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          "es" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Diagrama de inclusi&#243;n y clasificaci&#243;n de los pacientes con insuficiencia cardiaca aguda seg&#250;n tuviesen o no el diagn&#243;stico previo de enfermedad pulmonar obstructiva cr&#243;nica&#46;</p>"
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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Introducci&#243;n</span><p id="par0005" class="elsevierStylePara elsevierViewall">La insuficiencia cardiaca aguda &#40;ICA&#41; es una entidad compleja que ha recibido escasa atenci&#243;n en cuanto a la concordancia entre las concepciones actuales de manejo descritas en las gu&#237;as<a class="elsevierStyleCrossRef" href="#bib0245"><span class="elsevierStyleSup">1</span></a> y las pautas reales de tratamiento&#46; En consecuencia&#44; las gu&#237;as de manejo describen habitualmente la evoluci&#243;n natural y el tratamiento desde la perspectiva de una &#250;nica enfermedad<a class="elsevierStyleCrossRefs" href="#bib0245"><span class="elsevierStyleSup">1&#8211;3</span></a>&#46; Adem&#225;s&#44; los registros de ICA<a class="elsevierStyleCrossRefs" href="#bib0260"><span class="elsevierStyleSup">4&#44;5</span></a> han descrito habitualmente el uso de agentes cardiovasculares sin informar del uso de farmacoterapias no cardiacas&#46; Sin embargo&#44; los pacientes con ICA en los servicios de urgencias hospitalarios &#40;SUH&#41; en la pr&#225;ctica real son complejos&#44; y su tratamiento puede superar las categor&#237;as tradicionales debido a la incertidumbre diagn&#243;stica o a la coexistencia de diferentes enfermedades cr&#243;nicas o agudas<a class="elsevierStyleCrossRefs" href="#bib0485"><span class="elsevierStyleSup">6&#44;7</span></a>&#46; En los &#250;ltimos a&#241;os se ha prestado cada vez m&#225;s atenci&#243;n a comprender la superposici&#243;n de las enfermedades cardiacas y pulmonares&#46; Se ha demostrado que las enfermedades pulmonares y cardiacas cr&#243;nicas est&#225;n estrechamente relacionadas&#44; ya que la obstrucci&#243;n cr&#243;nica del flujo a&#233;reo puede alterar el llenado ventricular izquierdo&#44; el volumen sist&#243;lico y el gasto cardiaco<a class="elsevierStyleCrossRef" href="#bib0485"><span class="elsevierStyleSup">6</span></a>&#46; Adem&#225;s&#44; la extensi&#243;n de la enfermedad arterial pulmonar predice tanto la funci&#243;n ventricular derecha como las exacerbaciones de la enfermedad pulmonar obstructiva cr&#243;nica &#40;EPOC&#41;<a class="elsevierStyleCrossRef" href="#bib0275"><span class="elsevierStyleSup">7</span></a>&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">En este sentido&#44; la EPOC presenta un progresivo aumento de su prevalencia y la OMS considera que ser&#225; la tercera causa de mortalidad en el mundo para el 2030<a class="elsevierStyleCrossRef" href="#bib0280"><span class="elsevierStyleSup">8</span></a>&#46; Un gran porcentaje de los pacientes con EPOC experimentan concomitantemente insuficiencia cardiaca &#40;IC&#41;&#44; probablemente en parte debido a que comparten el consumo de tabaco como factor de riesgo com&#250;n<a class="elsevierStyleCrossRefs" href="#bib0285"><span class="elsevierStyleSup">9&#44;10</span></a>&#46; La prevalencia estimada de EPOC en los individuos con IC se encuentra entre el 20 y 32&#37; de los casos<a class="elsevierStyleCrossRef" href="#bib0295"><span class="elsevierStyleSup">11</span></a>&#44; y la coexistencia de estas enfermedades les confiere un mayor riesgo de morbimortalidad a largo plazo<a class="elsevierStyleCrossRefs" href="#bib0290"><span class="elsevierStyleSup">10&#44;12</span></a> Sin embargo&#44; el efecto que tiene la EPOC en el pron&#243;stico a corto plazo de las descompensaciones de los pacientes con IC es mucho menos conocido&#46; Uno de los obst&#225;culos m&#225;s grandes es que la descompensaci&#243;n tanto de la EPOC como de la IC se manifiesta como disnea en el paciente<a class="elsevierStyleCrossRefs" href="#bib0305"><span class="elsevierStyleSup">13&#44;14</span></a>&#44; y es por tanto muy importante distinguir ambas enfermedades a la hora de tratar al paciente&#46; Sin embargo&#44; hay pocos estudios prospectivos y ensayos cl&#237;nicos aleatorizados que aborden el tratamiento combinado de los pacientes con EPOC e IC en fase cr&#243;nica&#44; y menos a&#250;n estudios que eval&#250;en en pacientes con ICA<a class="elsevierStyleCrossRefs" href="#bib0290"><span class="elsevierStyleSup">10&#44;15&#8211;17</span></a> el tratamiento concomitante con terapias respiratorias agudas &#40;beta-2-agonistas inhalados o nebulizados&#44; anticolin&#233;rgicos&#44; corticoides sist&#233;micos o antibi&#243;ticos&#41; que reciben en los SUH&#46; Este tratamiento concomitante puede ser frecuente en la pr&#225;ctica habitual&#44; ya que los s&#237;ntomas y signos de la ICA suelen ser inespec&#237;ficos<a class="elsevierStyleCrossRef" href="#bib0310"><span class="elsevierStyleSup">14</span></a> y coinciden con afecciones respiratorias agudas y cr&#243;nicas comunes que tambi&#233;n se presentan con frecuencia<a class="elsevierStyleCrossRef" href="#bib0300"><span class="elsevierStyleSup">12</span></a>&#46; Adem&#225;s&#44; no existen hallazgos patognom&#243;nicos ni pruebas diagn&#243;sticas que diferencien la ICA de las afecciones respiratorias agudas comunes&#44; lo que puede contribuir con frecuencia a la incertidumbre en el diagn&#243;stico<a class="elsevierStyleCrossRef" href="#bib0285"><span class="elsevierStyleSup">9</span></a>&#46; El objetivo de este estudio es analizar si los pacientes con IC y EPOC presentan diferencias cl&#237;nicas y de manejo terap&#233;utico en urgencias cuando desarrollan un episodio de ICA y analizar la mortalidad precoz durante dicha descompensaci&#243;n&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">M&#233;todo</span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Dise&#241;o del estudio</span><p id="par0015" class="elsevierStylePara elsevierViewall">El presente estudio es un an&#225;lisis secundario del Registro EAHFE <span class="elsevierStyleItalic">&#40;Epidemiology of Acute Heart Failure in Emergency departments&#41;</span>&#44; el cual es un registro multic&#233;ntrico&#44; multiprop&#243;sito&#44; anal&#237;tico no intervencionista&#44; con seguimiento prospectivo y que incluye de forma consecutiva a los pacientes que acuden por episodio de ICA al SUH&#46; Hasta la fecha se han realizado 8 fases de reclutamiento &#40;en los a&#241;os 2007&#44; 2009&#44; 2011&#44; 2014&#44; 2016&#44; 2018&#44; 2019 y 2022&#41; en un total de 53 SUH espa&#241;oles y contiene 24&#46;248 episodios &#250;nicos de ICA&#46; Los detalles y caracter&#237;sticas de estos pacientes ya han sido previamente publicados<a class="elsevierStyleCrossRefs" href="#bib0260"><span class="elsevierStyleSup">4&#44;18</span></a>&#46; La inclusi&#243;n de pacientes con ICA en el registro EAHFE se basa en el cumplimiento de los criterios cl&#237;nicos de Framingham<a class="elsevierStyleCrossRef" href="#bib0335"><span class="elsevierStyleSup">19</span></a> y confirmaci&#243;n con p&#233;ptidos natriur&#233;ticos o ecocardiograf&#237;a<a class="elsevierStyleCrossRefs" href="#bib0245"><span class="elsevierStyleSup">1&#8211;3</span></a>&#46; El &#250;nico criterio de exclusi&#243;n para ser incluido en el Registro EAHFE es la presencia concomitante de un s&#237;ndrome coronario agudo con elevaci&#243;n del segmento ST e ICA&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">En este estudio se consideraron elegibles todos los pacientes del Registro EAHFE en los cuales se dispon&#237;a de informaci&#243;n del antecedente de EPOC como comorbilidad y del estado vital del paciente tras el episodio agudo &#40;dado de alta vivo o fallecido en urgencias o el hospital&#41;&#46; El diagn&#243;stico de EPOC fue cl&#237;nico y se aceptaba que este exist&#237;a si as&#237; lo relataba el paciente o sus acompa&#241;antes o bien figuraba entre los antecedentes del paciente en la historia cl&#237;nica previa del hospital o de su centro de salud&#46; El estado vital tras el episodio de descompensaci&#243;n se comprob&#243; por la consulta de la historia cl&#237;nica del hospital donde el paciente hab&#237;a sido atendido&#46; Adem&#225;s&#44; el estudio limit&#243; la inclusi&#243;n de pacientes a las fases 3 a 8 del Registro EAHFE&#44; pues en las hojas de recogida de datos figuraban todas las variables independientes que se relatan m&#225;s adelante&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Variables independientes</span><p id="par0025" class="elsevierStylePara elsevierViewall">Se recogieron 19 variables independientes relacionadas con la situaci&#243;n basal del paciente&#58; 2 referentes a datos demogr&#225;ficos &#40;edad&#44; sexo&#41;&#44; 14 comorbilidades &#40;hipertensi&#243;n arterial&#44; dislipidemia&#44; diabetes mellitus&#44; cardiopat&#237;a isqu&#233;mica&#44; episodios previos de ICA&#44; enfermedad renal cr&#243;nica&#44; enfermedad cerebrovascular&#44; fibrilaci&#243;n auricular&#44; valvulopat&#237;a&#44; arteriopat&#237;a perif&#233;rica&#44; EPOC&#44; demencia&#44; neoplasia&#44; cirrosis hep&#225;tica&#41; y 3 de situaci&#243;n funcional &#40;clase funcional de la <span class="elsevierStyleItalic">New York Heart Association</span> &#91;NYHA&#93;&#44; clasificaci&#243;n seg&#250;n la fracci&#243;n de eyecci&#243;n del ventr&#237;culo izquierdo &#91;FEVI&#93; e &#237;ndice de Barthel&#41;&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">En relaci&#243;n con el episodio de descompensaci&#243;n&#44; se recogieron 6 potenciales desencadenantes del episodio &#40;infecci&#243;n&#44; taquiarritmia&#44; anemia&#44; crisis hipertensiva&#44; transgresi&#243;n diet&#233;tico-terap&#233;utica&#44; s&#237;ndrome coronario agudo&#41;&#44; 4 constantes vitales a la llegada a urgencias &#40;presi&#243;n arterial sist&#243;lica&#44; frecuencia cardiaca y respiratoria&#44; pulsioximetr&#237;a&#41;&#44; 4 resultados anal&#237;ticos &#40;creatinina&#44; potasio&#44; NT-proBNP&#44; troponina&#41; y un dato del ECG &#40;hipertrofia ventricular izquierda&#44; siguiendo los criterios de Sokolof&#41;&#46; Se calcul&#243; la gravedad del episodio de descompensaci&#243;n mediante la estratificaci&#243;n del riesgo de los pacientes con la escala MEESSI-AHF <span class="elsevierStyleItalic">&#40;Multiple Estimation of risk based on the Emergency department Spanish Score in Acute Heart Failure&#41;</span>&#44; la cual utiliza 13 variables basales y del episodio para estimar el riesgo de fallecer durante los 30 d&#237;as siguientes a la consulta en urgencias<a class="elsevierStyleCrossRefs" href="#bib0340"><span class="elsevierStyleSup">20&#8211;22</span></a>&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">En relaci&#243;n con el manejo de la descompensaci&#243;n en urgencias&#44; se recogieron 13 tratamientos administrados en urgencias&#44; consistentes en oxigenoterapia&#44; ventilaci&#243;n no invasiva&#44; ventilaci&#243;n invasiva&#44; diur&#233;ticos endovenosos&#44; nitratos endovenosos&#44; inotr&#243;pico o vasopresores endovenosos&#44; morfina subcut&#225;nea o endovenosa&#44; amiodarona&#44; digoxina&#44; morfina&#44; beta-agonistas nebulizados&#44; anticolin&#233;rgicos nebulizados&#44; corticoides sist&#233;micos&#44; antibi&#243;ticos&#41;&#46; Adem&#225;s&#44; se consign&#243; si el paciente precis&#243; hospitalizaci&#243;n&#44; y si dicha hospitalizaci&#243;n fue en una unidad de cuidados intensivos &#40;UCI&#41;&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Variables de resultado</span><p id="par0040" class="elsevierStylePara elsevierViewall">Las variables de resultado que se analizaron fueron la mortalidad &#40;por cualquier causa&#41; intrahospitalaria &#40;independientemente de que se produjese en urgencias o durante la hospitalizaci&#243;n&#41; y a 30 d&#237;as &#40;los cuales se contaron a partir de la consulta del paciente en urgencias&#41;&#46; Para determinar la mortalidad a 30 d&#237;as&#44; se revis&#243; su historia cl&#237;nica electr&#243;nica &#40;del hospital y ambulatoria&#41; en los pacientes dados de alta vivos del evento &#237;ndice y&#44; en caso necesario&#44; se contact&#243; telef&#243;nicamente con el paciente o sus familiares&#46;</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">An&#225;lisis estad&#237;stico</span><p id="par0045" class="elsevierStylePara elsevierViewall">Las variables categ&#243;ricas fueron descritas mediante frecuencias y porcentajes&#46; Las continuas con la mediana y rango intercuartil &#40;RIC&#41;&#46; El an&#225;lisis de distribuci&#243;n de las variables categ&#243;ricas se realiz&#243; con el test de ji-cuadrado&#44; y el de las continuas mediante el test no param&#233;trico de la suma de rangos de Mann-Whitney&#46;</p><p id="par0050" class="elsevierStylePara elsevierViewall">Se investig&#243; si exist&#237;a relaci&#243;n entre la existencia de EPOC y mortalidad mediante modelos de regresi&#243;n log&#237;stica&#44; y el riesgo se expres&#243; como <span class="elsevierStyleItalic">odds ratio</span> &#40;OR&#41; con su intervalo de confianza del 95&#37; &#40;IC 95&#37;&#41;&#46; Esto se hizo de forma bivariable &#40;OR crudas&#41; y mediante un modelo multivariable &#40;m&#233;todo introducir&#41; en el que se incluyeron todas las variables basales&#44; del episodio de descompensaci&#243;n y de manejo en urgencias consideradas en el presente estudio&#46; Para dicho modelo multivariado&#44; se realiz&#243; imputaci&#243;n simple de los valores ausentes en las variables introducidas&#44; utilizando la moda o la mediana seg&#250;n la variable fuese cualitativa o cuantitativa&#46;</p><p id="par0055" class="elsevierStylePara elsevierViewall">En todas las comparaciones&#44; se acept&#243; que las diferencias eran estad&#237;sticamente significativas si el valor de p era inferior a 0&#44;05&#44; o si el IC 95&#37; de la OR exclu&#237;a el valor 1&#46; El an&#225;lisis estad&#237;stico se realiz&#243; con el programa SPSS versi&#243;n 29&#46;0 para Windows &#40;IBM Corp&#46; Released 2016&#46; IBM SPSS Statistics for Windows&#44; Version 24&#46;0&#46; Armonk&#44; NY&#44; EE&#46;UU&#46;&#41;&#46;</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Aspectos &#233;ticos</span><p id="par0060" class="elsevierStylePara elsevierViewall">Se siguieron los principios &#233;ticos de la Declaraci&#243;n de Helsinki sobre investigaci&#243;n en humanos&#44; y se solicit&#243; el consentimiento informado a todos los pacientes para participar en el estudio&#46; El protocolo fue aprobado por los Comit&#233;s de &#201;tica e Investigaci&#243;n Cl&#237;nica del Hospital Universitario Central de Asturias &#40;protocolos 69&#47;2011&#44; 166&#47;2013&#44; 160&#47;2015&#44; 205&#47;2017&#44; 015&#47;2022&#41; y del Hospital Cl&#237;nic de Barcelona &#40;2018&#47;0233&#41; como comit&#233;s principales y por los del resto de los centros participantes&#46;</p></span></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">Resultados</span><p id="par0065" class="elsevierStylePara elsevierViewall">Los pacientes recogidos en los registros EAHFE 3 a 8 &#40;del a&#241;o 2012 al 2022&#41; fueron 21&#46;817&#44; de los cuales se analizaron 21&#46;694 pacientes con ICA&#44; ya que se excluyeron 109 pacientes por no recogerse la existencia de diagn&#243;stico previo de EPOC y 14 por desconocerse su estado vital &#40;<a class="elsevierStyleCrossRef" href="#fig0005">fig&#46; 1</a>&#41;&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0070" class="elsevierStylePara elsevierViewall">De los pacientes incluidos&#44; la mediana de edad fue de 83 a&#241;os &#40;RIC&#58; 76-88&#41;&#44; el 56&#37; eran mujeres y 4&#46;942 &#40;23&#37;&#41; ten&#237;an el diagn&#243;stico previo de EPOC&#46; Estos pacientes con EPOC eran m&#225;s j&#243;venes que los pacientes sin EPOC &#40;82 frente a 84 a&#241;os&#44; p<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#44;001&#41;&#44; eran m&#225;s frecuentemente varones &#40;63&#44;9 frente a 38&#44;4&#37;&#44; p<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#44;001&#41;&#44; con m&#225;s comorbilidades &#40;con excepci&#243;n de valvulopat&#237;a y demencia&#44; m&#225;s frecuentes en pacientes no EPOC&#41;&#44; peor clase funcional de la NYHA &#40;28&#44;7&#37; con grado III-IV frente a 22&#44;5&#37;&#41; y mejor capacidad funcional global &#40;&#237;ndice de Barthel menor de 60 puntos&#58; 16&#44;4&#37; frente a 19&#44;9&#37;&#41; &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">tabla 1</a>&#41;&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0075" class="elsevierStylePara elsevierViewall">En relaci&#243;n con las caracter&#237;sticas de la descompensaci&#243;n de la IC en los pacientes EPOC &#40;<a class="elsevierStyleCrossRef" href="#tbl0010">tabla 2</a>&#41;&#44; esta estuvo m&#225;s frecuentemente desencadenada por una infecci&#243;n &#40;49&#44;1 frente a 36&#37;&#44; p<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#44;001&#41; y menos frecuentemente por taquiarritmia &#40;11&#44;7 frente a 16&#37;&#44; p<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#44;001&#41;&#44; crisis hipertensiva o s&#237;ndrome coronario agudo&#46; Aunque hubo m&#250;ltiples diferencias en los hallazgos cl&#237;nicos en urgencias &#40;principalmente mayor presencia de disnea de reposo &#40;48&#44;1 frente a 42&#44;4&#37;&#44; p<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#44;001&#41;&#44; menor saturaci&#243;n de ox&#237;geno &#40;93&#37;&#44; RIC 89-96 frente a 94&#37;&#44; RIC 91-97&#41; y mayor frecuencia respiratoria en los pacientes con EPOC&#44; la gravedad estimada mediante la Escala MEESSI-AHF fue similar en ambos grupos &#40;riesgo alto y muy alto&#58; 19&#44;8 frente a 20&#44;5&#37;&#44; p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;41&#41;&#46;</p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><p id="par0080" class="elsevierStylePara elsevierViewall">Los tratamientos administrados en urgencias se recogen en la <a class="elsevierStyleCrossRef" href="#tbl0015">tabla 3</a>&#46; Los pacientes con EPOC recibieron m&#225;s oxigenoterapia&#44; ventilaci&#243;n no invasiva &#40;VNI&#44; 9 frente a 6&#37;&#44; p<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#44;001&#41;&#44; broncodilatadores&#44; beta-agonistas nebulizados &#40;41 frente a 17&#44;6&#37;&#44; p<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#44;001&#41;&#44; anticolin&#233;rgicos nebulizados &#40;31&#44;3 frente a 20&#44;8&#37;&#44; p<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#44;001&#41;&#44; corticoides sist&#233;micos &#40;30&#44;6 frente a 14&#44;4&#37;&#44; p<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#44;001&#41; y antibi&#243;ticos &#40;48&#44;6 frente a 22&#44;8&#37;&#44; p<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#44;001&#41;&#46; En cambio&#44; recibieron con menor frecuencia nitroglicerina endovenosa&#46; De forma remarcable&#44; la frecuencia de uso de f&#225;rmacos relacionados con la ICA &#40;diur&#233;ticos&#44; vasoconstrictores e inotropos&#44; digoxina&#44; amiodarona&#44; morfina&#41; fue similar en ambos grupos&#46; La hospitalizaci&#243;n fue m&#225;s frecuente en los pacientes con ICA y coexistencia de EPOC &#40;77&#44;0 frente a 73&#44;7&#37;&#44; p<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#44;001&#41;&#46;</p><elsevierMultimedia ident="tbl0015"></elsevierMultimedia><p id="par0085" class="elsevierStylePara elsevierViewall">La mortalidad intrahospitalaria &#40;<a class="elsevierStyleCrossRef" href="#tbl0020">tabla 4</a>&#41; en pacientes con y sin EPOC fue del 8&#44;1&#37; y del 7&#44;5&#37;&#44; respectivamente&#44; sin diferencias significativas entre ambos grupos &#40;OR<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>1&#44;088&#44; IC 95&#37;<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;968-1&#44;224&#41;&#46; Por otro lado&#44; la mortalidad a 30 d&#237;as fue del 11&#44;0&#37; y del 10&#44;0&#37;&#44; y esta mayor mortalidad cruda entre los pacientes con EPOC result&#243; estad&#237;sticamente significativa &#40;OR<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>1&#44;111&#44; IC 95&#37;<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>1&#44;002-1&#44;231&#41;&#46; Sin embargo&#44; tras ajustar por las caracter&#237;sticas cl&#237;nicas&#44; del episodio de descompensaci&#243;n y del manejo en urgencias&#44; no se observaron diferencias significativas para ninguna de estas dos variables de resultado a corto plazo&#44; con unas OR que descendieron a 1&#44;040 &#40;0&#44;905-1&#44;195&#41; y de 1&#44;080 &#40;0&#44;957-1&#44;219&#41;&#44; respectivamente&#44; en el modelo con ajuste total&#46; El an&#225;lisis de la mortalidad a 30 d&#237;as en los modelos de ajuste parcial muestra que las diferencias de presentaci&#243;n cl&#237;nica y del manejo de la descompensaci&#243;n de la ICA corrigen de forma m&#225;s ostensible este incremento de mortalidad cruda que las diferencias en las caracter&#237;sticas basales entre los pacientes con y sin EPOC &#40;<a class="elsevierStyleCrossRef" href="#tbl0020">tabla 4</a>&#41;&#46;</p><elsevierMultimedia ident="tbl0020"></elsevierMultimedia></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0105">Discusi&#243;n</span><p id="par0090" class="elsevierStylePara elsevierViewall">Este estudio aporta 7 hallazgos relevantes en los pacientes con EPOC e ICA&#46; Primero&#44; son m&#225;s j&#243;venes&#44; m&#225;s frecuentemente varones y con m&#225;s comorbilidades&#44; principalmente de car&#225;cter cardiovascular&#46; En segundo lugar&#44; tienen una clase funcional de la NYHA m&#225;s avanzada&#46; Tercero&#44; el factor precipitante de la ICA involucrado m&#225;s com&#250;n son las infecciones&#46; Cuarto&#44; la gravedad del episodio de ICA fue similar en ambos grupos&#46; Quinto&#44; en el manejo terap&#233;utico destaca un mayor uso de VNI&#44; beta-2 agonistas y anticolin&#233;rgicos inhalados-nebulizados&#44; corticoides y antibi&#243;ticos&#46; Sexto&#44; la administraci&#243;n de beta-2 agonistas y anticolin&#233;rgicos inhalados-nebulizados&#44; en pacientes sin EPOC ocurre con frecuencia&#46; S&#233;ptimo&#44; el ingreso hospitalario es mayor en pacientes con EPOC&#44; pero la mortalidad a corto plazo es similar en ambos grupos&#46;</p><p id="par0095" class="elsevierStylePara elsevierViewall">Entre los factores relacionados con el paciente&#44; cabe destacar que la EPOC confiere una peor clase funcional a los pacientes con IC&#44; con mayor grado de disnea basal &#40;28&#44;7&#37; con clase funcional NYHA III-IV frente a 22&#44;5&#37; en IC sin EPOC&#41;&#46; Estos resultados se encuentran en la misma l&#237;nea que los obtenidos por Jacob et al<span class="elsevierStyleItalic">&#46;</span><a class="elsevierStyleCrossRef" href="#bib0320"><span class="elsevierStyleSup">16</span></a>&#44; donde en una poblaci&#243;n de 8089 pacientes con ICA atendidos en urgencias&#44; evidenciaron que un 29&#37; de los pacientes con IC y EPOC ten&#237;an una clase funcional de la NYHA III-IV frente a un 22&#44;9&#37; en pacientes con IC sin EPOC&#46; Por otra parte&#44; Ehteshami-Afshar et al<span class="elsevierStyleItalic">&#46;</span><a class="elsevierStyleCrossRef" href="#bib0290"><span class="elsevierStyleSup">10</span></a>&#44; en pacientes ambulatorios con IC cr&#243;nica&#44; mostraron que los pacientes con ambas enfermedades ten&#237;an peores s&#237;ntomas &#40;NYHA III&#47;IV 37&#37; frente a 23&#37;&#59; p<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#44;001&#41; y por ello peor calidad de vida&#44; a pesar de similar fracci&#243;n de eyecci&#243;n&#46;</p><p id="par0100" class="elsevierStylePara elsevierViewall">Tambi&#233;n se evidencia que existe una mayor comorbilidad cardiovascular &#40;enfermedad renal cr&#243;nica&#44; enfermedad arterial perif&#233;rica&#44; insuficiencia cardiaca previa&#44; fibrilaci&#243;n auricular&#41; similar a lo publicado por otros autores<a class="elsevierStyleCrossRefs" href="#bib0320"><span class="elsevierStyleSup">16&#44;23&#44;24</span></a>&#46; Esto no resulta sorprendente&#44; sobre todo si se tiene en cuenta que estos sujetos tienen un mayor riesgo de morbimortalidad cardiovascular&#44; con independencia de otros factores&#44; incluido el tabaco&#46; En consonancia con otras series<a class="elsevierStyleCrossRefs" href="#bib0290"><span class="elsevierStyleSup">10&#44;25&#44;26</span></a>&#44; la cardiopat&#237;a isqu&#233;mica fue tambi&#233;n m&#225;s frecuente en los pacientes con ICA y EPOC &#40;29&#44;6 frente a un 25&#44;8&#37; en ICA sin EPOC&#41; pues la cardiopat&#237;a isqu&#233;mica &#40;y no la ICA&#41; est&#225; considerada la principal causa de muerte entre los pacientes con EPOC&#46;</p><p id="par0105" class="elsevierStylePara elsevierViewall">La descompensaci&#243;n de la IC de los pacientes con EPOC estuvo m&#225;s frecuentemente desencadenada por una infecci&#243;n y menos por taquiarritmia&#44; crisis hipertensiva o s&#237;ndrome coronario agudo&#46; Las exacerbaciones de la EPOC suelen desencadenarse por infecciones respiratorias virales o bacterianas<a class="elsevierStyleCrossRef" href="#bib0375"><span class="elsevierStyleSup">27</span></a>&#44; pero factores ambientales como la contaminaci&#243;n y la temperatura ambiente pueden aumentar los s&#237;ntomas<a class="elsevierStyleCrossRef" href="#bib0380"><span class="elsevierStyleSup">28</span></a>&#46; En el estudio PAPRICA<a class="elsevierStyleCrossRef" href="#bib0385"><span class="elsevierStyleSup">29</span></a>&#44; al igual que en otros estudios&#44; el factor precipitante m&#225;s frecuente fue la infecci&#243;n&#44; fundamentalmente la respiratoria&#46; Este factor precipitante&#44; aunque no se asoci&#243; a una menor mortalidad&#44; s&#237; lo hizo con un menor porcentaje crudo de reconsultas a los 30 d&#237;as&#46; Por el contrario&#44; en el presente estudio&#44; las taquiarrtimias fueron m&#225;s frecuentes en pacientes con ICA sin EPOC &#40;16&#37; frente a 11&#44;7&#37;&#41;&#46; Es sabido que en ocasiones las arritmias son a su vez consecuencia de otros factores&#44; como pueden ser las infecciones respiratorias en pacientes con EPOC o la misma IC&#46; De hecho&#44; en el PAPRICA<a class="elsevierStyleCrossRef" href="#bib0385"><span class="elsevierStyleSup">29</span></a> el 42&#37; de los pacientes con infecci&#243;n como factor precipitante ten&#237;an&#44; adem&#225;s&#44; fibrilaci&#243;n auricular permanente&#46; As&#237; pues&#44; la infecci&#243;n es una causa muy importante de descompensaci&#243;n&#44; y por ello la prevenci&#243;n de infecciones como la gripe con la vacunaci&#243;n es de suma importancia&#44; ya que ha demostrado reducir la gravedad de la descompensaci&#243;n y la mortalidad<a class="elsevierStyleCrossRef" href="#bib0325"><span class="elsevierStyleSup">17</span></a>&#46;</p><p id="par0110" class="elsevierStylePara elsevierViewall">Aunque hubo diferencias en los hallazgos cl&#237;nicos en urgencias&#44; la gravedad estimada mediante la Escala MEESSI-AHF fue similar en ambos grupos&#46; Esta escala&#44; desarrollada y validada en SUH espa&#241;oles<a class="elsevierStyleCrossRef" href="#bib0260"><span class="elsevierStyleSup">4</span></a>&#44; permite clasificar la gravedad de la descompensaci&#243;n seg&#250;n un riesgo bajo&#44; medio&#44; alto o muy alto&#44; evaluando el riesgo de mortalidad a 30 d&#237;as tras la valoraci&#243;n en urgencias&#46; Es posible que algunas variables que forman parte de esta escala&#44; como el &#237;ndice de Barthel&#44; la clase funcional NYHA&#44; o la asociaci&#243;n con el s&#237;ndrome coronario agudo o el bajo gasto cardiaco&#44; se basan parcialmente en una interpretaci&#243;n subjetiva y la adjudicaci&#243;n puede variar entre diferentes observadores&#44; y que han podido infraestimar la gravedad en el subgrupo de pacientes con ICA y EPOC&#46; Por otra parte&#44; la escala no tiene en cuenta las variables con evidencia de impacto en los resultados como son el manejo prehospitalario por parte de los equipos m&#233;dicos de emergencias&#44; o el uso de terapia ventilatorias como la VNI o terapia de alto flujo<a class="elsevierStyleCrossRefs" href="#bib0390"><span class="elsevierStyleSup">30&#8211;32</span></a>&#46;</p><p id="par0115" class="elsevierStylePara elsevierViewall">Respecto al tratamiento realizado en los servicios de urgencias&#44; m&#225;s pacientes EPOC recibieron oxigenoterapia y VNI&#46; La generalizaci&#243;n de las indicaciones de la VNI ha hecho que su utilizaci&#243;n est&#233; aumentando de forma progresiva<a class="elsevierStyleCrossRefs" href="#bib0405"><span class="elsevierStyleSup">33&#44;34</span></a>&#46; Los estudios cl&#237;nicos muestran una reducci&#243;n de un 50-60&#37; en el riesgo de fracaso de tratamiento&#44; necesidad de intubaci&#243;n traqueal y mortalidad durante la agudizaci&#243;n cuando son tratados con VNI agudizaci&#243;n grave de la EPOC&#44; especialmente cuando se presenta con insuficiencia respiratoria hiperc&#225;pnica y acidosis respiratoria y no mejora con el tratamiento convencional de la agudizaci&#243;n<a class="elsevierStyleCrossRef" href="#bib0415"><span class="elsevierStyleSup">35</span></a>&#46; Estos hallazgos son congruentes con otros estudios&#46; Una serie de 11&#46;152 pacientes con ICA atendidos en SUH&#44; donde se estudiaba el efecto de la VNI sobre la evoluci&#243;n a corto plazo&#44; evidenci&#243; de forma significativa que en el grupo de pacientes con EPOC &#40;24&#44;1&#37;&#41; se us&#243; m&#225;s frecuentemente la VNI&#44; 31&#37; frente a un 23&#44;6&#37; en el que no se us&#243; este soporte respiratorio<a class="elsevierStyleCrossRef" href="#bib0405"><span class="elsevierStyleSup">33</span></a>&#46;</p><p id="par0120" class="elsevierStylePara elsevierViewall">Los pacientes con EPOC recibieron tambi&#233;n m&#225;s broncodilatadores &#40;41&#37; frente a un 17&#44;6&#37;&#41;&#46; Este resultado tambi&#233;n se encuentra en la l&#237;nea de otros estudios&#46; En un estudio realizado en Estados Unidos&#44; en 164&#46;494 pacientes hospitalizados por ICA&#44; y donde 63&#46;690 &#40;39&#37;&#41; padec&#237;an EPOC&#44; el 37&#37; recibieron tratamiento con broncodilatadores inhalados de acci&#243;n corta y este porcentaje aumentaba a un 59&#37; en el subgrupo de ICA y EPOC<a class="elsevierStyleCrossRef" href="#bib0315"><span class="elsevierStyleSup">15</span></a>&#46; Este hallazgo ilustra la complejidad del manejo de la ICA en la pr&#225;ctica habitual&#46; En primer lugar&#44; la presentaci&#243;n cl&#237;nica es a menudo inespec&#237;fica de forma inicial&#44; ya que el tratamiento respiratorio agudo conjunto &#40;agonistas-beta inhalados&#44; anticolin&#233;rgicos&#44; corticoides y antibi&#243;ticos&#41; se interrumpe durante el ingreso en m&#225;s del 20&#37; de las hospitalizaciones&#44; presumiblemente porque el diagn&#243;stico subyacente de ICA se hizo m&#225;s evidente&#46; Esta dificultad para diferenciar la ICA de otras afecciones que causan s&#237;ntomas respiratorios se evidencia adem&#225;s por el hecho de que las tasas de tratamiento respiratorio agudo conjunto fueron superiores al 25&#37;&#46; En el mismo estudio de Dharmarajan et al&#46;<a class="elsevierStyleCrossRef" href="#bib0315"><span class="elsevierStyleSup">15</span></a>&#44; se evidenci&#243; que hasta un 50&#37; de los pacientes con ICA hab&#237;an recibido dicho tratamiento conjunto&#46; Son necesarios estudios futuros para comprender los beneficios y los perjuicios del tratamiento respiratorio agudo conjunto en la poblaci&#243;n con ICA&#44; pues se desconoce si los broncodilatadores mejoran los s&#237;ntomas o pueden tener efectos hemodin&#225;micos positivos en las personas con disnea derivada exclusivamente de la ICA&#44; como pueden hacerlo en los pacientes con IC cr&#243;nica<a class="elsevierStyleCrossRefs" href="#bib0420"><span class="elsevierStyleSup">36&#44;37</span></a>&#46; Estos efectos beneficiosos pueden verse contrarrestados por una mayor probabilidad de arritmias<a class="elsevierStyleCrossRef" href="#bib0430"><span class="elsevierStyleSup">38</span></a>&#44; isquemia<a class="elsevierStyleCrossRef" href="#bib0435"><span class="elsevierStyleSup">39</span></a> o posibles consecuencias adversas a largo plazo de la estimulaci&#243;n simp&#225;tica<a class="elsevierStyleCrossRef" href="#bib0440"><span class="elsevierStyleSup">40</span></a>&#46; As&#237;&#44; el estudio BRONCH-AHF mostr&#243; que la adici&#243;n de broncodilatadores sin necesidad documentada en pacientes con diagn&#243;stico final de ICA en los SUH no modifica la supervivencia en comparaci&#243;n con el tratamiento est&#225;ndar de la ICA &#40;incluidos los diur&#233;ticos&#41;&#44; y que el uso de beta-2-agonistas &#40;solos o asociados a anticolin&#233;rgicos&#41; podr&#237;a incluso incrementar los eventos adversos<a class="elsevierStyleCrossRef" href="#bib0445"><span class="elsevierStyleSup">41</span></a>&#46;</p><p id="par0125" class="elsevierStylePara elsevierViewall">El uso de corticoides y antibi&#243;ticos tambi&#233;n fue mayor en los pacientes con EPOC&#46; En el estudio de Jacob et al&#46; se describe que en pacientes con ICA y EPOC el uso de corticoides fue mayor &#40;27&#44;9&#37; frente a 11&#44;1&#37;&#41;&#46; An&#225;logamente&#44; en la cohorte de Dharmarajan et al<span class="elsevierStyleItalic">&#46;</span><a class="elsevierStyleCrossRef" href="#bib0315"><span class="elsevierStyleSup">15</span></a>&#44; aproximadamente un tercio recibi&#243; antibi&#243;ticos y entre las hospitalizaciones por ICA con EPOC&#44; el 42&#37; recibi&#243; antibi&#243;ticos y&#44; aunque los corticosteroides fueron los menos utilizados de todas las terapias respiratorias agudas estudiadas&#44; los autores encontraron que el 17&#37; de las hospitalizaciones con EPOC recib&#237;an altas dosis de corticoides&#46; En el estudio CORT-AHF<a class="elsevierStyleCrossRef" href="#bib0305"><span class="elsevierStyleSup">13</span></a>&#44; se analizaron 11&#46;356 pacientes con ICA&#44; donde un 9&#44;7&#37; sin EPOC y un 27&#44;7&#37; con EPOC fueron tratados con corticosteroides sist&#233;micos&#46; En este mismo estudio no se encontraron diferencias en la mortalidad o reingreso a 90 d&#237;as en pacientes con o sin EPOC concomitante&#46; Esta falta de diferencia podr&#237;a ser debida&#44; hipot&#233;ticamente&#44; a un cierto efecto antiinflamatorio beneficioso de los corticoides en pacientes con ICA y sin EPOC&#46;</p><p id="par0130" class="elsevierStylePara elsevierViewall">Todos estos resultados son realmente importantes para conseguir un correcto tratamiento de estos pacientes m&#225;s complejos&#44; que comparten ambas comorbilidades&#46; El estudio de cohortes de Kostikas et al<span class="elsevierStyleItalic">&#46;</span><a class="elsevierStyleCrossRef" href="#bib0450"><span class="elsevierStyleSup">42</span></a> mostr&#243; que de un total de 12&#46;587 pacientes en situaci&#243;n cr&#243;nica con EPOC e IC reci&#233;n diagnosticada &#40;media de 75 a&#241;os&#44; 60&#37; varones&#41;&#44; se prescribi&#243; un tratamiento adecuado para la IC a 2&#46;251 &#40;18&#37;&#41;&#44; inadecuado a 5&#46;332 &#40;42&#37;&#41; y no recibieron tratamiento para la IC 5&#46;004 &#40;40&#37;&#41;&#46; Estos resultados respaldan la necesidad de mejorar la equidad en el acceso a la atenci&#243;n integrada para los pacientes afectados de ambos procesos m&#243;rbidos&#46;</p><p id="par0135" class="elsevierStylePara elsevierViewall">Respecto a la evoluci&#243;n&#44; los pacientes con EPOC fueron ingresados m&#225;s frecuentemente&#46; Se ha descrito que la presencia de EPOC empeora la presentaci&#243;n cl&#237;nica y el proceso de la IC&#44; y se asocia con un incremento del 20-30&#37; del riesgo de hospitalizaci&#243;n<a class="elsevierStyleCrossRefs" href="#bib0455"><span class="elsevierStyleSup">43&#44;44</span></a>&#46; En el estudio de Ehteshami-Afshar et al&#46;<a class="elsevierStyleCrossRef" href="#bib0290"><span class="elsevierStyleSup">10</span></a> se mostr&#243; un mayor riesgo de ingreso hospitalario en pacientes con IC y EPOC&#44; tanto en la hospitalizaci&#243;n de causa cardiovascular &#40;HR&#44; 1&#44;17&#59; IC 95&#37;&#44; 1&#44;05-1&#44;31&#41; como en la no cardiovascular &#40;HR&#44; 1&#44;45&#59; IC 95&#37;&#44; 1&#44;29-1&#44;64&#41;&#46; Esto muestra que la exacerbaci&#243;n de la EPOC con ICA asociada puede ser responsable de algunas hospitalizaciones&#44; m&#225;s que la propia ICA en s&#237;&#46;</p><p id="par0140" class="elsevierStylePara elsevierViewall">Nuestros resultados evidencian que la presencia de EPOC en un paciente con ICA &#40;independientemente de la gravedad&#41; no tiene un impacto significativo en la mortalidad intrahospitalaria&#44; pero en cambio s&#237; que se asocia a un incremento de la mortalidad cruda a los 30 d&#237;as&#46; Si embargo&#44; este incremento de mortalidad desaparece al ajustar los resultados por las diferencias entre grupos&#44; especialmente por las diferencias que existen en las caracter&#237;sticas de la descompensaci&#243;n y el manejo en urgencias de pacientes con y sin EPOC&#46; Esto va en consonancia con un estudio reciente de 3&#46;515 pacientes&#44; el 35&#37; con EPOC&#44; en el que el an&#225;lisis multivariante no mostr&#243; un mayor riesgo de muerte por cualquier causa en los pacientes con EPOC<a class="elsevierStyleCrossRef" href="#bib0300"><span class="elsevierStyleSup">12</span></a>&#46; Todo esto contrasta con la afirmaci&#243;n de las actuales gu&#237;as donde la presencia de EPOC se asocia con peores resultados<a class="elsevierStyleCrossRefs" href="#bib0250"><span class="elsevierStyleSup">2&#44;3</span></a>&#46; De todos los estudios que han demostrado una asociaci&#243;n significativa entre la presencia de EPOC y un mayor riesgo de resultados adversos en pacientes con IC<a class="elsevierStyleCrossRefs" href="#bib0305"><span class="elsevierStyleSup">13&#44;24&#44;43&#44;45&#44;46</span></a>&#44; solo 3 definieron la EPOC mediante espirometr&#237;a y la IC mediante ecocardiograf&#237;a o niveles de p&#233;ptidos natriur&#233;ticos<a class="elsevierStyleCrossRefs" href="#bib0455"><span class="elsevierStyleSup">43&#44;45&#44;46</span></a>&#46; Los resultados del presente estudio sugieren que&#44; en pacientes con ICA&#44; son las caracter&#237;sticas cl&#237;nicas y de manejo del episodio de ICA&#44; y no la presencia de EPOC&#44; lo que realmente aumenta el riesgo de resultados adversos en pacientes con EPOC<a class="elsevierStyleCrossRef" href="#bib0475"><span class="elsevierStyleSup">47</span></a>&#46;</p><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0110">Limitaciones</span><p id="par0145" class="elsevierStylePara elsevierViewall">El presente estudio tiene varias limitaciones&#46; La primera de ellas es que se trata de un estudio descriptivo prospectivo&#44; por lo que los resultados no implican causalidad&#46; La segunda&#44; los resultados se corresponden a diferentes SUH del sistema sanitario p&#250;blico espa&#241;ol&#44; y no ser&#237;a extrapolable a otros sistemas sanitarios por lo que es necesaria una validaci&#243;n externa de estos resultados&#46; Y la tercera&#44; a pesar de la innegable asociaci&#243;n entre la IC y la EPOC&#44; debe destacarse una importante limitaci&#243;n diagn&#243;stica de la que adolecen la casi totalidad de los estudios que han abordado la coexistencia de la EPOC en pacientes con IC&#44; incluido el presente&#46; El diagn&#243;stico de la EPOC no se efectu&#243; principalmente por los datos espirom&#233;tricos&#44; sino por los antecedentes cl&#237;nicos del paciente en la historia cl&#237;nica previa del hospital o de su centro de salud&#44; cuya fiabilidad para la detecci&#243;n de la EPOC es cuestionable&#46; Solo se ha identificado un trabajo en el que se realiz&#243; sistem&#225;ticamente espirometr&#237;a a todos los pacientes con IC&#44; y la prevalencia fue muy alta&#44; del 35&#37;<a class="elsevierStyleCrossRef" href="#bib0480"><span class="elsevierStyleSup">48</span></a>&#46; Este hallazgo indica que con frecuencia este problema m&#233;dico&#44; la EPOC&#44; pasa inadvertida y que su verdadera dimensi&#243;n es notablemente superior a la que en general se considera&#46; Por otra parte&#44; debe se&#241;alarse que la prevalencia de IC en pacientes con EPOC previa es tambi&#233;n elevada&#46; Adem&#225;s&#44; su diagn&#243;stico es con frecuencia complejo por la similitud entre ambos procesos en su expresi&#243;n cl&#237;nica y por la dificultad de obtener im&#225;genes ecocardiogr&#225;ficas de suficiente calidad<a class="elsevierStyleCrossRefs" href="#bib0305"><span class="elsevierStyleSup">13&#44;14</span></a>&#46;</p></span></span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0115">Conclusi&#243;n</span><p id="par0150" class="elsevierStylePara elsevierViewall">Los pacientes con ICA y EPOC tienen caracter&#237;sticas cl&#237;nicas y de manejo en urgencias diferenciales y presentan mayores tasas de ingreso&#46; Si bien la mortalidad cruda a 30 d&#237;as es superior en los pacientes con EPOC&#44; este incremento del riesgo de muerte desaparece cuando se tienen en cuenta las diferencias cl&#237;nicas del episodio de descompensaci&#243;n y el manejo en el SUH&#46;</p></span><span id="sec0060" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0120">Financiaci&#243;n</span><p id="par0155" class="elsevierStylePara elsevierViewall">Este trabajo fue posible en parte gracias a las ayudas del Instituto de Salud Carlos III con fondos del Ministerio de Sanidad y FEDER &#40;PI18&#47;00393&#41;&#46;</p></span><span id="sec0065" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0125">Conflicto de intereses</span><p id="par0160" class="elsevierStylePara elsevierViewall">Los autores declaran no tener ning&#250;n conflicto de intereses&#46;</p></span></span>"
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    "fechaRecibido" => "2024-06-28"
    "fechaAceptado" => "2024-07-29"
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            0 => "Insuficiencia cardiaca aguda"
            1 => "Enfermedad pulmonar obstructiva cr&#243;nica"
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            0 => "Acute heart failure"
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        "titulo" => "Resumen"
        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Objetivos</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Analizar si los pacientes con enfermedad pulmonar obstructiva cr&#243;nica &#40;EPOC&#41; presentan diferencias cl&#237;nicas y de manejo terap&#233;utico en urgencias cuando desarrollan un episodio de insuficiencia cardiaca aguda &#40;ICA&#41; y analizar la mortalidad durante dicha descompensaci&#243;n&#46;</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">M&#233;todo</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Se incluyeron pacientes diagnosticados de ICA en 50 servicios de urgencias espa&#241;oles entre 2012 y 2022 y que tambi&#233;n padec&#237;an EPOC&#44; y se compararon sus caracter&#237;sticas basales&#44; del episodio de descompensaci&#243;n y de manejo terap&#233;utico en urgencias con las de pacientes con ICA sin EPOC diagnosticados durante dicho periodo&#46; Se recogi&#243; la mortalidad por cualquier causa intrahospitalaria y a los 30 d&#237;as&#44; y se investig&#243; si exist&#237;an diferencias entre pacientes con y sin EPOC en modelos de regresi&#243;n log&#237;stica crudos y ajustados&#46;</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Resultados</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Se analizaron 21&#46;694 pacientes con ICA &#40;mediana<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>83 a&#241;os&#44; mujeres<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>56&#37;&#41;&#44; 4&#46;942 &#40;23&#37;&#41; con EPOC&#46; Estos eran m&#225;s j&#243;venes&#44; m&#225;s frecuentemente varones&#44; con m&#225;s comorbilidades &#40;con excepci&#243;n de valvulopat&#237;a y demencia&#44; m&#225;s frecuentes en pacientes no EPOC&#41;&#44; peor clase funcional respiratoria &#40;NYHA&#41; y mejor capacidad funcional global &#40;&#237;ndice de Barthel&#41;&#46; La descompensaci&#243;n de los pacientes EPOC estuvo m&#225;s frecuentemente desencadenada por una infecci&#243;n y menos por taquiarritmia&#44; crisis hipertensiva o s&#237;ndrome coronario agudo y&#44; aunque hubo diferencias en los hallazgos cl&#237;nicos en urgencias&#44; la gravedad estimada mediante la Escala MEESSI-AHF fue similar en ambos grupos&#46; Respecto al manejo en urgencias&#44; m&#225;s pacientes EPOC recibieron oxigenoterapia&#44; ventilaci&#243;n no invasiva&#44; broncodilatadores&#44; corticoides y antibi&#243;ticos y menos nitroglicerina endovenosa&#44; y hospitalizaron m&#225;s frecuentemente&#46; La mortalidad intrahospitalaria en pacientes con y sin EPOC fue del 8&#44;1&#37; y del 7&#44;5&#37;&#44; respectivamente &#40;OR<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>1&#44;088&#44; IC 95&#37;<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;968-1&#44;224&#41; y a 30 d&#237;as fue del 11&#44;0&#37; y del 10&#44;0&#37; &#40;OR<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>1&#44;111&#44; IC 95&#37;<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>1&#44;002-1&#44;231&#41;&#46; Tras ajustar por las caracter&#237;sticas cl&#237;nicas&#44; del episodio de descompensaci&#243;n y del manejo en urgencias&#44; estas OR descendieron a 1&#44;040 &#40;0&#44;905-1&#44;195&#41; y 1&#44;080 &#40;0&#44;957-1&#44;219&#41;&#44; respectivamente&#46;</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Conclusi&#243;n</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Los pacientes con ICA y EPOC tienen caracter&#237;sticas cl&#237;nicas y de manejo terap&#233;utico en urgencias diferenciales&#44; y precisan mayor hospitalizaci&#243;n&#46; Si bien presentan una mayor mortalidad cruda a los 30 d&#237;as&#44; esto se explica por este diferente perfil cl&#237;nico m&#225;s que por la propia existencia de la EPOC&#46;</p></span>"
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        "resumen" => "<span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Objectives</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">This study aims to analyse differences in clinical and therapeutic management for patients with chronic obstructive pulmonary disease &#40;COPD&#41; who present to the emergency department with acute heart failure &#40;AHF&#41;&#46; Additionally&#44; it examines mortality rates during such episodes&#46;</p></span> <span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Method</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">We included patients diagnosed with AHF at 50 Spanish emergency departments from 2012 to 2022 who also had COPD&#46; We compared their baseline characteristics&#44; decompensation episodes&#44; and emergency department management with those of AHF patients without COPD during the same period&#46; We collected data on in-hospital and 30-day all-cause mortality&#44; investigating differences between the two groups using crude and adjusted logistic regression models&#46;</p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Results</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">A total of 21&#44;694 AHF patients were analysed &#40;median age<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>83 years&#44; 56&#37; female&#41;&#44; including 4&#44;942 &#40;23&#37;&#41; with COPD&#46; COPD patients were generally younger and more frequently male&#44; with a higher prevalence of comorbidities &#40;excluding valve disease and dementia&#44; which were more common in non-COPD patients&#41;&#46; They exhibited a worse respiratory functional class &#40;NYHA&#41; but a better overall functional capacity &#40;Barthel Index&#41;&#46; Decompensation in COPD patients was more often triggered by infection and less frequently by tachyarrhythmia&#44; hypertensive crisis&#44; or acute coronary syndrome&#46; While there were differences in clinical findings in the emergency department&#44; the severity assessed by the MEESSI-AHF Scale was similar across both groups&#46; In terms of emergency department management&#44; a higher proportion of COPD patients received oxygen therapy&#44; non-invasive ventilation&#44; bronchodilators&#44; corticosteroids&#44; and antibiotics&#44; while fewer received intravenous nitroglycerin&#44; and they were hospitalized more frequently&#46; In-hospital mortality rates were 8&#46;1&#37; for patients with COPD and 7&#46;5&#37; for those without &#40;OR<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>1&#46;088&#44; 95&#37; CI<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;968-1&#46;224&#41;&#44; with 30-day mortality rates of 11&#46;0&#37; and 10&#46;0&#37;&#44; respectively &#40;OR<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>1&#46;111&#44; 95&#37; CI<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>1&#46;002-1&#46;231&#41;&#46; After adjusting for clinical characteristics&#44; decompensation episodes&#44; and emergency department management&#44; these odds ratios decreased to 1&#46;040 &#40;95&#37; CI<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;905-1&#46;195&#41; and 1&#46;080 &#40;95&#37; CI<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;957-1&#46;219&#41;&#44; respectively&#46;</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Conclusion</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">Patients with AHF and COPD exhibit distinct clinical and therapeutic management characteristics in the emergency department and require more frequent hospitalization&#46; Although they show higher crude 30-day mortality&#44; this is attributable to their differing clinical profiles rather than the presence of COPD itself&#46;</p></span>"
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            "apendice" => "<p id="par0165" class="elsevierStylePara elsevierViewall">Marta Fuentes&#44; Aitor D&#225;vila&#44; Sonia del Amo &#40;Hospital Universitario de Salamanca&#41;&#44; H&#233;ctor Alonso&#44; Enrique P&#233;rez-Llantada &#40;Hospital Marqu&#233;s de Valdecilla de Santander&#41;&#44; Francisco Javier Mart&#237;n-S&#225;nchez &#40;Hospital Cl&#237;nico San Carlos de Madrid&#41;&#44; &#210;scar Mir&#243;&#44; V&#237;ctor Gil&#44; Rosa Escoda&#44; Carolina S&#225;nchez&#44; Daniel Repullo&#44; Marta Mass&#243; &#40;Hospital Cl&#237;nic de Barcelona&#41;&#44; Javier Mill&#225;n&#44; Leticia Serrano &#40;Hospital Polit&#233;nic La Fe de Valencia&#41;&#44; Jos&#233; Pav&#243;n&#44; Nayra Cabrera Gonz&#225;lez &#40;Hospital Dr&#46; Negr&#237;n de Las Palmas de Gran Canaria&#41;&#44; Rafael Calvo Rodr&#237;guez&#44; Juan Antonio Vega Reyes &#40;Hospital Reina Sof&#237;a de C&#243;rdoba&#41;&#44; Mar&#237;a Luisa L&#243;pez-Grima&#44; Amparo Valero&#44; Mar&#237;a &#193;ngeles Juan &#40;Hospital Dr&#46; Peset de Valencia&#41;&#44; Alfons Aguirre&#44; Silvia M&#237;nguez Mas&#243; &#40;Hospital del Mar de Barcelona&#41;&#44; Virginia Fern&#225;ndez-T&#225;vora P&#233;rez &#40;Hospital de Valme de Sevilla&#41;&#44; Ana Bel&#233;n Mecina &#40;Hospital de Alcorc&#243;n de Madrid&#41;&#44; Josep Tost &#40;Consorci Sanitari de Terrassa&#41;&#44; Susana S&#225;nchez Ram&#243;n&#44; Virginia Carbajosa Rodr&#237;guez &#40;Hospital Universitario R&#237;o Hortega de Valladolid&#41;&#44; Pascual Pi&#241;era&#44; Jos&#233; Andr&#233;s S&#225;nchez Nicol&#225;s&#44; Paula L&#225;zaro Arag&#252;&#233;s &#40;Hospital Reina Sof&#237;a de Murcia&#41;&#44; Raquel Torres Garate&#44; Esther &#193;lvarez Rodr&#237;guez&#44; Pilar Paz Arias&#40;Hospital Severo Ochoa de Madrid&#41;&#44; Aitor Alqu&#233;zar-Arb&#233;&#44; Sergio Herrera&#44; Carlos Jos&#233; Romero Carrete &#40;Hospital de la Santa Creu y Sant Pau de Barcelona&#41;&#44; Javier Jacob&#44; Alex Roset&#44; Irene Cabello&#44; Antonio Haro&#44; Lidia Fuentes &#40;Hospital Universitari de Bellvitge de Barcelona&#41;&#44; Fernando Richard&#44; Elisa Fern&#225;ndez&#44; Mar&#237;a Pilar L&#243;pez Diez &#40;Hospital Universitario de Burgos&#41;&#44; Pablo Herrero Puente&#44; Joaqu&#237;n V&#225;zquez &#193;lvarez&#44; Bel&#233;n Prieto Garc&#237;a&#44; Alejandra Fern&#225;ndez Fern&#225;ndez&#44; Bel&#233;n &#193;lvarez Ramos&#44; Natalia Fern&#225;ndez Miranda &#40;Hospital Universitario Central de Asturias de Oviedo&#41;&#44; Pere Llorens&#44; Bego&#241;a Espinosa&#44; Sergio Guzm&#225;n&#44; Gema Jara&#44; Alba Felipe&#44; Adriana Gil &#40;Hospital General Universitario Dr&#46; Balmis de Alicante&#41;&#44; Juan Antonio Andueza &#40;Hospital General Universitario Gregorio Mara&#241;&#243;n de Madrid&#41;&#44; Rodolfo Romero&#44; Mariella Luengo L&#243;pez &#40;Hospital Universitario de Getafe de Madrid&#41;&#44; Gema Dom&#237;nguez&#44; Mart&#237;n Ru&#237;z &#40;Hospital de Henares de Madrid&#41;&#44; Beatriz Amores Arriaga&#44; Beatriz Sierra Bergua &#40;Hospital Cl&#237;nico Lozano Blesa de Zaragoza&#41;&#44; Enrique Mart&#237;n Mojarro&#44; Lidia Cuevas Jim&#233;nez &#40;Hospital Sant Pau i Santa Tecla de Tarragona&#41;&#44; Lisette Traver&#237;a B&#233;cquer&#44; Guillermo Burillo &#40;Hospital Universitario de Canarias de Tenerife&#41;&#44; Llu&#237;s Llauger Garc&#237;a &#40;Althaia Xarxa Assistencial Universitaria de Manresa&#41;&#44; Mar&#237;a de los &#193;ngeles Gonz&#225;lez de la Torre&#44; Carmen Esmeralda Romero Jim&#233;nez &#40;Hospital Costa del Sol de Marbella de M&#225;laga&#41;&#44; Ester Soy Ferrer&#44; Mar&#237;a Adroher M&#250;&#241;oz &#40;Hospital Josep Trueta de Girona&#41;&#46; Jos&#233; Manuel Garrido &#40;Hospital Virgen Macarena de Sevilla&#41;&#44; Francisco Javier Lucas-Imbern&#243;n &#40;Hospital General Universitario de Albacete&#41;&#44; Rut Gaya &#40;Hospital Juan XXIII de Tarragona&#41;&#44; Carlos Bibiano&#44; Mar&#237;a Mir&#44; Beatriz Rodr&#237;guez&#44; Monika Vicente Mart&#237;n&#44; Esther Rodr&#237;guez Adrada &#40;Hospital Universitario Infanta Leonor de Madrid&#41;&#46; Eva Domingo Baldrich&#44; Marianela Guzm&#225;n Carvajal &#40;Hospital Vall d&#8217;Hebron de Barcelona&#41;&#44; Mar&#237;a Jos&#233; Fortuny &#40;Hospital Francesc de Borja de Gandia&#41;&#44; Yelenis G&#243;mez Garc&#237;a&#44; Ver&#243;nica de las Nieves Segura Coronill &#40;Hospital de Manacor de Mallorca&#41;&#44; Marco Antonio Esquivias&#44; Mar&#237;a del Carmen Mart&#237;nez Pic&#243;n&#44; Marina Borox Callejas &#40;Hospital la Mancha de Ciudad Real&#41;&#44; Roc&#237;o Moyano Garc&#237;a &#40;Hospital Comarcal Valle de los Pedroches de C&#243;rdoba&#41;&#44; Pablo Rodr&#237;guez&#44; Mar&#237;a Mart&#237;nez Cuevas &#40;Hospital Universitario de la Paz de Madrid&#41;&#44; Jos&#233; Noceda&#44; Santiago Harris Blasco &#40;Hospital Cl&#237;nico de Valencia&#41;&#44; Marta Romero &#40;Hospital Universitario de M&#243;stoles de Madrid&#41;&#46; Oriol Aguil&#243; Pedret &#40;Hospital de Olot i Comarcal de la Garrotxa&#41;&#44; Jordi Estop&#225; Valladares &#40;Cl&#237;nica Universidad de Navarra de Madrid&#41;&#44; Natalia Ramos Gonz&#225;lez &#40;Hospital do Saln&#233;s de Pontevedra&#41;&#44; Rocio Lorenzo &#40;Hospital de la Axarqu&#237;a de M&#225;laga&#41;&#44; Juan Bautista Valencia &#40;Hospital Parc Taul&#237; de Sabadell&#41;&#44; Lorena Bembibre &#40;Hospital de A Coru&#241;a&#41;&#46; In&#233;s Fern&#225;ndez Guerrero &#40;Hospital Virgen de las Nieves de Granada&#41;&#46;</p>"
            "etiqueta" => "Anexo"
            "titulo" => "Investigadores del grupo ICA-SEMES &#40;lista completa&#41;"
            "identificador" => "sec0070"
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                  \t\t\t\t">8&#46;355 &#40;49&#44;9&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">100&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">1&#46;478 &#40;29&#44;9&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">4&#46;666 &#40;27&#44;9&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleBold">0&#44;007</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
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                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">Cardiopat&#237;a isqu&#233;mica</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">5&#46;776 &#40;26&#44;6&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">100&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">1&#46;465 &#40;29&#44;6&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleBold">&#60;</span><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleBold">0&#44;001</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
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                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">Valvulopat&#237;a</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">5&#46;562 &#40;25&#44;6&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">100&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">1&#46;086 &#40;21&#44;9&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">4&#46;476 &#40;26&#44;7&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t"><span class="elsevierStyleBold">&#60;</span><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleBold">0&#44;001</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">Neoplasia</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">3&#46;113 &#40;14&#44;4&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">100&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">820 &#40;16&#44;6&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">2&#46;293 &#40;13&#44;7&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleBold">&#60;</span><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleBold">0&#44;001</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
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                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">Enfermedad cerebrovascular</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">Demencia</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">485 &#40;9&#44;8&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">1&#46;974 &#40;11&#44;8&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleBold">&#60;</span><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleBold">0&#44;001</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
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                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">Enfermedad arterial perif&#233;rica</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t">1&#46;972 &#40;9&#44;1&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">567 &#40;11&#44;5&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">1&#46;405 &#40;8&#44;4&#41;&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
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                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">Cirrosis hep&#225;tica</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">312 &#40;1&#44;4&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">95 &#40;1&#44;9&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">217 &#40;1&#44;3&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="6" align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleBold">Situaci&#243;n funcional basal</span></td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">Clase funcional NYHA</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">92&#44;7&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"><span class="elsevierStyleBold">&#60;</span><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleBold">0&#44;001</span><a class="elsevierStyleCrossRef" href="#tblfn0005"><span class="elsevierStyleSup">a</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>I&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">4&#46;912 &#40;24&#44;4&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
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                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">781 &#40;16&#44;7&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t">4&#46;131 &#40;26&#44;8&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" 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><span class="elsevierStyleHsp" style=""></span>II&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">10&#46;379 &#40;51&#44;6&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" 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
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                  \t\t\t\t">2&#46;548 &#40;54&#44;6&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t">7&#46;831 &#40;50&#44;7&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" 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></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>III&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&#46;493 &#40;22&#44;3&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" 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">1&#46;244 &#40;26&#44;7&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">3&#46;249 &#40;21&#44;0&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>IV&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">319 &#40;1&#44;6&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" 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">91 &#40;2&#44;0&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">228 &#40;1&#44;5&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" 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></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">Tipo de disfunci&#243;n del ventr&#237;culo izquierdo</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="" 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">58&#44;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="" 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="" 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;96<a class="elsevierStyleCrossRef" href="#tblfn0005"><span class="elsevierStyleSup">a</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>Reducida&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&#46;203 &#40;9&#44;5&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" 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">297 &#40;9&#44;5&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">906 &#40;9&#44;5&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" 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></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>Moderadamente reducida&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">2&#46;671 &#40;21&#44;1&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \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">666 &#40;21&#44;1&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2&#46;005 &#40;21&#44;0&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>Preservada&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&#46;791 &#40;69&#44;4&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \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">2&#46;176 &#40;69&#44;3&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">6&#46;615 &#40;69&#44;3&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" 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></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">Capacidad funcional &#40;seg&#250;n &#237;ndice de Barthel&#41; &#40;RIC&#41;&#93;</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="" 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">90&#44;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
                  \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="" 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"><span class="elsevierStyleBold">0&#44;003</span><a class="elsevierStyleCrossRef" href="#tblfn0005"><span class="elsevierStyleSup">a</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>Independiente &#40;100 puntos&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">6&#46;912 &#40;35&#44;4&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \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">1&#46;549 &#40;34&#44;3&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">5&#46;363 &#40;35&#44;7&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" 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></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>Dependencia leve &#40;60-99 puntos&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">8&#46;875 &#40;45&#44;5&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" 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">2&#46;221 &#40;49&#44;2&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">6&#46;654 &#40;44&#44;3&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" 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></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>Dependencia moderada &#40;40-59 puntos&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2&#46;024 &#40;10&#44;4&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \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">434 &#40;9&#44;6&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&#46;590 &#40;10&#44;6&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" 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></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>Dependencia grave o total &#40;&#60;40 puntos&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&#46;705 &#40;8&#44;7&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" 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">308 &#40;6&#44;8&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&#46;397 &#40;9&#44;3&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" 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></tr></tbody></table>
                  """
              ]
              "imagenFichero" => array:1 [
                0 => "xTab3698921.png"
              ]
            ]
          ]
          "notaPie" => array:1 [
            0 => array:3 [
              "identificador" => "tblfn0005"
              "etiqueta" => "a"
              "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Calculado mediante test de ji cuadrado de tendencia lineal&#46;</p>"
            ]
          ]
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Anemia&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
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                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Crisis hipertensiva&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Trasgresi&#243;n diet&#233;tico-terap&#233;utica&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">0&#44;86&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
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                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>S&#237;ndrome coronario agudo&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">99&#44;2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">79 &#40;1&#44;6&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
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                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Frecuencia cardiaca &#40;lpm&#41; &#91;mediana &#40;RIC&#41;&#93;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttop\n
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                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">85 &#40;72-100&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">84 &#40;70-100&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#44;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="elsevierStyleHsp" style=""></span>Presi&#243;n arterial sist&#243;lica &#40;mmHg&#41; &#91;mediana &#40;RIC&#41;&#93;&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">138 &#40;120-156&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">98&#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">136 &#40;120-154&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">139 &#40;121-157&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleBold">&#60;</span><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleBold">0&#44;001</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Frecuencia respiratoria &#40;rpm&#41; &#91;mediana &#40;RIC&#41;&#93;&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">20 &#40;18-26&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">68&#44;8&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">22 &#40;18-26&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">20 &#40;18-26&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleBold">&#60;</span><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleBold">0&#44;001</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
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                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Saturaci&#243;n basal de ox&#237;geno &#40;&#37;&#41; &#91;mediana &#40;RIC&#41;&#93;&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">94 &#40;90-97&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">93 &#40;89-96&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">94 &#40;91-97&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>&#205;ndice de Barthel en urgencias &#40;puntos&#41; &#91;mediana &#40;RIC&#41;&#93;&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">70 &#40;45-90&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">70 &#40;45-90&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">0&#44;99&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>NYHA-IV en urgencias&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">8&#46;930 &#40;43&#44;8&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Signos de bajo gasto&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Hipertrofia ventricular izquierda en el ECG&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">608 &#40;2&#44;9&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">136 &#40;2&#44;8&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">472 &#40;2&#44;9&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Troponina superior al percentil 99&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Creatinina &#40;mg&#47;dL&#41; &#91;mediana &#40;RIC&#41;&#93;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">1&#44;16 &#40;0&#44;88-1&#44;59&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">98&#44;8&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>Potasio &#40;mmol&#47;L&#41; &#91;mediana &#40;RIC&#41;&#93;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">4&#44;4 &#40;4&#44;0-4&#44;8&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleBold">0&#44;037</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>NT-proBNP &#40;pg&#47;mL&#41; &#91;mediana &#40;RIC&#41;&#93;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">4&#46;017&#40;1&#46;954-8&#46;853&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">60&#44;6&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">3&#46;564&#40;1&#46;712-7&#46;757&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">4&#46;137&#40;2&#46;016-9&#46;127&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleBold">&#60;</span><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleBold">0&#44;001</span>&nbsp;\t\t\t\t\t\t\n
                  \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">Gravedad de la descompensaci&#243;n</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">&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">0&#44;41&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Grupo de riesgo seg&#250;n la escala MEESSI-AHF&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\ttop\n
                  \t\t\t\t">58&#44;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
                  \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="" 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="" 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></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>Riesgo bajo&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&#46;935 &#40;39&#44;2&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" 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">1&#46;122 &#40;37&#44;3&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">3&#46;813 &#40;39&#44;8&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" 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></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>Riesgo intermedio&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&#46;081 &#40;40&#44;4&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \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">1&#46;288 &#40;42&#44;9&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">3&#46;793 &#40;39&#44;6&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" 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></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>Riesgo alto&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&#46;356 &#40;10&#44;8&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" 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">312 &#40;10&#44;4&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&#46;044 &#40;10&#44;9&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" 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></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>Riesgo muy alto&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&#46;202 &#40;9&#44;6&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" 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">283 &#40;9&#44;4&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">919 &#40;9&#44;6&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" 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></tr></tbody></table>
                  """
              ]
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                0 => "xTab3698922.png"
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          "es" => "<p id="spar0065" class="elsevierStyleSimplePara elsevierViewall">Caracter&#237;sticas del episodio agudo de descompensaci&#243;n de insuficiencia cardiaca de los pacientes incluidos en el presente estudio y comparaci&#243;n en funci&#243;n de si existe el diagn&#243;stico previo de enfermedad pulmonar obstructiva cr&#243;nica</p>"
        ]
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      3 => array:8 [
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        "etiqueta" => "Tabla 3"
        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "detalles" => array:1 [
          0 => array:3 [
            "identificador" => "at3"
            "detalle" => "Tabla "
            "rol" => "short"
          ]
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        "tabla" => array:2 [
          "leyenda" => "<p id="spar0085" class="elsevierStyleSimplePara elsevierViewall">Los valores en negrita denotan significaci&#243;n estad&#237;stica &#40;p<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#44;05&#41;&#46;</p><p id="spar0090" class="elsevierStyleSimplePara elsevierViewall">EPOC&#58; enfermedad pulmonar obstructiva cr&#243;nica&#59; RIC&#58; rango intercuartil&#46;</p>"
          "tablatextoimagen" => array:1 [
            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">TodosN<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>21&#46;694n &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Dato disponible&#37;&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">Con EPOCN<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>4&#46;952n &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Sin EPOCN<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>16&#46;742n &#40;&#37;&#41;&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">p&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="6" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Tratamiento en urgencias</span></td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Furosemida endovenosa&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">17&#46;851 &#40;84&#44;7&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">97&#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">4&#46;071 &#40;84&#44;1&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">13&#46;780 &#40;84&#44;9&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#44;18&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>Oxigenoterapia&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">14&#46;612 &#40;69&#44;5&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">97&#44;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">3&#46;598 &#40;74&#44;5&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">11&#46;014 &#40;68&#44;0&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleBold">&#60;</span><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleBold">0&#44;001</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Antibi&#243;tico endovenoso&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&#46;032 &#40;28&#44;7&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">96&#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">2&#46;344 &#40;48&#44;6&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">3&#46;688 &#40;22&#44;8&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleBold">&#60;</span><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleBold">0&#44;001</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Anticolin&#233;rgicos nebulizados&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&#46;865 &#40;23&#44;2&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">96&#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">1&#46;510 &#40;31&#44;3&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">3&#46;355 &#40;20&#44;8&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleBold">&#60;</span><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleBold">0&#44;001</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Beta-agonistas nebulizados&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&#46;814 &#40;22&#44;9&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">96&#44;7&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&#46;976 &#40;41&#44;0&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2&#46;838 &#40;17&#44;6&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleBold">&#60;</span><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleBold">0&#44;001</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Corticoides sist&#233;micos&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">3&#46;807 &#40;18&#44;1&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">96&#44;7&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&#46;474 &#40;30&#44;6&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2&#46;333 &#40;14&#44;4&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleBold">&#60;</span><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleBold">0&#44;001</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Digoxina&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">2&#46;452 &#40;11&#44;7&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">96&#44;6&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">558 &#40;11&#44;6&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&#46;894 &#40;11&#44;7&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#44;77&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>Nitratos endovenosos&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">2&#46;211 &#40;10&#44;5&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">96&#44;6&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">446 &#40;9&#44;3&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&#46;765 &#40;10&#44;9&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleBold">&#60;</span><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleBold">0&#44;001</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Ventilaci&#243;n no invasiva&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&#46;411 &#40;6&#44;7&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">96&#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">434 &#40;9&#44;0&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">977 &#40;6&#44;0&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleBold">&#60;</span><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleBold">0&#44;001</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Morfina&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&#46;205 &#40;5&#44;7&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">96&#44;6&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">268 &#40;5&#44;6&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">937 &#40;5&#44;8&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#44;53&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>Amiodarona&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">728 &#40;3&#44;5&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">96&#44;6&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">178 &#40;3&#44;7&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">550 &#40;3&#44;4&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="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="elsevierStyleHsp" style=""></span>Ventilaci&#243;n mec&#225;nica invasiva&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">385 &#40;1&#44;8&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">96&#44;7&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">103 &#40;2&#44;1&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">282 &#40;1&#44;7&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#44;08&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Inotr&#243;picos&#47;vasopresores&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">271 &#40;1&#44;5&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">96&#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">72 &#40;1&#44;5&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">199 &#40;1&#44;2&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#44;16&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="6" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="6" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Disposici&#243;n tras la atenci&#243;n en urgencias</span></td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Hospitalizaci&#243;n&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">16&#46;144 &#40;74&#44;5&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">99&#44;9&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">3&#46;812 &#40;77&#44;0&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">12&#46;332 &#40;73&#44;7&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleBold">&#60;</span><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleBold">0&#44;001</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Hospitalizaci&#243;n en intensivos&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">270 &#40;1&#44;3&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">94&#44;7&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 &#40;1&#44;0&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">222 &#40;1&#44;4&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleBold">0&#44;036</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
              ]
              "imagenFichero" => array:1 [
                0 => "xTab3698923.png"
              ]
            ]
          ]
        ]
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          "es" => "<p id="spar0080" class="elsevierStyleSimplePara elsevierViewall">Manejo en urgencias de los pacientes con insuficiencia cardiaca aguda incluidos en el presente estudio y comparaci&#243;n en funci&#243;n de si existe el diagn&#243;stico previo de enfermedad pulmonar obstructiva cr&#243;nica</p>"
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          "leyenda" => "<p id="spar0100" class="elsevierStyleSimplePara elsevierViewall">EPOC&#58; enfermedad pulmonar obstructiva cr&#243;nica&#59; IC&#58; intervalo de confianza&#59; MEESSI-AHF&#58; <span class="elsevierStyleItalic">Multiple Estimation of risk based on the Emergency department Spanish Score in Acute Heart Failure</span>&#59; OR&#58; <span class="elsevierStyleItalic">odds ratio</span>&#46;</p>"
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                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="\n
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                  \t\t\t\t  " align="" valign="\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
                  \t\t\t\t\t\t</th><th class="td" title="\n
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Mortalidad intrahospitalaria&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Mortalidad a 30 d&#237;as<a class="elsevierStyleCrossRef" href="#tblfn0010"><span class="elsevierStyleSup">a</span></a>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleItalic">Todos los pacientes EPOC &#40;N</span><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">&#61;</span><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">21&#46;694&#41;</span></td></tr><tr title="table-row"><td class="td-with-role" title="\n
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                  \t\t\t\t">1&#46;655 &#40;7&#44;6&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">2&#46;209 &#40;10&#44;3&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
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                  \t\t\t\t"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="\n
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                  \t\t\t\t"><span class="elsevierStyleItalic">Pacientes EPOC &#40;N</span><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">&#61;</span><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">4&#46;952&#41;</span></td></tr><tr title="table-row"><td class="td-with-role" title="\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>N eventos &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">401 &#40;8&#44;1&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">542 &#40;11&#44;0&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="\n
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                  \t\t\t\t"><span class="elsevierStyleItalic">Pacientes sin EPOC &#40;N</span><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">&#61;</span><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">16&#46;742&#41;</span></td></tr><tr title="table-row"><td class="td-with-role" title="\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>N eventos &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&#46;254 &#40;7&#44;5&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&#46;667 &#40;10&#44;0&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="3" align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="\n
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                  \t\t\t\t"><span class="elsevierStyleItalic">Odds ratio &#40;IC 95&#37;&#41; para los pacientes EPOC &#40;N</span><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">&#61;</span><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">21&#46;694&#41;</span></td></tr><tr title="table-row"><td class="td-with-role" title="\n
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                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Cruda&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&#44;088 &#40;0&#44;968-1&#44;224&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleBold">1&#44;111 &#40;1&#44;007-1&#44;261&#41;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
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                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Ajustada por caracter&#237;sticas basales&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&#44;098 &#40;0&#44;966-1&#44;247&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleBold">1&#44;127 &#40;1&#44;053-1&#44;313&#41;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Ajustada por caracter&#237;sticas del episodio&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">1&#44;017 &#40;0&#44;898-1&#44;153&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">1&#44;041 &#40;0&#44;933-1&#44;162&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Ajustada por manejo en urgencias&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">0&#44;966 &#40;0&#44;852-1&#44;094&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t">1&#44;009 &#40;0&#44;905-1&#44;125&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Ajuste total&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&#44;040 &#40;0&#44;905-1&#44;195&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&#44;080 &#40;0&#44;957-1&#44;219&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="\n
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                  \t\t\t\t"><span class="elsevierStyleItalic">Odds ratio &#40;IC 95&#37;&#41; ajustada &#40;ajuste total&#41; para los pacientes EPOC para subgrupos de gravedad seg&#250;n la escala MEESSI-AHF &#40;N</span><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">&#61;</span><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">12&#46;574&#41;</span></td></tr><tr title="table-row"><td class="td-with-role" title="\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Riesgo bajo&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;899 &#40;0&#44;497-1&#44;626&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">1&#44;164 &#40;0&#44;759-1&#44;783&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Riesgo incrementado &#40;intermedio&#44; alto o muy alto&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">1&#44;148 &#40;0&#44;954-1&#44;381&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t">1&#44;087 &#40;0&#44;921-1&#44;284&#41;&nbsp;\t\t\t\t\t\t\n
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              "nota" => "<p class="elsevierStyleNotepara" id="npar0010">En 158 pacientes &#40;33 EPOC y 125 no EPOC&#41; no se dispone de la mortalidad a 30 d&#237;as&#46;</p> <p class="elsevierStyleNotepara" id="npar0015">Negrita&#58; datos estad&#237;sticamente significativos&#46;</p>"
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          "es" => "<p id="spar0095" class="elsevierStyleSimplePara elsevierViewall">Mortalidad intrahospitalaria y a los 30 d&#237;as de la consulta en urgencias en los pacientes con insuficiencia cardiaca aguda incluidos en el presente estudio y comparaci&#243;n en funci&#243;n de si existe el diagn&#243;stico previo de enfermedad pulmonar obstructiva cr&#243;nica</p>"
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          "identificador" => "bibs0015"
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              "identificador" => "bib0245"
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                0 => array:2 [
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                    0 => array:2 [
                      "titulo" => "2021 ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure"
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                          "colaboracion" => "ESC Scientific Document Group"
                          "etal" => true
                          "autores" => array:6 [
                            0 => "T&#46;A&#46; Donagh"
                            1 => "M&#46; Metra"
                            2 => "M&#46; Adamo"
                            3 => "R&#46;S&#46; Gardner"
                            4 => "A&#46; Baumbach"
                            5 => "M&#46; B&#246;hm"
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                        "tituloSerie" => "Eur Heart J&#46;"
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                        "paginaFinal" => "3726"
                      ]
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              "identificador" => "bib0250"
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                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Developed in collaboration with the Heart Failure Association &#40;HFA&#41; of the ESC"
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                          "colaboracion" => "ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure 2012&#58; The Task Force for the Diagnosis and Treatment of Acute and Chronic Heart Failure 2012 of the European Society of Cardiology"
                          "etal" => true
                          "autores" => array:6 [
                            0 => "J&#46;J&#46;V&#46; McMurray"
                            1 => "S&#46; Adamopoulos"
                            2 => "S&#46;D&#46; Anker"
                            3 => "A&#46; Auricchio"
                            4 => "M&#46; B&#246;hm"
                            5 => "K&#46; Dickstein"
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                    0 => array:1 [
                      "Revista" => array:5 [
                        "tituloSerie" => "Eur Heart J"
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              "identificador" => "bib0255"
              "etiqueta" => "3"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "2016 ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure&#58; The Task Force for the diagnosis and treatment of acute and chronic heart failure of the European Society of Cardiology &#40;ESC&#41; developed with the special contribution of the Heart Failure Association &#40;HFA&#41; of the ESC"
                      "autores" => array:1 [
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                          "etal" => true
                          "autores" => array:6 [
                            0 => "P&#46; Ponikowski"
                            1 => "A&#46;A&#46; Voors"
                            2 => "S&#46;D&#46; Anker"
                            3 => "H&#46; Bueno"
                            4 => "J&#46;G&#46;F&#46; Cleland"
                            5 => "A&#46;J&#46;S&#46; Coats"
                          ]
                        ]
                      ]
                    ]
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                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1093/eurheartj/ehw128"
                      "Revista" => array:6 [
                        "tituloSerie" => "Eur Heart J"
                        "fecha" => "2016"
                        "volumen" => "37"
                        "paginaInicial" => "2129"
                        "paginaFinal" => "2200"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/27206819"
                            "web" => "Medline"
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