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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Introducci&#243;n</span><p id="par0005" class="elsevierStylePara elsevierViewall">El bloqueo de rama derecho &#40;BRD&#41; es un patr&#243;n electrocardiogr&#225;fico visible cuando se interrumpe la actividad el&#233;ctrica normal del sistema His-Punkinje y se retrasa la despolarizaci&#243;n del ventr&#237;culo derecho&#46; Puede ser un hallazgo incidental en el electrocardiograma &#40;ECG&#41; o una manifestaci&#243;n de una enfermedad card&#237;aca &#40;cong&#233;nita&#44; isqu&#233;mica o inflamatoria&#41; o pulmonar &#40;<span class="elsevierStyleItalic">cor pulmonale</span> o embolismo pulmonar&#41;&#46; La prevalencia de BRD se incrementa con la edad y suele ser m&#225;s frecuente cuando existe alguna alteraci&#243;n &#40;estructural o funcional&#41; card&#237;aca subyacente&#44; en especial&#44; cuando afecta al ventr&#237;culo derecho<a class="elsevierStyleCrossRef" href="#bib0145"><span class="elsevierStyleSup">1</span></a>&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">El pron&#243;stico de los individuos con BRD suele ser excelente en ausencia de enfermedad subyacente<a class="elsevierStyleCrossRef" href="#bib0150"><span class="elsevierStyleSup">2</span></a>&#44; aunque existen estudios que lo relacionan con un incremento de mortalidad<a class="elsevierStyleCrossRef" href="#bib0155"><span class="elsevierStyleSup">3</span></a>&#46; En pacientes con enfermedad cardiovascular establecida &#40;especialmente coronaria&#41; parece claro que la presencia de BRD comporta un peor pron&#243;stico<a class="elsevierStyleCrossRefs" href="#bib0160"><span class="elsevierStyleSup">4&#44;5</span></a>&#46; La relaci&#243;n entre BRD e insuficiencia card&#237;aca &#40;IC&#41; se ha estudiado menos&#44; pero los pocos estudios que lo han hecho parecen indicar un peor pron&#243;stico cuando ambas entidades van asociadas<a class="elsevierStyleCrossRefs" href="#bib0170"><span class="elsevierStyleSup">6&#8211;9</span></a>&#46; Estos estudios son heterog&#233;neos y aportan datos de pacientes incluidos desde unidades de cuidados intensivos<a class="elsevierStyleCrossRef" href="#bib0175"><span class="elsevierStyleSup">7</span></a>&#44; servicios de urgencias<a class="elsevierStyleCrossRef" href="#bib0180"><span class="elsevierStyleSup">8</span></a> u hospitalizaciones en servicios de cardiolog&#237;a<a class="elsevierStyleCrossRefs" href="#bib0170"><span class="elsevierStyleSup">6&#44;9</span></a>&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">Por ello&#44; realizamos este estudio con el objetivo de determinar la prevalencia e impacto en el pron&#243;stico de la presencia de BRD en pacientes hospitalizados en los servicios de medicina interna por IC aguda &#40;ICA&#41;&#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">Poblaci&#243;n de estudio</span><p id="par0020" class="elsevierStylePara elsevierViewall">El presente estudio es un an&#225;lisis secundario de los pacientes incluidos en el Registro RICA desarrollado por el Grupo de Trabajo de IC de la Sociedad Espa&#241;ola de Medicina Interna&#44; cuyo dise&#241;o ya se ha explicado de forma detallada en otras publicaciones<a class="elsevierStyleCrossRefs" href="#bib0190"><span class="elsevierStyleSup">10&#44;11</span></a>&#46; De forma breve&#44; el registro RICA es un estudio de cohorte prospectivo y multic&#233;ntrico que incluye pacientes que&#44; de forma consecutiva&#44; ingresan &#40;y son dados de alta vivos&#41; en 34 servicios espa&#241;oles de medicina interna&#46; Despu&#233;s del ingreso &#237;ndice son obligatorias 2 visitas de seguimiento a 90 d&#237;as y 12 meses del alta hospitalaria&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">El dise&#241;o del estudio fue aprobado por el Comit&#233; de &#201;tica del Hospital Universitario Reina Sof&#237;a de C&#243;rdoba y todos los pacientes firmaron un consentimiento informado antes de su inclusi&#243;n&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Selecci&#243;n y clasificaci&#243;n de pacientes</span><p id="par0030" class="elsevierStylePara elsevierViewall">Para el presente estudio se incluyeron todos los pacientes del RICA que ten&#237;an informaci&#243;n disponible sobre el ECG en la visita basal y sobre su estado vital a 12 meses de seguimiento&#46; Se excluyeron aquellos pacientes que presentaban ritmo de marcapasos en el ECG basal y aquellos que requirieron el implante de marcapasos durante el ingreso &#237;ndice&#46; Se dividi&#243; a los pacientes incluidos en 2 grupos seg&#250;n la presencia o no de BRD en el ECG basal&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">El diagn&#243;stico de BRD lo realiz&#243; el investigador local de cada centro participante siguiendo los criterios diagn&#243;sticos internacionales<a class="elsevierStyleCrossRef" href="#bib0200"><span class="elsevierStyleSup">12</span></a>&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Variables independientes</span><p id="par0040" class="elsevierStylePara elsevierViewall">Se seleccionaron y agruparon las distintas variables en 2 grupos&#58; un primer grupo de variables incluy&#243; las caracter&#237;sticas basales de los pacientes y un segundo grupo las caracter&#237;sticas del episodio de descompensaci&#243;n&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">Respecto a las caracter&#237;sticas basales se incluyeron 28 variables&#58; 3 sobre datos demogr&#225;ficos &#40;edad&#44; sexo e &#237;ndice de masa corporal&#41;&#44; 14 relacionadas con comorbilidades &#40;tabaquismo&#44; hipertensi&#243;n arterial&#44; dislipidemia&#44; diabetes mellitus&#44; enfermedad coronaria&#44; valvulopat&#237;a&#44; enfermedad arterial perif&#233;rica&#44; enfermedad cerebrovascular&#44; fibrilaci&#243;n auricular&#44; IC previa&#44; enfermedad renal cr&#243;nica&#44; enfermedad pulmonar obstructiva cr&#243;nica &#91;EPOC&#93;&#44; demencia y c&#225;ncer activo&#41;&#44; 5 con la situaci&#243;n basal &#40;escala funcional de la <span class="elsevierStyleItalic">New York Heart Asssociation</span>&#44; fracci&#243;n de eyecci&#243;n del ventr&#237;culo izquierdo &#91;FEVI&#93; y los &#237;ndices de Barthel&#44; Charlson y Pfeiffer&#41; y 6 con los tratamientos de base &#40;diur&#233;ticos&#44; inhibidores del sistema renina angiotensina&#44; bloqueadores beta&#44; antagonistas de los receptores mineralcorticoides&#44; digoxina y amiodarona&#41;&#46;</p><p id="par0050" class="elsevierStylePara elsevierViewall">Respecto a las caracter&#237;sticas de la descompensaci&#243;n se incluyeron 14 variables&#58; 6 relacionadas con el factor desencadenante&#44; 2 con los signos vitales al ingreso &#40;presi&#243;n arterial y frecuencia card&#237;aca&#41; y 6 par&#225;metros anal&#237;ticos &#40;hemoglobina&#44; creatinina&#44; sodio&#44; potasio&#44; NT-proBNP y troponina&#41;&#46;</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Resultados <span class="elsevierStyleItalic">&#40;endpoints&#41;</span> principales y secundarios</span><p id="par0055" class="elsevierStylePara elsevierViewall">Para el presente estudio se seleccionaron 2 resultados o <span class="elsevierStyleItalic">endpoints</span>&#46; El resultado o <span class="elsevierStyleItalic">endpoint</span> principal fue la mortalidad por todas las causas al a&#241;o de seguimiento tras el alta hospitalaria&#46; El resultado o <span class="elsevierStyleItalic">endpoint</span> secundario fue la combinaci&#243;n de muerte por cualquier causa u hospitalizaci&#243;n por IC en los primeros 90 d&#237;as tras el alta hospitalaria&#46; La adjudicaci&#243;n de dichos resultados la realiz&#243; el investigador local de cada centro participante en las visitas de seguimiento a 90 d&#237;as y 12 meses&#46;</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">An&#225;lisis estad&#237;stico</span><p id="par0060" class="elsevierStylePara elsevierViewall">Las variables cuantitativas se expresan en mediana y rango intercuart&#237;lico&#44; y las cualitativas en n&#250;mero de pacientes y porcentaje&#46; El test de la Chi cuadrado y el test exacto de Fisher se usaron para comparar variables cualitativas&#46; El test &#171;t&#187; de Student se utiliz&#243; para comparar variables cuantitativas distribuidas de forma normal &#40;determinado mediante el test de Kolmogorov-Smirnov&#41; y el test no param&#233;trico U de Mann-Whitney cuando la distribuci&#243;n de dichas variables no fue normal&#46; El an&#225;lisis de Kaplan-Meier se utiliz&#243; para analizar las curvas de supervivencia de los pacientes con y sin BRD&#44; y para su comparaci&#243;n se us&#243; el Log-rank test&#46;</p><p id="par0065" class="elsevierStylePara elsevierViewall">Las diferencias en mortalidad al a&#241;o y en el evento combinado a 90 d&#237;as para los pacientes con BRD&#44; en comparaci&#243;n con los que no ten&#237;an BRD&#44; se expresan en <span class="elsevierStyleItalic">hazard ratio</span> con intervalo de confianza del 95&#37; &#40;IC 95&#37;&#41; usando un modelo de regresi&#243;n de Cox&#44; primero sin ajustar y posteriormente ajustado por las variables &#40;de las caracter&#237;sticas basales y del episodio de descompensaci&#243;n&#41; con un valor p<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#44;05 en la comparaci&#243;n bivariada &#40;modelo completamente ajustado&#41;&#46;</p><p id="par0070" class="elsevierStylePara elsevierViewall">Finalmente&#44; realizamos 2 an&#225;lisis de sensibilidad de los resultados o <span class="elsevierStyleItalic">endpoints</span>&#58; el primero eliminando del grupo de control a los pacientes con otras anomal&#237;as el&#233;ctricas en el ECG &#40;an&#225;lisis de sensibilidad A&#41; y el segundo incluyendo &#250;nicamente casos y controles en ritmo sinusal &#40;an&#225;lisis de sensibilidad B&#41;&#46; Se acept&#243; la significaci&#243;n estad&#237;stica si p<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#44;05 o el IC 95&#37; exclu&#237;a el valor 1&#46;</p><p id="par0075" class="elsevierStylePara elsevierViewall">Los an&#225;lisis se realizaron mediante el Statistical Package for Social Sciences versi&#243;n 23&#46;0 &#40;IBM&#44; Armonk&#44; Nueva York&#44; EE&#46; UU&#46;&#41;&#46;</p></span></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">Resultados</span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0105">Prevalencia de bloqueo de rama derecha</span><p id="par0080" class="elsevierStylePara elsevierViewall">Para el presente estudio se analizaron 4&#46;621 pacientes del RICA&#46; Tras excluir los pacientes que no ten&#237;an informaci&#243;n sobre el ECG basal o sobre su estado vital al a&#241;o de seguimiento&#44; as&#237; como aquellos que presentaban ritmo de marcapasos en el ECG basal o que requirieron implante de marcapasos en el ingreso &#237;ndice&#44; el n&#250;mero final de pacientes analizados fue de 3&#46;638 &#40;<a class="elsevierStyleCrossRef" href="#fig0005">fig&#46; 1</a>&#41;&#46; De ellos 398 ten&#237;an BRD en el ECG basal&#44; estableciendo una prevalencia del 10&#44;9&#37; &#40;IC 95&#37;&#58; 9&#44;9-12&#44;0&#41;&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0110">Caracter&#237;sticas basales y del episodio de descompensaci&#243;n</span><p id="par0085" class="elsevierStylePara elsevierViewall">Las caracter&#237;sticas basales de los pacientes se exponen de forma detallada en la <a class="elsevierStyleCrossRef" href="#tbl0005">tabla 1</a>&#46; De forma breve se trata de una cohorte de edad avanzada &#40;mediana de 81 a&#241;os&#41;&#44; con similar proporci&#243;n de hombres y mujeres&#44; y con elevada comorbilidad&#44; siendo las m&#225;s frecuentes &#40;presentes en m&#225;s del 50&#37; de los pacientes&#41;&#58; la hipertensi&#243;n arterial&#44; la dislipidemia&#44; la fibrilaci&#243;n auricular&#44; la IC previa y la insuficiencia renal cr&#243;nica&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0090" class="elsevierStylePara elsevierViewall">Encontramos diferencias significativas entre los pacientes con y sin BRD en 7 de las 28 variables basales comparadas&#46; Los pacientes con BRD eran de mayor edad y con mayor frecuencia de sexo masculino&#44; tabaquismo activo y EPOC&#46; Tambi&#233;n presentaban valores m&#225;s altos de FEVI&#44; peor situaci&#243;n funcional &#40;menor puntuaci&#243;n en el &#237;ndice de Barthel&#41; y menor prescripci&#243;n de bloqueadores beta&#46;</p><p id="par0095" class="elsevierStylePara elsevierViewall">En relaci&#243;n con las caracter&#237;sticas del episodio de descompensaci&#243;n&#44; los factores desencadenantes m&#225;s frecuentes fueron las infecciones &#40;32&#37;&#41;&#44; seguidas de la fibrilaci&#243;n auricular r&#225;pida &#40;26&#37;&#41;&#44; siendo poco frecuente el s&#237;ndrome coronario agudo &#40;270 pacientes &#91;7&#44;4&#37;&#93;&#44; de los cuales solo 58 eran con elevaci&#243;n del ST&#41;&#46; No encontramos diferencias significativas en relaci&#243;n con la presencia de BRD&#44; aunque el grupo con BRD tuvo una tendencia casi significativa a presentar m&#225;s anemia y transgresi&#243;n diet&#233;tica&#47;farmacol&#243;gica y menos s&#237;ndrome coronario agudo como desencadenantes &#40;<a class="elsevierStyleCrossRef" href="#tbl0010">tabla 2</a>&#41;&#46;</p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><p id="par0100" class="elsevierStylePara elsevierViewall">No encontramos tampoco diferencias entre los 2 grupos en relaci&#243;n con los valores de presi&#243;n arterial y frecuencia card&#237;aca al ingreso&#44; as&#237; como en ninguno de los valores anal&#237;ticos comparados&#46;</p><p id="par0105" class="elsevierStylePara elsevierViewall">Las causas m&#225;s frecuentes de mortalidad fueron cardiovasculares&#44; siendo la m&#225;s habitual el empeoramiento de la propia IC&#44; y no encontramos diferencias de causas de muerte seg&#250;n la presencia o no de BRD&#46;</p></span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0115"><span class="elsevierStyleItalic">Outcomes</span></span><p id="par0110" class="elsevierStylePara elsevierViewall">La mortalidad acumulada al a&#241;o de seguimiento fue del 18&#44;7&#37; &#40;IC 95&#37;&#58; 17&#44;5-20&#44;0&#41; y la proporci&#243;n acumulada del evento combinado a 90 d&#237;as fue del 15&#44;8&#37; &#40;IC 95&#37;&#58; 14&#44;6-17&#44;0&#41;&#46; No encontramos diferencias significativas en supervivencia en pacientes con y sin BRD para ninguno de los 2 resultados &#40;<a class="elsevierStyleCrossRef" href="#fig0010">fig&#46; 2</a>&#41;&#46; El riesgo de presentar resultados desfavorables en los 2 <span class="elsevierStyleItalic">outcomes</span> analizados se muestra en la <a class="elsevierStyleCrossRef" href="#tbl0015">tabla 3</a>&#46;</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><elsevierMultimedia ident="tbl0015"></elsevierMultimedia><p id="par0115" class="elsevierStylePara elsevierViewall">La presencia de BRD no se asoci&#243; a un mayor riesgo de mortalidad al a&#241;o ni del evento combinado a 90 d&#237;as en ninguno de los modelos ajustados&#46; Los an&#225;lisis de sensibilidad confirmaron esta falta de asociaci&#243;n entre la presencia de BRD y el mal pron&#243;stico a 90 d&#237;as y 12 meses en la cohorte RICA&#46;</p></span></span><span id="sec0060" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0120">Discusi&#243;n</span><p id="par0120" class="elsevierStylePara elsevierViewall">La IC es un s&#237;ndrome de proporciones epid&#233;micas para el que existe un gran inter&#233;s en conocer los factores que determinan su pron&#243;stico<a class="elsevierStyleCrossRefs" href="#bib0205"><span class="elsevierStyleSup">13&#44;14</span></a>&#46; Las arritmias son uno de dichos factores&#44; estando muy estudiada la relaci&#243;n de la IC con algunas de ellas&#44; como la fibrilaci&#243;n auricular&#44; pero existe mucha menos informaci&#243;n sobre el impacto en el pron&#243;stico de otras alteraciones electrocardiogr&#225;ficas como los bloqueos de conducci&#243;n<a class="elsevierStyleCrossRef" href="#bib0215"><span class="elsevierStyleSup">15</span></a>&#46;</p><p id="par0125" class="elsevierStylePara elsevierViewall">La relaci&#243;n entre bloqueos de conducci&#243;n e IC ha sido algo m&#225;s estudiada para los bloqueos de rama izquierda &#40;BRI&#41;&#44; existiendo controversia sobre su impacto en el pron&#243;stico al existir estudios que muestran un incremento del riesgo de mortalidad<a class="elsevierStyleCrossRefs" href="#bib0220"><span class="elsevierStyleSup">16&#44;17</span></a> y otros que no han encontrado dicha asociaci&#243;n<a class="elsevierStyleCrossRefs" href="#bib0170"><span class="elsevierStyleSup">6&#44;9&#44;18&#44;19</span></a>&#46; Son todav&#237;a menos los estudios que han analizado esta relaci&#243;n cuando el bloqueo es de la rama derecha del haz de His&#46; Se trata de estudios de tama&#241;o peque&#241;o&#44; en muchas ocasiones realizados en un solo centro&#44; con una procedencia heterog&#233;nea de los pacientes &#40;Unidades de Cuidados Intensivos<a class="elsevierStyleCrossRef" href="#bib0175"><span class="elsevierStyleSup">7</span></a>&#44; Servicios de Urgencias<a class="elsevierStyleCrossRef" href="#bib0180"><span class="elsevierStyleSup">8</span></a> y Servicios de Cardiolog&#237;a<a class="elsevierStyleCrossRef" href="#bib0185"><span class="elsevierStyleSup">9</span></a>&#41; y en ocasiones solo centrados en pacientes con FEVI deprimida y sin cubrir todo el &#171;espectro&#187; de la IC<a class="elsevierStyleCrossRef" href="#bib0170"><span class="elsevierStyleSup">6</span></a>&#46; Por otro lado&#44; la media de edad de los pacientes incluidos en estos estudios previos &#40;62-73<span class="elsevierStyleHsp" style=""></span>a&#241;os&#41;<a class="elsevierStyleCrossRefs" href="#bib0170"><span class="elsevierStyleSup">6&#8211;9</span></a> es inferior a la del registro RICA&#44; que es de edad mucho m&#225;s avanzada &#40;media de 81<span class="elsevierStyleHsp" style=""></span>a&#241;os&#41;&#46;</p><p id="par0130" class="elsevierStylePara elsevierViewall">As&#237;&#44; en este estudio hemos incluido una gran muestra de pacientes &#171;del mundo real&#187; cubriendo ampliamente el s&#237;ndrome de IC descompensada&#44; sin ninguna limitaci&#243;n de edad&#44; comorbilidades&#44; etiolog&#237;a o valores de FEVI&#46; Desde esta perspectiva podemos exponer los siguientes resultados principales&#58; la prevalencia de BRD en pacientes con ICA es del 11&#37;&#44; la presencia de BRD se asocia de forma consistente con algunas caracter&#237;sticas cl&#237;nicas basales&#44; pero no parece asociarse a un peor pron&#243;stico&#46; La prevalencia de BRD en nuestro estudio est&#225; en consonancia con la descrita en otros estudios&#44; que se sit&#250;a entre el 5&#44;4&#37; y el 14&#37;<a class="elsevierStyleCrossRefs" href="#bib0170"><span class="elsevierStyleSup">6&#8211;9</span></a>&#44; pero es claramente inferior a la prevalencia de BRI en IC&#44; que oscila entre el 15&#37; y el 30&#37; seg&#250;n los estudios<a class="elsevierStyleCrossRefs" href="#bib0185"><span class="elsevierStyleSup">9&#44;16&#44;18&#8211;22</span></a>&#46;</p><p id="par0135" class="elsevierStylePara elsevierViewall">Del mismo modo algunas caracter&#237;sticas basales asociadas a la presencia de BRD en pacientes con IC del registro RICA coinciden con las de otros estudios&#44; como son la edad m&#225;s avanzada<a class="elsevierStyleCrossRef" href="#bib0170"><span class="elsevierStyleSup">6</span></a>&#44; el sexo masculino<a class="elsevierStyleCrossRefs" href="#bib0170"><span class="elsevierStyleSup">6&#44;9</span></a>&#44; las comorbilidades pulmonares como la EPOC<a class="elsevierStyleCrossRef" href="#bib0180"><span class="elsevierStyleSup">8</span></a> y la FEVI preservada<a class="elsevierStyleCrossRef" href="#bib0185"><span class="elsevierStyleSup">9</span></a>&#46; La rama derecha del haz de His es vulnerable a alteraciones card&#237;acas funcionales y&#47;o estructurales&#44; como es el incremento en la presi&#243;n en el ventr&#237;culo derecho &#40;como ocurre de forma cr&#243;nica en el <span class="elsevierStyleItalic">cor pulmonale</span>&#41;<a class="elsevierStyleCrossRef" href="#bib0145"><span class="elsevierStyleSup">1</span></a>&#44; y ello puede explicar&#44; en parte&#44; la asociaci&#243;n del BRD con algunas de estas comorbilidades&#46;</p><p id="par0140" class="elsevierStylePara elsevierViewall">No todos los estudios han encontrado asociaci&#243;n del BRD con la FEVI y en alguno de ellos incluso se han analizado solo aquellos con FEVI deprimida<a class="elsevierStyleCrossRef" href="#bib0170"><span class="elsevierStyleSup">6</span></a>&#44; por lo que no podemos extraer conclusiones sobre la relaci&#243;n entre BRD y FEVI&#46; La asociaci&#243;n de BRD con una peor situaci&#243;n funcional es algo que&#44; en nuestro conocimiento&#44; no estaba descrito previamente&#44; pero que es de sumo inter&#233;s&#44; pues el &#237;ndice de Barthel es una variable claramente relacionada de forma independiente con el pron&#243;stico &#40;a corto y largo plazo&#41; de los pacientes con IC&#44; ya sea de forma cr&#243;nica o aguda<a class="elsevierStyleCrossRefs" href="#bib0255"><span class="elsevierStyleSup">23&#44;24</span></a>&#46;</p><p id="par0145" class="elsevierStylePara elsevierViewall">A pesar de esta asociaci&#243;n del BRD con edad m&#225;s avanzada&#44; algunas comorbilidades y un peor estado funcional&#44; en nuestro estudio no hemos encontrado que la presencia de BRD en el ECG basal se asocie de forma independiente con un peor pron&#243;stico a largo plazo &#40;mortalidad por todas las causas a los 12 meses de seguimiento tras el alta hospitalaria&#41;&#46; A pesar de que existe alg&#250;n estudio que tampoco ha encontrado asociaci&#243;n de BRD con mortalidad en ICA<a class="elsevierStyleCrossRef" href="#bib0220"><span class="elsevierStyleSup">16</span></a>&#44; la mayor&#237;a de estudios que han analizado este aspecto s&#237; que han descrito una mayor mortalidad relacionada con el BRD<a class="elsevierStyleCrossRefs" href="#bib0170"><span class="elsevierStyleSup">6&#8211;9</span></a>&#46; Este hallazgo&#44; por lo menos controvertido y de dif&#237;cil explicaci&#243;n&#44; es similar al descrito previamente con el BRI y la ICA&#46;</p><p id="par0150" class="elsevierStylePara elsevierViewall">Como se ha comentado previamente&#44; estos estudios son de tama&#241;o relativamente peque&#241;o&#44; heterog&#233;neos&#44; algunos no incluyen pacientes con FEVI preservada y en ocasiones mezclan el an&#225;lisis del BRD con el BRI&#44; por lo que es dif&#237;cil sacar conclusiones&#46; Es probable que este dilema se pudiera resolver si se llevara a cabo una revisi&#243;n sistem&#225;tica de la literatura con metaan&#225;lisis que agrupara todos estos estudios y pudiera discernir si realmente los bloqueos de conducci&#243;n &#40;BRI y BRD&#41; se asocian o no a un mayor riesgo de muerte en pacientes con ICA&#46; En nuestro conocimiento este estudio todav&#237;a no ha sido publicado&#44; pero s&#237; est&#225; registrado &#40;n&#250;mero de registro CRD42021228958&#41; en el registro internacional de revisiones sistem&#225;ticas PROSPERO<a class="elsevierStyleCrossRef" href="#bib0265"><span class="elsevierStyleSup">25</span></a>&#46;</p><p id="par0155" class="elsevierStylePara elsevierViewall">Respecto a las causas de muerte no hemos encontrado diferencias seg&#250;n la presencia o no de BRD&#44; y este hecho tambi&#233;n difiere con otros estudios en los que el BRD se asoci&#243; con una mayor proporci&#243;n de muertes de causa cardiovascular&#44; especialmente empeoramiento de la IC<a class="elsevierStyleCrossRef" href="#bib0270"><span class="elsevierStyleSup">26</span></a>&#46;</p><p id="par0160" class="elsevierStylePara elsevierViewall">Por otro lado&#44; tampoco hemos encontrado en nuestro estudio que los pacientes con BRD tengan un mayor riesgo de reingreso o muerte a los 90 d&#237;as tras el alta hospitalaria&#46; Este resultado todav&#237;a se ha estudiado menos en los estudios previos&#44; y solamente Hong et al&#46; describen que s&#237; existe un mayor riesgo de rehospitalizaci&#243;n en los pacientes con BRD<a class="elsevierStyleCrossRef" href="#bib0185"><span class="elsevierStyleSup">9</span></a>&#46; En esta fase temprana despu&#233;s del alta&#44; descrita como per&#237;odo de vulnerabilidad&#44; existe un mayor riesgo de complicaciones y es cuando suceden muchas de las rehospitalizaciones<a class="elsevierStyleCrossRefs" href="#bib0275"><span class="elsevierStyleSup">27&#44;28</span></a>&#46; A pesar de ello&#44; con la informaci&#243;n disponible&#44; no podemos afirmar que el BRD desempe&#241;e un papel en dicho riesgo en este per&#237;odo de vulnerabilidad&#46;</p><span id="sec0065" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0125">Limitaciones</span><p id="par0165" class="elsevierStylePara elsevierViewall">En el presente estudio existen algunas limitaciones&#46; En primer lugar&#44; a pesar de tratarse de una larga serie de pacientes con IC de diferentes hospitales espa&#241;oles&#44; todos proceden de la hospitalizaci&#243;n en servicios de medicina interna&#44; y es por ello que los resultados encontrados no se pueden extrapolar a otros escenarios&#46; En segundo lugar&#44; no se realiz&#243; un c&#225;lculo del tama&#241;o muestral&#44; y a pesar de ser superior al de otros estudios publicados&#44; quiz&#225; no fue suficiente para alcanzar la potencia estad&#237;stica necesaria para encontrar asociaci&#243;n con mortalidad&#46; En tercer lugar la lectura e interpretaci&#243;n de los ECG se realiz&#243; por los investigadores principales de cada centro sin realizar una doble comprobaci&#243;n del diagn&#243;stico de BRD&#46; A pesar de ello&#44; y en nuestra opini&#243;n&#44; la amplia experiencia de los investigadores del registro en la asistencia de pacientes con IC hace pensar que los errores de interpretaci&#243;n de los bloqueos de rama habr&#225;n sido poco relevantes&#46; Por &#250;ltimo&#44; la exclusi&#243;n de los pacientes que fallecen durante la hospitalizaci&#243;n &#237;ndice es una limitaci&#243;n del registro RICA&#44; y no podemos descartar que la inclusi&#243;n de dichos pacientes hubiera podido modificar los resultados de nuestro estudio&#46;</p></span></span><span id="sec0070" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0130">Conclusiones</span><p id="par0170" class="elsevierStylePara elsevierViewall">La prevalencia de BRD en los pacientes con IC del registro RICA es del 10&#44;9&#37;&#59; se asocia a algunas comorbilidades&#44; a valores m&#225;s elevados de FEVI y peor situaci&#243;n funcional&#44; pero no a un peor pron&#243;stico&#46;</p></span><span id="sec0075" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0135">Financiaci&#243;n</span><p id="par0175" class="elsevierStylePara elsevierViewall">La presente investigaci&#243;n no ha recibido ayudas espec&#237;ficas provenientes de agencias del sector p&#250;blico&#44; sector comercial o entidades sin &#225;nimo de lucro&#46;</p></span><span id="sec0080" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0140">Conflicto de intereses</span><p id="par0180" class="elsevierStylePara elsevierViewall">Los autores declaran no tener ning&#250;n conflicto de intereses&#46;</p></span></span>"
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          "titulo" => "Abstract"
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              "titulo" => "Selecci&#243;n y clasificaci&#243;n de pacientes"
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              "titulo" => "Prevalencia de bloqueo de rama derecha"
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              "titulo" => "Caracter&#237;sticas basales y del episodio de descompensaci&#243;n"
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              "titulo" => "Outcomes"
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    "fechaRecibido" => "2021-08-18"
    "fechaAceptado" => "2021-10-08"
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            1 => "Descompensaci&#243;n card&#237;aca"
            2 => "Bloqueo de rama derecha"
            3 => "Pron&#243;stico"
            4 => "Mortalidad"
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            0 => "Heart failure"
            1 => "Cardiac decompensation"
            2 => "Right bundle branch block"
            3 => "Prognosis"
            4 => "Mortality"
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    "resumen" => array:2 [
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        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Objetivos</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Determinar la prevalencia&#44; las caracter&#237;sticas y el impacto en el pron&#243;stico del bloqueo de rama derecha &#40;BRD&#41; en una cohorte de pacientes con insuficiencia card&#237;aca aguda &#40;ICA&#41;&#46;</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">M&#233;todos</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Analizamos prospectivamente 3&#46;638 pacientes con ICA incluidos en el Registro Nacional de Insuficiencia Card&#237;aca de la Sociedad Espa&#241;ola de Medicina Interna &#40;RICA&#41;&#46; Analizamos de forma independiente la relaci&#243;n entre las caracter&#237;sticas basales y cl&#237;nicas y la presencia de BRD&#44; y el impacto potencial del BRD en la mortalidad por todas las causas a un a&#241;o y el evento combinado de hospitalizaci&#243;n o muerte a 90 d&#237;as despu&#233;s del alta&#46;</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Resultados</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">La prevalencia de BRD fue del 10&#44;9&#37;&#46; Los pacientes con BRD eran de edad m&#225;s avanzada&#44; con mayor proporci&#243;n de sexo masculino y comorbilidades pulmonares&#44; valores m&#225;s altos de fracci&#243;n de eyecci&#243;n del ventr&#237;culo izquierdo y peor estado funcional&#46; No hubo diferencias en riesgo para los pacientes con BRD&#44; con un cociente de riesgo ajustado &#40;intervalo de confianza del 95&#37;&#41; para la mortalidad a un a&#241;o de 1&#44;05 &#40;0&#44;83-1&#44;32&#41; y para el evento combinado a 90 d&#237;as despu&#233;s del alta de 0&#44;97 &#40;0&#44;74-1&#44;25&#41;&#46; Estos resultados fueron consistentes en los an&#225;lisis de sensibilidad&#46;</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Conclusiones</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Pocos pacientes con ICA presentan BRD&#44; que se asocia consistentemente con la edad avanzada&#44; el sexo masculino&#44; las comorbilidades pulmonares&#44; la fracci&#243;n de eyecci&#243;n del ventr&#237;culo izquierdo preservada y el peor estado funcional&#46; Sin embargo&#44; despu&#233;s de tener en cuenta estos factores&#44; el BRD en pacientes con ICA no se asocia a peores resultados&#46;</p></span>"
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            "titulo" => "M&#233;todos"
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        "titulo" => "Abstract"
        "resumen" => "<span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Objectives</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">This work aims to determine the prevalence&#44; characteristics&#44; and impact on prognosis of right bundle branch block &#40;RBBB&#41; in a cohort of acute heart failure &#40;AHF&#41; patients&#46;</p></span> <span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Methods</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">We prospectively analyzed 3&#44;638 AHF patients included in the RICA registry &#40;National Heart Failure Registry of the Spanish Internal Medicine Society&#41;&#46; We independently analyzed the relationship between baseline and clinical characteristics and the presence of RBBB as well as the potential impact of RBBB on 1-year all-cause mortality and a composite endpoint of 90-day post-discharge hospitalization or death&#46;</p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Results</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">The prevalence of RBBB was 10&#46;9&#37;&#46; Patients with RBBB were older&#44; a higher proportion were male&#44; had more pulmonary comorbidities&#44; had higher left ventricular ejection fraction values&#44; and had worse functional status&#46; There were no differences in risk for patients with RBBB&#44; with an adjusted hazard ratio &#40;95&#37; confidence interval&#41; for 1-year mortality of 1&#46;05 &#40;0&#46;83-1&#46;32&#41;&#44; and for the composite endpoint of 90-day post-discharge hospitalization or death of 0&#46;97 &#40;0&#46;74-1&#46;25&#41;&#46; These results were consistent on the sensitivity analyses&#46;</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Conclusions</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">Few patients with AHF present with RBBB&#44; which is consistently associated with advanced age&#44; male sex&#44; pulmonary comorbidities&#44; preserved left ventricular ejection fraction&#44; and worse functional status&#46; Nonetheless&#44; after considering these factors&#44; RBBB in AHF patients is not associated with worse outcomes&#46;</p></span>"
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        "nota" => "<p class="elsevierStyleNotepara" id="npar0030">El listado con todos los investigadores del Registro RICA aparece en el <a class="elsevierStyleCrossRef" href="#sec0085">anexo</a>&#46;</p>"
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            "apendice" => "<p id="par0190" class="elsevierStylePara elsevierViewall">P&#46; &#193;lvarez Rocha&#44; L&#46; Anarte&#44; O&#46; Aramburu-Bodas&#44; J&#46;C&#46; Ar&#233;valo-Lorido&#44; J&#46;L&#46; Arias Jim&#233;nez&#44; S&#46; Carrascosa&#44; J&#46;M&#46; Cepeda&#44; J&#46;M&#46; Cerqueiro&#44; D&#46; Chivite Guill&#233;n&#44; A&#46; Conde-Martel&#44; M&#46;F&#46; D&#225;vila Ramos&#44; S&#46; D&#237;az de Castellv&#237;&#44; F&#46; Epelde&#44; F&#46; Formiga P&#233;rez&#44; A&#46; Garc&#237;a Campos&#44; A&#46; Gonz&#225;lez Franco&#44; A&#46; Le&#243;n Acu&#241;a&#44; G&#46; L&#243;pez Castellanos&#44; O&#46; Lorente Furi&#243;&#44; L&#46; Manzano&#44; M&#46; Montero-P&#233;rez-Barquero&#44; M&#46;C&#46; Moreno Garc&#237;a&#44; G&#46; Ormaechea Gorricho&#44; M&#46;A&#46; Quesada Sim&#243;n&#44; R&#46; Ruiz Ortega&#44; M&#46;P&#46; Salamanca Bautista&#44; G&#46; Silvera y J&#46;C&#46;Trull&#224;s&#46;</p>"
            "etiqueta" => "Appendix A"
            "titulo" => "Anexo&#46; Listado de investigadores del RICA"
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          "es" => "<p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">A&#46; Curvas de supervivencia de Kaplan Meier para mortalidad por todas las causas a un a&#241;o de seguimiento&#46; B&#46; Curvas de supervivencia de Kaplan Meier para el evento combinado a 90 d&#237;as tras el alta hospitalaria&#46; BRD&#58; bloqueo de rama derecha&#46;</p>"
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Con BRDN<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>398&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Sin BRDN<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>3240&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">p&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleBold">Demogr&#225;ficos</span></td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">Edad &#40;a&#241;os&#41;</span><a class="elsevierStyleCrossRef" href="#tblfn0005"><span class="elsevierStyleSup">a</span></a>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">81 &#40;75-86&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">Sexo femenino</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">0 &#40;0&#44;0&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">171 &#40;43&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">1670 &#40;52&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">IMC &#40;kg&#47;m</span><span class="elsevierStyleSup"><span class="elsevierStyleItalic">2</span></span><span class="elsevierStyleItalic">&#41;</span><a class="elsevierStyleCrossRef" href="#tblfn0005"><span class="elsevierStyleSup">a</span></a>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">28&#44;1 &#40;25&#44;0-31&#44;6&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">1 &#40;0&#44;0&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " colspan="6" align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">Fumador activo</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">1387 &#40;38&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">0 &#40;0&#44;0&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">171 &#40;43&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">1216 &#40;38&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleBold">0&#44;038</span>&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"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">Hipertensi&#243;n</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">3098 &#40;85&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">0 &#40;0&#44;0&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">339 &#40;85&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">2759 &#40;85&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">1&#44;000&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">Dislipidemia</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">1932 &#40;53&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">1724 &#40;53&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">Diabetes mellitus</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">Enfermedad coronaria</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">Valvulopat&#237;a</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t">1207 &#40;33&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">Enfermedad arterial perif&#233;rica</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t">393 &#40;11&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">Enfermedad cerebrovascular</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">475 &#40;13&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">Fibrilaci&#243;n auricular</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">2301 &#40;63&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">2040 &#40;63&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">Insuficiencia card&#237;aca cr&#243;nica</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">0 &#40;0&#44;0&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">Insuficiencia renal cr&#243;nica</span><a class="elsevierStyleCrossRef" href="#tblfn0020"><span class="elsevierStyleSup">b</span></a>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">0&#44;093&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
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                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">Crisis hipertensiva</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">243 &#40;6&#44;7&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0 &#40;0&#44;0&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">23 &#40;5&#44;8&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">220 &#40;6&#44;8&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">0&#44;523&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
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">Transgresi&#243;n diet&#233;tica&#47;farmacol&#243;gica</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">0 &#40;0&#44;0&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t</td><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
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                  \t\t\t\t">0&#44;058&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
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                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">S&#237;ndrome coronario agudo</span><a class="elsevierStyleCrossRef" href="#tblfn0010"><span class="elsevierStyleSup">a</span></a>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t">0 &#40;0&#44;0&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t\ttop\n
                  \t\t\t\t">20 &#40;5&#44;0&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
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                  \t\t\t\t  " colspan="6" align="left" valign="\n
                  \t\t\t\t\ttop\n
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                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">PAS &#40;mm</span><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">Hg&#41;</span><a class="elsevierStyleCrossRef" href="#tblfn0015"><span class="elsevierStyleSup">b</span></a>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">134 &#40;119-151&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t\ttop\n
                  \t\t\t\t">135 &#40;120-153&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
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                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">FC &#40;lpm&#41;</span><a class="elsevierStyleCrossRef" href="#tblfn0015"><span class="elsevierStyleSup">b</span></a>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">84 &#40;72-100&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">84 &#40;73-99&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">84 &#40;72-100&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">0&#44;803&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
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                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">Hemoglobina &#40;g&#47;L&#41;</span><a class="elsevierStyleCrossRef" href="#tblfn0015"><span class="elsevierStyleSup">b</span></a>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">Creatinina &#40;mg&#47;dL&#41;</span><a class="elsevierStyleCrossRef" href="#tblfn0015"><span class="elsevierStyleSup">b</span></a>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">Potasio &#40;mmolLl&#41;</span><a class="elsevierStyleCrossRef" href="#tblfn0015"><span class="elsevierStyleSup">b</span></a>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">Sodio &#40;mmol&#47;L&#41;</span><a class="elsevierStyleCrossRef" href="#tblfn0015"><span class="elsevierStyleSup">b</span></a>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">0&#44;134&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">NT-proBNP &#40;ng&#47;mL&#41;</span><a class="elsevierStyleCrossRef" href="#tblfn0015"><span class="elsevierStyleSup">b</span></a>&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">3486&#40;1666-7898&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">1165 &#40;32&#44;0&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">3481 &#40;1473-8359&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">3486 &#40;1700-7837&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">0&#44;860&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">Troponina elevada &#40;por encima del percentil 99&#41;</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">48 &#40;4&#44;7&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">2607 &#40;71&#44;7&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">3 &#40;3&#44;2&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">45 &#40;4&#44;8&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleBold">Causas de muerte</span></td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="6" align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">Causa cardiovascular</span></td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>Muerte card&#237;aca&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">35 &#40;2&#44;6&#37;&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">3 &#40;1&#44;9&#37;&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>Empeoramiento IC&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">678 &#40;50&#44;1&#37;&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">0 &#40;0&#44;0&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">78 &#40;50&#44;6&#37;&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">600 &#40;50&#44;0&#37;&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">0&#44;381&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
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                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>Muerte s&#250;bita&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">97 &#40;7&#44;2&#37;&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">0 &#40;0&#44;0&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">10 &#40;6&#44;4&#37;&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">87 &#40;7&#44;2&#37;&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">0&#44;482&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">Causa vascular</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">116 &#40;8&#44;6&#37;&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">0 &#40;0&#44;0&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">14 &#40;9&#44;1&#37;&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">102 &#40;8&#44;5&#37;&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t">0&#44;412&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">Causa extravascular</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">233 &#40;17&#44;2&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0 &#40;0&#44;0&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t">24 &#40;15&#44;6&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t">209 &#40;17&#44;4&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">Otras causas</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">170 &#40;14&#44;2&#37;&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">0&#44;249&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">An&#225;lisis principal</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>No ajustado&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>Modelo completamente ajustado&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">An&#225;lisis de sensibilidad para el modelo completamente ajustado</span><a class="elsevierStyleCrossRef" href="#tblfn0025"><span class="elsevierStyleSup">a</span></a></td></tr><tr title="table-row"><td class="td-with-role" title="\n
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                  \t\t\t\t">0&#44;712&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>An&#225;lisis de sensibilidad B&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">1&#44;418 &#40;0&#44;982-2&#44;048&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">0&#44;062&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleBold">Evento combinado a los 90 d&#237;as del alta hospitalaria</span></td></tr><tr title="table-row"><td class="td" title="\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>No ajustado&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">1&#44;084 &#40;0&#44;840-1&#44;398&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">0&#44;536&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>Modelo completamente ajustado&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">An&#225;lisis de sensibilidad para el modelo completamente ajustado</span><a class="elsevierStyleCrossRef" href="#tblfn0025"><span class="elsevierStyleSup">a</span></a></td></tr><tr title="table-row"><td class="td-with-role" title="\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>An&#225;lisis de sensibilidad A&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>An&#225;lisis de sensibilidad B&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">0&#44;969 &#40;0&#44;615-1&#44;529&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">0&#44;894&nbsp;\t\t\t\t\t\t\n
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              "nota" => "<p class="elsevierStyleNotepara" id="npar0025">El an&#225;lisis de sensibilidad A consisti&#243; en eliminar del grupo control los pacientes con otras alteraciones electrocardiogr&#225;ficas&#59; el an&#225;lisis de sensibilidad B incluy&#243; solo casos y controles en ritmo sinusal&#46;</p>"
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          "es" => "<p id="spar0085" class="elsevierStyleSimplePara elsevierViewall">An&#225;lisis de regresi&#243;n de Cox para mortalidad a un a&#241;o y para el evento combinado a los 90 d&#237;as en pacientes con bloqueo de rama derecha en la cohorte RICA&#44; incluyendo an&#225;lisis ajustado y an&#225;lisis de sensibilidad</p>"
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    ]
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                0 => array:2 [
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                    0 => array:2 [
                      "titulo" => "Right bundle branch block&#58; Current considerations"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:1 [
                            0 => "T&#46; Ikeda"
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                    0 => array:2 [
                      "doi" => "10.2174/1573403X16666200708111553"
                      "Revista" => array:6 [
                        "tituloSerie" => "Curr Cardiol Rev"
                        "fecha" => "2021"
                        "volumen" => "17"
                        "paginaInicial" => "24"
                        "paginaFinal" => "30"
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                      "titulo" => "Natural history of isolated bundle branch block"
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                          "autores" => array:6 [
                            0 => "G&#46;J&#46; Fahy"
                            1 => "S&#46;L&#46; Pinski"
                            2 => "D&#46;P&#46; Miller"
                            3 => "N&#46; McCabe"
                            4 => "C&#46; Pye"
                            5 => "M&#46;J&#46; Walsh"
                          ]
                        ]
                      ]
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                    0 => array:2 [
                      "doi" => "10.1016/s0002-9149(96)00160-9"
                      "Revista" => array:6 [
                        "tituloSerie" => "Am J Cardiol"
                        "fecha" => "1996"
                        "volumen" => "77"
                        "paginaInicial" => "1185"
                        "paginaFinal" => "1190"
                        "link" => array:1 [
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                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/8651093"
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                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "The prognostic significance of right Bundle branch block&#58; A meta-analysis of prospective cohort studies"
                      "autores" => array:1 [
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Original
Prevalencia e impacto en el pronóstico del bloqueo de rama derecha en pacientes con insuficiencia cardíaca aguda: hallazgos del registro RICA
Prevalence and impact on prognosis of right-bundle branch block in patients with acute heart failure: Findings from the RICA registry
J.C. Trullàsa,b,
Autor para correspondencia
jctv5153@comg.cat

Autor para correspondencia.
, O. Aguilób,c, Ó. Miròd, J. Díez-Manglanoe, M. Carrera-Izquierdof, M.A. Quesada-Simóng, P. Álvarez-Rochah, P. Llorensi, Á. González-Francoj, M. Montero-Pérez-Barquerok, en representación de los investigadores del registro RICA ◊
a Servicio de Medicina Interna, Hospital d’Olot i comarcal de la Garrotxa, Olot, Girona, España
b Laboratori de Reparació i Regeneració Tissular (TR2Lab), Facultat de Medicina, Universitat de Vic-Universitat Central de Catalunya, Vic, Barcelona, España
c Servicio de Urgencias, Hospital d’Olot i comarcal de la Garrotxa, Olot, Girona, España
d Servicio de Urgencias, Hospital Clínic de Barcelona, Universitat de Barcelona, IDIBAPS, Barcelona, España
e Servicio de Medicina Interna, Hospital Royo Villanova, Zaragoza, España
f Servicio de Medicina Interna, Complejo Hospitalario de Soria, Soria, España
g Servicio de Medicina Interna, Hospital Universitario La Paz, Madrid, España
h Unidad Multidisciplinar de Insuficiencia Cardíaca, Hospital de Clínicas Dr. Manuel Quintela, Montevideo, Uruguay
i Servicio de Urgencias, Estancia Corta y Hospitalización a Domicilio, Hospital General d’Alacant, Alicante, España
j Servicio de Medicina Interna, Hospital Universitario Central de Asturias, Oviedo, España
k Servicio de Medicina Interna, IMIBIC/Hospital Universitario Reina Sofía, Universidad de Córdoba, Córdoba, España
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          "es" => "<p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">A&#46; Curvas de supervivencia de Kaplan Meier para mortalidad por todas las causas a un a&#241;o de seguimiento&#46; B&#46; Curvas de supervivencia de Kaplan Meier para el evento combinado a 90 d&#237;as tras el alta hospitalaria&#46; BRD&#58; bloqueo de rama derecha&#46;</p>"
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aunque existen estudios que lo relacionan con un incremento de mortalidad<a class="elsevierStyleCrossRef" href="#bib0155"><span class="elsevierStyleSup">3</span></a>&#46; En pacientes con enfermedad cardiovascular establecida &#40;especialmente coronaria&#41; parece claro que la presencia de BRD comporta un peor pron&#243;stico<a class="elsevierStyleCrossRefs" href="#bib0160"><span class="elsevierStyleSup">4&#44;5</span></a>&#46; La relaci&#243;n entre BRD e insuficiencia card&#237;aca &#40;IC&#41; se ha estudiado menos&#44; pero los pocos estudios que lo han hecho parecen indicar un peor pron&#243;stico cuando ambas entidades van asociadas<a class="elsevierStyleCrossRefs" href="#bib0170"><span class="elsevierStyleSup">6&#8211;9</span></a>&#46; Estos estudios son heterog&#233;neos y aportan datos de pacientes incluidos desde unidades de cuidados intensivos<a class="elsevierStyleCrossRef" href="#bib0175"><span class="elsevierStyleSup">7</span></a>&#44; servicios de urgencias<a class="elsevierStyleCrossRef" href="#bib0180"><span class="elsevierStyleSup">8</span></a> u hospitalizaciones en servicios de cardiolog&#237;a<a class="elsevierStyleCrossRefs" href="#bib0170"><span class="elsevierStyleSup">6&#44;9</span></a>&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">Por ello&#44; realizamos este estudio con el objetivo de determinar la prevalencia e impacto en el pron&#243;stico de la presencia de BRD en pacientes hospitalizados en los servicios de medicina interna por IC aguda &#40;ICA&#41;&#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">Poblaci&#243;n de estudio</span><p id="par0020" class="elsevierStylePara elsevierViewall">El presente estudio es un an&#225;lisis secundario de los pacientes incluidos en el Registro RICA desarrollado por el Grupo de Trabajo de IC de la Sociedad Espa&#241;ola de Medicina Interna&#44; cuyo dise&#241;o ya se ha explicado de forma detallada en otras publicaciones<a class="elsevierStyleCrossRefs" href="#bib0190"><span class="elsevierStyleSup">10&#44;11</span></a>&#46; De forma breve&#44; el registro RICA es un estudio de cohorte prospectivo y multic&#233;ntrico que incluye pacientes que&#44; de forma consecutiva&#44; ingresan &#40;y son dados de alta vivos&#41; en 34 servicios espa&#241;oles de medicina interna&#46; Despu&#233;s del ingreso &#237;ndice son obligatorias 2 visitas de seguimiento a 90 d&#237;as y 12 meses del alta hospitalaria&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">El dise&#241;o del estudio fue aprobado por el Comit&#233; de &#201;tica del Hospital Universitario Reina Sof&#237;a de C&#243;rdoba y todos los pacientes firmaron un consentimiento informado antes de su inclusi&#243;n&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Selecci&#243;n y clasificaci&#243;n de pacientes</span><p id="par0030" class="elsevierStylePara elsevierViewall">Para el presente estudio se incluyeron todos los pacientes del RICA que ten&#237;an informaci&#243;n disponible sobre el ECG en la visita basal y sobre su estado vital a 12 meses de seguimiento&#46; Se excluyeron aquellos pacientes que presentaban ritmo de marcapasos en el ECG basal y aquellos que requirieron el implante de marcapasos durante el ingreso &#237;ndice&#46; Se dividi&#243; a los pacientes incluidos en 2 grupos seg&#250;n la presencia o no de BRD en el ECG basal&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">El diagn&#243;stico de BRD lo realiz&#243; el investigador local de cada centro participante siguiendo los criterios diagn&#243;sticos internacionales<a class="elsevierStyleCrossRef" href="#bib0200"><span class="elsevierStyleSup">12</span></a>&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Variables independientes</span><p id="par0040" class="elsevierStylePara elsevierViewall">Se seleccionaron y agruparon las distintas variables en 2 grupos&#58; un primer grupo de variables incluy&#243; las caracter&#237;sticas basales de los pacientes y un segundo grupo las caracter&#237;sticas del episodio de descompensaci&#243;n&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">Respecto a las caracter&#237;sticas basales se incluyeron 28 variables&#58; 3 sobre datos demogr&#225;ficos &#40;edad&#44; sexo e &#237;ndice de masa corporal&#41;&#44; 14 relacionadas con comorbilidades &#40;tabaquismo&#44; hipertensi&#243;n arterial&#44; dislipidemia&#44; diabetes mellitus&#44; enfermedad coronaria&#44; valvulopat&#237;a&#44; enfermedad arterial perif&#233;rica&#44; enfermedad cerebrovascular&#44; fibrilaci&#243;n auricular&#44; IC previa&#44; enfermedad renal cr&#243;nica&#44; enfermedad pulmonar obstructiva cr&#243;nica &#91;EPOC&#93;&#44; demencia y c&#225;ncer activo&#41;&#44; 5 con la situaci&#243;n basal &#40;escala funcional de la <span class="elsevierStyleItalic">New York Heart Asssociation</span>&#44; fracci&#243;n de eyecci&#243;n del ventr&#237;culo izquierdo &#91;FEVI&#93; y los &#237;ndices de Barthel&#44; Charlson y Pfeiffer&#41; y 6 con los tratamientos de base &#40;diur&#233;ticos&#44; inhibidores del sistema renina angiotensina&#44; bloqueadores beta&#44; antagonistas de los receptores mineralcorticoides&#44; digoxina y amiodarona&#41;&#46;</p><p id="par0050" class="elsevierStylePara elsevierViewall">Respecto a las caracter&#237;sticas de la descompensaci&#243;n se incluyeron 14 variables&#58; 6 relacionadas con el factor desencadenante&#44; 2 con los signos vitales al ingreso &#40;presi&#243;n arterial y frecuencia card&#237;aca&#41; y 6 par&#225;metros anal&#237;ticos &#40;hemoglobina&#44; creatinina&#44; sodio&#44; potasio&#44; NT-proBNP y troponina&#41;&#46;</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Resultados <span class="elsevierStyleItalic">&#40;endpoints&#41;</span> principales y secundarios</span><p id="par0055" class="elsevierStylePara elsevierViewall">Para el presente estudio se seleccionaron 2 resultados o <span class="elsevierStyleItalic">endpoints</span>&#46; El resultado o <span class="elsevierStyleItalic">endpoint</span> principal fue la mortalidad por todas las causas al a&#241;o de seguimiento tras el alta hospitalaria&#46; El resultado o <span class="elsevierStyleItalic">endpoint</span> secundario fue la combinaci&#243;n de muerte por cualquier causa u hospitalizaci&#243;n por IC en los primeros 90 d&#237;as tras el alta hospitalaria&#46; La adjudicaci&#243;n de dichos resultados la realiz&#243; el investigador local de cada centro participante en las visitas de seguimiento a 90 d&#237;as y 12 meses&#46;</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">An&#225;lisis estad&#237;stico</span><p id="par0060" class="elsevierStylePara elsevierViewall">Las variables cuantitativas se expresan en mediana y rango intercuart&#237;lico&#44; y las cualitativas en n&#250;mero de pacientes y porcentaje&#46; El test de la Chi cuadrado y el test exacto de Fisher se usaron para comparar variables cualitativas&#46; El test &#171;t&#187; de Student se utiliz&#243; para comparar variables cuantitativas distribuidas de forma normal &#40;determinado mediante el test de Kolmogorov-Smirnov&#41; y el test no param&#233;trico U de Mann-Whitney cuando la distribuci&#243;n de dichas variables no fue normal&#46; El an&#225;lisis de Kaplan-Meier se utiliz&#243; para analizar las curvas de supervivencia de los pacientes con y sin BRD&#44; y para su comparaci&#243;n se us&#243; el Log-rank test&#46;</p><p id="par0065" class="elsevierStylePara elsevierViewall">Las diferencias en mortalidad al a&#241;o y en el evento combinado a 90 d&#237;as para los pacientes con BRD&#44; en comparaci&#243;n con los que no ten&#237;an BRD&#44; se expresan en <span class="elsevierStyleItalic">hazard ratio</span> con intervalo de confianza del 95&#37; &#40;IC 95&#37;&#41; usando un modelo de regresi&#243;n de Cox&#44; primero sin ajustar y posteriormente ajustado por las variables &#40;de las caracter&#237;sticas basales y del episodio de descompensaci&#243;n&#41; con un valor p<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#44;05 en la comparaci&#243;n bivariada &#40;modelo completamente ajustado&#41;&#46;</p><p id="par0070" class="elsevierStylePara elsevierViewall">Finalmente&#44; realizamos 2 an&#225;lisis de sensibilidad de los resultados o <span class="elsevierStyleItalic">endpoints</span>&#58; el primero eliminando del grupo de control a los pacientes con otras anomal&#237;as el&#233;ctricas en el ECG &#40;an&#225;lisis de sensibilidad A&#41; y el segundo incluyendo &#250;nicamente casos y controles en ritmo sinusal &#40;an&#225;lisis de sensibilidad B&#41;&#46; Se acept&#243; la significaci&#243;n estad&#237;stica si p<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#44;05 o el IC 95&#37; exclu&#237;a el valor 1&#46;</p><p id="par0075" class="elsevierStylePara elsevierViewall">Los an&#225;lisis se realizaron mediante el Statistical Package for Social Sciences versi&#243;n 23&#46;0 &#40;IBM&#44; Armonk&#44; Nueva York&#44; EE&#46; UU&#46;&#41;&#46;</p></span></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">Resultados</span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0105">Prevalencia de bloqueo de rama derecha</span><p id="par0080" class="elsevierStylePara elsevierViewall">Para el presente estudio se analizaron 4&#46;621 pacientes del RICA&#46; Tras excluir los pacientes que no ten&#237;an informaci&#243;n sobre el ECG basal o sobre su estado vital al a&#241;o de seguimiento&#44; as&#237; como aquellos que presentaban ritmo de marcapasos en el ECG basal o que requirieron implante de marcapasos en el ingreso &#237;ndice&#44; el n&#250;mero final de pacientes analizados fue de 3&#46;638 &#40;<a class="elsevierStyleCrossRef" href="#fig0005">fig&#46; 1</a>&#41;&#46; De ellos 398 ten&#237;an BRD en el ECG basal&#44; estableciendo una prevalencia del 10&#44;9&#37; &#40;IC 95&#37;&#58; 9&#44;9-12&#44;0&#41;&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0110">Caracter&#237;sticas basales y del episodio de descompensaci&#243;n</span><p id="par0085" class="elsevierStylePara elsevierViewall">Las caracter&#237;sticas basales de los pacientes se exponen de forma detallada en la <a class="elsevierStyleCrossRef" href="#tbl0005">tabla 1</a>&#46; De forma breve se trata de una cohorte de edad avanzada &#40;mediana de 81 a&#241;os&#41;&#44; con similar proporci&#243;n de hombres y mujeres&#44; y con elevada comorbilidad&#44; siendo las m&#225;s frecuentes &#40;presentes en m&#225;s del 50&#37; de los pacientes&#41;&#58; la hipertensi&#243;n arterial&#44; la dislipidemia&#44; la fibrilaci&#243;n auricular&#44; la IC previa y la insuficiencia renal cr&#243;nica&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0090" class="elsevierStylePara elsevierViewall">Encontramos diferencias significativas entre los pacientes con y sin BRD en 7 de las 28 variables basales comparadas&#46; Los pacientes con BRD eran de mayor edad y con mayor frecuencia de sexo masculino&#44; tabaquismo activo y EPOC&#46; Tambi&#233;n presentaban valores m&#225;s altos de FEVI&#44; peor situaci&#243;n funcional &#40;menor puntuaci&#243;n en el &#237;ndice de Barthel&#41; y menor prescripci&#243;n de bloqueadores beta&#46;</p><p id="par0095" class="elsevierStylePara elsevierViewall">En relaci&#243;n con las caracter&#237;sticas del episodio de descompensaci&#243;n&#44; los factores desencadenantes m&#225;s frecuentes fueron las infecciones &#40;32&#37;&#41;&#44; seguidas de la fibrilaci&#243;n auricular r&#225;pida &#40;26&#37;&#41;&#44; siendo poco frecuente el s&#237;ndrome coronario agudo &#40;270 pacientes &#91;7&#44;4&#37;&#93;&#44; de los cuales solo 58 eran con elevaci&#243;n del ST&#41;&#46; No encontramos diferencias significativas en relaci&#243;n con la presencia de BRD&#44; aunque el grupo con BRD tuvo una tendencia casi significativa a presentar m&#225;s anemia y transgresi&#243;n diet&#233;tica&#47;farmacol&#243;gica y menos s&#237;ndrome coronario agudo como desencadenantes &#40;<a class="elsevierStyleCrossRef" href="#tbl0010">tabla 2</a>&#41;&#46;</p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><p id="par0100" class="elsevierStylePara elsevierViewall">No encontramos tampoco diferencias entre los 2 grupos en relaci&#243;n con los valores de presi&#243;n arterial y frecuencia card&#237;aca al ingreso&#44; as&#237; como en ninguno de los valores anal&#237;ticos comparados&#46;</p><p id="par0105" class="elsevierStylePara elsevierViewall">Las causas m&#225;s frecuentes de mortalidad fueron cardiovasculares&#44; siendo la m&#225;s habitual el empeoramiento de la propia IC&#44; y no encontramos diferencias de causas de muerte seg&#250;n la presencia o no de BRD&#46;</p></span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0115"><span class="elsevierStyleItalic">Outcomes</span></span><p id="par0110" class="elsevierStylePara elsevierViewall">La mortalidad acumulada al a&#241;o de seguimiento fue del 18&#44;7&#37; &#40;IC 95&#37;&#58; 17&#44;5-20&#44;0&#41; y la proporci&#243;n acumulada del evento combinado a 90 d&#237;as fue del 15&#44;8&#37; &#40;IC 95&#37;&#58; 14&#44;6-17&#44;0&#41;&#46; No encontramos diferencias significativas en supervivencia en pacientes con y sin BRD para ninguno de los 2 resultados &#40;<a class="elsevierStyleCrossRef" href="#fig0010">fig&#46; 2</a>&#41;&#46; El riesgo de presentar resultados desfavorables en los 2 <span class="elsevierStyleItalic">outcomes</span> analizados se muestra en la <a class="elsevierStyleCrossRef" href="#tbl0015">tabla 3</a>&#46;</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><elsevierMultimedia ident="tbl0015"></elsevierMultimedia><p id="par0115" class="elsevierStylePara elsevierViewall">La presencia de BRD no se asoci&#243; a un mayor riesgo de mortalidad al a&#241;o ni del evento combinado a 90 d&#237;as en ninguno de los modelos ajustados&#46; Los an&#225;lisis de sensibilidad confirmaron esta falta de asociaci&#243;n entre la presencia de BRD y el mal pron&#243;stico a 90 d&#237;as y 12 meses en la cohorte RICA&#46;</p></span></span><span id="sec0060" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0120">Discusi&#243;n</span><p id="par0120" class="elsevierStylePara elsevierViewall">La IC es un s&#237;ndrome de proporciones epid&#233;micas para el que existe un gran inter&#233;s en conocer los factores que determinan su pron&#243;stico<a class="elsevierStyleCrossRefs" href="#bib0205"><span class="elsevierStyleSup">13&#44;14</span></a>&#46; Las arritmias son uno de dichos factores&#44; estando muy estudiada la relaci&#243;n de la IC con algunas de ellas&#44; como la fibrilaci&#243;n auricular&#44; pero existe mucha menos informaci&#243;n sobre el impacto en el pron&#243;stico de otras alteraciones electrocardiogr&#225;ficas como los bloqueos de conducci&#243;n<a class="elsevierStyleCrossRef" href="#bib0215"><span class="elsevierStyleSup">15</span></a>&#46;</p><p id="par0125" class="elsevierStylePara elsevierViewall">La relaci&#243;n entre bloqueos de conducci&#243;n e IC ha sido algo m&#225;s estudiada para los bloqueos de rama izquierda &#40;BRI&#41;&#44; existiendo controversia sobre su impacto en el pron&#243;stico al existir estudios que muestran un incremento del riesgo de mortalidad<a class="elsevierStyleCrossRefs" href="#bib0220"><span class="elsevierStyleSup">16&#44;17</span></a> y otros que no han encontrado dicha asociaci&#243;n<a class="elsevierStyleCrossRefs" href="#bib0170"><span class="elsevierStyleSup">6&#44;9&#44;18&#44;19</span></a>&#46; Son todav&#237;a menos los estudios que han analizado esta relaci&#243;n cuando el bloqueo es de la rama derecha del haz de His&#46; Se trata de estudios de tama&#241;o peque&#241;o&#44; en muchas ocasiones realizados en un solo centro&#44; con una procedencia heterog&#233;nea de los pacientes &#40;Unidades de Cuidados Intensivos<a class="elsevierStyleCrossRef" href="#bib0175"><span class="elsevierStyleSup">7</span></a>&#44; Servicios de Urgencias<a class="elsevierStyleCrossRef" href="#bib0180"><span class="elsevierStyleSup">8</span></a> y Servicios de Cardiolog&#237;a<a class="elsevierStyleCrossRef" href="#bib0185"><span class="elsevierStyleSup">9</span></a>&#41; y en ocasiones solo centrados en pacientes con FEVI deprimida y sin cubrir todo el &#171;espectro&#187; de la IC<a class="elsevierStyleCrossRef" href="#bib0170"><span class="elsevierStyleSup">6</span></a>&#46; Por otro lado&#44; la media de edad de los pacientes incluidos en estos estudios previos &#40;62-73<span class="elsevierStyleHsp" style=""></span>a&#241;os&#41;<a class="elsevierStyleCrossRefs" href="#bib0170"><span class="elsevierStyleSup">6&#8211;9</span></a> es inferior a la del registro RICA&#44; que es de edad mucho m&#225;s avanzada &#40;media de 81<span class="elsevierStyleHsp" style=""></span>a&#241;os&#41;&#46;</p><p id="par0130" class="elsevierStylePara elsevierViewall">As&#237;&#44; en este estudio hemos incluido una gran muestra de pacientes &#171;del mundo real&#187; cubriendo ampliamente el s&#237;ndrome de IC descompensada&#44; sin ninguna limitaci&#243;n de edad&#44; comorbilidades&#44; etiolog&#237;a o valores de FEVI&#46; Desde esta perspectiva podemos exponer los siguientes resultados principales&#58; la prevalencia de BRD en pacientes con ICA es del 11&#37;&#44; la presencia de BRD se asocia de forma consistente con algunas caracter&#237;sticas cl&#237;nicas basales&#44; pero no parece asociarse a un peor pron&#243;stico&#46; La prevalencia de BRD en nuestro estudio est&#225; en consonancia con la descrita en otros estudios&#44; que se sit&#250;a entre el 5&#44;4&#37; y el 14&#37;<a class="elsevierStyleCrossRefs" href="#bib0170"><span class="elsevierStyleSup">6&#8211;9</span></a>&#44; pero es claramente inferior a la prevalencia de BRI en IC&#44; que oscila entre el 15&#37; y el 30&#37; seg&#250;n los estudios<a class="elsevierStyleCrossRefs" href="#bib0185"><span class="elsevierStyleSup">9&#44;16&#44;18&#8211;22</span></a>&#46;</p><p id="par0135" class="elsevierStylePara elsevierViewall">Del mismo modo algunas caracter&#237;sticas basales asociadas a la presencia de BRD en pacientes con IC del registro RICA coinciden con las de otros estudios&#44; como son la edad m&#225;s avanzada<a class="elsevierStyleCrossRef" href="#bib0170"><span class="elsevierStyleSup">6</span></a>&#44; el sexo masculino<a class="elsevierStyleCrossRefs" href="#bib0170"><span class="elsevierStyleSup">6&#44;9</span></a>&#44; las comorbilidades pulmonares como la EPOC<a class="elsevierStyleCrossRef" href="#bib0180"><span class="elsevierStyleSup">8</span></a> y la FEVI preservada<a class="elsevierStyleCrossRef" href="#bib0185"><span class="elsevierStyleSup">9</span></a>&#46; La rama derecha del haz de His es vulnerable a alteraciones card&#237;acas funcionales y&#47;o estructurales&#44; como es el incremento en la presi&#243;n en el ventr&#237;culo derecho &#40;como ocurre de forma cr&#243;nica en el <span class="elsevierStyleItalic">cor pulmonale</span>&#41;<a class="elsevierStyleCrossRef" href="#bib0145"><span class="elsevierStyleSup">1</span></a>&#44; y ello puede explicar&#44; en parte&#44; la asociaci&#243;n del BRD con algunas de estas comorbilidades&#46;</p><p id="par0140" class="elsevierStylePara elsevierViewall">No todos los estudios han encontrado asociaci&#243;n del BRD con la FEVI y en alguno de ellos incluso se han analizado solo aquellos con FEVI deprimida<a class="elsevierStyleCrossRef" href="#bib0170"><span class="elsevierStyleSup">6</span></a>&#44; por lo que no podemos extraer conclusiones sobre la relaci&#243;n entre BRD y FEVI&#46; La asociaci&#243;n de BRD con una peor situaci&#243;n funcional es algo que&#44; en nuestro conocimiento&#44; no estaba descrito previamente&#44; pero que es de sumo inter&#233;s&#44; pues el &#237;ndice de Barthel es una variable claramente relacionada de forma independiente con el pron&#243;stico &#40;a corto y largo plazo&#41; de los pacientes con IC&#44; ya sea de forma cr&#243;nica o aguda<a class="elsevierStyleCrossRefs" href="#bib0255"><span class="elsevierStyleSup">23&#44;24</span></a>&#46;</p><p id="par0145" class="elsevierStylePara elsevierViewall">A pesar de esta asociaci&#243;n del BRD con edad m&#225;s avanzada&#44; algunas comorbilidades y un peor estado funcional&#44; en nuestro estudio no hemos encontrado que la presencia de BRD en el ECG basal se asocie de forma independiente con un peor pron&#243;stico a largo plazo &#40;mortalidad por todas las causas a los 12 meses de seguimiento tras el alta hospitalaria&#41;&#46; A pesar de que existe alg&#250;n estudio que tampoco ha encontrado asociaci&#243;n de BRD con mortalidad en ICA<a class="elsevierStyleCrossRef" href="#bib0220"><span class="elsevierStyleSup">16</span></a>&#44; la mayor&#237;a de estudios que han analizado este aspecto s&#237; que han descrito una mayor mortalidad relacionada con el BRD<a class="elsevierStyleCrossRefs" href="#bib0170"><span class="elsevierStyleSup">6&#8211;9</span></a>&#46; Este hallazgo&#44; por lo menos controvertido y de dif&#237;cil explicaci&#243;n&#44; es similar al descrito previamente con el BRI y la ICA&#46;</p><p id="par0150" class="elsevierStylePara elsevierViewall">Como se ha comentado previamente&#44; estos estudios son de tama&#241;o relativamente peque&#241;o&#44; heterog&#233;neos&#44; algunos no incluyen pacientes con FEVI preservada y en ocasiones mezclan el an&#225;lisis del BRD con el BRI&#44; por lo que es dif&#237;cil sacar conclusiones&#46; Es probable que este dilema se pudiera resolver si se llevara a cabo una revisi&#243;n sistem&#225;tica de la literatura con metaan&#225;lisis que agrupara todos estos estudios y pudiera discernir si realmente los bloqueos de conducci&#243;n &#40;BRI y BRD&#41; se asocian o no a un mayor riesgo de muerte en pacientes con ICA&#46; En nuestro conocimiento este estudio todav&#237;a no ha sido publicado&#44; pero s&#237; est&#225; registrado &#40;n&#250;mero de registro CRD42021228958&#41; en el registro internacional de revisiones sistem&#225;ticas PROSPERO<a class="elsevierStyleCrossRef" href="#bib0265"><span class="elsevierStyleSup">25</span></a>&#46;</p><p id="par0155" class="elsevierStylePara elsevierViewall">Respecto a las causas de muerte no hemos encontrado diferencias seg&#250;n la presencia o no de BRD&#44; y este hecho tambi&#233;n difiere con otros estudios en los que el BRD se asoci&#243; con una mayor proporci&#243;n de muertes de causa cardiovascular&#44; especialmente empeoramiento de la IC<a class="elsevierStyleCrossRef" href="#bib0270"><span class="elsevierStyleSup">26</span></a>&#46;</p><p id="par0160" class="elsevierStylePara elsevierViewall">Por otro lado&#44; tampoco hemos encontrado en nuestro estudio que los pacientes con BRD tengan un mayor riesgo de reingreso o muerte a los 90 d&#237;as tras el alta hospitalaria&#46; Este resultado todav&#237;a se ha estudiado menos en los estudios previos&#44; y solamente Hong et al&#46; describen que s&#237; existe un mayor riesgo de rehospitalizaci&#243;n en los pacientes con BRD<a class="elsevierStyleCrossRef" href="#bib0185"><span class="elsevierStyleSup">9</span></a>&#46; En esta fase temprana despu&#233;s del alta&#44; descrita como per&#237;odo de vulnerabilidad&#44; existe un mayor riesgo de complicaciones y es cuando suceden muchas de las rehospitalizaciones<a class="elsevierStyleCrossRefs" href="#bib0275"><span class="elsevierStyleSup">27&#44;28</span></a>&#46; A pesar de ello&#44; con la informaci&#243;n disponible&#44; no podemos afirmar que el BRD desempe&#241;e un papel en dicho riesgo en este per&#237;odo de vulnerabilidad&#46;</p><span id="sec0065" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0125">Limitaciones</span><p id="par0165" class="elsevierStylePara elsevierViewall">En el presente estudio existen algunas limitaciones&#46; En primer lugar&#44; a pesar de tratarse de una larga serie de pacientes con IC de diferentes hospitales espa&#241;oles&#44; todos proceden de la hospitalizaci&#243;n en servicios de medicina interna&#44; y es por ello que los resultados encontrados no se pueden extrapolar a otros escenarios&#46; En segundo lugar&#44; no se realiz&#243; un c&#225;lculo del tama&#241;o muestral&#44; y a pesar de ser superior al de otros estudios publicados&#44; quiz&#225; no fue suficiente para alcanzar la potencia estad&#237;stica necesaria para encontrar asociaci&#243;n con mortalidad&#46; En tercer lugar la lectura e interpretaci&#243;n de los ECG se realiz&#243; por los investigadores principales de cada centro sin realizar una doble comprobaci&#243;n del diagn&#243;stico de BRD&#46; A pesar de ello&#44; y en nuestra opini&#243;n&#44; la amplia experiencia de los investigadores del registro en la asistencia de pacientes con IC hace pensar que los errores de interpretaci&#243;n de los bloqueos de rama habr&#225;n sido poco relevantes&#46; Por &#250;ltimo&#44; la exclusi&#243;n de los pacientes que fallecen durante la hospitalizaci&#243;n &#237;ndice es una limitaci&#243;n del registro RICA&#44; y no podemos descartar que la inclusi&#243;n de dichos pacientes hubiera podido modificar los resultados de nuestro estudio&#46;</p></span></span><span id="sec0070" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0130">Conclusiones</span><p id="par0170" class="elsevierStylePara elsevierViewall">La prevalencia de BRD en los pacientes con IC del registro RICA es del 10&#44;9&#37;&#59; se asocia a algunas comorbilidades&#44; a valores m&#225;s elevados de FEVI y peor situaci&#243;n funcional&#44; pero no a un peor pron&#243;stico&#46;</p></span><span id="sec0075" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0135">Financiaci&#243;n</span><p id="par0175" class="elsevierStylePara elsevierViewall">La presente investigaci&#243;n no ha recibido ayudas espec&#237;ficas provenientes de agencias del sector p&#250;blico&#44; sector comercial o entidades sin &#225;nimo de lucro&#46;</p></span><span id="sec0080" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0140">Conflicto de intereses</span><p id="par0180" class="elsevierStylePara elsevierViewall">Los autores declaran no tener ning&#250;n conflicto de intereses&#46;</p></span></span>"
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    "fechaAceptado" => "2021-10-08"
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      "es" => array:1 [
        0 => array:4 [
          "clase" => "keyword"
          "titulo" => "Palabras clave"
          "identificador" => "xpalclavsec1504639"
          "palabras" => array:5 [
            0 => "Insuficiencia card&#237;aca"
            1 => "Descompensaci&#243;n card&#237;aca"
            2 => "Bloqueo de rama derecha"
            3 => "Pron&#243;stico"
            4 => "Mortalidad"
          ]
        ]
      ]
      "en" => array:1 [
        0 => array:4 [
          "clase" => "keyword"
          "titulo" => "Keywords"
          "identificador" => "xpalclavsec1504640"
          "palabras" => array:5 [
            0 => "Heart failure"
            1 => "Cardiac decompensation"
            2 => "Right bundle branch block"
            3 => "Prognosis"
            4 => "Mortality"
          ]
        ]
      ]
    ]
    "tieneResumen" => true
    "resumen" => array:2 [
      "es" => array:3 [
        "titulo" => "Resumen"
        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Objetivos</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Determinar la prevalencia&#44; las caracter&#237;sticas y el impacto en el pron&#243;stico del bloqueo de rama derecha &#40;BRD&#41; en una cohorte de pacientes con insuficiencia card&#237;aca aguda &#40;ICA&#41;&#46;</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">M&#233;todos</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Analizamos prospectivamente 3&#46;638 pacientes con ICA incluidos en el Registro Nacional de Insuficiencia Card&#237;aca de la Sociedad Espa&#241;ola de Medicina Interna &#40;RICA&#41;&#46; Analizamos de forma independiente la relaci&#243;n entre las caracter&#237;sticas basales y cl&#237;nicas y la presencia de BRD&#44; y el impacto potencial del BRD en la mortalidad por todas las causas a un a&#241;o y el evento combinado de hospitalizaci&#243;n o muerte a 90 d&#237;as despu&#233;s del alta&#46;</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Resultados</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">La prevalencia de BRD fue del 10&#44;9&#37;&#46; Los pacientes con BRD eran de edad m&#225;s avanzada&#44; con mayor proporci&#243;n de sexo masculino y comorbilidades pulmonares&#44; valores m&#225;s altos de fracci&#243;n de eyecci&#243;n del ventr&#237;culo izquierdo y peor estado funcional&#46; No hubo diferencias en riesgo para los pacientes con BRD&#44; con un cociente de riesgo ajustado &#40;intervalo de confianza del 95&#37;&#41; para la mortalidad a un a&#241;o de 1&#44;05 &#40;0&#44;83-1&#44;32&#41; y para el evento combinado a 90 d&#237;as despu&#233;s del alta de 0&#44;97 &#40;0&#44;74-1&#44;25&#41;&#46; Estos resultados fueron consistentes en los an&#225;lisis de sensibilidad&#46;</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Conclusiones</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Pocos pacientes con ICA presentan BRD&#44; que se asocia consistentemente con la edad avanzada&#44; el sexo masculino&#44; las comorbilidades pulmonares&#44; la fracci&#243;n de eyecci&#243;n del ventr&#237;culo izquierdo preservada y el peor estado funcional&#46; Sin embargo&#44; despu&#233;s de tener en cuenta estos factores&#44; el BRD en pacientes con ICA no se asocia a peores resultados&#46;</p></span>"
        "secciones" => array:4 [
          0 => array:2 [
            "identificador" => "abst0005"
            "titulo" => "Objetivos"
          ]
          1 => array:2 [
            "identificador" => "abst0010"
            "titulo" => "M&#233;todos"
          ]
          2 => array:2 [
            "identificador" => "abst0015"
            "titulo" => "Resultados"
          ]
          3 => array:2 [
            "identificador" => "abst0020"
            "titulo" => "Conclusiones"
          ]
        ]
      ]
      "en" => array:3 [
        "titulo" => "Abstract"
        "resumen" => "<span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Objectives</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">This work aims to determine the prevalence&#44; characteristics&#44; and impact on prognosis of right bundle branch block &#40;RBBB&#41; in a cohort of acute heart failure &#40;AHF&#41; patients&#46;</p></span> <span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Methods</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">We prospectively analyzed 3&#44;638 AHF patients included in the RICA registry &#40;National Heart Failure Registry of the Spanish Internal Medicine Society&#41;&#46; We independently analyzed the relationship between baseline and clinical characteristics and the presence of RBBB as well as the potential impact of RBBB on 1-year all-cause mortality and a composite endpoint of 90-day post-discharge hospitalization or death&#46;</p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Results</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">The prevalence of RBBB was 10&#46;9&#37;&#46; Patients with RBBB were older&#44; a higher proportion were male&#44; had more pulmonary comorbidities&#44; had higher left ventricular ejection fraction values&#44; and had worse functional status&#46; There were no differences in risk for patients with RBBB&#44; with an adjusted hazard ratio &#40;95&#37; confidence interval&#41; for 1-year mortality of 1&#46;05 &#40;0&#46;83-1&#46;32&#41;&#44; and for the composite endpoint of 90-day post-discharge hospitalization or death of 0&#46;97 &#40;0&#46;74-1&#46;25&#41;&#46; These results were consistent on the sensitivity analyses&#46;</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Conclusions</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">Few patients with AHF present with RBBB&#44; which is consistently associated with advanced age&#44; male sex&#44; pulmonary comorbidities&#44; preserved left ventricular ejection fraction&#44; and worse functional status&#46; Nonetheless&#44; after considering these factors&#44; RBBB in AHF patients is not associated with worse outcomes&#46;</p></span>"
        "secciones" => array:4 [
          0 => array:2 [
            "identificador" => "abst0025"
            "titulo" => "Objectives"
          ]
          1 => array:2 [
            "identificador" => "abst0030"
            "titulo" => "Methods"
          ]
          2 => array:2 [
            "identificador" => "abst0035"
            "titulo" => "Results"
          ]
          3 => array:2 [
            "identificador" => "abst0040"
            "titulo" => "Conclusions"
          ]
        ]
      ]
    ]
    "NotaPie" => array:1 [
      0 => array:3 [
        "etiqueta" => "&#9674;"
        "nota" => "<p class="elsevierStyleNotepara" id="npar0030">El listado con todos los investigadores del Registro RICA aparece en el <a class="elsevierStyleCrossRef" href="#sec0085">anexo</a>&#46;</p>"
        "identificador" => "fn0005"
      ]
    ]
    "apendice" => array:1 [
      0 => array:1 [
        "seccion" => array:1 [
          0 => array:4 [
            "apendice" => "<p id="par0190" class="elsevierStylePara elsevierViewall">P&#46; &#193;lvarez Rocha&#44; L&#46; Anarte&#44; O&#46; Aramburu-Bodas&#44; J&#46;C&#46; Ar&#233;valo-Lorido&#44; J&#46;L&#46; Arias Jim&#233;nez&#44; S&#46; Carrascosa&#44; J&#46;M&#46; Cepeda&#44; J&#46;M&#46; Cerqueiro&#44; D&#46; Chivite Guill&#233;n&#44; A&#46; Conde-Martel&#44; M&#46;F&#46; D&#225;vila Ramos&#44; S&#46; D&#237;az de Castellv&#237;&#44; F&#46; Epelde&#44; F&#46; Formiga P&#233;rez&#44; A&#46; Garc&#237;a Campos&#44; A&#46; Gonz&#225;lez Franco&#44; A&#46; Le&#243;n Acu&#241;a&#44; G&#46; L&#243;pez Castellanos&#44; O&#46; Lorente Furi&#243;&#44; L&#46; Manzano&#44; M&#46; Montero-P&#233;rez-Barquero&#44; M&#46;C&#46; Moreno Garc&#237;a&#44; G&#46; Ormaechea Gorricho&#44; M&#46;A&#46; Quesada Sim&#243;n&#44; R&#46; Ruiz Ortega&#44; M&#46;P&#46; Salamanca Bautista&#44; G&#46; Silvera y J&#46;C&#46;Trull&#224;s&#46;</p>"
            "etiqueta" => "Appendix A"
            "titulo" => "Anexo&#46; Listado de investigadores del RICA"
            "identificador" => "sec0085"
          ]
        ]
      ]
    ]
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        "identificador" => "fig0005"
        "etiqueta" => "Figura 1"
        "tipo" => "MULTIMEDIAFIGURA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
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          0 => array:4 [
            "imagen" => "gr1.jpeg"
            "Alto" => 2973
            "Ancho" => 2500
            "Tamanyo" => 274970
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        "descripcion" => array:1 [
          "es" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Flujo de pacientes para su inclusi&#243;n en el estudio&#46; ECG&#58; electrocardiograma&#46;</p>"
        ]
      ]
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        "identificador" => "fig0010"
        "etiqueta" => "Figura 2"
        "tipo" => "MULTIMEDIAFIGURA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "figura" => array:1 [
          0 => array:4 [
            "imagen" => "gr2.jpeg"
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        "descripcion" => array:1 [
          "es" => "<p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">A&#46; Curvas de supervivencia de Kaplan Meier para mortalidad por todas las causas a un a&#241;o de seguimiento&#46; B&#46; Curvas de supervivencia de Kaplan Meier para el evento combinado a 90 d&#237;as tras el alta hospitalaria&#46; BRD&#58; bloqueo de rama derecha&#46;</p>"
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        "identificador" => "tbl0005"
        "etiqueta" => "Tabla 1"
        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "detalles" => array:1 [
          0 => array:3 [
            "identificador" => "at1"
            "detalle" => "Tabla "
            "rol" => "short"
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          "leyenda" => "<p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">ARM&#58; antagonistas de los receptores mineralocorticoides&#59; BRD&#58; bloqueo de rama derecha&#59; EPOC&#58; enfermedad pulmonar obstructiva cr&#243;nica&#59; FEVI&#58; fracci&#243;n de eyecci&#243;n del ventr&#237;culo izquierdo&#59; IMC&#58; &#237;ndice de masa corporal&#59; NYHA&#58; <span class="elsevierStyleItalic">New York Heart Association</span>&#59; SRA&#58; sistema renina-angiotensina&#46;</p><p id="spar0065" class="elsevierStyleSimplePara elsevierViewall">Los valores p en negrita denotan significaci&#243;n estad&#237;stica &#40;p<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#44;05&#41;&#46;</p>"
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">Edad &#40;a&#241;os&#41;</span><a class="elsevierStyleCrossRef" href="#tblfn0005"><span class="elsevierStyleSup">a</span></a>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">0&#44;102&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">Insuficiencia renal cr&#243;nica</span><a class="elsevierStyleCrossRef" href="#tblfn0020"><span class="elsevierStyleSup">b</span></a>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">Demencia</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">&#205;ndice de Charlson</span><a class="elsevierStyleCrossRef" href="#tblfn0005"><span class="elsevierStyleSup">a</span></a>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">Transgresi&#243;n diet&#233;tica&#47;farmacol&#243;gica</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">S&#237;ndrome coronario agudo</span><a class="elsevierStyleCrossRef" href="#tblfn0010"><span class="elsevierStyleSup">a</span></a>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">Hemoglobina &#40;g&#47;L&#41;</span><a class="elsevierStyleCrossRef" href="#tblfn0015"><span class="elsevierStyleSup">b</span></a>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">Potasio &#40;mmolLl&#41;</span><a class="elsevierStyleCrossRef" href="#tblfn0015"><span class="elsevierStyleSup">b</span></a>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">Sodio &#40;mmol&#47;L&#41;</span><a class="elsevierStyleCrossRef" href="#tblfn0015"><span class="elsevierStyleSup">b</span></a>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">NT-proBNP &#40;ng&#47;mL&#41;</span><a class="elsevierStyleCrossRef" href="#tblfn0015"><span class="elsevierStyleSup">b</span></a>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">3486&#40;1666-7898&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">1165 &#40;32&#44;0&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">3481 &#40;1473-8359&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>An&#225;lisis de sensibilidad A&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&#44;053 &#40;0&#44;801-1&#44;383&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#44;712&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>An&#225;lisis de sensibilidad B&nbsp;\t\t\t\t\t\t\n
                  \t\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;418 &#40;0&#44;982-2&#44;048&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">0&#44;062&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t  " colspan="3" align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleBold">Evento combinado a los 90 d&#237;as del alta hospitalaria</span></td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="3" align="left" valign="\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>No ajustado&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">0&#44;536&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><span class="elsevierStyleItalic">An&#225;lisis de sensibilidad para el modelo completamente ajustado</span><a class="elsevierStyleCrossRef" href="#tblfn0025"><span class="elsevierStyleSup">a</span></a></td></tr><tr title="table-row"><td class="td-with-role" title="\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>An&#225;lisis de sensibilidad 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
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>An&#225;lisis de sensibilidad B&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t">0&#44;969 &#40;0&#44;615-1&#44;529&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">0&#44;894&nbsp;\t\t\t\t\t\t\n
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              "nota" => "<p class="elsevierStyleNotepara" id="npar0025">El an&#225;lisis de sensibilidad A consisti&#243; en eliminar del grupo control los pacientes con otras alteraciones electrocardiogr&#225;ficas&#59; el an&#225;lisis de sensibilidad B incluy&#243; solo casos y controles en ritmo sinusal&#46;</p>"
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          "es" => "<p id="spar0085" class="elsevierStyleSimplePara elsevierViewall">An&#225;lisis de regresi&#243;n de Cox para mortalidad a un a&#241;o y para el evento combinado a los 90 d&#237;as en pacientes con bloqueo de rama derecha en la cohorte RICA&#44; incluyendo an&#225;lisis ajustado y an&#225;lisis de sensibilidad</p>"
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                  "contribucion" => array:1 [
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                          "etal" => true
                          "autores" => array:6 [
                            0 => "J&#46;C&#46; Trull&#224;s"
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        "texto" => "<p id="par0185" class="elsevierStylePara elsevierViewall">Agradecemos a todos los investigadores que forman parte del RICA&#46; Agradecemos al Centro Coordinador de Registros S&#38;H <span class="elsevierStyleItalic">Medical Science Service</span> de RICA sus datos de control de calidad&#44; apoyo log&#237;stico y trabajo administrativo y al Prof&#46; Salvador Ortiz&#44; Universidad Aut&#243;noma de Madrid y asesor estad&#237;stico del S&#38;H <span class="elsevierStyleItalic">Medical Science Service</span> el an&#225;lisis estad&#237;stico de los datos presentados en este documento&#46;</p>"
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Información del artículo
ISSN: 00142565
Idioma original: Español
DOI:10.1016/j.rce.2021.10.001
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