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es probable que la congesti&#243;n sist&#233;mica<a class="elsevierStyleCrossRefs" href="#bib0215"><span class="elsevierStyleSup">11&#44;12</span></a>&#44; o la del territorio espl&#225;cnico<a class="elsevierStyleCrossRef" href="#bib0225"><span class="elsevierStyleSup">13</span></a>&#44; desencadenando mecanismos inflamatorios<a class="elsevierStyleCrossRefs" href="#bib0230"><span class="elsevierStyleSup">14&#44;15</span></a> jueguen un papel crucial en la fisiopatolog&#237;a de las descompensaciones cardiacas&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">De lo que no hay duda es de que los signos y s&#237;ntomas congestivos son el heraldo de las descompensaciones<a class="elsevierStyleCrossRef" href="#bib0180"><span class="elsevierStyleSup">4</span></a>&#46; De hecho&#44; es la lucha contra la congesti&#243;n lo que centra el tratamiento al inicio del ingreso<a class="elsevierStyleCrossRefs" href="#bib0180"><span class="elsevierStyleSup">4&#44;16</span></a>&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">La persistencia de signos congestivos al alta se asocia con mayor riesgo de rehospitalizaci&#243;n por IC y mortalidad<a class="elsevierStyleCrossRefs" href="#bib0245"><span class="elsevierStyleSup">17-20</span></a>&#44; por lo que una descongesti&#243;n completa podr&#237;a ser el objetivo terap&#233;utico primario en las descompensaciones&#46; A la luz de estudios recientes<a class="elsevierStyleCrossRefs" href="#bib0250"><span class="elsevierStyleSup">18&#44;19</span></a>&#44; alcanzar un grado de descongesti&#243;n que consiga el alivio sintom&#225;tico y permita el alta puede no ser suficiente&#46; Entre la descongesti&#243;n que alivia los s&#237;ntomas y la que mejora el pron&#243;stico&#44; hay diferencias sustanciales&#46; Al grado de congesti&#243;n que permanece despu&#233;s del tratamiento inicial&#44; de modo sutil&#44; poco relevante desde el punto de vista semiol&#243;gico&#44; pero con incidencia negativa en la mortalidad&#44; es a lo que podemos llamar &#171;congesti&#243;n residual&#187;&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">Mediante un sistema sencillo de puntuaci&#243;n <span class="elsevierStyleItalic">&#40;score&#41;</span>&#44; basado en la presencia de disnea&#44; ortopnea&#44; astenia&#44; crepitantes&#44; edemas e ingurgitaci&#243;n yugular &#40;<a class="elsevierStyleCrossRef" href="#tbl0010">tabla 2</a>&#41;&#44; Ambrosy<a class="elsevierStyleCrossRef" href="#bib0250"><span class="elsevierStyleSup">18</span></a> demostr&#243; en una cohorte de 2&#46;061 pacientes con IC y fracci&#243;n de eyecci&#243;n del ventr&#237;culo izquierdo &#40;FEVI&#41; reducida &#40;ICFEr&#41; que&#44; a mayor <span class="elsevierStyleItalic">score</span> al alta&#44; mayor mortalidad y m&#225;s reingresos por IC durante el seguimiento&#46; En un estudio posterior&#44; Rubio et al&#46;<a class="elsevierStyleCrossRef" href="#bib0255"><span class="elsevierStyleSup">19</span></a>&#44; empleando un <span class="elsevierStyleItalic">score</span> simplificado &#40;<a class="elsevierStyleCrossRef" href="#tbl0010">tabla 2</a>&#41;&#44; que inclu&#237;a solamente el grado de ortopnea&#44; ingurgitaci&#243;n yugular y edemas&#44; demostraron en una cohorte de 1&#46;572 pacientes con ICFEr que la congesti&#243;n residual&#44; cl&#237;nicamente no aparente&#44; es muy frecuente al alta y confirmaron su mal pron&#243;stico&#46; En este estudio<a class="elsevierStyleCrossRef" href="#bib0255"><span class="elsevierStyleSup">19</span></a>&#44; tan solo el 23&#37; de los pacientes no mostraban signos de congesti&#243;n al alta&#44; mientras que en el 48 y 29&#37; estaban presentes en grado leve&#44; o significativo&#44; lo que se asociaba con un incremento de las rehospitalizaciones y la mortalidad&#44; respectivamente&#46;</p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><p id="par0050" class="elsevierStylePara elsevierViewall">Es evidente que el reto para el futuro inmediato es detectar y combatir la congesti&#243;n residual&#44; la que se resiste a la acci&#243;n de la terapia diur&#233;tica intensiva inmediatamente tras el ingreso&#46; Para hacerlo de modo eficaz y seguro&#44; primero hay que reconocerla&#46; Probablemente&#44; los <span class="elsevierStyleItalic">scores</span> cl&#237;nicos pueden complementarse con la respuesta diur&#233;tica<a class="elsevierStyleCrossRef" href="#bib0260"><span class="elsevierStyleSup">20</span></a>&#44; par&#225;metros bioqu&#237;micos como el hematocrito<a class="elsevierStyleCrossRef" href="#bib0265"><span class="elsevierStyleSup">21</span></a>&#44; las variaciones en la concentraci&#243;n de p&#233;ptido natriur&#233;tico &#40;PN&#41;<a class="elsevierStyleCrossRefs" href="#bib0270"><span class="elsevierStyleSup">22&#44;23</span></a>&#44; o el ant&#237;geno carbohidrato 125 &#40;CA125&#41;<a class="elsevierStyleCrossRef" href="#bib0280"><span class="elsevierStyleSup">24</span></a>&#46; Adem&#225;s&#44; tendremos que analizar la utilidad y el rendimiento de procedimientos ecogr&#225;ficos<a class="elsevierStyleCrossRefs" href="#bib0285"><span class="elsevierStyleSup">25&#44;26</span></a> y otros m&#233;todos no invasivos&#44; como la bioimpedanciometr&#237;a<a class="elsevierStyleCrossRefs" href="#bib0295"><span class="elsevierStyleSup">27&#44;28</span></a>&#46;</p><p id="par0055" class="elsevierStylePara elsevierViewall">El papel de la congesti&#243;n en la toma de decisiones de cara al alta y la percepci&#243;n de la congesti&#243;n residual&#44; una situaci&#243;n emergente&#44; en la pr&#225;ctica diaria son cuestiones sobre las que no existe mucha evidencia&#46; Para profundizar en ambos aspectos&#44; elaboramos una encuesta an&#243;nima con 13 preguntas&#44; distribuidas por correo electr&#243;nico a los miembros del Grupo de Insuficiencia Cardiaca &#40;GIC&#41; de la SEMI&#44; abierta del 22 de agosto al 23 de septiembre de 2018&#46; La encuesta se orient&#243; al modo de evaluar la congesti&#243;n y la importancia que los participantes le asignan en dos momentos clave de la evoluci&#243;n&#46; En la finalizaci&#243;n del tratamiento diur&#233;tico intensivo&#44; es decir&#44; cuando se consideran superados los s&#237;ntomas congestivos que motivaron el ingreso&#46; Y en la decisi&#243;n de proceder al alta&#44; es decir&#44; cuando consideran que ya no existe congesti&#243;n&#44; o esta puede tratarse con seguridad ambulatoriamente &#40;<a class="elsevierStyleCrossRef" href="#sec0015">material suplementario</a>&#41;&#46;</p><p id="par0060" class="elsevierStylePara elsevierViewall">Respondieron 253 especialistas&#44; la mayor&#237;a de medicina interna &#40;247&#41;&#44; y sus respuestas pueden consultarse en el blog del GIC &#40;<a href="http://cardioclinico.com/">http&#58;&#47;&#47;cardioclinico&#46;com&#47;</a>&#41; y en el <a class="elsevierStyleCrossRef" href="#sec0015">material suplementario</a>&#46;</p><p id="par0065" class="elsevierStylePara elsevierViewall">Para el reconocimiento y estimaci&#243;n de la congesti&#243;n&#44; utilizamos s&#237;ntomas y signos &#40;disnea&#44; ortopnea&#44; ingurgitaci&#243;n yugular y edemas&#59; m&#225;s de un 50&#37; cada uno&#41;&#44; las concentraciones de PN &#40;43&#37;&#41;&#44; la ultrasonograf&#237;a de la vena cava inferior &#40;45&#37;&#41;&#44; la pulmonar &#40;43&#37;&#41; y el CA125 &#40;16&#37;&#41;&#46;</p><p id="par0070" class="elsevierStylePara elsevierViewall">Sobre la respuesta precoz de la congesti&#243;n&#44; aquella que permite desescalar el tratamiento diur&#233;tico&#44; pasando de la v&#237;a i&#46;v&#46; a la oral&#44; respondieron 247 personas&#46; La mayor&#237;a recurre de nuevo a la semiolog&#237;a &#40;mejor&#237;a de disnea &#91;80&#37;&#93;&#44; reducci&#243;n de edemas &#91;78&#37;&#93; o peso &#91;63&#37;&#93;&#41; y la estabilidad de la dosis de diur&#233;tico oral &#40;62&#37;&#41;&#46; Un 86&#37; de los participantes estima la eficacia diur&#233;tica&#44; aunque la forma de medirla es muy variada y recae en la disminuci&#243;n de los signos y s&#237;ntomas de congesti&#243;n en el 86&#37;&#44; las concentraciones de PN &#40;24&#37;&#41; o en la ecograf&#237;a seriada pulmonar &#40;8&#37;&#41; o de la vena cava inferior &#40;5&#37;&#41;&#46;</p><p id="par0075" class="elsevierStylePara elsevierViewall">Se pregunt&#243; abiertamente si el t&#233;rmino &#171;congesti&#243;n residual&#187; suger&#237;a algo y&#44; en caso afirmativo&#44; c&#243;mo se interpretaba&#46; De las 247 respuestas&#44; 185 &#40;75&#37;&#41; manifestaron conocer tal situaci&#243;n cl&#237;nica&#44; y su percepci&#243;n&#44; aunque variable&#44; se ajusta de modo razonable a lo que cl&#237;nicamente se podr&#237;a esperar &#40;las respuestas individualizadas pueden consultarse en el blog&#41;&#46;</p><p id="par0080" class="elsevierStylePara elsevierViewall">El alta se gu&#237;a mayoritariamente por la reducci&#243;n de los edemas &#40;72&#37;&#41;&#44; la mejora de la clase funcional &#40;63&#37;&#41; y la dosis de diur&#233;tico oral estable &#40;62&#37;&#41;&#44; de nuevo mediante criterios eminentemente cl&#237;nicos&#46;</p><p id="par0085" class="elsevierStylePara elsevierViewall">Resulta llamativo que la mayor parte de las decisiones sobre la evaluaci&#243;n&#44; seguimiento y tratamiento de la congesti&#243;n en las descompensaciones de la IC se basen en la percepci&#243;n cl&#237;nica&#44; es decir&#44; en elementos semiol&#243;gicos&#46; Esto es al mismo tiempo l&#243;gico si tenemos en cuenta que no existen herramientas cuantitativas para su correcta medida y que la consciencia de la importancia que tiene la congesti&#243;n que persiste larvada a pesar del tratamiento es muy reciente&#46;</p><p id="par0090" class="elsevierStylePara elsevierViewall">Debe llamarse la atenci&#243;n&#44; no obstante&#44; sobre el empleo de m&#233;todos complementarios como los PN y la ultrasonograf&#237;a pulmonar para evaluar la evoluci&#243;n de la congesti&#243;n&#46; Aunque ambos han demostrado una indiscutible utilidad en el diagn&#243;stico de la IC&#44; especialmente durante las descompensaciones<a class="elsevierStyleCrossRefs" href="#bib0305"><span class="elsevierStyleSup">29&#44;30</span></a>&#44; no existe suficiente evidencia de su fiabilidad para el uso seriado&#44; por ejemplo diario&#44; para estimar la congesti&#243;n<a class="elsevierStyleCrossRefs" href="#bib0315"><span class="elsevierStyleSup">31&#44;32</span></a>&#44; y por tanto sus resultados deben interpretarse con prudencia para la toma de decisiones&#46;</p><p id="par0095" class="elsevierStylePara elsevierViewall">El presente trabajo tiene limitaciones metodol&#243;gicas&#46; En primer lugar&#44; se trata de una encuesta dise&#241;ada &#171;ad hoc&#187; y&#44; en segundo lugar&#44; el n&#250;mero de respuestas&#44; aunque significativo&#44; supone aproximadamente algo menos de la mitad de los receptores de la misma&#46; No obstante&#44; su prop&#243;sito era indagar en la percepci&#243;n subjetiva de los internistas habituados a tratar pacientes descompensados por IC&#44; en un aspecto &#8212;la congesti&#243;n residual&#8212; muy poco estudiado y del que por tanto se carece de evidencia firme&#46; Los resultados de la encuesta muestran que la intuici&#243;n cl&#237;nica&#44; algo que alcanzar&#237;a a duras penas una fuerza de recomendaci&#243;n &#171;C&#187; en el entorno de la medicina basada en la evidencia&#44; es una poderosa herramienta en la pr&#225;ctica diaria&#59; capaz de detectar un problema real&#44; para el que todav&#237;a no hay respuestas y&#44; de modo consensuado&#44; afrontarlo razonablemente&#46;</p><p id="par0100" class="elsevierStylePara elsevierViewall">La tarea a partir de ahora es determinar el umbral preciso &#8212;aquel que a&#241;ada una informaci&#243;n de relevancia pron&#243;stica en la pr&#225;ctica cl&#237;nica&#8212; de la congesti&#243;n residual&#46; Un umbral a situar entre la detecci&#243;n por m&#233;todos cl&#237;nicos&#44; accesibles&#44; pero poco sensibles&#44; y el cateterismo cardiaco&#44; sensible pero invasivo&#46;</p><p id="par0105" class="elsevierStylePara elsevierViewall">Es tarea nuestra y debemos afrontarla de modo cooperativo sin demora&#46; Intuici&#243;n y posibilidades no son ajenas al grupo de IC&#46;</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Conflicto de intereses</span><p id="par0110" class="elsevierStylePara elsevierViewall">Los autores declaran no tener conflictos de inter&#233;s relativos al art&#237;culo&#46;</p></span></span>"
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        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Los s&#237;ntomas congestivos son la clave para reconocer las descompensaciones de la insuficiencia cardiaca&#46; Su tratamiento se basa en la reducci&#243;n de la congesti&#243;n hasta alcanzar una situaci&#243;n cl&#237;nica que permita el alta del paciente para continuar el tratamiento ambulatoriamente&#46; Lo importante&#44; no obstante&#44; no es el grado de congesti&#243;n al ingreso&#44; sino la que persiste despu&#233;s de un tratamiento diur&#233;tico en&#233;rgico&#46; A la persistencia de signos congestivos despu&#233;s de un tratamiento aparentemente correcto y eficaz&#44; se le ha denominado &#171;congesti&#243;n residual&#187; y se asocia con mal pron&#243;stico&#46; Las herramientas para su estimaci&#243;n son todav&#237;a rudimentarias&#44; por lo que deben desarrollarse m&#233;todos que permitan una valoraci&#243;n m&#225;s precisa&#46;</p></span>"
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        "resumen" => "<span id="abst0010" class="elsevierStyleSection elsevierViewall"><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Congestive symptoms are the key to recognising decompensated heart failure&#44; whose treatment is based on reducing the congestion until a clinical situation has been reached that allows the patient to be discharged to continue outpatient treatment&#46; The important aspect is not the degree of congestion at admission but rather the congestion that persists after energetic diuretic therapy&#46; The persistence of congestive signs following an apparently correct and effective therapy has been called residual congestion and is associated with a poor prognosis&#46; The tools for determining this condition are still rudimentary&#46; Methods therefore need to be developed that enable a more accurate assessment&#46;</p></span>"
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                  \t\t\t\t">13-94&#37;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">86&#37;&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">40&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
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          "es" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Rendimiento de las diferentes t&#233;cnicas de estimaci&#243;n de la congesti&#243;n</p>"
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                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " colspan="5" align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black"><span class="elsevierStyleItalic">Score</span> de Ambrosy<a class="elsevierStyleCrossRef" href="#bib0250"><span class="elsevierStyleSup">18</span></a></th></tr><tr title="table-row"><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Signos&#47;s&#237;ntomas&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">1&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">3&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Disnea&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Ausente&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">M&#237;nima&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Frecuente&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Continua&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Ortopnea&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Ausente&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">M&#237;nima&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Frecuente&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Continua&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Astenia&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Ausente&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">M&#237;nima&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Frecuente&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Continua&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Ingurgitaci&#243;n yugular &#40;cm H<span class="elsevierStyleInf">2</span>O&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#60;<span class="elsevierStyleHsp" style=""></span>6&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">6-9&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">10-15&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#62;<span class="elsevierStyleHsp" style=""></span>15&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Crepitantes pulmonares&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Ausente&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">En bases&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#60;<span class="elsevierStyleHsp" style=""></span>50&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#62;<span class="elsevierStyleHsp" style=""></span>50&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Edema extremidades inferiores&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Ausente&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Leve&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
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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">Marcados&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">1&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">3&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Ortopnea&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Ausente&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Una almohada&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">Dos almohadas&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\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">Ausente&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Ingurgitaci&#243;n yugular &#40;cm H<span class="elsevierStyleInf">2</span>O&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#60;<span class="elsevierStyleHsp" style=""></span>6&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">&#62;<span class="elsevierStyleHsp" style=""></span>10&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">&#8212;&nbsp;\t\t\t\t\t\t\n
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Artículo especial
La congestión residual y la intuición clínica en la insuficiencia cardiaca descompensada
Residual congestion and clinical intuition in decompensated heart failure
J.I. Pérez Calvoa,b,c,
Autor para correspondencia
jiperez@unizar.es

Autor para correspondencia.
, J. Rubio Graciaa,c, C. Josa Laordena,c, J.L. Morales Rulld,e
a Servicio de Medicina Interna, Hospital Clínico Universitario Lozano Blesa, Zaragoza, España
b Facultad de Medicina, Universidad de Zaragoza, Zaragoza, España
c Instituto de Investigación Sanitaria de Aragón, Zaragoza, España
d Servicio de Medicina Interna, Hospital Universitario Arnau de Vilanova, Lleida, España
e Instituto de Investigación Biomédica Dr. Pifarré, Lleida, España
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Por una parte&#44; la proped&#233;utica requiere entrenamiento<a class="elsevierStyleCrossRef" href="#bib0195"><span class="elsevierStyleSup">7</span></a>&#44; y las t&#233;cnicas de adquisici&#243;n pueden ser m&#250;ltiples<a class="elsevierStyleCrossRef" href="#bib0200"><span class="elsevierStyleSup">8</span></a>&#44; lo que implica un cierto grado de variabilidad en la propia adquisici&#243;n de los datos&#46; Adem&#225;s&#44; la semiolog&#237;a cl&#237;nica es poco espec&#237;fica&#44; como tantos otros m&#233;todos diagn&#243;sticos&#44; con un alto valor predictivo negativo&#44; pero no positivo<a class="elsevierStyleCrossRefs" href="#bib0180"><span class="elsevierStyleSup">4&#44;9&#44;10</span></a>&#46; Adem&#225;s de m&#233;todos cl&#237;nicos&#44; el grado de congesti&#243;n puede estimarse mediante el uso de ecograf&#237;a &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">tabla 1</a>&#41;<a class="elsevierStyleCrossRef" href="#bib0180"><span class="elsevierStyleSup">4</span></a>&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0030" class="elsevierStylePara elsevierViewall">Aunque todav&#237;a especulativo&#44; es probable que la congesti&#243;n sist&#233;mica<a class="elsevierStyleCrossRefs" href="#bib0215"><span class="elsevierStyleSup">11&#44;12</span></a>&#44; o la del territorio espl&#225;cnico<a class="elsevierStyleCrossRef" href="#bib0225"><span class="elsevierStyleSup">13</span></a>&#44; desencadenando mecanismos inflamatorios<a class="elsevierStyleCrossRefs" href="#bib0230"><span class="elsevierStyleSup">14&#44;15</span></a> jueguen un papel crucial en la fisiopatolog&#237;a de las descompensaciones cardiacas&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">De lo que no hay duda es de que los signos y s&#237;ntomas congestivos son el heraldo de las descompensaciones<a class="elsevierStyleCrossRef" href="#bib0180"><span class="elsevierStyleSup">4</span></a>&#46; De hecho&#44; es la lucha contra la congesti&#243;n lo que centra el tratamiento al inicio del ingreso<a class="elsevierStyleCrossRefs" href="#bib0180"><span class="elsevierStyleSup">4&#44;16</span></a>&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">La persistencia de signos congestivos al alta se asocia con mayor riesgo de rehospitalizaci&#243;n por IC y mortalidad<a class="elsevierStyleCrossRefs" href="#bib0245"><span class="elsevierStyleSup">17-20</span></a>&#44; por lo que una descongesti&#243;n completa podr&#237;a ser el objetivo terap&#233;utico primario en las descompensaciones&#46; A la luz de estudios recientes<a class="elsevierStyleCrossRefs" href="#bib0250"><span class="elsevierStyleSup">18&#44;19</span></a>&#44; alcanzar un grado de descongesti&#243;n que consiga el alivio sintom&#225;tico y permita el alta puede no ser suficiente&#46; Entre la descongesti&#243;n que alivia los s&#237;ntomas y la que mejora el pron&#243;stico&#44; hay diferencias sustanciales&#46; Al grado de congesti&#243;n que permanece despu&#233;s del tratamiento inicial&#44; de modo sutil&#44; poco relevante desde el punto de vista semiol&#243;gico&#44; pero con incidencia negativa en la mortalidad&#44; es a lo que podemos llamar &#171;congesti&#243;n residual&#187;&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">Mediante un sistema sencillo de puntuaci&#243;n <span class="elsevierStyleItalic">&#40;score&#41;</span>&#44; basado en la presencia de disnea&#44; 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cl&#237;nicamente no aparente&#44; es muy frecuente al alta y confirmaron su mal pron&#243;stico&#46; En este estudio<a class="elsevierStyleCrossRef" href="#bib0255"><span class="elsevierStyleSup">19</span></a>&#44; tan solo el 23&#37; de los pacientes no mostraban signos de congesti&#243;n al alta&#44; mientras que en el 48 y 29&#37; estaban presentes en grado leve&#44; o significativo&#44; lo que se asociaba con un incremento de las rehospitalizaciones y la mortalidad&#44; respectivamente&#46;</p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><p id="par0050" class="elsevierStylePara elsevierViewall">Es evidente que el reto para el futuro inmediato es detectar y combatir la congesti&#243;n residual&#44; la que se resiste a la acci&#243;n de la terapia diur&#233;tica intensiva inmediatamente tras el ingreso&#46; Para hacerlo de modo eficaz y seguro&#44; primero hay que reconocerla&#46; Probablemente&#44; los <span class="elsevierStyleItalic">scores</span> cl&#237;nicos pueden complementarse con la respuesta diur&#233;tica<a class="elsevierStyleCrossRef" href="#bib0260"><span class="elsevierStyleSup">20</span></a>&#44; par&#225;metros bioqu&#237;micos como el hematocrito<a class="elsevierStyleCrossRef" href="#bib0265"><span class="elsevierStyleSup">21</span></a>&#44; las variaciones en la concentraci&#243;n de p&#233;ptido natriur&#233;tico &#40;PN&#41;<a class="elsevierStyleCrossRefs" href="#bib0270"><span class="elsevierStyleSup">22&#44;23</span></a>&#44; o el ant&#237;geno carbohidrato 125 &#40;CA125&#41;<a class="elsevierStyleCrossRef" href="#bib0280"><span class="elsevierStyleSup">24</span></a>&#46; Adem&#225;s&#44; tendremos que analizar la utilidad y el rendimiento de procedimientos ecogr&#225;ficos<a class="elsevierStyleCrossRefs" href="#bib0285"><span class="elsevierStyleSup">25&#44;26</span></a> y otros m&#233;todos no invasivos&#44; como la bioimpedanciometr&#237;a<a class="elsevierStyleCrossRefs" href="#bib0295"><span class="elsevierStyleSup">27&#44;28</span></a>&#46;</p><p id="par0055" class="elsevierStylePara elsevierViewall">El papel de la congesti&#243;n en la toma de decisiones de cara al alta y la percepci&#243;n de la congesti&#243;n residual&#44; una situaci&#243;n emergente&#44; en la pr&#225;ctica diaria son cuestiones sobre las que no existe mucha evidencia&#46; Para profundizar en ambos aspectos&#44; elaboramos una encuesta an&#243;nima con 13 preguntas&#44; distribuidas por correo electr&#243;nico a los miembros del Grupo de Insuficiencia Cardiaca &#40;GIC&#41; de la SEMI&#44; abierta del 22 de agosto al 23 de septiembre de 2018&#46; La encuesta se orient&#243; al modo de evaluar la congesti&#243;n y la importancia que los participantes le asignan en dos momentos clave de la evoluci&#243;n&#46; En la finalizaci&#243;n del tratamiento diur&#233;tico intensivo&#44; es decir&#44; cuando se consideran superados los s&#237;ntomas congestivos que motivaron el ingreso&#46; Y en la decisi&#243;n de proceder al alta&#44; es decir&#44; cuando consideran que ya no existe congesti&#243;n&#44; o esta puede tratarse con seguridad ambulatoriamente &#40;<a class="elsevierStyleCrossRef" href="#sec0015">material suplementario</a>&#41;&#46;</p><p id="par0060" class="elsevierStylePara elsevierViewall">Respondieron 253 especialistas&#44; la mayor&#237;a de medicina interna &#40;247&#41;&#44; y sus respuestas pueden consultarse en el blog del GIC &#40;<a href="http://cardioclinico.com/">http&#58;&#47;&#47;cardioclinico&#46;com&#47;</a>&#41; y en el <a class="elsevierStyleCrossRef" href="#sec0015">material suplementario</a>&#46;</p><p id="par0065" class="elsevierStylePara elsevierViewall">Para el reconocimiento y estimaci&#243;n de la congesti&#243;n&#44; utilizamos s&#237;ntomas y signos &#40;disnea&#44; ortopnea&#44; ingurgitaci&#243;n yugular y edemas&#59; m&#225;s de un 50&#37; cada uno&#41;&#44; las concentraciones de PN &#40;43&#37;&#41;&#44; la ultrasonograf&#237;a de la vena cava inferior &#40;45&#37;&#41;&#44; la pulmonar &#40;43&#37;&#41; y el CA125 &#40;16&#37;&#41;&#46;</p><p id="par0070" class="elsevierStylePara elsevierViewall">Sobre la respuesta precoz de la congesti&#243;n&#44; aquella que permite desescalar el tratamiento diur&#233;tico&#44; pasando de la v&#237;a i&#46;v&#46; a la oral&#44; respondieron 247 personas&#46; La mayor&#237;a recurre de nuevo a la semiolog&#237;a &#40;mejor&#237;a de disnea &#91;80&#37;&#93;&#44; reducci&#243;n de edemas &#91;78&#37;&#93; o peso &#91;63&#37;&#93;&#41; y la estabilidad de la dosis de diur&#233;tico oral &#40;62&#37;&#41;&#46; Un 86&#37; de los participantes estima la eficacia diur&#233;tica&#44; aunque la forma de medirla es muy variada y recae en la disminuci&#243;n de los signos y s&#237;ntomas de congesti&#243;n en el 86&#37;&#44; las concentraciones de PN &#40;24&#37;&#41; o en la ecograf&#237;a seriada pulmonar &#40;8&#37;&#41; o de la vena cava inferior &#40;5&#37;&#41;&#46;</p><p id="par0075" class="elsevierStylePara elsevierViewall">Se pregunt&#243; abiertamente si el t&#233;rmino &#171;congesti&#243;n residual&#187; suger&#237;a algo y&#44; en caso afirmativo&#44; c&#243;mo se interpretaba&#46; De las 247 respuestas&#44; 185 &#40;75&#37;&#41; manifestaron conocer tal situaci&#243;n cl&#237;nica&#44; y su percepci&#243;n&#44; aunque variable&#44; se ajusta de modo razonable a lo que cl&#237;nicamente se podr&#237;a esperar &#40;las respuestas individualizadas pueden consultarse en el blog&#41;&#46;</p><p id="par0080" class="elsevierStylePara elsevierViewall">El alta se gu&#237;a mayoritariamente por la reducci&#243;n de los edemas &#40;72&#37;&#41;&#44; la mejora de la clase funcional &#40;63&#37;&#41; y la dosis de diur&#233;tico oral estable &#40;62&#37;&#41;&#44; de nuevo mediante criterios eminentemente cl&#237;nicos&#46;</p><p id="par0085" class="elsevierStylePara elsevierViewall">Resulta llamativo que la mayor parte de las decisiones sobre la evaluaci&#243;n&#44; seguimiento y tratamiento de la congesti&#243;n en las descompensaciones de la IC se basen en la percepci&#243;n cl&#237;nica&#44; es decir&#44; en elementos semiol&#243;gicos&#46; Esto es al mismo tiempo l&#243;gico si tenemos en cuenta que no existen herramientas cuantitativas para su correcta medida y que la consciencia de la importancia que tiene la congesti&#243;n que persiste larvada a pesar del tratamiento es muy reciente&#46;</p><p id="par0090" class="elsevierStylePara elsevierViewall">Debe llamarse la atenci&#243;n&#44; no obstante&#44; sobre el empleo de m&#233;todos complementarios como los PN y la ultrasonograf&#237;a pulmonar para evaluar la evoluci&#243;n de la congesti&#243;n&#46; Aunque ambos han demostrado una indiscutible utilidad en el diagn&#243;stico de la IC&#44; especialmente durante las descompensaciones<a class="elsevierStyleCrossRefs" href="#bib0305"><span class="elsevierStyleSup">29&#44;30</span></a>&#44; no existe suficiente evidencia de su fiabilidad para el uso seriado&#44; por ejemplo diario&#44; para estimar la congesti&#243;n<a class="elsevierStyleCrossRefs" href="#bib0315"><span class="elsevierStyleSup">31&#44;32</span></a>&#44; y por tanto sus resultados deben interpretarse con prudencia para la toma de decisiones&#46;</p><p id="par0095" class="elsevierStylePara elsevierViewall">El presente trabajo tiene limitaciones metodol&#243;gicas&#46; En primer lugar&#44; se trata de una encuesta dise&#241;ada &#171;ad hoc&#187; y&#44; en segundo lugar&#44; el n&#250;mero de respuestas&#44; aunque significativo&#44; supone aproximadamente algo menos de la mitad de los receptores de la misma&#46; No obstante&#44; su prop&#243;sito era indagar en la percepci&#243;n subjetiva de los internistas habituados a tratar pacientes descompensados por IC&#44; en un aspecto &#8212;la congesti&#243;n residual&#8212; muy poco estudiado y del que por tanto se carece de evidencia firme&#46; Los resultados de la encuesta muestran que la intuici&#243;n cl&#237;nica&#44; algo que alcanzar&#237;a a duras penas una fuerza de recomendaci&#243;n &#171;C&#187; en el entorno de la medicina basada en la evidencia&#44; es una poderosa herramienta en la pr&#225;ctica diaria&#59; capaz de detectar un problema real&#44; para el que todav&#237;a no hay respuestas y&#44; de modo consensuado&#44; afrontarlo razonablemente&#46;</p><p id="par0100" class="elsevierStylePara elsevierViewall">La tarea a partir de ahora es determinar el umbral preciso &#8212;aquel que a&#241;ada una informaci&#243;n de relevancia pron&#243;stica en la pr&#225;ctica cl&#237;nica&#8212; de la congesti&#243;n residual&#46; Un umbral a situar entre la detecci&#243;n por m&#233;todos cl&#237;nicos&#44; accesibles&#44; pero poco sensibles&#44; y el cateterismo cardiaco&#44; sensible pero invasivo&#46;</p><p id="par0105" class="elsevierStylePara elsevierViewall">Es tarea nuestra y debemos afrontarla de modo cooperativo sin demora&#46; Intuici&#243;n y posibilidades no son ajenas al grupo de IC&#46;</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Conflicto de intereses</span><p id="par0110" class="elsevierStylePara elsevierViewall">Los autores declaran no tener conflictos de inter&#233;s relativos al art&#237;culo&#46;</p></span></span>"
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        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Los s&#237;ntomas congestivos son la clave para reconocer las descompensaciones de la insuficiencia cardiaca&#46; Su tratamiento se basa en la reducci&#243;n de la congesti&#243;n hasta alcanzar una situaci&#243;n cl&#237;nica que permita el alta del paciente para continuar el tratamiento ambulatoriamente&#46; Lo importante&#44; no obstante&#44; no es el grado de congesti&#243;n al ingreso&#44; sino la que persiste despu&#233;s de un tratamiento diur&#233;tico en&#233;rgico&#46; A la persistencia de signos congestivos despu&#233;s de un tratamiento aparentemente correcto y eficaz&#44; se le ha denominado &#171;congesti&#243;n residual&#187; y se asocia con mal pron&#243;stico&#46; Las herramientas para su estimaci&#243;n son todav&#237;a rudimentarias&#44; por lo que deben desarrollarse m&#233;todos que permitan una valoraci&#243;n m&#225;s precisa&#46;</p></span>"
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        "resumen" => "<span id="abst0010" class="elsevierStyleSection elsevierViewall"><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Congestive symptoms are the key to recognising decompensated heart failure&#44; whose treatment is based on reducing the congestion until a clinical situation has been reached that allows the patient to be discharged to continue outpatient treatment&#46; The important aspect is not the degree of congestion at admission but rather the congestion that persists after energetic diuretic therapy&#46; The persistence of congestive signs following an apparently correct and effective therapy has been called residual congestion and is associated with a poor prognosis&#46; The tools for determining this condition are still rudimentary&#46; Methods therefore need to be developed that enable a more accurate assessment&#46;</p></span>"
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                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Disnea&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Ausente&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">M&#237;nima&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Frecuente&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Continua&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Ortopnea&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Ausente&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">M&#237;nima&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Frecuente&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Continua&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Astenia&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Ausente&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">M&#237;nima&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Frecuente&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Continua&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Ingurgitaci&#243;n yugular &#40;cm H<span class="elsevierStyleInf">2</span>O&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#60;<span class="elsevierStyleHsp" style=""></span>6&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">6-9&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">10-15&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#62;<span class="elsevierStyleHsp" style=""></span>15&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Crepitantes pulmonares&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Ausente&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">En bases&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#60;<span class="elsevierStyleHsp" style=""></span>50&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#62;<span class="elsevierStyleHsp" style=""></span>50&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Edema extremidades inferiores&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Ausente&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Leve&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Moderado&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Marcados&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
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                0 => "xTab2092822.png"
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            1 => array:2 [
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                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " colspan="5" align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col"><span class="elsevierStyleItalic">Score</span> de Rubio<a class="elsevierStyleCrossRef" href="#bib0255"><span class="elsevierStyleSup">19</span></a></th></tr><tr title="table-row"><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Ortopnea&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Ausente&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Una almohada&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Dos almohadas&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#62;<span class="elsevierStyleHsp" style=""></span>30 grados&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Edemas&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Ausente&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Leve&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Moderados&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Maracdos&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Ingurgitaci&#243;n yugular &#40;cm H<span class="elsevierStyleInf">2</span>O&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#60;<span class="elsevierStyleHsp" style=""></span>6&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">6-10&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#62;<span class="elsevierStyleHsp" style=""></span>10&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#8212;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
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                0 => "xTab2092823.png"
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        "descripcion" => array:1 [
          "es" => "<p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Evaluaci&#243;n de la congesti&#243;n mediante <span class="elsevierStyleItalic">scores</span> cl&#237;nicos</p>"
        ]
      ]
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        "identificador" => "upi0005"
        "tipo" => "MULTIMEDIAECOMPONENTE"
        "mostrarFloat" => false
        "mostrarDisplay" => true
        "Ecomponente" => array:2 [
          "fichero" => "mmc1.pdf"
          "ficheroTamanyo" => 337899
        ]
      ]
    ]
    "bibliografia" => array:2 [
      "titulo" => "Bibliograf&#237;a"
      "seccion" => array:1 [
        0 => array:2 [
          "identificador" => "bibs0015"
          "bibliografiaReferencia" => array:32 [
            0 => array:3 [
              "identificador" => "bib0165"
              "etiqueta" => "1"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "The &#8220;modern&#8221; view of heart failure&#46; How did we get there&#63;"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:1 [
                            0 => "A&#46;M&#46; Katz"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1161/CIRCHEARTFAILURE.108.772756"
                      "Revista" => array:6 [
                        "tituloSerie" => "Circ Heart Fail&#46;"
                        "fecha" => "2008"
                        "volumen" => "1"
                        "paginaInicial" => "63"
                        "paginaFinal" => "71"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/19808272"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            1 => array:3 [
              "identificador" => "bib0170"
              "etiqueta" => "2"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Da&#241;o org&#225;nico y s&#237;ndrome cardiorrenal en la insuficiencia cardiaca aguda"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:2 [
                            0 => "J&#46; Casado Cerrada"
                            1 => "J&#46;I&#46; P&#233;rez Calvo"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1016/S0025-7753(14)70079-X"
                      "Revista" => array:7 [
                        "tituloSerie" => "Med Clin &#40;Barc&#41;&#46;"
                        "fecha" => "2014"
                        "volumen" => "142"
                        "numero" => "Supl&#46; 1"
                        "paginaInicial" => "26"
                        "paginaFinal" => "31"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/24930080"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            2 => array:3 [
              "identificador" => "bib0175"
              "etiqueta" => "3"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Implicaci&#243;n de la congesti&#243;n venosa sist&#233;mica en la insuficiencia cardiaca"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:3 [
                            0 => "J&#46; Rubio Gracia"
                            1 => "M&#46; S&#225;nchez Marteles"
                            2 => "J&#46;I&#46; P&#233;rez Calvo"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1016/j.rce.2016.10.012"
                      "Revista" => array:6 [
                        "tituloSerie" => "Rev Clin Esp&#46;"
                        "fecha" => "2017"
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ISSN: 00142565
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