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as&#237; como las tendencias observadas en el tratamiento al alta y mortalidad &#8211;por cualquier causa&#8211; intrahospitalaria y al a&#241;o de seguimiento&#46;</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Material y m&#233;todos</span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Tipo de estudio</span><p id="par0045" class="elsevierStylePara elsevierViewall">Observacional&#44; retrospectivo y unic&#233;ntrico &#40;pacientes atendidos en el Hospital Don Benito-Villanueva en el per&#237;odo 2000-2009&#41;&#46; Con motivo del an&#225;lisis consideramos <span class="elsevierStyleItalic">a priori</span> la estratificaci&#243;n de la cohorte total en 4 per&#237;odos iguales de 30 meses de duraci&#243;n cada uno&#44; en funci&#243;n del momento del ingreso hospitalario&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Poblaci&#243;n de referencia</span><p id="par0050" class="elsevierStylePara elsevierViewall">El &#193;rea Sanitaria de Don Benito-Villanueva de la Serena est&#225; situada al este de la provincia de Badajoz&#59; su poblaci&#243;n es de 141&#46;337 habitantes &#40;69&#46;962 varones&#41;&#46;</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Poblaci&#243;n estudiada</span><p id="par0055" class="elsevierStylePara elsevierViewall">Se reclutaron todos los individuos con diagn&#243;stico principal al alta de IC &#40;c&#243;digo&#58; 428 de la CIE-9&#41; en el &#225;rea sanitaria de Don Benito-Villanueva y que fueran ingresados consecutivamente desde el 1 de enero de 2000 hasta el 31 de diciembre de 2009 en el Hospital Don Benito Villanueva&#44; &#250;nico hospital del &#225;rea con ingreso de pacientes hasta noviembre de 2008&#46; Se trata de es una poblaci&#243;n atendida en un centro hospitalario de car&#225;cter secundario o comarcal&#46;</p><p id="par0060" class="elsevierStylePara elsevierViewall">Las fuentes de informaci&#243;n fueron el Servicio de Codificaci&#243;n e Inform&#225;tica del Hospital Don Benito-Villanueva y el &#237;ndice nacional de defunciones &#40;IND&#41;&#46;</p><p id="par0065" class="elsevierStylePara elsevierViewall">Se obtuvieron datos de la mortalidad al a&#241;o por confrontaci&#243;n de base hospitalaria con el IND&#44; en la totalidad de los pacientes &#40;100&#37;&#41;&#46; Este estudio fue aprobado por el comit&#233; de &#233;tica del Hospital Universitario Infanta Cristina de Badajoz&#46;</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Variables</span><p id="par0070" class="elsevierStylePara elsevierViewall">De la historia cl&#237;nica se recogi&#243; informaci&#243;n demogr&#225;fica detallada&#58; sexo&#44; edad&#44; antecedentes de enfermedad cardiovascular &#40;AECV&#41;&#44; infarto de miocardio &#40;IM&#41;&#44; enfermedad arterial perif&#233;rica &#40;EAP&#41; e ictus&#44; comorbilidad&#58; enfermedad pulmonar obstructiva cr&#243;nica &#40;EPOC&#41;&#44; insuficiencia renal cr&#243;nica &#40;IRC&#41; y neoplasias&#46; Factores de riesgo cardiovascular&#58; HTA&#44; diabetes mellitus &#40;DM&#41;&#44; hipercolesterolemia &#40;HCOL&#41; y tabaquismo&#44; ritmo basal electrocardiogr&#225;fico y trastornos de la conducci&#243;n&#46; D&#237;as de hospitalizaci&#243;n&#46; Atenci&#243;n de internista o cardi&#243;logo durante la hospitalizaci&#243;n&#46; Tratamiento farmacol&#243;gico al alta&#58; antiagregantes plaquetarios &#40;aspirina&#44; trifusal&#44; clopidogrel&#44; ticlopidina&#41;&#44; heparina&#44; dicumar&#237;nicos&#44; estatinas&#44; bloqueadores beta&#44; antagonistas c&#225;lcicos&#44; nitratos&#44; inhibidores del enzima convertidor de angiotensina &#40;IECA&#41;&#44; bloqueadores del receptor tipo 1 de angiotensina 2 &#40;ARA-<span class="elsevierStyleSmallCaps">ii</span>&#41;&#44; digoxina&#44; amiodarona&#44; diur&#233;ticos&#46; Mortalidad hospitalaria&#44; a los 28 d&#237;as y al a&#241;o del alta&#46;</p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Control de calidad</span><p id="par0075" class="elsevierStylePara elsevierViewall">Para garantizar la calidad de los datos todos los investigadores que participaron en el estudio fueron entrenados y acreditados en el centro coordinador del estudio&#46; Se realiz&#243; un control de la concordancia en el proceso de clasificaci&#243;n diagn&#243;stica mediante la evaluaci&#243;n de 40 casos patr&#243;n &#40;10 repetidos&#41; por todos los codificadores&#46; Se calcularon los &#237;ndices kappa intra e interobservador y se requiri&#243; que fueran superiores a 0&#44;90 en todos ellos y en ambos casos&#46;</p></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">An&#225;lisis estad&#237;stico</span><p id="par0080" class="elsevierStylePara elsevierViewall">Las variables categ&#243;ricas se presentaron como frecuencia absoluta y relativa&#44; y se compararon en los 4 grupos &#40;seg&#250;n fecha de ingreso&#41; mediante la prueba de Chi-cuadrado bajo la hip&#243;tesis nula de tendencia lineal&#46; Para evaluar la supervivencia se eligi&#243; el m&#233;todo de Kaplan-Meier&#44; compar&#225;ndose los estratos mediante la prueba de tendencias&#46; Las variables asociadas a la ocurrencia de mortalidad por cualquier causa a un a&#241;o se estudiaron mediante el <span class="elsevierStyleItalic">hazard ratio</span> &#40;HR&#41; no ajustado en modelo de remisi&#243;n de Cox&#46; Las variables que se consideraron &#243;ptimas para ser introducidas en el modelo final deb&#237;an cumplir al menos una de las siguientes&#58; <span class="elsevierStyleItalic">1&#41;</span> Asociaci&#243;n no ajustada a la ocurrencia de muerte por cualquier causa y valor de p<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#44;20 &#40;bajo este criterio se seleccionaron&#58; edad&#44; HTA&#44; tabaquismo activo&#44; dislipemia&#44; obesidad&#44; EPOC&#44; ictus&#44; IRC&#44; anticoagulantes&#44; bloqueadores beta&#44; IECA&#44; ARA-<span class="elsevierStyleSmallCaps">ii</span>&#44; estatinas&#41;&#59; <span class="elsevierStyleItalic">2&#41;</span> Variables consideradas de importancia pron&#243;stica por estudios previos &#40;DM&#44; fibrilaci&#243;n auricular&#41;&#44; o <span class="elsevierStyleItalic">3&#41;</span> Aquellas que no se incluyeran en las categor&#237;as previas&#44; pero que cambiaran de forma sustancial &#40;20&#37;&#41; el HR&#46; En todos los casos se eligi&#243; el m&#233;todo &#171;introducir&#187;&#46; Asimismo evaluamos la discriminaci&#243;n del modelo mediante una curva <span class="elsevierStyleItalic">Receiver Operating Characteristic</span> y la calibraci&#243;n mediante la prueba de Hosmer-Lemeshow&#46; Para asegurar la robustez de los predictores de mortalidad&#44; se calcularon los intervalos de confianza &#40;IC&#41; al 95&#37; de los mismos mediante an&#225;lisis con remuestreo <span class="elsevierStyleItalic">&#40;bootstrapping&#41;</span> con 3&#46;000 replicaciones&#46; Se utiliz&#243; el paquete estad&#237;stico SPSS<span class="elsevierStyleSup">&#174;</span> v 17&#46;0 y STATA<span class="elsevierStyleSup">&#174;</span> 9&#46;1&#46;</p></span></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Resultados</span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Caracter&#237;sticas basales de la poblaci&#243;n incluida y su evoluci&#243;n temporal</span><p id="par0085" class="elsevierStylePara elsevierViewall">Se incluyeron 2&#46;220 pacientes&#46; La edad media fue de 76&#44;3 &#40;DE<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>10&#44;1&#41; a&#241;os y el 53&#44;9&#37; fueron mujeres&#46; Las caracter&#237;sticas basales de la muestra se presentan en la <a class="elsevierStyleCrossRef" href="#tbl0005">tabla 1</a>&#46; La media de hospitalizaci&#243;n fue 8&#44;55 d&#237;as &#40;DE<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>5&#44;90&#41;&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0090" class="elsevierStylePara elsevierViewall">Los pacientes fueron atendidos en su gran mayor&#237;a por m&#233;dicos internistas &#40;86&#44;4&#37;&#41;&#44; no se registraron diferencias en cuanto a prescripci&#243;n farmacol&#243;gica al alta&#44; aunque si en cuanto a su significativa mayor edad &#40;77&#44;1 &#91;DE<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>9&#44;7&#93; vs&#46;71&#44;3 &#91;DE<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>11&#44;3&#93;&#41; y mortalidad &#40;intrahospitalaria&#58; 10&#44;4 vs&#46; 6&#44;6&#37;&#59; al a&#241;o&#58; 30&#44;6 vs&#46; 20&#44;5&#37;&#41;&#44; p<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#44;001&#59; esta diferencia desapareci&#243; cuando se ajust&#243; por edad&#44; factores de riesgo&#44; comorbilidad y tratamiento al alta &#40;OR&#58;<span class="elsevierStyleHsp" style=""></span>1&#44;20&#59; IC del 95&#37;&#58;<span class="elsevierStyleHsp" style=""></span>0&#44;88-1&#44;84&#59; p<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#44;193&#41;&#46;</p><p id="par0095" class="elsevierStylePara elsevierViewall">En la <a class="elsevierStyleCrossRef" href="#tbl0005">tabla 1</a> se observa<span class="elsevierStyleBold">&#44;</span> en los 4 per&#237;odos estudiados&#44; que el perfil epidemiol&#243;gico de los pacientes con IC ha ido cambiando a lo largo del tiempo&#44; con una tendencia hacia una mayor edad&#44; as&#237; como mayor prevalencia de hipertensi&#243;n e hipercolesterolemia previas&#46; Por el contrario&#44; la proporci&#243;n de fumadores activos present&#243; una tendencia a la baja&#46; Merece la pena se&#241;alarse que a pesar de la mayor edad de los pacientes no se observ&#243; una mayor comorbilidad&#59; as&#237;&#44; apreciamos una tendencia hacia una menor proporci&#243;n de pacientes con IM previo y EPOC&#44; sin cambios significativos en la proporci&#243;n de ictus o EAP previa&#46;</p></span><span id="sec0060" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Medicaci&#243;n al alta&#46; Evoluci&#243;n temporal</span><p id="par0100" class="elsevierStylePara elsevierViewall">En la <a class="elsevierStyleCrossRef" href="#tbl0010">tabla 2</a> se presenta la evoluci&#243;n de la medicaci&#243;n al alta en los 4 per&#237;odos estudiados&#46; En ella observamos el significativo aumento de prescripci&#243;n de bloqueadores beta&#44; estatinas&#44; anticoagulantes y antagonistas c&#225;lcicos&#46; Por el contrario&#44; disminuy&#243; significativamente la indicaci&#243;n de digoxina&#44; nitroglicerina oral o transd&#233;rmica&#44; diur&#233;ticos y antiagregantes plaquetarios&#46; Se mantuvieron sin cambios el uso de antialdoster&#243;nicos&#46; Si bien la prescripci&#243;n de IECA disminuy&#243; su indicaci&#243;n durante el per&#237;odo del estudio&#44; se aprecia que este hecho fue paralelo a un aumento progresivo de la indicaci&#243;n de ARA-<span class="elsevierStyleSmallCaps">ii</span>&#44; de forma tal que la prescripci&#243;n &#171;neta&#187; de IECA o ARA-<span class="elsevierStyleSmallCaps">ii</span> no cambi&#243; significativamente a lo largo del tiempo&#46;</p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia></span><span id="sec0065" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Mortalidad hospitalaria&#44; al mes y al a&#241;o de seguimiento&#46; Evoluci&#243;n temporal</span><p id="par0105" class="elsevierStylePara elsevierViewall">En la <a class="elsevierStyleCrossRef" href="#tbl0015">tabla 3</a> se presentan los datos referidos a la mortalidad por cualquier causa&#44; seg&#250;n los 4 per&#237;odos estudiados&#58; intrahospitalaria&#44; a los 28 d&#237;as y al a&#241;o&#46; La <a class="elsevierStyleCrossRef" href="#fig0005">figura 1</a> muestra en una curva de Kaplan-Meier la mortalidad total seg&#250;n los per&#237;odos de estudio&#46; En ella se puede apreciar una separaci&#243;n precoz de las curvas&#44; lo cual refleja diferencias en mortalidad ya en la fase hospitalaria &#40;<a class="elsevierStyleCrossRef" href="#tbl0015">tabla 3</a>&#41; en virtud de la cual se produjo una reducci&#243;n progresiva y paulatina de la misma mediante 4 per&#237;odos&#46; Dichas diferencias en mortalidad se suavizan &#8211;hasta casi desaparecer&#8211; a los 28 d&#237;as entre los 3 primeros per&#237;odos del estudio&#46; Destaca&#44; sin embargo&#44; una significativa menor mortalidad a los 28 d&#237;as y a&#250;n mayor al a&#241;o en el &#250;ltimo per&#237;odo valorado&#46;</p><elsevierMultimedia ident="tbl0015"></elsevierMultimedia><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0110" class="elsevierStylePara elsevierViewall">El estudio comparativo de la mortalidad total por per&#237;odos nos muestra que la reducci&#243;n de la misma del &#250;ltimo per&#237;odo &#8211;el m&#225;s reciente&#8211; estudiado con respecto al primero fue significativa &#40;HR sin ajustar de per&#237;odo 4 vs&#46; 1<span class="elsevierStyleHsp" style=""></span>&#58;<span class="elsevierStyleHsp" style=""></span>0&#44;73 &#91;IC del 95&#37;&#58;<span class="elsevierStyleHsp" style=""></span>0&#44;58-0&#44;92&#93;&#41;&#59; El ajuste adicional&#44; de este &#250;ltimo modelo&#44; por tratamiento al alta &#40;excluyendo los muertos durante la hospitalizaci&#243;n&#41; con la inclusi&#243;n de los f&#225;rmacos que han demostrado aumentar la supervivencia &#40;bloqueadores beta&#44; IECA&#47;ARA-<span class="elsevierStyleSmallCaps">ii</span> y&#47;o antialdoster&#243;nicos&#41; no logr&#243; atenuar la reducci&#243;n de mortalidad observada del cuarto per&#237;odo&#44; aunque hace perder la significaci&#243;n estad&#237;stica &#40;HR&#58;<span class="elsevierStyleHsp" style=""></span>0&#44;75 &#91;IC del 95&#37;&#58;<span class="elsevierStyleHsp" style=""></span>0&#44;55-1&#44;01&#93;&#41;&#46;</p></span><span id="sec0070" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Predictores de mortalidad a un a&#241;o</span><p id="par0115" class="elsevierStylePara elsevierViewall">En el an&#225;lisis bivariado observamos una mortalidad significativamente mayor en los pacientes de mayor edad &#40;HR &#8211;a&#241;os&#8211;&#58; 1&#44;04 &#91;IC del 95&#37;&#58;<span class="elsevierStyleHsp" style=""></span>1&#44;03-1&#44;95&#41;&#44; con antecedentes de ictus &#40;HR&#58;<span class="elsevierStyleHsp" style=""></span>1&#44;28 &#91;IC del 95&#37;&#58;<span class="elsevierStyleHsp" style=""></span>1&#44;02-1&#44;60&#93;&#41; e IRC &#40;HR&#58;<span class="elsevierStyleHsp" style=""></span>1&#44;63 &#91;IC del 95&#37;&#58;<span class="elsevierStyleHsp" style=""></span>1&#44;36-1&#44;95&#93;&#41; y una disminuci&#243;n de la misma en aquellos pacientes que recib&#237;an anticoagulantes &#40;dicumar&#237;nicos&#41; &#40;HR&#58;<span class="elsevierStyleHsp" style=""></span>0&#44;67 &#91;IC del 95&#37;&#58;<span class="elsevierStyleHsp" style=""></span>0&#44;52-0&#44;87&#93;&#41; y estatinas &#40;HR&#58;<span class="elsevierStyleHsp" style=""></span>0&#44;67 &#91;IC del 95&#37;&#58;<span class="elsevierStyleHsp" style=""></span>0&#44;51-0&#44;88&#93;&#41;&#44; eran fumadores activos &#40;HR&#58;<span class="elsevierStyleHsp" style=""></span>0&#44;46 &#91;IC del 95&#37;&#58;<span class="elsevierStyleHsp" style=""></span>0&#44;30-0&#44;70&#93;&#41;&#44; hipertensos &#40;HR&#58;<span class="elsevierStyleHsp" style=""></span>0&#44;35 &#91;IC del 95&#37;&#58;<span class="elsevierStyleHsp" style=""></span>0&#44;29-0&#44;43&#93;&#41; o dislip&#233;micos &#40;HR&#58;<span class="elsevierStyleHsp" style=""></span>0&#44;55 &#91;IC del 95&#37;&#58;<span class="elsevierStyleHsp" style=""></span>0&#44;45-0&#44;66&#93;&#41;&#46; El uso de bloqueadores beta fue protector aunque con significaci&#243;n l&#237;mite &#40;HR&#58;<span class="elsevierStyleHsp" style=""></span>0&#44;79 &#91;IC del 95&#37;&#58;<span class="elsevierStyleHsp" style=""></span>0&#44;62-1&#44;00&#93;&#41;&#46; En un modelo de Cox &#40;<a class="elsevierStyleCrossRef" href="#tbl0020">tabla 4</a>&#41; ajustado resultaron factores predictivos de riesgo de mortalidad la edad&#44; IRC y DM&#44; mientras que los anticoagulantes fueron protectores&#46; La hipercolesterolemia tambi&#233;n se comport&#243; como protectora&#46;</p><elsevierMultimedia ident="tbl0020"></elsevierMultimedia></span></span><span id="sec0075" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Discusi&#243;n</span><p id="par0120" class="elsevierStylePara elsevierViewall">Con este estudio mostramos como la poblaci&#243;n que ingresa por IC en un hospital comarcal es cada vez de mayor edad&#44; con alta prevalencia de factores de riesgo cardiovascular y fibrilaci&#243;n auricular y moderada de antecedentes de enfermedad cardiovascular&#44; pulmonar y renal&#46; Una observaci&#243;n principal de nuestro estudio es la disminuci&#243;n de la mortalidad total a lo largo del tiempo&#44; y un incremento progresivo en la prescripci&#243;n de bloqueadores beta&#44; ARA-<span class="elsevierStyleSmallCaps">ii</span> y anticoagulantes dicumar&#237;nicos&#46;</p><span id="sec0080" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Comparaci&#243;n con otros estudios</span><p id="par0125" class="elsevierStylePara elsevierViewall">En la <a class="elsevierStyleCrossRef" href="#tbl0025">tabla 5</a> se pueden observar las caracter&#237;sticas y la mortalidad de los pacientes ingresados por IC en distintos registros espa&#241;oles&#44; europeos y estadounidenses<a class="elsevierStyleCrossRefs" href="#bib0030"><span class="elsevierStyleSup">6&#8211;14</span></a>&#46; La heterogeneidad de los mismos impide una comparaci&#243;n directa&#44; aunque puede decirse que en general muestran poblaciones discretamente m&#225;s j&#243;venes que la nuestra&#44; con menos factores de riesgo&#44; m&#225;s antecedentes de cardiopat&#237;a isqu&#233;mica y menor mortalidad&#46; Respecto a las principales causas de IC<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">15</span></a>&#44; la prevalencia creciente de la HTA como antecedente con respecto a la cardiopat&#237;a isqu&#233;mica&#44; convierten a este factor de riesgo en el m&#225;s importante en nuestro medio a pesar del mayor riesgo relativo que confiere el segundo<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">16</span></a>&#46;</p><elsevierMultimedia ident="tbl0025"></elsevierMultimedia></span><span id="sec0085" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Factores pron&#243;sticos</span><p id="par0130" class="elsevierStylePara elsevierViewall">A pesar de reunir nuestro estudio una poblaci&#243;n m&#225;s envejecida&#44; observamos una reducci&#243;n de la mortalidad al a&#241;o&#44; sobre todo en el cuarto per&#237;odo&#44; que no se atenu&#243; tras el ajuste incluyendo la medicaci&#243;n a alta&#46; No tenemos una explicaci&#243;n para este singular fen&#243;meno&#44; y no puede descartarse la presencia de variables no medidas que puedan tener un papel en este sentido&#46; La DM e IRC fueron predictores independientes de mortalidad al a&#241;o&#44; como en otros estudios<a class="elsevierStyleCrossRefs" href="#bib0085"><span class="elsevierStyleSup">17&#44;18</span></a>&#44; por lo que altas prevalencias de estas empeoran el pron&#243;stico&#46;</p><p id="par0135" class="elsevierStylePara elsevierViewall">La presencia de FA al ingreso no mostr&#243; sin embargo relaci&#243;n&#44; al contrario que otros estudios recientes<a class="elsevierStyleCrossRefs" href="#bib0095"><span class="elsevierStyleSup">19&#44;20</span></a>&#44; aunque s&#237; result&#243; protector el uso de dicumar&#237;nicos&#46; Ello deber&#237;a reforzar su prescripci&#243;n siempre que est&#233; indicado en este tipo de pacientes&#46;</p><p id="par0140" class="elsevierStylePara elsevierViewall">La asociaci&#243;n del antecedente de hipercolesterolemia con una menor mortalidad ha sido ya rese&#241;ada anteriormente<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">14</span></a>&#44; postul&#225;ndose que pueda ser un marcador de IC menos severa o un posible mediador de mejor evoluci&#243;n&#46; El fen&#243;meno por el cual ciertos factores de riesgo cl&#225;sicos resultan protectores en pacientes ancianos <span class="elsevierStyleItalic">&#40;reverse epidemiology&#41;</span> permanece en el terreno de las hip&#243;tesis<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">21</span></a>&#46;</p><p id="par0145" class="elsevierStylePara elsevierViewall">A lo largo de la serie se aprecia un incremento significativo de los ARA-<span class="elsevierStyleSmallCaps">ii</span> y los bloqueadores beta&#44; aunque no se alcanzan los est&#225;ndares que recomiendan las gu&#237;as cl&#237;nicas&#44; fen&#243;meno ya analizado por la Sociedad Europea de Cardiolog&#237;a<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">22</span></a>&#46; El motivo puede ser que las recomendaciones de las gu&#237;as cl&#237;nicas se basan en ensayos cl&#237;nicos que no siempre representan la poblaci&#243;n del llamado &#171;mundo real&#187;&#46; As&#237;&#44; en grandes series de pacientes solo el 13 y el 18&#37; cumpl&#237;an los criterios de inclusi&#243;n de los estudios MERIT-HF y SOLVD<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">23</span></a> respectivamente&#59; o el 9&#44; 5 y 7&#37; de los estudios SOLVD&#44; MERIT HF y RALES de la encuesta de la ESC<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">22</span></a>&#44; siendo las mayores causas de exclusi&#243;n&#58; la edad&#44; la insuficiencia renal y la EPOC&#46;</p></span><span id="sec0090" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Limitaciones y fortalezas</span><p id="par0150" class="elsevierStylePara elsevierViewall">Nuestro estudio presenta las limitaciones propias de un registro retrospectivo&#46; La variabilidad entre los distintos codificadores de historias se intent&#243; controlar mediante personal estable para todo el estudio y adecuado entrenamiento&#46; La variable tratamiento al alta sin conocimiento preciso de la &#171;adherencia&#187; es otra posible limitaci&#243;n del mismo&#46; El limitado n&#250;mero de ecocardiogramas &#40;45&#44;5&#37;&#41; nos hizo desestimar incluir en el an&#225;lisis la funci&#243;n sist&#243;lica ventricular izquierda&#44; as&#237; como la falta de determinaci&#243;n rutinaria del BNP o de datos de la funci&#243;n f&#237;sica o cognitiva de los pacientes&#44; que hubieran tenido inter&#233;s diagn&#243;stico y pron&#243;stico&#46; El an&#225;lisis de la mortalidad total y no de causas espec&#237;ficas es otra limitaci&#243;n&#44; aunque ya se ha hecho notar que la mortalidad del paciente con IC es debida en su amplia mayor&#237;a a causas cardiovasculares&#46;</p><p id="par0155" class="elsevierStylePara elsevierViewall">Las fortalezas m&#225;s destacables fueron el prolongado per&#237;odo de reclutamiento&#44; el elevado tama&#241;o muestral y la procedencia de los casos de un solo hospital que atiende a toda la poblaci&#243;n de un &#225;rea de salud&#44; por lo que estimamos que los sujetos estudiados representan adecuadamente las caracter&#237;sticas de la enfermedad en la poblaci&#243;n general&#46; Tambi&#233;n que el efecto de reducci&#243;n de mortalidad cardiovascular debe ser importante al proceder de una poblaci&#243;n envejecida donde los riesgos por otras causas de muerte suelen ser muy elevados&#46;</p></span></span><span id="sec0095" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Conclusiones</span><p id="par0160" class="elsevierStylePara elsevierViewall">Concluimos que a lo largo 10 a&#241;os hemos observado un cambio en el perfil etario y cl&#237;nico de los pacientes ingresados en un hospital general de &#225;rea con diagn&#243;stico de IC descompensada&#46; Los principales predictores de mortalidad a un a&#241;o fueron&#58; la edad&#44; la DM y la IRC&#46; La mortalidad por cualquier causa ha disminuido significativamente en la d&#233;cada fundamentalmente a expensas de la mortalidad intrahospitalaria en los primeros per&#237;odos y extrahospitalaria en el &#250;ltimo&#46; La anticoagulaci&#243;n se mostr&#243; como el &#250;nico tratamiento farmacol&#243;gico que result&#243; protector&#46;</p></span><span id="sec0100" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Conflictos de intereses</span><p id="par0165" class="elsevierStylePara elsevierViewall">Los autores declaran no tener ning&#250;n conflicto de intereses&#46;</p></span></span>"
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              "titulo" => "Mortalidad hospitalaria&#44; al mes y al a&#241;o de seguimiento&#46; Evoluci&#243;n temporal"
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    "fechaRecibido" => "2012-04-14"
    "fechaAceptado" => "2012-07-01"
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        "resumen" => "<span class="elsevierStyleSectionTitle">Antecedentes y objetivos</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">La insuficiencia cardiaca es la causante del mayor gasto sanitario en hospitalizaci&#243;n y la tercera causa de mortalidad cardiovascular&#46; Fue nuestro objetivo determinar la evoluci&#243;n de las caracter&#237;sticas cl&#237;nicas&#44; y los factores relacionados con el pron&#243;stico en pacientes ingresados por insuficiencia cardiaca en un &#225;rea de salud de Extremadura durante 10 a&#241;os&#46;</p> <span class="elsevierStyleSectionTitle">Pacientes y m&#233;todos</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Estudio observacional&#44; retrospectivo y unic&#233;ntrico en pacientes consecutivos ingresados por insuficiencia cardiaca descompensada en un Hospital General de la provincia de Badajoz en el per&#237;odo 2000&#47;2009&#46;</p> <span class="elsevierStyleSectionTitle">Resultados</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Se incluyeron 2&#46;220 pacientes con una edad media de 76&#44;3 &#40;DE<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>10&#44;1&#41; a&#241;os&#44; 54&#37; mujeres&#46; Estratificados en 4 per&#237;odos de 30 meses&#44; se observ&#243;&#58; un significativo incremento de los pacientes mayores de 75 a&#241;os &#40;55 al 71&#37;&#59; p<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#44;001&#41; y al alta una mayor prescripci&#243;n de bloqueadores beta &#40;12 al 34&#37;&#59; p<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#44;001&#41;&#44; estatinas &#40;8 al 31&#37;&#59; p<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#44;001&#41;&#44; y anticoagulantes orales &#40;13 al 25&#37;&#59; p<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#44;001&#41;&#46; La mortalidad intrahospitalaria disminuy&#243; del 13 al 8&#37; &#40;p<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#44;01&#41; y al a&#241;o del 30 al 23&#37; &#40;p<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#44;01&#41;&#46; Fueron predictores independientes de mortalidad al a&#241;o la edad &#40;HR<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>1&#44;04 &#91;IC del 95&#37;&#58; 1&#44;02-1&#44;05&#93;&#41;&#44; la diabetes &#40;HR<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>1&#44;35 &#91;IC del 95&#37;&#58; 1&#44;11-1&#44;66&#93;&#41; y la insuficiencia renal &#40;HR<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>1&#44;49 &#91;IC del 95&#37;&#58; 1&#44;18-1&#44;87&#93;&#41;&#46;</p> <span class="elsevierStyleSectionTitle">Conclusiones</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">La mortalidad ha disminuido significativamente en la d&#233;cada a pesar del incremento de la edad&#46; La edad&#44; la diabetes y la insuficiencia renal cr&#243;nica resultaron predictores independientes de mortalidad al a&#241;o&#46; La anticoagulaci&#243;n result&#243; protectora&#46;</p>"
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        "resumen" => "<span class="elsevierStyleSectionTitle">Background and objectives</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Heart failure is responsible for a major part of hospital health expenditure and the third cause of cardiovascular death&#46; To describe the evolution of clinical features&#44; and factors related to prognosis of patients admitted due to decompensated heart failure in a region of Extremadura during a period 10 years&#46;</p> <span class="elsevierStyleSectionTitle">Patients and methods</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Observational&#44; retrospective and single centre study of consecutive patients admitted due to decompensated heart failure in a general hospital in the province of Badajoz<span class="elsevierStyleBold">&#44;</span> during the period 2000&#47;2009&#46;</p> <span class="elsevierStyleSectionTitle">Results</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">A total of 2220 patients with mean age of 76&#46;3 &#40;SD<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>10&#46;1&#41;&#44; being 54&#37; female were included in the study&#46; Stratified into four periods &#40;30 months each&#41;&#44; a significant increase in patients over 75 years was observed &#40;55 vs&#46; 71&#37;&#59; <span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>&#46;001&#41;&#44; as well as an increase in the prescription of beta blockers at discharge &#40;12 vs&#46; 34&#37;&#44; <span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>&#46;001&#41;&#44; statins &#40;8 vs&#46; 31&#37;&#59; <span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>&#46;001&#41;&#44; and oral anticoagulants &#40;13 vs&#46; 25&#37;&#59; <span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>&#46;001&#41;&#46; Hospital mortality significantly decreased from 13 to 8&#37; &#40;<span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>&#46;01&#41;&#44; and from 30 to 23&#37; &#40;<span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>&#46;01&#41; at one year follow-up&#46; Age &#40;HR per year<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>1&#46;04 &#91;95&#37; CI&#58; 1&#46;02 to 1&#46;05&#93;&#41;&#44; diabetes &#40;HR<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>1&#46;35 &#91;95&#37; CI&#58; 1&#46;11 to 1&#46;66&#93;&#41; and chronic renal failure &#40;HR<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>1&#46;49 &#91;95&#37; CI&#58; 1&#46;18 to 1&#46;87&#93;&#41; were identified as independent predictors of all-cause mortality at one year of follow-up&#46;</p> <span class="elsevierStyleSectionTitle">Conclusions</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">Total mortality in patients with decompensated heart failure has declined significantly over the last decade&#44; despite the increasing age&#46; Age&#44; diabetes and chronic renal failure were independent predictors of total mortality at one year&#46; Oral anticoagulation was a protective factor&#46;</p>"
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                  \t\t\t\t">279 &#40;53&#44;8&#37;&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">1&#46;196 &#40;53&#44;1&#37;&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">0&#44;25&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#8805;<span class="elsevierStyleHsp" style=""></span>75 a&#241;os&nbsp;\t\t\t\t\t\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">328 &#40;54&#44;8&#37;&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">279 &#40;58&#44;5&#37;&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">404 &#40;65&#44;0&#37;&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t">367 &#40;70&#44;7&#37;&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">1&#46;378 &#40;62&#44;0&#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
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#60;<span class="elsevierStyleHsp" style=""></span>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">Hipertensi&#243;n arterial&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">493 &#40;82&#44;9&#37;&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">426 &#40;89&#44;5&#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">563 &#40;91&#44;1&#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
                  \t\t\t\t\ttop\n
                  \t\t\t\t">479 &#40;92&#44;5&#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">1&#46;963 &#40;88&#44;4&#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
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#60;<span class="elsevierStyleHsp" style=""></span>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">Diabetes mellitus tipo 2&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">283 &#40;47&#44;6&#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
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                  \t\t\t\t">193 &#40;40&#44;5&#37;&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">281 &#40;45&#44;5&#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
                  \t\t\t\t\ttop\n
                  \t\t\t\t">211 &#40;40&#44;7&#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
                  \t\t\t\t\ttop\n
                  \t\t\t\t">970 &#40;43&#44;7&#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
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#44;13&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">Hipercolesterolemia&nbsp;\t\t\t\t\t\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">137 &#40;23&#44;0&#37;&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t">128 &#40;26&#44;9&#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">212 &#40;34&#44;3&#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">198 &#40;38&#44;2&#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">676 &#40;30&#44;5&#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
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#60;<span class="elsevierStyleHsp" style=""></span>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">Fumador activo&nbsp;\t\t\t\t\t\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">45 &#40;7&#44;6&#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
                  \t\t\t\t\ttop\n
                  \t\t\t\t">37 &#40;7&#44;8&#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">39 &#40;6&#44;3&#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
                  \t\t\t\t\ttop\n
                  \t\t\t\t">22 &#40;4&#44;2&#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">143 &#40;6&#44;4&#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
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#44;01&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">Infarto de miocardio previo&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">89 &#40;14&#44;9&#37;&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t">69 &#40;14&#44;5&#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
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                  \t\t\t\t">66 &#40;10&#44;7&#37;&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t">50 &#40;9&#44;7&#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">274 &#40;12&#44;3&#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
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#60;<span class="elsevierStyleHsp" style=""></span>0&#44;002&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">Ictus previo&nbsp;\t\t\t\t\t\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">78 &#40;13&#44;1&#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">50 &#40;10&#44;5&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t">75 &#40;12&#44;1&#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">63 &#40;12&#44;2&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t">266 &#40;12&#44;0&#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
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#44;76&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">Enfermedad arterial perif&#233;rica&nbsp;\t\t\t\t\t\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">22 &#40;3&#44;7&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t">11 &#40;2&#44;3&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t">18 &#40;2&#44;9&#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
                  \t\t\t\t\ttop\n
                  \t\t\t\t">10 &#40;1&#44;9&#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
                  \t\t\t\t\ttop\n
                  \t\t\t\t">61 &#40;2&#44;7&#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
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#44;50&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">Fibrilaci&#243;n auricular&nbsp;\t\t\t\t\t\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">239 &#40;39&#44;9&#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
                  \t\t\t\t\ttop\n
                  \t\t\t\t">196 &#40;41&#44;0&#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
                  \t\t\t\t\ttop\n
                  \t\t\t\t">275 &#40;44&#44;2&#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
                  \t\t\t\t\ttop\n
                  \t\t\t\t">225 &#40;43&#44;4&#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
                  \t\t\t\t\ttop\n
                  \t\t\t\t">936 &#40;42&#44;2&#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
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#44;51&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">Enfermedad pulmonar cr&#243;nica&nbsp;\t\t\t\t\t\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">198 &#40;33&#44;3&#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">151 &#40;31&#44;7&#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
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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\ttable-entry\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">Hipertensi&#243;n arterial &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">Diabetes mellitus &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">Tabaquismo &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">Insuficiencia renal cr&#243;nica &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">Fibrilaci&#243;n auricular &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">37<a class="elsevierStyleCrossRef" href="#tblfn0030"><span class="elsevierStyleSup">a</span></a>37&#44;5<a class="elsevierStyleCrossRef" href="#tblfn0035"><span class="elsevierStyleSup">b</span></a>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">IAM previo &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
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Original
Características clínicas y mortalidad de la insuficiencia cardiaca. Estudio INCAex
Clinical characteristics and mortality of heart failure. INCAex study
D. Fernández-Bergésa,d,
Autor para correspondencia
polonibo@gmail.com

Autor para correspondencia.
, L. Consuegra-Sánchezb, F.J. Félix-Redondoc,d, N.R. Roblese, M. Galán Montejanof, L. Lozano-Merad
a Sección Cardiología, Departamento de Medicina Interna, Hospital Don Benito-Villanueva, Badajoz, España
b Servicio de Cardiología, Hospital General Universitario de Santa Lucía, Cartagena, Murcia, España
c Centro de Salud Villanueva Norte, Villanueva de la Serena, Badajoz, España
d Unidad de Investigación Don Benito-Villanueva, Grupo GRIMEX, Villanueva de la Serena, Programa de Investigación Cardiovascular: PERICLES, Badajoz, España
e Unidad de Hipertensión Arterial, Hospital Universitario Infanta Cristina, Badajoz, España
f Departamento de Medicina Interna, Hospital Don Benito-Villanueva, Badajoz, España
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          "es" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Curva de Kaplan-Meier&#44; evoluci&#243;n de la mortalidad total de acuerdo a los per&#237;odos estudiados &#40;t<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0 representa el momento del ingreso &#237;ndice por insuficiencia card&#237;aca&#41;&#46;</p>"
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    "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall"><elsevierMultimedia ident="tb0005"></elsevierMultimedia></p><span id="sec0105" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Introducci&#243;n</span><p id="par0025" class="elsevierStylePara elsevierViewall">La insuficiencia cardiaca &#40;IC&#41; constituye uno de los problemas de salud p&#250;blica m&#225;s relevantes dado que su prevalencia<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#44;2</span></a> y su incidencia van en aumento debido al incremento progresivo de la edad poblacional&#44; la mejora en el cuidado y la supervivencia de las enfermedades cr&#243;nicas&#44; como as&#237; tambi&#233;n al hecho de que constituye el estadio final de la mayor&#237;a de las enfermedades cardiacas<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a>&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">La IC constituye la tercera causa de muerte por enfermedades cardiovasculares&#44; detr&#225;s de la cardiopat&#237;a isqu&#233;mica y la enfermedad cerebrovascular<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a>&#44; existiendo una infraestimaci&#243;n general debido a que prevalecen otros diagn&#243;sticos&#44; tales como la cardiopat&#237;a isqu&#233;mica o la enfermedad hipertensiva en el proceso de elaboraci&#243;n de las estad&#237;sticas&#46; Es conocida la mortalidad al alta&#44; pero no existen muchos registros que ofrezcan seguimiento al a&#241;o en nuestro pa&#237;s<a class="elsevierStyleCrossRefs" href="#bib0025"><span class="elsevierStyleSup">5&#8211;9</span></a>&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">La supervivencia es de alrededor del 50&#37; a los 5 a&#241;os&#44; lo cual es muy similar al c&#225;ncer<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a>&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">En el presente estudio nos propusimos estudiar la evoluci&#243;n en el perfil cl&#237;nico-demogr&#225;fico del paciente ingresado en un Hospital General de &#225;rea con diagn&#243;stico de IC descompensada durante 10 a&#241;os &#40;2000-2009&#41;&#44; as&#237; como las tendencias observadas en el tratamiento al alta y mortalidad &#8211;por cualquier causa&#8211; intrahospitalaria y al a&#241;o de seguimiento&#46;</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Material y m&#233;todos</span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Tipo de estudio</span><p id="par0045" class="elsevierStylePara elsevierViewall">Observacional&#44; retrospectivo y unic&#233;ntrico &#40;pacientes atendidos en el Hospital Don Benito-Villanueva en el per&#237;odo 2000-2009&#41;&#46; Con motivo del an&#225;lisis consideramos <span class="elsevierStyleItalic">a priori</span> la estratificaci&#243;n de la cohorte total en 4 per&#237;odos iguales de 30 meses de duraci&#243;n cada uno&#44; en funci&#243;n del momento del ingreso hospitalario&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Poblaci&#243;n de referencia</span><p id="par0050" class="elsevierStylePara elsevierViewall">El &#193;rea Sanitaria de Don Benito-Villanueva de la Serena est&#225; situada al este de la provincia de Badajoz&#59; su poblaci&#243;n es de 141&#46;337 habitantes &#40;69&#46;962 varones&#41;&#46;</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Poblaci&#243;n estudiada</span><p id="par0055" class="elsevierStylePara elsevierViewall">Se reclutaron todos los individuos con diagn&#243;stico principal al alta de IC &#40;c&#243;digo&#58; 428 de la CIE-9&#41; en el &#225;rea sanitaria de Don Benito-Villanueva y que fueran ingresados consecutivamente desde el 1 de enero de 2000 hasta el 31 de diciembre de 2009 en el Hospital Don Benito Villanueva&#44; &#250;nico hospital del &#225;rea con ingreso de pacientes hasta noviembre de 2008&#46; Se trata de es una poblaci&#243;n atendida en un centro hospitalario de car&#225;cter secundario o comarcal&#46;</p><p id="par0060" class="elsevierStylePara elsevierViewall">Las fuentes de informaci&#243;n fueron el Servicio de Codificaci&#243;n e Inform&#225;tica del Hospital Don Benito-Villanueva y el &#237;ndice nacional de defunciones &#40;IND&#41;&#46;</p><p id="par0065" class="elsevierStylePara elsevierViewall">Se obtuvieron datos de la mortalidad al a&#241;o por confrontaci&#243;n de base hospitalaria con el IND&#44; en la totalidad de los pacientes &#40;100&#37;&#41;&#46; Este estudio fue aprobado por el comit&#233; de &#233;tica del Hospital Universitario Infanta Cristina de Badajoz&#46;</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Variables</span><p id="par0070" class="elsevierStylePara elsevierViewall">De la historia cl&#237;nica se recogi&#243; informaci&#243;n demogr&#225;fica detallada&#58; sexo&#44; edad&#44; antecedentes de enfermedad cardiovascular &#40;AECV&#41;&#44; infarto de miocardio &#40;IM&#41;&#44; enfermedad arterial perif&#233;rica &#40;EAP&#41; e ictus&#44; comorbilidad&#58; enfermedad pulmonar obstructiva cr&#243;nica &#40;EPOC&#41;&#44; insuficiencia renal cr&#243;nica &#40;IRC&#41; y neoplasias&#46; Factores de riesgo cardiovascular&#58; HTA&#44; diabetes mellitus &#40;DM&#41;&#44; hipercolesterolemia &#40;HCOL&#41; y tabaquismo&#44; ritmo basal electrocardiogr&#225;fico y trastornos de la conducci&#243;n&#46; D&#237;as de hospitalizaci&#243;n&#46; Atenci&#243;n de internista o cardi&#243;logo durante la hospitalizaci&#243;n&#46; Tratamiento farmacol&#243;gico al alta&#58; antiagregantes plaquetarios &#40;aspirina&#44; trifusal&#44; clopidogrel&#44; ticlopidina&#41;&#44; heparina&#44; dicumar&#237;nicos&#44; estatinas&#44; bloqueadores beta&#44; antagonistas c&#225;lcicos&#44; nitratos&#44; inhibidores del enzima convertidor de angiotensina &#40;IECA&#41;&#44; bloqueadores del receptor tipo 1 de angiotensina 2 &#40;ARA-<span class="elsevierStyleSmallCaps">ii</span>&#41;&#44; digoxina&#44; amiodarona&#44; diur&#233;ticos&#46; Mortalidad hospitalaria&#44; a los 28 d&#237;as y al a&#241;o del alta&#46;</p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Control de calidad</span><p id="par0075" class="elsevierStylePara elsevierViewall">Para garantizar la calidad de los datos todos los investigadores que participaron en el estudio fueron entrenados y acreditados en el centro coordinador del estudio&#46; Se realiz&#243; un control de la concordancia en el proceso de clasificaci&#243;n diagn&#243;stica mediante la evaluaci&#243;n de 40 casos patr&#243;n &#40;10 repetidos&#41; por todos los codificadores&#46; Se calcularon los &#237;ndices kappa intra e interobservador y se requiri&#243; que fueran superiores a 0&#44;90 en todos ellos y en ambos casos&#46;</p></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">An&#225;lisis estad&#237;stico</span><p id="par0080" class="elsevierStylePara elsevierViewall">Las variables categ&#243;ricas se presentaron como frecuencia absoluta y relativa&#44; y se compararon en los 4 grupos &#40;seg&#250;n fecha de ingreso&#41; mediante la prueba de Chi-cuadrado bajo la hip&#243;tesis nula de tendencia lineal&#46; Para evaluar la supervivencia se eligi&#243; el m&#233;todo de Kaplan-Meier&#44; compar&#225;ndose los estratos mediante la prueba de tendencias&#46; Las variables asociadas a la ocurrencia de mortalidad por cualquier causa a un a&#241;o se estudiaron mediante el <span class="elsevierStyleItalic">hazard ratio</span> &#40;HR&#41; no ajustado en modelo de remisi&#243;n de Cox&#46; Las variables que se consideraron &#243;ptimas para ser introducidas en el modelo final deb&#237;an cumplir al menos una de las siguientes&#58; <span class="elsevierStyleItalic">1&#41;</span> Asociaci&#243;n no ajustada a la ocurrencia de muerte por cualquier causa y valor de p<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#44;20 &#40;bajo este criterio se seleccionaron&#58; edad&#44; HTA&#44; tabaquismo activo&#44; dislipemia&#44; obesidad&#44; EPOC&#44; ictus&#44; IRC&#44; anticoagulantes&#44; bloqueadores beta&#44; IECA&#44; ARA-<span class="elsevierStyleSmallCaps">ii</span>&#44; estatinas&#41;&#59; <span class="elsevierStyleItalic">2&#41;</span> Variables consideradas de importancia pron&#243;stica por estudios previos &#40;DM&#44; fibrilaci&#243;n auricular&#41;&#44; o <span class="elsevierStyleItalic">3&#41;</span> Aquellas que no se incluyeran en las categor&#237;as previas&#44; pero que cambiaran de forma sustancial &#40;20&#37;&#41; el HR&#46; En todos los casos se eligi&#243; el m&#233;todo &#171;introducir&#187;&#46; Asimismo evaluamos la discriminaci&#243;n del modelo mediante una curva <span class="elsevierStyleItalic">Receiver Operating Characteristic</span> y la calibraci&#243;n mediante la prueba de Hosmer-Lemeshow&#46; Para asegurar la robustez de los predictores de mortalidad&#44; se calcularon los intervalos de confianza &#40;IC&#41; al 95&#37; de los mismos mediante an&#225;lisis con remuestreo <span class="elsevierStyleItalic">&#40;bootstrapping&#41;</span> con 3&#46;000 replicaciones&#46; Se utiliz&#243; el paquete estad&#237;stico SPSS<span class="elsevierStyleSup">&#174;</span> v 17&#46;0 y STATA<span class="elsevierStyleSup">&#174;</span> 9&#46;1&#46;</p></span></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Resultados</span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Caracter&#237;sticas basales de la poblaci&#243;n incluida y su evoluci&#243;n temporal</span><p id="par0085" class="elsevierStylePara elsevierViewall">Se incluyeron 2&#46;220 pacientes&#46; La edad media fue de 76&#44;3 &#40;DE<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>10&#44;1&#41; a&#241;os y el 53&#44;9&#37; fueron mujeres&#46; Las caracter&#237;sticas basales de la muestra se presentan en la <a class="elsevierStyleCrossRef" href="#tbl0005">tabla 1</a>&#46; La media de hospitalizaci&#243;n fue 8&#44;55 d&#237;as &#40;DE<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>5&#44;90&#41;&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0090" class="elsevierStylePara elsevierViewall">Los pacientes fueron atendidos en su gran mayor&#237;a por m&#233;dicos internistas &#40;86&#44;4&#37;&#41;&#44; no se registraron diferencias en cuanto a prescripci&#243;n farmacol&#243;gica al alta&#44; aunque si en cuanto a su significativa mayor edad &#40;77&#44;1 &#91;DE<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>9&#44;7&#93; vs&#46;71&#44;3 &#91;DE<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>11&#44;3&#93;&#41; y mortalidad &#40;intrahospitalaria&#58; 10&#44;4 vs&#46; 6&#44;6&#37;&#59; al a&#241;o&#58; 30&#44;6 vs&#46; 20&#44;5&#37;&#41;&#44; p<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#44;001&#59; esta diferencia desapareci&#243; cuando se ajust&#243; por edad&#44; factores de riesgo&#44; comorbilidad y tratamiento al alta &#40;OR&#58;<span class="elsevierStyleHsp" style=""></span>1&#44;20&#59; IC del 95&#37;&#58;<span class="elsevierStyleHsp" style=""></span>0&#44;88-1&#44;84&#59; p<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#44;193&#41;&#46;</p><p id="par0095" class="elsevierStylePara elsevierViewall">En la <a class="elsevierStyleCrossRef" href="#tbl0005">tabla 1</a> se observa<span class="elsevierStyleBold">&#44;</span> en los 4 per&#237;odos estudiados&#44; que el perfil epidemiol&#243;gico de los pacientes con IC ha ido cambiando a lo largo del tiempo&#44; con una tendencia hacia una mayor edad&#44; as&#237; como mayor prevalencia de hipertensi&#243;n e hipercolesterolemia previas&#46; Por el contrario&#44; la proporci&#243;n de fumadores activos present&#243; una tendencia a la baja&#46; Merece la pena se&#241;alarse que a pesar de la mayor edad de los pacientes no se observ&#243; una mayor comorbilidad&#59; as&#237;&#44; apreciamos una tendencia hacia una menor proporci&#243;n de pacientes con IM previo y EPOC&#44; sin cambios significativos en la proporci&#243;n de ictus o EAP previa&#46;</p></span><span id="sec0060" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Medicaci&#243;n al alta&#46; Evoluci&#243;n temporal</span><p id="par0100" class="elsevierStylePara elsevierViewall">En la <a class="elsevierStyleCrossRef" href="#tbl0010">tabla 2</a> se presenta la evoluci&#243;n de la medicaci&#243;n al alta en los 4 per&#237;odos estudiados&#46; En ella observamos el significativo aumento de prescripci&#243;n de bloqueadores beta&#44; estatinas&#44; anticoagulantes y antagonistas c&#225;lcicos&#46; Por el contrario&#44; disminuy&#243; significativamente la indicaci&#243;n de digoxina&#44; nitroglicerina oral o transd&#233;rmica&#44; diur&#233;ticos y antiagregantes plaquetarios&#46; Se mantuvieron sin cambios el uso de antialdoster&#243;nicos&#46; Si bien la prescripci&#243;n de IECA disminuy&#243; su indicaci&#243;n durante el per&#237;odo del estudio&#44; se aprecia que este hecho fue paralelo a un aumento progresivo de la indicaci&#243;n de ARA-<span class="elsevierStyleSmallCaps">ii</span>&#44; de forma tal que la prescripci&#243;n &#171;neta&#187; de IECA o ARA-<span class="elsevierStyleSmallCaps">ii</span> no cambi&#243; significativamente a lo largo del tiempo&#46;</p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia></span><span id="sec0065" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Mortalidad hospitalaria&#44; al mes y al a&#241;o de seguimiento&#46; Evoluci&#243;n temporal</span><p id="par0105" class="elsevierStylePara elsevierViewall">En la <a class="elsevierStyleCrossRef" href="#tbl0015">tabla 3</a> se presentan los datos referidos a la mortalidad por cualquier causa&#44; seg&#250;n los 4 per&#237;odos estudiados&#58; intrahospitalaria&#44; a los 28 d&#237;as y al a&#241;o&#46; La <a class="elsevierStyleCrossRef" href="#fig0005">figura 1</a> muestra en una curva de Kaplan-Meier la mortalidad total seg&#250;n los per&#237;odos de estudio&#46; En ella se puede apreciar una separaci&#243;n precoz de las curvas&#44; lo cual refleja diferencias en mortalidad ya en la fase hospitalaria &#40;<a class="elsevierStyleCrossRef" href="#tbl0015">tabla 3</a>&#41; en virtud de la cual se produjo una reducci&#243;n progresiva y paulatina de la misma mediante 4 per&#237;odos&#46; Dichas diferencias en mortalidad se suavizan &#8211;hasta casi desaparecer&#8211; a los 28 d&#237;as entre los 3 primeros per&#237;odos del estudio&#46; Destaca&#44; sin embargo&#44; una significativa menor mortalidad a los 28 d&#237;as y a&#250;n mayor al a&#241;o en el &#250;ltimo per&#237;odo valorado&#46;</p><elsevierMultimedia ident="tbl0015"></elsevierMultimedia><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0110" class="elsevierStylePara elsevierViewall">El estudio comparativo de la mortalidad total por per&#237;odos nos muestra que la reducci&#243;n de la misma del &#250;ltimo per&#237;odo &#8211;el m&#225;s reciente&#8211; estudiado con respecto al primero fue significativa &#40;HR sin ajustar de per&#237;odo 4 vs&#46; 1<span class="elsevierStyleHsp" style=""></span>&#58;<span class="elsevierStyleHsp" style=""></span>0&#44;73 &#91;IC del 95&#37;&#58;<span class="elsevierStyleHsp" style=""></span>0&#44;58-0&#44;92&#93;&#41;&#59; El ajuste adicional&#44; de este &#250;ltimo modelo&#44; por tratamiento al alta &#40;excluyendo los muertos durante la hospitalizaci&#243;n&#41; con la inclusi&#243;n de los f&#225;rmacos que han demostrado aumentar la supervivencia &#40;bloqueadores beta&#44; IECA&#47;ARA-<span class="elsevierStyleSmallCaps">ii</span> y&#47;o antialdoster&#243;nicos&#41; no logr&#243; atenuar la reducci&#243;n de mortalidad observada del cuarto per&#237;odo&#44; aunque hace perder la significaci&#243;n estad&#237;stica &#40;HR&#58;<span class="elsevierStyleHsp" style=""></span>0&#44;75 &#91;IC del 95&#37;&#58;<span class="elsevierStyleHsp" style=""></span>0&#44;55-1&#44;01&#93;&#41;&#46;</p></span><span id="sec0070" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Predictores de mortalidad a un a&#241;o</span><p id="par0115" class="elsevierStylePara elsevierViewall">En el an&#225;lisis bivariado observamos una mortalidad significativamente mayor en los pacientes de mayor edad &#40;HR &#8211;a&#241;os&#8211;&#58; 1&#44;04 &#91;IC del 95&#37;&#58;<span class="elsevierStyleHsp" style=""></span>1&#44;03-1&#44;95&#41;&#44; con antecedentes de ictus &#40;HR&#58;<span class="elsevierStyleHsp" style=""></span>1&#44;28 &#91;IC del 95&#37;&#58;<span class="elsevierStyleHsp" style=""></span>1&#44;02-1&#44;60&#93;&#41; e IRC &#40;HR&#58;<span class="elsevierStyleHsp" style=""></span>1&#44;63 &#91;IC del 95&#37;&#58;<span class="elsevierStyleHsp" style=""></span>1&#44;36-1&#44;95&#93;&#41; y una disminuci&#243;n de la misma en aquellos pacientes que recib&#237;an anticoagulantes &#40;dicumar&#237;nicos&#41; &#40;HR&#58;<span class="elsevierStyleHsp" style=""></span>0&#44;67 &#91;IC del 95&#37;&#58;<span class="elsevierStyleHsp" style=""></span>0&#44;52-0&#44;87&#93;&#41; y estatinas &#40;HR&#58;<span class="elsevierStyleHsp" style=""></span>0&#44;67 &#91;IC del 95&#37;&#58;<span class="elsevierStyleHsp" style=""></span>0&#44;51-0&#44;88&#93;&#41;&#44; eran fumadores activos &#40;HR&#58;<span class="elsevierStyleHsp" style=""></span>0&#44;46 &#91;IC del 95&#37;&#58;<span class="elsevierStyleHsp" style=""></span>0&#44;30-0&#44;70&#93;&#41;&#44; hipertensos &#40;HR&#58;<span class="elsevierStyleHsp" style=""></span>0&#44;35 &#91;IC del 95&#37;&#58;<span class="elsevierStyleHsp" style=""></span>0&#44;29-0&#44;43&#93;&#41; o dislip&#233;micos &#40;HR&#58;<span class="elsevierStyleHsp" style=""></span>0&#44;55 &#91;IC del 95&#37;&#58;<span class="elsevierStyleHsp" style=""></span>0&#44;45-0&#44;66&#93;&#41;&#46; El uso de bloqueadores beta fue protector aunque con significaci&#243;n l&#237;mite &#40;HR&#58;<span class="elsevierStyleHsp" style=""></span>0&#44;79 &#91;IC del 95&#37;&#58;<span class="elsevierStyleHsp" style=""></span>0&#44;62-1&#44;00&#93;&#41;&#46; En un modelo de Cox &#40;<a class="elsevierStyleCrossRef" href="#tbl0020">tabla 4</a>&#41; ajustado resultaron factores predictivos de riesgo de mortalidad la edad&#44; IRC y DM&#44; mientras que los anticoagulantes fueron protectores&#46; La hipercolesterolemia tambi&#233;n se comport&#243; como protectora&#46;</p><elsevierMultimedia ident="tbl0020"></elsevierMultimedia></span></span><span id="sec0075" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Discusi&#243;n</span><p id="par0120" class="elsevierStylePara elsevierViewall">Con este estudio mostramos como la poblaci&#243;n que ingresa por IC en un hospital comarcal es cada vez de mayor edad&#44; con alta prevalencia de factores de riesgo cardiovascular y fibrilaci&#243;n auricular y moderada de antecedentes de enfermedad cardiovascular&#44; pulmonar y renal&#46; Una observaci&#243;n principal de nuestro estudio es la disminuci&#243;n de la mortalidad total a lo largo del tiempo&#44; y un incremento progresivo en la prescripci&#243;n de bloqueadores beta&#44; ARA-<span class="elsevierStyleSmallCaps">ii</span> y anticoagulantes dicumar&#237;nicos&#46;</p><span id="sec0080" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Comparaci&#243;n con otros estudios</span><p id="par0125" class="elsevierStylePara elsevierViewall">En la <a class="elsevierStyleCrossRef" href="#tbl0025">tabla 5</a> se pueden observar las caracter&#237;sticas y la mortalidad de los pacientes ingresados por IC en distintos registros espa&#241;oles&#44; europeos y estadounidenses<a class="elsevierStyleCrossRefs" href="#bib0030"><span class="elsevierStyleSup">6&#8211;14</span></a>&#46; La heterogeneidad de los mismos impide una comparaci&#243;n directa&#44; aunque puede decirse que en general muestran poblaciones discretamente m&#225;s j&#243;venes que la nuestra&#44; con menos factores de riesgo&#44; m&#225;s antecedentes de cardiopat&#237;a isqu&#233;mica y menor mortalidad&#46; Respecto a las principales causas de IC<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">15</span></a>&#44; la prevalencia creciente de la HTA como antecedente con respecto a la cardiopat&#237;a isqu&#233;mica&#44; convierten a este factor de riesgo en el m&#225;s importante en nuestro medio a pesar del mayor riesgo relativo que confiere el segundo<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">16</span></a>&#46;</p><elsevierMultimedia ident="tbl0025"></elsevierMultimedia></span><span id="sec0085" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Factores pron&#243;sticos</span><p id="par0130" class="elsevierStylePara elsevierViewall">A pesar de reunir nuestro estudio una poblaci&#243;n m&#225;s envejecida&#44; observamos una reducci&#243;n de la mortalidad al a&#241;o&#44; sobre todo en el cuarto per&#237;odo&#44; que no se atenu&#243; tras el ajuste incluyendo la medicaci&#243;n a alta&#46; No tenemos una explicaci&#243;n para este singular fen&#243;meno&#44; y no puede descartarse la presencia de variables no medidas que puedan tener un papel en este sentido&#46; La DM e IRC fueron predictores independientes de mortalidad al a&#241;o&#44; como en otros estudios<a class="elsevierStyleCrossRefs" href="#bib0085"><span class="elsevierStyleSup">17&#44;18</span></a>&#44; por lo que altas prevalencias de estas empeoran el pron&#243;stico&#46;</p><p id="par0135" class="elsevierStylePara elsevierViewall">La presencia de FA al ingreso no mostr&#243; sin embargo relaci&#243;n&#44; al contrario que otros estudios recientes<a class="elsevierStyleCrossRefs" href="#bib0095"><span class="elsevierStyleSup">19&#44;20</span></a>&#44; aunque s&#237; result&#243; protector el uso de dicumar&#237;nicos&#46; Ello deber&#237;a reforzar su prescripci&#243;n siempre que est&#233; indicado en este tipo de pacientes&#46;</p><p id="par0140" class="elsevierStylePara elsevierViewall">La asociaci&#243;n del antecedente de hipercolesterolemia con una menor mortalidad ha sido ya rese&#241;ada anteriormente<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">14</span></a>&#44; postul&#225;ndose que pueda ser un marcador de IC menos severa o un posible mediador de mejor evoluci&#243;n&#46; El fen&#243;meno por el cual ciertos factores de riesgo cl&#225;sicos resultan protectores en pacientes ancianos <span class="elsevierStyleItalic">&#40;reverse epidemiology&#41;</span> permanece en el terreno de las hip&#243;tesis<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">21</span></a>&#46;</p><p id="par0145" class="elsevierStylePara elsevierViewall">A lo largo de la serie se aprecia un incremento significativo de los ARA-<span class="elsevierStyleSmallCaps">ii</span> y los bloqueadores beta&#44; aunque no se alcanzan los est&#225;ndares que recomiendan las gu&#237;as cl&#237;nicas&#44; fen&#243;meno ya analizado por la Sociedad Europea de Cardiolog&#237;a<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">22</span></a>&#46; El motivo puede ser que las recomendaciones de las gu&#237;as cl&#237;nicas se basan en ensayos cl&#237;nicos que no siempre representan la poblaci&#243;n del llamado &#171;mundo real&#187;&#46; As&#237;&#44; en grandes series de pacientes solo el 13 y el 18&#37; cumpl&#237;an los criterios de inclusi&#243;n de los estudios MERIT-HF y SOLVD<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">23</span></a> respectivamente&#59; o el 9&#44; 5 y 7&#37; de los estudios SOLVD&#44; MERIT HF y RALES de la encuesta de la ESC<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">22</span></a>&#44; siendo las mayores causas de exclusi&#243;n&#58; la edad&#44; la insuficiencia renal y la EPOC&#46;</p></span><span id="sec0090" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Limitaciones y fortalezas</span><p id="par0150" class="elsevierStylePara elsevierViewall">Nuestro estudio presenta las limitaciones propias de un registro retrospectivo&#46; La variabilidad entre los distintos codificadores de historias se intent&#243; controlar mediante personal estable para todo el estudio y adecuado entrenamiento&#46; La variable tratamiento al alta sin conocimiento preciso de la &#171;adherencia&#187; es otra posible limitaci&#243;n del mismo&#46; El limitado n&#250;mero de ecocardiogramas &#40;45&#44;5&#37;&#41; nos hizo desestimar incluir en el an&#225;lisis la funci&#243;n sist&#243;lica ventricular izquierda&#44; as&#237; como la falta de determinaci&#243;n rutinaria del BNP o de datos de la funci&#243;n f&#237;sica o cognitiva de los pacientes&#44; que hubieran tenido inter&#233;s diagn&#243;stico y pron&#243;stico&#46; El an&#225;lisis de la mortalidad total y no de causas espec&#237;ficas es otra limitaci&#243;n&#44; aunque ya se ha hecho notar que la mortalidad del paciente con IC es debida en su amplia mayor&#237;a a causas cardiovasculares&#46;</p><p id="par0155" class="elsevierStylePara elsevierViewall">Las fortalezas m&#225;s destacables fueron el prolongado per&#237;odo de reclutamiento&#44; el elevado tama&#241;o muestral y la procedencia de los casos de un solo hospital que atiende a toda la poblaci&#243;n de un &#225;rea de salud&#44; por lo que estimamos que los sujetos estudiados representan adecuadamente las caracter&#237;sticas de la enfermedad en la poblaci&#243;n general&#46; Tambi&#233;n que el efecto de reducci&#243;n de mortalidad cardiovascular debe ser importante al proceder de una poblaci&#243;n envejecida donde los riesgos por otras causas de muerte suelen ser muy elevados&#46;</p></span></span><span id="sec0095" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Conclusiones</span><p id="par0160" class="elsevierStylePara elsevierViewall">Concluimos que a lo largo 10 a&#241;os hemos observado un cambio en el perfil etario y cl&#237;nico de los pacientes ingresados en un hospital general de &#225;rea con diagn&#243;stico de IC descompensada&#46; Los principales predictores de mortalidad a un a&#241;o fueron&#58; la edad&#44; la DM y la IRC&#46; La mortalidad por cualquier causa ha disminuido significativamente en la d&#233;cada fundamentalmente a expensas de la mortalidad intrahospitalaria en los primeros per&#237;odos y extrahospitalaria en el &#250;ltimo&#46; La anticoagulaci&#243;n se mostr&#243; como el &#250;nico tratamiento farmacol&#243;gico que result&#243; protector&#46;</p></span><span id="sec0100" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Conflictos de intereses</span><p id="par0165" class="elsevierStylePara elsevierViewall">Los autores declaran no tener ning&#250;n conflicto de intereses&#46;</p></span></span>"
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              "titulo" => "Mortalidad hospitalaria&#44; al mes y al a&#241;o de seguimiento&#46; Evoluci&#243;n temporal"
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    "fechaRecibido" => "2012-04-14"
    "fechaAceptado" => "2012-07-01"
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        "resumen" => "<span class="elsevierStyleSectionTitle">Antecedentes y objetivos</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">La insuficiencia cardiaca es la causante del mayor gasto sanitario en hospitalizaci&#243;n y la tercera causa de mortalidad cardiovascular&#46; Fue nuestro objetivo determinar la evoluci&#243;n de las caracter&#237;sticas cl&#237;nicas&#44; y los factores relacionados con el pron&#243;stico en pacientes ingresados por insuficiencia cardiaca en un &#225;rea de salud de Extremadura durante 10 a&#241;os&#46;</p> <span class="elsevierStyleSectionTitle">Pacientes y m&#233;todos</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Estudio observacional&#44; retrospectivo y unic&#233;ntrico en pacientes consecutivos ingresados por insuficiencia cardiaca descompensada en un Hospital General de la provincia de Badajoz en el per&#237;odo 2000&#47;2009&#46;</p> <span class="elsevierStyleSectionTitle">Resultados</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Se incluyeron 2&#46;220 pacientes con una edad media de 76&#44;3 &#40;DE<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>10&#44;1&#41; a&#241;os&#44; 54&#37; mujeres&#46; Estratificados en 4 per&#237;odos de 30 meses&#44; se observ&#243;&#58; un significativo incremento de los pacientes mayores de 75 a&#241;os &#40;55 al 71&#37;&#59; p<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#44;001&#41; y al alta una mayor prescripci&#243;n de bloqueadores beta &#40;12 al 34&#37;&#59; p<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#44;001&#41;&#44; estatinas &#40;8 al 31&#37;&#59; p<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#44;001&#41;&#44; y anticoagulantes orales &#40;13 al 25&#37;&#59; p<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#44;001&#41;&#46; La mortalidad intrahospitalaria disminuy&#243; del 13 al 8&#37; &#40;p<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#44;01&#41; y al a&#241;o del 30 al 23&#37; &#40;p<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#44;01&#41;&#46; Fueron predictores independientes de mortalidad al a&#241;o la edad &#40;HR<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>1&#44;04 &#91;IC del 95&#37;&#58; 1&#44;02-1&#44;05&#93;&#41;&#44; la diabetes &#40;HR<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>1&#44;35 &#91;IC del 95&#37;&#58; 1&#44;11-1&#44;66&#93;&#41; y la insuficiencia renal &#40;HR<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>1&#44;49 &#91;IC del 95&#37;&#58; 1&#44;18-1&#44;87&#93;&#41;&#46;</p> <span class="elsevierStyleSectionTitle">Conclusiones</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">La mortalidad ha disminuido significativamente en la d&#233;cada a pesar del incremento de la edad&#46; La edad&#44; la diabetes y la insuficiencia renal cr&#243;nica resultaron predictores independientes de mortalidad al a&#241;o&#46; La anticoagulaci&#243;n result&#243; protectora&#46;</p>"
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        "resumen" => "<span class="elsevierStyleSectionTitle">Background and objectives</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Heart failure is responsible for a major part of hospital health expenditure and the third cause of cardiovascular death&#46; To describe the evolution of clinical features&#44; and factors related to prognosis of patients admitted due to decompensated heart failure in a region of Extremadura during a period 10 years&#46;</p> <span class="elsevierStyleSectionTitle">Patients and methods</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Observational&#44; retrospective and single centre study of consecutive patients admitted due to decompensated heart failure in a general hospital in the province of Badajoz<span class="elsevierStyleBold">&#44;</span> during the period 2000&#47;2009&#46;</p> <span class="elsevierStyleSectionTitle">Results</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">A total of 2220 patients with mean age of 76&#46;3 &#40;SD<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>10&#46;1&#41;&#44; being 54&#37; female were included in the study&#46; Stratified into four periods &#40;30 months each&#41;&#44; a significant increase in patients over 75 years was observed &#40;55 vs&#46; 71&#37;&#59; <span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>&#46;001&#41;&#44; as well as an increase in the prescription of beta blockers at discharge &#40;12 vs&#46; 34&#37;&#44; <span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>&#46;001&#41;&#44; statins &#40;8 vs&#46; 31&#37;&#59; <span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>&#46;001&#41;&#44; and oral anticoagulants &#40;13 vs&#46; 25&#37;&#59; <span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>&#46;001&#41;&#46; Hospital mortality significantly decreased from 13 to 8&#37; &#40;<span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>&#46;01&#41;&#44; and from 30 to 23&#37; &#40;<span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>&#46;01&#41; at one year follow-up&#46; Age &#40;HR per year<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>1&#46;04 &#91;95&#37; CI&#58; 1&#46;02 to 1&#46;05&#93;&#41;&#44; diabetes &#40;HR<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>1&#46;35 &#91;95&#37; CI&#58; 1&#46;11 to 1&#46;66&#93;&#41; and chronic renal failure &#40;HR<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>1&#46;49 &#91;95&#37; CI&#58; 1&#46;18 to 1&#46;87&#93;&#41; were identified as independent predictors of all-cause mortality at one year of follow-up&#46;</p> <span class="elsevierStyleSectionTitle">Conclusions</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">Total mortality in patients with decompensated heart failure has declined significantly over the last decade&#44; despite the increasing age&#46; Age&#44; diabetes and chronic renal failure were independent predictors of total mortality at one year&#46; Oral anticoagulation was a protective factor&#46;</p>"
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        "nota" => "<p class="elsevierStyleNotepara">Este estudio est&#225; financiado por el Instituto Carlos <span class="elsevierStyleSmallCaps">iii</span>-Ayudas a grupos de investigaci&#243;n emergentes &#40;EMER 07&#47;046&#41;&#46;</p>"
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                  \t\t\t\t">622 &#40;28&#44;0&#37;&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">2&#46;220&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttop\n
                  \t\t\t\t">Mujeres&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#8805;<span class="elsevierStyleHsp" style=""></span>75 a&#241;os&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">279 &#40;58&#44;5&#37;&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">404 &#40;65&#44;0&#37;&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">367 &#40;70&#44;7&#37;&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">1&#46;378 &#40;62&#44;0&#37;&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t">&#60;<span class="elsevierStyleHsp" style=""></span>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">Hipertensi&#243;n arterial&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">426 &#40;89&#44;5&#37;&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">563 &#40;91&#44;1&#37;&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">479 &#40;92&#44;5&#37;&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">1&#46;963 &#40;88&#44;4&#37;&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">&#60;<span class="elsevierStyleHsp" style=""></span>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
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                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Diabetes mellitus tipo 2&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">281 &#40;45&#44;5&#37;&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">211 &#40;40&#44;7&#37;&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">970 &#40;43&#44;7&#37;&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">0&#44;13&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Hipercolesterolemia&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">137 &#40;23&#44;0&#37;&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">128 &#40;26&#44;9&#37;&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">212 &#40;34&#44;3&#37;&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">198 &#40;38&#44;2&#37;&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">676 &#40;30&#44;5&#37;&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t">&#60;<span class="elsevierStyleHsp" style=""></span>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
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                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Fumador activo&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t">45 &#40;7&#44;6&#37;&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">37 &#40;7&#44;8&#37;&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">39 &#40;6&#44;3&#37;&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">22 &#40;4&#44;2&#37;&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">143 &#40;6&#44;4&#37;&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">0&#44;01&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">Infarto de miocardio previo&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">89 &#40;14&#44;9&#37;&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">69 &#40;14&#44;5&#37;&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">66 &#40;10&#44;7&#37;&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">50 &#40;9&#44;7&#37;&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">274 &#40;12&#44;3&#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">&#60;<span class="elsevierStyleHsp" style=""></span>0&#44;002&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">Ictus previo&nbsp;\t\t\t\t\t\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">78 &#40;13&#44;1&#37;&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t">50 &#40;10&#44;5&#37;&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t">75 &#40;12&#44;1&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t">63 &#40;12&#44;2&#37;&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">266 &#40;12&#44;0&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t">0&#44;76&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">Enfermedad arterial perif&#233;rica&nbsp;\t\t\t\t\t\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">22 &#40;3&#44;7&#37;&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t">11 &#40;2&#44;3&#37;&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t">18 &#40;2&#44;9&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t">10 &#40;1&#44;9&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t">61 &#40;2&#44;7&#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">0&#44;50&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">Fibrilaci&#243;n auricular&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t">Fibrilaci&#243;n auricular &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
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                            3 => "N&#46; Jim&#233;nez"
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Información del artículo
ISSN: 00142565
Idioma original: Español
DOI:10.1016/j.rce.2012.07.004
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