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          "es" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Estudio DIG-ICA&#46;</p> <p id="spar2045" class="elsevierStyleSimplePara elsevierViewall">&#42;BEC&#58; bloqueadores de entrada de calcio&#46; BB&#58; betabloqueantes&#46;</p>"
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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">Las descompensaciones en los pacientes con insuficiencia cardiaca &#40;IC&#41; son uno de los principales motivos de consulta a los servicios de urgencias hospitalarios &#40;SUH&#41; y una de las primeras causas de hospitalizaci&#243;n en Espa&#241;a<a class="elsevierStyleCrossRefs" href="#bib0175"><span class="elsevierStyleSup">1&#44;2</span></a>&#46; Conlleva adem&#225;s&#44; una elevada mortalidad intrahospitalaria y tras el alta&#44; as&#237; como un alto &#237;ndice de reingreso<a class="elsevierStyleCrossRefs" href="#bib0185"><span class="elsevierStyleSup">3&#44;4</span></a>&#46; Aunque en una peque&#241;a parte de los casos los pacientes hospitalizan de forma directa procedentes de atenci&#243;n primaria o especializada&#44; en m&#225;s del 90&#37; de las hospitalizaciones de los pacientes con ICA se realizan tras su consulta y tratamiento inicial en SUH<a class="elsevierStyleCrossRefs" href="#bib0195"><span class="elsevierStyleSup">5&#44;6</span></a>&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">El enfoque actual del tratamiento de los pacientes con insuficiencia cardiaca aguda &#40;ICA&#41; en el SU tiene como objetivo la mejor&#237;a de los signos y s&#237;ntomas del paciente&#44; corregir la sobrecarga de volumen&#44; aumentar la perfusi&#243;n de los &#243;rganos diana y mejorar el estado hemodin&#225;mico contrarrestando la hiperactivaci&#243;n neurohormonal que constituye el principal mecanismo fisiopatol&#243;gico de la enfermedad&#46; Se ha demostrado que un abordaje en&#233;rgico y apropiado del tratamiento de la ICA resulta &#250;til para mejorar la evoluci&#243;n cl&#237;nica de los pacientes&#46; A pesar del inicio m&#225;s temprano del tratamiento&#44; y aun cuando este sea en&#233;rgico&#44; la mortalidad de los pacientes con ICA sigue siendo muy elevada&#44; lo cual pone de manifiesto la necesidad de mejorar los resultados cl&#237;nicos mediante nuevas estrategias terap&#233;uticas<a class="elsevierStyleCrossRefs" href="#bib0205"><span class="elsevierStyleSup">7&#44;8</span></a>&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">La digoxina es un gluc&#243;sido cardiot&#243;nico&#44; usado como agente antiarr&#237;tmico empleado en la insuficiencia cardiaca&#44; y utilizado en otros trastornos cardiacos como la fibrilaci&#243;n auricular &#40;FA&#41;&#44; y por este mecanismo podr&#237;a ser &#250;til en el tratamiento de los pacientes con ICA&#44; a pesar de que no se la considera tratamiento de primera l&#237;nea&#46; Posee efectos vagomim&#233;ticos&#44; reduce la actividad del sistema renina-angiotensina&#44; la resistencia venosa sist&#233;mica y aumenta el gasto card&#237;aco y&#44; aunque la gu&#237;a de la Sociedad Europea de Cardiolog&#237;a considera el uso de digoxina en la ICA para controlar la frecuencia cardiaca<a class="elsevierStyleCrossRef" href="#bib0180"><span class="elsevierStyleSup">2</span></a>&#44; en especial en presencia de FA aguda&#44; las gu&#237;as de la <span class="elsevierStyleItalic">American Heart Association</span> y la <span class="elsevierStyleItalic">Heart Failure Society of America</span> no indican su empleo<a class="elsevierStyleCrossRef" href="#bib0215"><span class="elsevierStyleSup">9</span></a>&#46; Adem&#225;s&#44; no se conocen estudios en los que se haya examinado los resultados cl&#237;nicos para determinar su efecto terap&#233;utico favorable en la ICA<a class="elsevierStyleCrossRef" href="#bib0220"><span class="elsevierStyleSup">10</span></a>&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">La digoxina se recomienda en pacientes con IC congestiva &#40;ICC&#41; y FA&#44; y en pacientes con ICC moderada y grave &#40;grado III-IV o II-III sintom&#225;ticos seg&#250;n la New York Heart Association &#91;NYHA&#93;&#41;&#44; que no se controlan con otros tratamientos<a class="elsevierStyleCrossRefs" href="#bib0225"><span class="elsevierStyleSup">11&#44;12</span></a>&#46; Tambi&#233;n se puede considerar la digoxina en pacientes con ICC con FEVI reducida y en ritmo sinusal para reducir el riesgo de hospitalizaci&#243;n<a class="elsevierStyleCrossRef" href="#bib0235"><span class="elsevierStyleSup">13</span></a>&#44; aunque su efecto en aquellos pacientes tratados habitualmente con betabloqueantes no ha sido probado&#46; En el ensayo DIG&#44; el efecto general sobre la mortalidad con digoxina fue neutral&#46; Los efectos de la digoxina en pacientes con ICC con fracci&#243;n de eyecci&#243;n reducida &#40;FEr&#41; y FA no ha sido estudiado en ensayos controlados aleatorizados y adem&#225;s&#44; algunos estudios han sugerido un mayor potencial riesgo de eventos en pacientes con FA que reciben digoxina<a class="elsevierStyleCrossRefs" href="#bib0240"><span class="elsevierStyleSup">14&#44;15</span></a>&#44; mientras que otro metaan&#225;lisis concluy&#243; sobre la base de ensayos no controlados no aleatorios que dicho f&#225;rmaco no tiene efectos nocivos sobre la mortalidad en pacientes con FA e ICA&#44; la mayor&#237;a de los cuales ten&#237;an FEr<a class="elsevierStyleCrossRef" href="#bib0250"><span class="elsevierStyleSup">16</span></a>&#46; Por lo tanto&#44; en aquellos casos con IC sintom&#225;tica y FA&#44; la digoxina puede ser &#250;til para el tratamiento en pacientes con FEr y FA con frecuencia ventricular r&#225;pida cuando no haya otras opciones terap&#233;uticas posibles<a class="elsevierStyleCrossRefs" href="#bib0245"><span class="elsevierStyleSup">15&#44;17&#44;18</span></a>&#46; Fuera de las situaciones anteriormente comentadas&#44; la digoxina no debiera usarse en pacientes con ICA&#46; Adem&#225;s de no aportar valor&#44; la digoxina tiene una ventana terap&#233;utica estrecha&#44; por lo que los niveles s&#233;ricos tambi&#233;n deben ser controlados peri&#243;dicamente con el objetivo de una concentraci&#243;n s&#233;rica &#60;<span class="elsevierStyleHsp" style=""></span>1&#44;2<span class="elsevierStyleHsp" style=""></span>ng&#47;mL<a class="elsevierStyleCrossRefs" href="#bib0265"><span class="elsevierStyleSup">19&#44;20</span></a>&#46; Por ello el objetivo de este estudio fue identificar los pacientes con IC que reciben tratamiento cr&#243;nico con digoxina de forma inadecuada e investigar si esta inadecuaci&#243;n se asocia con unos peores resultados a corto plazo en los pacientes que presentan una descompensaci&#243;n de su IC&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">M&#233;todolog&#237;a</span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Dise&#241;o del estudio</span><p id="par0025" class="elsevierStylePara elsevierViewall">An&#225;lisis secundario del Registro Epidemiology of Acute Heart Failure in Emergency &#40;EAHFE&#41; departments&#44; el cual es un registro multic&#233;ntrico&#44; multiprop&#243;sito&#44; anal&#237;tico no intervencionista&#44; con seguimiento prospectivo y que incluye de forma consecutiva a los pacientes que acuden por episodio de ICA al SUH&#46; Hasta la fecha se han realizado 7 fases de reclutamiento &#40;en los a&#241;os 2007&#44; 2009&#44; 2011&#44; 2014&#44; 2016&#44; 2018 y 2019&#41; en un total de 45 SUH espa&#241;oles&#46; Los detalles y las caracter&#237;sticas de estos pacientes ya han sido previamente publicados<a class="elsevierStyleCrossRefs" href="#bib0275"><span class="elsevierStyleSup">21&#44;22</span></a>&#46; La inclusi&#243;n de pacientes con ICA en el Registro EAHFE se basa en el cumplimiento de los criterios cl&#237;nicos de Framingham<a class="elsevierStyleCrossRef" href="#bib0285"><span class="elsevierStyleSup">23</span></a>&#46; El diagn&#243;stico cl&#237;nico final es adjudicado por el investigador principal de cada centro&#44; y siempre que es posible se confirma con la determinaci&#243;n de p&#233;ptidos natriur&#233;ticos en plasma o mediante una ecocardiograf&#237;a durante la estancia del paciente en urgencias&#44; hospitalizaci&#243;n&#44; o en su defecto&#44; en los 6 meses previos al actual evento siguiendo las recomendaciones de la Sociedad Europea de Cardiolog&#237;a vigentes en cada momento<a class="elsevierStyleCrossRefs" href="#bib0290"><span class="elsevierStyleSup">24&#44;25</span></a>&#46; El &#250;nico criterio de exclusi&#243;n para ser incluido en el Registro EAHFE es la presencia concomitante de un s&#237;ndrome coronario agudo con elevaci&#243;n del segmento ST e ICA&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">Para el presente estudio &#40;Estudio DIG-ICA&#41; se incluyeron todos los pacientes del Registro EAHFE que estaban recibiendo digoxina de manera cr&#243;nica en el momento de consultar al SUH por el episodio actual de ICA y en los cuales se contase con los datos necesarios para poder clasificar dicho tratamiento como no adecuado o adecuado&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">La clasificaci&#243;n de tratamiento adecuado se realiz&#243; en funci&#243;n de las siguientes consideraciones&#58;<ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005"><span class="elsevierStyleLabel">1&#41;</span><p id="par0040" class="elsevierStylePara elsevierViewall">Pacientes con ICC moderada y grave &#40;grado III-IV o II-III sintom&#225;ticos seg&#250;n la New York Heart Association &#40;NYHA&#41; que no se controlan con otros tratamientos&#58; beta-bloqueantes &#40;BB&#41;&#44; inhibidores del enzima convertidor de angiotensina &#40;IECA&#41; o antagonistas del receptor de angiotensina II &#40;ARA-II&#41;&#44; y antagonistas del receptor de pacientes con ICC y FA&#46;</p></li><li class="elsevierStyleListItem" id="lsti0010"><span class="elsevierStyleLabel">2&#41;</span><p id="par0045" class="elsevierStylePara elsevierViewall">Mineralcorticoides &#40;ARM&#41;&#59; o pacientes con IC asociada a FA cr&#243;nica&#46;</p></li></ul></p><p id="par0050" class="elsevierStylePara elsevierViewall">En los pacientes que presentan FEVI deprimida asociada a FA la digoxina estar&#237;a m&#225;s indicada y podr&#237;a ir mejor&#44; pese a que es ampliamente conocido que BB tiene un impacto mayor en la supervivencia&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Variables independientes y de resultado</span><p id="par0055" class="elsevierStylePara elsevierViewall">Se recogieron 22 variables independientes relacionadas con la situaci&#243;n basal del paciente&#58; 2 demogr&#225;ficas &#40;edad&#44; sexo&#41;&#44; 13 comorbilidades &#40;hipertensi&#243;n arterial&#44; dislipidemia&#44; diabetes mellitus&#44; cardiopat&#237;a isqu&#233;mica&#44; episodios previos de ICA&#44; enfermedad renal cr&#243;nica&#44; enfermedad cerebrovascular&#44; FA&#44; valvulopat&#237;a&#44; arteriopat&#237;a perif&#233;rica&#44; enfermedad pulmonar obstructiva cr&#243;nica&#44; demencia y neoplasia&#41;&#44; 4 de tratamiento cr&#243;nico &#40;diur&#233;ticos&#44; IECA&#44; ARA-II&#44; BB y ARM&#41; y 3 de situaci&#243;n funcional basal &#40;clase funcional NYHA&#44; clasificaci&#243;n de la funci&#243;n de la fracci&#243;n de eyecci&#243;n del ventr&#237;culo izquierdo e &#237;ndice de Barthel&#41;&#46; En relaci&#243;n al episodio de descompensaci&#243;n&#44; se recogieron 6 potenciales desencadenantes del episodio &#40;infecci&#243;n&#44; taquiarritmia&#44; anemia&#44; crisis hipertensiva&#44; transgresi&#243;n diet&#233;tico-terap&#233;utica y s&#237;ndrome coronario agudo&#41;&#44; 3 constantes vitales a la llegada a urgencias &#40;presi&#243;n arterial sist&#243;lica&#44; frecuencia card&#237;aca y pulsioximetr&#237;a&#41; y 2 estimadores de la gravedad de la descompensaci&#243;n &#40;estratificaci&#243;n del riesgo de muerte utilizando la escala MEESSI<a class="elsevierStyleCrossRef" href="#bib0300"><span class="elsevierStyleSup">26</span></a> y necesidad de hospitalizaci&#243;n&#41;&#46;</p><p id="par0060" class="elsevierStylePara elsevierViewall">Las variables de resultado fueron mortalidad &#40;por cualquier causa&#41; intrahospitalaria y a 30 d&#237;as y&#44; entre los pacientes que sobrevivieron al episodio &#237;ndice&#44; ingreso prolongado &#40;&#62;7 d&#237;as a contar desde el d&#237;a de consulta en urgencias&#41; y evento adverso combinado &#40;formado por reconsulta en urgencias o hospitalizaci&#243;n por ICA o muerte por cualquier causa&#41; durante los 30 d&#237;as siguientes al alta del paciente&#46; La asignaci&#243;n de los eventos fue realizada localmente por el investigador principal mediante contacto telef&#243;nico o acceso a las historias cl&#237;nicas&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">An&#225;lisis estad&#237;stico</span><p id="par0065" class="elsevierStylePara elsevierViewall">Las variables categ&#243;ricas fueron descritas mediante frecuencias y porcentajes&#46; Las continuas con la mediana y rango intercuartil &#40;RIC&#41;&#46; El an&#225;lisis de distribuci&#243;n de las variables categ&#243;ricas se realiz&#243; con el test de Chi-cuadrado o test exacto de Fisher seg&#250;n correspondiera&#44; y el de las continuas mediante el test no param&#233;trico de la suma de rangos de Mann-Whitney&#46; La asociaci&#243;n entre el tratamiento no adecuado con digoxina y eventos adversos&#44; se investig&#243; mediante un modelo de regresi&#243;n log&#237;stica&#44; y se expres&#243; como <span class="elsevierStyleItalic">odds ratio</span> &#40;OR&#41; con su intervalo de confianza del 95&#37; &#40;IC 95&#37;&#41;&#44; tanto crudos como ajustados por las diferencias en las caracter&#237;sticas basales &#40;modelo A&#41;&#44; las caracter&#237;sticas de la descompensaci&#243;n &#40;modelo B&#41;&#44; y por ambas a la vez &#40;modelo C&#44; ajuste total&#41;&#46; En dichos modelos se introdujeron las variables para las que se hab&#237;an identificado diferencias estad&#237;sticamente significativas entre los grupos con tratamiento cr&#243;nico con digoxina no adecuado y adecuado en el an&#225;lisis bivariable&#46; Para dicho modelo multivariado&#44; se utilizaron 10 conjuntos de datos obtenidos mediante imputaci&#243;n m&#250;ltiple con sustituci&#243;n aleatoria de aquellos valores ausentes en las variables introducidas&#46; La aleatorizaci&#243;n se realiz&#243; mediante el tornado de Mersene y utilizando como semilla 2&#46;000&#46;000&#46; En todas las comparaciones&#44; se acept&#243; que las diferencias eran estad&#237;sticamente significativas si el valor de p era inferior a 0&#44;05&#44; o si el IC 95&#37; de la OR exclu&#237;a el valor 1&#46; El an&#225;lisis estad&#237;stico se realiz&#243; con el programa SPSS&#174; versi&#243;n 24&#46;0 para Windows &#40;IBM Corp&#46; Released 2016&#46; IBM SPSS Statistics for Windows&#44; version 24&#46;0&#46; Armonk&#44; NY&#44; EE&#46; UU&#46;&#41;&#46;</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Aspectos &#233;ticos</span><p id="par0070" class="elsevierStylePara elsevierViewall">Se siguieron los principios &#233;ticos de la Declaraci&#243;n de Helsinki sobre investigaci&#243;n en humanos&#44; y se solicit&#243; el consentimiento informado a todos los pacientes para participar en el estudio&#46; El protocolo fue aprobado por el Comit&#233; de &#201;tica e Investigaci&#243;n Cl&#237;nica del Hospital Universitario Central de Asturias como comit&#233; principal &#40;protocolos 49&#47;2010&#44; 69&#47;2011&#44; 166&#47;13&#44; 160&#47;15 y 205&#47;17&#41; y por los del resto de los centros participantes&#46;</p></span></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Resultados</span><p id="par0075" class="elsevierStylePara elsevierViewall">De los 19&#46;947 pacientes diagnosticados de ICA en el Registro EAHFE&#44; se incluyeron finalmente 2&#46;366 en el Estudio DIG-ICA &#40;<a class="elsevierStyleCrossRef" href="#fig0005">fig&#46; 1</a>&#41;&#46; La mediana de edad fue de 83 a&#241;os &#40;RIC&#58; 76-88&#41;&#44; el 61&#44;4&#37; eran mujeres&#44; la comorbilidad result&#243; muy frecuente&#44; entre las que destacaba FA &#40;85&#37;&#41;&#44; hipertensi&#243;n arterial &#40;81&#44;7&#37;&#41;&#44; episodios previos de ICA &#40;72&#44;4&#37;&#41;&#44; diabetes mellitus &#40;41&#44;9&#37;&#41; y dislipidemia &#40;40&#44;7&#37;&#41;&#46; El resto de las caracter&#237;sticas cl&#237;nicas puede consultarse en la <a class="elsevierStyleCrossRef" href="#tbl0005">tabla 1</a>&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0080" class="elsevierStylePara elsevierViewall">En total&#44; de toda la cohorte de 2&#46;366 pacientes&#44; se consider&#243; que en 993 pacientes &#40;42&#37;&#41; que no hab&#237;a datos cl&#237;nicos que soportasen el uso cr&#243;nico de digoxina&#44; mientras que en 1&#46;373 &#40;58&#37;&#41; se consider&#243; que su uso fuese posiblemente adecuado &#40;<a class="elsevierStyleCrossRef" href="#fig0005">fig&#46; 1</a>&#41;&#46; Cuando se comparan ambos grupos&#44; se observ&#243; que los siguientes factores basales se asociaron con un uso adecuado de digoxina&#58; FA&#44; hipertensi&#243;n arterial&#44; episodios previos de ICA&#44; dislipidemia&#44; cardiopat&#237;a isqu&#233;mica&#44; enfermedad renal cr&#243;nica&#44; &#237;ndice de Barthel mayor&#44; FEr y tratamiento cr&#243;nico con IECA&#47;ARA-II y BB&#46; Por el contrario&#44; los pacientes de mayor edad con mayor frecuencia no sol&#237;an tener una indicaci&#243;n adecuada de dicho tratamiento&#46; No hubo diferencias en ambos grupos en cuanto a la presencia de NYHA III-IV &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">tabla 1</a>&#41;&#46; En cuanto a las caracter&#237;sticas del episodio de descompensaci&#243;n&#44; solo se encontr&#243; que los pacientes con indicaci&#243;n no adecuada de digoxina ten&#237;an como causa de descompensaci&#243;n de la ICA a la anemia y ten&#237;an cierta tendencia a mayor frecuencia cardiaca&#46; No se encontraron diferencias entre ambos grupos asociadas a la gravedad del episodio que motiv&#243; la consulta al SUH &#40;<a class="elsevierStyleCrossRef" href="#tbl0010">tabla 2</a>&#41;&#46;</p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><p id="par0085" class="elsevierStylePara elsevierViewall">En el an&#225;lisis estad&#237;stico de resultados en ambos grupos &#40;adecuado y no adecuado&#41; se pudo observar que la mortalidad intrahospitalaria y a 30 d&#237;as fue mayor en el grupo con tratamiento no adecuado con digoxina &#40;9&#44;9 versus 7&#44;6&#37;&#44; p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;05&#59; y 12&#44;6 versus 9&#44;1&#37;&#44; p<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#44;001&#59; respectivamente&#41;&#44; en tanto que no se registraron diferencias en estancia prolongada &#40;35&#44;7 versus 33&#44;8&#37;&#41; ni en eventos adversos posalta &#40;32&#44;9 versus 31&#44;8&#37;&#41;&#46; Sin embargo&#44; en el modelo ajustado por las diferencias basales y del episodio de descompensaci&#243;n &#40;ajuste total&#41;&#44; el tratamiento no indicado con digoxina no se asoci&#243; con peor evoluci&#243;n a corto plazo&#44; con OR de 1&#44;31 &#40;IC 95&#37;&#58; 0&#44;85-2&#44;03&#41; para mortalidad intrahospitalaria&#59; 1&#44;29 &#40;0&#44;74-2&#44;25&#41; para mortalidad a 30 d&#237;as&#59; 1&#44;07 &#40;0&#44;82-1&#44;40&#41; para estancia prolongada&#59; y 0&#44;88 &#40;0&#44;65-1&#44;19&#41; para evento adverso posalta &#40;<a class="elsevierStyleCrossRef" href="#tbl0015">tabla 3</a>&#41;&#46;</p><elsevierMultimedia ident="tbl0015"></elsevierMultimedia></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">Discusi&#243;n</span><p id="par0090" class="elsevierStylePara elsevierViewall">El Estudio DIG-ICA analiza la idoneidad del tratamiento con digoxina en la IC en los pacientes incluidos en el Registro EAHFE y explora si su uso en ausencia de indicaci&#243;n se asocia a peores resultados pron&#243;sticos&#46; Sus resultados permiten concluir que&#44; a pesar de la no correcta indicaci&#243;n del f&#225;rmaco resulta frecuente &#40;casi en la mitad de las descompensaciones se produjo esta circunstancia&#41;&#44; esta inadecuaci&#243;n no parece asociarse a peores resultados a corto plazo&#46;</p><p id="par0095" class="elsevierStylePara elsevierViewall">El uso de digoxina en los pacientes con IC es controvertido&#46; Las gu&#237;as de la Sociedad Europea de Cardiolog&#237;a le confieren al f&#225;rmaco un nivel de evidencia IIb&#47;B<a class="elsevierStyleCrossRef" href="#bib0305"><span class="elsevierStyleSup">27</span></a> en base al Estudio Digitalis Investigation Group &#40;DIG&#41;<a class="elsevierStyleCrossRef" href="#bib0175"><span class="elsevierStyleSup">1</span></a>&#44; a partir del cual se considera su uso en pacientes con IC con FEr en ritmo sinusal que permanecen sintom&#225;ticos a pesar de tratamiento con IECA&#47;ARA-II&#44; BB y ARM&#44; pues se ha visto que se reduce el riesgo de hospitalizaci&#243;n&#46; Dicho estudio mostr&#243; un efecto neutro sobre la mortalidad&#44; aunque estudios posteriores han asociado incrementos de la misma por encima de concentraciones de digoxina &#8805;<span class="elsevierStyleHsp" style=""></span>1&#44;2<span class="elsevierStyleHsp" style=""></span>ng&#47;mL<a class="elsevierStyleCrossRef" href="#bib0310"><span class="elsevierStyleSup">28</span></a>&#46; Adem&#225;s&#44; los efectos de tratamiento cr&#243;nico con digoxina en pacientes con IC con FEr y FA &#40;otro potencial uso cl&#237;nico habitual&#41; no han sido estudiados en ning&#250;n ensayo cl&#237;nico&#46; Diversos estudios han sugerido un mayor riesgo de eventos adversos en pacientes con FA y que reciben digoxina<a class="elsevierStyleCrossRefs" href="#bib0240"><span class="elsevierStyleSup">14&#44;15&#44;29</span></a>&#46; Sin embargo&#44; un metaan&#225;lisis realizado sobre la base de ensayos cl&#237;nicos no aleatorios concluye que digoxina no modifica la mortalidad en pacientes con FA e IC<a class="elsevierStyleCrossRef" href="#bib0250"><span class="elsevierStyleSup">16</span></a>&#46; No obstante&#44; la mayor&#237;a de pacientes ten&#237;an IC con FEr&#46; Por ello&#44; la digoxina puede ser &#250;til en dicho escenario cuando no se pueden utilizar otras terapias para el control de la frecuencia cardiaca&#44; y siempre con especial precauci&#243;n en ancianos&#44; mujeres&#44; pacientes fr&#225;giles o con insuficiencia renal<a class="elsevierStyleCrossRefs" href="#bib0255"><span class="elsevierStyleSup">17&#44;18&#44;30</span></a>&#46;</p><p id="par0100" class="elsevierStylePara elsevierViewall">Independientemente de esta controversia sobre el uso de digoxina&#44; el presente estudio explor&#243; si su uso fuera de las indicaciones m&#225;s recomendadas en pacientes con IC se asociaba a peores resultados pron&#243;sticos&#46; Como se ha comentado anteriormente&#44; el grupo de uso no adecuado de digoxina supon&#237;a el 42&#37; del total de enfermos tratados con dicho f&#225;rmaco&#46; Pese a ser una cohorte de edad avanzada y mayoritariamente mujeres&#44; el grupo de uso no adecuado se asoci&#243; a mayor edad&#44; peor &#237;ndice de Barthel&#44; mejor funci&#243;n ventricular y menor uso de otros tratamientos con impacto positivo sobre la supervivencia &#40;BB y IECA&#47;ARA-II&#41;&#46; Esto est&#225; en consonancia con la tendencia habitual del uso de digoxina en pacientes m&#225;s mayores y con peor calidad de vida<a class="elsevierStyleCrossRef" href="#bib0250"><span class="elsevierStyleSup">16</span></a>&#44; lo cual les somete&#44; <span class="elsevierStyleItalic">a priori</span>&#44; a un mayor riesgo de eventos adversos&#46;</p><p id="par0105" class="elsevierStylePara elsevierViewall">Cuando se analiz&#243; en la presente cohorte los resultados evolutivos entre pacientes con tratamiento adecuado e inadecuado con digoxina&#44; se objetiv&#243; una mayor mortalidad cruda intrahospitalaria y a corto plazo&#44; que luego no se confirm&#243; en el modelo ajustado por las diferencias basales y del episodio de descompensaci&#243;n entre ambos grupos&#46; Por tanto&#44; a pesar de ser pacientes con te&#243;rico mayor riesgo&#44; no presentaron peores resultados a corto plazo tras una descompensaci&#243;n de su IC&#46; Cabe destacar&#44; no obstante&#44; que&#44; a pesar de tener m&#225;s edad y mayor fragilidad&#44; este grupo con tratamiento no adecuado ten&#237;a menos comorbilidades y quiz&#225;s este hecho podr&#237;a haber influido en los resultados obtenidos&#46; Por otra parte&#44; por las caracter&#237;sticas del dise&#241;o del estudio&#44; no se han comparado subgrupos de pacientes con IC y tratamiento con digoxina&#44; ni se les ha comparado con pacientes sin dicho tratamiento&#46; Aunque esto podr&#237;a haber arrojado m&#225;s informaci&#243;n&#44; el objetivo del Estudio DIG-ICA se focaliz&#243; en testar si la hip&#243;tesis de si una te&#243;rica inadecuada utilizaci&#243;n de dicho f&#225;rmaco se asociaba a peor pron&#243;stico en relaci&#243;n a los pacientes en los que el uso de digoxina era adecuado&#46; Por &#250;ltimo&#44; rese&#241;ar que el uso de digoxina en pacientes con IC es&#44; a d&#237;a de hoy&#44; relativamente bajo&#44; de aproximadamente el 14&#37; en la cohorte EAHFE&#44; de la que proceden los pacientes de este estudio&#46; Cabr&#237;a ver si con el paso de los a&#241;os este porcentaje disminuye con la nueva entrada de otros f&#225;rmacos con mayor impacto sobre la supervivencia en pacientes con IC con FEr y FEp&#44; independientemente del ritmo en que se encuentren&#44; como son los inhibidores del receptor de angiotensina-neprilisina &#40;ARNI&#41; y los inhibidores del cotransportador sodio-glucosa tipo 2 &#40;iSGLT2&#41;&#46;</p><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0105">Limitaciones</span><p id="par0110" class="elsevierStylePara elsevierViewall">Como limitaciones&#44; cabe destacar las propias de todos los estudios observacionales&#44; que son solo generadores de hip&#243;tesis&#46; Sin embargo&#44; estos estudios reflejan el mundo real de la enfermedad estudiada&#44; en este caso&#44; el de la ICA&#46; Como segunda limitaci&#243;n&#44; la determinaci&#243;n de la adecuaci&#243;n o no del tratamiento con digoxina se hizo mediante la revisi&#243;n de historias cl&#237;nicas y los datos disponibles en ella y en algunos casos puede no haber sido correcto&#46; Tercera&#44; no existi&#243; un grupo control de pacientes con ICA sin tratamiento con digoxina&#44; tanto en ritmo sinusal como en FA&#46; Cuarta&#44; no se tuvo en cuenta los pacientes tratados con digoxina eran recientes iniciadores del f&#225;rmaco &#40;no se dispon&#237;a del tiempo en tratamiento con digoxina&#41;&#46; Existen estudios que asocian este inicio a mayor incremento de muerte s&#250;bita y al a&#241;o&#46; Quinta&#44; no se dispuso de las concentraciones plasm&#225;ticas de digoxina&#44; por lo que desconocemos si los pacientes se encontraban dentro del rango terap&#233;utico&#46; Sexta&#44; aunque se recogieron m&#250;ltiples aspectos basales&#44; puede haber otros que pudiesen haber influido en los resultados y causar confusi&#243;n&#46; Entre ellos&#44; durante los &#250;ltimos a&#241;os se ha llamado la atenci&#243;n sobre la fragilidad&#44; que no suele determinarse en urgencias y que est&#225; claramente asociada a resultados adversos en los pacientes con ICA<a class="elsevierStyleCrossRefs" href="#bib0325"><span class="elsevierStyleSup">31&#44;32</span></a>&#46; Finalmente&#44; el uso de digoxina y la organizaci&#243;n de la asistencia a los pacientes con IC var&#237;a entre pa&#237;ses<a class="elsevierStyleCrossRefs" href="#bib0335"><span class="elsevierStyleSup">33&#44;34</span></a>&#44; por lo que nuestros resultados precisar&#225;n de validaci&#243;n externa&#46;</p></span></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0110">Conclusi&#243;n</span><p id="par0115" class="elsevierStylePara elsevierViewall">Existe un perfil de paciente con ICA que recibe de forma no adecuada digoxina&#44; si bien esta no justificaci&#243;n de tratamiento cr&#243;nico digit&#225;lico no parece asociarse de forma significativa con resultados adversos a corto plazo&#46; El uso de dicho f&#225;rmaco&#44; no obstante&#44; debe relegarse a las indicaciones recomendadas en las gu&#237;as cl&#237;nicas y con especial precauci&#243;n en los grupos de riesgo&#46;</p></span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0115">Financiaci&#243;n</span><p id="par0125" class="elsevierStylePara elsevierViewall">Este trabajo fue posible en parte gracias a las ayudas del Instituto de Salud Carlos III con fondos del Ministerio de Sanidad y FEDER &#40;PI18&#47;00393&#41;&#46;</p></span><span id="sec00055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect00115">Conflicto de intereses</span><p id="par0120" class="elsevierStylePara elsevierViewall">Los autores declaran no tener ning&#250;n conflicto de intereses&#46;</p></span></span>"
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          "titulo" => "Abstract"
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              "titulo" => "Variables independientes y de resultado"
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              "titulo" => "An&#225;lisis estad&#237;stico"
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    "fechaRecibido" => "2023-04-13"
    "fechaAceptado" => "2023-08-18"
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            0 => "Acute heart failure"
            1 => "Digoxin"
            2 => "Mortality"
            3 => "Emergency department"
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    "resumen" => array:2 [
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        "titulo" => "Resumen"
        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Objetivos</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Analizar los factores relacionados con el tratamiento cr&#243;nico inadecuado con digoxina&#44; y si esta inadecuaci&#243;n impacta en la evoluci&#243;n a corto plazo&#46;</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">M&#233;todo</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Se incluyeron pacientes diagnosticados de insuficiencia cardiaca aguda &#40;ICA&#41; en tratamiento cr&#243;nico con digoxina&#44; y se clasificaron como con tratamiento indicado o no indicado&#44; investig&#225;ndose los factores asociados a este hecho&#44; y si se asociaba a mortalidad intrahospitalaria a 30 d&#237;as&#44; estancia hospitalaria prolongada &#40;&#62;<span class="elsevierStyleHsp" style=""></span>7 d&#237;as&#41; y evento adverso combinado &#40;reconsulta a urgencias&#44; hospitalizaci&#243;n por ICA o muerte por cualquier causa&#41; durante los 30 d&#237;as postalta&#46;</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Resultados</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Se analizaron 2&#46;366 pacientes en tratamiento cr&#243;nico con digoxina &#40;mediana<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>83 a&#241;os&#44; mujeres<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>61&#37;&#41;&#58; adecuado en 1&#46;373 casos &#40;58&#44;0&#37;&#41;&#44; inadecuado en 993 &#40;42&#44;0&#37;&#41;&#46; La inadecuaci&#243;n se asoci&#243; con mayor edad&#44; menor comorbilidad&#44; menor tratamiento con betabloqueantes e IECA&#44; mejor funci&#243;n ventricular y peor &#237;ndice de Barthel&#46; La mortalidad intrahospitalaria y a 30 d&#237;as fue mayor en pacientes con tratamiento inadecuado &#40;9&#44;9 versus 7&#44;6&#37;&#44; p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;05&#59; y 12&#44;6 versus 9&#44;1&#37;&#44; p<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#44;001&#59; respectivamente&#41;&#59; no hubo diferencias en estancia prolongada &#40;35&#44;7 versus 33&#44;8&#37;&#41; ni en eventos adversos posalta &#40;32&#44;9 versus 31&#44;8&#37;&#41;&#46; Ajustando las diferencias basales y del episodio de descompensaci&#243;n&#44; el tratamiento cr&#243;nico inadecuado con digoxina no se asoci&#243; con ning&#250;n resultado&#44; con <span class="elsevierStyleItalic">odds ratio</span> de 1&#44;31 &#40;IC 95&#37;&#58; 0&#44;85-2&#44;03&#41; para mortalidad intrahospitalaria&#44; 1&#44;29 &#40;0&#44;74-2&#44;25&#41; para mortalidad a 30 d&#237;as&#59; 1&#44;07 &#40;0&#44;82-1&#44;40&#41; para estancia prolongada y 0&#44;88 &#40;0&#44;65-1&#44;19&#41; para evento adverso posalta&#46;</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Conclusi&#243;n</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Existe un perfil de paciente que recibe de forma inadecuada tratamiento cr&#243;nico con digoxina&#44; si bien ello no se asocia con resultados adversos a corto plazo durante los episodios de ICA&#46;</p></span>"
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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">To analyze the factors related to inadequate chronic treatment with digoxin and whether the inadequacy of treatment has an impact on short-term outcome&#46;</p></span> <span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Method</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Patients diagnosed with AHF who were in chronic treatment with digoxin were selected&#46; Digoxin treatment was classified as adequate or inadequate&#46; We investigated factors associated to inadequacy and whether such inadequacy was associated with in-hospital and 30-day mortality&#44; prolonged hospital stay &#40;&#62;7 days&#41; and combined adverse event &#40;re-consultation to the ED or hospitalization for AHF or death from any cause&#41; during the 30 days after discharge&#46;</p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Results</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">We analyzed 2366 patients on chronic digoxin treatment &#40;median age<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>83 years&#44; women<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>61&#37;&#41;&#44; which was considered adequate in 1373 cases &#40;58&#46;0&#37;&#41; and inadequate in 993 &#40;42&#46;0&#37;&#41;&#46; The inadequacy was associated with older age&#44; less comorbidity&#44; less treatment with beta-blockers and renin&#8211;angiotensin inhibitors&#44; better ventricular function&#44; and worse Barthel index&#46; In-hospital and 30-day mortality was higher in patients with inadequate digoxin treatment &#40;9&#46;9&#37; vs&#46; 7&#46;6&#37;&#44; <span class="elsevierStyleItalic">p</span>&#61;0&#46;05&#59; and 12&#46;6&#37; vs&#46; 9&#46;1&#37;&#44; <span class="elsevierStyleItalic">p</span>&#60;0&#46;001&#44; respectively&#41;&#46; No differences were recorded in prolonged stay &#40;35&#46;7&#37; vs&#46; 33&#46;8&#37;&#41; or post-discharge adverse events &#40;32&#46;9&#37; vs&#46; 31&#46;8&#37;&#41;&#46; In the model adjusted for baseline and decompensation episode differences&#44; inadequate treatment with digoxin was not significantly associated with any outcome&#44; with an odds ratio of 1&#46;31 &#40;95&#37; <span class="elsevierStyleSmallCaps">C</span>I<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;85-2&#46;03&#41; for in-hospital mortality&#59; 1&#46;29 &#40;0&#46;74-2&#46;25&#41; for 30-day mortality&#59; 1&#46;07 &#40;0&#46;82-1&#46;40&#41; for prolonged stay&#59; and 0&#46;88 &#40;0&#46;65-1&#46;19&#41; for post-discharge adverse event&#46;</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Conclusion</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">There is a profile of patients with AHF who inadequately receive digoxin&#44; although this inadequateness for chronic digitalis treatment was not associated with short-term adverse outcomes&#46;</p></span>"
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            "apendice" => "<p id="par0130" class="elsevierStylePara elsevierViewall">Marta Fuentes&#44; Cristina Gil &#40;Hospital Universitario de Salamanca&#41;&#59; H&#233;ctor Alonso y Enrique P&#233;rez-Llantada &#40;Hospital Marqu&#233;s de Valdecilla de Santander&#41;&#59; Francisco Javier Mart&#237;n-S&#225;nchez&#44; Guillermo Llopis Garc&#237;a y Mar Su&#225;rez Cadenas &#40;Hospital Cl&#237;nico San Carlos de Madrid&#41;&#59; &#210;scar Mir&#243;&#44; V&#237;ctor Gil&#44; Rosa Escoda&#44; Sira Aguil&#243; y Carolina S&#225;nchez &#40;Hospital Cl&#237;nic de Barcelona&#41;&#59; Carmen Gargallo &#40;Hospital Polit&#233;nic La Fe de Valencia&#41;&#59; Jos&#233; Pav&#243;n &#40;Hospital Dr&#46; Negr&#237;n de Las Palmas de Gran Canaria&#41;&#59; Antonio Noval &#40;Hospital Insular de Las Palmas de Gran Canaria&#41;&#59; Mar&#237;a Luisa L&#243;pez-Grima&#44; Amparo Valero y Mar&#237;a &#193;ngeles Juan &#40;Hospital Dr&#46; Peset de Valencia&#41;&#59; Alfons Aguirre&#44; Maria Angels Pedragosa y Silvia M&#237;nguez Mas&#243; &#40;Hospital del Mar de Barcelona&#41;&#59; Mar&#237;a Isabel Alonso y Francisco Ruiz &#40;Hospital de Valme de Sevilla&#41;&#59; Jos&#233; Miguel Franco &#40;Hospital Miguel Servet de Zaragoza&#41;&#59; Ana Bel&#233;n Mecina &#40;Hospital de Alcorc&#243;n de Madrid&#41;&#59; Josep Tost&#44; Marta Berenguer y Ruxandra Donea &#40;Consorci Sanitari de Terrassa&#41;&#59; Susana S&#225;nchez Ram&#243;n y Virginia Carbajosa Rodr&#237;guez &#40;Hospital Universitario R&#237;o Hortega de Valladolid&#41;&#59; Pascual Pi&#241;era y Jos&#233; Andr&#233;s S&#225;nchez Nicol&#225;s &#40;Hospital Reina Sof&#237;a de Murcia&#41;&#59; Raquel Torres Garate &#40;Hospital Severo Ochoa de Madrid&#41;&#59; Aitor Alqu&#233;zar-Arb&#233;&#44; Miguel Alberto Rizzi y Sergio Herrera &#40;Hospital de la Santa Creu y Sant Pau de Barcelona&#41;&#59; Javier Jacob&#44; Alex Roset&#44; Irene Cabello y Antonio Haro &#40;Hospital Universitari de Bellvitge de Barcelona&#41;&#59; Fernando Richard&#44; Jos&#233; Mar&#237;a &#193;lvarez P&#233;rez y Mar&#237;a Pilar L&#243;pez Diez &#40;Hospital Universitario de Burgos&#41;&#59; Pablo Herrero Puente&#44; Joaqu&#237;n V&#225;zquez &#193;lvarez&#44; Bel&#233;n Prieto Garc&#237;a&#44; Mar&#237;a Garc&#237;a Garc&#237;a y Marta S&#225;nchez Gonz&#225;lez &#40;Hospital Universitario Central de Asturias de Oviedo&#41;&#59; Pere Llorens&#44; Patricia Javaloyes&#44; Inmaculada Jim&#233;nez&#44; N&#233;stor Hern&#225;ndez&#44; Bego&#241;a Espinosa&#44; Adriana Gil&#44; Francisca Molina y Tamara Garc&#237;a &#40;Hospital General de Alicante&#41;&#59; Juan Antonio Andueza &#40;Hospital General Universitario Gregorio Mara&#241;&#243;n de Madrid&#41;&#59; Rodolfo Romero &#40;Hospital Universitario de Getafe de Madrid&#41;&#59; Mart&#237;n Ru&#237;z&#44; Roberto Calvache &#40;Hospital de Henares de Madrid&#41;&#59; Mar&#237;a Teresa Lorca Serralta y Luis Ernesto Calder&#243;n Jave &#40;Hospital del Tajo de Madrid&#41;&#59; Beatriz Amores Arriaga y Beatriz Sierra Bergua &#40;Hospital Cl&#237;nico Lozano Blesa de Zaragoza&#41;&#59; Enrique Mart&#237;n Mojarro y Brigitte Silvana Alarc&#243;n Jim&#233;nez &#40;Hospital Sant Pau i Santa Tecla de Tarragona&#41;&#59; Lisette Traver&#237;a B&#233;cquer y Guillermo Burillo &#40;Hospital Universitario de Canarias de Tenerife&#41;&#59; Llu&#237;s Llauger Garc&#237;a y Gerard Corominas LaSalle &#40;Hospital Universitari de Vic de Barcelona&#41;&#59; Carmen Ag&#252;era Urbano&#44; Ana Bel&#233;n Garc&#237;a Soto y Elisa Delgado Padial &#40;Hospital Costa del Sol de Marbella de M&#225;laga&#41;&#59; Ester Soy Ferrer y Mar&#237;a Adroher M&#250;&#241;oz &#40;Hospital Josep Trueta de Girona&#41;&#59; Jos&#233; Manuel Garrido &#40;Hospital Virgen Macarena de Sevilla&#41;&#59; Francisco Javier Lucas-Imbern&#243;n &#40;Hospital General Universitario de Albacete&#41;&#59; Rut Gaya &#40;Hospital Juan XXIII de Tarragona&#41;&#59; Carlos Bibiano&#44; Mar&#237;a Mir y Beatriz Rodr&#237;guez &#40;Hospital Infanta Leonor de Madrid&#41;&#59; Jos&#233; Luis Carballo &#40;Complejo Hospitalario Universitario de Ourense&#41;&#59; Esther Rodr&#237;guez-Adrada&#44; Bel&#233;n Rodr&#237;guez Miranda y Monika Vicente Mart&#237;n &#40;Hospital Rey Juan Carlos de M&#243;stoles de Madrid&#41; y Pere Coma Casanova y Joan Espinach Alvar&#243;s &#40;Hospital San Joan de Deu de Martorell&#44; Barcelona&#41;&#46;</p>"
            "etiqueta" => "Anexo 1"
            "titulo" => "Investigadores del grupo ICA-SEMES"
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          "es" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Estudio DIG-ICA&#46;</p> <p id="spar2045" class="elsevierStyleSimplePara elsevierViewall">&#42;BEC&#58; bloqueadores de entrada de calcio&#46; BB&#58; betabloqueantes&#46;</p>"
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                  \t\t\t\t">1&#46;356 &#40;98&#44;8&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleBold">&#60;</span><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleBold">0&#44;001</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">611 &#40;61&#44;5&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">991 &#40;41&#44;9&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">2 &#40;0&#44;1&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">596 &#40;43&#44;4&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#44;08&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>Dislipidemia&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">964 &#40;40&#44;7&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">366 &#40;36&#44;9&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">598 &#40;43&#44;6&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleBold">0&#44;001</span>&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>Valvulopat&#237;a cardiaca&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">893 &#40;37&#44;7&#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&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">378 &#40;38&#44;1&#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">515 &#40;37&#44;5&#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;78&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>Enfermedad pulmonar obstructiva cr&#243;nica&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">652 &#40;27&#44;6&#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">3 &#40;0&#44;1&#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
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                  \t\t\t\t">292 &#40;29&#44;4&#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">360 &#40;26&#44;3&#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;09&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>Cardiopat&#237;a isqu&#233;mica&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">512 &#40;21&#44;6&#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">1 &#40;1&#44;1&#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">184 &#40;18&#44;5&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">328 &#40;23&#44;9&#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;002&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>Enfermedad renal cr&#243;nica &#40;creatinina &#62;<span class="elsevierStyleHsp" style=""></span>2<span class="elsevierStyleHsp" style=""></span>mg&#47;dL&#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">483 &#40;20&#44;4&#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&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">173 &#40;17&#44;4&#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">310 &#40;22&#44;6&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">0&#44;002&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>Enfermedad cerebrovascular&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">300 &#40;12&#44;7&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">0&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">118 &#40;11&#44;9&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">182 &#40;13&#44;3&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">0&#44;32&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>Neoplasia&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">278 &#40;12&#44;9&#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">214 &#40;9&#44;0&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">117 &#40;13&#44;1&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">161 &#40;12&#44;8&#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;79&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>Demencia&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">244 &#40;11&#44;3&#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">215 &#40;9&#44;1&#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">110 &#40;12&#44;4&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">134 &#40;10&#44;6&#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;21&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>Enfermedad arterial perif&#233;rica&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">180 &#40;7&#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  " align="left" valign="\n
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                  \t\t\t\t">73 &#40;7&#44;4&#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">107 &#40;7&#44;8&#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;69&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="6" align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="6" align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleItalic">Tratamiento cr&#243;nico en el domicilio</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>Diur&#233;ticos&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">2&#46;049 &#40;86&#44;7&#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">2 &#40;0&#44;1&#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">853 &#40;85&#44;9&#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">1&#46;196 &#40;87&#44;2&#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;35&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>Inhibidores del sistema renina-angiotensina&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">1&#46;397 &#40;59&#44;1&#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">2 &#40;0&#44;2&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t">554 &#40;55&#44;8&#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">843 &#40;61&#44;5&#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
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>&#205;ndice de Barthel&#44; mediana &#40;RIC&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#44;31&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Taquiarritmia&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Anemia&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Crisis hipertensiva&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Trasgresi&#243;n diet&#233;tico-terap&#233;utica&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>S&#237;ndrome coronario agudo&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleItalic">Constantes vitales en urgencias</span></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>Presi&#243;n arterial sist&#243;lica &#40;mmHg&#41;&#44; mediana &#40;RIC&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">138 &#40;120-155&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">138 &#40;120-154&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Frecuencia cardiaca &#40;lpm&#41;&#44; mediana &#40;RIC&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">82 &#40;70-100&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">47 &#40;2&#44;0&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">83 &#40;71-100&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">81 &#40;70-99&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleBold">0&#44;04</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Pulsioximetr&#237;a basal &#40;&#37;&#41;&#44; mediana &#40;RIC&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">93 &#40;90-96&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">89 &#40;3&#44;8&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">93 &#40;90-96&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">94 &#40;90-96&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="\n
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                  \t\t\t\t"><span class="elsevierStyleItalic">Gravedad de la descompensaci&#243;n</span></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>Categor&#237;a de riesgo seg&#250;n la escala MEESSI<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">1&#46;065 &#40;45&#44;0&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Riesgo bajo&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">512 &#40;39&#44;4&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Riesgo intermedio&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttop\n
                  \t\t\t\t">218 &#40;41&#44;1&#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">324 &#40;42&#44;1&#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="" valign="\n
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                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Riesgo alto&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</td><td class="td" title="\n
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                  \t\t\t\t  " align="" valign="\n
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                  \t\t\t\t">&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">45 &#40;8&#44;5&#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">88 &#40;11&#44;4&#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="" valign="\n
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                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Riesgo muy alto&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">114 &#40;8&#44;8&#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="" valign="\n
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                  \t\t\t\t">&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">60 &#40;11&#44;3&#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">54 &#40;7&#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="" valign="\n
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                  \t\t\t\t">&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>Necesidad de hospitalizaci&#243;n&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&#46;795 &#40;75&#44;9&#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">1 &#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">742 &#40;74&#44;8&#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
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                  \t\t\t\t">1&#46;053 &#40;76&#44;7&#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;29&nbsp;\t\t\t\t\t\t\n
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              "nota" => "<p class="elsevierStyleNotepara" id="npar0005">La escala MEESSI est&#225; integrada por 13 variables obtenidas a la llegada del paciente a urgencias &#40;edad del paciente&#59; presencia de un s&#237;ndrome coronario agudo como desencadenante de la descompensaci&#243;n&#59; &#237;ndice de Barthel&#44; clase NYHA&#44; presi&#243;n arterial sist&#243;lica&#44; frecuencia respiratoria&#44; saturaci&#243;n basal de ox&#237;geno y signos de bajo gasto cardiaco a la llegada a urgencias&#59; cifras de NT-proBNP&#44; troponina&#44; creatinina y potasio en la primera anal&#237;tica&#44; y existencia de hipertrofia ventricular izquierda en el electrocardiograma&#41; y estratifican el riesgo de fallecer durante los 30 d&#237;as siguientes a la llegada a urgencias&#46;</p> <p class="elsevierStyleNotepara" id="npar0010">Los valores 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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          "es" => "<p id="spar0065" class="elsevierStyleSimplePara elsevierViewall">Caracter&#237;sticas del episodio de descompensaci&#243;n de los pacientes en tratamiento con digoxina incluidos en el presente estudio&#44; y comparaci&#243;n en funci&#243;n de si el tratamiento con digoxina se consider&#243; adecuado o no adecuado</p>"
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">&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" scope="col" style="border-bottom: 2px solid black">Indicaci&#243;n no adecuada de digoxinaN <span class="elsevierStyleInf">eventos</span> &#47; N <span class="elsevierStyleInf">total</span> &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Indicaci&#243;n adecuada de digoxinaN <span class="elsevierStyleInf">eventos</span> &#47; N <span class="elsevierStyleInf">total</span> &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Riesgo asociado a indicaci&#243;n no adecuada de digoxina<span class="elsevierStyleItalic">odds ratio</span> &#40;IC 95&#37;&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " colspan="4" align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleItalic">Mortalidad intrahospitalaria</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
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Cruda&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">97&#47;983 &#40;9&#44;9&#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">103&#47;1&#46;361 &#40;7&#44;6&#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">1&#44;34 &#40;1&#44;00-1&#44;79&#41;&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>Ajustada &#40;por caracter&#237;sticas basales<a class="elsevierStyleCrossRef" href="#tblfn0010"><span class="elsevierStyleSup">a</span></a>&#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">&#8212;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#8212;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><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;32 &#40;0&#44;85-2&#44;04&#41;&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>Ajustada &#40;por caracter&#237;sticas de la descompensaci&#243;n<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
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#8212;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#8212;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><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;33 &#40;0&#44;99-1&#44;78&#41;&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>Ajustada &#40;ajuste total&#59; por caracter&#237;sticas basales y de la descompensaci&#243;n&#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">&#8212;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#8212;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><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;31 &#40;0&#44;85-2&#44;03&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="4" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="4" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Mortalidad a 30 d&#237;as</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
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Cruda&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">123&#47;975 &#40;12&#44;6&#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">122&#47;1&#46;345 &#40;9&#44;1&#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"><span class="elsevierStyleBold">1&#44;45 &#40;1&#44;11-1&#44;89&#41;</span>&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>Ajustada &#40;por caracter&#237;sticas basales<a class="elsevierStyleCrossRef" href="#tblfn0010"><span class="elsevierStyleSup">a</span></a>&#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">&#8212;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#8212;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><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;32 &#40;0&#44;89-1&#44;96&#41;&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>Ajustada &#40;por caracter&#237;sticas de la descompensaci&#243;n<a class="elsevierStyleCrossRef" href="#tblfn0015"><span class="elsevierStyleSup">b</span></a>&#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">&#8212;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#8212;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleBold">1&#44;45 &#40;1&#44;11-1&#44;89&#41;</span>&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>Ajustada &#40;ajuste total&#59; por caracter&#237;sticas basales y de la descompensaci&#243;n&#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">&#8212;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#8212;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><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;32 &#40;0&#44;89-1&#44;96&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="4" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="4" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Estancia prolongada &#40;&#62;</span><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">7 d&#237;as&#41; en supervivientes</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
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Cruda&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">306&#47;857 &#40;35&#44;7&#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">412&#47;1&#46;220 &#40;33&#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
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&#44;09 &#40;0&#44;91-1&#44;31&#41;&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>Ajustada &#40;por caracter&#237;sticas basales<a class="elsevierStyleCrossRef" href="#tblfn0010"><span class="elsevierStyleSup">a</span></a>&#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">&#8212;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#8212;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><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;07 &#40;0&#44;82-1&#44;40&#41;&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>Ajustada &#40;por caracter&#237;sticas de la descompensaci&#243;n<a class="elsevierStyleCrossRef" href="#tblfn0015"><span class="elsevierStyleSup">b</span></a>&#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">&#8212;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#8212;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><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;09 &#40;0&#44;91-1&#44;31&#41;&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>Ajustada &#40;ajuste total&#59; por caracter&#237;sticas basales y de la descompensaci&#243;n&#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">&#8212;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#8212;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><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;07 &#40;0&#44;82-1&#44;40&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="4" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="4" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Evento adverso a 30 d&#237;as posalta en supervivientes</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
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Cruda&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">218&#47;663 &#40;32&#44;9&#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">321&#47;1&#46;008 &#40;31&#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
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#44;88 &#40;0&#44;65-1&#44;19&#41;&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>Ajustada &#40;por caracter&#237;sticas basales<a class="elsevierStyleCrossRef" href="#tblfn0010"><span class="elsevierStyleSup">a</span></a>&#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">&#8212;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#8212;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><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;05 &#40;0&#44;85-1&#44;29&#41;&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>Ajustada &#40;por caracter&#237;sticas de la descompensaci&#243;n<a class="elsevierStyleCrossRef" href="#tblfn0015"><span class="elsevierStyleSup">b</span></a>&#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">&#8212;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#8212;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><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;88 &#40;0&#44;65-1&#44;19&#41;&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>Ajustada &#40;ajuste total&#59; por caracter&#237;sticas basales y de la descompensaci&#243;n&#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">&#8212;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#8212;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><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;05 &#40;0&#44;70-1&#44;56&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
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            0 => array:3 [
              "identificador" => "tblfn0010"
              "etiqueta" => "a"
              "nota" => "<p class="elsevierStyleNotepara" id="npar0015">Las caracter&#237;sticas basales utilizadas como covariables en el modelo ajustado fueron edad&#44; fibrilaci&#243;n auricular&#44; hipertensi&#243;n arterial&#44; episodios previos de insuficiencia cardiaca aguda&#44; dislipidemia&#44; cardiopat&#237;a isqu&#233;mica&#44; enfermedad renal cr&#243;nica&#44; tratamiento cr&#243;nico con inhibidores del eje renina-angiotensina o con betabloqueantes&#44; tipo de disfunci&#243;n del ventr&#237;culo izquierdo e &#237;ndice de Barthel&#46;</p>"
            ]
            1 => array:3 [
              "identificador" => "tblfn0015"
              "etiqueta" => "b"
              "nota" => "<p class="elsevierStyleNotepara" id="npar0020">Las caracter&#237;sticas del episodio de descompensaci&#243;n utilizadas como covariables en el modelo ajustado fueron la existencia de an&#233;mica como factor desencadenante de la descompensaci&#243;n y la frecuencia cardiaca a la llegada a urgencias&#46;</p> <p class="elsevierStyleNotepara" id="npar0025">Los valores en <span class="elsevierStyleBold">negrita</span> 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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          ]
        ]
        "descripcion" => array:1 [
          "es" => "<p id="spar0080" class="elsevierStyleSimplePara elsevierViewall">Caracter&#237;sticas del episodio de descompensaci&#243;n de los pacientes en tratamiento con digoxina incluidos en el presente estudio&#44; y comparaci&#243;n en funci&#243;n de si el tratamiento con digoxina se consider&#243; adecuado o no adecuado</p>"
        ]
      ]
    ]
    "bibliografia" => array:2 [
      "titulo" => "Bibliograf&#237;a"
      "seccion" => array:1 [
        0 => array:2 [
          "identificador" => "bibs0015"
          "bibliografiaReferencia" => array:34 [
            0 => array:3 [
              "identificador" => "bib0175"
              "etiqueta" => "1"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "The global health and economic burden of hospitalizations for heart failure&#58; essons learned from hospitalized heart failure registries"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [
                            0 => "A&#46;P&#46; Ambrosy"
                            1 => "G&#46;C&#46; Fonarow"
                            2 => "J&#46; Butler"
                            3 => "O&#46;L&#46; Chioncel"
                            4 => "S&#46;J&#46; Greene"
                            5 => "M&#46; Vaduganathan"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1016/j.jacc.2013.11.053"
                      "Revista" => array:6 [
                        "tituloSerie" => "J Am Coll Cardiol"
                        "fecha" => "2014"
                        "volumen" => "63"
                        "paginaInicial" => "1123"
                        "paginaFinal" => "1133"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/24491689"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            1 => array:3 [
              "identificador" => "bib0180"
              "etiqueta" => "2"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Epidemiology of heart failure in Spain over the last 20 years"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:3 [
                            0 => "I&#46; Sayago-Silva"
                            1 => "F&#46; Garc&#237;a-L&#243;pez"
                            2 => "J&#46; Segovia-Cubero"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1016/j.rec.2013.03.012"
                      "Revista" => array:6 [
                        "tituloSerie" => "Rev Esp Cardiol"
                        "fecha" => "2013"
                        "volumen" => "66"
                        "paginaInicial" => "649"
                        "paginaFinal" => "656"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/24776334"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            2 => array:3 [
              "identificador" => "bib0185"
              "etiqueta" => "3"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Time trends in characteristics&#44; clinical course&#44; and outcomes of 13&#44;791 patients with acute heart failure"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [
                            0 => "P&#46; Llorens"
                            1 => "P&#46; Javaloyes"
                            2 => "F&#46;J&#46; Mart&#237;n-S&#225;nchez"
                            3 => "J&#46; Jacob"
                            4 => "P&#46; Herrero-Puente"
                            5 => "V&#46; Gil"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1007/s00392-018-1261-z"
                      "Revista" => array:6 [
                        "tituloSerie" => "Clin Res Cardiol"
                        "fecha" => "2018"
                        "volumen" => "107"
                        "paginaInicial" => "897"
                        "paginaFinal" => "913"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/29728831"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            3 => array:3 [
              "identificador" => "bib0190"
              "etiqueta" => "4"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Acute heart failure congestion and perfusion status &#8211; impact of the clinical classification on in-hospital and long-term outcomes&#59; insights from the ESC-EORP-HFA Heart Failure Long-Term Registry"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [
                            0 => "O&#46; Chioncel"
                            1 => "A&#46; Mebazaa"
                            2 => "A&#46;P&#46; Maggioni"
                            3 => "V&#46;P&#46; Harjola"
                            4 => "G&#46; Rosano"
                            5 => "C&#46; Laroche"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1002/ejhf.1492"
                      "Revista" => array:6 [
                        "tituloSerie" => "Eur J Heart Fail"
                        "fecha" => "2019"
                        "volumen" => "21"
                        "paginaInicial" => "1338"
                        "paginaFinal" => "1352"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/31127678"
                            "web" => "Medline"
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                ]
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            4 => array:3 [
              "identificador" => "bib0195"
              "etiqueta" => "5"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Departments involved during the first episode of acute heart failure and subsequent emergency department revisits and rehospitalisations&#58; An outlook through the NOVICA cohort"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [
                            0 => "&#210;&#46; Mir&#243;"
                            1 => "A&#46; Garc&#237;a Sarasola"
                            2 => "C&#46; Fuenzalida"
                            3 => "S&#46; Calder&#243;n"
                            4 => "J&#46; Jacob"
                            5 => "A&#46; Aguirre"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:5 [
                        "tituloSerie" => "Eur J Heart Fail"
                        "fecha" => "2019"
                        "volumen" => "21"
                        "paginaInicial" => "1231"
                        "paginaFinal" => "1244"
                      ]
                    ]
                  ]
                ]
              ]
            ]
            5 => array:3 [
              "identificador" => "bib0200"
              "etiqueta" => "6"
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Original
Factores asociados al tratamiento crónico no justificado con digoxina en pacientes con insuficiencia cardiaca aguda y relación con el pronóstico a corto plazo
Factors associated with unjustified chronic treatment with digoxin in patients with acute heart failure and relationship with short-term prognosis
E. Martín-Mojarroa,h, V. Gilb,h, P. Llorensc,h, S. Flores-Quesadaa,h, O.J. Troiano-Ungerera,h, A. Alquézar-Arbéd,h, J. Jacobe,h, P. Herrerof,h, C. Sánchezg,h, Ò. Mirób,h,
Autor para correspondencia
omiro@clinic.cat

Autor para correspondencia.
, investigadores del grupo ICA-SEMES
a Servicio de Urgencias, Hospital Sant Pau i Santa Tecla, Tarragona, España
b Área de Urgencias, Hospital Clínic Barcelona, IDIBAPS, Universitat de Barcelona, Barcelona, España
c Servicio de Urgencias, Corta Estancia y Hospitalización a Domicilio, Hospital General Dr. Balmis, Alicante, Instituto de Investigación Sanitaria y Biómedica de Alicante (ISABIAL), Universidad Miguel Hernández, Alicante, España
d Servicio de Urgencias, Hospital de la Santa Creu i Sant Pau, Barcelona, España
e Servicio de Urgencias, Hospital Universitari de Bellvitge, l’Hospitalet de Llobregat, Barcelona, España
f Servicio de Urgencias, Hospital Universitario Central de Asturias, Oviedo, Asturias, España
g Servicio de Urgencias, Hospital Universitari de Vic, Vic, Barcelona, España
h Servicio de Urgencias, Consorci Hospitalari de Terrassa, Terrassa, Barcelona, España
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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">Las descompensaciones en los pacientes con insuficiencia cardiaca &#40;IC&#41; son uno de los principales motivos de consulta a los servicios de urgencias hospitalarios &#40;SUH&#41; y una de las primeras causas de hospitalizaci&#243;n en Espa&#241;a<a class="elsevierStyleCrossRefs" href="#bib0175"><span class="elsevierStyleSup">1&#44;2</span></a>&#46; Conlleva adem&#225;s&#44; una elevada mortalidad intrahospitalaria y tras el alta&#44; as&#237; como un alto &#237;ndice de reingreso<a class="elsevierStyleCrossRefs" href="#bib0185"><span class="elsevierStyleSup">3&#44;4</span></a>&#46; Aunque en una peque&#241;a parte de los casos los pacientes hospitalizan de forma directa procedentes de atenci&#243;n primaria o especializada&#44; en m&#225;s del 90&#37; de las hospitalizaciones de los pacientes con ICA se realizan tras su consulta y tratamiento inicial en SUH<a class="elsevierStyleCrossRefs" href="#bib0195"><span class="elsevierStyleSup">5&#44;6</span></a>&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">El enfoque actual del tratamiento de los pacientes con insuficiencia cardiaca aguda &#40;ICA&#41; en el SU tiene como objetivo la mejor&#237;a de los signos y s&#237;ntomas del paciente&#44; corregir la sobrecarga de volumen&#44; aumentar la perfusi&#243;n de los &#243;rganos diana y mejorar el estado hemodin&#225;mico contrarrestando la hiperactivaci&#243;n neurohormonal que constituye el principal mecanismo fisiopatol&#243;gico de la enfermedad&#46; Se ha demostrado que un abordaje en&#233;rgico y apropiado del tratamiento de la ICA resulta &#250;til para mejorar la evoluci&#243;n cl&#237;nica de los pacientes&#46; A pesar del inicio m&#225;s temprano del tratamiento&#44; y aun cuando este sea en&#233;rgico&#44; la mortalidad de los pacientes con ICA sigue siendo muy elevada&#44; lo cual pone de manifiesto la necesidad de mejorar los resultados cl&#237;nicos mediante nuevas estrategias terap&#233;uticas<a class="elsevierStyleCrossRefs" href="#bib0205"><span class="elsevierStyleSup">7&#44;8</span></a>&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">La digoxina es un gluc&#243;sido cardiot&#243;nico&#44; usado como agente antiarr&#237;tmico empleado en la insuficiencia cardiaca&#44; y utilizado en otros trastornos cardiacos como la fibrilaci&#243;n auricular &#40;FA&#41;&#44; y por este mecanismo podr&#237;a ser &#250;til en el tratamiento de los pacientes con ICA&#44; a pesar de que no se la considera tratamiento de primera l&#237;nea&#46; Posee efectos vagomim&#233;ticos&#44; reduce la actividad del sistema renina-angiotensina&#44; la resistencia venosa sist&#233;mica y aumenta el gasto card&#237;aco y&#44; aunque la gu&#237;a de la Sociedad Europea de Cardiolog&#237;a considera el uso de digoxina en la ICA para controlar la frecuencia cardiaca<a class="elsevierStyleCrossRef" href="#bib0180"><span class="elsevierStyleSup">2</span></a>&#44; en especial en presencia de FA aguda&#44; las gu&#237;as de la <span class="elsevierStyleItalic">American Heart Association</span> y la <span class="elsevierStyleItalic">Heart Failure Society of America</span> no indican su empleo<a class="elsevierStyleCrossRef" href="#bib0215"><span class="elsevierStyleSup">9</span></a>&#46; Adem&#225;s&#44; no se conocen estudios en los que se haya examinado los resultados cl&#237;nicos para determinar su efecto terap&#233;utico favorable en la ICA<a class="elsevierStyleCrossRef" href="#bib0220"><span class="elsevierStyleSup">10</span></a>&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">La digoxina se recomienda en pacientes con IC congestiva &#40;ICC&#41; y FA&#44; y en pacientes con ICC moderada y grave &#40;grado III-IV o II-III sintom&#225;ticos seg&#250;n la New York Heart Association &#91;NYHA&#93;&#41;&#44; que no se controlan con otros tratamientos<a class="elsevierStyleCrossRefs" href="#bib0225"><span class="elsevierStyleSup">11&#44;12</span></a>&#46; Tambi&#233;n se puede considerar la digoxina en pacientes con ICC con FEVI reducida y en ritmo sinusal para reducir el riesgo de hospitalizaci&#243;n<a class="elsevierStyleCrossRef" href="#bib0235"><span class="elsevierStyleSup">13</span></a>&#44; aunque su efecto en aquellos pacientes tratados habitualmente con betabloqueantes no ha sido probado&#46; En el ensayo DIG&#44; el efecto general sobre la mortalidad con digoxina fue neutral&#46; Los efectos de la digoxina en pacientes con ICC con fracci&#243;n de eyecci&#243;n reducida &#40;FEr&#41; y FA no ha sido estudiado en ensayos controlados aleatorizados y adem&#225;s&#44; algunos estudios han sugerido un mayor potencial riesgo de eventos en pacientes con FA que reciben digoxina<a class="elsevierStyleCrossRefs" href="#bib0240"><span class="elsevierStyleSup">14&#44;15</span></a>&#44; mientras que otro metaan&#225;lisis concluy&#243; sobre la base de ensayos no controlados no aleatorios que dicho f&#225;rmaco no tiene efectos nocivos sobre la mortalidad en pacientes con FA e ICA&#44; la mayor&#237;a de los cuales ten&#237;an FEr<a class="elsevierStyleCrossRef" href="#bib0250"><span class="elsevierStyleSup">16</span></a>&#46; Por lo tanto&#44; en aquellos casos con IC sintom&#225;tica y FA&#44; la digoxina puede ser &#250;til para el tratamiento en pacientes con FEr y FA con frecuencia ventricular r&#225;pida cuando no haya otras opciones terap&#233;uticas posibles<a class="elsevierStyleCrossRefs" href="#bib0245"><span class="elsevierStyleSup">15&#44;17&#44;18</span></a>&#46; Fuera de las situaciones anteriormente comentadas&#44; la digoxina no debiera usarse en pacientes con ICA&#46; Adem&#225;s de no aportar valor&#44; la digoxina tiene una ventana terap&#233;utica estrecha&#44; por lo que los niveles s&#233;ricos tambi&#233;n deben ser controlados peri&#243;dicamente con el objetivo de una concentraci&#243;n s&#233;rica &#60;<span class="elsevierStyleHsp" style=""></span>1&#44;2<span class="elsevierStyleHsp" style=""></span>ng&#47;mL<a class="elsevierStyleCrossRefs" href="#bib0265"><span class="elsevierStyleSup">19&#44;20</span></a>&#46; Por ello el objetivo de este estudio fue identificar los pacientes con IC que reciben tratamiento cr&#243;nico con digoxina de forma inadecuada e investigar si esta inadecuaci&#243;n se asocia con unos peores resultados a corto plazo en los pacientes que presentan una descompensaci&#243;n de su IC&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">M&#233;todolog&#237;a</span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Dise&#241;o del estudio</span><p id="par0025" class="elsevierStylePara elsevierViewall">An&#225;lisis secundario del Registro Epidemiology of Acute Heart Failure in Emergency &#40;EAHFE&#41; departments&#44; el cual es un registro multic&#233;ntrico&#44; multiprop&#243;sito&#44; anal&#237;tico no intervencionista&#44; con seguimiento prospectivo y que incluye de forma consecutiva a los pacientes que acuden por episodio de ICA al SUH&#46; Hasta la fecha se han realizado 7 fases de reclutamiento &#40;en los a&#241;os 2007&#44; 2009&#44; 2011&#44; 2014&#44; 2016&#44; 2018 y 2019&#41; en un total de 45 SUH espa&#241;oles&#46; Los detalles y las caracter&#237;sticas de estos pacientes ya han sido previamente publicados<a class="elsevierStyleCrossRefs" href="#bib0275"><span class="elsevierStyleSup">21&#44;22</span></a>&#46; La inclusi&#243;n de pacientes con ICA en el Registro EAHFE se basa en el cumplimiento de los criterios cl&#237;nicos de Framingham<a class="elsevierStyleCrossRef" href="#bib0285"><span class="elsevierStyleSup">23</span></a>&#46; El diagn&#243;stico cl&#237;nico final es adjudicado por el investigador principal de cada centro&#44; y siempre que es posible se confirma con la determinaci&#243;n de p&#233;ptidos natriur&#233;ticos en plasma o mediante una ecocardiograf&#237;a durante la estancia del paciente en urgencias&#44; hospitalizaci&#243;n&#44; o en su defecto&#44; en los 6 meses previos al actual evento siguiendo las recomendaciones de la Sociedad Europea de Cardiolog&#237;a vigentes en cada momento<a class="elsevierStyleCrossRefs" href="#bib0290"><span class="elsevierStyleSup">24&#44;25</span></a>&#46; El &#250;nico criterio de exclusi&#243;n para ser incluido en el Registro EAHFE es la presencia concomitante de un s&#237;ndrome coronario agudo con elevaci&#243;n del segmento ST e ICA&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">Para el presente estudio &#40;Estudio DIG-ICA&#41; se incluyeron todos los pacientes del Registro EAHFE que estaban recibiendo digoxina de manera cr&#243;nica en el momento de consultar al SUH por el episodio actual de ICA y en los cuales se contase con los datos necesarios para poder clasificar dicho tratamiento como no adecuado o adecuado&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">La clasificaci&#243;n de tratamiento adecuado se realiz&#243; en funci&#243;n de las siguientes consideraciones&#58;<ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005"><span class="elsevierStyleLabel">1&#41;</span><p id="par0040" class="elsevierStylePara elsevierViewall">Pacientes con ICC moderada y grave &#40;grado III-IV o II-III sintom&#225;ticos seg&#250;n la New York Heart Association &#40;NYHA&#41; que no se controlan con otros tratamientos&#58; beta-bloqueantes &#40;BB&#41;&#44; inhibidores del enzima convertidor de angiotensina &#40;IECA&#41; o antagonistas del receptor de angiotensina II &#40;ARA-II&#41;&#44; y antagonistas del receptor de pacientes con ICC y FA&#46;</p></li><li class="elsevierStyleListItem" id="lsti0010"><span class="elsevierStyleLabel">2&#41;</span><p id="par0045" class="elsevierStylePara elsevierViewall">Mineralcorticoides &#40;ARM&#41;&#59; o pacientes con IC asociada a FA cr&#243;nica&#46;</p></li></ul></p><p id="par0050" class="elsevierStylePara elsevierViewall">En los pacientes que presentan FEVI deprimida asociada a FA la digoxina estar&#237;a m&#225;s indicada y podr&#237;a ir mejor&#44; pese a que es ampliamente conocido que BB tiene un impacto mayor en la supervivencia&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Variables independientes y de resultado</span><p id="par0055" class="elsevierStylePara elsevierViewall">Se recogieron 22 variables independientes relacionadas con la situaci&#243;n basal del paciente&#58; 2 demogr&#225;ficas &#40;edad&#44; sexo&#41;&#44; 13 comorbilidades &#40;hipertensi&#243;n arterial&#44; dislipidemia&#44; diabetes mellitus&#44; cardiopat&#237;a isqu&#233;mica&#44; episodios previos de ICA&#44; enfermedad renal cr&#243;nica&#44; enfermedad cerebrovascular&#44; FA&#44; valvulopat&#237;a&#44; arteriopat&#237;a perif&#233;rica&#44; enfermedad pulmonar obstructiva cr&#243;nica&#44; demencia y neoplasia&#41;&#44; 4 de tratamiento cr&#243;nico &#40;diur&#233;ticos&#44; IECA&#44; ARA-II&#44; BB y ARM&#41; y 3 de situaci&#243;n funcional basal &#40;clase funcional NYHA&#44; clasificaci&#243;n de la funci&#243;n de la fracci&#243;n de eyecci&#243;n del ventr&#237;culo izquierdo e &#237;ndice de Barthel&#41;&#46; En relaci&#243;n al episodio de descompensaci&#243;n&#44; se recogieron 6 potenciales desencadenantes del episodio &#40;infecci&#243;n&#44; taquiarritmia&#44; anemia&#44; crisis hipertensiva&#44; transgresi&#243;n diet&#233;tico-terap&#233;utica y s&#237;ndrome coronario agudo&#41;&#44; 3 constantes vitales a la llegada a urgencias &#40;presi&#243;n arterial sist&#243;lica&#44; frecuencia card&#237;aca y pulsioximetr&#237;a&#41; y 2 estimadores de la gravedad de la descompensaci&#243;n &#40;estratificaci&#243;n del riesgo de muerte utilizando la escala MEESSI<a class="elsevierStyleCrossRef" href="#bib0300"><span class="elsevierStyleSup">26</span></a> y necesidad de hospitalizaci&#243;n&#41;&#46;</p><p id="par0060" class="elsevierStylePara elsevierViewall">Las variables de resultado fueron mortalidad &#40;por cualquier causa&#41; intrahospitalaria y a 30 d&#237;as y&#44; entre los pacientes que sobrevivieron al episodio &#237;ndice&#44; ingreso prolongado &#40;&#62;7 d&#237;as a contar desde el d&#237;a de consulta en urgencias&#41; y evento adverso combinado &#40;formado por reconsulta en urgencias o hospitalizaci&#243;n por ICA o muerte por cualquier causa&#41; durante los 30 d&#237;as siguientes al alta del paciente&#46; La asignaci&#243;n de los eventos fue realizada localmente por el investigador principal mediante contacto telef&#243;nico o acceso a las historias cl&#237;nicas&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">An&#225;lisis estad&#237;stico</span><p id="par0065" class="elsevierStylePara elsevierViewall">Las variables categ&#243;ricas fueron descritas mediante frecuencias y porcentajes&#46; Las continuas con la mediana y rango intercuartil &#40;RIC&#41;&#46; El an&#225;lisis de distribuci&#243;n de las variables categ&#243;ricas se realiz&#243; con el test de Chi-cuadrado o test exacto de Fisher seg&#250;n correspondiera&#44; y el de las continuas mediante el test no param&#233;trico de la suma de rangos de Mann-Whitney&#46; La asociaci&#243;n entre el tratamiento no adecuado con digoxina y eventos adversos&#44; se investig&#243; mediante un modelo de regresi&#243;n log&#237;stica&#44; y se expres&#243; como <span class="elsevierStyleItalic">odds ratio</span> &#40;OR&#41; con su intervalo de confianza del 95&#37; &#40;IC 95&#37;&#41;&#44; tanto crudos como ajustados por las diferencias en las caracter&#237;sticas basales &#40;modelo A&#41;&#44; las caracter&#237;sticas de la descompensaci&#243;n &#40;modelo B&#41;&#44; y por ambas a la vez &#40;modelo C&#44; ajuste total&#41;&#46; En dichos modelos se introdujeron las variables para las que se hab&#237;an identificado diferencias estad&#237;sticamente significativas entre los grupos con tratamiento cr&#243;nico con digoxina no adecuado y adecuado en el an&#225;lisis bivariable&#46; Para dicho modelo multivariado&#44; se utilizaron 10 conjuntos de datos obtenidos mediante imputaci&#243;n m&#250;ltiple con sustituci&#243;n aleatoria de aquellos valores ausentes en las variables introducidas&#46; La aleatorizaci&#243;n se realiz&#243; mediante el tornado de Mersene y utilizando como semilla 2&#46;000&#46;000&#46; En todas las comparaciones&#44; se acept&#243; que las diferencias eran estad&#237;sticamente significativas si el valor de p era inferior a 0&#44;05&#44; o si el IC 95&#37; de la OR exclu&#237;a el valor 1&#46; El an&#225;lisis estad&#237;stico se realiz&#243; con el programa SPSS&#174; versi&#243;n 24&#46;0 para Windows &#40;IBM Corp&#46; Released 2016&#46; IBM SPSS Statistics for Windows&#44; version 24&#46;0&#46; Armonk&#44; NY&#44; EE&#46; UU&#46;&#41;&#46;</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Aspectos &#233;ticos</span><p id="par0070" class="elsevierStylePara elsevierViewall">Se siguieron los principios &#233;ticos de la Declaraci&#243;n de Helsinki sobre investigaci&#243;n en humanos&#44; y se solicit&#243; el consentimiento informado a todos los pacientes para participar en el estudio&#46; El protocolo fue aprobado por el Comit&#233; de &#201;tica e Investigaci&#243;n Cl&#237;nica del Hospital Universitario Central de Asturias como comit&#233; principal &#40;protocolos 49&#47;2010&#44; 69&#47;2011&#44; 166&#47;13&#44; 160&#47;15 y 205&#47;17&#41; y por los del resto de los centros participantes&#46;</p></span></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Resultados</span><p id="par0075" class="elsevierStylePara elsevierViewall">De los 19&#46;947 pacientes diagnosticados de ICA en el Registro EAHFE&#44; se incluyeron finalmente 2&#46;366 en el Estudio DIG-ICA &#40;<a class="elsevierStyleCrossRef" href="#fig0005">fig&#46; 1</a>&#41;&#46; La mediana de edad fue de 83 a&#241;os &#40;RIC&#58; 76-88&#41;&#44; el 61&#44;4&#37; eran mujeres&#44; la comorbilidad result&#243; muy frecuente&#44; entre las que destacaba FA &#40;85&#37;&#41;&#44; hipertensi&#243;n arterial &#40;81&#44;7&#37;&#41;&#44; episodios previos de ICA &#40;72&#44;4&#37;&#41;&#44; diabetes mellitus &#40;41&#44;9&#37;&#41; y dislipidemia &#40;40&#44;7&#37;&#41;&#46; El resto de las caracter&#237;sticas cl&#237;nicas puede consultarse en la <a class="elsevierStyleCrossRef" href="#tbl0005">tabla 1</a>&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0080" class="elsevierStylePara elsevierViewall">En total&#44; de toda la cohorte de 2&#46;366 pacientes&#44; se consider&#243; que en 993 pacientes &#40;42&#37;&#41; que no hab&#237;a datos cl&#237;nicos que soportasen el uso cr&#243;nico de digoxina&#44; mientras que en 1&#46;373 &#40;58&#37;&#41; se consider&#243; que su uso fuese posiblemente adecuado &#40;<a class="elsevierStyleCrossRef" href="#fig0005">fig&#46; 1</a>&#41;&#46; Cuando se comparan ambos grupos&#44; se observ&#243; que los siguientes factores basales se asociaron con un uso adecuado de digoxina&#58; FA&#44; hipertensi&#243;n arterial&#44; episodios previos de ICA&#44; dislipidemia&#44; cardiopat&#237;a isqu&#233;mica&#44; enfermedad renal cr&#243;nica&#44; &#237;ndice de Barthel mayor&#44; FEr y tratamiento cr&#243;nico con IECA&#47;ARA-II y BB&#46; Por el contrario&#44; los pacientes de mayor edad con mayor frecuencia no sol&#237;an tener una indicaci&#243;n adecuada de dicho tratamiento&#46; No hubo diferencias en ambos grupos en cuanto a la presencia de NYHA III-IV &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">tabla 1</a>&#41;&#46; En cuanto a las caracter&#237;sticas del episodio de descompensaci&#243;n&#44; solo se encontr&#243; que los pacientes con indicaci&#243;n no adecuada de digoxina ten&#237;an como causa de descompensaci&#243;n de la ICA a la anemia y ten&#237;an cierta tendencia a mayor frecuencia cardiaca&#46; No se encontraron diferencias entre ambos grupos asociadas a la gravedad del episodio que motiv&#243; la consulta al SUH &#40;<a class="elsevierStyleCrossRef" href="#tbl0010">tabla 2</a>&#41;&#46;</p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><p id="par0085" class="elsevierStylePara elsevierViewall">En el an&#225;lisis estad&#237;stico de resultados en ambos grupos &#40;adecuado y no adecuado&#41; se pudo observar que la mortalidad intrahospitalaria y a 30 d&#237;as fue mayor en el grupo con tratamiento no adecuado con digoxina &#40;9&#44;9 versus 7&#44;6&#37;&#44; p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;05&#59; y 12&#44;6 versus 9&#44;1&#37;&#44; p<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#44;001&#59; respectivamente&#41;&#44; en tanto que no se registraron diferencias en estancia prolongada &#40;35&#44;7 versus 33&#44;8&#37;&#41; ni en eventos adversos posalta &#40;32&#44;9 versus 31&#44;8&#37;&#41;&#46; Sin embargo&#44; en el modelo ajustado por las diferencias basales y del episodio de descompensaci&#243;n &#40;ajuste total&#41;&#44; el tratamiento no indicado con digoxina no se asoci&#243; con peor evoluci&#243;n a corto plazo&#44; con OR de 1&#44;31 &#40;IC 95&#37;&#58; 0&#44;85-2&#44;03&#41; para mortalidad intrahospitalaria&#59; 1&#44;29 &#40;0&#44;74-2&#44;25&#41; para mortalidad a 30 d&#237;as&#59; 1&#44;07 &#40;0&#44;82-1&#44;40&#41; para estancia prolongada&#59; y 0&#44;88 &#40;0&#44;65-1&#44;19&#41; para evento adverso posalta &#40;<a class="elsevierStyleCrossRef" href="#tbl0015">tabla 3</a>&#41;&#46;</p><elsevierMultimedia ident="tbl0015"></elsevierMultimedia></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">Discusi&#243;n</span><p id="par0090" class="elsevierStylePara elsevierViewall">El Estudio DIG-ICA analiza la idoneidad del tratamiento con digoxina en la IC en los pacientes incluidos en el Registro EAHFE y explora si su uso en ausencia de indicaci&#243;n se asocia a peores resultados pron&#243;sticos&#46; Sus resultados permiten concluir que&#44; a pesar de la no correcta indicaci&#243;n del f&#225;rmaco resulta frecuente &#40;casi en la mitad de las descompensaciones se produjo esta circunstancia&#41;&#44; esta inadecuaci&#243;n no parece asociarse a peores resultados a corto plazo&#46;</p><p id="par0095" class="elsevierStylePara elsevierViewall">El uso de digoxina en los pacientes con IC es controvertido&#46; Las gu&#237;as de la Sociedad Europea de Cardiolog&#237;a le confieren al f&#225;rmaco un nivel de evidencia IIb&#47;B<a class="elsevierStyleCrossRef" href="#bib0305"><span class="elsevierStyleSup">27</span></a> en base al Estudio Digitalis Investigation Group &#40;DIG&#41;<a class="elsevierStyleCrossRef" href="#bib0175"><span class="elsevierStyleSup">1</span></a>&#44; a partir del cual se considera su uso en pacientes con IC con FEr en ritmo sinusal que permanecen sintom&#225;ticos a pesar de tratamiento con IECA&#47;ARA-II&#44; BB y ARM&#44; pues se ha visto que se reduce el riesgo de hospitalizaci&#243;n&#46; Dicho estudio mostr&#243; un efecto neutro sobre la mortalidad&#44; aunque estudios posteriores han asociado incrementos de la misma por encima de concentraciones de digoxina &#8805;<span class="elsevierStyleHsp" style=""></span>1&#44;2<span class="elsevierStyleHsp" style=""></span>ng&#47;mL<a class="elsevierStyleCrossRef" href="#bib0310"><span class="elsevierStyleSup">28</span></a>&#46; Adem&#225;s&#44; los efectos de tratamiento cr&#243;nico con digoxina en pacientes con IC con FEr y FA &#40;otro potencial uso cl&#237;nico habitual&#41; no han sido estudiados en ning&#250;n ensayo cl&#237;nico&#46; Diversos estudios han sugerido un mayor riesgo de eventos adversos en pacientes con FA y que reciben digoxina<a class="elsevierStyleCrossRefs" href="#bib0240"><span class="elsevierStyleSup">14&#44;15&#44;29</span></a>&#46; Sin embargo&#44; un metaan&#225;lisis realizado sobre la base de ensayos cl&#237;nicos no aleatorios concluye que digoxina no modifica la mortalidad en pacientes con FA e IC<a class="elsevierStyleCrossRef" href="#bib0250"><span class="elsevierStyleSup">16</span></a>&#46; No obstante&#44; la mayor&#237;a de pacientes ten&#237;an IC con FEr&#46; Por ello&#44; la digoxina puede ser &#250;til en dicho escenario cuando no se pueden utilizar otras terapias para el control de la frecuencia cardiaca&#44; y siempre con especial precauci&#243;n en ancianos&#44; mujeres&#44; pacientes fr&#225;giles o con insuficiencia renal<a class="elsevierStyleCrossRefs" href="#bib0255"><span class="elsevierStyleSup">17&#44;18&#44;30</span></a>&#46;</p><p id="par0100" class="elsevierStylePara elsevierViewall">Independientemente de esta controversia sobre el uso de digoxina&#44; el presente estudio explor&#243; si su uso fuera de las indicaciones m&#225;s recomendadas en pacientes con IC se asociaba a peores resultados pron&#243;sticos&#46; Como se ha comentado anteriormente&#44; el grupo de uso no adecuado de digoxina supon&#237;a el 42&#37; del total de enfermos tratados con dicho f&#225;rmaco&#46; Pese a ser una cohorte de edad avanzada y mayoritariamente mujeres&#44; el grupo de uso no adecuado se asoci&#243; a mayor edad&#44; peor &#237;ndice de Barthel&#44; mejor funci&#243;n ventricular y menor uso de otros tratamientos con impacto positivo sobre la supervivencia &#40;BB y IECA&#47;ARA-II&#41;&#46; Esto est&#225; en consonancia con la tendencia habitual del uso de digoxina en pacientes m&#225;s mayores y con peor calidad de vida<a class="elsevierStyleCrossRef" href="#bib0250"><span class="elsevierStyleSup">16</span></a>&#44; lo cual les somete&#44; <span class="elsevierStyleItalic">a priori</span>&#44; a un mayor riesgo de eventos adversos&#46;</p><p id="par0105" class="elsevierStylePara elsevierViewall">Cuando se analiz&#243; en la presente cohorte los resultados evolutivos entre pacientes con tratamiento adecuado e inadecuado con digoxina&#44; se objetiv&#243; una mayor mortalidad cruda intrahospitalaria y a corto plazo&#44; que luego no se confirm&#243; en el modelo ajustado por las diferencias basales y del episodio de descompensaci&#243;n entre ambos grupos&#46; Por tanto&#44; a pesar de ser pacientes con te&#243;rico mayor riesgo&#44; no presentaron peores resultados a corto plazo tras una descompensaci&#243;n de su IC&#46; Cabe destacar&#44; no obstante&#44; que&#44; a pesar de tener m&#225;s edad y mayor fragilidad&#44; este grupo con tratamiento no adecuado ten&#237;a menos comorbilidades y quiz&#225;s este hecho podr&#237;a haber influido en los resultados obtenidos&#46; Por otra parte&#44; por las caracter&#237;sticas del dise&#241;o del estudio&#44; no se han comparado subgrupos de pacientes con IC y tratamiento con digoxina&#44; ni se les ha comparado con pacientes sin dicho tratamiento&#46; Aunque esto podr&#237;a haber arrojado m&#225;s informaci&#243;n&#44; el objetivo del Estudio DIG-ICA se focaliz&#243; en testar si la hip&#243;tesis de si una te&#243;rica inadecuada utilizaci&#243;n de dicho f&#225;rmaco se asociaba a peor pron&#243;stico en relaci&#243;n a los pacientes en los que el uso de digoxina era adecuado&#46; Por &#250;ltimo&#44; rese&#241;ar que el uso de digoxina en pacientes con IC es&#44; a d&#237;a de hoy&#44; relativamente bajo&#44; de aproximadamente el 14&#37; en la cohorte EAHFE&#44; de la que proceden los pacientes de este estudio&#46; Cabr&#237;a ver si con el paso de los a&#241;os este porcentaje disminuye con la nueva entrada de otros f&#225;rmacos con mayor impacto sobre la supervivencia en pacientes con IC con FEr y FEp&#44; independientemente del ritmo en que se encuentren&#44; como son los inhibidores del receptor de angiotensina-neprilisina &#40;ARNI&#41; y los inhibidores del cotransportador sodio-glucosa tipo 2 &#40;iSGLT2&#41;&#46;</p><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0105">Limitaciones</span><p id="par0110" class="elsevierStylePara elsevierViewall">Como limitaciones&#44; cabe destacar las propias de todos los estudios observacionales&#44; que son solo generadores de hip&#243;tesis&#46; Sin embargo&#44; estos estudios reflejan el mundo real de la enfermedad estudiada&#44; en este caso&#44; el de la ICA&#46; Como segunda limitaci&#243;n&#44; la determinaci&#243;n de la adecuaci&#243;n o no del tratamiento con digoxina se hizo mediante la revisi&#243;n de historias cl&#237;nicas y los datos disponibles en ella y en algunos casos puede no haber sido correcto&#46; Tercera&#44; no existi&#243; un grupo control de pacientes con ICA sin tratamiento con digoxina&#44; tanto en ritmo sinusal como en FA&#46; Cuarta&#44; no se tuvo en cuenta los pacientes tratados con digoxina eran recientes iniciadores del f&#225;rmaco &#40;no se dispon&#237;a del tiempo en tratamiento con digoxina&#41;&#46; Existen estudios que asocian este inicio a mayor incremento de muerte s&#250;bita y al a&#241;o&#46; Quinta&#44; no se dispuso de las concentraciones plasm&#225;ticas de digoxina&#44; por lo que desconocemos si los pacientes se encontraban dentro del rango terap&#233;utico&#46; Sexta&#44; aunque se recogieron m&#250;ltiples aspectos basales&#44; puede haber otros que pudiesen haber influido en los resultados y causar confusi&#243;n&#46; Entre ellos&#44; durante los &#250;ltimos a&#241;os se ha llamado la atenci&#243;n sobre la fragilidad&#44; que no suele determinarse en urgencias y que est&#225; claramente asociada a resultados adversos en los pacientes con ICA<a class="elsevierStyleCrossRefs" href="#bib0325"><span class="elsevierStyleSup">31&#44;32</span></a>&#46; Finalmente&#44; el uso de digoxina y la organizaci&#243;n de la asistencia a los pacientes con IC var&#237;a entre pa&#237;ses<a class="elsevierStyleCrossRefs" href="#bib0335"><span class="elsevierStyleSup">33&#44;34</span></a>&#44; por lo que nuestros resultados precisar&#225;n de validaci&#243;n externa&#46;</p></span></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0110">Conclusi&#243;n</span><p id="par0115" class="elsevierStylePara elsevierViewall">Existe un perfil de paciente con ICA que recibe de forma no adecuada digoxina&#44; si bien esta no justificaci&#243;n de tratamiento cr&#243;nico digit&#225;lico no parece asociarse de forma significativa con resultados adversos a corto plazo&#46; El uso de dicho f&#225;rmaco&#44; no obstante&#44; debe relegarse a las indicaciones recomendadas en las gu&#237;as cl&#237;nicas y con especial precauci&#243;n en los grupos de riesgo&#46;</p></span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0115">Financiaci&#243;n</span><p id="par0125" class="elsevierStylePara elsevierViewall">Este trabajo fue posible en parte gracias a las ayudas del Instituto de Salud Carlos III con fondos del Ministerio de Sanidad y FEDER &#40;PI18&#47;00393&#41;&#46;</p></span><span id="sec00055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect00115">Conflicto de intereses</span><p id="par0120" class="elsevierStylePara elsevierViewall">Los autores declaran no tener ning&#250;n conflicto de intereses&#46;</p></span></span>"
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          "titulo" => "Abstract"
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              "titulo" => "Variables independientes y de resultado"
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              "titulo" => "An&#225;lisis estad&#237;stico"
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          "titulo" => "Financiaci&#243;n"
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          "identificador" => "sec00055"
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    "fechaRecibido" => "2023-04-13"
    "fechaAceptado" => "2023-08-18"
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            0 => "Insuficiencia cardiaca aguda"
            1 => "Digoxina"
            2 => "Mortalidad"
            3 => "Urgencias"
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        0 => array:4 [
          "clase" => "keyword"
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          "palabras" => array:4 [
            0 => "Acute heart failure"
            1 => "Digoxin"
            2 => "Mortality"
            3 => "Emergency department"
          ]
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    "resumen" => array:2 [
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        "titulo" => "Resumen"
        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Objetivos</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Analizar los factores relacionados con el tratamiento cr&#243;nico inadecuado con digoxina&#44; y si esta inadecuaci&#243;n impacta en la evoluci&#243;n a corto plazo&#46;</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">M&#233;todo</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Se incluyeron pacientes diagnosticados de insuficiencia cardiaca aguda &#40;ICA&#41; en tratamiento cr&#243;nico con digoxina&#44; y se clasificaron como con tratamiento indicado o no indicado&#44; investig&#225;ndose los factores asociados a este hecho&#44; y si se asociaba a mortalidad intrahospitalaria a 30 d&#237;as&#44; estancia hospitalaria prolongada &#40;&#62;<span class="elsevierStyleHsp" style=""></span>7 d&#237;as&#41; y evento adverso combinado &#40;reconsulta a urgencias&#44; hospitalizaci&#243;n por ICA o muerte por cualquier causa&#41; durante los 30 d&#237;as postalta&#46;</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Resultados</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Se analizaron 2&#46;366 pacientes en tratamiento cr&#243;nico con digoxina &#40;mediana<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>83 a&#241;os&#44; mujeres<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>61&#37;&#41;&#58; adecuado en 1&#46;373 casos &#40;58&#44;0&#37;&#41;&#44; inadecuado en 993 &#40;42&#44;0&#37;&#41;&#46; La inadecuaci&#243;n se asoci&#243; con mayor edad&#44; menor comorbilidad&#44; menor tratamiento con betabloqueantes e IECA&#44; mejor funci&#243;n ventricular y peor &#237;ndice de Barthel&#46; La mortalidad intrahospitalaria y a 30 d&#237;as fue mayor en pacientes con tratamiento inadecuado &#40;9&#44;9 versus 7&#44;6&#37;&#44; p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;05&#59; y 12&#44;6 versus 9&#44;1&#37;&#44; p<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#44;001&#59; respectivamente&#41;&#59; no hubo diferencias en estancia prolongada &#40;35&#44;7 versus 33&#44;8&#37;&#41; ni en eventos adversos posalta &#40;32&#44;9 versus 31&#44;8&#37;&#41;&#46; Ajustando las diferencias basales y del episodio de descompensaci&#243;n&#44; el tratamiento cr&#243;nico inadecuado con digoxina no se asoci&#243; con ning&#250;n resultado&#44; con <span class="elsevierStyleItalic">odds ratio</span> de 1&#44;31 &#40;IC 95&#37;&#58; 0&#44;85-2&#44;03&#41; para mortalidad intrahospitalaria&#44; 1&#44;29 &#40;0&#44;74-2&#44;25&#41; para mortalidad a 30 d&#237;as&#59; 1&#44;07 &#40;0&#44;82-1&#44;40&#41; para estancia prolongada y 0&#44;88 &#40;0&#44;65-1&#44;19&#41; para evento adverso posalta&#46;</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Conclusi&#243;n</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Existe un perfil de paciente que recibe de forma inadecuada tratamiento cr&#243;nico con digoxina&#44; si bien ello no se asocia con resultados adversos a corto plazo durante los episodios de ICA&#46;</p></span>"
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            "identificador" => "abst0005"
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            "identificador" => "abst0010"
            "titulo" => "M&#233;todo"
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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">To analyze the factors related to inadequate chronic treatment with digoxin and whether the inadequacy of treatment has an impact on short-term outcome&#46;</p></span> <span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Method</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Patients diagnosed with AHF who were in chronic treatment with digoxin were selected&#46; Digoxin treatment was classified as adequate or inadequate&#46; We investigated factors associated to inadequacy and whether such inadequacy was associated with in-hospital and 30-day mortality&#44; prolonged hospital stay &#40;&#62;7 days&#41; and combined adverse event &#40;re-consultation to the ED or hospitalization for AHF or death from any cause&#41; during the 30 days after discharge&#46;</p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Results</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">We analyzed 2366 patients on chronic digoxin treatment &#40;median age<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>83 years&#44; women<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>61&#37;&#41;&#44; which was considered adequate in 1373 cases &#40;58&#46;0&#37;&#41; and inadequate in 993 &#40;42&#46;0&#37;&#41;&#46; The inadequacy was associated with older age&#44; less comorbidity&#44; less treatment with beta-blockers and renin&#8211;angiotensin inhibitors&#44; better ventricular function&#44; and worse Barthel index&#46; In-hospital and 30-day mortality was higher in patients with inadequate digoxin treatment &#40;9&#46;9&#37; vs&#46; 7&#46;6&#37;&#44; <span class="elsevierStyleItalic">p</span>&#61;0&#46;05&#59; and 12&#46;6&#37; vs&#46; 9&#46;1&#37;&#44; <span class="elsevierStyleItalic">p</span>&#60;0&#46;001&#44; respectively&#41;&#46; No differences were recorded in prolonged stay &#40;35&#46;7&#37; vs&#46; 33&#46;8&#37;&#41; or post-discharge adverse events &#40;32&#46;9&#37; vs&#46; 31&#46;8&#37;&#41;&#46; In the model adjusted for baseline and decompensation episode differences&#44; inadequate treatment with digoxin was not significantly associated with any outcome&#44; with an odds ratio of 1&#46;31 &#40;95&#37; <span class="elsevierStyleSmallCaps">C</span>I<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;85-2&#46;03&#41; for in-hospital mortality&#59; 1&#46;29 &#40;0&#46;74-2&#46;25&#41; for 30-day mortality&#59; 1&#46;07 &#40;0&#46;82-1&#46;40&#41; for prolonged stay&#59; and 0&#46;88 &#40;0&#46;65-1&#46;19&#41; for post-discharge adverse event&#46;</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Conclusion</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">There is a profile of patients with AHF who inadequately receive digoxin&#44; although this inadequateness for chronic digitalis treatment was not associated with short-term adverse outcomes&#46;</p></span>"
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        "nota" => "<p class="elsevierStyleNotepara" id="npar0030">Los nombres de los investigadores del grupo ICA-SEMES est&#225;n relacionados en el <a class="elsevierStyleCrossRef" href="#sec0060">anexo 1</a>&#46;</p>"
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            "apendice" => "<p id="par0130" class="elsevierStylePara elsevierViewall">Marta Fuentes&#44; Cristina Gil &#40;Hospital Universitario de Salamanca&#41;&#59; H&#233;ctor Alonso y Enrique P&#233;rez-Llantada &#40;Hospital Marqu&#233;s de Valdecilla de Santander&#41;&#59; Francisco Javier Mart&#237;n-S&#225;nchez&#44; Guillermo Llopis Garc&#237;a y Mar Su&#225;rez Cadenas &#40;Hospital Cl&#237;nico San Carlos de Madrid&#41;&#59; &#210;scar Mir&#243;&#44; V&#237;ctor Gil&#44; Rosa Escoda&#44; Sira Aguil&#243; y Carolina S&#225;nchez &#40;Hospital Cl&#237;nic de Barcelona&#41;&#59; Carmen Gargallo &#40;Hospital Polit&#233;nic La Fe de Valencia&#41;&#59; Jos&#233; Pav&#243;n &#40;Hospital Dr&#46; Negr&#237;n de Las Palmas de Gran Canaria&#41;&#59; Antonio Noval &#40;Hospital Insular de Las Palmas de Gran Canaria&#41;&#59; Mar&#237;a Luisa L&#243;pez-Grima&#44; Amparo Valero y Mar&#237;a &#193;ngeles Juan &#40;Hospital Dr&#46; Peset de Valencia&#41;&#59; Alfons Aguirre&#44; Maria Angels Pedragosa y Silvia M&#237;nguez Mas&#243; &#40;Hospital del Mar de Barcelona&#41;&#59; Mar&#237;a Isabel Alonso y Francisco Ruiz &#40;Hospital de Valme de Sevilla&#41;&#59; Jos&#233; Miguel Franco &#40;Hospital Miguel Servet de Zaragoza&#41;&#59; Ana Bel&#233;n Mecina &#40;Hospital de Alcorc&#243;n de Madrid&#41;&#59; Josep Tost&#44; Marta Berenguer y Ruxandra Donea &#40;Consorci Sanitari de Terrassa&#41;&#59; Susana S&#225;nchez Ram&#243;n y Virginia Carbajosa Rodr&#237;guez &#40;Hospital Universitario R&#237;o Hortega de Valladolid&#41;&#59; Pascual Pi&#241;era y Jos&#233; Andr&#233;s S&#225;nchez Nicol&#225;s &#40;Hospital Reina Sof&#237;a de Murcia&#41;&#59; Raquel Torres Garate &#40;Hospital Severo Ochoa de Madrid&#41;&#59; Aitor Alqu&#233;zar-Arb&#233;&#44; Miguel Alberto Rizzi y Sergio Herrera &#40;Hospital de la Santa Creu y Sant Pau de Barcelona&#41;&#59; Javier Jacob&#44; Alex Roset&#44; Irene Cabello y Antonio Haro &#40;Hospital Universitari de Bellvitge de Barcelona&#41;&#59; Fernando Richard&#44; Jos&#233; Mar&#237;a &#193;lvarez P&#233;rez y Mar&#237;a Pilar L&#243;pez Diez &#40;Hospital Universitario de Burgos&#41;&#59; Pablo Herrero Puente&#44; Joaqu&#237;n V&#225;zquez &#193;lvarez&#44; Bel&#233;n Prieto Garc&#237;a&#44; Mar&#237;a Garc&#237;a Garc&#237;a y Marta S&#225;nchez Gonz&#225;lez &#40;Hospital Universitario Central de Asturias de Oviedo&#41;&#59; Pere Llorens&#44; Patricia Javaloyes&#44; Inmaculada Jim&#233;nez&#44; N&#233;stor Hern&#225;ndez&#44; Bego&#241;a Espinosa&#44; Adriana Gil&#44; Francisca Molina y Tamara Garc&#237;a &#40;Hospital General de Alicante&#41;&#59; Juan Antonio Andueza &#40;Hospital General Universitario Gregorio Mara&#241;&#243;n de Madrid&#41;&#59; Rodolfo Romero &#40;Hospital Universitario de Getafe de Madrid&#41;&#59; Mart&#237;n Ru&#237;z&#44; Roberto Calvache &#40;Hospital de Henares de Madrid&#41;&#59; Mar&#237;a Teresa Lorca Serralta y Luis Ernesto Calder&#243;n Jave &#40;Hospital del Tajo de Madrid&#41;&#59; Beatriz Amores Arriaga y Beatriz Sierra Bergua &#40;Hospital Cl&#237;nico Lozano Blesa de Zaragoza&#41;&#59; Enrique Mart&#237;n Mojarro y Brigitte Silvana Alarc&#243;n Jim&#233;nez &#40;Hospital Sant Pau i Santa Tecla de Tarragona&#41;&#59; Lisette Traver&#237;a B&#233;cquer y Guillermo Burillo &#40;Hospital Universitario de Canarias de Tenerife&#41;&#59; Llu&#237;s Llauger Garc&#237;a y Gerard Corominas LaSalle &#40;Hospital Universitari de Vic de Barcelona&#41;&#59; Carmen Ag&#252;era Urbano&#44; Ana Bel&#233;n Garc&#237;a Soto y Elisa Delgado Padial &#40;Hospital Costa del Sol de Marbella de M&#225;laga&#41;&#59; Ester Soy Ferrer y Mar&#237;a Adroher M&#250;&#241;oz &#40;Hospital Josep Trueta de Girona&#41;&#59; Jos&#233; Manuel Garrido &#40;Hospital Virgen Macarena de Sevilla&#41;&#59; Francisco Javier Lucas-Imbern&#243;n &#40;Hospital General Universitario de Albacete&#41;&#59; Rut Gaya &#40;Hospital Juan XXIII de Tarragona&#41;&#59; Carlos Bibiano&#44; Mar&#237;a Mir y Beatriz Rodr&#237;guez &#40;Hospital Infanta Leonor de Madrid&#41;&#59; Jos&#233; Luis Carballo &#40;Complejo Hospitalario Universitario de Ourense&#41;&#59; Esther Rodr&#237;guez-Adrada&#44; Bel&#233;n Rodr&#237;guez Miranda y Monika Vicente Mart&#237;n &#40;Hospital Rey Juan Carlos de M&#243;stoles de Madrid&#41; y Pere Coma Casanova y Joan Espinach Alvar&#243;s &#40;Hospital San Joan de Deu de Martorell&#44; Barcelona&#41;&#46;</p>"
            "etiqueta" => "Anexo 1"
            "titulo" => "Investigadores del grupo ICA-SEMES"
            "identificador" => "sec0060"
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Todos los pacientesN<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>2&#46;366n &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Indicaci&#243;n no adecuada de digoxinaN<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>993n &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Indicaci&#243;n adecuada de digoxinaN<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>1&#46;373n &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">2 &#40;0&#44;1&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">83 &#40;76-88&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">82 &#40;76-87&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Sexo femenino&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">1&#46;451 &#40;61&#44;4&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">4 &#40;0&#44;2&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">620 &#40;62&#44;4&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">831 &#40;60&#44;7&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">0&#44;39&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">2&#46;012 &#40;85&#44;0&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">0&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">656 &#40;66&#44;1&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">1&#46;356 &#40;98&#44;8&#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"><span class="elsevierStyleBold">&#60;</span><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleBold">0&#44;001</span>&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>Hipertensi&#243;n arterial&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">1&#46;933 &#40;81&#44;7&#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">788 &#40;79&#44;3&#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">1&#46;145 &#40;83&#44;5&#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"><span class="elsevierStyleBold">0&#44;01</span>&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>Previos episodios de insuficiencia cardiaca aguda&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">1&#46;713 &#40;72&#44;4&#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&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">611 &#40;61&#44;5&#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">1&#46;102 &#40;80&#44;3&#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"><span class="elsevierStyleBold">&#60;</span><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleBold">0&#44;001</span>&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>Diabetes mellitus&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">991 &#40;41&#44;9&#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">2 &#40;0&#44;1&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t\ttop\n
                  \t\t\t\t">395 &#40;39&#44;9&#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">596 &#40;43&#44;4&#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;08&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
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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">964 &#40;40&#44;7&#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&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">366 &#40;36&#44;9&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">598 &#40;43&#44;6&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleBold">0&#44;001</span>&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>Valvulopat&#237;a cardiaca&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">893 &#40;37&#44;7&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">0&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">378 &#40;38&#44;1&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">515 &#40;37&#44;5&#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;78&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>Enfermedad pulmonar obstructiva cr&#243;nica&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">652 &#40;27&#44;6&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">3 &#40;0&#44;1&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">292 &#40;29&#44;4&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">360 &#40;26&#44;3&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">0&#44;09&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>Cardiopat&#237;a isqu&#233;mica&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">512 &#40;21&#44;6&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">1 &#40;1&#44;1&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">184 &#40;18&#44;5&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">328 &#40;23&#44;9&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">0&#44;002&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>Enfermedad renal cr&#243;nica &#40;creatinina &#62;<span class="elsevierStyleHsp" style=""></span>2<span class="elsevierStyleHsp" style=""></span>mg&#47;dL&#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">483 &#40;20&#44;4&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">0&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">173 &#40;17&#44;4&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">310 &#40;22&#44;6&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">0&#44;002&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>Enfermedad cerebrovascular&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">300 &#40;12&#44;7&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">0&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">118 &#40;11&#44;9&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">182 &#40;13&#44;3&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">0&#44;32&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>Neoplasia&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">278 &#40;12&#44;9&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">214 &#40;9&#44;0&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">117 &#40;13&#44;1&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">161 &#40;12&#44;8&#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">0&#44;79&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>Demencia&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">244 &#40;11&#44;3&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t">215 &#40;9&#44;1&#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">110 &#40;12&#44;4&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">134 &#40;10&#44;6&#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;21&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>Enfermedad arterial perif&#233;rica&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">180 &#40;7&#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  " align="left" valign="\n
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                  \t\t\t\t">73 &#40;7&#44;4&#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">107 &#40;7&#44;8&#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">0&#44;69&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="6" align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="6" align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleItalic">Tratamiento cr&#243;nico en el domicilio</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
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Diur&#233;ticos&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">2&#46;049 &#40;86&#44;7&#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">2 &#40;0&#44;1&#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">853 &#40;85&#44;9&#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">1&#46;196 &#40;87&#44;2&#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;35&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>Inhibidores del sistema renina-angiotensina&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">1&#46;397 &#40;59&#44;1&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t">2 &#40;0&#44;2&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t">554 &#40;55&#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">843 &#40;61&#44;5&#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;005&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>Betabloqueante&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"><span class="elsevierStyleHsp" style=""></span>&#205;ndice de Barthel&#44; mediana &#40;RIC&#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"><span class="elsevierStyleHsp" style=""></span>Anemia&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Crisis hipertensiva&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Trasgresi&#243;n diet&#233;tico-terap&#233;utica&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>S&#237;ndrome coronario agudo&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleItalic">Constantes vitales en urgencias</span></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>Presi&#243;n arterial sist&#243;lica &#40;mmHg&#41;&#44; mediana &#40;RIC&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Frecuencia cardiaca &#40;lpm&#41;&#44; mediana &#40;RIC&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">83 &#40;71-100&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Pulsioximetr&#237;a basal &#40;&#37;&#41;&#44; mediana &#40;RIC&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">93 &#40;90-96&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleItalic">Gravedad de la descompensaci&#243;n</span></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>Categor&#237;a de riesgo seg&#250;n la escala MEESSI<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>Riesgo bajo&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Riesgo intermedio&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttop\n
                  \t\t\t\t">&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>Riesgo alto&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</td><td class="td" title="\n
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                  \t\t\t\t  " align="" valign="\n
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                  \t\t\t\t">&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">45 &#40;8&#44;5&#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">88 &#40;11&#44;4&#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="" valign="\n
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                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Riesgo muy alto&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">114 &#40;8&#44;8&#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="" valign="\n
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                  \t\t\t\t">&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">60 &#40;11&#44;3&#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">54 &#40;7&#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="" valign="\n
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                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Necesidad de hospitalizaci&#243;n&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&#46;795 &#40;75&#44;9&#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">1 &#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">742 &#40;74&#44;8&#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
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                  \t\t\t\t">1&#46;053 &#40;76&#44;7&#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;29&nbsp;\t\t\t\t\t\t\n
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              "nota" => "<p class="elsevierStyleNotepara" id="npar0005">La escala MEESSI est&#225; integrada por 13 variables obtenidas a la llegada del paciente a urgencias &#40;edad del paciente&#59; presencia de un s&#237;ndrome coronario agudo como desencadenante de la descompensaci&#243;n&#59; &#237;ndice de Barthel&#44; clase NYHA&#44; presi&#243;n arterial sist&#243;lica&#44; frecuencia respiratoria&#44; saturaci&#243;n basal de ox&#237;geno y signos de bajo gasto cardiaco a la llegada a urgencias&#59; cifras de NT-proBNP&#44; troponina&#44; creatinina y potasio en la primera anal&#237;tica&#44; y existencia de hipertrofia ventricular izquierda en el electrocardiograma&#41; y estratifican el riesgo de fallecer durante los 30 d&#237;as siguientes a la llegada a urgencias&#46;</p> <p class="elsevierStyleNotepara" id="npar0010">Los valores 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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          "es" => "<p id="spar0065" class="elsevierStyleSimplePara elsevierViewall">Caracter&#237;sticas del episodio de descompensaci&#243;n de los pacientes en tratamiento con digoxina incluidos en el presente estudio&#44; y comparaci&#243;n en funci&#243;n de si el tratamiento con digoxina se consider&#243; adecuado o no adecuado</p>"
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">&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" scope="col" style="border-bottom: 2px solid black">Indicaci&#243;n no adecuada de digoxinaN <span class="elsevierStyleInf">eventos</span> &#47; N <span class="elsevierStyleInf">total</span> &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Indicaci&#243;n adecuada de digoxinaN <span class="elsevierStyleInf">eventos</span> &#47; N <span class="elsevierStyleInf">total</span> &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Riesgo asociado a indicaci&#243;n no adecuada de digoxina<span class="elsevierStyleItalic">odds ratio</span> &#40;IC 95&#37;&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " colspan="4" align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleItalic">Mortalidad intrahospitalaria</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
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Cruda&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">97&#47;983 &#40;9&#44;9&#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">103&#47;1&#46;361 &#40;7&#44;6&#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">1&#44;34 &#40;1&#44;00-1&#44;79&#41;&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>Ajustada &#40;por caracter&#237;sticas basales<a class="elsevierStyleCrossRef" href="#tblfn0010"><span class="elsevierStyleSup">a</span></a>&#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">&#8212;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#8212;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><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;32 &#40;0&#44;85-2&#44;04&#41;&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>Ajustada &#40;por caracter&#237;sticas de la descompensaci&#243;n<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
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#8212;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#8212;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><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;33 &#40;0&#44;99-1&#44;78&#41;&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>Ajustada &#40;ajuste total&#59; por caracter&#237;sticas basales y de la descompensaci&#243;n&#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">&#8212;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#8212;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><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;31 &#40;0&#44;85-2&#44;03&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="4" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="4" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Mortalidad a 30 d&#237;as</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
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Cruda&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">123&#47;975 &#40;12&#44;6&#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">122&#47;1&#46;345 &#40;9&#44;1&#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"><span class="elsevierStyleBold">1&#44;45 &#40;1&#44;11-1&#44;89&#41;</span>&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>Ajustada &#40;por caracter&#237;sticas basales<a class="elsevierStyleCrossRef" href="#tblfn0010"><span class="elsevierStyleSup">a</span></a>&#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">&#8212;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#8212;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><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;32 &#40;0&#44;89-1&#44;96&#41;&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>Ajustada &#40;por caracter&#237;sticas de la descompensaci&#243;n<a class="elsevierStyleCrossRef" href="#tblfn0015"><span class="elsevierStyleSup">b</span></a>&#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">&#8212;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#8212;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleBold">1&#44;45 &#40;1&#44;11-1&#44;89&#41;</span>&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>Ajustada &#40;ajuste total&#59; por caracter&#237;sticas basales y de la descompensaci&#243;n&#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">&#8212;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#8212;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><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;32 &#40;0&#44;89-1&#44;96&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="4" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="4" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Estancia prolongada &#40;&#62;</span><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">7 d&#237;as&#41; en supervivientes</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
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Cruda&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">306&#47;857 &#40;35&#44;7&#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">412&#47;1&#46;220 &#40;33&#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
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&#44;09 &#40;0&#44;91-1&#44;31&#41;&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>Ajustada &#40;por caracter&#237;sticas basales<a class="elsevierStyleCrossRef" href="#tblfn0010"><span class="elsevierStyleSup">a</span></a>&#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">&#8212;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#8212;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><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;07 &#40;0&#44;82-1&#44;40&#41;&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>Ajustada &#40;por caracter&#237;sticas de la descompensaci&#243;n<a class="elsevierStyleCrossRef" href="#tblfn0015"><span class="elsevierStyleSup">b</span></a>&#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">&#8212;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#8212;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><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;09 &#40;0&#44;91-1&#44;31&#41;&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>Ajustada &#40;ajuste total&#59; por caracter&#237;sticas basales y de la descompensaci&#243;n&#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">&#8212;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#8212;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><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;07 &#40;0&#44;82-1&#44;40&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="4" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="4" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Evento adverso a 30 d&#237;as posalta en supervivientes</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
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Cruda&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">218&#47;663 &#40;32&#44;9&#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">321&#47;1&#46;008 &#40;31&#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
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#44;88 &#40;0&#44;65-1&#44;19&#41;&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>Ajustada &#40;por caracter&#237;sticas basales<a class="elsevierStyleCrossRef" href="#tblfn0010"><span class="elsevierStyleSup">a</span></a>&#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">&#8212;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#8212;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><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;05 &#40;0&#44;85-1&#44;29&#41;&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>Ajustada &#40;por caracter&#237;sticas de la descompensaci&#243;n<a class="elsevierStyleCrossRef" href="#tblfn0015"><span class="elsevierStyleSup">b</span></a>&#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">&#8212;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#8212;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><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;88 &#40;0&#44;65-1&#44;19&#41;&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>Ajustada &#40;ajuste total&#59; por caracter&#237;sticas basales y de la descompensaci&#243;n&#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">&#8212;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#8212;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><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;05 &#40;0&#44;70-1&#44;56&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
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            0 => array:3 [
              "identificador" => "tblfn0010"
              "etiqueta" => "a"
              "nota" => "<p class="elsevierStyleNotepara" id="npar0015">Las caracter&#237;sticas basales utilizadas como covariables en el modelo ajustado fueron edad&#44; fibrilaci&#243;n auricular&#44; hipertensi&#243;n arterial&#44; episodios previos de insuficiencia cardiaca aguda&#44; dislipidemia&#44; cardiopat&#237;a isqu&#233;mica&#44; enfermedad renal cr&#243;nica&#44; tratamiento cr&#243;nico con inhibidores del eje renina-angiotensina o con betabloqueantes&#44; tipo de disfunci&#243;n del ventr&#237;culo izquierdo e &#237;ndice de Barthel&#46;</p>"
            ]
            1 => array:3 [
              "identificador" => "tblfn0015"
              "etiqueta" => "b"
              "nota" => "<p class="elsevierStyleNotepara" id="npar0020">Las caracter&#237;sticas del episodio de descompensaci&#243;n utilizadas como covariables en el modelo ajustado fueron la existencia de an&#233;mica como factor desencadenante de la descompensaci&#243;n y la frecuencia cardiaca a la llegada a urgencias&#46;</p> <p class="elsevierStyleNotepara" id="npar0025">Los valores en <span class="elsevierStyleBold">negrita</span> 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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          ]
        ]
        "descripcion" => array:1 [
          "es" => "<p id="spar0080" class="elsevierStyleSimplePara elsevierViewall">Caracter&#237;sticas del episodio de descompensaci&#243;n de los pacientes en tratamiento con digoxina incluidos en el presente estudio&#44; y comparaci&#243;n en funci&#243;n de si el tratamiento con digoxina se consider&#243; adecuado o no adecuado</p>"
        ]
      ]
    ]
    "bibliografia" => array:2 [
      "titulo" => "Bibliograf&#237;a"
      "seccion" => array:1 [
        0 => array:2 [
          "identificador" => "bibs0015"
          "bibliografiaReferencia" => array:34 [
            0 => array:3 [
              "identificador" => "bib0175"
              "etiqueta" => "1"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "The global health and economic burden of hospitalizations for heart failure&#58; essons learned from hospitalized heart failure registries"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [
                            0 => "A&#46;P&#46; Ambrosy"
                            1 => "G&#46;C&#46; Fonarow"
                            2 => "J&#46; Butler"
                            3 => "O&#46;L&#46; Chioncel"
                            4 => "S&#46;J&#46; Greene"
                            5 => "M&#46; Vaduganathan"
                          ]
                        ]
                      ]
                    ]
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                    0 => array:2 [
                      "doi" => "10.1016/j.jacc.2013.11.053"
                      "Revista" => array:6 [
                        "tituloSerie" => "J Am Coll Cardiol"
                        "fecha" => "2014"
                        "volumen" => "63"
                        "paginaInicial" => "1123"
                        "paginaFinal" => "1133"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/24491689"
                            "web" => "Medline"
                          ]
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                      ]
                    ]
                  ]
                ]
              ]
            ]
            1 => array:3 [
              "identificador" => "bib0180"
              "etiqueta" => "2"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Epidemiology of heart failure in Spain over the last 20 years"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:3 [
                            0 => "I&#46; Sayago-Silva"
                            1 => "F&#46; Garc&#237;a-L&#243;pez"
                            2 => "J&#46; Segovia-Cubero"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1016/j.rec.2013.03.012"
                      "Revista" => array:6 [
                        "tituloSerie" => "Rev Esp Cardiol"
                        "fecha" => "2013"
                        "volumen" => "66"
                        "paginaInicial" => "649"
                        "paginaFinal" => "656"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/24776334"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            2 => array:3 [
              "identificador" => "bib0185"
              "etiqueta" => "3"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Time trends in characteristics&#44; clinical course&#44; and outcomes of 13&#44;791 patients with acute heart failure"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [
                            0 => "P&#46; Llorens"
                            1 => "P&#46; Javaloyes"
                            2 => "F&#46;J&#46; Mart&#237;n-S&#225;nchez"
                            3 => "J&#46; Jacob"
                            4 => "P&#46; Herrero-Puente"
                            5 => "V&#46; Gil"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1007/s00392-018-1261-z"
                      "Revista" => array:6 [
                        "tituloSerie" => "Clin Res Cardiol"
                        "fecha" => "2018"
                        "volumen" => "107"
                        "paginaInicial" => "897"
                        "paginaFinal" => "913"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/29728831"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            3 => array:3 [
              "identificador" => "bib0190"
              "etiqueta" => "4"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Acute heart failure congestion and perfusion status &#8211; impact of the clinical classification on in-hospital and long-term outcomes&#59; insights from the ESC-EORP-HFA Heart Failure Long-Term Registry"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [
                            0 => "O&#46; Chioncel"
                            1 => "A&#46; Mebazaa"
                            2 => "A&#46;P&#46; Maggioni"
                            3 => "V&#46;P&#46; Harjola"
                            4 => "G&#46; Rosano"
                            5 => "C&#46; Laroche"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1002/ejhf.1492"
                      "Revista" => array:6 [
                        "tituloSerie" => "Eur J Heart Fail"
                        "fecha" => "2019"
                        "volumen" => "21"
                        "paginaInicial" => "1338"
                        "paginaFinal" => "1352"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/31127678"
                            "web" => "Medline"
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            4 => array:3 [
              "identificador" => "bib0195"
              "etiqueta" => "5"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Departments involved during the first episode of acute heart failure and subsequent emergency department revisits and rehospitalisations&#58; An outlook through the NOVICA cohort"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [
                            0 => "&#210;&#46; Mir&#243;"
                            1 => "A&#46; Garc&#237;a Sarasola"
                            2 => "C&#46; Fuenzalida"
                            3 => "S&#46; Calder&#243;n"
                            4 => "J&#46; Jacob"
                            5 => "A&#46; Aguirre"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:5 [
                        "tituloSerie" => "Eur J Heart Fail"
                        "fecha" => "2019"
                        "volumen" => "21"
                        "paginaInicial" => "1231"
                        "paginaFinal" => "1244"
                      ]
                    ]
                  ]
                ]
              ]
            ]
            5 => array:3 [
              "identificador" => "bib0200"
              "etiqueta" => "6"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Classification and Quality Standards of Heart Failure Units&#58; Scientific Consensus of the Spanish Society of Cardiology &#91;Article in English&#44; Spanish&#93;"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [
                            0 => "M&#46; Anguita S&#225;nchez"
                            1 => "J&#46;L&#46; Lambert Rodr&#237;guez"
                            2 => "R&#46; Bover Freire"
                            3 => "J&#46; Com&#237;n Colet"
                            4 => "M&#46;G&#46; Crespo Leiro"
                            5 => "F&#46; Gonz&#225;lez V&#237;lchez"
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Información del artículo
ISSN: 00142565
Idioma original: Español
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