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          "es" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Relaci&#243;n entre las diferentes comorbilidades cardiovasculares y los grupos GOLD 2017&#46;</p> <p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">ACV&#58; accidente cerebrovascular&#59; AP&#58; arteriopat&#237;a perif&#233;rica&#46; Arritmia cardiaca&#58; fibrilaci&#243;n auricular&#59; CI&#58; cardiopat&#237;a isqu&#233;mica&#59; DM&#58; diabetes mellitus tipo 2&#59; ERC&#58; enfermedad renal cr&#243;nica&#59; GOLD&#58; <span class="elsevierStyleItalic">Global Initiative for Chronic Obstructive Lung Disease</span>&#59; HTA&#58; hipertensi&#243;n arterial&#59; IC&#58; insuficiencia cardiaca&#59; SAHS&#58; apnea del sue&#241;o&#46;</p> <p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">El tama&#241;o de cada nodo es proporcional a la prevalencia de cada una de las comorbilidades representadas&#46; La anchura de los nexos es proporcional al valor al cuadrado del coeficiente phi&#46; El color azul representa un aumento en la probabilidad de aparici&#243;n conjunta de 2 comorbilidades en un paciente&#44; mientras que las l&#237;neas rojas representan una disminuci&#243;n en la probabilidad de aparici&#243;n conjunta de ambas comorbilidades &#40;RRij<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>1&#41;&#46; Solo se representan asociaciones estad&#237;sticamente significativas entre 2 enfermedades&#46;</p>"
        ]
      ]
    ]
    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Introducci&#243;n</span><p id="par0125" class="elsevierStylePara elsevierViewall">Diversos estudios han mostrado como entre el 60-90&#37; de los pacientes con enfermedad pulmonar obstructiva cr&#243;nica &#40;EPOC&#41; presentan alguna comorbilidad concomitante&#44; con una media de cuatro enfermedades cr&#243;nicas por paciente<a class="elsevierStyleCrossRefs" href="#bib0225"><span class="elsevierStyleSup">1&#44;2</span></a>&#59; los accidentes cerebrovasculares &#40;ACV&#41; y las enfermedades cardiacas &#40;insuficiencia cardiaca &#91;IC&#93;&#44; cardiopat&#237;a isqu&#233;mica &#91;CI&#93; y arritmia&#41; se encuentran entre las comorbilidades m&#225;s prevalentes &#40;1&#44;2&#41;&#44; siendo de las principales causa de muerte en estos pacientes incluso desde las fases m&#225;s precoces de la enfermedad<a class="elsevierStyleCrossRef" href="#bib0235"><span class="elsevierStyleSup">3</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">En trabajos realizados en poblaci&#243;n adulta ambulatoria se estima que los pacientes con EPOC tienen un riesgo ajustado entre 2 y 5 veces mayor de presentar CI frente a sujetos sin EPOC<a class="elsevierStyleCrossRef" href="#bib0240"><span class="elsevierStyleSup">4</span></a>&#46; La amplia evidencia cient&#237;fica demuestra que la dislipidemia &#40;DLP&#41; es uno de los principales factores de riesgo para el desarrollo de CI<a class="elsevierStyleCrossRef" href="#bib0245"><span class="elsevierStyleSup">5</span></a>&#44; con una prevalencia en pacientes con EPOC entre el 30&#37; y el 70&#37;<a class="elsevierStyleCrossRefs" href="#bib0225"><span class="elsevierStyleSup">1&#44;2&#44;6&#44;7</span></a>&#44; muy superior a la de la poblaci&#243;n general<a class="elsevierStyleCrossRefs" href="#bib0230"><span class="elsevierStyleSup">2&#44;4&#44;6</span></a>&#46; Divo et al&#46;<a class="elsevierStyleCrossRef" href="#bib0255"><span class="elsevierStyleSup">7</span></a> demostraron que comorbilidades como la CI&#44; la fibrilaci&#243;n auricular y la IC tienen un impacto negativo sobre el pron&#243;stico vital de estos pacientes&#44; siendo la DLP junto a la hipertensi&#243;n arterial &#40;HTA&#41; los factores de riesgo mas prevalentes&#46;</p><p id="par0130" class="elsevierStylePara elsevierViewall">Este hecho nos debe hacer reflexionar acerca de la importancia de su control&#46; Ser conocedores de c&#243;mo en un paciente con EPOC dichos factores de riesgo se relacionan con la existencia de enfermedad cardiovascular es un elemento clave a la hora de realizar una adecuada prevenci&#243;n en su aparici&#243;n y&#47;o un mejor control de la patolog&#237;a&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">Los objetivos del presente estudio fueron&#58; 1&#41; evaluar la relaci&#243;n existente entre el diagn&#243;stico de DLP y las presencia de enfermedad cardiovascular&#44; y compararlo con otros factores conocidos de riesgo cardiovascular como son la HTA&#44; la obesidad&#44; la diabetes mellitus tipo 2 &#40;DMT2&#41; y el s&#237;ndrome de apnea-hipopnea del sue&#241;o &#40;SAHS&#41;&#44; y 2&#41; determinar la relaci&#243;n entre las distintas comorbilidades cardiovasculares y los grupos de gravedad seg&#250;n la clasificaci&#243;n <span class="elsevierStyleItalic">Global Initiative for Chronic Obstructive Lung Disease</span> &#40;GOLD&#41; 2017&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">M&#233;todos</span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Fuente de datos</span><p id="par0020" class="elsevierStylePara elsevierViewall">Entre el 1 de enero de 2012 y el 31 de diciembre de 2014 se realiz&#243; un estudio observacional transversal con pacientes con EPOC seguidos en la consulta ambulatoria de Neumolog&#237;a del Hospital Universitario Nuestra Se&#241;ora de Candelaria&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Poblaci&#243;n de pacientes</span><p id="par0025" class="elsevierStylePara elsevierViewall">Se incluy&#243; en el estudio un total de 454 pacientes&#46; Se establecieron los siguientes criterios de inclusi&#243;n&#58; edad<span class="elsevierStyleHsp" style=""></span>&#62;<span class="elsevierStyleHsp" style=""></span>40 a&#241;os&#44; fumador activo o exfumador con un &#237;ndice paquetes-a&#241;o &#40;IPA&#41;<span class="elsevierStyleHsp" style=""></span>&#8805;<span class="elsevierStyleHsp" style=""></span>10 y una ratio volumen espiratorio forzado en el primer segundo &#40;FEV<span class="elsevierStyleInf">1</span>&#41;&#47;capacidad vital forzada &#40;FVC&#41; menor del 70&#37; tras la administraci&#243;n de 400<span class="elsevierStyleHsp" style=""></span>&#956;g de salbutamol&#44; as&#237; como un seguimiento previo por neumolog&#237;a durante al menos 6 meses&#46; Los criterios de exclusi&#243;n considerados fueron la presencia de enfermedad respiratoria cr&#243;nica distinta de la EPOC y la existencia de obstrucci&#243;n cr&#243;nica al flujo a&#233;reo sin exposici&#243;n a humo de tabaco o con un IPA inferior a 10&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Covariantes</span><p id="par0030" class="elsevierStylePara elsevierViewall">A trav&#233;s de la historia cl&#237;nica informatizada se recogieron de cada paciente los siguientes par&#225;metros en el momento de la inclusi&#243;n&#58; edad&#44; sexo&#44; &#237;ndice de masa corporal &#40;&#91;IMC&#93; calculado por el peso en kg&#47;altura en m<span class="elsevierStyleSup">2</span>&#41;&#44; h&#225;bito tab&#225;quico &#40;fumador activo si por lo menos hab&#237;a fumado un cigarrillo en los 6 &#250;ltimos meses&#59; exfumador si hab&#237;a mantenido una abstinencia continuada de al menos 6 meses&#41; e intensidad tab&#225;quica mediante el IPA &#40;&#91;n&#250;mero de cigarrillos al d&#237;a<span class="elsevierStyleHsp" style=""></span>&#215;<span class="elsevierStyleHsp" style=""></span>a&#241;os fumando&#93;&#47;20&#41;&#44; as&#237; como la disnea evaluada con la escala modificada del <span class="elsevierStyleItalic">Medical Research Council</span>&#46; En relaci&#243;n con las comorbilidades&#44; se recogi&#243; informaci&#243;n acerca de factores de riesgo cardiovascular&#58;&#58; HTA&#44; DMT2&#44; DLP&#44; SAHS &#40;definido como un &#237;ndice apnea-hipopnea &#62; 15&#41; y obesidad &#40;definida como un IMC<span class="elsevierStyleHsp" style=""></span>&#62;<span class="elsevierStyleHsp" style=""></span>30&#41;&#59; presencia de enfermedad cardiovascular&#58; CI&#44; fibrilaci&#243;n auricular&#44; IC&#44; ACV&#44; arteriopat&#237;a perif&#233;rica &#40;AP&#41; y enfermedad renal cr&#243;nica &#40;ERC&#41;&#46; Estas comorbilidades fueron confirmadas en consulta y mediante la revisi&#243;n de la prescripci&#243;n farmacol&#243;gica&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">Se calcul&#243; el &#237;ndice de comorbilidad de Charlson para cada paciente<a class="elsevierStyleCrossRef" href="#bib0260"><span class="elsevierStyleSup">8</span></a>&#46; Tambi&#233;n se registraron los datos obtenidos de la espirometr&#237;a forzada como son el FEV<span class="elsevierStyleInf">1</span>&#44; el FVC y el cociente FEV1&#47;FVC&#46; Los pacientes se estratificaron conforme a los 4 grados de gravedad recogidos en la clasificaci&#243;n GOLD 2009<a class="elsevierStyleCrossRef" href="#bib0265"><span class="elsevierStyleSup">9</span></a> y GOLD 2017<a class="elsevierStyleCrossRef" href="#bib0270"><span class="elsevierStyleSup">10</span></a>&#46;</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">An&#225;lisis estad&#237;stico</span><p id="par0040" class="elsevierStylePara elsevierViewall">Dependiendo de la naturaleza de las variables se utilizaron estad&#237;sticas descriptivas distintas para las variables cuantitativas &#40;media&#44; desviaci&#243;n est&#225;ndar&#44; mediana e intercuartil&#41; y cualitativas &#40;&#37;&#41;&#46; La prevalencia puntual de comorbilidades se calcul&#243; estimando las proporciones conforme al m&#233;todo Clopper-Pearson del paquete binGroup<a class="elsevierStyleCrossRef" href="#bib0275"><span class="elsevierStyleSup">11</span></a>&#46; Dependiendo de qu&#233; condiciones se cumplieran&#44; el an&#225;lisis de la asociaci&#243;n entre comorbilidades se realiz&#243; mediante el test de Fisher o la prueba de Chi-cuadrado cuando no se cumplieran las condiciones para el anterior&#46; De acuerdo con lo propuesto por Hidalgo et al&#46;<a class="elsevierStyleCrossRef" href="#bib0280"><span class="elsevierStyleSup">12</span></a> el grado de asociaci&#243;n entre comorbilidades se cuantific&#243; por estimaci&#243;n del riesgo relativo &#40;RRij&#41;&#44; as&#237; como por el coeficiente de correlaci&#243;n phi &#40;&#632;&#41;&#46; Para calcular el RRij en el caso de 2 enfermedades en el mismo paciente&#44; se emple&#243; la siguiente ecuaci&#243;n&#58; RRij<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span> &#40;Cij<span class="elsevierStyleHsp" style=""></span>x<span class="elsevierStyleHsp" style=""></span>N&#41;&#47;&#40;Pi<span class="elsevierStyleHsp" style=""></span>&#215;<span class="elsevierStyleHsp" style=""></span>Pj&#41;&#44; donde Cij es el n&#250;mero de pacientes que sufren ambas enfermedades &#40;ij&#41;&#44; N el n&#250;mero total de pacientes y P el n&#250;mero de pacientes que presentan una de las 2 enfermedades&#46; La correlaci&#243;n phi &#40;&#632;&#41; se calcul&#243; mediante la funci&#243;n &#632; del paquete psych<a class="elsevierStyleCrossRef" href="#bib0285"><span class="elsevierStyleSup">13</span></a>&#46; Las asociaciones entre comorbilidades se representaron gr&#225;ficamente mediante nodos y enlaces&#44; donde el tama&#241;o de cada nodo es proporcional a la prevalencia de cada comorbilidad y la anchura de los enlaces al valor al cuadrado del coeficiente de &#632;&#46; As&#237;&#44; los bordes restantes representan las asociaciones estad&#237;sticamente significativas entre las 2 enfermedades&#46; Esta manera de presentaci&#243;n de los datos mejora la visi&#243;n general del patr&#243;n de comorbilidades&#46; Adem&#225;s&#44; en la gr&#225;fica se incluyeron los diferentes grupos seg&#250;n la GOLD 2017&#46;</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Aspectos &#233;ticos</span><p id="par0045" class="elsevierStylePara elsevierViewall">El estudio fue aprobado por el Comit&#233; de &#201;tica del Hospital Universitario Nuestra Se&#241;ora de la Candelaria&#46;</p></span></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">Resultados</span><p id="par0050" class="elsevierStylePara elsevierViewall">La <a class="elsevierStyleCrossRef" href="#tbl0005">tabla 1</a> describe las caracter&#237;sticas de los 454 pacientes con EPOC&#46; La mayor&#237;a de ellos fueron hombres &#40;78&#37; vs&#46; 22&#37; mujeres&#41;&#44; con una media de edad de 69 a&#241;os&#44; un FEV<span class="elsevierStyleInf">1</span> predicho medio de 55 &#177; 20&#37;&#44; y m&#225;s de un tercio eran fumadores activos &#40;36&#37;&#41;&#46; De acuerdo con las categor&#237;as GOLD 2017&#44; 146 &#40;32&#37;&#41; pacientes se clasificaron como GOLD A&#44; 213 &#40;47&#37;&#41; como GOLD B&#44; 10 &#40;2&#37;&#41; como GOLD C y 85 &#40;19&#37;&#41; como GOLD D&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0055" class="elsevierStylePara elsevierViewall">Con respecto al perfil cardiovascular nuestros pacientes con EPOC presentan una alta tasa de DLP&#44; HTA&#44; DMT2 y obesidad&#46; En lo referente a la enfermedad cardiovascular&#44; se encontr&#243; una alta prevalencia de CI&#44; fibrilaci&#243;n auricular e IC &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">tabla 1</a>&#41;&#46;</p><p id="par0060" class="elsevierStylePara elsevierViewall">En cuanto a los factores de riesgo cardiovascular la DLP se relacion&#243; con la presencia de ACV &#40;RRij 1&#44;36&#59; p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;0054&#41;&#44; ERC &#40;RRij 1&#44;34&#59; p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;00023&#41;&#44; AP &#40;RRij 1&#44;38&#59; p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;00015&#41;&#44; IC &#40;RRij 1&#44;22&#59; p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;012&#41;&#44; CI &#40;RRij 1&#44;22&#59; p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;0055&#41; y fibrilaci&#243;n auricular &#40;RRij 1&#44;28&#59; p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;0004&#41;&#46; Tanto la HTA como la DMT2 fueron relacionadas con estas mismas patolog&#237;as cardiovasculares&#46; Adem&#225;s&#44; la obesidad y el SAHS estaban significativamente relacionadas con presencia de IC y ERC &#40;<a class="elsevierStyleCrossRef" href="#tbl0010">tabla 2</a>&#44; <a class="elsevierStyleCrossRef" href="#fig0005">fig&#46; 1</a>&#41;&#46;</p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0065" class="elsevierStylePara elsevierViewall">A todo ello hay que a&#241;adir que la presencia de DLP estaba significativamente relacionada con los dem&#225;s factores de riesgo cardiovascular &#40;SAHS&#44; HTA&#44; DMT2 y obesidad&#41; &#40;<a class="elsevierStyleCrossRef" href="#tbl0015">tabla 3</a>&#44; <a class="elsevierStyleCrossRef" href="#fig0005">fig&#46; 1</a>&#41;&#46;</p><elsevierMultimedia ident="tbl0015"></elsevierMultimedia><p id="par0070" class="elsevierStylePara elsevierViewall">En lo que respecta a la clasificaci&#243;n de la GOLD 2017&#44; el grupo B presenta una mayor relaci&#243;n con la comorbilidad cardiovascular respecto al resto de grupos &#40;<a class="elsevierStyleCrossRef" href="#tbl0020">tabla 4</a>&#41;&#46;</p><elsevierMultimedia ident="tbl0020"></elsevierMultimedia></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0105">Discusi&#243;n</span><p id="par0075" class="elsevierStylePara elsevierViewall">En nuestra muestra aproximadamente el 70&#37; de los pacientes con EPOC fueron dislipid&#233;micos&#46; Qued&#243; demostrado que la DLP de estos pacientes estaba significativamente relacionada con la presencia de enfermedad cardiovascular&#44; sobre todo con el ACV&#44; ERC y AP&#46; La HTA y la DMT2 fueron los factores de riesgo cardiovascular m&#225;s relacionados con la presencia de la enfermedad cardiovascular&#46; Adem&#225;s&#44; el grupo B de la clasificaci&#243;n GOLD 2017 mostr&#243; una marcada asociaci&#243;n con la comorbilidad cardiovascular&#46;</p><p id="par0080" class="elsevierStylePara elsevierViewall">En nuestro estudio&#44; la existencia de DLP se relacionaba de forma significativa con la presencia de fibrilaci&#243;n auricular&#44; CI&#44; e IC&#44; adquiriendo especial relevancia en el ACV&#44; AP y ERC&#46; Este hecho nos orienta acerca de su relevante implicaci&#243;n en el desarrollo de la patolog&#237;a cardiovascular y la importancia en su prevenci&#243;n&#46; Aunque las enfermedades cardiovasculares son una comorbilidad habitual en los pacientes con EPOC<a class="elsevierStyleCrossRefs" href="#bib0225"><span class="elsevierStyleSup">1&#44;4&#44;6&#44;7</span></a>&#44; los estudios dirigidos a evaluar el papel de la DLP en esta enfermedad son escasos<a class="elsevierStyleCrossRefs" href="#bib0290"><span class="elsevierStyleSup">14&#8211;17</span></a> sin poder encontrar un perfil lip&#237;dico propio<a class="elsevierStyleCrossRefs" href="#bib0290"><span class="elsevierStyleSup">14&#8211;16</span></a>&#46; Un estudio realizado por nuestro grupo determin&#243; como los pacientes con EPOC mostraban 5 veces m&#225;s riesgo de presentar DLP &#40;OR&#58; 5&#44;04&#59; IC 95&#37;&#58; 2&#44;36-10&#44;74&#41; comparado con el grupo control tras corregir por variables de confusi&#243;n como son la edad&#44; el sexo y el &#237;ndice paquetes-a&#241;o<a class="elsevierStyleCrossRef" href="#bib0250"><span class="elsevierStyleSup">6</span></a>&#46; En este sentido&#44; diversos trabajos han descrito que en los pacientes con EPOC los niveles de colesterol total&#44; triglic&#233;ridos y lipoprote&#237;nas de baja densidad eran m&#225;s altos que los de la poblaci&#243;n control&#44; adem&#225;s de acompa&#241;arse de un descenso de los niveles lipoproteinas de alta densidad &#40;HDL&#41; y apolipoproteina &#40;Apo&#41; B-100&#44; lo que podr&#237;a estar influenciado por el grado de inflamaci&#243;n sist&#233;mica del paciente<a class="elsevierStyleCrossRef" href="#bib0295"><span class="elsevierStyleSup">15</span></a>&#46; En l&#237;nea con estos datos el estudio de Krakhmalova et al&#46;<a class="elsevierStyleCrossRef" href="#bib0300"><span class="elsevierStyleSup">16</span></a> describi&#243; que aquellos pacientes con EPOC con CI concomitante mostraban mayores niveles de LDL frente a pacientes sin afectaci&#243;n coronaria&#44; describi&#233;ndose una peor evoluci&#243;n del fen&#243;meno ateroescler&#243;tico especialmente en aquellos sujetos con hipoxemia cr&#243;nica&#44; un aspecto que podr&#237;a agravarse en aquellos sujetos con diagn&#243;stico de SAHS<a class="elsevierStyleCrossRef" href="#bib0310"><span class="elsevierStyleSup">18</span></a>&#46;</p><p id="par0085" class="elsevierStylePara elsevierViewall">Por el contrario&#44; la ERC parece promover cambios en el perfil lip&#237;dico<a class="elsevierStyleCrossRefs" href="#bib0315"><span class="elsevierStyleSup">19&#8211;21</span></a>&#46; Se han descrito niveles de LDL ligeramente elevados&#44; de HDL bajos&#44; de triglic&#233;ridos altos y de lipoprote&#237;na &#40;a&#41; aumentados&#46; Estas alteraciones est&#225;n relacionadas con el grado de afectaci&#243;n renal&#44; la etiolog&#237;a primaria de la ERC&#44; la presencia de s&#237;ndrome nefr&#243;tico y con la t&#233;cnica de di&#225;lisis empleada en la terapia de reemplazo renal<a class="elsevierStyleCrossRefs" href="#bib0320"><span class="elsevierStyleSup">20&#44;21</span></a>&#46; Los hechos m&#225;s arriba mencionados sugieren que tanto el estado inflamatorio subyacente en pacientes con EPOC como las comorbilidades asociadas podr&#237;an facilitar alteraciones en las fracciones lip&#237;dicas&#44; lo que puede explicar la ausencia de una relaci&#243;n clara entre el grado de obstrucci&#243;n del flujo a&#233;reo y los cambios en el perfil lip&#237;dico<a class="elsevierStyleCrossRefs" href="#bib0330"><span class="elsevierStyleSup">22&#44;23</span></a>&#46; Adem&#225;s&#44; el efecto a&#241;adido del tabaco as&#237; como la intensidad del consumo &#40;recordemos que existe una relaci&#243;n dosis-respuesta entre el n&#250;mero de cigarros consumidos y los cambios en el perfil lip&#237;dico&#41;<a class="elsevierStyleCrossRef" href="#bib0340"><span class="elsevierStyleSup">24</span></a>&#44; pueden incrementar paralelamente el grado de inflamaci&#243;n sist&#233;mica en estos pacientes&#44; lo que favorecer&#225; que encontremos variaciones en las fracciones lip&#237;dicas de estos enfermos&#46; Siendo conocedores de ello es razonable valorar la posibilidad de que en los pacientes con EPOC&#44; especialmente en aquellos con tabaquismo activo y&#47;o presencia de SAHS o ERC concomitante&#44; debamos aplicar una actitud terap&#233;utica &#8220;m&#225;s agresiva&#8221; tanto en las recomendaciones diet&#233;ticas como en el uso de hipolipemiantes comparado con sujetos dislip&#233;micos sin EPOC&#46; No obstante&#44; son precisos estudios que avalen esta hip&#243;tesis&#46;</p><p id="par0090" class="elsevierStylePara elsevierViewall">Debemos a&#241;adir que en nuestra poblaci&#243;n tanto la DLP como la DMT2 y la HTA&#44; fueron factores relacionados con la presencia de AP&#46; Houben-Wilke et al&#46;<a class="elsevierStyleCrossRef" href="#bib0345"><span class="elsevierStyleSup">25</span></a> mostraron el impacto cl&#237;nico negativo de este hecho en los pacientes con EPOC&#44; en los que la capacidad funcional evaluada con la prueba de caminata de 6<span class="elsevierStyleHsp" style=""></span>minutos disminu&#237;a y empeoraba el estado de salud y la calidad de vida&#44; razones todas ellas por las que el control de dichos factores de riesgo cardiovascular es clave en su prevenci&#243;n y manejo<a class="elsevierStyleCrossRefs" href="#bib0350"><span class="elsevierStyleSup">26&#44;27</span></a>&#46;</p><p id="par0095" class="elsevierStylePara elsevierViewall">Adem&#225;s&#44; debemos destacar el hecho de que la HTA y la DMT2 fueron los factores de riesgo cardiovascular que mayor relaci&#243;n mostraron con la presencia de CI y de ACV&#44; lo que confirma la importancia del manejo correcto de estos factores de riesgo a fin de prevenir dichos eventos<a class="elsevierStyleCrossRefs" href="#bib0360"><span class="elsevierStyleSup">28&#44;29</span></a>&#46; Los principales factores de riesgo de accidente cerebrovascular&#44; que combinados representan el 88&#44;1&#37; de los riesgos atribuibles a la poblaci&#243;n&#44; incluyen antecedentes de HTA&#44; tabaquismo activo&#44; &#237;ndice cintura-cadera&#44; tipo de alimentaci&#243;n&#44; inactividad f&#237;sica&#44; diabetes mellitus&#44; ingesta de alcohol&#44; estr&#233;s psicosocial&#44; causas card&#237;acas y la proporci&#243;n de apolipoprote&#237;nas B a A1<a class="elsevierStyleCrossRef" href="#bib0370"><span class="elsevierStyleSup">30</span></a>&#46; Estos factores de riesgo tambi&#233;n se aplican a los pacientes con EPOC&#46; As&#237;&#44; el v&#237;nculo entre la EPOC e ictus puede presentar sesgo por un efecto de confusi&#243;n<a class="elsevierStyleCrossRef" href="#bib0375"><span class="elsevierStyleSup">31</span></a>&#46; Parece ser que las estatinas pudieran aportar un efecto beneficioso en la EPOC&#44; ya que se ha sugerido que reducen el riesgo de exacerbaci&#243;n de hasta un 30&#37; y del riesgo de mortalidad en un 21-78&#37;<a class="elsevierStyleCrossRefs" href="#bib0380"><span class="elsevierStyleSup">32&#44;33</span></a>&#46; Sin embargo&#44; los datos siguen siendo confusos&#44; y mientras que un metaan&#225;lisis reciente confirm&#243; la asociaci&#243;n de las estatinas con una reducci&#243;n significativa del riesgo de infarto de miocardio&#44; no pudo demostrar ning&#250;n beneficio en cuanto a la prevenci&#243;n del ictus<a class="elsevierStyleCrossRef" href="#bib0390"><span class="elsevierStyleSup">34</span></a>&#46;</p><p id="par0100" class="elsevierStylePara elsevierViewall">Para finalizar&#44; la obesidad se relacion&#243; con la presencia de DLP&#44; DMT2 y HTA lo que nos puede alertar acerca de la importancia de detectar a este tipo de pacientes por la alta probabilidad de padecer un s&#237;ndrome metab&#243;lico&#46; Este s&#237;ndrome es un problema complejo&#44; caracterizado por obesidad abdominal&#44; DLP aterog&#233;nica&#44; HTA y resistencia a la insulina-intolerancia a la glucosa&#44; las cuales se asocian con un estado protromb&#243;tico y proinflamatorio mayor&#46; Estos pacientes tienen un mayor IMC&#44; una funci&#243;n pulmonar m&#225;s conservada y un mayor grado de inflamaci&#243;n sist&#233;mica&#44; respecto a aquellos pacientes con EPOC sin s&#237;ndrome metab&#243;lico<a class="elsevierStyleCrossRef" href="#bib0395"><span class="elsevierStyleSup">35</span></a>&#46; A dicho aspecto se suma que en nuestros pacientes obesos se duplica el riesgo de padecer SAHS&#46; Soler et al&#46;<a class="elsevierStyleCrossRef" href="#bib0400"><span class="elsevierStyleSup">36</span></a> han establecido que hasta el 65&#37; de los pacientes con EPOC con obstrucci&#243;n al flujo a&#233;reo moderada-grave muestran un &#237;ndice de apnea-hipopnea superior a 5&#44; a lo que se a&#241;ade los resultados obtenidos por Raherinson et al&#46;<span class="elsevierStyleSup">37</span> en donde los grupo A y B de la GOLD 2011 eran los que mayor prevalencia de SAHS mostraban&#46; Es esencial un diagn&#243;stico precoz de esta enfermedad ya que dichos pacientes con s&#237;ndrome <span class="elsevierStyleItalic">overlap</span> muestran una mayor mortalidad si no son tratados correctamente con CPAP<a class="elsevierStyleCrossRef" href="#bib0410"><span class="elsevierStyleSup">38</span></a>&#46; Desde el punto del perfil lip&#237;dico&#44; un meta-an&#225;lisis publicado por Nadeem et al&#46;39 &#40;39&#41; determin&#243; como el uso de estos dispositivos en pacientes con SAHS disminuye los niveles de colesterol total y LDL as&#237; como incrementa los niveles de HDL</p><p id="par0105" class="elsevierStylePara elsevierViewall">En lo que respecta a los grupos de la GOLD 2017 y su relaci&#243;n con la comorbilidad cardiovascular&#44; vemos como el grupo A es el que menor relaci&#243;n presenta con la existencia de dichas patolog&#237;as&#44; siendo el grupo B el mayormente afectado&#46; Estos hallazgos refrendan lo publicado por diversos estudios en los que los pacientes con EPOC presentaron una mayor carga de comorbilidades&#44; en especial de tipo cardiovascular<a class="elsevierStyleCrossRefs" href="#bib0405"><span class="elsevierStyleSup">37&#8211;41</span></a>&#46; Sorprendentemente&#44; el grupo D&#44; un grupo de pacientes sintom&#225;ticos con riesgo elevado de exacerbaciones&#44; no mostr&#243; una asociaci&#243;n positiva con las distintas enfermedades analizadas&#46; Este hecho podr&#237;a explicarse bien por la falta de poder estad&#237;stico&#44; ya que el grupo D solo inclu&#237;a al 19&#37; de la muestra total&#44; bien por el hecho de que&#44; en estos pacientes&#44; tanto la sintomatolog&#237;a como las exacerbaciones proced&#237;an exclusivamente de la enfermedad respiratoria&#46; Podr&#237;a haber un sesgo de supervivencia&#44; donde los pacientes con estadios m&#225;s avanzados de la EPOC carecer&#237;an de factores predisponentes para desarrollar enfermedades cardiovasculares y&#44; por lo tanto&#44; lograr&#237;an estadios evolutivos m&#225;s avanzados<a class="elsevierStyleCrossRef" href="#bib0430"><span class="elsevierStyleSup">42</span></a>&#46;</p><p id="par0110" class="elsevierStylePara elsevierViewall">Nuestro estudio tiene algunas limitaciones&#44; la primera y m&#225;s importante&#44; su localismo y el tama&#241;o de la muestra&#46; Es obvio que una muestra mayor habr&#237;a revelado diferencias significativas no detectadas en nuestro estudio&#46; Tenemos que se&#241;alar la elevada prevalencia de la DLP en nuestra poblaci&#243;n&#44; mucho mayor que la media de otros estudios nacionales<a class="elsevierStyleCrossRef" href="#bib0435"><span class="elsevierStyleSup">43</span></a>&#59; esto podr&#237;a deberse a una condici&#243;n caracter&#237;stica de la poblaci&#243;n general de las Islas Canarias<a class="elsevierStyleCrossRef" href="#bib0440"><span class="elsevierStyleSup">44</span></a>&#46; En segundo lugar se podr&#237;a haber incurrido en un sesgo de informaci&#243;n debido a la recuperaci&#243;n de las variables a partir los registros cl&#237;nicos de los pacientes&#44; no obstante la estandarizaci&#243;n actual de los criterios diagn&#243;sticos minimiza las diferencias entre los estudios consultados&#46; En todos los pacientes se confirm&#243; el diagn&#243;stico de DLP&#44; basado en la revisi&#243;n de la medicaci&#243;n prescrita en la historia cl&#237;nica electr&#243;nica&#46; Tercero&#44; el registro de nuestros pacientes no se hizo conforme al CAT&#59; de esta manera las relaciones y proporciones de los grupos variar&#237;an con respecto a la clasificaci&#243;n basada en la escala modificada del <span class="elsevierStyleItalic">Medical Research Council</span><a class="elsevierStyleCrossRef" href="#bib0425"><span class="elsevierStyleSup">41</span></a>&#46; Tambi&#233;n debemos mencionar que las limitaciones derivadas de las caracter&#237;sticas del estudio &#40;transversal&#41;&#44; as&#237; como la falta de un grupo control no permiten determinar la causalidad&#46; Finalmente&#44; no podemos ignorar que no se pueden extraer conclusiones significativas relativas al grupo C debido a su peque&#241;o tama&#241;o&#46;</p></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0110">Conclusiones</span><p id="par0115" class="elsevierStylePara elsevierViewall">La DLP en el paciente con EPOC es una comorbilidad relevante con un importante nexo de uni&#243;n con la presencia de enfermedad cardiovascular&#46; La HTA y la DMT2 son las enfermedades que m&#225;s se relacionan con IC y ACV&#46; El grupo B de las categor&#237;as GOLD 2017 es el que mayor relaci&#243;n mostraba con la presencia de comorbilidad cardiovascular&#46;</p></span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0115">Conflicto de intereses</span><p id="par0120" class="elsevierStylePara elsevierViewall">Los autores declaran no tener ning&#250;n conflicto de intereses&#46;</p></span></span>"
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              "titulo" => "Covariantes"
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            0 => "Enfermedad pulmonar obstructiva cr&#243;nica"
            1 => "Dislipidemia"
            2 => "Hipertensi&#243;n Arterial"
            3 => "Comorbilidades"
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            0 => "Chronic obstructive pulmonary disease"
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        "titulo" => "Resumen"
        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Introducci&#243;n</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">La enfermedad cardiovascular tiene un impacto negativo en el pron&#243;stico vital de los pacientes con enfermedad pulmonar obstructiva cr&#243;nica &#40;EPOC&#41;&#44; siendo la dislipidemia &#40;DLP&#41; y la hipertensi&#243;n arterial &#40;HTA&#41; los factores de riesgo m&#225;s prevalentes&#46; El objetivo del estudio fue&#58; 1&#41; evaluar la relaci&#243;n existente entre el diagn&#243;stico de DLP y la presencia de enfermedad cardiovascular en pacientes con EPOC&#44; y compararlo con otros factores conocidos de riesgo cardiovascular&#59; y 2&#41; determinar la relaci&#243;n entre las diferentes comorbilidades cardiovasculares y los grupos de gravedad seg&#250;n la clasificaci&#243;n GOLD 2017&#46;</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">M&#233;todos</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Estudio observacional transversal de 454 pacientes con EPOC en seguimiento ambulatorio&#46; Se calcul&#243; la prevalencia de cada una de las comorbilidades cardiovasculares y el riesgo de que cada uno de los factores de riesgo cardiovascular se presentase conjuntamente con una enfermedad vascular &#40;RR<span class="elsevierStyleInf">ij</span>&#41;<span class="elsevierStyleInf">&#46;</span></p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Resultados</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">El 66&#44;7&#37; de los pacientes eran dislipid&#233;micos&#46; La DLP mostr&#243; una mayor relaci&#243;n con la presencia de accidentes cerebrovasculares &#40;ACV&#41; &#40;RR<span class="elsevierStyleInf">ij</span> 1&#46;36&#59; p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;0054&#41;&#44; enfermedad renal cr&#243;nica &#40;ERC&#41; &#40;RR<span class="elsevierStyleInf">ij</span> 1&#46;34&#59; p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;00023&#41; y arteriopat&#237;a perif&#233;rica &#40;AP&#41; &#40;RR<span class="elsevierStyleInf">ij</span> 1&#46;38&#59; p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;00015&#41;&#59; la HTA se relacion&#243; mayormente con ACV &#40;RR<span class="elsevierStyleInf">ij</span> 1&#44;41&#59; p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;0014&#41; y ERC &#40;RR<span class="elsevierStyleInf">ij</span> 1&#44;42&#59; p<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#44;0001&#41;&#59; la DMT2 con AP &#40;RR<span class="elsevierStyleInf">ij</span> 1&#44;90&#59; p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;0001&#41;&#44; insuficiencia cardiaca &#40;IC&#41; &#40;RR<span class="elsevierStyleInf">ij</span> 1&#44;74&#59; p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;0002&#41; y ERC &#40;RR<span class="elsevierStyleInf">ij</span> 1&#44;76&#59; p<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#44;0001&#41;&#59; la obesidad con IC &#40;RR<span class="elsevierStyleInf">ij</span> 1&#44;60&#59; p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;0009&#41; y ERC &#40;RR<span class="elsevierStyleInf">ij</span> 1&#46;54&#59; p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;0001&#41;&#46;</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Conclusi&#243;n</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">La DLP se relacion&#243; con la presencia de ACV&#44; ERC y AP&#46; La HTA y DMT2 se relacionaban mayoritariamente con IC y ACV&#46;</p></span>"
        "secciones" => array:4 [
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        "resumen" => "<span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Introduction</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Cardiovascular disease has a negative impact on the vital prognosis of patients with chronic obstructive pulmonary disease &#40;COPD&#41;&#44; where dyslipidaemia &#40;DLP&#41; and arterial hypertension &#40;AHT&#41; are considered the most prevalent risk factors&#46; The objective of this study was 1&#41; to assess the relationship between diagnosed DLP and cardiovascular disease in COPD patients and compare it with other known cardiovascular risk factors and 2&#41; to determine the relationship between the different cardiovascular comorbidities and the severity groups according to the GOLD 2017 classification&#46;</p></span> <span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Methods</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">A cross-sectional&#44; observational study was performed in 454 outpatients with COPD during their follow up&#46; We calculated the prevalence of each of the cardiovascular comorbidities and the probability of each of the cardiovascular risk factors to occur jointly with a vascular disease &#40;RRij&#41;&#46;</p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Results</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">A total of 66&#46;7&#37; of the patients had DLP&#44; whereby DLP was related to cerebrovascular accidents &#40;CVA&#41; &#40;RRij 1&#46;36&#44; <span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>&#46;0054&#41;&#44; chronic kidney disease &#40;CKD&#41; &#40;RRij 1&#46;34&#44; <span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>&#46;00023&#41;&#44; and peripheral arterial disease &#40;PAD&#41; &#40;RRij 1&#46;38&#44; <span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>&#46;00015&#41;&#46; AHT was mostly related to CVA &#40;RRij 1&#46;41&#44; <span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>&#46;0014&#41; and CKD &#40;RRij 1&#46;42&#44; <span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>&#46;0001&#41;&#46; Type 2 diabetes mellitus &#40;T2DM&#41; correlated with PAD &#40;RRij 1&#46;90&#44; <span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>&#46;0001&#41;&#44; heart failure &#40;HF&#41; &#40;RRij 1&#44;74&#44; <span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>&#46;0002&#41;&#44; and CKD &#40;RRij 1&#46;76&#44; <span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>&#46;0001&#41;&#44; and obesity was associated with HF &#40;RRij 1&#46;60&#44; <span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>&#46;0009&#41; and CKD &#40;RRij 1&#46;54&#44; <span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>&#46;0001&#41;&#46;</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Conclusion</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">DLP was related to CVA&#44; CKD<span class="elsevierStyleBold">&#44;</span> and PAD&#46; AHT and T2DM are the conditions that mostly relate to HF and CVA&#46;</p></span>"
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          "es" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Relaci&#243;n entre las diferentes comorbilidades cardiovasculares y los grupos GOLD 2017&#46;</p> <p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">ACV&#58; accidente cerebrovascular&#59; AP&#58; arteriopat&#237;a perif&#233;rica&#46; Arritmia cardiaca&#58; fibrilaci&#243;n auricular&#59; CI&#58; cardiopat&#237;a isqu&#233;mica&#59; DM&#58; diabetes mellitus tipo 2&#59; ERC&#58; enfermedad renal cr&#243;nica&#59; GOLD&#58; <span class="elsevierStyleItalic">Global Initiative for Chronic Obstructive Lung Disease</span>&#59; HTA&#58; hipertensi&#243;n arterial&#59; IC&#58; insuficiencia cardiaca&#59; SAHS&#58; apnea del sue&#241;o&#46;</p> <p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">El tama&#241;o de cada nodo es proporcional a la prevalencia de cada una de las comorbilidades representadas&#46; La anchura de los nexos es proporcional al valor al cuadrado del coeficiente phi&#46; El color azul representa un aumento en la probabilidad de aparici&#243;n conjunta de 2 comorbilidades en un paciente&#44; mientras que las l&#237;neas rojas representan una disminuci&#243;n en la probabilidad de aparici&#243;n conjunta de ambas comorbilidades &#40;RRij<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>1&#41;&#46; Solo se representan asociaciones estad&#237;sticamente significativas entre 2 enfermedades&#46;</p>"
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>DLP &#37; &#91;IC 95&#37;&#93;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>HTA &#37; &#91;IC 95&#37;&#93;&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\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>IC &#37; &#91;IC 95&#37;&#93;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">14&#44;1 &#91;11&#44;0&#59; 17&#44;6&#93;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>CI &#37; &#91;IC 95&#37;&#93;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">12&#44;4 &#91;9&#44;5&#59; 15&#44;8&#93;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>AP &#37; &#91;IC 95&#37;&#93;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">10&#44;8 &#91;8&#44;1&#59; 14&#44;0&#93;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>ACV &#37; &#91;IC 95&#37;&#93;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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          "leyenda" => "<p id="spar0075" class="elsevierStyleSimplePara elsevierViewall">ACV&#58; accidente cerebrovascular&#59; AP&#58; arteriopat&#237;a perif&#233;rica&#59; CI&#58; cardiopat&#237;a isqu&#233;mica&#59; DLP&#58; dislipidemia&#59; ERC&#58; enfermedad renal cr&#243;nica&#59; HTA&#58; hipertensi&#243;n arterial&#59; IC&#58; insuficiencia cardiaca&#59; DMT2&#58; diabetes mellitus tipo 2&#59; SAHS&#58; apnea del sue&#241;o&#46;</p>"
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                  \t\t\t\t\ttable-head\n
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                  \t\t\t\t\ttable-head\n
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                  \t\t\t\t">1&#44;34<a class="elsevierStyleCrossRef" href="#tblfn0015">&#42;&#42;&#42;</a>&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">1&#44;39<a class="elsevierStyleCrossRef" href="#tblfn0015">&#42;&#42;&#42;</a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">1&#44;42<a class="elsevierStyleCrossRef" href="#tblfn0015">&#42;&#42;&#42;</a>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">1&#44;32<a class="elsevierStyleCrossRef" href="#tblfn0010">&#42;&#42;</a>&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
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">1&#44;44<a class="elsevierStyleCrossRef" href="#tblfn0010">&#42;&#42;</a>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&#44;54<a class="elsevierStyleCrossRef" href="#tblfn0005">&#42;</a>&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">1&#44;74<a class="elsevierStyleCrossRef" href="#tblfn0015">&#42;&#42;&#42;</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</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">1&#44;89<a class="elsevierStyleCrossRef" href="#tblfn0015">&#42;&#42;&#42;</a>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">Obesidad&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</td><td class="td" title="\n
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                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">---&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">---&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">p<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#44;001&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">---&nbsp;\t\t\t\t\t\t\n
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