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reducida<a class="elsevierStyleCrossRefs" href="#bib0195"><span class="elsevierStyleSup">8&#44;9</span></a>&#46; El objetivo de este estudio fue evaluar la utilidad combinada de la exploraci&#243;n f&#237;sica y de la determinaci&#243;n de NTproBNP&#44; como marcadores de congesti&#243;n combinada&#44; en el paciente ambulatorio con insuficiencia card&#237;aca&#44; para estratificar su pron&#243;stico&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Pacientes y m&#233;todos</span><p id="par0020" class="elsevierStylePara elsevierViewall">Se trata de un estudio descriptivo&#44; observacional y retrospectivo&#44; en el que se analizan los datos de pacientes con insuficiencia cardiaca en seguimiento entre los a&#241;os 2010 y 2018 en una consulta monogr&#225;fica en el servicio de Medicina Interna del Hospital Universitario de la Princesa&#46; Los pacientes eran derivados a la consulta tras un ingreso hospitalario por insuficiencia card&#237;aca &#40;tanto <span class="elsevierStyleItalic">de novo</span> como cr&#243;nica reagudizada&#41; en el propio servicio&#44; o bien derivados de otros servicios&#44; con el motivo principal de insuficiencia card&#237;aca&#46; La consulta ha sido atendida por el mismo m&#233;dico&#44; y se han seguido pautas de tratamiento acorde a gu&#237;as cl&#237;nicas&#46;</p><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Dise&#241;o del estudio</span><p id="par0025" class="elsevierStylePara elsevierViewall">En la visita inicial o basal se realiz&#243; una exploraci&#243;n f&#237;sica completa y la determinaci&#243;n de NTproBNP&#44; junto con una anal&#237;tica general&#44; unos d&#237;as antes de la consulta&#46; Se recogi&#243; la mortalidad global&#44; la mortalidad por insuficiencia card&#237;aca y los ingresos por insuficiencia card&#237;aca al a&#241;o de la visita basal&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">La congesti&#243;n cl&#237;nica se defini&#243; como&#58; ausente &#40;no signos&#41; o presentes &#40;edemas y&#47;o crepitantes&#41;&#46; La presencia de crepitantes pulmonares se interpret&#243; como positiva cuando eran audibles&#44; al menos&#44; en el tercio basal de uno o ambos pulmones&#46; Los edemas perif&#233;ricos se interpretaron como positivos a partir de presentar f&#243;vea maleolar bilateral&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">Se clasificaron los pacientes en 4 grupos en funci&#243;n del patr&#243;n congestivo&#58; G1 &#40;no congesti&#243;n&#41;&#44; G2 &#40;congesti&#243;n cl&#237;nica<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>NTproBNP<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>1500<span class="elsevierStyleHsp" style=""></span>pg&#47;mL&#41;&#44; G3 &#40;sin congesti&#243;n cl&#237;nica<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>NTproBNP<span class="elsevierStyleHsp" style=""></span>&#8805;<span class="elsevierStyleHsp" style=""></span>1500<span class="elsevierStyleHsp" style=""></span>pg&#47;mL o congesti&#243;n hemodin&#225;mica&#41; y G4 &#40;congesti&#243;n cl&#237;nica y NTproBNP<span class="elsevierStyleHsp" style=""></span>&#8805;<span class="elsevierStyleHsp" style=""></span>1500<span class="elsevierStyleHsp" style=""></span>pg&#47;mL o congesti&#243;n combinada&#41;&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Variables analizadas</span><p id="par0040" class="elsevierStylePara elsevierViewall">Se recogieron datos demogr&#225;ficos&#44; cl&#237;nicos &#40;n&#250;mero de ingresos previos por insuficiencia card&#237;aca&#44; alta hospitalaria reciente por insuficiencia card&#237;aca &#91;entre 1-4 meses antes de visita basal&#93; y comorbilidades&#41;&#44; anal&#237;ticos &#40;hemoglobina&#44; par&#225;metros de funci&#243;n renal&#41; y ecocardiogr&#225;ficos &#40;funci&#243;n del ventr&#237;culo izquierdo y derecho&#44; tama&#241;o de aur&#237;cula izquierda&#44; presi&#243;n pulmonar estimada&#41;&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">Se evalu&#243; como variable principal la muerte por cualquier causa y como variable secundaria la variable combinada de muerte o ingreso por insuficiencia card&#237;aca al a&#241;o de la visita inicial&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Seguimiento</span><p id="par0050" class="elsevierStylePara elsevierViewall">Los pacientes tuvieron un seguimiento a los 3&#44; 6 y 12 meses de incorporarse a la consulta&#44; con ajuste en funci&#243;n de sus necesidades cl&#237;nicas&#46;</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">An&#225;lisis estad&#237;stico</span><p id="par0055" class="elsevierStylePara elsevierViewall">Las variables cuantitativas se presentan como media y desviaci&#243;n est&#225;ndar o como mediana y rango intercuart&#237;lico y las variables cualitativas como frecuencias absolutas y porcentajes&#46; Para las variables cuantitativas&#44; la comparaci&#243;n entre grupos se ha realizado con la prueba <span class="elsevierStyleItalic">t</span> de Student&#44; la prueba de Mann-Whitney&#44; el ANOVA de un factor y la prueba post-hoc de Tukey o Games Howell&#59; y para las variables cualitativas la comparaci&#243;n entre grupos se ha llevado a cabo con la prueba de chi cuadrado&#44; utilizando cuando fue necesario los residuos de Haberman o la prueba exacta de Fisher&#46;</p><p id="par0060" class="elsevierStylePara elsevierViewall">Con objeto de estudiar los factores relacionados con la muerte por cualquier causa y la muerte&#47;ingreso por insuficiencia card&#237;aca se han desarrollado modelos de regresi&#243;n log&#237;stica en los que se han introducido como variables de confusi&#243;n aquellas que en un estudio bivariante se asociaron a los desenlaces estudiados&#46; Se han utilizado modelos de Cox con las mismas variables de confusi&#243;n para estudiar el tiempo hasta los desenlaces&#46; Adem&#225;s&#44; el an&#225;lisis de supervivencia se ha estratificado seg&#250;n los pacientes presentasen FEVI reducida &#40;ICFER&#41; &#40;&#60;<span class="elsevierStyleHsp" style=""></span>40&#37;&#41;&#44; moderadamente reducida &#40;ICFEmr&#41; &#40;40-49&#37;&#41; y preservada &#40;ICFEP&#41; &#40;&#8805;<span class="elsevierStyleHsp" style=""></span>50&#37;&#41;&#44; comparando en cada nivel de FEVI las funciones de supervivencia de diferentes grupos de congesti&#243;n cl&#237;nica y&#47;o hemodin&#225;mica por el procedimiento log-rank&#46; Los valores p menores de 0&#44;05 se consideran estad&#237;sticamente significativos&#46;</p><p id="par0065" class="elsevierStylePara elsevierViewall">Todos los an&#225;lisis se han realizado con el paquete estad&#237;stico IBM SPSS 23&#46;0 &#40;Armonk&#44; NY&#59; EE&#58; UU&#46;&#41;&#46;</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Aspectos &#233;ticos</span><p id="par0070" class="elsevierStylePara elsevierViewall">Se siguieron los principios &#233;ticos de la Declaraci&#243;n de Helsinki y se solicit&#243; el consentimiento informado a los pacientes para participar en el estudio&#46; El protocolo fue aprobado por el Comit&#233; de &#201;tica en Investigaci&#243;n Cl&#237;nica del Hospital Universitario de La Princesa de Madrid&#46;</p></span></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">Resultados</span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0105">Caracter&#237;sticas de la cohorte</span><p id="par0075" class="elsevierStylePara elsevierViewall">La cohorte inicial engloba a un total de 341 pacientes&#46; Se perdieron 7 pacientes en el seguimiento y 96 pacientes no ten&#237;an determinaciones de NTproBNP al inicio del seguimiento&#46; As&#237;&#44; se pudo realizar una valoraci&#243;n de la congesti&#243;n cl&#237;nica y hemodin&#225;mica combinadas en 238 pacientes&#44; que es la poblaci&#243;n objeto del estudio&#46;</p><p id="par0080" class="elsevierStylePara elsevierViewall">Predominaba el sexo femenino&#44; con 148 mujeres &#40;61&#44;8&#37;&#41; y la edad avanzada&#44; con una mediana de 83 a&#241;os &#40;rango&#58; 51-101&#41;&#46; La cardiopat&#237;a basal m&#225;s frecuente fue la valvular y la hipertensiva&#46; El 70&#37; ten&#237;a fibrilaci&#243;n auricular y el 71&#44;6&#37; de los pacientes presentaba ICFEP&#46; El 43&#44;4&#37; de los pacientes presentaba hipertensi&#243;n pulmonar severa&#46; El 80&#37; de los pacientes fue valorado tras un alta hospitalaria reciente por insuficiencia card&#237;aca&#46; El filtrado glomerular &#40;FGe&#41; medio fue de 52&#44;35<span class="elsevierStyleHsp" style=""></span>mL&#47;min&#47;1&#44;73<span class="elsevierStyleHsp" style=""></span>m<span class="elsevierStyleSup">2</span>&#46; El 77&#44;4&#37; de los pacientes recib&#237;a tratamiento con IECA&#47;ARA II&#59; el 52&#37; tomaba betabloqueantes&#44; y el 9&#44;8&#37; de los pacientes no recib&#237;a diur&#233;tico del asa &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">tabla 1</a>&#41;&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0110">Congesti&#243;n y pron&#243;stico</span><p id="par0085" class="elsevierStylePara elsevierViewall">La poblaci&#243;n se distribuy&#243; en 4 grupos en funci&#243;n de la exploraci&#243;n f&#237;sica y el NTproBNP&#58; 18&#37; G1&#59; 21&#37; G2&#59; 31&#37; G3 y 30&#37; G4&#46; Las diferencias entre la poblaci&#243;n en funci&#243;n de la congesti&#243;n est&#225;n recogidas en la <a class="elsevierStyleCrossRef" href="#tbl0005">tabla 1</a>&#46;</p><p id="par0090" class="elsevierStylePara elsevierViewall">A lo largo del primer a&#241;o de seguimiento fallecieron 30 pacientes &#40;12&#44;6&#37;&#41;&#44; mientras que 69 &#40;29&#37;&#41; murieron o fueron ingresados por insuficiencia card&#237;aca&#46; La tasa de mortalidad global vari&#243; en funci&#243;n del tipo de congesti&#243;n&#44; siendo la menor la de G1 &#40;4&#37;&#41; y la mayor la de G4 &#40;24&#37;&#41;&#46;</p><p id="par0095" class="elsevierStylePara elsevierViewall">En los an&#225;lisis multivariantes para estudiar la relaci&#243;n de la congesti&#243;n combinada con los desenlaces&#44; se utilizaron como variables de confusi&#243;n el sexo&#44; el alta hospitalaria reciente por insuficiencia card&#237;aca&#44; el FGe y la FEVI&#44; en base a los hallazgos del an&#225;lisis univariante&#46; La congesti&#243;n combinada fue el &#250;nico factor independiente asociado a la muerte por cualquier causa &#40;p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;012&#41;&#46; El riesgo de muerte por cualquier causa&#44; tomando G1 como grupo de referencia&#44; fue&#58; G2&#44; HR 4&#44;121 &#40;IC95&#37; 1&#44;131-15&#44;019&#41;&#59; G3&#44; HR 2&#44;511 &#40;IC95&#37; 1&#44;007-6&#44;263&#41;&#44; y G4&#44; HR 7&#44;418 &#40;IC95&#37; 1&#44;630-33&#44;763&#41;&#46; No se encontraron diferencias significativas entre los grupos G1 y G2 &#40;p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;183&#41;&#44; ni G1 y G3 &#40;p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;177&#41;&#46;</p><p id="par0100" class="elsevierStylePara elsevierViewall">La congesti&#243;n combinada no se asoci&#243; significativamente con la muerte&#47;ingreso por insuficiencia cardiaca&#44; mientras que s&#237; lo hicieron el alta hospitalaria reciente &#40;p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;027&#41; y el FGe basal &#40;p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;038&#41;&#46; Los pacientes que iniciaron seguimiento tras un alta hospitalaria por insuficiencia card&#237;aca presentaban mayor riesgo de muerte o ingreso por insuficiencia card&#237;aca que los pacientes sin ingresos recientes &#40;HR 2&#44;827 &#91;IC95&#37; 1&#44;170-6&#44;833&#93;&#41;&#44; mientras que los pacientes con un FGe<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>30<span class="elsevierStyleHsp" style=""></span>mL&#47;min&#47;1&#44;73<span class="elsevierStyleHsp" style=""></span>m<span class="elsevierStyleSup">2</span> presentaron un riesgo de muerte&#47;ingreso por insuficiencia card&#237;aca mayor que los pacientes con FGe<span class="elsevierStyleHsp" style=""></span>&#8805;<span class="elsevierStyleHsp" style=""></span>60<span class="elsevierStyleHsp" style=""></span>mL&#47;min&#47;1&#44;73<span class="elsevierStyleHsp" style=""></span>m<span class="elsevierStyleSup">2</span>&#44; HR 2&#44;723 &#91;IC95&#37; 1&#44;164-6&#44;347&#41;&#44; sin encontrarse diferencias significativas entre los pacientes con FGe 30-60<span class="elsevierStyleHsp" style=""></span>mL&#47;min y los pacientes con FGe<span class="elsevierStyleHsp" style=""></span>&#8805;<span class="elsevierStyleHsp" style=""></span>60<span class="elsevierStyleHsp" style=""></span>mL&#47;min&#47;1&#44;73m<span class="elsevierStyleSup">2</span> &#40;p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;650&#41;&#44; ni interacci&#243;n significativa entre variables &#40;p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;446&#41;&#46;</p><p id="par0105" class="elsevierStylePara elsevierViewall">La velocidad de muerte por cualquier causa se asoci&#243; con la presencia de congesti&#243;n combinada &#40;p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;007&#41;&#46; La velocidad de muerte&#44; tomando G1 como grupo referencia&#44; fue&#58; G2&#44; HR 3&#44;909 &#40;IC95&#37; 1&#44;145-13&#44;347&#41;&#59; G3&#44; HR 2&#44;380 &#40;IC95&#37; 1&#44;027-5&#44;517&#41;&#44; y G4&#44; HR 7&#44;460 &#40;IC95&#37; 1&#44;717-32&#44;406&#41;&#46; No se encontraron diferencias significativas entre los grupos G1 y G2 &#40;p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;149&#41;&#44; ni G1 y G3 &#40;p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;479&#41;&#46;</p><p id="par0110" class="elsevierStylePara elsevierViewall">Se realiz&#243; un an&#225;lisis de supervivencia estratificando la FEVI basal en 3 categor&#237;as&#46; Se representan las funciones de supervivencia para mortalidad por cualquier causa &#40;<a class="elsevierStyleCrossRef" href="#fig0005">fig&#46; 1</a>&#41; y mortalidad o ingreso por insuficiencia card&#237;aca &#40;<a class="elsevierStyleCrossRef" href="#fig0010">fig&#46; 2</a><span class="elsevierStyleBold">&#41;</span> en cada grupo de pacientes&#46; No se objetivaron diferencias en la mortalidad por cualquier causa en funci&#243;n de la FEVI&#46; Sin embargo&#44; se observ&#243; significativamente mayor mortalidad o ingreso por insuficiencia card&#237;aca en los pacientes G4 vs&#46; G3&#44; con FEVI basal<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>40&#37; &#40;p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;027&#41;&#44; con una tendencia similar entre G1 vs&#46; G4 y G2 vs&#46; G4&#46; Por ello&#44; se realiz&#243; un nuevo an&#225;lisis de regresi&#243;n log&#237;stica agrupando los pacientes sin congesti&#243;n y con congesti&#243;n simple&#44; G1<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>G2<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>G3&#44; encontrando que el riesgo de muerte o ingreso por insuficiencia card&#237;aca era el doble en G4&#44; HR 2&#44;167 &#40;IC95&#37; 1&#44;174-4&#44;002&#41; que en G1<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>G2<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>G3&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0115" class="elsevierStylePara elsevierViewall">La FEVI no se asoci&#243; significativamente al combinado de muerte o ingreso por insuficiencia card&#237;aca &#40;p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;365&#41;&#46; En el an&#225;lisis de supervivencia&#44; la velocidad de muerte o ingreso por insuficiencia card&#237;aca fue significativamente mayor en G4 &#40;media estimada 13&#44;8 meses &#91;IC95&#37; 12&#44;0-15&#44;6&#93;&#41;&#44; que en los pacientes G1<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>G2<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>G3 &#40;media estimada 16&#44;5 meses &#91;IC95&#37; 15&#44;6-17&#44;5&#93;&#41; &#40;p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;009&#41;&#44; mientras que el an&#225;lisis estratificado por FEVI el grupo G4 demostr&#243; mayor velocidad para alcanzar el desenlace muerte&#47;ingreso por insuficiencia card&#237;aca&#44; tanto en pacientes con ICFER &#40;p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;028&#41;&#44; como con ICFEP &#40;p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;041&#41;&#44; pero no en los pacientes con ICFEmr &#40;p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;869&#41;&#46; Las funciones de supervivencia se presentan en la <a class="elsevierStyleCrossRef" href="#fig0015">figura 3</a>&#46;</p><elsevierMultimedia ident="fig0015"></elsevierMultimedia></span></span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0115">Discusi&#243;n</span><p id="par0120" class="elsevierStylePara elsevierViewall">En los pacientes ancianos con insuficiencia cardiaca en seguimiento ambulatorio&#44; la congesti&#243;n combinada&#44; cl&#237;nica y hemodin&#225;mica&#44; es un factor predictor de mortalidad global y de muerte o ingreso por insuficiencia card&#237;aca&#46; El alta hospitalaria reciente y la insuficiencia renal tambi&#233;n se asocian a la variable combinada de ingreso&#47;muerte por insuficiencia card&#237;aca&#46;</p><p id="par0125" class="elsevierStylePara elsevierViewall">En el presente estudio el 30&#37; de los pacientes presentaban congesti&#243;n combinada y el 52&#37; congesti&#243;n simple &#40;cl&#237;nica o hemodin&#225;mica aislada&#41;&#46; La congesti&#243;n en la insuficiencia card&#237;aca se ha identificado como un factor pron&#243;stico&#44; fundamentalmente en el contexto de la descompensaci&#243;n aguda&#44; tanto cuando se eval&#250;a al ingreso<a class="elsevierStyleCrossRef" href="#bib0205"><span class="elsevierStyleSup">10</span></a> como al alta hospitalaria<a class="elsevierStyleCrossRefs" href="#bib0160"><span class="elsevierStyleSup">1&#44;2</span></a>&#46;</p><p id="par0130" class="elsevierStylePara elsevierViewall">Para vencer las limitaciones derivadas de la exploraci&#243;n f&#237;sica&#44; se han desarrollado escalas que suman varios signos o s&#237;ntomas de congesti&#243;n&#44; y que est&#225;n basados en trabajos que engloban cohortes diferentes a la estudiada&#44; con 70-80&#37; de pacientes varones&#44; con una edad entre 51-68 a&#241;os&#44; FEVI media entre 20-36&#37;&#44; de etiolog&#237;a mayoritariamente isqu&#233;mica y en el contexto del alta hospitalaria o el seguimiento ambulatorio precoz<a class="elsevierStyleCrossRefs" href="#bib0160"><span class="elsevierStyleSup">1&#44;2&#44;11&#8211;13</span></a>&#46;</p><p id="par0135" class="elsevierStylePara elsevierViewall">Algunas de estas escalas incluyen m&#250;ltiples variables&#44; entre ellas&#44; la valoraci&#243;n de la ingurgitaci&#243;n venosa yugular&#44; que conlleva limitaci&#243;n t&#233;cnica y de interpretaci&#243;n<a class="elsevierStyleCrossRef" href="#bib0225"><span class="elsevierStyleSup">14</span></a>&#44; mientras que los pacientes con insuficiencia renal avanzada o valvulopat&#237;as severas suelen estar excluidos&#46;</p><p id="par0140" class="elsevierStylePara elsevierViewall">En cuanto a los p&#233;ptidos natriur&#233;ticos&#44; los niveles elevados de NTproBNP al alta tras una hospitalizaci&#243;n por insuficiencia card&#237;aca aguda o la falta de descenso durante el ingreso se correlacionan con peor pron&#243;stico a corto plazo<a class="elsevierStyleCrossRef" href="#bib0165"><span class="elsevierStyleSup">2</span></a>&#46; Los niveles de p&#233;ptidos natriur&#233;ticos se correlacionan con la severidad de la congesti&#243;n&#44; indicando los valores<span class="elsevierStyleHsp" style=""></span>&#62;<span class="elsevierStyleHsp" style=""></span>1500-3000<span class="elsevierStyleHsp" style=""></span>pg&#47;mL un grado de congesti&#243;n moderado-severo<a class="elsevierStyleCrossRef" href="#bib0160"><span class="elsevierStyleSup">1</span></a>&#46; Sin embargo&#44; en el contexto de la insuficiencia card&#237;aca cr&#243;nica&#44; la terapia guiada por p&#233;ptidos natriur&#233;ticos frente a manejo cl&#237;nico no ha demostrado mejores resultados en mortalidad o reingresos&#44; especialmente en pacientes mayores de 75 a&#241;os<a class="elsevierStyleCrossRef" href="#bib0230"><span class="elsevierStyleSup">15</span></a>&#46;</p><p id="par0145" class="elsevierStylePara elsevierViewall">La mayor&#237;a de los estudios muestran que beneficios del tratamiento guiado seg&#250;n NTproBNP se han observado solo en pacientes con ICFER y que las comorbilidades explican la menor capacidad predictiva de los p&#233;ptidos natriur&#233;ticos en los pacientes ancianos<a class="elsevierStyleCrossRef" href="#bib0235"><span class="elsevierStyleSup">16</span></a>&#46; No obstante&#44; Rubio-Gracia et al&#46; han mostrado de manera reciente c&#243;mo los valores al alta hospitalaria muy elevados de NTproBNP fueron predictores independientes de mortalidad global tras un a&#241;o de seguimiento en una consulta monogr&#225;fica de insuficiencia card&#237;aca&#44; en pacientes con perfil muy similar al descrito en el actual trabajo<a class="elsevierStyleCrossRef" href="#bib0205"><span class="elsevierStyleSup">10</span></a>&#46;</p><p id="par0150" class="elsevierStylePara elsevierViewall">A nivel ambulatorio&#44; Curbelo et al&#46;<a class="elsevierStyleCrossRef" href="#bib0240"><span class="elsevierStyleSup">17</span></a>&#44; de nuestro grupo&#44; han mostrado la utilidad pron&#243;stica del uso combinado de p&#233;ptidos natriur&#233;ticos&#44; ecograf&#237;a de vena cava inferior y pulmonar y bioimpedancia en pacientes con insuficiencia card&#237;aca cr&#243;nica&#46; Sin embargo&#44; en ambos trabajos el punto de corte del NTproBNP fue m&#225;s elevado que el del trabajo actual y las t&#233;cnicas ecogr&#225;ficas no son con frecuencia accesibles y precisan formaci&#243;n&#46; En nuestro estudio&#44; solo la presencia de congesti&#243;n combinada fue un factor de riesgo independiente para mortalidad por cualquier causa&#44; aumentando en m&#225;s de 7 veces el riesgo al compararla con los pacientes sin congesti&#243;n&#46; El riesgo de muerte o ingreso por insuficiencia card&#237;aca fue el doble en los pacientes con congesti&#243;n combinada en comparaci&#243;n con los pacientes sin congesti&#243;n y con congesti&#243;n simple&#46;</p><p id="par0155" class="elsevierStylePara elsevierViewall">Resultados comparables con los de la cohorte de Damy et al&#46;<a class="elsevierStyleCrossRef" href="#bib0245"><span class="elsevierStyleSup">18</span></a>&#44; donde la mortalidad global aument&#243; tambi&#233;n a mayor congesti&#243;n&#44; siendo del 5&#44;1&#37; en los pacientes sin congesti&#243;n y del 23&#44;1&#37; en los pacientes que presentaban congesti&#243;n card&#237;aca de cavidades derechas e izquierdas&#46; En un an&#225;lisis <span class="elsevierStyleItalic">post-hoc</span> del estudio AF-CHF &#40;Atrial Fibrillation and Chronic Heart Failure&#41;&#44; los 4 signos congestivos evaluados &#40;ingurgitaci&#243;n venosa yugular&#44; tercer ruido card&#237;aco&#44; edemas perif&#233;ricos y crepitantes pulmonares&#41; aportaron informaci&#243;n pron&#243;stica&#44; si bien solo los 2 &#250;ltimos se asociaron a la mortalidad cardiovascular<a class="elsevierStyleCrossRef" href="#bib0250"><span class="elsevierStyleSup">19</span></a>&#46; Tambi&#233;n los valores elevados de NTproBNP &#40;&#8805;<span class="elsevierStyleHsp" style=""></span>1000<span class="elsevierStyleHsp" style=""></span>pg&#47;mL&#41; se han asociado a peor pron&#243;stico&#44; sobre todo en pacientes ambulatorios a&#241;osos con ICFER o ICFEmr<a class="elsevierStyleCrossRef" href="#bib0255"><span class="elsevierStyleSup">20</span></a>&#46;</p><p id="par0160" class="elsevierStylePara elsevierViewall">En trabajos previos con poblaci&#243;n anciana hospitalizada por insuficiencia card&#237;aca&#44; no se han observado diferencias de pron&#243;stico en funci&#243;n de la FEVI<a class="elsevierStyleCrossRef" href="#bib0260"><span class="elsevierStyleSup">21</span></a>&#46; Los signos cl&#237;nicos y los par&#225;metros ecocardiogr&#225;ficos de congesti&#243;n no difieren entre ICFER vs&#46; ICFEP&#44; mientras que en ICFEP se describen menores valores de NTproBNP<a class="elsevierStyleCrossRef" href="#bib0265"><span class="elsevierStyleSup">22</span></a>&#46; En nuestro estudio&#44; la mortalidad global no difiri&#243; tampoco en funci&#243;n de la FEVI&#46; La muerte o ingreso por insuficiencia card&#237;aca ocurri&#243; antes en los pacientes con congesti&#243;n combinada que en el resto de los pacientes&#44; para cualquier grupo de FEVI excepto en los pacientes con ICFEmr&#44; si bien este efecto puede deberse al menor tama&#241;o de este grupo&#46;</p><p id="par0165" class="elsevierStylePara elsevierViewall">Es importante resaltar que los pacientes con congesti&#243;n combinada aglutinan varias caracter&#237;sticas asociadas a peor pron&#243;stico&#58; el sexo masculino<a class="elsevierStyleCrossRef" href="#bib0270"><span class="elsevierStyleSup">23</span></a>&#44; el alta hospitalaria reciente<a class="elsevierStyleCrossRef" href="#bib0275"><span class="elsevierStyleSup">24</span></a>&#44; la insuficiencia renal<a class="elsevierStyleCrossRefs" href="#bib0280"><span class="elsevierStyleSup">25&#44;26</span></a>&#44; la presencia de disfunci&#243;n del ventr&#237;culo derecho o la hipertensi&#243;n pulmonar<a class="elsevierStyleCrossRef" href="#bib0290"><span class="elsevierStyleSup">27</span></a> o el crecimiento de la aur&#237;cula izquierda<a class="elsevierStyleCrossRef" href="#bib0295"><span class="elsevierStyleSup">28</span></a>&#44; los valores bajos de presi&#243;n arterial o hemoglobina<a class="elsevierStyleCrossRef" href="#bib0300"><span class="elsevierStyleSup">29</span></a> y el tratamiento con dosis altas de furosemida<a class="elsevierStyleCrossRefs" href="#bib0305"><span class="elsevierStyleSup">30&#44;31</span></a>&#46;</p><span id="sec0060" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0120">Limitaciones y fortalezas</span><p id="par0170" class="elsevierStylePara elsevierViewall">Se trata de un estudio retrospectivo&#44; realizado en un &#250;nico centro&#46; El ecocardiograma estaba realizado en el contexto de pr&#225;ctica cl&#237;nica diaria&#44; y los par&#225;metros se incluyeron en la fecha m&#225;s cercana a la inclusi&#243;n en el registro&#44; sin poder incluir datos de funci&#243;n diast&#243;lica&#46; Tampoco se han recogido datos sobre la dependencia&#44; la fragilidad&#44; el estado nutricional o el &#237;ndice de masa corporal&#44; que pueden actuar como variables relacionadas con la mortalidad en esta poblaci&#243;n&#46;</p><p id="par0175" class="elsevierStylePara elsevierViewall">Los datos de la exploraci&#243;n f&#237;sica se han recogido sin una supervisi&#243;n independiente&#46; Tampoco se han recogido los cambios de tratamiento a los 6 meses de seguimiento&#46; Ser&#237;a necesario un estudio de mayores dimensiones para demostrar diferencias en la variable combinada de insuficiencia card&#237;aca para el grupo de ICFEmr&#46; A cambio&#44; los datos obtenidos son derivados de pacientes de la &#171;vida real&#187;&#44; y vienen a aportar evidencia en un campo de incertidumbre&#46;</p><p id="par0180" class="elsevierStylePara elsevierViewall">En conclusi&#243;n&#44; la exploraci&#243;n f&#237;sica y la determinaci&#243;n del NTproBNP se muestran &#250;tiles de manera combinada&#44; para identificar a los pacientes ambulatorios con insuficiencia card&#237;aca con peor pron&#243;stico&#44; tanto en pacientes con ICFER e ICFEP&#46; La identificaci&#243;n de este perfil de paciente de alto riesgo deber&#237;a conllevar una revisi&#243;n de la idoneidad del tratamiento y una estrategia de control m&#225;s estrecha en la planificaci&#243;n del seguimiento&#44; para intentar mejorar el pron&#243;stico&#46;</p></span></span><span id="sec0065" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0125">Conflicto de intereses</span><p id="par0185" class="elsevierStylePara elsevierViewall">Los autores declaran no tener ning&#250;n conflicto de intereses&#46;</p></span><span id="sec0070" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0130">Financiaci&#243;n</span><p id="par0190" class="elsevierStylePara elsevierViewall">Este estudio no ha recibido ning&#250;n tipo de financiaci&#243;n&#46;</p></span></span>"
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        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Introducci&#243;n</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">El objetivo del estudio fue evaluar si la exploraci&#243;n f&#237;sica y la determinaci&#243;n de la fracci&#243;n N-terminal del prop&#233;ptido natriur&#233;tico cerebral pueden predecir un peor pron&#243;stico en pacientes ambulatorios con insuficiencia card&#237;aca&#46;</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Pacientes y m&#233;todos</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Estudio retrospectivo llevado a cabo entre 2010 y 2018&#44; en 238 pacientes diagnosticados de insuficiencia card&#237;aca&#46; Al inicio&#44; se evalu&#243; la presencia de crepitantes pulmonares y edema de miembros inferiores &#40;congesti&#243;n cl&#237;nica&#41; junto con la fracci&#243;n N-terminal del prop&#233;ptido natriur&#233;tico cerebral<span class="elsevierStyleHsp" style=""></span>&#8805;<span class="elsevierStyleHsp" style=""></span>1500<span class="elsevierStyleHsp" style=""></span>pg&#47;mL &#40;congesti&#243;n hemodin&#225;mica&#41;&#46; Los pacientes se clasificaron en 4 grupos en funci&#243;n del patr&#243;n congestivo&#58; sin congesti&#243;n &#40;G1&#41; &#40;n<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>50&#41;&#59; con congesti&#243;n cl&#237;nica &#40;G2&#41; &#40;n<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>43&#41;&#59; con congesti&#243;n hemodin&#225;mica &#40;G3&#41; &#40;n<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>73&#41; y con congesti&#243;n cl&#237;nica y hemodin&#225;mica &#40;G4&#41; &#40;n<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>72&#41;&#46; El objetivo primario fue la muerte por cualquier causa al a&#241;o de seguimiento&#46;</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Resultados</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Se analizaron un total de 238 pacientes&#44; edad media 82 a&#241;os&#44; 61&#44;8&#37; mujeres&#44; y 20&#44;7&#37; con fracci&#243;n de eyecci&#243;n del ventr&#237;culo izquierdo reducida&#46; Treinta pacientes &#40;12&#44;6&#37;&#41; fallecieron en el primer a&#241;o de seguimiento&#46; Despu&#233;s de ajustar por variables de confusi&#243;n &#40;sexo&#44; alta hospitalaria reciente por insuficiencia card&#237;aca&#44; filtrado glomerular estimado&#44; y fracci&#243;n de eyecci&#243;n del ventr&#237;culo izquierdo&#41;&#44; el riesgo de muerte en cada grupo&#44;al compararlos con el grupo de referencia G1&#44; fue&#58; G2&#44; HR 4&#44;121 &#40;IC95&#37; 1&#44;131&#8211;15&#44;019&#41;&#59; G3&#44; HR 2&#44;511 &#40;IC95&#37; 1&#44;007-6&#44;263&#41;&#44; y&#59; G4&#44; HR 7&#44;418 &#40;IC95&#37; 1&#44;630-33&#44;763&#41;&#46;</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Conclusi&#243;n</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">La congesti&#243;n en pacientes ambulatorios con insuficiencia card&#237;aca se correlaciona con el pron&#243;stico&#46; Los pacientes con congesti&#243;n cl&#237;nica y hemodin&#225;mica tuvieron el mayor riesgo de muerte global al a&#241;o&#46;</p></span>"
        "secciones" => array:4 [
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            "titulo" => "Pacientes y m&#233;todos"
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        "resumen" => "<span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Introduction</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">This work aims to evaluate whether a clinical examination and measurement of N-terminal pro-brain natriuretic peptide can predict poor prognosis in outpatients with heart failure&#46;</p></span> <span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Patients and methods</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">We carried out a retrospective study from 2010 to 2018 in 238 patients diagnosed with heart failure&#46; At baseline&#44; we evaluated the presence of pulmonary rales and bilateral leg edema &#40;clinical congestion&#41; together with N-terminal pro-brain natriuretic peptide<span class="elsevierStyleHsp" style=""></span>&#8805;<span class="elsevierStyleHsp" style=""></span>1500 pg&#47;mL &#40;hemodynamic congestion&#41;&#46; Patients were classified into 4 groups depending on their congestion pattern&#58; no congestion &#40;G1&#41; &#40;n<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>50&#41;&#59; clinical congestion &#40;G2&#41; &#40;n<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>43&#41;&#59; hemodynamic congestion &#40;G3&#41; &#40;n<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>73&#41;&#59; and clinical and hemodynamic congestion &#40;G4&#41; &#40;n<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>72&#41;&#46; The primary outcome was all-cause mortality at one year of follow-up&#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 238 patients were included&#46; The mean age was 82 years&#44; 61&#46;8&#37; were women&#44; and 20&#46;7&#37; had reduced left ventricular ejection fraction&#46; Thirty patients died in the first year of follow-up &#40;12&#46;6&#37;&#41;&#46; After controlling for confounding variables &#40;sex&#44; recent discharge for heart failure&#44; estimated glomerular filtration rate&#44; and left ventricular ejection fraction&#41;&#44; the independent risk of death in each group compared to G1 as the reference group was&#58; G2&#58; HR 4&#46;121 &#40;95&#37;<span class="elsevierStyleSmallCaps">C</span>I 1&#46;131-15&#46;019&#41;&#59; G3&#58; HR 2&#46;511 &#40;95&#37;CI 1&#46;007-6&#46;263&#41;&#59; and G4&#58; HR 7&#46;418 &#40;95&#37;CI 1&#46;630-33&#46;763&#41;&#46;</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Conclusion</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">Congestion in outpatients with heart failure correlates with prognosis&#46; Patients with both clinical and hemodynamic congestion had the highest risk of all-cause death at one year&#46;</p></span>"
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          "es" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Funci&#243;n de supervivencia para el desenlace muerte por cualquier causa en funci&#243;n de la congesti&#243;n cl&#237;nica y&#47;o hemodin&#225;mica y la FEVI&#46; An&#225;lisis de supervivencia de Kaplan-Meier para el desenlace primario mortalidad global seg&#250;n la presencia de congesti&#243;n en los grupos&#58; &#40;G1&#41; No congesti&#243;n cl&#237;nica<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>NTproBNP<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>1500&#59; &#40;G2&#41; S&#237; congesti&#243;n cl&#237;nica<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>NTproBNP<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>1500&#59; &#40;G3&#41; No congesti&#243;n cl&#237;nica<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>NTproBNP<span class="elsevierStyleHsp" style=""></span>&#8805;<span class="elsevierStyleHsp" style=""></span>1500&#59; &#40;G4&#41; S&#237; congesti&#243;n cl&#237;nica<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>NTproBNP<span class="elsevierStyleHsp" style=""></span>&#8805;<span class="elsevierStyleHsp" style=""></span>1500&#44; y las categor&#237;as de fracci&#243;n de eyecci&#243;n del ventr&#237;culo izquierdo &#40;FEVI&#41;<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>40&#37;&#44; 40-49&#37; y<span class="elsevierStyleHsp" style=""></span>&#8805;<span class="elsevierStyleHsp" style=""></span>50&#37;&#46;</p>"
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          "es" => "<p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">Funci&#243;n de supervivencia para el desenlace muerte&#47;ingreso por IC en funci&#243;n de la congesti&#243;n cl&#237;nica y&#47;o hemodin&#225;mica y la FEVI&#46; An&#225;lisis de supervivencia de Kaplan-Meier para el desenlace muerte&#47;ingreso por IC seg&#250;n la presencia de congesti&#243;n en los grupos&#58; &#40;G1&#41; No congesti&#243;n cl&#237;nica<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>NTproBNP<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>1500&#59; &#40;G2&#41; S&#237; congesti&#243;n cl&#237;nica<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>NTproBNP<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>1500&#59; &#40;G3&#41; No congesti&#243;n cl&#237;nica<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>NTproBNP<span class="elsevierStyleHsp" style=""></span>&#8805;<span class="elsevierStyleHsp" style=""></span>1500&#59; &#40;G4&#41; S&#237; congesti&#243;n cl&#237;nica<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>NTproBNP<span class="elsevierStyleHsp" style=""></span>&#8805;<span class="elsevierStyleHsp" style=""></span>1500&#44; y las categor&#237;as de fracci&#243;n de eyecci&#243;n del ventr&#237;culo izquierdo &#40;FEVI&#41;<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>40&#37;&#44; 40-49&#37; y<span class="elsevierStyleHsp" style=""></span>&#8805;<span class="elsevierStyleHsp" style=""></span>50&#37;&#46;</p>"
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          "es" => "<p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">Funci&#243;n de supervivencia para el desenlace muerte&#47;ingreso por IC en funci&#243;n de la congesti&#243;n reagrupada en 2 categor&#237;as &#40;con&#47;sin congesti&#243;n combinada&#41; y la FEVI&#46; An&#225;lisis de supervivencia de Kaplan-Meier para el desenlace muerte&#47;ingreso por IC seg&#250;n la presencia de congesti&#243;n en los grupos&#58; &#40;G1<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>G2<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>G3&#41;&#58; congesti&#243;n simple o ninguna&#59; &#40;G4&#41; congesti&#243;n combinada o mixta&#44; y las categor&#237;as de fracci&#243;n de eyecci&#243;n del ventr&#237;culo izquierdo &#40;FEVI&#41;<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>40&#37;&#44; 40-49&#37; y<span class="elsevierStyleHsp" style=""></span>&#8805;<span class="elsevierStyleHsp" style=""></span>50&#37;&#46;</p>"
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          "leyenda" => "<p id="spar0065" class="elsevierStyleSimplePara elsevierViewall">AI&#58; aur&#237;cula izquierda&#59; ARA II&#58; antagonista del receptor de la angiotensina <span class="elsevierStyleSmallCaps">ii</span>&#59; DM&#58; diabetes mellitus&#59; EPOC&#58; enfermedad pulmonar obstructiva cr&#243;nica&#59; FEVI&#58; fracci&#243;n eyecci&#243;n ventr&#237;culo izquierdo&#59; FGe&#58; filtrado glomerular estimado&#59; HTA&#58; hipertensi&#243;n arterial&#59; IC&#58; insuficiencia card&#237;aca&#59; IECA&#58; inhibidor de la enzima convertidora de la angiotensina&#59; NYHA&#58; New York Heart Association&#59; PAD&#58; presi&#243;n arterial diast&#243;lica&#59; PAPS&#58; presi&#243;n arterial pulmonar sist&#243;lica&#59; PAS&#58; presi&#243;n arterial sist&#243;lica&#59; TAPSE&#58; excursi&#243;n sist&#243;lica plana del anillo tricusp&#237;deo&#46;</p><p id="spar0070" class="elsevierStyleSimplePara elsevierViewall">Grupos en funci&#243;n de la congesti&#243;n&#58; &#40;G1&#41; No congesti&#243;n cl&#237;nica<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>NTproBNP<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>1500&#59; &#40;G2&#41; S&#237; congesti&#243;n cl&#237;nica<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>NTproBNP<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>1500&#59; &#40;G3&#41; No congesti&#243;n cl&#237;nica<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>NTproBNP<span class="elsevierStyleHsp" style=""></span>&#8805;<span class="elsevierStyleHsp" style=""></span>1500&#59; &#40;G4&#41; S&#237; congesti&#243;n cl&#237;nica<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>NTproBNP<span class="elsevierStyleHsp" style=""></span>&#8805;<span class="elsevierStyleHsp" style=""></span>1500&#46;</p><p id="spar0095" class="elsevierStyleSimplePara elsevierViewall">Variables cualitativas representadas como media y desviaci&#243;n est&#225;ndar&#46; Variables cuantitativas representadas como n&#250;mero &#40;n&#41; y porcentaje &#40;&#37;&#41;&#46;</p><p id="spar0100" class="elsevierStyleSimplePara elsevierViewall">Comparaciones <span class="elsevierStyleItalic">post-hoc</span> con las pruebas de Tukey o Games-Howell&#58; significaci&#243;n estad&#237;stica a nivel 0&#44;05 con&#58; <span class="elsevierStyleSup">a</span> G1&#59; <span class="elsevierStyleSup">b</span> G2&#59; <span class="elsevierStyleSup">c</span> G3&#46;</p><p id="spar0105" class="elsevierStyleSimplePara elsevierViewall">&#8593;&#8595; Residuos estandarizados corregidos&#46; Casillas que presentan frecuencias absolutas significativamente mayores &#40;&#8593;&#41; o menores &#40;&#8595;&#41; a nivel 0&#44;05 que las esperadas bajo la hip&#243;tesis de independencia&#46;</p>"
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                  \t\t\t\t\ttable-head\n
                  \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
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Poblaci&#243;n total &#40;n<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>238&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">G1 &#40;18&#37;&#41;&#40;n<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>50&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">G2 &#40;21&#37;&#41;&#40;n<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>43&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">G3 &#40;31&#37;&#41;&#40;n<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>73&#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">G4 &#40;30&#37;&#41;&#40;n<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>72&#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
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">p&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><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="elsevierStyleBold">Edad&#44; a&#241;os</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">82&#44;6 &#40;7&#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">81&#44;7 &#40;7&#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
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                  \t\t\t\t">80&#44;8 &#40;8&#44;2&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">84&#44;5 &#40;6&#44;2&#41;<span class="elsevierStyleSup">b</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">82&#44;4 &#40;7&#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;039&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="elsevierStyleBold">Sexo femenino</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">148 &#40;61&#44;8&#37;&#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">41 &#40;82&#44;0&#37;&#41;&#8593;&nbsp;\t\t\t\t\t\t\n
                  \t\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">30 &#40;69&#44;8&#37;&#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">45 &#40;61&#44;6&#37;&#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">32 &#40;44&#44;4&#37;&#41;&#8595;&nbsp;\t\t\t\t\t\t\n
                  \t\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">&#60;<span class="elsevierStyleHsp" style=""></span>0&#44;001&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleBold">Ingresos previos IC</span><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleBold">&#8805;</span><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleBold">3</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">55 &#40;25&#44;9&#37;&#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">9 &#40;20&#44;0&#37;&#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 &#40;21&#44;1&#37;&#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">21 &#40;31&#44;8&#37;&#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">17 &#40;26&#44;6&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">0&#44;474&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleBold">NYHA</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
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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="" valign="\n
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                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
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                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
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                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
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                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">I</span><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">&#43;</span><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">II</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">155 &#40;65&#44;4&#37;&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">PAD&#44; mm Hg</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">Frecuencia card&#237;aca&#44; lpm</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">74 &#40;14&#44;4&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">95 &#40;41&#44;8&#37;&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleBold">Anal&#237;tica</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">Hemoglobina&#44; g&#47;dL</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">FGe&#44; mL&#47;min&#47;1&#44;73 m</span><span class="elsevierStyleSup"><span class="elsevierStyleItalic">2</span></span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleBold">Tratamiento al inicio</span>&nbsp;\t\t\t\t\t\t\n
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          "es" => "<p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">Caracter&#237;sticas de la poblaci&#243;n en funci&#243;n de la congesti&#243;n cl&#237;nica y hemodin&#225;mica</p>"
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