an una clase funcional de la NYHA III-IV frente a un 22&#44;9&#37; en pacientes con IC sin EPOC&#46; Por otra parte&#44; Ehteshami-Afshar et al<span class="elsevierStyleItalic">&#46;</span><a class="elsevierStyleCrossRef" href="#bib0290"><span class="elsevierStyleSup">10</span></a>&#44; en pacientes ambulatorios con IC cr&#243;nica&#44; mostraron que los pacientes con ambas enfermedades ten&#237;an peores s&#237;ntomas &#40;NYHA III&#47;IV 37&#37; frente a 23&#37;&#59; p<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#44;001&#41; y por ello peor calidad de vida&#44; a pesar de similar fracci&#243;n de eyecci&#243;n&#46;</p><p id="par0100" class="elsevierStylePara elsevierViewall">Tambi&#233;n se evidencia que existe una mayor comorbilidad cardiovascular &#40;enfermedad renal cr&#243;nica&#44; enfermedad arterial perif&#233;rica&#44; insuficiencia cardiaca previa&#44; fibrilaci&#243;n auricular&#41; similar a lo publicado por otros autores<a class="elsevierStyleCrossRefs" href="#bib0320"><span class="elsevierStyleSup">16&#44;23&#44;24</span></a>&#46; Esto no resulta sorprendente&#44; sobre todo si se tiene en cuenta que estos sujetos tienen un mayor riesgo de morbimortalidad cardiovascular&#44; con independencia de otros factores&#44; incluido el tabaco&#46; En consonancia con otras series<a class="elsevierStyleCrossRefs" href="#bib0290"><span class="elsevierStyleSup">10&#44;25&#44;26</span></a>&#44; la cardiopat&#237;a isqu&#233;mica fue tambi&#233;n m&#225;s frecuente en los pacientes con ICA y EPOC &#40;29&#44;6 frente a un 25&#44;8&#37; en ICA sin EPOC&#41; pues la cardiopat&#237;a isqu&#233;mica &#40;y no la ICA&#41; est&#225; considerada la principal causa de muerte entre los pacientes con EPOC&#46;</p><p id="par0105" class="elsevierStylePara elsevierViewall">La descompensaci&#243;n de la IC de los pacientes con EPOC estuvo m&#225;s frecuentemente desencadenada por una infecci&#243;n y menos por taquiarritmia&#44; crisis hipertensiva o s&#237;ndrome coronario agudo&#46; Las exacerbaciones de la EPOC suelen desencadenarse por infecciones respiratorias virales o bacterianas<a class="elsevierStyleCrossRef" href="#bib0375"><span class="elsevierStyleSup">27</span></a>&#44; pero factores ambientales como la contaminaci&#243;n y la temperatura ambiente pueden aumentar los s&#237;ntomas<a class="elsevierStyleCrossRef" href="#bib0380"><span class="elsevierStyleSup">28</span></a>&#46; En el estudio PAPRICA<a class="elsevierStyleCrossRef" href="#bib0385"><span class="elsevierStyleSup">29</span></a>&#44; al igual que en otros estudios&#44; el factor precipitante m&#225;s frecuente fue la infecci&#243;n&#44; fundamentalmente la respiratoria&#46; Este factor precipitante&#44; aunque no se asoci&#243; a una menor mortalidad&#44; s&#237; lo hizo con un menor porcentaje crudo de reconsultas a los 30 d&#237;as&#46; Por el contrario&#44; en el presente estudio&#44; las taquiarrtimias fueron m&#225;s frecuentes en pacientes con ICA sin EPOC &#40;16&#37; frente a 11&#44;7&#37;&#41;&#46; Es sabido que en ocasiones las arritmias son a su vez consecuencia de otros factores&#44; como pueden ser las infecciones respiratorias en pacientes con EPOC o la misma IC&#46; De hecho&#44; en el PAPRICA<a class="elsevierStyleCrossRef" href="#bib0385"><span class="elsevierStyleSup">29</span></a> el 42&#37; de los pacientes con infecci&#243;n como factor precipitante ten&#237;an&#44; adem&#225;s&#44; fibrilaci&#243;n auricular permanente&#46; As&#237; pues&#44; la infecci&#243;n es una causa muy importante de descompensaci&#243;n&#44; y por ello la prevenci&#243;n de infecciones como la gripe con la vacunaci&#243;n es de suma importancia&#44; ya que ha demostrado reducir la gravedad de la descompensaci&#243;n y la mortalidad<a class="elsevierStyleCrossRef" href="#bib0325"><span class="elsevierStyleSup">17</span></a>&#46;</p><p id="par0110" class="elsevierStylePara elsevierViewall">Aunque hubo diferencias en los hallazgos cl&#237;nicos en urgencias&#44; la gravedad estimada mediante la Escala MEESSI-AHF fue similar en ambos grupos&#46; Esta escala&#44; desarrollada y validada en SUH espa&#241;oles<a class="elsevierStyleCrossRef" href="#bib0260"><span class="elsevierStyleSup">4</span></a>&#44; permite clasificar la gravedad de la descompensaci&#243;n seg&#250;n un riesgo bajo&#44; medio&#44; alto o muy alto&#44; evaluando el riesgo de mortalidad a 30 d&#237;as tras la valoraci&#243;n en urgencias&#46; Es posible que algunas variables que forman parte de esta escala&#44; como el &#237;ndice de Barthel&#44; la clase funcional NYHA&#44; o la asociaci&#243;n con el s&#237;ndrome coronario agudo o el bajo gasto cardiaco&#44; se basan parcialmente en una interpretaci&#243;n subjetiva y la adjudicaci&#243;n puede variar entre diferentes observadores&#44; y que han podido infraestimar la gravedad en el subgrupo de pacientes con ICA y EPOC&#46; Por otra parte&#44; la escala no tiene en cuenta las variables con evidencia de impacto en los resultados como son el manejo prehospitalario por parte de los equipos m&#233;dicos de emergencias&#44; o el uso de terapia ventilatorias como la VNI o terapia de alto flujo<a class="elsevierStyleCrossRefs" href="#bib0390"><span class="elsevierStyleSup">30&#8211;32</span></a>&#46;</p><p id="par0115" class="elsevierStylePara elsevierViewall">Respecto al tratamiento realizado en los servicios de urgencias&#44; m&#225;s pacientes EPOC recibieron oxigenoterapia y VNI&#46; La generalizaci&#243;n de las indicaciones de la VNI ha hecho que su utilizaci&#243;n est&#233; aumentando de forma progresiva<a class="elsevierStyleCrossRefs" href="#bib0405"><span class="elsevierStyleSup">33&#44;34</span></a>&#46; Los estudios cl&#237;nicos muestran una reducci&#243;n de un 50-60&#37; en el riesgo de fracaso de tratamiento&#44; necesidad de intubaci&#243;n traqueal y mortalidad durante la agudizaci&#243;n cuando son tratados con VNI agudizaci&#243;n grave de la EPOC&#44; especialmente cuando se presenta con insuficiencia respiratoria hiperc&#225;pnica y acidosis respiratoria y no mejora con el tratamiento convencional de la agudizaci&#243;n<a class="elsevierStyleCrossRef" href="#bib0415"><span class="elsevierStyleSup">35</span></a>&#46; Estos hallazgos son congruentes con otros estudios&#46; Una serie de 11&#46;152 pacientes con ICA atendidos en SUH&#44; donde se estudiaba el efecto de la VNI sobre la evoluci&#243;n a corto plazo&#44; evidenci&#243; de forma significativa que en el grupo de pacientes con EPOC &#40;24&#44;1&#37;&#41; se us&#243; m&#225;s frecuentemente la VNI&#44; 31&#37; frente a un 23&#44;6&#37; en el que no se us&#243; este soporte respiratorio<a class="elsevierStyleCrossRef" href="#bib0405"><span class="elsevierStyleSup">33</span></a>&#46;</p><p id="par0120" class="elsevierStylePara elsevierViewall">Los pacientes con EPOC recibieron tambi&#233;n m&#225;s broncodilatadores &#40;41&#37; frente a un 17&#44;6&#37;&#41;&#46; Este resultado tambi&#233;n se encuentra en la l&#237;nea de otros estudios&#46; En un estudio realizado en Estados Unidos&#44; en 164&#46;494 pacientes hospitalizados por ICA&#44; y donde 63&#46;690 &#40;39&#37;&#41; padec&#237;an EPOC&#44; el 37&#37; recibieron tratamiento con broncodilatadores inhalados de acci&#243;n corta y este porcentaje aumentaba a un 59&#37; en el subgrupo de ICA y EPOC<a class="elsevierStyleCrossRef" href="#bib0315"><span class="elsevierStyleSup">15</span></a>&#46; Este hallazgo ilustra la complejidad del manejo de la ICA en la pr&#225;ctica habitual&#46; En primer lugar&#44; la presentaci&#243;n cl&#237;nica es a menudo inespec&#237;fica de forma inicial&#44; ya que el tratamiento respiratorio agudo conjunto &#40;agonistas-beta inhalados&#44; anticolin&#233;rgicos&#44; corticoides y antibi&#243;ticos&#41; se interrumpe durante el ingreso en m&#225;s del 20&#37; de las hospitalizaciones&#44; presumiblemente porque el diagn&#243;stico subyacente de ICA se hizo m&#225;s evidente&#46; Esta dificultad para diferenciar la ICA de otras afecciones que causan s&#237;ntomas respiratorios se evidencia adem&#225;s por el hecho de que las tasas de tratamiento respiratorio agudo conjunto fueron superiores al 25&#37;&#46; En el mismo estudio de Dharmarajan et al&#46;<a class="elsevierStyleCrossRef" href="#bib0315"><span class="elsevierStyleSup">15</span></a>&#44; se evidenci&#243; que hasta un 50&#37; de los pacientes con ICA hab&#237;an recibido dicho tratamiento conjunto&#46; Son necesarios estudios futuros para comprender los beneficios y los perjuicios del tratamiento respiratorio agudo conjunto en la poblaci&#243;n con ICA&#44; pues se desconoce si los broncodilatadores mejoran los s&#237;ntomas o pueden tener efectos hemodin&#225;micos positivos en las personas con disnea derivada exclusivamente de la ICA&#44; como pueden hacerlo en los pacientes con IC cr&#243;nica<a class="elsevierStyleCrossRefs" href="#bib0420"><span class="elsevierStyleSup">36&#44;37</span></a>&#46; Estos efectos beneficiosos pueden verse contrarrestados por una mayor probabilidad de arritmias<a class="elsevierStyleCrossRef" href="#bib0430"><span class="elsevierStyleSup">38</span></a>&#44; isquemia<a class="elsevierStyleCrossRef" href="#bib0435"><span class="elsevierStyleSup">39</span></a> o posibles consecuencias adversas a largo plazo de la estimulaci&#243;n simp&#225;tica<a class="elsevierStyleCrossRef" href="#bib0440"><span class="elsevierStyleSup">40</span></a>&#46; As&#237;&#44; el estudio BRONCH-AHF mostr&#243; que la adici&#243;n de broncodilatadores sin necesidad documentada en pacientes con diagn&#243;stico final de ICA en los SUH no modifica la supervivencia en comparaci&#243;n con el tratamiento est&#225;ndar de la ICA &#40;incluidos los diur&#233;ticos&#41;&#44; y que el uso de beta-2-agonistas &#40;solos o asociados a anticolin&#233;rgicos&#41; podr&#237;a incluso incrementar los eventos adversos<a class="elsevierStyleCrossRef" href="#bib0445"><span class="elsevierStyleSup">41</span></a>&#46;</p><p id="par0125" class="elsevierStylePara elsevierViewall">El uso de corticoides y antibi&#243;ticos tambi&#233;n fue mayor en los pacientes con EPOC&#46; En el estudio de Jacob et al&#46; se describe que en pacientes con ICA y EPOC el uso de corticoides fue mayor &#40;27&#44;9&#37; frente a 11&#44;1&#37;&#41;&#46; An&#225;logamente&#44; en la cohorte de Dharmarajan et al<span class="elsevierStyleItalic">&#46;</span><a class="elsevierStyleCrossRef" href="#bib0315"><span class="elsevierStyleSup">15</span></a>&#44; aproximadamente un tercio recibi&#243; antibi&#243;ticos y entre las hospitalizaciones por ICA con EPOC&#44; el 42&#37; recibi&#243; antibi&#243;ticos y&#44; aunque los corticosteroides fueron los menos utilizados de todas las terapias respiratorias agudas estudiadas&#44; los autores encontraron que el 17&#37; de las hospitalizaciones con EPOC recib&#237;an altas dosis de corticoides&#46; En el estudio CORT-AHF<a class="elsevierStyleCrossRef" href="#bib0305"><span class="elsevierStyleSup">13</span></a>&#44; se analizaron 11&#46;356 pacientes con ICA&#44; donde un 9&#44;7&#37; sin EPOC y un 27&#44;7&#37; con EPOC fueron tratados con corticosteroides sist&#233;micos&#46; En este mismo estudio no se encontraron diferencias en la mortalidad o reingreso a 90 d&#237;as en pacientes con o sin EPOC concomitante&#46; Esta falta de diferencia podr&#237;a ser debida&#44; hipot&#233;ticamente&#44; a un cierto efecto antiinflamatorio beneficioso de los corticoides en pacientes con ICA y sin EPOC&#46;</p><p id="par0130" class="elsevierStylePara elsevierViewall">Todos estos resultados son realmente importantes para conseguir un correcto tratamiento de estos pacientes m&#225;s complejos&#44; que comparten ambas comorbilidades&#46; El estudio de cohortes de Kostikas et al<span class="elsevierStyleItalic">&#46;</span><a class="elsevierStyleCrossRef" href="#bib0450"><span class="elsevierStyleSup">42</span></a> mostr&#243; que de un total de 12&#46;587 pacientes en situaci&#243;n cr&#243;nica con EPOC e IC reci&#233;n diagnosticada &#40;media de 75 a&#241;os&#44; 60&#37; varones&#41;&#44; se prescribi&#243; un tratamiento adecuado para la IC a 2&#46;251 &#40;18&#37;&#41;&#44; inadecuado a 5&#46;332 &#40;42&#37;&#41; y no recibieron tratamiento para la IC 5&#46;004 &#40;40&#37;&#41;&#46; Estos resultados respaldan la necesidad de mejorar la equidad en el acceso a la atenci&#243;n integrada para los pacientes afectados de ambos procesos m&#243;rbidos&#46;</p><p id="par0135" class="elsevierStylePara elsevierViewall">Respecto a la evoluci&#243;n&#44; los pacientes con EPOC fueron ingresados m&#225;s frecuentemente&#46; Se ha descrito que la presencia de EPOC empeora la presentaci&#243;n cl&#237;nica y el proceso de la IC&#44; y se asocia con un incremento del 20-30&#37; del riesgo de hospitalizaci&#243;n<a class="elsevierStyleCrossRefs" href="#bib0455"><span class="elsevierStyleSup">43&#44;44</span></a>&#46; En el estudio de Ehteshami-Afshar et al&#46;<a class="elsevierStyleCrossRef" href="#bib0290"><span class="elsevierStyleSup">10</span></a> se mostr&#243; un mayor riesgo de ingreso hospitalario en pacientes con IC y EPOC&#44; tanto en la hospitalizaci&#243;n de causa cardiovascular &#40;HR&#44; 1&#44;17&#59; IC 95&#37;&#44; 1&#44;05-1&#44;31&#41; como en la no cardiovascular &#40;HR&#44; 1&#44;45&#59; IC 95&#37;&#44; 1&#44;29-1&#44;64&#41;&#46; Esto muestra que la exacerbaci&#243;n de la EPOC con ICA asociada puede ser responsable de algunas hospitalizaciones&#44; m&#225;s que la propia ICA en s&#237;&#46;</p><p id="par0140" class="elsevierStylePara elsevierViewall">Nuestros resultados evidencian que la presencia de EPOC en un paciente con ICA &#40;independientemente de la gravedad&#41; no tiene un impacto significativo en la mortalidad intrahospitalaria&#44; pero en cambio s&#237; que se asocia a un incremento de la mortalidad cruda a los 30 d&#237;as&#46; Si embargo&#44; este incremento de mortalidad desaparece al ajustar los resultados por las diferencias entre grupos&#44; especialmente por las diferencias que existen en las caracter&#237;sticas de la descompensaci&#243;n y el manejo en urgencias de pacientes con y sin EPOC&#46; Esto va en consonancia con un estudio reciente de 3&#46;515 pacientes&#44; el 35&#37; con EPOC&#44; en el que el an&#225;lisis multivariante no mostr&#243; un mayor riesgo de muerte por cualquier causa en los pacientes con EPOC<a class="elsevierStyleCrossRef" href="#bib0300"><span class="elsevierStyleSup">12</span></a>&#46; Todo esto contrasta con la afirmaci&#243;n de las actuales gu&#237;as donde la presencia de EPOC se asocia con peores resultados<a class="elsevierStyleCrossRefs" href="#bib0250"><span class="elsevierStyleSup">2&#44;3</span></a>&#46; De todos los estudios que han demostrado una asociaci&#243;n significativa entre la presencia de EPOC y un mayor riesgo de resultados adversos en pacientes con IC<a class="elsevierStyleCrossRefs" href="#bib0305"><span class="elsevierStyleSup">13&#44;24&#44;43&#44;45&#44;46</span></a>&#44; solo 3 definieron la EPOC mediante espirometr&#237;a y la IC mediante ecocardiograf&#237;a o niveles de p&#233;ptidos natriur&#233;ticos<a class="elsevierStyleCrossRefs" href="#bib0455"><span class="elsevierStyleSup">43&#44;45&#44;46</span></a>&#46; Los resultados del presente estudio sugieren que&#44; en pacientes con ICA&#44; son las caracter&#237;sticas cl&#237;nicas y de manejo del episodio de ICA&#44; y no la presencia de EPOC&#44; lo que realmente aumenta el riesgo de resultados adversos en pacientes con EPOC<a class="elsevierStyleCrossRef" href="#bib0475"><span class="elsevierStyleSup">47</span></a>&#46;</p><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0110">Limitaciones</span><p id="par0145" class="elsevierStylePara elsevierViewall">El presente estudio tiene varias limitaciones&#46; La primera de ellas es que se trata de un estudio descriptivo prospectivo&#44; por lo que los resultados no implican causalidad&#46; La segunda&#44; los resultados se corresponden a diferentes SUH del sistema sanitario p&#250;blico espa&#241;ol&#44; y no ser&#237;a extrapolable a otros sistemas sanitarios por lo que es necesaria una validaci&#243;n externa de estos resultados&#46; Y la tercera&#44; a pesar de la innegable asociaci&#243;n entre la IC y la EPOC&#44; debe destacarse una importante limitaci&#243;n diagn&#243;stica de la que adolecen la casi totalidad de los estudios que han abordado la coexistencia de la EPOC en pacientes con IC&#44; incluido el presente&#46; El diagn&#243;stico de la EPOC no se efectu&#243; principalmente por los datos espirom&#233;tricos&#44; sino por los antecedentes cl&#237;nicos del paciente en la historia cl&#237;nica previa del hospital o de su centro de salud&#44; cuya fiabilidad para la detecci&#243;n de la EPOC es cuestionable&#46; Solo se ha identificado un trabajo en el que se realiz&#243; sistem&#225;ticamente espirometr&#237;a a todos los pacientes con IC&#44; y la prevalencia fue muy alta&#44; del 35&#37;<a class="elsevierStyleCrossRef" href="#bib0480"><span class="elsevierStyleSup">48</span></a>&#46; Este hallazgo indica que con frecuencia este problema m&#233;dico&#44; la EPOC&#44; pasa inadvertida y que su verdadera dimensi&#243;n es notablemente superior a la que en general se considera&#46; Por otra parte&#44; debe se&#241;alarse que la prevalencia de IC en pacientes con EPOC previa es tambi&#233;n elevada&#46; Adem&#225;s&#44; su diagn&#243;stico es con frecuencia complejo por la similitud entre ambos procesos en su expresi&#243;n cl&#237;nica y por la dificultad de obtener im&#225;genes ecocardiogr&#225;ficas de suficiente calidad<a class="elsevierStyleCrossRefs" href="#bib0305"><span class="elsevierStyleSup">13&#44;14</span></a>&#46;</p></span></span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0115">Conclusi&#243;n</span><p id="par0150" class="elsevierStylePara elsevierViewall">Los pacientes con ICA y EPOC tienen caracter&#237;sticas cl&#237;nicas y de manejo en urgencias diferenciales y presentan mayores tasas de ingreso&#46; Si bien la mortalidad cruda a 30 d&#237;as es superior en los pacientes con EPOC&#44; este incremento del riesgo de muerte desaparece cuando se tienen en cuenta las diferencias cl&#237;nicas del episodio de descompensaci&#243;n y el manejo en el SUH&#46;</p></span><span id="sec0060" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0120">Financiaci&#243;n</span><p id="par0155" class="elsevierStylePara elsevierViewall">Este trabajo fue posible en parte gracias a las ayudas del Instituto de Salud Carlos III con fondos del Ministerio de Sanidad y FEDER &#40;PI18&#47;00393&#41;&#46;</p></span><span id="sec0065" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0125">Conflicto de intereses</span><p id="par0160" class="elsevierStylePara elsevierViewall">Los autores declaran no tener ning&#250;n conflicto de intereses&#46;</p></span></span>"
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    "fechaRecibido" => "2024-06-28"
    "fechaAceptado" => "2024-07-29"
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            0 => "Insuficiencia cardiaca aguda"
            1 => "Enfermedad pulmonar obstructiva cr&#243;nica"
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            0 => "Acute heart failure"
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        "titulo" => "Resumen"
        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Objetivos</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Analizar si los pacientes con enfermedad pulmonar obstructiva cr&#243;nica &#40;EPOC&#41; presentan diferencias cl&#237;nicas y de manejo terap&#233;utico en urgencias cuando desarrollan un episodio de insuficiencia cardiaca aguda &#40;ICA&#41; y analizar la mortalidad durante dicha descompensaci&#243;n&#46;</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">M&#233;todo</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Se incluyeron pacientes diagnosticados de ICA en 50 servicios de urgencias espa&#241;oles entre 2012 y 2022 y que tambi&#233;n padec&#237;an EPOC&#44; y se compararon sus caracter&#237;sticas basales&#44; del episodio de descompensaci&#243;n y de manejo terap&#233;utico en urgencias con las de pacientes con ICA sin EPOC diagnosticados durante dicho periodo&#46; Se recogi&#243; la mortalidad por cualquier causa intrahospitalaria y a los 30 d&#237;as&#44; y se investig&#243; si exist&#237;an diferencias entre pacientes con y sin EPOC en modelos de regresi&#243;n log&#237;stica crudos y ajustados&#46;</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Resultados</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Se analizaron 21&#46;694 pacientes con ICA &#40;mediana<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>83 a&#241;os&#44; mujeres<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>56&#37;&#41;&#44; 4&#46;942 &#40;23&#37;&#41; con EPOC&#46; Estos eran m&#225;s j&#243;venes&#44; m&#225;s frecuentemente varones&#44; con m&#225;s comorbilidades &#40;con excepci&#243;n de valvulopat&#237;a y demencia&#44; m&#225;s frecuentes en pacientes no EPOC&#41;&#44; peor clase funcional respiratoria &#40;NYHA&#41; y mejor capacidad funcional global &#40;&#237;ndice de Barthel&#41;&#46; La descompensaci&#243;n de los pacientes EPOC estuvo m&#225;s frecuentemente desencadenada por una infecci&#243;n y menos por taquiarritmia&#44; crisis hipertensiva o s&#237;ndrome coronario agudo y&#44; aunque hubo diferencias en los hallazgos cl&#237;nicos en urgencias&#44; la gravedad estimada mediante la Escala MEESSI-AHF fue similar en ambos grupos&#46; Respecto al manejo en urgencias&#44; m&#225;s pacientes EPOC recibieron oxigenoterapia&#44; ventilaci&#243;n no invasiva&#44; broncodilatadores&#44; corticoides y antibi&#243;ticos y menos nitroglicerina endovenosa&#44; y hospitalizaron m&#225;s frecuentemente&#46; La mortalidad intrahospitalaria en pacientes con y sin EPOC fue del 8&#44;1&#37; y del 7&#44;5&#37;&#44; respectivamente &#40;OR<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>1&#44;088&#44; IC 95&#37;<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;968-1&#44;224&#41; y a 30 d&#237;as fue del 11&#44;0&#37; y del 10&#44;0&#37; &#40;OR<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>1&#44;111&#44; IC 95&#37;<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>1&#44;002-1&#44;231&#41;&#46; Tras ajustar por las caracter&#237;sticas cl&#237;nicas&#44; del episodio de descompensaci&#243;n y del manejo en urgencias&#44; estas OR descendieron a 1&#44;040 &#40;0&#44;905-1&#44;195&#41; y 1&#44;080 &#40;0&#44;957-1&#44;219&#41;&#44; respectivamente&#46;</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Conclusi&#243;n</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Los pacientes con ICA y EPOC tienen caracter&#237;sticas cl&#237;nicas y de manejo terap&#233;utico en urgencias diferenciales&#44; y precisan mayor hospitalizaci&#243;n&#46; Si bien presentan una mayor mortalidad cruda a los 30 d&#237;as&#44; esto se explica por este diferente perfil cl&#237;nico m&#225;s que por la propia existencia de la EPOC&#46;</p></span>"
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        "resumen" => "<span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Objectives</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">This study aims to analyse differences in clinical and therapeutic management for patients with chronic obstructive pulmonary disease &#40;COPD&#41; who present to the emergency department with acute heart failure &#40;AHF&#41;&#46; Additionally&#44; it examines mortality rates during such episodes&#46;</p></span> <span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Method</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">We included patients diagnosed with AHF at 50 Spanish emergency departments from 2012 to 2022 who also had COPD&#46; We compared their baseline characteristics&#44; decompensation episodes&#44; and emergency department management with those of AHF patients without COPD during the same period&#46; We collected data on in-hospital and 30-day all-cause mortality&#44; investigating differences between the two groups using crude and adjusted logistic regression models&#46;</p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Results</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">A total of 21&#44;694 AHF patients were analysed &#40;median age<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>83 years&#44; 56&#37; female&#41;&#44; including 4&#44;942 &#40;23&#37;&#41; with COPD&#46; COPD patients were generally younger and more frequently male&#44; with a higher prevalence of comorbidities &#40;excluding valve disease and dementia&#44; which were more common in non-COPD patients&#41;&#46; They exhibited a worse respiratory functional class &#40;NYHA&#41; but a better overall functional capacity &#40;Barthel Index&#41;&#46; Decompensation in COPD patients was more often triggered by infection and less frequently by tachyarrhythmia&#44; hypertensive crisis&#44; or acute coronary syndrome&#46; While there were differences in clinical findings in the emergency department&#44; the severity assessed by the MEESSI-AHF Scale was similar across both groups&#46; In terms of emergency department management&#44; a higher proportion of COPD patients received oxygen therapy&#44; non-invasive ventilation&#44; bronchodilators&#44; corticosteroids&#44; and antibiotics&#44; while fewer received intravenous nitroglycerin&#44; and they were hospitalized more frequently&#46; In-hospital mortality rates were 8&#46;1&#37; for patients with COPD and 7&#46;5&#37; for those without &#40;OR<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>1&#46;088&#44; 95&#37; CI<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;968-1&#46;224&#41;&#44; with 30-day mortality rates of 11&#46;0&#37; and 10&#46;0&#37;&#44; respectively &#40;OR<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>1&#46;111&#44; 95&#37; CI<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>1&#46;002-1&#46;231&#41;&#46; After adjusting for clinical characteristics&#44; decompensation episodes&#44; and emergency department management&#44; these odds ratios decreased to 1&#46;040 &#40;95&#37; CI<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;905-1&#46;195&#41; and 1&#46;080 &#40;95&#37; CI<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;957-1&#46;219&#41;&#44; respectively&#46;</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Conclusion</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">Patients with AHF and COPD exhibit distinct clinical and therapeutic management characteristics in the emergency department and require more frequent hospitalization&#46; Although they show higher crude 30-day mortality&#44; this is attributable to their differing clinical profiles rather than the presence of COPD itself&#46;</p></span>"
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            "apendice" => "<p id="par0165" class="elsevierStylePara elsevierViewall">Marta Fuentes&#44; Aitor D&#225;vila&#44; Sonia del Amo &#40;Hospital Universitario de Salamanca&#41;&#44; H&#233;ctor Alonso&#44; Enrique P&#233;rez-Llantada &#40;Hospital Marqu&#233;s de Valdecilla de Santander&#41;&#44; Francisco Javier Mart&#237;n-S&#225;nchez &#40;Hospital Cl&#237;nico San Carlos de Madrid&#41;&#44; &#210;scar Mir&#243;&#44; V&#237;ctor Gil&#44; Rosa Escoda&#44; Carolina S&#225;nchez&#44; Daniel Repullo&#44; Marta Mass&#243; &#40;Hospital Cl&#237;nic de Barcelona&#41;&#44; Javier Mill&#225;n&#44; Leticia Serrano &#40;Hospital Polit&#233;nic La Fe de Valencia&#41;&#44; Jos&#233; Pav&#243;n&#44; Nayra Cabrera Gonz&#225;lez &#40;Hospital Dr&#46; Negr&#237;n de Las Palmas de Gran Canaria&#41;&#44; Rafael Calvo Rodr&#237;guez&#44; Juan Antonio Vega Reyes &#40;Hospital Reina Sof&#237;a de C&#243;rdoba&#41;&#44; Mar&#237;a Luisa L&#243;pez-Grima&#44; Amparo Valero&#44; Mar&#237;a &#193;ngeles Juan &#40;Hospital Dr&#46; Peset de Valencia&#41;&#44; Alfons Aguirre&#44; Silvia M&#237;nguez Mas&#243; &#40;Hospital del Mar de Barcelona&#41;&#44; Virginia Fern&#225;ndez-T&#225;vora P&#233;rez &#40;Hospital de Valme de Sevilla&#41;&#44; Ana Bel&#233;n Mecina &#40;Hospital de Alcorc&#243;n de Madrid&#41;&#44; Josep Tost &#40;Consorci Sanitari de Terrassa&#41;&#44; Susana S&#225;nchez Ram&#243;n&#44; Virginia Carbajosa Rodr&#237;guez &#40;Hospital Universitario R&#237;o Hortega de Valladolid&#41;&#44; Pascual Pi&#241;era&#44; Jos&#233; Andr&#233;s S&#225;nchez Nicol&#225;s&#44; Paula L&#225;zaro Arag&#252;&#233;s &#40;Hospital Reina Sof&#237;a de Murcia&#41;&#44; Raquel Torres Garate&#44; Esther &#193;lvarez Rodr&#237;guez&#44; Pilar Paz Arias&#40;Hospital Severo Ochoa de Madrid&#41;&#44; Aitor Alqu&#233;zar-Arb&#233;&#44; Sergio Herrera&#44; Carlos Jos&#233; Romero Carrete &#40;Hospital de la Santa Creu y Sant Pau de Barcelona&#41;&#44; Javier Jacob&#44; Alex Roset&#44; Irene Cabello&#44; Antonio Haro&#44; Lidia Fuentes &#40;Hospital Universitari de Bellvitge de Barcelona&#41;&#44; Fernando Richard&#44; Elisa Fern&#225;ndez&#44; Mar&#237;a Pilar L&#243;pez Diez &#40;Hospital Universitario de Burgos&#41;&#44; Pablo Herrero Puente&#44; Joaqu&#237;n V&#225;zquez &#193;lvarez&#44; Bel&#233;n Prieto Garc&#237;a&#44; Alejandra Fern&#225;ndez Fern&#225;ndez&#44; Bel&#233;n &#193;lvarez Ramos&#44; Natalia Fern&#225;ndez Miranda &#40;Hospital Universitario Central de Asturias de Oviedo&#41;&#44; Pere Llorens&#44; Bego&#241;a Espinosa&#44; Sergio Guzm&#225;n&#44; Gema Jara&#44; Alba Felipe&#44; Adriana Gil &#40;Hospital General Universitario Dr&#46; Balmis de Alicante&#41;&#44; Juan Antonio Andueza &#40;Hospital General Universitario Gregorio Mara&#241;&#243;n de Madrid&#41;&#44; Rodolfo Romero&#44; Mariella Luengo L&#243;pez &#40;Hospital Universitario de Getafe de Madrid&#41;&#44; Gema Dom&#237;nguez&#44; Mart&#237;n Ru&#237;z &#40;Hospital de Henares de Madrid&#41;&#44; Beatriz Amores Arriaga&#44; Beatriz Sierra Bergua &#40;Hospital Cl&#237;nico Lozano Blesa de Zaragoza&#41;&#44; Enrique Mart&#237;n Mojarro&#44; Lidia Cuevas Jim&#233;nez &#40;Hospital Sant Pau i Santa Tecla de Tarragona&#41;&#44; Lisette Traver&#237;a B&#233;cquer&#44; Guillermo Burillo &#40;Hospital Universitario de Canarias de Tenerife&#41;&#44; Llu&#237;s Llauger Garc&#237;a &#40;Althaia Xarxa Assistencial Universitaria de Manresa&#41;&#44; Mar&#237;a de los &#193;ngeles Gonz&#225;lez de la Torre&#44; Carmen Esmeralda Romero Jim&#233;nez &#40;Hospital Costa del Sol de Marbella de M&#225;laga&#41;&#44; Ester Soy Ferrer&#44; Mar&#237;a Adroher M&#250;&#241;oz &#40;Hospital Josep Trueta de Girona&#41;&#46; Jos&#233; Manuel Garrido &#40;Hospital Virgen Macarena de Sevilla&#41;&#44; Francisco Javier Lucas-Imbern&#243;n &#40;Hospital General Universitario de Albacete&#41;&#44; Rut Gaya &#40;Hospital Juan XXIII de Tarragona&#41;&#44; Carlos Bibiano&#44; Mar&#237;a Mir&#44; Beatriz Rodr&#237;guez&#44; Monika Vicente Mart&#237;n&#44; Esther Rodr&#237;guez Adrada &#40;Hospital Universitario Infanta Leonor de Madrid&#41;&#46; Eva Domingo Baldrich&#44; Marianela Guzm&#225;n Carvajal &#40;Hospital Vall d&#8217;Hebron de Barcelona&#41;&#44; Mar&#237;a Jos&#233; Fortuny &#40;Hospital Francesc de Borja de Gandia&#41;&#44; Yelenis G&#243;mez Garc&#237;a&#44; Ver&#243;nica de las Nieves Segura Coronill &#40;Hospital de Manacor de Mallorca&#41;&#44; Marco Antonio Esquivias&#44; Mar&#237;a del Carmen Mart&#237;nez Pic&#243;n&#44; Marina Borox Callejas &#40;Hospital la Mancha de Ciudad Real&#41;&#44; Roc&#237;o Moyano Garc&#237;a &#40;Hospital Comarcal Valle de los Pedroches de C&#243;rdoba&#41;&#44; Pablo Rodr&#237;guez&#44; Mar&#237;a Mart&#237;nez Cuevas &#40;Hospital Universitario de la Paz de Madrid&#41;&#44; Jos&#233; Noceda&#44; Santiago Harris Blasco &#40;Hospital Cl&#237;nico de Valencia&#41;&#44; Marta Romero &#40;Hospital Universitario de M&#243;stoles de Madrid&#41;&#46; Oriol Aguil&#243; Pedret &#40;Hospital de Olot i Comarcal de la Garrotxa&#41;&#44; Jordi Estop&#225; Valladares &#40;Cl&#237;nica Universidad de Navarra de Madrid&#41;&#44; Natalia Ramos Gonz&#225;lez &#40;Hospital do Saln&#233;s de Pontevedra&#41;&#44; Rocio Lorenzo &#40;Hospital de la Axarqu&#237;a de M&#225;laga&#41;&#44; Juan Bautista Valencia &#40;Hospital Parc Taul&#237; de Sabadell&#41;&#44; Lorena Bembibre &#40;Hospital de A Coru&#241;a&#41;&#46; In&#233;s Fern&#225;ndez Guerrero &#40;Hospital Virgen de las Nieves de Granada&#41;&#46;</p>"
            "etiqueta" => "Anexo"
            "titulo" => "Investigadores del grupo ICA-SEMES &#40;lista completa&#41;"
            "identificador" => "sec0070"
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                  \t\t\t\t">8&#46;355 &#40;49&#44;9&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">100&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">1&#46;478 &#40;29&#44;9&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">4&#46;666 &#40;27&#44;9&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleBold">0&#44;007</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
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                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">Cardiopat&#237;a isqu&#233;mica</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">5&#46;776 &#40;26&#44;6&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">100&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">1&#46;465 &#40;29&#44;6&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleBold">&#60;</span><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleBold">0&#44;001</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
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                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">Valvulopat&#237;a</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">5&#46;562 &#40;25&#44;6&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">100&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">1&#46;086 &#40;21&#44;9&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">4&#46;476 &#40;26&#44;7&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t"><span class="elsevierStyleBold">&#60;</span><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleBold">0&#44;001</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">Neoplasia</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">3&#46;113 &#40;14&#44;4&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">100&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">820 &#40;16&#44;6&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">2&#46;293 &#40;13&#44;7&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleBold">&#60;</span><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleBold">0&#44;001</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
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                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">Enfermedad cerebrovascular</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">Demencia</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">485 &#40;9&#44;8&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">1&#46;974 &#40;11&#44;8&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleBold">&#60;</span><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleBold">0&#44;001</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
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                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">Enfermedad arterial perif&#233;rica</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t">1&#46;972 &#40;9&#44;1&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">567 &#40;11&#44;5&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">1&#46;405 &#40;8&#44;4&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
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                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">Cirrosis hep&#225;tica</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t">312 &#40;1&#44;4&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">95 &#40;1&#44;9&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">217 &#40;1&#44;3&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="6" align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleBold">Situaci&#243;n funcional basal</span></td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">Clase funcional NYHA</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
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                  \t\t\t\t">92&#44;7&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleBold">&#60;</span><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleBold">0&#44;001</span><a class="elsevierStyleCrossRef" href="#tblfn0005"><span class="elsevierStyleSup">a</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>I&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">4&#46;912 &#40;24&#44;4&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
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                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">781 &#40;16&#44;7&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t">4&#46;131 &#40;26&#44;8&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
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                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>II&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">10&#46;379 &#40;51&#44;6&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
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                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t">2&#46;548 &#40;54&#44;6&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t">7&#46;831 &#40;50&#44;7&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>III&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">4&#46;493 &#40;22&#44;3&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&#46;244 &#40;26&#44;7&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">3&#46;249 &#40;21&#44;0&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>IV&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">319 &#40;1&#44;6&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">91 &#40;2&#44;0&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">228 &#40;1&#44;5&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">Tipo de disfunci&#243;n del ventr&#237;culo izquierdo</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">58&#44;4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#44;96<a class="elsevierStyleCrossRef" href="#tblfn0005"><span class="elsevierStyleSup">a</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>Reducida&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&#46;203 &#40;9&#44;5&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">297 &#40;9&#44;5&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">906 &#40;9&#44;5&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>Moderadamente reducida&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2&#46;671 &#40;21&#44;1&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">666 &#40;21&#44;1&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2&#46;005 &#40;21&#44;0&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>Preservada&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">8&#46;791 &#40;69&#44;4&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2&#46;176 &#40;69&#44;3&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">6&#46;615 &#40;69&#44;3&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">Capacidad funcional &#40;seg&#250;n &#237;ndice de Barthel&#41; &#40;RIC&#41;&#93;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">90&#44;0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleBold">0&#44;003</span><a class="elsevierStyleCrossRef" href="#tblfn0005"><span class="elsevierStyleSup">a</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>Independiente &#40;100 puntos&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">6&#46;912 &#40;35&#44;4&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&#46;549 &#40;34&#44;3&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">5&#46;363 &#40;35&#44;7&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>Dependencia leve &#40;60-99 puntos&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">8&#46;875 &#40;45&#44;5&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2&#46;221 &#40;49&#44;2&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">6&#46;654 &#40;44&#44;3&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>Dependencia moderada &#40;40-59 puntos&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2&#46;024 &#40;10&#44;4&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">434 &#40;9&#44;6&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&#46;590 &#40;10&#44;6&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>Dependencia grave o total &#40;&#60;40 puntos&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&#46;705 &#40;8&#44;7&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">308 &#40;6&#44;8&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&#46;397 &#40;9&#44;3&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
              ]
              "imagenFichero" => array:1 [
                0 => "xTab3698921.png"
              ]
            ]
          ]
          "notaPie" => array:1 [
            0 => array:3 [
              "identificador" => "tblfn0005"
              "etiqueta" => "a"
              "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Calculado mediante test de ji cuadrado de tendencia lineal&#46;</p>"
            ]
          ]
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Anemia&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
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                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Crisis hipertensiva&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Trasgresi&#243;n diet&#233;tico-terap&#233;utica&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">0&#44;86&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
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                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>S&#237;ndrome coronario agudo&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">99&#44;2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">79 &#40;1&#44;6&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
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                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Frecuencia cardiaca &#40;lpm&#41; &#91;mediana &#40;RIC&#41;&#93;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttop\n
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                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">85 &#40;72-100&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">84 &#40;70-100&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#44;26&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Presi&#243;n arterial sist&#243;lica &#40;mmHg&#41; &#91;mediana &#40;RIC&#41;&#93;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">138 &#40;120-156&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">98&#44;5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">136 &#40;120-154&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">139 &#40;121-157&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleBold">&#60;</span><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleBold">0&#44;001</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Frecuencia respiratoria &#40;rpm&#41; &#91;mediana &#40;RIC&#41;&#93;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">20 &#40;18-26&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">68&#44;8&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t">22 &#40;18-26&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">20 &#40;18-26&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleBold">&#60;</span><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleBold">0&#44;001</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
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                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Saturaci&#243;n basal de ox&#237;geno &#40;&#37;&#41; &#91;mediana &#40;RIC&#41;&#93;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t">94 &#40;90-97&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">93 &#40;89-96&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">94 &#40;91-97&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>&#205;ndice de Barthel en urgencias &#40;puntos&#41; &#91;mediana &#40;RIC&#41;&#93;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t">70 &#40;45-90&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">70 &#40;45-90&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">0&#44;99&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>NYHA-IV en urgencias&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">8&#46;930 &#40;43&#44;8&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Signos de bajo gasto&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Hipertrofia ventricular izquierda en el ECG&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">608 &#40;2&#44;9&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">136 &#40;2&#44;8&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">472 &#40;2&#44;9&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Troponina superior al percentil 99&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Creatinina &#40;mg&#47;dL&#41; &#91;mediana &#40;RIC&#41;&#93;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">1&#44;16 &#40;0&#44;88-1&#44;59&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">98&#44;8&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Potasio &#40;mmol&#47;L&#41; &#91;mediana &#40;RIC&#41;&#93;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">4&#44;4 &#40;4&#44;0-4&#44;8&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleBold">0&#44;037</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>NT-proBNP &#40;pg&#47;mL&#41; &#91;mediana &#40;RIC&#41;&#93;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">4&#46;017&#40;1&#46;954-8&#46;853&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">60&#44;6&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">3&#46;564&#40;1&#46;712-7&#46;757&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">4&#46;137&#40;2&#46;016-9&#46;127&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleBold">&#60;</span><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleBold">0&#44;001</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
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                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Gravedad de la descompensaci&#243;n</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">0&#44;41&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Grupo de riesgo seg&#250;n la escala MEESSI-AHF&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttop\n
                  \t\t\t\t">58&#44;0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>Riesgo bajo&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">4&#46;935 &#40;39&#44;2&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&#46;122 &#40;37&#44;3&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">3&#46;813 &#40;39&#44;8&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>Riesgo intermedio&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">5&#46;081 &#40;40&#44;4&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&#46;288 &#40;42&#44;9&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">3&#46;793 &#40;39&#44;6&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>Riesgo alto&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&#46;356 &#40;10&#44;8&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">312 &#40;10&#44;4&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&#46;044 &#40;10&#44;9&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>Riesgo muy alto&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&#46;202 &#40;9&#44;6&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">283 &#40;9&#44;4&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">919 &#40;9&#44;6&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
              ]
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                0 => "xTab3698922.png"
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          "es" => "<p id="spar0065" class="elsevierStyleSimplePara elsevierViewall">Caracter&#237;sticas del episodio agudo de descompensaci&#243;n de insuficiencia cardiaca de los pacientes incluidos en el presente estudio y comparaci&#243;n en funci&#243;n de si existe el diagn&#243;stico previo de enfermedad pulmonar obstructiva cr&#243;nica</p>"
        ]
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      3 => array:8 [
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        "etiqueta" => "Tabla 3"
        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "detalles" => array:1 [
          0 => array:3 [
            "identificador" => "at3"
            "detalle" => "Tabla "
            "rol" => "short"
          ]
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        "tabla" => array:2 [
          "leyenda" => "<p id="spar0085" class="elsevierStyleSimplePara elsevierViewall">Los valores en negrita denotan significaci&#243;n estad&#237;stica &#40;p<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#44;05&#41;&#46;</p><p id="spar0090" class="elsevierStyleSimplePara elsevierViewall">EPOC&#58; enfermedad pulmonar obstructiva cr&#243;nica&#59; RIC&#58; rango intercuartil&#46;</p>"
          "tablatextoimagen" => array:1 [
            0 => array:2 [
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                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">TodosN<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>21&#46;694n &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Dato disponible&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Con EPOCN<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>4&#46;952n &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Sin EPOCN<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>16&#46;742n &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">p&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="6" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Tratamiento en urgencias</span></td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Furosemida endovenosa&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">17&#46;851 &#40;84&#44;7&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">97&#44;1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">4&#46;071 &#40;84&#44;1&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">13&#46;780 &#40;84&#44;9&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#44;18&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Oxigenoterapia&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">14&#46;612 &#40;69&#44;5&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">97&#44;0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">3&#46;598 &#40;74&#44;5&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">11&#46;014 &#40;68&#44;0&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleBold">&#60;</span><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleBold">0&#44;001</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Antibi&#243;tico endovenoso&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">6&#46;032 &#40;28&#44;7&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">96&#44;8&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2&#46;344 &#40;48&#44;6&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">3&#46;688 &#40;22&#44;8&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleBold">&#60;</span><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleBold">0&#44;001</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Anticolin&#233;rgicos nebulizados&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">4&#46;865 &#40;23&#44;2&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">96&#44;8&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&#46;510 &#40;31&#44;3&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">3&#46;355 &#40;20&#44;8&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleBold">&#60;</span><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleBold">0&#44;001</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Beta-agonistas nebulizados&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">4&#46;814 &#40;22&#44;9&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">96&#44;7&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&#46;976 &#40;41&#44;0&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2&#46;838 &#40;17&#44;6&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleBold">&#60;</span><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleBold">0&#44;001</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Corticoides sist&#233;micos&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">3&#46;807 &#40;18&#44;1&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">96&#44;7&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&#46;474 &#40;30&#44;6&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2&#46;333 &#40;14&#44;4&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleBold">&#60;</span><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleBold">0&#44;001</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Digoxina&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2&#46;452 &#40;11&#44;7&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">96&#44;6&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">558 &#40;11&#44;6&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&#46;894 &#40;11&#44;7&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#44;77&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Nitratos endovenosos&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2&#46;211 &#40;10&#44;5&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">96&#44;6&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">446 &#40;9&#44;3&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&#46;765 &#40;10&#44;9&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleBold">&#60;</span><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleBold">0&#44;001</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Ventilaci&#243;n no invasiva&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&#46;411 &#40;6&#44;7&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">96&#44;8&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">434 &#40;9&#44;0&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">977 &#40;6&#44;0&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleBold">&#60;</span><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleBold">0&#44;001</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Morfina&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&#46;205 &#40;5&#44;7&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">96&#44;6&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">268 &#40;5&#44;6&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">937 &#40;5&#44;8&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#44;53&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Amiodarona&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">728 &#40;3&#44;5&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">96&#44;6&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">178 &#40;3&#44;7&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">550 &#40;3&#44;4&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#44;34&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Ventilaci&#243;n mec&#225;nica invasiva&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">385 &#40;1&#44;8&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">96&#44;7&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">103 &#40;2&#44;1&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">282 &#40;1&#44;7&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#44;08&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Inotr&#243;picos&#47;vasopresores&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">271 &#40;1&#44;5&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">96&#44;5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">72 &#40;1&#44;5&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">199 &#40;1&#44;2&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#44;16&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="6" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="6" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Disposici&#243;n tras la atenci&#243;n en urgencias</span></td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Hospitalizaci&#243;n&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">16&#46;144 &#40;74&#44;5&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">99&#44;9&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">3&#46;812 &#40;77&#44;0&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">12&#46;332 &#40;73&#44;7&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleBold">&#60;</span><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleBold">0&#44;001</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Hospitalizaci&#243;n en intensivos&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">270 &#40;1&#44;3&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">94&#44;7&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">48 &#40;1&#44;0&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">222 &#40;1&#44;4&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleBold">0&#44;036</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
              ]
              "imagenFichero" => array:1 [
                0 => "xTab3698923.png"
              ]
            ]
          ]
        ]
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          "es" => "<p id="spar0080" class="elsevierStyleSimplePara elsevierViewall">Manejo en urgencias de los pacientes con insuficiencia cardiaca aguda incluidos en el presente estudio y comparaci&#243;n en funci&#243;n de si existe el diagn&#243;stico previo de enfermedad pulmonar obstructiva cr&#243;nica</p>"
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          "leyenda" => "<p id="spar0100" class="elsevierStyleSimplePara elsevierViewall">EPOC&#58; enfermedad pulmonar obstructiva cr&#243;nica&#59; IC&#58; intervalo de confianza&#59; MEESSI-AHF&#58; <span class="elsevierStyleItalic">Multiple Estimation of risk based on the Emergency department Spanish Score in Acute Heart Failure</span>&#59; OR&#58; <span class="elsevierStyleItalic">odds ratio</span>&#46;</p>"
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                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="\n
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                  \t\t\t\t  " align="" valign="\n
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Mortalidad intrahospitalaria&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Mortalidad a 30 d&#237;as<a class="elsevierStyleCrossRef" href="#tblfn0010"><span class="elsevierStyleSup">a</span></a>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleItalic">Todos los pacientes EPOC &#40;N</span><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">&#61;</span><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">21&#46;694&#41;</span></td></tr><tr title="table-row"><td class="td-with-role" title="\n
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                  \t\t\t\t">1&#46;655 &#40;7&#44;6&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">2&#46;209 &#40;10&#44;3&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
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                  \t\t\t\t"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="\n
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                  \t\t\t\t"><span class="elsevierStyleItalic">Pacientes EPOC &#40;N</span><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">&#61;</span><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">4&#46;952&#41;</span></td></tr><tr title="table-row"><td class="td-with-role" title="\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>N eventos &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">401 &#40;8&#44;1&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">542 &#40;11&#44;0&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="\n
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                  \t\t\t\t"><span class="elsevierStyleItalic">Pacientes sin EPOC &#40;N</span><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">&#61;</span><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">16&#46;742&#41;</span></td></tr><tr title="table-row"><td class="td-with-role" title="\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>N eventos &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&#46;254 &#40;7&#44;5&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&#46;667 &#40;10&#44;0&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="3" align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="\n
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                  \t\t\t\t"><span class="elsevierStyleItalic">Odds ratio &#40;IC 95&#37;&#41; para los pacientes EPOC &#40;N</span><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">&#61;</span><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">21&#46;694&#41;</span></td></tr><tr title="table-row"><td class="td-with-role" title="\n
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                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Cruda&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">1&#44;088 &#40;0&#44;968-1&#44;224&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleBold">1&#44;111 &#40;1&#44;007-1&#44;261&#41;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
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                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Ajustada por caracter&#237;sticas basales&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&#44;098 &#40;0&#44;966-1&#44;247&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleBold">1&#44;127 &#40;1&#44;053-1&#44;313&#41;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Ajustada por caracter&#237;sticas del episodio&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">1&#44;017 &#40;0&#44;898-1&#44;153&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">1&#44;041 &#40;0&#44;933-1&#44;162&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Ajustada por manejo en urgencias&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">0&#44;966 &#40;0&#44;852-1&#44;094&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t">1&#44;009 &#40;0&#44;905-1&#44;125&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Ajuste total&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&#44;040 &#40;0&#44;905-1&#44;195&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&#44;080 &#40;0&#44;957-1&#44;219&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="\n
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                  \t\t\t\t"><span class="elsevierStyleItalic">Odds ratio &#40;IC 95&#37;&#41; ajustada &#40;ajuste total&#41; para los pacientes EPOC para subgrupos de gravedad seg&#250;n la escala MEESSI-AHF &#40;N</span><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">&#61;</span><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">12&#46;574&#41;</span></td></tr><tr title="table-row"><td class="td-with-role" title="\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Riesgo bajo&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">0&#44;899 &#40;0&#44;497-1&#44;626&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">1&#44;164 &#40;0&#44;759-1&#44;783&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Riesgo incrementado &#40;intermedio&#44; alto o muy alto&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">1&#44;148 &#40;0&#44;954-1&#44;381&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t">1&#44;087 &#40;0&#44;921-1&#44;284&#41;&nbsp;\t\t\t\t\t\t\n
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              "nota" => "<p class="elsevierStyleNotepara" id="npar0010">En 158 pacientes &#40;33 EPOC y 125 no EPOC&#41; no se dispone de la mortalidad a 30 d&#237;as&#46;</p> <p class="elsevierStyleNotepara" id="npar0015">Negrita&#58; datos estad&#237;sticamente significativos&#46;</p>"
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          "es" => "<p id="spar0095" class="elsevierStyleSimplePara elsevierViewall">Mortalidad intrahospitalaria y a los 30 d&#237;as de la consulta en urgencias en los pacientes con insuficiencia cardiaca aguda incluidos en el presente estudio y comparaci&#243;n en funci&#243;n de si existe el diagn&#243;stico previo de enfermedad pulmonar obstructiva cr&#243;nica</p>"
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          "identificador" => "bibs0015"
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              "identificador" => "bib0245"
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                0 => array:2 [
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                    0 => array:2 [
                      "titulo" => "2021 ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure"
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                          "colaboracion" => "ESC Scientific Document Group"
                          "etal" => true
                          "autores" => array:6 [
                            0 => "T&#46;A&#46; Donagh"
                            1 => "M&#46; Metra"
                            2 => "M&#46; Adamo"
                            3 => "R&#46;S&#46; Gardner"
                            4 => "A&#46; Baumbach"
                            5 => "M&#46; B&#246;hm"
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                        "tituloSerie" => "Eur Heart J&#46;"
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                        "paginaFinal" => "3726"
                      ]
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              "identificador" => "bib0250"
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                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Developed in collaboration with the Heart Failure Association &#40;HFA&#41; of the ESC"
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                          "colaboracion" => "ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure 2012&#58; The Task Force for the Diagnosis and Treatment of Acute and Chronic Heart Failure 2012 of the European Society of Cardiology"
                          "etal" => true
                          "autores" => array:6 [
                            0 => "J&#46;J&#46;V&#46; McMurray"
                            1 => "S&#46; Adamopoulos"
                            2 => "S&#46;D&#46; Anker"
                            3 => "A&#46; Auricchio"
                            4 => "M&#46; B&#246;hm"
                            5 => "K&#46; Dickstein"
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                    0 => array:1 [
                      "Revista" => array:5 [
                        "tituloSerie" => "Eur Heart J"
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              "identificador" => "bib0255"
              "etiqueta" => "3"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "2016 ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure&#58; The Task Force for the diagnosis and treatment of acute and chronic heart failure of the European Society of Cardiology &#40;ESC&#41; developed with the special contribution of the Heart Failure Association &#40;HFA&#41; of the ESC"
                      "autores" => array:1 [
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                          "etal" => true
                          "autores" => array:6 [
                            0 => "P&#46; Ponikowski"
                            1 => "A&#46;A&#46; Voors"
                            2 => "S&#46;D&#46; Anker"
                            3 => "H&#46; Bueno"
                            4 => "J&#46;G&#46;F&#46; Cleland"
                            5 => "A&#46;J&#46;S&#46; Coats"
                          ]
                        ]
                      ]
                    ]
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                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1093/eurheartj/ehw128"
                      "Revista" => array:6 [
                        "tituloSerie" => "Eur Heart J"
                        "fecha" => "2016"
                        "volumen" => "37"
                        "paginaInicial" => "2129"
                        "paginaFinal" => "2200"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/27206819"
                            "web" => "Medline"
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Original
Disponible online el 24 de octubre de 2024
Características clínicas, manejo en urgencias y mortalidad de los episodios de insuficiencia cardiaca aguda en pacientes con enfermedad pulmonar obstructiva crónica
Clinical features, management in the emergency department and mortality of acute heart failure episodes in patients with chronic obstructive pulmonary disease
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N. Ivarsa, P. Llorensa, A. Alquézarc, J. Jacobd, B. Rodrígueze, M. Guzmánf, L. Serrano Lázarog, M.C. Martínez Picónh, L. Cuevas Jiménezi, Ò. Mirób,
Autor para correspondencia
omiro@clinic.cat

Autor para correspondencia.
, en representación del grupo de investigación ICA-SEMES
a Servicio de Urgencias, Corta Estancia y Hospitalización a Domicilio, Hospital General Dr. Balmis, ISABIAL, Universidad Miguel Hernández, Alicante, España
b Servicio de Urgencias, Hospital Clínic Barcelona, IDIBAPS, Universitat de Barcelona, España
c Servicio de Urgencias, Hospital de la Santa Creu i Sant Pau, Barcelona, España
d Servicio de Urgencias, Hospital Universitari de Bellvitge, L’Hospitalet de Llobregat, Barcelona, España
e Servicio de Urgencias, Hospital Infanta Leonor, Madrid, España
f Servicio de Urgencias, Hospital Universitari Vall d’Hebron, Barcelona, España
g Servicio de Urgencias, Hospital Universitario La Fe, Valencia, España
h Servicio de Urgencias, Hospital La Mancha Centro, Ciudad Real, España
i Servicio de Urgencias, Hospital Sant Pau i Santa Tecla, Tarragona, España
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Tablas (4)
Tabla 1. Características basales de los pacientes con insuficiencia cardiaca aguda incluidos en el estudio y comparación en función de si existe el diagnóstico previo de enfermedad pulmonar obstructiva crónica
Tabla 2. Características del episodio agudo de descompensación de insuficiencia cardiaca de los pacientes incluidos en el presente estudio y comparación en función de si existe el diagnóstico previo de enfermedad pulmonar obstructiva crónica
Tabla 3. Manejo en urgencias de los pacientes con insuficiencia cardiaca aguda incluidos en el presente estudio y comparación en función de si existe el diagnóstico previo de enfermedad pulmonar obstructiva crónica
Tabla 4. Mortalidad intrahospitalaria y a los 30 días de la consulta en urgencias en los pacientes con insuficiencia cardiaca aguda incluidos en el presente estudio y comparación en función de si existe el diagnóstico previo de enfermedad pulmonar obstructiva crónica
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Resumen
Objetivos

Analizar si los pacientes con enfermedad pulmonar obstructiva crónica (EPOC) presentan diferencias clínicas y de manejo terapéutico en urgencias cuando desarrollan un episodio de insuficiencia cardiaca aguda (ICA) y analizar la mortalidad durante dicha descompensación.

Método

Se incluyeron pacientes diagnosticados de ICA en 50 servicios de urgencias españoles entre 2012 y 2022 y que también padecían EPOC, y se compararon sus características basales, del episodio de descompensación y de manejo terapéutico en urgencias con las de pacientes con ICA sin EPOC diagnosticados durante dicho periodo. Se recogió la mortalidad por cualquier causa intrahospitalaria y a los 30 días, y se investigó si existían diferencias entre pacientes con y sin EPOC en modelos de regresión logística crudos y ajustados.

Resultados

Se analizaron 21.694 pacientes con ICA (mediana=83 años, mujeres=56%), 4.942 (23%) con EPOC. Estos eran más jóvenes, más frecuentemente varones, con más comorbilidades (con excepción de valvulopatía y demencia, más frecuentes en pacientes no EPOC), peor clase funcional respiratoria (NYHA) y mejor capacidad funcional global (índice de Barthel). La descompensación de los pacientes EPOC estuvo más frecuentemente desencadenada por una infección y menos por taquiarritmia, crisis hipertensiva o síndrome coronario agudo y, aunque hubo diferencias en los hallazgos clínicos en urgencias, la gravedad estimada mediante la Escala MEESSI-AHF fue similar en ambos grupos. Respecto al manejo en urgencias, más pacientes EPOC recibieron oxigenoterapia, ventilación no invasiva, broncodilatadores, corticoides y antibióticos y menos nitroglicerina endovenosa, y hospitalizaron más frecuentemente. La mortalidad intrahospitalaria en pacientes con y sin EPOC fue del 8,1% y del 7,5%, respectivamente (OR=1,088, IC 95%=0,968-1,224) y a 30 días fue del 11,0% y del 10,0% (OR=1,111, IC 95%=1,002-1,231). Tras ajustar por las características clínicas, del episodio de descompensación y del manejo en urgencias, estas OR descendieron a 1,040 (0,905-1,195) y 1,080 (0,957-1,219), respectivamente.

Conclusión

Los pacientes con ICA y EPOC tienen características clínicas y de manejo terapéutico en urgencias diferenciales, y precisan mayor hospitalización. Si bien presentan una mayor mortalidad cruda a los 30 días, esto se explica por este diferente perfil clínico más que por la propia existencia de la EPOC.

Palabras clave:
Insuficiencia cardiaca aguda
Enfermedad pulmonar obstructiva crónica
Mortalidad
Urgencias
Abstract
Objectives

This study aims to analyse differences in clinical and therapeutic management for patients with chronic obstructive pulmonary disease (COPD) who present to the emergency department with acute heart failure (AHF). Additionally, it examines mortality rates during such episodes.

Method

We included patients diagnosed with AHF at 50 Spanish emergency departments from 2012 to 2022 who also had COPD. We compared their baseline characteristics, decompensation episodes, and emergency department management with those of AHF patients without COPD during the same period. We collected data on in-hospital and 30-day all-cause mortality, investigating differences between the two groups using crude and adjusted logistic regression models.

Results

A total of 21,694 AHF patients were analysed (median age=83 years, 56% female), including 4,942 (23%) with COPD. COPD patients were generally younger and more frequently male, with a higher prevalence of comorbidities (excluding valve disease and dementia, which were more common in non-COPD patients). They exhibited a worse respiratory functional class (NYHA) but a better overall functional capacity (Barthel Index). Decompensation in COPD patients was more often triggered by infection and less frequently by tachyarrhythmia, hypertensive crisis, or acute coronary syndrome. While there were differences in clinical findings in the emergency department, the severity assessed by the MEESSI-AHF Scale was similar across both groups. In terms of emergency department management, a higher proportion of COPD patients received oxygen therapy, non-invasive ventilation, bronchodilators, corticosteroids, and antibiotics, while fewer received intravenous nitroglycerin, and they were hospitalized more frequently. In-hospital mortality rates were 8.1% for patients with COPD and 7.5% for those without (OR=1.088, 95% CI=0.968-1.224), with 30-day mortality rates of 11.0% and 10.0%, respectively (OR=1.111, 95% CI=1.002-1.231). After adjusting for clinical characteristics, decompensation episodes, and emergency department management, these odds ratios decreased to 1.040 (95% CI=0.905-1.195) and 1.080 (95% CI=0.957-1.219), respectively.

Conclusion

Patients with AHF and COPD exhibit distinct clinical and therapeutic management characteristics in the emergency department and require more frequent hospitalization. Although they show higher crude 30-day mortality, this is attributable to their differing clinical profiles rather than the presence of COPD itself.

Keywords:
Acute heart failure
Chronic obstructive pulmonary disease
Mortality
Emergencies

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