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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Introducci&#243;n</span><p id="par0005" class="elsevierStylePara elsevierViewall">La diabetes mellitus &#40;DM&#41; es un s&#237;ndrome caracterizado por trastornos metab&#243;licos generalizados donde la hiperglucemia cr&#243;nica es el factor dominante y el endotelio es el &#243;rgano diana por excelencia&#46; Su prevalencia en Espa&#241;a oscila alrededor del 10&#37;&#46; En el a&#241;o 2025 se estima que habr&#225; entre 300 y 380 millones de pacientes con DM tipo 2 en todo el mundo<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#44;2</span></a>&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">La enfermedad arterioscler&#243;tica&#44; sobre todo a nivel coronario es la principal causa de morbimortalidad y hasta un 80&#37; de los pacientes con DM fallecer&#225;n por esta causa<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a>&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">La detecci&#243;n de hiperglucemia es frecuente en pacientes que ingresan con SCA en probable relaci&#243;n con la liberaci&#243;n de hormonas contrarreguladoras &#40;catecolaminas&#44; glucag&#243;n&#44; cortisol y hormona de crecimiento&#41;&#44; derivadas del estr&#233;s que acompa&#241;a al evento coronario&#46; Diversos estudios en pacientes con SCA han observado una relaci&#243;n entre la aparici&#243;n y severidad de la hiperglucemia y el incremento de la morbimortalidad<a class="elsevierStyleCrossRefs" href="#bib0020"><span class="elsevierStyleSup">4&#8211;6</span></a>&#44; con independencia de tener un diagn&#243;stico previo de DM<a class="elsevierStyleCrossRefs" href="#bib0035"><span class="elsevierStyleSup">7&#8211;10</span></a>&#46; La relaci&#243;n entre la hiperglucemia y el pron&#243;stico del SCA no est&#225; bien definida&#46; La hiperglucemia podr&#237;a ser simplemente un marcador de riesgo&#44; indicando mayor severidad de la enfermedad de base y por ello&#44; un peor pron&#243;stico&#46; No obstante&#44; tambi&#233;n podr&#237;a ser un aut&#233;ntico factor de riesgo para la mala evoluci&#243;n del SCA&#44; ya que la hiperglucemia se ha relacionado con la producci&#243;n de arritmias por alargamiento del intervalo QT<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">11</span></a> con la depresi&#243;n en la fracci&#243;n de eyecci&#243;n<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">12</span></a> o con el incremento del tama&#241;o del infarto por fen&#243;meno de <span class="elsevierStyleItalic">no reflow</span><a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">13</span></a>&#46; La hiperglucemia adem&#225;s amplifica el sustrato inflamatorio y facilita la activaci&#243;n y agregaci&#243;n plaquetaria favoreciendo la disfunci&#243;n endotelial y la trombosis coronaria<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">14</span></a>&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">En este trabajo hemos pretendido confirmar la importancia pron&#243;stica de la hiperglucemia al ingreso sobre la evoluci&#243;n del SCA de alto riesgo con o sin elevaci&#243;n del segmento ST&#44; independientemente del antecedente de DM&#44; y responder a la pregunta de si la hiperglucemia al ingreso se relaciona con el pron&#243;stico de los pacientes que sufren un SCA independientemente de otros factores conocidos&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Pacientes</span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Dise&#241;o</span><p id="par0025" class="elsevierStylePara elsevierViewall">Estudio anal&#237;tico de cohortes prospectivo&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Pacientes</span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Criterios de inclusi&#243;n</span><p id="par0030" class="elsevierStylePara elsevierViewall">Pacientes ingresados consecutivamente en nuestro hospital durante el per&#237;odo comprendido entre enero de 2006 y diciembre de 2007 con diagn&#243;stico de SCA de alto riesgo&#44; tanto con elevaci&#243;n como sin elevaci&#243;n del segmento ST&#44; seg&#250;n los criterios de la ACA&#47;AHA <span class="elsevierStyleItalic">&#40;American College of Cardiology&#47;American Heart Association&#41;</span><a class="elsevierStyleCrossRefs" href="#bib0075"><span class="elsevierStyleSup">15&#44;16</span></a>&#46; Los pacientes recibieron el tratamiento necesario para su proceso patol&#243;gico siguiendo las recomendaciones de las gu&#237;as de las anteriores sociedades cient&#237;ficas&#46;</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Criterios de exclusi&#243;n</span><p id="par0035" class="elsevierStylePara elsevierViewall">Presencia de neoplasia maligna de &#243;rgano s&#243;lido o hematol&#243;gica&#44; s&#237;ndrome febril o sepsis en el momento del estudio&#44; enfermedades autoinmunes o inflamatorias&#44; insuficiencia renal cr&#243;nica en estadio 5 seg&#250;n las gu&#237;as K&#47;DOQI 2002 de la <span class="elsevierStyleItalic">National Kidney Foundation</span><a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">17</span></a> o falta de informaci&#243;n en las variables analizadas&#46; Se excluyeron 31 de los 486 pacientes inicialmente seleccionados&#44; por lo que la muestra final analizada fue de 455 pacientes&#46;</p></span></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Variables del estudio</span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Variables cl&#237;nicas</span><p id="par0040" class="elsevierStylePara elsevierViewall">Edad&#44; sexo&#44; antecedentes personales recogidos en la historia cl&#237;nica previa o al ingreso &#40;hipertensi&#243;n arterial&#44; DM&#44; dislipemia&#44; tabaquismo&#44; insuficiencia cardiaca&#44; infarto agudo de miocardio&#41; frecuencia cardiaca&#44; presi&#243;n arterial sist&#243;lica&#44; presi&#243;n arterial diast&#243;lica y presi&#243;n de pulso&#46; Se realiz&#243; estratificaci&#243;n de riesgo mediante la escala GRACE&#44; en bajo&#44; medio y alto riesgo&#46;</p></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Variables anal&#237;ticas</span><p id="par0045" class="elsevierStylePara elsevierViewall">Glucemia&#44; creatinina &#40;con estimaci&#243;n del filtrado glomerular mediante la f&#243;rmula del estudio MDRD-4<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">17</span></a>&#41;&#44; recuento leucocitario&#44; fibrin&#243;geno&#44; creatincinasa &#40;CK&#41; y&#47;o fracci&#243;n MB de creatincinasa &#40;CK-MB&#41;&#44; y troponina I&#46; Las variables bioqu&#237;micas se obtuvieron con los m&#233;todos espec&#237;ficos del sistema Synchron Lx20pro al ingreso en las dos primeras horas tras la entrada al hospital&#46;</p></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Electrocardiograma</span><p id="par0050" class="elsevierStylePara elsevierViewall">Los pacientes con SCA se clasificaron seg&#250;n las caracter&#237;sticas del segmento ST en tres grupos&#58; normal&#44; descendido o elevado&#46; Se document&#243; la aparici&#243;n de arritmias cardiacas durante la evoluci&#243;n&#46;</p></span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Ecocardiograma</span><p id="par0055" class="elsevierStylePara elsevierViewall">Se determin&#243; la fracci&#243;n de eyecci&#243;n del ventr&#237;culo izquierdo de todos los pacientes durante el ingreso y se clasific&#243; como normal&#44; depresi&#243;n ligera&#44; depresi&#243;n moderada o depresi&#243;n severa&#46;</p></span></span><span id="sec0060" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Definici&#243;n de eventos y seguimiento</span><p id="par0060" class="elsevierStylePara elsevierViewall">El evento principal analizado fue la mortalidad por cualquier causa&#46; El per&#237;odo de seguimiento se limit&#243; a seis meses desde el momento del ingreso&#46; Los datos fueron recogidos mediante historia cl&#237;nica y&#47;o contacto telef&#243;nico con el paciente o sus familiares&#46; En los 455 pacientes se pudieron recoger los datos necesarios para el estudio&#46;</p></span><span id="sec0065" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">An&#225;lisis estad&#237;stico</span><p id="par0065" class="elsevierStylePara elsevierViewall">Las variables continuas fueron expresadas como media<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>desviaci&#243;n est&#225;ndar y las variables cualitativas como distribuci&#243;n de frecuencias&#46; La comparaci&#243;n de variables cuantitativas entre grupos&#44; en caso de seguir una distribuci&#243;n normal se realiz&#243; con el test de <span class="elsevierStyleItalic">t</span> de Student para muestras independientes&#59; en caso de no seguir una distribuci&#243;n normal se emple&#243; el test no param&#233;trico U&#46; de Mann-Whitney&#46; Las variables discretas se compararon mediante la prueba de la Chi cuadrado o el test exacto de Fisher&#46;</p><p id="par0070" class="elsevierStylePara elsevierViewall">La glucemia como variable independiente principal del estudio se clasific&#243; en dos grupos a partir de su mediana&#58; &#60; 139<span class="elsevierStyleHsp" style=""></span>mg&#47;dl y &#8805; 139<span class="elsevierStyleHsp" style=""></span>mg&#47;dl&#46; La representaci&#243;n gr&#225;fica de la supervivencia acumulada para cada categor&#237;a de glucemia se model&#243; mediante curvas de Kaplan-Meier&#44; mientras que la comparaci&#243;n entre dichas categor&#237;as se realiz&#243; 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La glucemia media al ingreso fue de 163&#44;3<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>71&#44;8<span class="elsevierStyleHsp" style=""></span>mg&#47;dl con un m&#225;ximo de 522<span class="elsevierStyleHsp" style=""></span>mg&#47;dl y un m&#237;nimo de 43<span class="elsevierStyleHsp" style=""></span>mg&#47;dl&#46; Los pacientes con hiperglucemia al ingreso &#40;&#8805; 139<span class="elsevierStyleHsp" style=""></span>mg&#47;dL&#41; eran con mayor frecuencia del sexo femenino&#44; ten&#237;an una edad m&#225;s avanzada y una mayor prevalencia de antecedentes de hipertensi&#243;n arterial y DM&#46; Por el contrario&#44; la prevalencia de hiperglucemia fue inferior en los fumadores&#46; La presencia de hiperglucemia se asoci&#243; a una frecuencia cardiaca m&#225;s elevada&#44; a un mayor riesgo de SCA con elevaci&#243;n del segmento ST&#44; a una menor fracci&#243;n de eyecci&#243;n&#44; a un riesgo m&#225;s elevado &#40;escala GRACE&#41; y a una mayor incidencia de arritmias&#46; Adem&#225;s hubo una relaci&#243;n significativa con un mayor recuento leucocitario al ingreso y con un menor filtrado glomerular calculado &#40;<a class="elsevierStyleCrossRef" href="#tbl0010">tabla 2</a>&#41; lo que concuerda con los resultados de otros trabajos<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">18</span></a>&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><elsevierMultimedia ident="tbl0010"></elsevierMultimedia></span><span id="sec0080" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Hiperglucemia como factor pron&#243;stico</span><p id="par0090" class="elsevierStylePara elsevierViewall">La supervivencia media en los 6 meses siguientes al SCA fue de 165<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>49 d&#237;as &#40;mediana 180 d&#237;as&#59; rango&#58; 1-180 d&#237;as&#41;&#46; Se registraron 47 fallecimientos &#40;10&#44;3&#37;&#41;&#59; las causas m&#225;s frecuentes fueron&#58; shock cardiog&#233;nico &#40;68&#44;1&#37;&#41;&#44; seguido de rotura cardiaca &#40;8&#44;5&#37;&#41; y de fibrilaci&#243;n ventricular no controlada &#40;2&#44;1&#37;&#41;&#46; Las variables relacionadas con la mortalidad est&#225;n recogidas en la <a class="elsevierStyleCrossRef" href="#tbl0015">tabla 3</a>&#46; En el grupo de fallecidos la glucemia media fue de 190<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>79<span class="elsevierStyleHsp" style=""></span>mg&#47;dl frente a 160<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>71<span class="elsevierStyleHsp" style=""></span>mg&#47;dl en el de no fallecidos &#40;p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;003&#41;&#46; Otros predictores de mortalidad fueron el sexo femenino&#44; la edad&#44; las constantes medidas al ingreso &#40;incremento de frecuencia cardiaca y descenso de presi&#243;n arterial sist&#243;lica y diast&#243;lica&#41;&#44; los antecedentes de ausencia de tabaquismo y presencia de DM e infarto previo&#44; la hiperfibrinogenemia&#44; el descenso del filtrado glomerular&#44; la fracci&#243;n de eyecci&#243;n severamente deprimida&#44; la presencia de arritmias y la pertenencia al grupo de alto riesgo seg&#250;n la escala GRACE&#46;</p><elsevierMultimedia ident="tbl0015"></elsevierMultimedia><p id="par0095" class="elsevierStylePara elsevierViewall">En la curva de Kaplan-Meier se observa la menor supervivencia de los pacientes con hiperglucemia en el momento del ingreso &#40;<a class="elsevierStyleCrossRef" href="#fig0005">fig&#46; 1</a>&#41;&#46; La presencia de hiperglucemia increment&#243; de modo significativo la mortalidad &#40;14&#44;9 vs 5&#44;7&#37;&#41; con un HR<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>2&#44;7&#59; IC 95&#37;&#58; 1&#44;4-5&#44;2&#59; p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;002&#41;&#46; En an&#225;lisis multivariante &#40;ajustado para edad&#44; sexo&#44; antecedentes de tabaquismo&#44; DM o infarto previo&#44; frecuencia cardiaca y presi&#243;n arterial sist&#243;lica al ingreso&#44; filtrado glomerular&#44; niveles de leucocitos y fibrin&#243;geno&#44; morfolog&#237;a del segmento ST&#44; fracci&#243;n de eyecci&#243;n y gravedad seg&#250;n la clasificaci&#243;n de GRACE&#41;&#44; la hiperglucemia tambi&#233;n fue un predictor significativo de mortalidad &#40;HR<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>2&#44;98&#59; IC 95&#37;&#58; 1&#44;06-8&#44;4&#59; p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;039&#41;&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0100" class="elsevierStylePara elsevierViewall">El mejor modelo predictivo de mortalidad tras la aplicaci&#243;n de procedimiento de exclusi&#243;n secuencial fue el formado por las variables recogidas en la <a class="elsevierStyleCrossRef" href="#tbl0020">tabla 4</a>&#44; listadas seg&#250;n su poder predictivo&#46; El principal factor predictivo de mortalidad fue la depresi&#243;n severa de la fracci&#243;n de eyecci&#243;n&#46; La presencia de hiperglucemia al ingreso tambi&#233;n fue un predictor independiente de mortalidad&#46;</p><elsevierMultimedia ident="tbl0020"></elsevierMultimedia></span></span><span id="sec0085" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Discusi&#243;n</span><p id="par0105" class="elsevierStylePara elsevierViewall">En nuestro trabajo hemos confirmado que la hiperglucemia al ingreso es un factor pron&#243;stico negativo en la evoluci&#243;n de los pacientes con SCA&#46; Adem&#225;s su poder predictivo es independiente de otros factores pron&#243;sticos y de la existencia de un diagn&#243;stico previo de DM&#46;</p><p id="par0110" class="elsevierStylePara elsevierViewall">Seg&#250;n nuestros resultados&#44; el 50&#37; de los pacientes presentaron glucemias al ingreso &#8805; 139<span class="elsevierStyleHsp" style=""></span>mg&#47;dL&#44; a pesar de que tan solo el 21&#44;8&#37; ten&#237;an DM conocida&#46; Estos datos son equivalentes a los de otros trabajos donde tambi&#233;n se ha constatado que la hiperglucemia aguda es un fen&#243;meno com&#250;n en el SCA<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">19</span></a>&#46; A pesar de haberse comprobado su asociaci&#243;n con un peor pron&#243;stico&#44; tanto a corto como a largo plazo<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a>&#44; la hiperglucemia ha sido infravalorada y deficientemente tratada&#46; En la muestra recogida podemos ver que los pacientes que fallec&#237;an ten&#237;an al ingreso cifras m&#225;s altas de glucemia y que la presencia de cifras de glucemia superiores a la mediana pr&#225;cticamente triplicaban el riesgo de mortalidad&#46;</p><p id="par0115" class="elsevierStylePara elsevierViewall">Parece que la hiperglucemia no s&#243;lo es un marcador&#44; sino tambi&#233;n un mediador&#44; en la aparici&#243;n de eventos cardiovasculares adversos y de mortalidad&#46; En este trabajo hallamos una clara asociaci&#243;n entre hiperglucemia al ingreso&#44; elevaci&#243;n de marcadores inflamatorios &#40;leucocitosis&#41; y mayor prevalencia de reconocidos factores pron&#243;sticos negativos en la evoluci&#243;n del SCA &#40;la edad m&#225;s avanzada&#44; la estratificaci&#243;n de alto riesgo seg&#250;n la escala GRACE&#44; los antecedentes de DM&#44; la presencia al ingreso de mayor frecuencia cardiaca y de mayor prevalencia de elevaci&#243;n del segmento ST&#44; la fracci&#243;n de eyecci&#243;n m&#225;s reducida y el menor filtrado glomerular&#41;&#59; por el contrario&#44; la proporci&#243;n de fumadores activos era inferior en los pacientes con hiperglucemia&#46; A pesar de la diferencia entre los grupos&#44; el ajuste multivariante no atenu&#243; el impacto pron&#243;stico perjudicial de la hiperglucemia&#46;</p><p id="par0120" class="elsevierStylePara elsevierViewall">Nuestros datos apoyan la hip&#243;tesis de que la hiperglucemia al ingreso puede ejercer un da&#241;o cardiovascular durante el SCA&#46; En los &#250;ltimos a&#241;os se han identificado diversos mecanismos responsables que podr&#237;an justificar estos resultados&#46; La hiperglucemia induce un incremento de la respuesta inflamatoria y del estr&#233;s oxidativo generando aniones super&#243;xido a nivel mitocondrial&#46; &#201;stos promueven lesi&#243;n&#44; disfunci&#243;n y apoptosis de c&#233;lulas endoteliales a trav&#233;s de mediadores secundarios o de la transcripci&#243;n de diferentes factores<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">20</span></a>&#46; Adem&#225;s Monnier L et al<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">21</span></a> observaron que el da&#241;o inducido por la hiperglucemia a trav&#233;s del estr&#233;s oxidativo es mayor en las fluctuaciones agudas que en un estado de hiperglucemia mantenida&#44; por lo que la toxicidad podr&#237;a ser mayor en pacientes con hiperglucemia de estr&#233;s que en diab&#233;ticos que mantienen valores permanentemente elevados<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">22</span></a>&#46; De hecho&#44; en nuestro trabajo el antecedente de DM conocida antes del SCA no fue predictivo de mortalidad en an&#225;lisis multivariante&#46;</p><p id="par0125" class="elsevierStylePara elsevierViewall">La hiperglucemia aguda produce una situaci&#243;n de insulinopenia relativa lo cual induce lipolisis y la liberaci&#243;n de &#225;cidos grasos libres&#44; cuya oxidaci&#243;n tambi&#233;n genera aniones super&#243;xido&#46; Adem&#225;s&#44; estos &#225;cidos grasos oxidados dificultan el transporte de glucosa al interior de la c&#233;lula mioc&#225;rdica a trav&#233;s del transportador GLUT-4&#44; y por tanto&#44; reducen el sustrato energ&#233;tico de la misma&#46; Teniendo en cuenta que la necesidad de ox&#237;geno por mol&#233;cula de adenos&#237;n trifosfato &#40;ATP&#41; es mayor en la oxidaci&#243;n de &#225;cidos grasos que en la de glucosa&#44; finalmente se genera un estado de mayor demanda de ox&#237;geno para la obtenci&#243;n de energ&#237;a&#44; lo que agrava el contexto de isquemia aguda<a class="elsevierStyleCrossRefs" href="#bib0115"><span class="elsevierStyleSup">23&#44;24</span></a>&#46; Shivu GN et al<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">25</span></a> demostraron en pacientes j&#243;venes con DM 1 de menos de 5 a&#241;os de evoluci&#243;n y sin complicaciones microvasculares previas&#44; alteraciones en los mecanismos de obtenci&#243;n de energ&#237;a mioc&#225;rdicos&#44; medidos a trav&#233;s de una disminuci&#243;n del ratio fosfocreatina&#47;&#947;-ATP&#59; esta alteraci&#243;n estar&#237;a relacionada con el desarrollo de la disfunci&#243;n contr&#225;ctil que justificar&#237;a la aparici&#243;n de insuficiencia cardiaca&#46; El peor pron&#243;stico del SCA podr&#237;a pues justificarse por la profunda crisis metab&#243;lica inducida por la hiperglucemia&#46;</p><p id="par0130" class="elsevierStylePara elsevierViewall">Otros factores predictivos de mal pron&#243;stico fueron de forma no sorprendente&#44; la edad avanzada&#44; el sexo masculino&#44; la disfunci&#243;n ventricular y el descenso inicial de la presi&#243;n arterial&#46; M&#225;s dif&#237;cil de explicar fue el factor protector del tabaquismo &#40;aunque hay que tener en cuenta que solo recogimos el tabaquismo activo&#44; no los ex-fumadores&#41; y del sexo femenino &#40;especialmente teniendo en cuenta que en an&#225;lisis univariante el riesgo era superior en las mujeres&#44; aunque el limitado tama&#241;o de la muestra gener&#243; una marcada desproporci&#243;n entre distintos factores de riesgo&#41;&#46;</p><p id="par0135" class="elsevierStylePara elsevierViewall">Aunque est&#225; por confirmar definitivamente el beneficio del tratamiento intensivo de la hiperglucemia en el contexto del SCA&#44; el an&#225;lisis de datos secundarios ha comprobado el descenso de la mortalidad a los 6 meses en los pacientes con glucemias por debajo de 140<span class="elsevierStyleHsp" style=""></span>mg&#47;dl&#44; independientemente del tratamiento a que fueron asignados<a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">26</span></a>&#46; Estos datos reforzar&#237;an las observaciones realizadas en nuestro medio&#46;</p><p id="par0140" class="elsevierStylePara elsevierViewall">Como limitaciones del estudio debemos mencionar el restringido n&#250;mero de pacientes y el no haber recogido cifras de glucemia durante el ingreso&#46; No obstante&#44; las cifras de glucemia en el momento del ingreso y durante el mismo son igualmente predictivas<a class="elsevierStyleCrossRef" href="#bib0135"><span class="elsevierStyleSup">27</span></a>&#46; La determinaci&#243;n de la hemoglobina glicosilada hubiera sido interesante para discriminar si los pacientes con hiperglucemia al ingreso&#44; considerados no diab&#225;ticos&#44; padec&#237;an o no diabetes antes del ingreso&#46; La ventaja de nuestro trabajo fue que conseguimos ajustar el an&#225;lisis multivariante para las principales variables que podr&#237;an haber mediado la asociaci&#243;n entre hiperglucemia y mortalidad&#46;</p><p id="par0145" class="elsevierStylePara elsevierViewall">Los resultados que se derivan de este trabajo apoyan una relaci&#243;n directa entre la hiperglucemia al ingreso de un evento coronario agudo y la mortalidad&#46; Por lo tanto&#44; parece razonable tratar de restablecer lo antes posible la normoglucemia en estos pacientes&#44; para conseguir una evoluci&#243;n m&#225;s favorable e incrementar la supervivencia tras un SCA&#46; Quedan por identificar nuevos mecanismos responsables&#44; demostrar la seguridad y efectividad de un control intensivo de la glucemia sobre el pron&#243;stico del SCA especialmente cuando evoluciona a insuficiencia card&#237;aca<a class="elsevierStyleCrossRef" href="#bib0140"><span class="elsevierStyleSup">28</span></a> y definir nuevos objetivos terap&#233;uticos&#44; tanto en pacientes diab&#233;ticos como en no diab&#233;ticos que sufren un evento coronario agudo&#46;</p></span><span id="sec0090" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Conflicto de intereses</span><p id="par0150" class="elsevierStylePara elsevierViewall">Los autores declaran no tener ning&#250;n conflicto de intereses&#46;<elsevierMultimedia ident="tb0005"></elsevierMultimedia></p></span></span>"
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        "resumen" => "<span class="elsevierStyleSectionTitle">Objetivo</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">La hiperglucemia es una observaci&#243;n frecuente en el s&#237;ndrome coronario agudo &#40;SCA&#41;&#46; Hemos analizado la relaci&#243;n existente entre la hiperglucemia al ingreso y el pron&#243;stico de los pacientes que ha sufrido un SCA&#46;</p> <span class="elsevierStyleSectionTitle">Material y m&#233;todos</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Estudio prospectivo de 455 pacientes con SCA con y sin elevaci&#243;n del segmento ST de alto riesgo &#40;criterios de la ACA&#47;AHA&#41;&#46; Dividimos la muestra seg&#250;n la mediana de la glucemia al ingreso en &#60; 139<span class="elsevierStyleHsp" style=""></span>mg&#47;dl y &#8805; 139<span class="elsevierStyleHsp" style=""></span>mg&#47;dl&#44; y observamos variables anal&#237;ticas&#44; electrocardiogr&#225;ficas&#44; ecocardiogr&#225;ficas y epidemiol&#243;gicas&#46; Mediante un an&#225;lisis de riesgos proporcionales de Cox se analiz&#243; su relaci&#243;n con la mortalidad como variable principal en los siguientes seis meses al evento&#46;</p> <span class="elsevierStyleSectionTitle">Resultados</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">La edad media fue de 64&#44;3<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>12&#44;7 a&#241;os&#44; el 80&#44;4&#37; eran varones y el 21&#44;8&#37; hab&#237;an sido diagnosticados de diabetes&#46; La glucemia media al ingreso fue de 163<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>72<span class="elsevierStyleHsp" style=""></span>mg&#47;dL&#46; Un total de 47 pacientes fallecieron &#40;10&#44;3&#37;&#41;&#46; La glucemia media de los que fallecieron fue de 190<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>79<span class="elsevierStyleHsp" style=""></span>mg&#47;dl frente a 160<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>70<span class="elsevierStyleHsp" style=""></span>mg&#47;dl en los supervivientes &#40;p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;003&#41;&#46; Aquellos que presentaban al ingreso hiperglucemia &#40;&#8805; 139<span class="elsevierStyleHsp" style=""></span>mg&#47;dL&#41; tuvieron una mayor mortalidad &#40;<span class="elsevierStyleItalic">Hazard ratio</span> &#91;HR&#93;<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>2&#44;98&#59; intervalo de confianza &#91;IC&#93; 95&#37;&#58; 1&#44;06-8&#44;4&#59; p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;039&#41;&#46; La edad avanzada&#44; el sexo masculino&#44; la disfunci&#243;n ventricular y el descenso inicial de la presi&#243;n arterial tambi&#233;n mostraron relaci&#243;n independiente con la mortalidad&#46;</p> <span class="elsevierStyleSectionTitle">Conclusiones</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">La hiperglucemia al ingreso &#8805; 139<span class="elsevierStyleHsp" style=""></span>mg&#47;dl en pacientes con SCA se asocia a un mayor riesgo de fallecer en los pr&#243;ximos seis meses&#44; independientemente del antecedente de diabetes y otros factores de riesgo conocidos&#46;</p>"
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        "titulo" => "Abstract"
        "resumen" => "<span class="elsevierStyleSectionTitle">Objective</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Hyperglycemia is a frequent observation in the acute coronary syndrome&#46; We analyzed the relationship between hyperglycemia on admission and patients with acute coronary syndrome&#46;</p> <span class="elsevierStyleSectionTitle">Material and methods</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Prospective study of 455 patients with acute coronary syndrome with and without elevation of ST segment with high risk according to ACA&#47;AHA criteria&#46; We divided the sample according to the median glycemia on admission into &#60;139<span class="elsevierStyleHsp" style=""></span>mg&#47;dl and &#8805;139<span class="elsevierStyleHsp" style=""></span>mg&#47;dl&#46; We studied the analytic&#44; electrocardiography&#44; echocardiography and epidemiologic variables&#46; Using the Cox Proportional Hazard Model&#44; we analyzed their relationship with the mortality as principal variable during a six-month period after the acute coronary syndrome&#46;</p> <span class="elsevierStyleSectionTitle">Results</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Mean age was 64&#46;3<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>12&#46;7 years&#44; 80&#46;4&#37; were male and 21&#46;8&#37; had been diagnosed with diabetes&#46; Mean glycemia on admission was 163&#46;3<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>71&#46;8<span class="elsevierStyleHsp" style=""></span>mg&#47;dl&#46; Forty-seven patients died &#40;10&#46;3&#37;&#41;&#44; Mean glycemia of those who had died was 189&#46;8<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>78&#46;8<span class="elsevierStyleHsp" style=""></span>mg&#47;dl compared to 160&#46;3<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>70&#46;4<span class="elsevierStyleHsp" style=""></span>mg&#47;dl in the survival group &#40;<span class="elsevierStyleItalic">P</span>&#61;0&#46;003&#41;&#46; Patients with hyperglycemia on admission &#8805;139<span class="elsevierStyleHsp" style=""></span>mg&#47;dl had higher mortality&#44; hazard ratio &#40;HR&#41;&#61;2&#46;98 &#40;confidence interval &#91;CI 95&#37;&#93;&#58; 1&#46;06-8&#46;4&#59; <span class="elsevierStyleItalic">P</span>&#61;0&#46;039&#41;&#46; Elderly patients&#44; being a male&#44; having ventricular dysfunction and initial decrease of blood pressure also showed an independent relationship with mortality&#46;</p> <span class="elsevierStyleSectionTitle">Conclusions</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">Hyperglycemia on admission &#8805;139<span class="elsevierStyleHsp" style=""></span>mg&#47;dl in acute coronary syndrome patients is associated with a higher risk of death in the following six months&#44; independently of diabetes or other risk factors known&#46;</p>"
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                  \t\t\t\t">77&#44;5<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>21&#44;3&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Presi&#243;n arterial sist&#243;lica &#40;mmHg&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">135&#44;4<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>27&#44;9&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Presi&#243;n arterial diast&#243;lica &#40;mmHg&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">79&#44;4<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>17&#44;5&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">55&#44;7<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>18&#44;9&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t">292 &#40;64&#44;2&#37;&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Segmento ST descendido&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t">94 &#40;20&#44;7&#37;&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Segmento ST isoel&#233;ctrico&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">69 &#40;15&#44;2&#37;&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " colspan="2" 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
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>FE conservada &#40;<span class="elsevierStyleUnderline">&#62;</span> 50&#37;&#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="char" valign="\n
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                  \t\t\t\t">256 &#40;63&#44;7&#37;&#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  " align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>FE ligeramente deprimida &#40;40-50&#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="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">82 &#40;20&#44;4&#37;&#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\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>FE moderadamente deprimida &#40;30-40&#37;&#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="char" valign="\n
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                  \t\t\t\t">47 &#40;11&#44;7&#37;&#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\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>FE severamente deprimida &#40;&#60; 30&#37;&#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="char" valign="\n
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                  \t\t\t\t">17&#40;4&#44;2&#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  " colspan="2" align="left" valign="\n
                  \t\t\t\t\ttop\n
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                  \t\t\t\t"><span class="elsevierStyleItalic">Estratificaci&#243;n de riesgo GRACE n&#46;&#176; &#40;&#37;&#41;</span><a class="elsevierStyleCrossRef" href="#tblfn0005"><span class="elsevierStyleSup">a</span></a></td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>GRACE Alto &#40;&#8805; 118 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="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">83 &#40;18&#44;2&#37;&#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  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>GRACE Medio &#40;89-118 puntos&#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  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">12&#44;8&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">16&#44;7&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#44;149&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="4" 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="4" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Exploraci&#243;n f&#237;sica</span></td></tr><tr title="table-row"><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="elsevierStyleHsp" style=""></span>Frecuencia cardiaca &#40;lpm&#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">74&#44;2<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>17&#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">80&#44;7<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>24&#44;2&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;001&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  " 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;&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">134&#44;1<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>25&#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">136&#44;8<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>30&#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">0&#44;293&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  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Presi&#243;n arterial diast&#243;lica &#40;mmHg&#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">79&#44;4<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>16&#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">79&#44;5<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>18&#44;2&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;951&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  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Presi&#243;n de pulso &#40;mmHg&#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">54&#44;3<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>17&#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">57&#44;1<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>20&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;125&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  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Segmento ST elevado&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">57&#44;3&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">71&#44;1&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#44;004&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  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>FE severamente deprimida &#40;&#60; 30&#37;&#41;<a class="elsevierStyleCrossRef" href="#tblfn0020"><span class="elsevierStyleSup">a</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2&#44;6&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">5&#44;8&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#44;014&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  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>GRACE alto &#40;&#8805; 118 puntos&#41;<a class="elsevierStyleCrossRef" href="#tblfn0025"><span class="elsevierStyleSup">b</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">12&#44;8&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">23&#44;9&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#60; 0&#44;001&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  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Arritmias&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">21&#44;1&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">26&#44;8&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#44;098&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="4" 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="4" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Alteraciones anal&#237;ticas</span></td></tr><tr title="table-row"><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="elsevierStyleHsp" style=""></span>Enzimas cardiacas elevadas &#40;CK&#44; CK-MB&#41;<a class="elsevierStyleCrossRef" href="#tblfn0030"><span class="elsevierStyleSup">c</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">79&#44;1&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">86&#44;3&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#44;028&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  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Troponina I elevada<a class="elsevierStyleCrossRef" href="#tblfn0035"><span class="elsevierStyleSup">d</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">98&#44;2&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">98&#44;2&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#44;636&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  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Recuento leucocitario &#40;cell&#47;mm<span class="elsevierStyleSup">3</span>&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">10&#46;448&#44;5<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>3&#46;482&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;862&#44;9<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>4563&#44;2&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="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#60; 0&#44;001&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  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Fibrin&#243;geno &#40;mg&#47;dl&#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">408&#44;4<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>139&#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">430&#44;3<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>138&#44;3&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="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#44;100&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  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Funci&#243;n renal &#8211;MDRD-4 &#40;mL&#47;min&#47;1&#44;73 m<span class="elsevierStyleSup">2</span>&#41;&#8211;&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">82&#44;6<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>26&#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">71&#44;8<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>24&#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="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#60; 0&#44;001&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  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Mortalidad&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&#44;7&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">14&#44;9&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#44;001&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
              ]
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            0 => array:3 [
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Presi&#243;n arterial diast&#243;lica &#40;mmHg&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">48&#37;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">0&#44;000&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">0&#44;172 &#40;0&#44;07-0&#44;4&#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">27&#44;7&#37;&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">13&#44;2&#37;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Frecuencia cardiaca &#40;lpm&#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="char" valign="\n
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                  \t\t\t\t">84&#44;9<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>23&#44;5&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="char" valign="\n
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                  \t\t\t\t">76&#44;6<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>21&#44;0&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="char" valign="\n
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                  \t\t\t\t">0&#44;008&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="char" valign="\n
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                  \t\t\t\t">1&#44;014&#40;1&#44;003-1&#44;025&#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="elsevierStyleHsp" style=""></span>Presi&#243;n arterial sist&#243;lica &#40;mmHg&#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="char" valign="\n
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                  \t\t\t\t">125&#44;1<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>26&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">136&#44;6<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>28&#44;0&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="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#44;005&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>Presi&#243;n arterial diast&#243;lica &#40;mmHg&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">0&#44;004&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">0&#44;976 &#40;0&#44;96-0&#44;99&#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="elsevierStyleHsp" style=""></span>FE severamente deprimida &#40;&#60; 30&#37;&#41;<a class="elsevierStyleCrossRef" href="#tblfn0040"><span class="elsevierStyleSup">a</span></a>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">30&#44;3&#37;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">1&#44;9&#37;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>GRACE alto &#40;&#8805; 118 puntos&#41;<a class="elsevierStyleCrossRef" href="#tblfn0045"><span class="elsevierStyleSup">b</span></a>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">12&#44;3&#37;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">&#60; 0&#44;001&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Funci&#243;n renal &#8211;MDRD-4 &#40;mL&#47;min&#47;1&#44;73m<span class="elsevierStyleSup">2</span>&#41;&#8211;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t" style="border-bottom: 2px solid black">Inferior&nbsp;\t\t\t\t\t\t\n
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          "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0095" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">&#191;Qu&#233; sabemos&#63;</span><p id="par0160" class="elsevierStylePara elsevierViewall">El pron&#243;stico de los pacientes con s&#237;ndrome coronario agudo es muy variable y depende de multitud de factores&#46; La relaci&#243;n entre hiperglucemia al ingreso y mortalidad no ha sido establecida en nuestro medio&#46;</p></span><span id="sec0100" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">&#191;Qu&#233; aporta este estudio&#63;</span><p id="par0165" class="elsevierStylePara elsevierViewall">En pacientes con s&#237;ndrome coronario agudo el aumento de la glucemia al ingreso &#40;&#8805; 139<span class="elsevierStyleHsp" style=""></span>mg&#47;dL&#41; se asoci&#243; de forma independiente de otros factores a una mayor mortalidad a los 6 meses&#46;</p><p id="par0170" class="elsevierStylePara elsevierViewall">Los editores</p></span></span>"
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                      "titulo" => "El impacto de la obesidad en el manejo y evoluci&#243;n de la diabetes mellitus"
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                            2 => "R&#46;E&#46; van Gelder"
                            3 => "H&#46;J&#46; Spruijt"
                            4 => "J&#46;W&#46; Twisk"
                            5 => "R&#46;J&#46; Heine"
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                    0 => array:2 [
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                            3 => "H&#46;C&#46; Gerstein"
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                            4 => "H&#46; L&#246;wel"
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                0 => array:2 [
                  "contribucion" => array:1 [
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                      "titulo" => "Niveles de glucemia en pacientes no diab&#233;ticos&#46; &#191;Es un factor pron&#243;stico en el s&#237;ndrome coronario agudo&#63;"
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                            3 => "V&#46; Bod&#237;"
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                            5 => "A&#46; Ll&#225;cer"
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                          "autores" => array:6 [
                            0 => "R&#46; Marfella"
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                            2 => "L&#46; De Angelis"
                            3 => "M&#46; Siniscalchi"
                            4 => "F&#46; Rossi"
                            5 => "D&#46; Giugliano"
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Original
La hiperglucemia como factor de mal pronóstico en el síndrome coronario agudo
Hyperglycaemia as bad prognostic factor in acute coronary syndrome
J.L. Cabrerizo-Garcíaa,
Autor para correspondencia
j_cabrerizo@hotmail.com

Autor para correspondencia.
, J.A. Gimeno-Ornab, B. Zalba-Etayoc, J.I. Pérez-Calvoa
a Servicio de Medicina Interna, Hospital Clínico Universitario Lozano Blesa, Zaragoza, España
b Servicio de Endocrinología y Nutrición, Hospital Clínico Universitario Lozano Blesa, Zaragoza, España
c Unidad de Cuidados Intensivos, Hospital Clínico Universitario Lozano Blesa, Zaragoza, España
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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Introducci&#243;n</span><p id="par0005" class="elsevierStylePara elsevierViewall">La diabetes mellitus &#40;DM&#41; es un s&#237;ndrome caracterizado por trastornos metab&#243;licos generalizados donde la hiperglucemia cr&#243;nica es el factor dominante y el endotelio es el &#243;rgano diana por excelencia&#46; Su prevalencia en Espa&#241;a oscila alrededor del 10&#37;&#46; En el a&#241;o 2025 se estima que habr&#225; entre 300 y 380 millones de pacientes con DM tipo 2 en todo el mundo<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#44;2</span></a>&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">La enfermedad arterioscler&#243;tica&#44; sobre todo a nivel coronario es la principal causa de morbimortalidad y hasta un 80&#37; de los pacientes con DM fallecer&#225;n por esta causa<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a>&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">La detecci&#243;n de hiperglucemia es frecuente en pacientes que ingresan con SCA en probable relaci&#243;n con la liberaci&#243;n de hormonas contrarreguladoras &#40;catecolaminas&#44; glucag&#243;n&#44; cortisol y hormona de crecimiento&#41;&#44; derivadas del estr&#233;s que acompa&#241;a al evento coronario&#46; Diversos estudios en pacientes con SCA han observado una relaci&#243;n entre la aparici&#243;n y severidad de la hiperglucemia y el incremento de la morbimortalidad<a class="elsevierStyleCrossRefs" href="#bib0020"><span class="elsevierStyleSup">4&#8211;6</span></a>&#44; con independencia de tener un diagn&#243;stico previo de DM<a class="elsevierStyleCrossRefs" href="#bib0035"><span class="elsevierStyleSup">7&#8211;10</span></a>&#46; La relaci&#243;n entre la hiperglucemia y el pron&#243;stico del SCA no est&#225; bien definida&#46; La hiperglucemia podr&#237;a ser simplemente un marcador de riesgo&#44; indicando mayor severidad de la enfermedad de base y por ello&#44; un peor pron&#243;stico&#46; No obstante&#44; tambi&#233;n podr&#237;a ser un aut&#233;ntico factor de riesgo para la mala evoluci&#243;n del SCA&#44; ya que la hiperglucemia se ha relacionado con la producci&#243;n de arritmias por alargamiento del intervalo QT<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">11</span></a> con la depresi&#243;n en la fracci&#243;n de eyecci&#243;n<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">12</span></a> o con el incremento del tama&#241;o del infarto por fen&#243;meno de <span class="elsevierStyleItalic">no reflow</span><a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">13</span></a>&#46; La hiperglucemia adem&#225;s amplifica el sustrato inflamatorio y facilita la activaci&#243;n y agregaci&#243;n plaquetaria favoreciendo la disfunci&#243;n endotelial y la trombosis coronaria<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">14</span></a>&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">En este trabajo hemos pretendido confirmar la importancia pron&#243;stica de la hiperglucemia al ingreso sobre la evoluci&#243;n del SCA de alto riesgo con o sin elevaci&#243;n del segmento ST&#44; independientemente del antecedente de DM&#44; y responder a la pregunta de si la hiperglucemia al ingreso se relaciona con el pron&#243;stico de los pacientes que sufren un SCA independientemente de otros factores conocidos&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Pacientes</span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Dise&#241;o</span><p id="par0025" class="elsevierStylePara elsevierViewall">Estudio anal&#237;tico de cohortes prospectivo&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Pacientes</span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Criterios de inclusi&#243;n</span><p id="par0030" class="elsevierStylePara elsevierViewall">Pacientes ingresados consecutivamente en nuestro hospital durante el per&#237;odo comprendido entre enero de 2006 y diciembre de 2007 con diagn&#243;stico de SCA de alto riesgo&#44; tanto con elevaci&#243;n como sin elevaci&#243;n del segmento ST&#44; seg&#250;n los criterios de la ACA&#47;AHA <span class="elsevierStyleItalic">&#40;American College of Cardiology&#47;American Heart Association&#41;</span><a class="elsevierStyleCrossRefs" href="#bib0075"><span class="elsevierStyleSup">15&#44;16</span></a>&#46; Los pacientes recibieron el tratamiento necesario para su proceso patol&#243;gico siguiendo las recomendaciones de las gu&#237;as de las anteriores sociedades cient&#237;ficas&#46;</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Criterios de exclusi&#243;n</span><p id="par0035" class="elsevierStylePara elsevierViewall">Presencia de neoplasia maligna de &#243;rgano s&#243;lido o hematol&#243;gica&#44; s&#237;ndrome febril o sepsis en el momento del estudio&#44; enfermedades autoinmunes o inflamatorias&#44; insuficiencia renal cr&#243;nica en estadio 5 seg&#250;n las gu&#237;as K&#47;DOQI 2002 de la <span class="elsevierStyleItalic">National Kidney Foundation</span><a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">17</span></a> o falta de informaci&#243;n en las variables analizadas&#46; Se excluyeron 31 de los 486 pacientes inicialmente seleccionados&#44; por lo que la muestra final analizada fue de 455 pacientes&#46;</p></span></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Variables del estudio</span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Variables cl&#237;nicas</span><p id="par0040" class="elsevierStylePara elsevierViewall">Edad&#44; sexo&#44; antecedentes personales recogidos en la historia cl&#237;nica previa o al ingreso &#40;hipertensi&#243;n arterial&#44; DM&#44; dislipemia&#44; tabaquismo&#44; insuficiencia cardiaca&#44; infarto agudo de miocardio&#41; frecuencia cardiaca&#44; presi&#243;n arterial sist&#243;lica&#44; presi&#243;n arterial diast&#243;lica y presi&#243;n de pulso&#46; Se realiz&#243; estratificaci&#243;n de riesgo mediante la escala GRACE&#44; en bajo&#44; medio y alto riesgo&#46;</p></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Variables anal&#237;ticas</span><p id="par0045" class="elsevierStylePara elsevierViewall">Glucemia&#44; creatinina &#40;con estimaci&#243;n del filtrado glomerular mediante la f&#243;rmula del estudio MDRD-4<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">17</span></a>&#41;&#44; recuento leucocitario&#44; fibrin&#243;geno&#44; creatincinasa &#40;CK&#41; y&#47;o fracci&#243;n MB de creatincinasa &#40;CK-MB&#41;&#44; y troponina I&#46; Las variables bioqu&#237;micas se obtuvieron con los m&#233;todos espec&#237;ficos del sistema Synchron Lx20pro al ingreso en las dos primeras horas tras la entrada al hospital&#46;</p></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Electrocardiograma</span><p id="par0050" class="elsevierStylePara elsevierViewall">Los pacientes con SCA se clasificaron seg&#250;n las caracter&#237;sticas del segmento ST en tres grupos&#58; normal&#44; descendido o elevado&#46; Se document&#243; la aparici&#243;n de arritmias cardiacas durante la evoluci&#243;n&#46;</p></span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Ecocardiograma</span><p id="par0055" class="elsevierStylePara elsevierViewall">Se determin&#243; la fracci&#243;n de eyecci&#243;n del ventr&#237;culo izquierdo de todos los pacientes durante el ingreso y se clasific&#243; como normal&#44; depresi&#243;n ligera&#44; depresi&#243;n moderada o depresi&#243;n severa&#46;</p></span></span><span id="sec0060" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Definici&#243;n de eventos y seguimiento</span><p id="par0060" class="elsevierStylePara elsevierViewall">El evento principal analizado fue la mortalidad por cualquier causa&#46; El per&#237;odo de seguimiento se limit&#243; a seis meses desde el momento del ingreso&#46; Los datos fueron recogidos mediante historia cl&#237;nica y&#47;o contacto telef&#243;nico con el paciente o sus familiares&#46; En los 455 pacientes se pudieron recoger los datos necesarios para el estudio&#46;</p></span><span id="sec0065" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">An&#225;lisis estad&#237;stico</span><p id="par0065" class="elsevierStylePara elsevierViewall">Las variables continuas fueron expresadas como media<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>desviaci&#243;n est&#225;ndar y las variables cualitativas como distribuci&#243;n de frecuencias&#46; La comparaci&#243;n de variables cuantitativas entre grupos&#44; en caso de seguir una distribuci&#243;n normal se realiz&#243; con el test de <span class="elsevierStyleItalic">t</span> de Student para muestras independientes&#59; en caso de no seguir una distribuci&#243;n normal se emple&#243; el test no param&#233;trico U&#46; de Mann-Whitney&#46; Las variables discretas se compararon mediante la prueba de la Chi cuadrado o el test exacto de Fisher&#46;</p><p id="par0070" class="elsevierStylePara elsevierViewall">La glucemia como variable independiente principal del estudio se clasific&#243; en dos grupos a partir de su mediana&#58; &#60; 139<span class="elsevierStyleHsp" style=""></span>mg&#47;dl y &#8805; 139<span class="elsevierStyleHsp" style=""></span>mg&#47;dl&#46; La representaci&#243;n gr&#225;fica de la supervivencia acumulada para cada categor&#237;a de glucemia se model&#243; mediante curvas de Kaplan-Meier&#44; mientras que la comparaci&#243;n entre dichas categor&#237;as se realiz&#243; 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La glucemia media al ingreso fue de 163&#44;3<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>71&#44;8<span class="elsevierStyleHsp" style=""></span>mg&#47;dl con un m&#225;ximo de 522<span class="elsevierStyleHsp" style=""></span>mg&#47;dl y un m&#237;nimo de 43<span class="elsevierStyleHsp" style=""></span>mg&#47;dl&#46; Los pacientes con hiperglucemia al ingreso &#40;&#8805; 139<span class="elsevierStyleHsp" style=""></span>mg&#47;dL&#41; eran con mayor frecuencia del sexo femenino&#44; ten&#237;an una edad m&#225;s avanzada y una mayor prevalencia de antecedentes de hipertensi&#243;n arterial y DM&#46; Por el contrario&#44; la prevalencia de hiperglucemia fue inferior en los fumadores&#46; La presencia de hiperglucemia se asoci&#243; a una frecuencia cardiaca m&#225;s elevada&#44; a un mayor riesgo de SCA con elevaci&#243;n del segmento ST&#44; a una menor fracci&#243;n de eyecci&#243;n&#44; a un riesgo m&#225;s elevado &#40;escala GRACE&#41; y a una mayor incidencia de arritmias&#46; Adem&#225;s hubo una relaci&#243;n significativa con un mayor recuento leucocitario al ingreso y con un menor filtrado glomerular calculado &#40;<a class="elsevierStyleCrossRef" href="#tbl0010">tabla 2</a>&#41; lo que concuerda con los resultados de otros trabajos<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">18</span></a>&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><elsevierMultimedia ident="tbl0010"></elsevierMultimedia></span><span id="sec0080" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Hiperglucemia como factor pron&#243;stico</span><p id="par0090" class="elsevierStylePara elsevierViewall">La supervivencia media en los 6 meses siguientes al SCA fue de 165<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>49 d&#237;as &#40;mediana 180 d&#237;as&#59; rango&#58; 1-180 d&#237;as&#41;&#46; Se registraron 47 fallecimientos &#40;10&#44;3&#37;&#41;&#59; las causas m&#225;s frecuentes fueron&#58; shock cardiog&#233;nico &#40;68&#44;1&#37;&#41;&#44; seguido de rotura cardiaca &#40;8&#44;5&#37;&#41; y de fibrilaci&#243;n ventricular no controlada &#40;2&#44;1&#37;&#41;&#46; Las variables relacionadas con la mortalidad est&#225;n recogidas en la <a class="elsevierStyleCrossRef" href="#tbl0015">tabla 3</a>&#46; En el grupo de fallecidos la glucemia media fue de 190<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>79<span class="elsevierStyleHsp" style=""></span>mg&#47;dl frente a 160<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>71<span class="elsevierStyleHsp" style=""></span>mg&#47;dl en el de no fallecidos &#40;p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;003&#41;&#46; Otros predictores de mortalidad fueron el sexo femenino&#44; la edad&#44; las constantes medidas al ingreso &#40;incremento de frecuencia cardiaca y descenso de presi&#243;n arterial sist&#243;lica y diast&#243;lica&#41;&#44; los antecedentes de ausencia de tabaquismo y presencia de DM e infarto previo&#44; la hiperfibrinogenemia&#44; el descenso del filtrado glomerular&#44; la fracci&#243;n de eyecci&#243;n severamente deprimida&#44; la presencia de arritmias y la pertenencia al grupo de alto riesgo seg&#250;n la escala GRACE&#46;</p><elsevierMultimedia ident="tbl0015"></elsevierMultimedia><p id="par0095" class="elsevierStylePara elsevierViewall">En la curva de Kaplan-Meier se observa la menor supervivencia de los pacientes con hiperglucemia en el momento del ingreso &#40;<a class="elsevierStyleCrossRef" href="#fig0005">fig&#46; 1</a>&#41;&#46; La presencia de hiperglucemia increment&#243; de modo significativo la mortalidad &#40;14&#44;9 vs 5&#44;7&#37;&#41; con un HR<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>2&#44;7&#59; IC 95&#37;&#58; 1&#44;4-5&#44;2&#59; p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;002&#41;&#46; En an&#225;lisis multivariante &#40;ajustado para edad&#44; sexo&#44; antecedentes de tabaquismo&#44; DM o infarto previo&#44; frecuencia cardiaca y presi&#243;n arterial sist&#243;lica al ingreso&#44; filtrado glomerular&#44; niveles de leucocitos y fibrin&#243;geno&#44; morfolog&#237;a del segmento ST&#44; fracci&#243;n de eyecci&#243;n y gravedad seg&#250;n la clasificaci&#243;n de GRACE&#41;&#44; la hiperglucemia tambi&#233;n fue un predictor significativo de mortalidad &#40;HR<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>2&#44;98&#59; IC 95&#37;&#58; 1&#44;06-8&#44;4&#59; p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;039&#41;&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0100" class="elsevierStylePara elsevierViewall">El mejor modelo predictivo de mortalidad tras la aplicaci&#243;n de procedimiento de exclusi&#243;n secuencial fue el formado por las variables recogidas en la <a class="elsevierStyleCrossRef" href="#tbl0020">tabla 4</a>&#44; listadas seg&#250;n su poder predictivo&#46; El principal factor predictivo de mortalidad fue la depresi&#243;n severa de la fracci&#243;n de eyecci&#243;n&#46; La presencia de hiperglucemia al ingreso tambi&#233;n fue un predictor independiente de mortalidad&#46;</p><elsevierMultimedia ident="tbl0020"></elsevierMultimedia></span></span><span id="sec0085" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Discusi&#243;n</span><p id="par0105" class="elsevierStylePara elsevierViewall">En nuestro trabajo hemos confirmado que la hiperglucemia al ingreso es un factor pron&#243;stico negativo en la evoluci&#243;n de los pacientes con SCA&#46; Adem&#225;s su poder predictivo es independiente de otros factores pron&#243;sticos y de la existencia de un diagn&#243;stico previo de DM&#46;</p><p id="par0110" class="elsevierStylePara elsevierViewall">Seg&#250;n nuestros resultados&#44; el 50&#37; de los pacientes presentaron glucemias al ingreso &#8805; 139<span class="elsevierStyleHsp" style=""></span>mg&#47;dL&#44; a pesar de que tan solo el 21&#44;8&#37; ten&#237;an DM conocida&#46; Estos datos son equivalentes a los de otros trabajos donde tambi&#233;n se ha constatado que la hiperglucemia aguda es un fen&#243;meno com&#250;n en el SCA<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">19</span></a>&#46; A pesar de haberse comprobado su asociaci&#243;n con un peor pron&#243;stico&#44; tanto a corto como a largo plazo<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a>&#44; la hiperglucemia ha sido infravalorada y deficientemente tratada&#46; En la muestra recogida podemos ver que los pacientes que fallec&#237;an ten&#237;an al ingreso cifras m&#225;s altas de glucemia y que la presencia de cifras de glucemia superiores a la mediana pr&#225;cticamente triplicaban el riesgo de mortalidad&#46;</p><p id="par0115" class="elsevierStylePara elsevierViewall">Parece que la hiperglucemia no s&#243;lo es un marcador&#44; sino tambi&#233;n un mediador&#44; en la aparici&#243;n de eventos cardiovasculares adversos y de mortalidad&#46; En este trabajo hallamos una clara asociaci&#243;n entre hiperglucemia al ingreso&#44; elevaci&#243;n de marcadores inflamatorios &#40;leucocitosis&#41; y mayor prevalencia de reconocidos factores pron&#243;sticos negativos en la evoluci&#243;n del SCA &#40;la edad m&#225;s avanzada&#44; la estratificaci&#243;n de alto riesgo seg&#250;n la escala GRACE&#44; los antecedentes de DM&#44; la presencia al ingreso de mayor frecuencia cardiaca y de mayor prevalencia de elevaci&#243;n del segmento ST&#44; la fracci&#243;n de eyecci&#243;n m&#225;s reducida y el menor filtrado glomerular&#41;&#59; por el contrario&#44; la proporci&#243;n de fumadores activos era inferior en los pacientes con hiperglucemia&#46; A pesar de la diferencia entre los grupos&#44; el ajuste multivariante no atenu&#243; el impacto pron&#243;stico perjudicial de la hiperglucemia&#46;</p><p id="par0120" class="elsevierStylePara elsevierViewall">Nuestros datos apoyan la hip&#243;tesis de que la hiperglucemia al ingreso puede ejercer un da&#241;o cardiovascular durante el SCA&#46; En los &#250;ltimos a&#241;os se han identificado diversos mecanismos responsables que podr&#237;an justificar estos resultados&#46; La hiperglucemia induce un incremento de la respuesta inflamatoria y del estr&#233;s oxidativo generando aniones super&#243;xido a nivel mitocondrial&#46; &#201;stos promueven lesi&#243;n&#44; disfunci&#243;n y apoptosis de c&#233;lulas endoteliales a trav&#233;s de mediadores secundarios o de la transcripci&#243;n de diferentes factores<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">20</span></a>&#46; Adem&#225;s Monnier L et al<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">21</span></a> observaron que el da&#241;o inducido por la hiperglucemia a trav&#233;s del estr&#233;s oxidativo es mayor en las fluctuaciones agudas que en un estado de hiperglucemia mantenida&#44; por lo que la toxicidad podr&#237;a ser mayor en pacientes con hiperglucemia de estr&#233;s que en diab&#233;ticos que mantienen valores permanentemente elevados<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">22</span></a>&#46; De hecho&#44; en nuestro trabajo el antecedente de DM conocida antes del SCA no fue predictivo de mortalidad en an&#225;lisis multivariante&#46;</p><p id="par0125" class="elsevierStylePara elsevierViewall">La hiperglucemia aguda produce una situaci&#243;n de insulinopenia relativa lo cual induce lipolisis y la liberaci&#243;n de &#225;cidos grasos libres&#44; cuya oxidaci&#243;n tambi&#233;n genera aniones super&#243;xido&#46; Adem&#225;s&#44; estos &#225;cidos grasos oxidados dificultan el transporte de glucosa al interior de la c&#233;lula mioc&#225;rdica a trav&#233;s del transportador GLUT-4&#44; y por tanto&#44; reducen el sustrato energ&#233;tico de la misma&#46; Teniendo en cuenta que la necesidad de ox&#237;geno por mol&#233;cula de adenos&#237;n trifosfato &#40;ATP&#41; es mayor en la oxidaci&#243;n de &#225;cidos grasos que en la de glucosa&#44; finalmente se genera un estado de mayor demanda de ox&#237;geno para la obtenci&#243;n de energ&#237;a&#44; lo que agrava el contexto de isquemia aguda<a class="elsevierStyleCrossRefs" href="#bib0115"><span class="elsevierStyleSup">23&#44;24</span></a>&#46; Shivu GN et al<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">25</span></a> demostraron en pacientes j&#243;venes con DM 1 de menos de 5 a&#241;os de evoluci&#243;n y sin complicaciones microvasculares previas&#44; alteraciones en los mecanismos de obtenci&#243;n de energ&#237;a mioc&#225;rdicos&#44; medidos a trav&#233;s de una disminuci&#243;n del ratio fosfocreatina&#47;&#947;-ATP&#59; esta alteraci&#243;n estar&#237;a relacionada con el desarrollo de la disfunci&#243;n contr&#225;ctil que justificar&#237;a la aparici&#243;n de insuficiencia cardiaca&#46; El peor pron&#243;stico del SCA podr&#237;a pues justificarse por la profunda crisis metab&#243;lica inducida por la hiperglucemia&#46;</p><p id="par0130" class="elsevierStylePara elsevierViewall">Otros factores predictivos de mal pron&#243;stico fueron de forma no sorprendente&#44; la edad avanzada&#44; el sexo masculino&#44; la disfunci&#243;n ventricular y el descenso inicial de la presi&#243;n arterial&#46; M&#225;s dif&#237;cil de explicar fue el factor protector del tabaquismo &#40;aunque hay que tener en cuenta que solo recogimos el tabaquismo activo&#44; no los ex-fumadores&#41; y del sexo femenino &#40;especialmente teniendo en cuenta que en an&#225;lisis univariante el riesgo era superior en las mujeres&#44; aunque el limitado tama&#241;o de la muestra gener&#243; una marcada desproporci&#243;n entre distintos factores de riesgo&#41;&#46;</p><p id="par0135" class="elsevierStylePara elsevierViewall">Aunque est&#225; por confirmar definitivamente el beneficio del tratamiento intensivo de la hiperglucemia en el contexto del SCA&#44; el an&#225;lisis de datos secundarios ha comprobado el descenso de la mortalidad a los 6 meses en los pacientes con glucemias por debajo de 140<span class="elsevierStyleHsp" style=""></span>mg&#47;dl&#44; independientemente del tratamiento a que fueron asignados<a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">26</span></a>&#46; Estos datos reforzar&#237;an las observaciones realizadas en nuestro medio&#46;</p><p id="par0140" class="elsevierStylePara elsevierViewall">Como limitaciones del estudio debemos mencionar el restringido n&#250;mero de pacientes y el no haber recogido cifras de glucemia durante el ingreso&#46; No obstante&#44; las cifras de glucemia en el momento del ingreso y durante el mismo son igualmente predictivas<a class="elsevierStyleCrossRef" href="#bib0135"><span class="elsevierStyleSup">27</span></a>&#46; La determinaci&#243;n de la hemoglobina glicosilada hubiera sido interesante para discriminar si los pacientes con hiperglucemia al ingreso&#44; considerados no diab&#225;ticos&#44; padec&#237;an o no diabetes antes del ingreso&#46; La ventaja de nuestro trabajo fue que conseguimos ajustar el an&#225;lisis multivariante para las principales variables que podr&#237;an haber mediado la asociaci&#243;n entre hiperglucemia y mortalidad&#46;</p><p id="par0145" class="elsevierStylePara elsevierViewall">Los resultados que se derivan de este trabajo apoyan una relaci&#243;n directa entre la hiperglucemia al ingreso de un evento coronario agudo y la mortalidad&#46; Por lo tanto&#44; parece razonable tratar de restablecer lo antes posible la normoglucemia en estos pacientes&#44; para conseguir una evoluci&#243;n m&#225;s favorable e incrementar la supervivencia tras un SCA&#46; Quedan por identificar nuevos mecanismos responsables&#44; demostrar la seguridad y efectividad de un control intensivo de la glucemia sobre el pron&#243;stico del SCA especialmente cuando evoluciona a insuficiencia card&#237;aca<a class="elsevierStyleCrossRef" href="#bib0140"><span class="elsevierStyleSup">28</span></a> y definir nuevos objetivos terap&#233;uticos&#44; tanto en pacientes diab&#233;ticos como en no diab&#233;ticos que sufren un evento coronario agudo&#46;</p></span><span id="sec0090" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Conflicto de intereses</span><p id="par0150" class="elsevierStylePara elsevierViewall">Los autores declaran no tener ning&#250;n conflicto de intereses&#46;<elsevierMultimedia ident="tb0005"></elsevierMultimedia></p></span></span>"
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        "resumen" => "<span class="elsevierStyleSectionTitle">Objetivo</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">La hiperglucemia es una observaci&#243;n frecuente en el s&#237;ndrome coronario agudo &#40;SCA&#41;&#46; Hemos analizado la relaci&#243;n existente entre la hiperglucemia al ingreso y el pron&#243;stico de los pacientes que ha sufrido un SCA&#46;</p> <span class="elsevierStyleSectionTitle">Material y m&#233;todos</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Estudio prospectivo de 455 pacientes con SCA con y sin elevaci&#243;n del segmento ST de alto riesgo &#40;criterios de la ACA&#47;AHA&#41;&#46; Dividimos la muestra seg&#250;n la mediana de la glucemia al ingreso en &#60; 139<span class="elsevierStyleHsp" style=""></span>mg&#47;dl y &#8805; 139<span class="elsevierStyleHsp" style=""></span>mg&#47;dl&#44; y observamos variables anal&#237;ticas&#44; electrocardiogr&#225;ficas&#44; ecocardiogr&#225;ficas y epidemiol&#243;gicas&#46; Mediante un an&#225;lisis de riesgos proporcionales de Cox se analiz&#243; su relaci&#243;n con la mortalidad como variable principal en los siguientes seis meses al evento&#46;</p> <span class="elsevierStyleSectionTitle">Resultados</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">La edad media fue de 64&#44;3<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>12&#44;7 a&#241;os&#44; el 80&#44;4&#37; eran varones y el 21&#44;8&#37; hab&#237;an sido diagnosticados de diabetes&#46; La glucemia media al ingreso fue de 163<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>72<span class="elsevierStyleHsp" style=""></span>mg&#47;dL&#46; Un total de 47 pacientes fallecieron &#40;10&#44;3&#37;&#41;&#46; La glucemia media de los que fallecieron fue de 190<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>79<span class="elsevierStyleHsp" style=""></span>mg&#47;dl frente a 160<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>70<span class="elsevierStyleHsp" style=""></span>mg&#47;dl en los supervivientes &#40;p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;003&#41;&#46; Aquellos que presentaban al ingreso hiperglucemia &#40;&#8805; 139<span class="elsevierStyleHsp" style=""></span>mg&#47;dL&#41; tuvieron una mayor mortalidad &#40;<span class="elsevierStyleItalic">Hazard ratio</span> &#91;HR&#93;<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>2&#44;98&#59; intervalo de confianza &#91;IC&#93; 95&#37;&#58; 1&#44;06-8&#44;4&#59; p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;039&#41;&#46; La edad avanzada&#44; el sexo masculino&#44; la disfunci&#243;n ventricular y el descenso inicial de la presi&#243;n arterial tambi&#233;n mostraron relaci&#243;n independiente con la mortalidad&#46;</p> <span class="elsevierStyleSectionTitle">Conclusiones</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">La hiperglucemia al ingreso &#8805; 139<span class="elsevierStyleHsp" style=""></span>mg&#47;dl en pacientes con SCA se asocia a un mayor riesgo de fallecer en los pr&#243;ximos seis meses&#44; independientemente del antecedente de diabetes y otros factores de riesgo conocidos&#46;</p>"
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        "titulo" => "Abstract"
        "resumen" => "<span class="elsevierStyleSectionTitle">Objective</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Hyperglycemia is a frequent observation in the acute coronary syndrome&#46; We analyzed the relationship between hyperglycemia on admission and patients with acute coronary syndrome&#46;</p> <span class="elsevierStyleSectionTitle">Material and methods</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Prospective study of 455 patients with acute coronary syndrome with and without elevation of ST segment with high risk according to ACA&#47;AHA criteria&#46; We divided the sample according to the median glycemia on admission into &#60;139<span class="elsevierStyleHsp" style=""></span>mg&#47;dl and &#8805;139<span class="elsevierStyleHsp" style=""></span>mg&#47;dl&#46; We studied the analytic&#44; electrocardiography&#44; echocardiography and epidemiologic variables&#46; Using the Cox Proportional Hazard Model&#44; we analyzed their relationship with the mortality as principal variable during a six-month period after the acute coronary syndrome&#46;</p> <span class="elsevierStyleSectionTitle">Results</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Mean age was 64&#46;3<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>12&#46;7 years&#44; 80&#46;4&#37; were male and 21&#46;8&#37; had been diagnosed with diabetes&#46; Mean glycemia on admission was 163&#46;3<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>71&#46;8<span class="elsevierStyleHsp" style=""></span>mg&#47;dl&#46; Forty-seven patients died &#40;10&#46;3&#37;&#41;&#44; Mean glycemia of those who had died was 189&#46;8<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>78&#46;8<span class="elsevierStyleHsp" style=""></span>mg&#47;dl compared to 160&#46;3<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>70&#46;4<span class="elsevierStyleHsp" style=""></span>mg&#47;dl in the survival group &#40;<span class="elsevierStyleItalic">P</span>&#61;0&#46;003&#41;&#46; Patients with hyperglycemia on admission &#8805;139<span class="elsevierStyleHsp" style=""></span>mg&#47;dl had higher mortality&#44; hazard ratio &#40;HR&#41;&#61;2&#46;98 &#40;confidence interval &#91;CI 95&#37;&#93;&#58; 1&#46;06-8&#46;4&#59; <span class="elsevierStyleItalic">P</span>&#61;0&#46;039&#41;&#46; Elderly patients&#44; being a male&#44; having ventricular dysfunction and initial decrease of blood pressure also showed an independent relationship with mortality&#46;</p> <span class="elsevierStyleSectionTitle">Conclusions</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">Hyperglycemia on admission &#8805;139<span class="elsevierStyleHsp" style=""></span>mg&#47;dl in acute coronary syndrome patients is associated with a higher risk of death in the following six months&#44; independently of diabetes or other risk factors known&#46;</p>"
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                  \t\t\t\t">77&#44;5<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>21&#44;3&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Presi&#243;n arterial sist&#243;lica &#40;mmHg&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">135&#44;4<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>27&#44;9&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Presi&#243;n arterial diast&#243;lica &#40;mmHg&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">79&#44;4<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>17&#44;5&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">55&#44;7<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>18&#44;9&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t">292 &#40;64&#44;2&#37;&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Segmento ST descendido&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t">94 &#40;20&#44;7&#37;&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Segmento ST isoel&#233;ctrico&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">69 &#40;15&#44;2&#37;&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " colspan="2" 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
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>FE conservada &#40;<span class="elsevierStyleUnderline">&#62;</span> 50&#37;&#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="char" valign="\n
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                  \t\t\t\t">256 &#40;63&#44;7&#37;&#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  " align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>FE ligeramente deprimida &#40;40-50&#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="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">82 &#40;20&#44;4&#37;&#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\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>FE moderadamente deprimida &#40;30-40&#37;&#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="char" valign="\n
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                  \t\t\t\t">47 &#40;11&#44;7&#37;&#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\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>FE severamente deprimida &#40;&#60; 30&#37;&#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="char" valign="\n
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                  \t\t\t\t">17&#40;4&#44;2&#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  " colspan="2" align="left" valign="\n
                  \t\t\t\t\ttop\n
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                  \t\t\t\t"><span class="elsevierStyleItalic">Estratificaci&#243;n de riesgo GRACE n&#46;&#176; &#40;&#37;&#41;</span><a class="elsevierStyleCrossRef" href="#tblfn0005"><span class="elsevierStyleSup">a</span></a></td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>GRACE Alto &#40;&#8805; 118 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="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">83 &#40;18&#44;2&#37;&#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  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>GRACE Medio &#40;89-118 puntos&#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  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">12&#44;8&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">16&#44;7&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#44;149&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="4" 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="4" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Exploraci&#243;n f&#237;sica</span></td></tr><tr title="table-row"><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="elsevierStyleHsp" style=""></span>Frecuencia cardiaca &#40;lpm&#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">74&#44;2<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>17&#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">80&#44;7<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>24&#44;2&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;001&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  " 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;&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">134&#44;1<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>25&#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">136&#44;8<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>30&#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">0&#44;293&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  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Presi&#243;n arterial diast&#243;lica &#40;mmHg&#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">79&#44;4<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>16&#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">79&#44;5<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>18&#44;2&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;951&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  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Presi&#243;n de pulso &#40;mmHg&#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">54&#44;3<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>17&#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">57&#44;1<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>20&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;125&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  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Segmento ST elevado&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">57&#44;3&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">71&#44;1&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#44;004&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  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>FE severamente deprimida &#40;&#60; 30&#37;&#41;<a class="elsevierStyleCrossRef" href="#tblfn0020"><span class="elsevierStyleSup">a</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2&#44;6&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">5&#44;8&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#44;014&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  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>GRACE alto &#40;&#8805; 118 puntos&#41;<a class="elsevierStyleCrossRef" href="#tblfn0025"><span class="elsevierStyleSup">b</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">12&#44;8&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">23&#44;9&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#60; 0&#44;001&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  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Arritmias&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">21&#44;1&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">26&#44;8&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#44;098&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="4" 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="4" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Alteraciones anal&#237;ticas</span></td></tr><tr title="table-row"><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="elsevierStyleHsp" style=""></span>Enzimas cardiacas elevadas &#40;CK&#44; CK-MB&#41;<a class="elsevierStyleCrossRef" href="#tblfn0030"><span class="elsevierStyleSup">c</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">79&#44;1&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">86&#44;3&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#44;028&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  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Troponina I elevada<a class="elsevierStyleCrossRef" href="#tblfn0035"><span class="elsevierStyleSup">d</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">98&#44;2&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">98&#44;2&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#44;636&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  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Recuento leucocitario &#40;cell&#47;mm<span class="elsevierStyleSup">3</span>&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">10&#46;448&#44;5<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>3&#46;482&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;862&#44;9<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>4563&#44;2&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="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#60; 0&#44;001&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  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Fibrin&#243;geno &#40;mg&#47;dl&#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">408&#44;4<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>139&#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">430&#44;3<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>138&#44;3&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="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#44;100&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  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Funci&#243;n renal &#8211;MDRD-4 &#40;mL&#47;min&#47;1&#44;73 m<span class="elsevierStyleSup">2</span>&#41;&#8211;&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">82&#44;6<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>26&#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">71&#44;8<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>24&#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="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#60; 0&#44;001&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  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Mortalidad&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&#44;7&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">14&#44;9&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#44;001&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
              ]
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            0 => array:3 [
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Presi&#243;n arterial diast&#243;lica &#40;mmHg&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">48&#37;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">0&#44;000&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">0&#44;172 &#40;0&#44;07-0&#44;4&#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">27&#44;7&#37;&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">13&#44;2&#37;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Frecuencia cardiaca &#40;lpm&#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="char" valign="\n
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                  \t\t\t\t">84&#44;9<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>23&#44;5&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="char" valign="\n
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                  \t\t\t\t">76&#44;6<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>21&#44;0&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="char" valign="\n
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                  \t\t\t\t">0&#44;008&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="char" valign="\n
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                  \t\t\t\t">1&#44;014&#40;1&#44;003-1&#44;025&#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="elsevierStyleHsp" style=""></span>Presi&#243;n arterial sist&#243;lica &#40;mmHg&#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="char" valign="\n
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                  \t\t\t\t">125&#44;1<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>26&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">136&#44;6<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>28&#44;0&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="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#44;005&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>Presi&#243;n arterial diast&#243;lica &#40;mmHg&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">0&#44;004&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">0&#44;976 &#40;0&#44;96-0&#44;99&#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="elsevierStyleHsp" style=""></span>FE severamente deprimida &#40;&#60; 30&#37;&#41;<a class="elsevierStyleCrossRef" href="#tblfn0040"><span class="elsevierStyleSup">a</span></a>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">30&#44;3&#37;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">1&#44;9&#37;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>GRACE alto &#40;&#8805; 118 puntos&#41;<a class="elsevierStyleCrossRef" href="#tblfn0045"><span class="elsevierStyleSup">b</span></a>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">12&#44;3&#37;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">&#60; 0&#44;001&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Funci&#243;n renal &#8211;MDRD-4 &#40;mL&#47;min&#47;1&#44;73m<span class="elsevierStyleSup">2</span>&#41;&#8211;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t" style="border-bottom: 2px solid black">Inferior&nbsp;\t\t\t\t\t\t\n
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          "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0095" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">&#191;Qu&#233; sabemos&#63;</span><p id="par0160" class="elsevierStylePara elsevierViewall">El pron&#243;stico de los pacientes con s&#237;ndrome coronario agudo es muy variable y depende de multitud de factores&#46; La relaci&#243;n entre hiperglucemia al ingreso y mortalidad no ha sido establecida en nuestro medio&#46;</p></span><span id="sec0100" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">&#191;Qu&#233; aporta este estudio&#63;</span><p id="par0165" class="elsevierStylePara elsevierViewall">En pacientes con s&#237;ndrome coronario agudo el aumento de la glucemia al ingreso &#40;&#8805; 139<span class="elsevierStyleHsp" style=""></span>mg&#47;dL&#41; se asoci&#243; de forma independiente de otros factores a una mayor mortalidad a los 6 meses&#46;</p><p id="par0170" class="elsevierStylePara elsevierViewall">Los editores</p></span></span>"
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                      "titulo" => "El impacto de la obesidad en el manejo y evoluci&#243;n de la diabetes mellitus"
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                            2 => "R&#46;E&#46; van Gelder"
                            3 => "H&#46;J&#46; Spruijt"
                            4 => "J&#46;W&#46; Twisk"
                            5 => "R&#46;J&#46; Heine"
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                    0 => array:2 [
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                            3 => "H&#46;C&#46; Gerstein"
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                            4 => "H&#46; L&#246;wel"
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                0 => array:2 [
                  "contribucion" => array:1 [
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                      "titulo" => "Niveles de glucemia en pacientes no diab&#233;ticos&#46; &#191;Es un factor pron&#243;stico en el s&#237;ndrome coronario agudo&#63;"
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                            3 => "V&#46; Bod&#237;"
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                            5 => "A&#46; Ll&#225;cer"
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                          "autores" => array:6 [
                            0 => "R&#46; Marfella"
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                            2 => "L&#46; De Angelis"
                            3 => "M&#46; Siniscalchi"
                            4 => "F&#46; Rossi"
                            5 => "D&#46; Giugliano"
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