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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">La embolia pulmonar &#40;EP&#41; ocupa el tercer lugar en cuanto a la incidencia anual dentro de las enfermedades cardiovasculares<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">1</span></a>&#46; La complicaci&#243;n m&#225;s grave tras la EP es la hipertensi&#243;n tromboemb&#243;lica cr&#243;nica &#40;HPTEC&#41;<a class="elsevierStyleCrossRefs" href="#bib0100"><span class="elsevierStyleSup">2&#8211;4</span></a>&#46; Esta es debida a una obstrucci&#243;n mantenida de las arterias pulmonares por persistencia de un trombo fibr&#243;tico y un remodelado microvascular que conduce a un aumento de la resistencia vascular pulmonar que ocasiona la hipertensi&#243;n pulmonar &#40;HP&#41;<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">5</span></a>&#46; Su diagn&#243;stico de presunci&#243;n se realiza por la persistencia de defectos de perfusi&#243;n gammagr&#225;ficos y un ecocardiograma con datos de probabilidad intermedia&#47;alta de hipertensi&#243;n pulmonar<a class="elsevierStyleCrossRefs" href="#bib0120"><span class="elsevierStyleSup">6&#44;7</span></a>&#46; El diagn&#243;stico definitivo es hemodin&#225;mico y requiere de la realizaci&#243;n de un cateterismo card&#237;aco derecho&#46; Detectar la HPTEC de manera temprana es de vital importancia&#44; ya que el retraso en el diagn&#243;stico se ha asociado con un aumento de la mortalidad y p&#233;rdida de a&#241;os de calidad de vida<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">4</span></a>&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">Aunque la probabilidad individual de desarrollar HPTEC tras sufrir una EP es baja &#40;alrededor del 3&#44;13&#37;&#41;<a class="elsevierStyleCrossRefs" href="#bib0130"><span class="elsevierStyleSup">8&#8211;10</span></a>&#44; la alta incidencia de EP &#40;1-2 casos por 1&#46;000 habitantes&#47;a&#241;o&#41; elevar&#237;a el n&#250;mero de pacientes europeos con HPTEC hasta el entorno de 4&#46;000-8&#46;000 cada a&#241;o<a class="elsevierStyleCrossRef" href="#bib0145"><span class="elsevierStyleSup">11</span></a>&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">Las gu&#237;as sobre EP del 2019 de la Sociedad Europea de Cardiolog&#237;a y la Sociedad Respiratoria Europea sugirieron un algoritmo que recomendaba realizar ecocardiograma a los 3-6 meses de la EP a todos los pacientes con disnea persistente y&#47;o condiciones predisponentes para la HPTEC<a class="elsevierStyleCrossRef" href="#bib0150"><span class="elsevierStyleSup">12</span></a>&#46; Sin embargo&#44; despu&#233;s de 3 meses de tratamiento anticoagulante&#44; aproximadamente un 50&#37; de los pacientes refieren disnea&#44; lo que supondr&#237;a que hay que realizar un gran n&#250;mero ecocardiograf&#237;as&#46; Algunos autores han cuestionado si la disnea sea el &#250;nico s&#237;ntoma para hacer el cribado del diagn&#243;stico de HPTEC&#44; y han propuesto algoritmos que ayuden a seleccionar pacientes con mayor riesgo&#44; en los que realizar el estudio&#46; El estudio InShape II<a class="elsevierStyleCrossRef" href="#bib0155"><span class="elsevierStyleSup">13</span></a> propuso un algoritmo para el diagn&#243;stico precoz de la HPTEC que alcanz&#243; una sensibilidad del 91&#37;&#44; y reduc&#237;a el n&#250;mero de ecocardiogramas a realizar&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">El objetivo de nuestro estudio es realizar una validaci&#243;n externa de dicho algoritmo en nuestra serie de pacientes diagnosticados de EP y con seguimiento durante un a&#241;o&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Material y m&#233;todos</span><p id="par0030" class="elsevierStylePara elsevierViewall">Estudio de cohortes retrospectivo con identificaci&#243;n de todos los pacientes con ingreso en el Hospital Universitario Rey Juan Carlos&#44; hospital terciario de Madrid&#44; por un episodio de EP entre noviembre de 2017 y febrero de 2020&#46; Se incluyeron en el estudio pacientes mayores de 18 a&#241;os&#44; cuyo diagn&#243;stico hubiera sido confirmado mediante angio-tomograf&#237;a computarizada &#40;angio-TC&#41; de arterias pulmonares y que hubieran tenido al menos un a&#241;o de seguimiento cl&#237;nico tras el episodio agudo&#46; Los pacientes elegibles fueron todos aquellos con diagn&#243;stico al alta con el c&#243;digo CIE-10&#58; I26 &#40;embolia pulmonar&#41;&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">Siguiendo el protocolo de nuestro centro para el manejo de pacientes con EP&#44; en cada visita se hab&#237;a registrado la clase funcional seg&#250;n la escala de la New York Heart Association &#40;NYHA&#41;&#44; el NT-proBNP&#44; ECG y ecocardiograma basal a los 3 y 12 meses&#46; Aquellos que ten&#237;an ecocardiograma con probabilidad intermedia&#47;alta se les realizaba gammagraf&#237;a y si era positiva se valoraba el angio-TC y el cateterismo derecho<a class="elsevierStyleCrossRefs" href="#bib0120"><span class="elsevierStyleSup">6&#44;7</span></a>&#46; El seguimiento de estos pacientes se hab&#237;a hecho en una consulta monogr&#225;fica de ETEV por los facultativos asignados a la unidad&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">Este estudio cuenta con la aprobaci&#243;n del Comit&#233; de &#201;tica de la Investigaci&#243;n Fundaci&#243;n Jim&#233;nez D&#237;az&#46;</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Validaci&#243;n escala</span><p id="par0045" class="elsevierStylePara elsevierViewall">Para validar la escala se siguieron los m&#233;todos descritos por sus autores&#58;</p><p id="par0050" class="elsevierStylePara elsevierViewall">Primer paso</p><p id="par0055" class="elsevierStylePara elsevierViewall">Con los datos a los 3 meses&#44; se calcul&#243; la puntuaci&#243;n en la escala propuesta en el estudio InShape II<a class="elsevierStyleCrossRef" href="#bib0155"><span class="elsevierStyleSup">13</span></a> &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">tabla 1</a>&#41;&#46; El punto de corte de alto riesgo se establece en &#8805;<span class="elsevierStyleHsp" style=""></span>6&#46; Si el paciente hab&#237;a presentado s&#237;ntomas sugestivos de HPTEC &#40;disnea&#44; edema&#44; palpitaciones recientes&#44; s&#237;ncope o dolor tor&#225;cico&#41; o una puntuaci&#243;n &#8805;<span class="elsevierStyleHsp" style=""></span>6 en la escala&#44; pasaban al segundo paso&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0060" class="elsevierStylePara elsevierViewall">Segundo paso</p><p id="par0065" class="elsevierStylePara elsevierViewall">Se valoraba la presencia de signos de sobrecarga de ventr&#237;culo derecho en ECG&#44; definida como&#58; 1&#41; Patr&#243;n rSR&#8242; or rSr&#8242; en la derivaci&#243;n V1&#59; 2&#41; R&#58;S<span class="elsevierStyleHsp" style=""></span>&#62;<span class="elsevierStyleHsp" style=""></span>1 en la derivaci&#243;n V1 con R<span class="elsevierStyleHsp" style=""></span>&#62;<span class="elsevierStyleHsp" style=""></span>0&#44;5<span class="elsevierStyleHsp" style=""></span>mV y 3&#41; Eje QRS<span class="elsevierStyleHsp" style=""></span>&#62;<span class="elsevierStyleHsp" style=""></span>90&#176; y&#47;o NT-ProBNP elevado&#46; Si presentaba un criterio electrocardiogr&#225;fico o el NT-proBNP estaba elevado&#44; tendr&#237;an indicaci&#243;n de realizarse ecocardiograma&#44; que estadifica a los pacientes en probabilidad baja o intermedia&#47;alta de HPTEC&#46; En los pacientes con alta probabilidad de HPTEC se revis&#243; si se hab&#237;a proseguido estudio seg&#250;n gu&#237;as de pr&#225;ctica cl&#237;nica&#46;</p><p id="par0070" class="elsevierStylePara elsevierViewall">De este modo&#44; se obtuvo una cohorte te&#243;rica de pacientes a los que se habr&#237;a realizado ecocardiograf&#237;a de acuerdo con el algoritmo&#44; y pacientes en los que no corresponder&#237;a la realizaci&#243;n de esta&#46; Dicha cohorte virtual se compar&#243; con la real&#44; en la que todos los pacientes ten&#237;an datos ecocardiogr&#225;ficos a los 3 meses del diagn&#243;stico&#46; Por comparaci&#243;n de ambas cohortes se obtuvieron los &#237;ndices de validez del algoritmo propuesto&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">An&#225;lisis estad&#237;stico</span><p id="par0075" class="elsevierStylePara elsevierViewall">Una vez completada la base&#44; se analizaron los datos mediante el <span class="elsevierStyleItalic">software</span> estad&#237;stico XLSTAT&#174;&#46; Las variables categ&#243;ricas se expresan seg&#250;n su distribuci&#243;n de frecuencias y las variables continuas como media &#40;DE&#41; y mediana &#40;rango&#41; seg&#250;n corresponda&#46;</p><p id="par0080" class="elsevierStylePara elsevierViewall">Se hizo un an&#225;lisis de validez del <span class="elsevierStyleItalic">score</span> InShape calculando la sensibilidad&#44; la especificidad&#44; el valor predictivo positivo y negativo y el &#225;rea bajo la curva &#40;AUC&#41; con los resultados obtenidos&#46;</p><p id="par0085" class="elsevierStylePara elsevierViewall">Se realiz&#243; un an&#225;lisis comparativo de las caracter&#237;sticas de los pacientes con probabilidad baja de hipertensi&#243;n pulmonar y probabilidad intermedia&#47;alta y con ello se plante&#243; si la inclusi&#243;n de alguna de las variables con clara diferencias estad&#237;sticas podr&#237;a mejorar la sensibilidad del <span class="elsevierStyleItalic">score</span> y si reclasificara de forma significativa a los pacientes&#44; pero por la N baja el c&#225;lculo no se llev&#243; a cabo&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Resultados</span><p id="par0090" class="elsevierStylePara elsevierViewall">En el periodo de estudio se identificaron 236 pacientes con diagn&#243;stico de EP&#44; de los cuales 118 &#40;50&#37;&#41; quedaron excluidos por&#58; fallecimiento&#44; embarazo&#44; diagn&#243;stico de EP por gammagraf&#237;a&#44; tener criterios de paciente paliativo&#44; deterioro cognitivo o problemas psicol&#243;gicos&#46; Otros 19 que se perdieron durante el seguimiento &#40;<a class="elsevierStyleCrossRef" href="#fig0005">fig&#46; 1</a>&#41;&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0095" class="elsevierStylePara elsevierViewall">Noventa y nueve pacientes con EP cumplieron nuestros criterios de inclusi&#243;n&#46; De ellos&#44; 48 &#40;48&#37;&#41; eran varones&#44; la edad media fue de 61&#44;5 a&#241;os &#40;20-86&#41; y el 14&#37; ten&#237;a antecedentes de enfermedad tromboemb&#243;lica y neoplasia&#46; La presencia de otras comorbilidades &#40;valvulopat&#237;as&#44; conectivopat&#237;as&#44; hipertensi&#243;n portal&#44; VIH&#8230;&#41; fue poco frecuente &#40;<a class="elsevierStyleCrossRef" href="#tbl0010">tabla 2</a>&#41;&#46; El 16&#37; de los sujetos presentaron alg&#250;n tipo de trombofilia&#46; La forma de presentaci&#243;n m&#225;s frecuente fue la disnea y el dolor tor&#225;cico&#46; Al diagn&#243;stico un 24&#37; de los pacientes presentaba disfunci&#243;n del ventr&#237;culo derecho&#44; aunque solo el 4&#37; precisaron terapia de reperfusi&#243;n&#46;</p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><p id="par0100" class="elsevierStylePara elsevierViewall">A los 99 pacientes se les aplic&#243; el algoritmo del InShape II con los datos cl&#237;nicos&#44; anal&#237;ticos&#44; del ECG y ecocardiograma que dispon&#237;amos a los 3 meses &#40;media de tiempo hasta la evaluaci&#243;n en d&#237;as&#44; 95&#44; mediana&#58; 100&#59; rango&#58; 60-145&#41;&#46; Treinta y ocho pacientes ten&#237;an una puntuaci&#243;n &#8805;<span class="elsevierStyleHsp" style=""></span>6&#44; 32 ten&#237;an disnea&#44; edemas&#44; palpitaciones o dolor tor&#225;cico y 19 ten&#237;an alteraciones en el proBNP o el ECG&#46;</p><p id="par0105" class="elsevierStylePara elsevierViewall">Seg&#250;n el algoritmo 80 pacientes tendr&#237;an bajo riesgo cl&#237;nico de HTPEC y&#44; por tanto&#44; no precisar&#237;an realizar ecocardiograma&#44; ya que presentaron una puntuaci&#243;n menor de 6 o ausencia de s&#237;ntomas&#44; o ausencia alteraciones en el proBNP o ECG&#46; Sin embargo&#44; de estos pacientes&#44; 2 ten&#237;an un ecocardiograma con probabilidad intermedia&#47;alta de HTPEC&#44; por lo que se deben considerar &#171;falsos negativos&#187;&#46; De estos dos casos en uno se realiz&#243; TAC de t&#243;rax de control sin lesi&#243;n tromb&#243;tica residual por lo que se descart&#243; HPTEC y no se realiz&#243; cateterismo&#46; En el otro caso se asumi&#243; que la HTP estaba asociada a patolog&#237;a neumol&#243;gica&#44; ya que se trataba de un paciente mayor&#44; con comorbilidad y un s&#237;ndrome de apnea del sue&#241;o con oxigeno domiciliario previo a la EP y una EP segmentaria&#44; por lo que no se hizo cateterismo&#46;</p><p id="par0110" class="elsevierStylePara elsevierViewall">Frente a ellos&#44; 19 pacientes ser&#237;an susceptibles realizarse un ecocardiograma&#44; por tener alto riesgo cl&#237;nico de HPTEC&#46; En el ecocardiograma de estos pacientes 3 tuvieron probabilidad intermedia&#47;alta de HPTEC por lo que 16 ser&#237;an falsos positivos&#46; Una paciente ten&#237;a una gammagraf&#237;a positiva por lo que se hizo cateterismo en el que presentaba PAP de 24<span class="elsevierStyleHsp" style=""></span>mmHg&#46; En los otros 2 casos no se hizo cateterismo&#58; una paciente ten&#237;a una neumectom&#237;a previa que podr&#237;a explicar la HTP y la otra paciente ten&#237;a una gammagraf&#237;a normal que descartaba HPTEC &#40;<a class="elsevierStyleCrossRef" href="#fig0010">fig&#46; 2</a>&#41;&#46;</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0115" class="elsevierStylePara elsevierViewall">De los 5 pacientes &#40;5&#44;05&#37;&#41; con probabilidad intermedia&#47;alta de hipertensi&#243;n pulmonar en la ecocardiograf&#237;a&#44; la edad media era m&#225;s alta que los que ten&#237;an riesgo bajo &#40;77 vs&#46; 61&#41;&#44; con m&#225;s frecuencia del sexo femenino &#40;100 vs&#46; 51&#37;&#41;&#44; y con mucha mayor frecuencia presentaron datos sugerentes de hipertensi&#243;n arterial pulmonar al diagn&#243;stico &#40;80 vs&#46; 22&#37;&#41;&#46;</p><p id="par0120" class="elsevierStylePara elsevierViewall">Por lo tanto&#44; en nuestra serie el algoritmo tiene una sensibilidad de un 60&#37; y un valor predictivo positivo del 15&#44;8&#37; con una especificidad de un 83&#37; y un valor predictivo negativo del 97&#44;5&#37;&#46; En la <a class="elsevierStyleCrossRef" href="#fig0015">figura 3</a> se muestra la curva ROC que describe la capacidad discriminativa del algoritmo en estudio&#44; con un &#225;rea bajo la curva de 0&#44;715 &#40;IC 95&#37;&#58; 0&#44;472-0&#44;958&#41;&#46;</p><elsevierMultimedia ident="fig0015"></elsevierMultimedia></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Discusi&#243;n</span><p id="par0125" class="elsevierStylePara elsevierViewall">Seg&#250;n los resultados de nuestra serie&#44; el algoritmo propuesto en el estudio InShape II muestra un buen valor predictivo negativo bajo la premisa de una baja prevalencia de HPTEC como la observada en nuestra muestra&#46;</p><p id="par0130" class="elsevierStylePara elsevierViewall">Nuestros pacientes son de similares caracter&#237;sticas a los del estudio In Shape II en cuanto a sexo&#44; edad y comorbilidades&#44; como enfermedad pulmonar y conectivopat&#237;as&#44; y difieren&#44; en que en nuestra serie hab&#237;a m&#225;s pacientes que ten&#237;an enfermedad neopl&#225;sica &#40;14 vs&#46; 7&#44;8&#37; en el InShape II&#41;&#46;</p><p id="par0135" class="elsevierStylePara elsevierViewall">De los 99 pacientes&#44; 3 ten&#237;an una probabilidad intermedia&#47;alta seg&#250;n los resultados del ecocardiograma&#44; mientras que en 2 casos no hubieran sido detectados si hubi&#233;ramos seguido estrictamente las indicaciones del protocolo InShape II&#46; Por ello nuestra sensibilidad es de un 60&#37;&#44; por debajo de la publicada por los autores que alcanzaba un 81&#37;&#46;</p><p id="par0140" class="elsevierStylePara elsevierViewall">En nuestra muestra&#44; el valor predictivo negativo &#40;VPN&#41; fue del 97&#44;5&#37;&#44; teniendo en cuenta una muy baja prevalencia de HPTEC&#46; Por tanto&#44; en contextos de prevalencia similar a la de nuestra serie&#44; el algoritmo podr&#237;a ser v&#225;lido&#44; ya que supondr&#237;a evitar la realizaci&#243;n del 80&#37; de ecocardiogramas&#46; De los 19 ecocardiogramas que se habr&#237;an realizado siguiendo estrictamente el algoritmo&#44; solo en 3 la probabilidad fue intermedia&#47;alta&#44; lo que indica que existe un n&#250;mero considerable de falsos positivos que lleva a realizar pruebas adicionales para descartar HPTEC&#46; Sin embargo&#44; sin ning&#250;n algoritmo de cribado este n&#250;mero ser&#237;a mucho mayor<a class="elsevierStyleCrossRefs" href="#bib0160"><span class="elsevierStyleSup">14&#44;15</span></a>&#44; por lo cual&#44; a falta de un algoritmo mejor&#44; consideramos que el algoritmo propuesto por Boon et al&#46;<a class="elsevierStyleCrossRef" href="#bib0155"><span class="elsevierStyleSup">13</span></a> puede ayudar a tomar las decisiones sobre a qu&#233; pacientes se debe continuar el estudio&#46;</p><p id="par0145" class="elsevierStylePara elsevierViewall">Nuestros pacientes con probabilidad ecocardiogr&#225;fica intermedia&#47;alta de HPTEC son mayores y todos son mujeres&#44; algo ya descrito en otros estudios como factores de riesgo de peor grado funcional tras la EP<a class="elsevierStyleCrossRefs" href="#bib0170"><span class="elsevierStyleSup">16&#44;17</span></a>&#46; Adem&#225;s&#44; los 2 pacientes con probabilidad intermedia&#47;alta no identificados por el algoritmo de cribado ten&#237;an HTP en el momento agudo&#44; lo que ha sido descrito como un factor de riesgo de HPTEC<a class="elsevierStyleCrossRef" href="#bib0180"><span class="elsevierStyleSup">18</span></a>&#46; Si hubi&#233;ramos incluido este criterio como uno de los que hay que tener en cuenta a la hora de hacer ecocardiograma de control&#44; no habr&#237;amos pasado por alto ning&#250;n paciente&#46;</p><p id="par0150" class="elsevierStylePara elsevierViewall">Nuestro trabajo tiene algunas limitaciones&#46; Se trata de un estudio retrospectivo&#44; con los sesgos que esto implica&#44; con un n&#250;mero reducido de enfermos&#44; y realizado en un &#250;nico hospital&#46; Sin embargo&#44; dicha limitaci&#243;n puede verse balanceada por la fortaleza que ofrece el seguimiento completo de casi un centenar de pacientes durante un a&#241;o&#44; con un protocolo exhaustivo de estudio&#44; hecho por un grupo reducido de m&#233;dicos expertos en esta enfermedad&#46;</p><p id="par0155" class="elsevierStylePara elsevierViewall">Nuestros resultados respaldan la utilidad del algoritmo propuesto en el estudio InShape II<a class="elsevierStyleCrossRef" href="#bib0155"><span class="elsevierStyleSup">13</span></a> como una herramienta valiosa&#44; aunque no exclusiva&#44; en el cribado inicial de HPTEC&#46; Se confirma que logra evitar la realizaci&#243;n de m&#250;ltiples ecocardiogramas&#46; A la luz de nuestros hallazgos&#44; sugerimos que incorporar el dato de HTP en el ecocardiograma en fase aguda como criterio para la realizaci&#243;n del cribado aumentar&#237;a la sensibilidad del algoritmo&#46; Ser&#237;an necesarios estudios prospectivos para confirmar esta teor&#237;a&#46;</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Financiaci&#243;n</span><p id="par0160" class="elsevierStylePara elsevierViewall">La presente investigaci&#243;n no ha recibido ayudas espec&#237;ficas provenientes de agencias del sector p&#250;blico&#44; sector comercial o entidades sin &#225;nimo de lucro&#46;</p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">Conflicto de intereses</span><p id="par0165" class="elsevierStylePara elsevierViewall">Los autores declaran no tener ning&#250;n conflicto de intereses&#46;</p></span></span>"
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          "titulo" => "Abstract"
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    "fechaRecibido" => "2023-06-21"
    "fechaAceptado" => "2023-08-24"
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            0 => "Ecocardiograf&#237;a"
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            2 => "Embolismo pulmonar"
            3 => "Disfunci&#243;n ventricular"
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            0 => "Echocardiography"
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            3 => "Ventricular dysfunction"
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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">Antecedentes y objetivo</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">La complicaci&#243;n a largo plazo m&#225;s grave del embolismo pulmonar &#40;EP&#41; es la hipertensi&#243;n pulmonar tromboemb&#243;lica cr&#243;nica &#40;HPTEC&#41;&#44; cuyo diagn&#243;stico precoz implica la realizaci&#243;n de un gran n&#250;mero pruebas&#46; El estudio InShape II propone un algoritmo de cribado precoz que pretende disminuir el n&#250;mero de estudios ecocardiogr&#225;ficos&#46; El objetivo de nuestro estudio es validar este algoritmo en nuestra cohorte de pacientes&#46;</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Material y m&#233;todos</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Se analizaron retrospectivamente los pacientes ingresados con diagn&#243;stico de EP por angio-TC&#44; en el Hospital Rey Juan Carlos entre noviembre del 2017 y febrero del 2020&#44; seguidos durante al menos un a&#241;o&#46; Se recogieron datos cl&#237;nicos&#44; anal&#237;ticos&#44; y pruebas complementarias a los 3 meses y al a&#241;o&#46; Se aplic&#243; a estos pacientes el algoritmo del estudio InShape II para validar sus resultados&#46;</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Resultados</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">En el periodo de estudio fueron diagnosticados de EP 236 pacientes&#44; de los cuales 137 fueron excluidos&#46; Se valid&#243; el algoritmo en 99 pacientes&#46; Aplicando el <span class="elsevierStyleItalic">score</span> del InShape II hubi&#233;ramos realizado 19 ecocardiogramas &#40;3 de ellos con probabilidad intermedia&#47;alta de HPTEC&#41; y no se hubieran hecho en 80 &#40;2 de ellos con probabilidad intermedia&#47;alta&#41;&#44; por lo que se estableci&#243; una sensibilidad del <span class="elsevierStyleItalic">score</span> de un 60&#37;&#44; con una especificidad de un 83&#37;&#44; y un &#225;rea bajo la curva &#40;AUC&#41; de 0&#44;715 &#40;IC 95&#37;&#58; 0&#44;472-0&#44;958&#41;&#46;</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Conclusiones</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Nuestros resultados apoyan que el algoritmo del estudio InShape II podr&#237;a ser una herramienta &#250;til en el cribado inicial del estudio de HPTEC en entornos de baja incidencia&#44; ya que evitar&#237;a la realizaci&#243;n de ecocardiogramas que no aportan valor&#46;</p></span>"
        "secciones" => array:4 [
          0 => array:2 [
            "identificador" => "abst0005"
            "titulo" => "Antecedentes y objetivo"
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          1 => array:2 [
            "identificador" => "abst0010"
            "titulo" => "Material y m&#233;todos"
          ]
          2 => array:2 [
            "identificador" => "abst0015"
            "titulo" => "Resultados"
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            "identificador" => "abst0020"
            "titulo" => "Conclusiones"
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      "en" => array:3 [
        "titulo" => "Abstract"
        "resumen" => "<span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Background and aim</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">The most severe long-term complication of pulmonary embolism &#40;PE&#41; is chronic thromboembolic pulmonary hypertension &#40;CTEPH&#41;&#44; and its early diagnosis often requires numerous diagnostic tests&#46; The InShape II study proposes an early screening algorithm that aims to reduce the number of echocardiographic studies&#46; The objective of our study is to validate this algorithm in our patient cohort&#46;</p></span> <span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Materials and methods</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">We retrospectively analyzed patients admitted to Hospital Rey Juan Carlos between November 2017 and February 2020&#44; who were diagnosed with PE based on computed tomography angiography &#40;CTA&#41;&#46; Patients were followed for at least one year&#44; and clinical&#44; laboratory&#44; and complementary test data were collected at three months and one year&#46; The InShape II algorithm was applied to these patients to validate its results&#46;</p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Results</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">During the study period&#44; 236 patients were diagnosed with PE&#44; of which 137 were excluded&#46; The algorithm was validated in 99 patients&#46; Applying the InShape II score&#44; 19 echocardiograms would have been performed &#40;three of them with intermediate-high probability of CTEPH&#41;&#44; while 80 echocardiograms would have been avoided &#40;two of them with intermediate-high probability&#41;&#46; This yielded a sensitivity of 60&#37; and a specificity of 83&#37; for the score&#44; with an area under the curve &#40;AUC&#41; of 0&#46;715 &#40;95&#37; CI&#58; 0&#46;472-0&#46;958&#41;&#46;</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Conclusions</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">Our results support the notion that the InShape II algorithm could be a useful tool for initial screening of CTEPH in low-incidence settings&#44; as it would avoid unnecessary echocardiograms that do not provide additional value&#46;</p></span>"
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                  \t\t\t\t">Hipotiroidismo conocido&nbsp;\t\t\t\t\t\t\n
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                  <table border="0" frame="\n
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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"><span class="elsevierStyleItalic">Edad &#40;a&#241;os&#41;</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\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="elsevierStyleItalic">Antecedentes familiares ETEV &#40;n&#41;</span>&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">77&#44;5<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>14&#44;3&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 ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleItalic">NT-ProBNP &#40;pg&#47;mL&#44; &#177;</span><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">SD&#41;</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">500&#44;8<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>539&#44;4&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">0&#44;66&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
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">0&#44;015<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>0&#44;015&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleItalic">Trombofilia &#40;n&#41;</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleItalic">Presentaci&#243;n s&#237;ntomas &#40;n&#41;</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Asintom&#225;tico&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Agudo&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Subagudo&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 ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Cr&#243;nico&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleItalic">S&#237;ntomas &#40;n&#41;</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">0&#44;14&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Disnea&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>Dolor tor&#225;cico&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>S&#237;ncope&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>Otros&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 ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Ingreso en la UCI &#40;n&#41;</span>&nbsp;\t\t\t\t\t\t\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
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                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Relaci&#243;n VDVI</span><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">&#62;</span><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">1 &#40;n&#41;</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">28&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">1&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">0&#44;63&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Afectaci&#243;n VD agudo &#40;n&#41;</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">0&#44;81&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="elsevierStyleItalic">HTP agudo &#40;n&#41;</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">4&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">&#60;<span class="elsevierStyleHsp" style=""></span>0&#44;01&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="elsevierStyleItalic">Tratamiento &#40;n&#41;</span>&nbsp;\t\t\t\t\t\t\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  " align="left" valign="\n
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                  \t\t\t\t">0&#44;89&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>Nada&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">0&nbsp;\t\t\t\t\t\t\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></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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Original
Validación externa del algoritmo InShape II para la exclusión de la enfermedad tromboembólica crónica en los pacientes con tromboembolismo pulmonar
External validation of the InShape II study algorithm for exclusion of chronic thromboembolic pulmonary hypertension in patients with pulmonary thromboembolism
M.D. Joya-Seijoa,b,c,
Autor para correspondencia
dolores.joya@hospitalreyjuancarlos.es

Autor para correspondencia.
, M.E. Barrios Garrido-Lestached,c, J.A. Rueda-Caminoa,c, M. Angelina-Garcíaa,c, A.C. Gil-Abizandaa, A. Sáenz de Urturi-Rodrígueza, J. Carrillo Hernández-Rubioe,c, P. del Valle-Loartef, M.L. Salto-Camachod,c, R. Barba-Martína,b,c
a Unidad Enfermedad Tromboembólica, Servicio de Medicina Interna, Hospital Universitario Rey Juan Carlos, Móstoles, Madrid, España
b Escuela Internacional de Doctorado, Universidad Rey Juan Carlos, Móstoles, Madrid, España
c Instituto de Investigación Fundación Jiménez Díaz, Madrid, España
d Unidad Enfermedad Tromboembólica, Servicio de Cardiología, Hospital Universitario Rey Juan Carlos, Móstoles, Madrid, España
e Unidad Enfermedad Tromboembólica, Servicio de Neumología, Hospital Universitario Rey Juan Carlos, Móstoles, Madrid, España
f Servicio de Medicina Interna, Hospital Universitario Severo Ochoa, Leganés, Madrid, España
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Su diagn&#243;stico de presunci&#243;n se realiza por la persistencia de defectos de perfusi&#243;n gammagr&#225;ficos y un ecocardiograma con datos de probabilidad intermedia&#47;alta de hipertensi&#243;n pulmonar<a class="elsevierStyleCrossRefs" href="#bib0120"><span class="elsevierStyleSup">6&#44;7</span></a>&#46; El diagn&#243;stico definitivo es hemodin&#225;mico y requiere de la realizaci&#243;n de un cateterismo card&#237;aco derecho&#46; Detectar la HPTEC de manera temprana es de vital importancia&#44; ya que el retraso en el diagn&#243;stico se ha asociado con un aumento de la mortalidad y p&#233;rdida de a&#241;os de calidad de vida<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">4</span></a>&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">Aunque la probabilidad individual de desarrollar HPTEC tras sufrir una EP es baja &#40;alrededor del 3&#44;13&#37;&#41;<a class="elsevierStyleCrossRefs" href="#bib0130"><span class="elsevierStyleSup">8&#8211;10</span></a>&#44; la alta incidencia de EP &#40;1-2 casos por 1&#46;000 habitantes&#47;a&#241;o&#41; elevar&#237;a el n&#250;mero de pacientes europeos con HPTEC hasta el entorno de 4&#46;000-8&#46;000 cada a&#241;o<a class="elsevierStyleCrossRef" href="#bib0145"><span class="elsevierStyleSup">11</span></a>&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">Las gu&#237;as sobre EP del 2019 de la Sociedad Europea de Cardiolog&#237;a y la Sociedad Respiratoria Europea sugirieron un algoritmo que recomendaba realizar ecocardiograma a los 3-6 meses de la EP a todos los pacientes con disnea persistente y&#47;o condiciones predisponentes para la HPTEC<a class="elsevierStyleCrossRef" href="#bib0150"><span class="elsevierStyleSup">12</span></a>&#46; Sin embargo&#44; despu&#233;s de 3 meses de tratamiento anticoagulante&#44; aproximadamente un 50&#37; de los pacientes refieren disnea&#44; lo que supondr&#237;a que hay que realizar un gran n&#250;mero ecocardiograf&#237;as&#46; Algunos autores han cuestionado si la disnea sea el &#250;nico s&#237;ntoma para hacer el cribado del diagn&#243;stico de HPTEC&#44; y han propuesto algoritmos que ayuden a seleccionar pacientes con mayor riesgo&#44; en los que realizar el estudio&#46; El estudio InShape II<a class="elsevierStyleCrossRef" href="#bib0155"><span class="elsevierStyleSup">13</span></a> propuso un algoritmo para el diagn&#243;stico precoz de la HPTEC que alcanz&#243; una sensibilidad del 91&#37;&#44; y reduc&#237;a el n&#250;mero de ecocardiogramas a realizar&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">El objetivo de nuestro estudio es realizar una validaci&#243;n externa de dicho algoritmo en nuestra serie de pacientes diagnosticados de EP y con seguimiento durante un a&#241;o&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Material y m&#233;todos</span><p id="par0030" class="elsevierStylePara elsevierViewall">Estudio de cohortes retrospectivo con identificaci&#243;n de todos los pacientes con ingreso en el Hospital Universitario Rey Juan Carlos&#44; hospital terciario de Madrid&#44; por un episodio de EP entre noviembre de 2017 y febrero de 2020&#46; Se incluyeron en el estudio pacientes mayores de 18 a&#241;os&#44; cuyo diagn&#243;stico hubiera sido confirmado mediante angio-tomograf&#237;a computarizada &#40;angio-TC&#41; de arterias pulmonares y que hubieran tenido al menos un a&#241;o de seguimiento cl&#237;nico tras el episodio agudo&#46; Los pacientes elegibles fueron todos aquellos con diagn&#243;stico al alta con el c&#243;digo CIE-10&#58; I26 &#40;embolia pulmonar&#41;&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">Siguiendo el protocolo de nuestro centro para el manejo de pacientes con EP&#44; en cada visita se hab&#237;a registrado la clase funcional seg&#250;n la escala de la New York Heart Association &#40;NYHA&#41;&#44; el NT-proBNP&#44; ECG y ecocardiograma basal a los 3 y 12 meses&#46; Aquellos que ten&#237;an ecocardiograma con probabilidad intermedia&#47;alta se les realizaba gammagraf&#237;a y si era positiva se valoraba el angio-TC y el cateterismo derecho<a class="elsevierStyleCrossRefs" href="#bib0120"><span class="elsevierStyleSup">6&#44;7</span></a>&#46; El seguimiento de estos pacientes se hab&#237;a hecho en una consulta monogr&#225;fica de ETEV por los facultativos asignados a la unidad&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">Este estudio cuenta con la aprobaci&#243;n del Comit&#233; de &#201;tica de la Investigaci&#243;n Fundaci&#243;n Jim&#233;nez D&#237;az&#46;</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Validaci&#243;n escala</span><p id="par0045" class="elsevierStylePara elsevierViewall">Para validar la escala se siguieron los m&#233;todos descritos por sus autores&#58;</p><p id="par0050" class="elsevierStylePara elsevierViewall">Primer paso</p><p id="par0055" class="elsevierStylePara elsevierViewall">Con los datos a los 3 meses&#44; se calcul&#243; la puntuaci&#243;n en la escala propuesta en el estudio InShape II<a class="elsevierStyleCrossRef" href="#bib0155"><span class="elsevierStyleSup">13</span></a> &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">tabla 1</a>&#41;&#46; El punto de corte de alto riesgo se establece en &#8805;<span class="elsevierStyleHsp" style=""></span>6&#46; Si el paciente hab&#237;a presentado s&#237;ntomas sugestivos de HPTEC &#40;disnea&#44; edema&#44; palpitaciones recientes&#44; s&#237;ncope o dolor tor&#225;cico&#41; o una puntuaci&#243;n &#8805;<span class="elsevierStyleHsp" style=""></span>6 en la escala&#44; pasaban al segundo paso&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0060" class="elsevierStylePara elsevierViewall">Segundo paso</p><p id="par0065" class="elsevierStylePara elsevierViewall">Se valoraba la presencia de signos de sobrecarga de ventr&#237;culo derecho en ECG&#44; definida como&#58; 1&#41; Patr&#243;n rSR&#8242; or rSr&#8242; en la derivaci&#243;n V1&#59; 2&#41; R&#58;S<span class="elsevierStyleHsp" style=""></span>&#62;<span class="elsevierStyleHsp" style=""></span>1 en la derivaci&#243;n V1 con R<span class="elsevierStyleHsp" style=""></span>&#62;<span class="elsevierStyleHsp" style=""></span>0&#44;5<span class="elsevierStyleHsp" style=""></span>mV y 3&#41; 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Por comparaci&#243;n de ambas cohortes se obtuvieron los &#237;ndices de validez del algoritmo propuesto&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">An&#225;lisis estad&#237;stico</span><p id="par0075" class="elsevierStylePara elsevierViewall">Una vez completada la base&#44; se analizaron los datos mediante el <span class="elsevierStyleItalic">software</span> estad&#237;stico XLSTAT&#174;&#46; Las variables categ&#243;ricas se expresan seg&#250;n su distribuci&#243;n de frecuencias y las variables continuas como media &#40;DE&#41; y mediana &#40;rango&#41; seg&#250;n corresponda&#46;</p><p id="par0080" class="elsevierStylePara elsevierViewall">Se hizo un an&#225;lisis de validez del <span class="elsevierStyleItalic">score</span> InShape calculando la sensibilidad&#44; la especificidad&#44; el valor predictivo positivo y negativo y el &#225;rea bajo la curva &#40;AUC&#41; con los resultados obtenidos&#46;</p><p id="par0085" class="elsevierStylePara elsevierViewall">Se realiz&#243; un an&#225;lisis comparativo de las caracter&#237;sticas de los pacientes con probabilidad baja de hipertensi&#243;n pulmonar y probabilidad intermedia&#47;alta y con ello se plante&#243; si la inclusi&#243;n de alguna de las variables con clara diferencias estad&#237;sticas podr&#237;a mejorar la sensibilidad del <span class="elsevierStyleItalic">score</span> y si reclasificara de forma significativa a los pacientes&#44; pero por la N baja el c&#225;lculo no se llev&#243; a cabo&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Resultados</span><p id="par0090" class="elsevierStylePara elsevierViewall">En el periodo de estudio se identificaron 236 pacientes con diagn&#243;stico de EP&#44; de los cuales 118 &#40;50&#37;&#41; quedaron excluidos por&#58; fallecimiento&#44; embarazo&#44; diagn&#243;stico de EP por gammagraf&#237;a&#44; tener criterios de paciente paliativo&#44; deterioro cognitivo o problemas psicol&#243;gicos&#46; Otros 19 que se perdieron durante el seguimiento &#40;<a class="elsevierStyleCrossRef" href="#fig0005">fig&#46; 1</a>&#41;&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0095" class="elsevierStylePara elsevierViewall">Noventa y nueve pacientes con EP cumplieron nuestros criterios de inclusi&#243;n&#46; De ellos&#44; 48 &#40;48&#37;&#41; eran varones&#44; la edad media fue de 61&#44;5 a&#241;os &#40;20-86&#41; y el 14&#37; ten&#237;a antecedentes de enfermedad tromboemb&#243;lica y neoplasia&#46; La presencia de otras comorbilidades &#40;valvulopat&#237;as&#44; conectivopat&#237;as&#44; hipertensi&#243;n portal&#44; VIH&#8230;&#41; fue poco frecuente &#40;<a class="elsevierStyleCrossRef" href="#tbl0010">tabla 2</a>&#41;&#46; El 16&#37; de los sujetos presentaron alg&#250;n tipo de trombofilia&#46; La forma de presentaci&#243;n m&#225;s frecuente fue la disnea y el dolor tor&#225;cico&#46; Al diagn&#243;stico un 24&#37; de los pacientes presentaba disfunci&#243;n del ventr&#237;culo derecho&#44; aunque solo el 4&#37; precisaron terapia de reperfusi&#243;n&#46;</p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><p id="par0100" class="elsevierStylePara elsevierViewall">A los 99 pacientes se les aplic&#243; el algoritmo del InShape II con los datos cl&#237;nicos&#44; anal&#237;ticos&#44; del ECG y ecocardiograma que dispon&#237;amos a los 3 meses &#40;media de tiempo hasta la evaluaci&#243;n en d&#237;as&#44; 95&#44; mediana&#58; 100&#59; rango&#58; 60-145&#41;&#46; Treinta y ocho pacientes ten&#237;an una puntuaci&#243;n &#8805;<span class="elsevierStyleHsp" style=""></span>6&#44; 32 ten&#237;an disnea&#44; edemas&#44; palpitaciones o dolor tor&#225;cico y 19 ten&#237;an alteraciones en el proBNP o el ECG&#46;</p><p id="par0105" class="elsevierStylePara elsevierViewall">Seg&#250;n el algoritmo 80 pacientes tendr&#237;an bajo riesgo cl&#237;nico de HTPEC y&#44; por tanto&#44; no precisar&#237;an realizar ecocardiograma&#44; ya que presentaron una puntuaci&#243;n menor de 6 o ausencia de s&#237;ntomas&#44; o ausencia alteraciones en el proBNP o ECG&#46; Sin embargo&#44; de estos pacientes&#44; 2 ten&#237;an un ecocardiograma con probabilidad intermedia&#47;alta de HTPEC&#44; por lo que se deben considerar &#171;falsos negativos&#187;&#46; De estos dos casos en uno se realiz&#243; TAC de t&#243;rax de control sin lesi&#243;n tromb&#243;tica residual por lo que se descart&#243; HPTEC y no se realiz&#243; cateterismo&#46; En el otro caso se asumi&#243; que la HTP estaba asociada a patolog&#237;a neumol&#243;gica&#44; ya que se trataba de un paciente mayor&#44; con comorbilidad y un s&#237;ndrome de apnea del sue&#241;o con oxigeno domiciliario previo a la EP y una EP segmentaria&#44; por lo que no se hizo cateterismo&#46;</p><p id="par0110" class="elsevierStylePara elsevierViewall">Frente a ellos&#44; 19 pacientes ser&#237;an susceptibles realizarse un ecocardiograma&#44; por tener alto riesgo cl&#237;nico de HPTEC&#46; En el ecocardiograma de estos pacientes 3 tuvieron probabilidad intermedia&#47;alta de HPTEC por lo que 16 ser&#237;an falsos positivos&#46; Una paciente ten&#237;a una gammagraf&#237;a positiva por lo que se hizo cateterismo en el que presentaba PAP de 24<span class="elsevierStyleHsp" style=""></span>mmHg&#46; En los otros 2 casos no se hizo cateterismo&#58; una paciente ten&#237;a una neumectom&#237;a previa que podr&#237;a explicar la HTP y la otra paciente ten&#237;a una gammagraf&#237;a normal que descartaba HPTEC &#40;<a class="elsevierStyleCrossRef" href="#fig0010">fig&#46; 2</a>&#41;&#46;</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0115" class="elsevierStylePara elsevierViewall">De los 5 pacientes &#40;5&#44;05&#37;&#41; con probabilidad intermedia&#47;alta de hipertensi&#243;n pulmonar en la ecocardiograf&#237;a&#44; la edad media era m&#225;s alta que los que ten&#237;an riesgo bajo &#40;77 vs&#46; 61&#41;&#44; con m&#225;s frecuencia del sexo femenino &#40;100 vs&#46; 51&#37;&#41;&#44; y con mucha mayor frecuencia presentaron datos sugerentes de hipertensi&#243;n arterial pulmonar al diagn&#243;stico &#40;80 vs&#46; 22&#37;&#41;&#46;</p><p id="par0120" class="elsevierStylePara elsevierViewall">Por lo tanto&#44; en nuestra serie el algoritmo tiene una sensibilidad de un 60&#37; y un valor predictivo positivo del 15&#44;8&#37; con una especificidad de un 83&#37; y un valor predictivo negativo del 97&#44;5&#37;&#46; En la <a class="elsevierStyleCrossRef" href="#fig0015">figura 3</a> se muestra la curva ROC que describe la capacidad discriminativa del algoritmo en estudio&#44; con un &#225;rea bajo la curva de 0&#44;715 &#40;IC 95&#37;&#58; 0&#44;472-0&#44;958&#41;&#46;</p><elsevierMultimedia ident="fig0015"></elsevierMultimedia></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Discusi&#243;n</span><p id="par0125" class="elsevierStylePara elsevierViewall">Seg&#250;n los resultados de nuestra serie&#44; el algoritmo propuesto en el estudio InShape II muestra un buen valor predictivo negativo bajo la premisa de una baja prevalencia de HPTEC como la observada en nuestra muestra&#46;</p><p id="par0130" class="elsevierStylePara elsevierViewall">Nuestros pacientes son de similares caracter&#237;sticas a los del estudio In Shape II en cuanto a sexo&#44; edad y comorbilidades&#44; como enfermedad pulmonar y conectivopat&#237;as&#44; y difieren&#44; en que en nuestra serie hab&#237;a m&#225;s pacientes que ten&#237;an enfermedad neopl&#225;sica &#40;14 vs&#46; 7&#44;8&#37; en el InShape II&#41;&#46;</p><p id="par0135" class="elsevierStylePara elsevierViewall">De los 99 pacientes&#44; 3 ten&#237;an una probabilidad intermedia&#47;alta seg&#250;n los resultados del ecocardiograma&#44; mientras que en 2 casos no hubieran sido detectados si hubi&#233;ramos seguido estrictamente las indicaciones del protocolo InShape II&#46; Por ello nuestra sensibilidad es de un 60&#37;&#44; por debajo de la publicada por los autores que alcanzaba un 81&#37;&#46;</p><p id="par0140" class="elsevierStylePara elsevierViewall">En nuestra muestra&#44; el valor predictivo negativo &#40;VPN&#41; fue del 97&#44;5&#37;&#44; teniendo en cuenta una muy baja prevalencia de HPTEC&#46; Por tanto&#44; en contextos de prevalencia similar a la de nuestra serie&#44; el algoritmo podr&#237;a ser v&#225;lido&#44; ya que supondr&#237;a evitar la realizaci&#243;n del 80&#37; de ecocardiogramas&#46; De los 19 ecocardiogramas que se habr&#237;an realizado siguiendo estrictamente el algoritmo&#44; solo en 3 la probabilidad fue intermedia&#47;alta&#44; lo que indica que existe un n&#250;mero considerable de falsos positivos que lleva a realizar pruebas adicionales para descartar HPTEC&#46; Sin embargo&#44; sin ning&#250;n algoritmo de cribado este n&#250;mero ser&#237;a mucho mayor<a class="elsevierStyleCrossRefs" href="#bib0160"><span class="elsevierStyleSup">14&#44;15</span></a>&#44; por lo cual&#44; a falta de un algoritmo mejor&#44; consideramos que el algoritmo propuesto por Boon et al&#46;<a class="elsevierStyleCrossRef" href="#bib0155"><span class="elsevierStyleSup">13</span></a> puede ayudar a tomar las decisiones sobre a qu&#233; pacientes se debe continuar el estudio&#46;</p><p id="par0145" class="elsevierStylePara elsevierViewall">Nuestros pacientes con probabilidad ecocardiogr&#225;fica intermedia&#47;alta de HPTEC son mayores y todos son mujeres&#44; algo ya descrito en otros estudios como factores de riesgo de peor grado funcional tras la EP<a class="elsevierStyleCrossRefs" href="#bib0170"><span class="elsevierStyleSup">16&#44;17</span></a>&#46; Adem&#225;s&#44; los 2 pacientes con probabilidad intermedia&#47;alta no identificados por el algoritmo de cribado ten&#237;an HTP en el momento agudo&#44; lo que ha sido descrito como un factor de riesgo de HPTEC<a class="elsevierStyleCrossRef" href="#bib0180"><span class="elsevierStyleSup">18</span></a>&#46; Si hubi&#233;ramos incluido este criterio como uno de los que hay que tener en cuenta a la hora de hacer ecocardiograma de control&#44; no habr&#237;amos pasado por alto ning&#250;n paciente&#46;</p><p id="par0150" class="elsevierStylePara elsevierViewall">Nuestro trabajo tiene algunas limitaciones&#46; Se trata de un estudio retrospectivo&#44; con los sesgos que esto implica&#44; con un n&#250;mero reducido de enfermos&#44; y realizado en un &#250;nico hospital&#46; Sin embargo&#44; dicha limitaci&#243;n puede verse balanceada por la fortaleza que ofrece el seguimiento completo de casi un centenar de pacientes durante un a&#241;o&#44; con un protocolo exhaustivo de estudio&#44; hecho por un grupo reducido de m&#233;dicos expertos en esta enfermedad&#46;</p><p id="par0155" class="elsevierStylePara elsevierViewall">Nuestros resultados respaldan la utilidad del algoritmo propuesto en el estudio InShape II<a class="elsevierStyleCrossRef" href="#bib0155"><span class="elsevierStyleSup">13</span></a> como una herramienta valiosa&#44; aunque no exclusiva&#44; en el cribado inicial de HPTEC&#46; Se confirma que logra evitar la realizaci&#243;n de m&#250;ltiples ecocardiogramas&#46; A la luz de nuestros hallazgos&#44; sugerimos que incorporar el dato de HTP en el ecocardiograma en fase aguda como criterio para la realizaci&#243;n del cribado aumentar&#237;a la sensibilidad del algoritmo&#46; Ser&#237;an necesarios estudios prospectivos para confirmar esta teor&#237;a&#46;</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Financiaci&#243;n</span><p id="par0160" class="elsevierStylePara elsevierViewall">La presente investigaci&#243;n no ha recibido ayudas espec&#237;ficas provenientes de agencias del sector p&#250;blico&#44; sector comercial o entidades sin &#225;nimo de lucro&#46;</p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">Conflicto de intereses</span><p id="par0165" class="elsevierStylePara elsevierViewall">Los autores declaran no tener ning&#250;n conflicto de intereses&#46;</p></span></span>"
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          "titulo" => "Validaci&#243;n escala"
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          "titulo" => "An&#225;lisis estad&#237;stico"
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            0 => "Ecocardiograf&#237;a"
            1 => "Hipertensi&#243;n pulmonar"
            2 => "Embolismo pulmonar"
            3 => "Disfunci&#243;n ventricular"
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            0 => "Echocardiography"
            1 => "Pulmonary hypertension"
            2 => "Pulmonary embolism"
            3 => "Ventricular dysfunction"
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        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Antecedentes y objetivo</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">La complicaci&#243;n a largo plazo m&#225;s grave del embolismo pulmonar &#40;EP&#41; es la hipertensi&#243;n pulmonar tromboemb&#243;lica cr&#243;nica &#40;HPTEC&#41;&#44; cuyo diagn&#243;stico precoz implica la realizaci&#243;n de un gran n&#250;mero pruebas&#46; El estudio InShape II propone un algoritmo de cribado precoz que pretende disminuir el n&#250;mero de estudios ecocardiogr&#225;ficos&#46; El objetivo de nuestro estudio es validar este algoritmo en nuestra cohorte de pacientes&#46;</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Material y m&#233;todos</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Se analizaron retrospectivamente los pacientes ingresados con diagn&#243;stico de EP por angio-TC&#44; en el Hospital Rey Juan Carlos entre noviembre del 2017 y febrero del 2020&#44; seguidos durante al menos un a&#241;o&#46; Se recogieron datos cl&#237;nicos&#44; anal&#237;ticos&#44; y pruebas complementarias a los 3 meses y al a&#241;o&#46; Se aplic&#243; a estos pacientes el algoritmo del estudio InShape II para validar sus resultados&#46;</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Resultados</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">En el periodo de estudio fueron diagnosticados de EP 236 pacientes&#44; de los cuales 137 fueron excluidos&#46; Se valid&#243; el algoritmo en 99 pacientes&#46; Aplicando el <span class="elsevierStyleItalic">score</span> del InShape II hubi&#233;ramos realizado 19 ecocardiogramas &#40;3 de ellos con probabilidad intermedia&#47;alta de HPTEC&#41; y no se hubieran hecho en 80 &#40;2 de ellos con probabilidad intermedia&#47;alta&#41;&#44; por lo que se estableci&#243; una sensibilidad del <span class="elsevierStyleItalic">score</span> de un 60&#37;&#44; con una especificidad de un 83&#37;&#44; y un &#225;rea bajo la curva &#40;AUC&#41; de 0&#44;715 &#40;IC 95&#37;&#58; 0&#44;472-0&#44;958&#41;&#46;</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Conclusiones</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Nuestros resultados apoyan que el algoritmo del estudio InShape II podr&#237;a ser una herramienta &#250;til en el cribado inicial del estudio de HPTEC en entornos de baja incidencia&#44; ya que evitar&#237;a la realizaci&#243;n de ecocardiogramas que no aportan valor&#46;</p></span>"
        "secciones" => array:4 [
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        "resumen" => "<span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Background and aim</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">The most severe long-term complication of pulmonary embolism &#40;PE&#41; is chronic thromboembolic pulmonary hypertension &#40;CTEPH&#41;&#44; and its early diagnosis often requires numerous diagnostic tests&#46; The InShape II study proposes an early screening algorithm that aims to reduce the number of echocardiographic studies&#46; The objective of our study is to validate this algorithm in our patient cohort&#46;</p></span> <span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Materials and methods</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">We retrospectively analyzed patients admitted to Hospital Rey Juan Carlos between November 2017 and February 2020&#44; who were diagnosed with PE based on computed tomography angiography &#40;CTA&#41;&#46; Patients were followed for at least one year&#44; and clinical&#44; laboratory&#44; and complementary test data were collected at three months and one year&#46; The InShape II algorithm was applied to these patients to validate its results&#46;</p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Results</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">During the study period&#44; 236 patients were diagnosed with PE&#44; of which 137 were excluded&#46; The algorithm was validated in 99 patients&#46; Applying the InShape II score&#44; 19 echocardiograms would have been performed &#40;three of them with intermediate-high probability of CTEPH&#41;&#44; while 80 echocardiograms would have been avoided &#40;two of them with intermediate-high probability&#41;&#46; This yielded a sensitivity of 60&#37; and a specificity of 83&#37; for the score&#44; with an area under the curve &#40;AUC&#41; of 0&#46;715 &#40;95&#37; CI&#58; 0&#46;472-0&#46;958&#41;&#46;</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Conclusions</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">Our results support the notion that the InShape II algorithm could be a useful tool for initial screening of CTEPH in low-incidence settings&#44; as it would avoid unnecessary echocardiograms that do not provide additional value&#46;</p></span>"
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          "es" => "<p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">Curva ROC para el cribado de ETT con riesgo intermedio&#47;alto de HTPEC con algoritmo InShape II&#46;</p> <p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">AUC&#58; 0&#44;715 &#40;0&#44;472-0&#44;958&#41;&#59; error est&#225;ndar 0&#44;124&#46; AUC&#58; &#225;rea bajo la curva&#46;</p>"
        ]
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          "leyenda" => "<p id="spar0070" class="elsevierStyleSimplePara elsevierViewall">TC&#58; tomograf&#237;a computarizada&#59; TEP&#58; tromboembolismo pulmonar&#59; VD&#58; ventr&#237;culo derecho&#46;</p><p id="spar0075" class="elsevierStyleSimplePara elsevierViewall">Punto de corte&#58; &#8804;<span class="elsevierStyleHsp" style=""></span>6 bajo riesgo&#44; &#8805;<span class="elsevierStyleHsp" style=""></span>6 alto riesgo&#46;</p>"
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                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">&#43;6 puntos&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">Hipotiroidismo conocido&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">&#43;3 puntos&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">Retraso en el diagn&#243;stico de 2 semanas&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">&#43;3 puntos&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">Disfunci&#243;n de Vd por ecocardiograma o TC al diagn&#243;stico&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">&#43;2 puntos&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">Diabetes conocida&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">&#8722;3 puntos&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">Terapia trombol&#237;tica o embolectom&#237;a para el TEP agudo&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">&#8722;3 puntos&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
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          "es" => "<p id="spar0065" class="elsevierStyleSimplePara elsevierViewall"><span class="elsevierStyleItalic">Score</span> de predicci&#243;n de HPTEC</p>"
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      ]
      4 => array:8 [
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        "etiqueta" => "Tabla 2"
        "tipo" => "MULTIMEDIATABLA"
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          0 => array:3 [
            "identificador" => "at2"
            "detalle" => "Tabla "
            "rol" => "short"
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          "leyenda" => "<p id="spar0085" class="elsevierStyleSimplePara elsevierViewall">ETEV&#58; enfermedad tromboemb&#243;lica venosa&#59; HTP&#58; hipertensi&#243;n pulmonar&#59; SD&#58; <span class="elsevierStyleItalic">standard deviation&#59;</span> UCI&#58; unidad de cuidados intensivos&#59; VD&#58; ventr&#237;culo derecho&#46;</p>"
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            0 => array:2 [
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                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Sin HTP &#40;94&#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">Con HTP &#40;5&#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">Valor de p&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="elsevierStyleItalic">Edad &#40;a&#241;os&#41;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">60&#44;7<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>17&#44;8&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">76&#44;8<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>10&#44;2&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;04&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="elsevierStyleItalic">G&#233;nero &#40;n&#44; var&#243;n&#41;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">48&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&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;03&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="elsevierStyleItalic">Fumador &#40;n&#41;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">13&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&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;63&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="elsevierStyleItalic">Estancia media &#40;d&#237;as&#44; &#177;</span><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">SD&#41;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">8&#44;1<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>10&#44;3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">6&#44;4<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>1&#44;8&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;94&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="elsevierStyleItalic">Peso &#40;kg&#44; &#177;</span><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">SD&#41;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">83&#44;01<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>17&#44;8&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">76&#44;6<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>16&#44;1&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;39&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="elsevierStyleItalic">Talla &#40;cm&#44; &#177;</span><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">SD&#41;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">166&#44;1<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>9&#44;5&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">157&#44;8<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>8&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;06&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="elsevierStyleItalic">ETEV previa &#40;n&#41;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">13&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&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;34&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="elsevierStyleItalic">Valvulopat&#237;a &#40;n&#41;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&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&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;82&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="elsevierStyleItalic">Conectivopat&#237;a &#40;n&#41;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">4&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&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;64&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="elsevierStyleItalic">Hipertensi&#243;n portal&#40;n&#41;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&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&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 ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleItalic">Neoplasia &#40;n&#41;</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">13&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleItalic">VIH &#40;n&#41;</span>&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 ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleItalic">Enfermedad pulmonar &#40;n&#41;</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">11&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">2&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="elsevierStyleItalic">Antecedentes familiares ETEV &#40;n&#41;</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">1&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">1&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">0&#44;58&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="elsevierStyleItalic">Filtrado glomerular &#40;mL&#47;min&#47;1&#44;73</span><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">m</span><span class="elsevierStyleSup"><span class="elsevierStyleItalic">2</span></span><span class="elsevierStyleItalic">&#44; &#177;</span><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">SD&#41;</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">77&#44;5<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>14&#44;3&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;64&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="elsevierStyleItalic">Hemoglobina &#40;g&#47;dL&#44; &#177;</span><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">SD&#41;</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">0&#44;26&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="elsevierStyleItalic">NT-ProBNP &#40;pg&#47;mL&#44; &#177;</span><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">SD&#41;</span>&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">869<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>2300&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">500&#44;8<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>539&#44;4&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;66&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="elsevierStyleItalic">Troponina &#40;ng&#47;mL&#44; &#177;</span><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">SD&#41;</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#44;345<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>1&#44;98&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;13&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="elsevierStyleItalic">Trombofilia &#40;n&#41;</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t">15&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">1&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">0&#44;81&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="elsevierStyleItalic">Presentaci&#243;n s&#237;ntomas &#40;n&#41;</span>&nbsp;\t\t\t\t\t\t\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  " align="left" valign="\n
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                  \t\t\t\t">0&#44;65&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>Asintom&#225;tico&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">6&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</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>Agudo&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">61&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">3&nbsp;\t\t\t\t\t\t\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>Subagudo&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">19&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">2&nbsp;\t\t\t\t\t\t\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></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>Cr&#243;nico&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">8&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
                  \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="elsevierStyleItalic">S&#237;ntomas &#40;n&#41;</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" 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="" valign="\n
                  \t\t\t\t\ttop\n
                  \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">0&#44;14&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>Disnea&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">43&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">5&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>Dolor tor&#225;cico&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">25&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
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">9&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"><span class="elsevierStyleHsp" style=""></span>Otros&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">16&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="elsevierStyleItalic">Ingreso en la UCI &#40;n&#41;</span>&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">28&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">1&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">23&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">Score <span class="elsevierStyleItalic">InShape &#40;media&#44; &#177;</span><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">SD&#41;</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">3&#44;4<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>3&#44;6&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">4&#44;4<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>4&#44;2&nbsp;\t\t\t\t\t\t\n
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                          "etal" => true
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                            0 => "J&#46; De Miguel-Diez"
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                            3 => "M&#46; Monreal"
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                            0 => "F&#46;A&#46; Klok"
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                            2 => "P&#46;L&#46; den Exter"
                            3 => "M&#46; Lankeit"
                            4 => "M&#46;V&#46; Huisman"
                            5 => "S&#46; Konstantinides"
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                    0 => array:2 [
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                            0 => "K&#46;D&#46; Fabyan"
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                    0 => array:2 [
                      "doi" => "10.1097/MCP.0000000000000789"
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                        "tituloSerie" => "Curr Opin Pulm Med"
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