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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Introducci&#243;n</span><p id="par0005" class="elsevierStylePara elsevierViewall">El tabaquismo es la primera causa de enfermedad&#44; invalidez y muerte evitable<a class="elsevierStyleCrossRefs" href="#bib0270"><span class="elsevierStyleSup">1-4</span></a>&#46; El abandono del tabaco tiene potencialmente m&#225;s capacidad de aumentar la esperanza de vida que cualquier otra medida de salud p&#250;blica&#46; La asociaci&#243;n del tabaco con los eventos cardiovasculares es dosis-dependiente y aumenta si coexisten otros factores de riesgo<a class="elsevierStyleCrossRefs" href="#bib0290"><span class="elsevierStyleSup">5&#44;6</span></a>&#46; Por otro lado&#44; el abandono del tabaquismo conlleva una disminuci&#243;n del riesgo asociado al mismo<a class="elsevierStyleCrossRefs" href="#bib0300"><span class="elsevierStyleSup">7-10</span></a>&#46; Sin embargo&#44; los pacientes fumadores que presentan un s&#237;ndrome coronario agudo &#40;SCA&#41; presentan un mejor pron&#243;stico a corto plazo que aquellos que no son fumadores<a class="elsevierStyleCrossRefs" href="#bib0320"><span class="elsevierStyleSup">11-16</span></a>&#44; lo que se ha descrito como <span class="elsevierStyleItalic">la paradoja del tabaco</span><a class="elsevierStyleCrossRef" href="#bib0350"><span class="elsevierStyleSup">17</span></a>&#46; Seg&#250;n esta teor&#237;a&#44; aunque un individuo fumador tiene m&#225;s riesgo de presenta un evento coronario&#44; las posibilidades de sobrevivir en el momento agudo son mayores que en los no fumadores<a class="elsevierStyleCrossRefs" href="#bib0355"><span class="elsevierStyleSup">18&#44;19</span></a>&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">En este estudio se describe la presencia de la paradoja del tabaco en nuestro medio y se intenta explicar mediante otros factores pron&#243;sticos&#46; Adem&#225;s&#44; intentamos clarificar la influencia de la condici&#243;n de exfumador en el curso hospitalario tras presentar un evento coronario&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Material y m&#233;todos</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 registro de SCA de la plataforma ARIAM-Andaluc&#237;a es un estudio observacional&#44; prospectivo y multic&#233;ntrico de los pacientes ingresados en las Unidades de Cuidados Intensivos &#40;UCI&#41; o Unidades Coronarias de hospitales de Andaluc&#237;a<a class="elsevierStyleCrossRef" href="#bib0365"><span class="elsevierStyleSup">20</span></a>&#46; Los datos fueron recogidos por los m&#233;dicos en cada centro&#44; mediante un programa inform&#225;tico v&#237;a web&#46; El software posee una serie de herramientas&#44; denominadas CoreTools&#44; que dotan al registro de unos estrictos controles de calidad de la informaci&#243;n introducida&#44; que aplican rangos a todas las variables&#44; dependencias entre las mismas y un conjunto m&#237;nimo de datos registrados&#46; Este estudio cumple con la declaraci&#243;n de Helsinki y la protecci&#243;n de los derechos de los pacientes<a class="elsevierStyleCrossRef" href="#bib0370"><span class="elsevierStyleSup">21</span></a>&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">Analizamos un periodo de 11 a&#241;os&#44; entre enero de 2001 y enero del 2012&#44; con un n&#250;mero total de 42&#46;827 pacientes pertenecientes a 49 hospitales &#40;el listado completo de centros e investigadores se ha publicado previamente&#41;<a class="elsevierStyleCrossRef" href="#bib0365"><span class="elsevierStyleSup">20</span></a>&#46; Se recogieron variables epidemiol&#243;gicas y cl&#237;nicas al ingreso&#44; y se realiz&#243; un seguimiento de los pacientes desde su ingreso hasta el alta hospitalaria&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Criterios de inclusi&#243;n</span><p id="par0025" class="elsevierStylePara elsevierViewall">El &#250;nico criterio de inclusi&#243;n consist&#237;a en ser diagnosticado de SCA&#44; tanto con elevaci&#243;n como sin elevaci&#243;n del ST&#44; y requerir ingreso en la UCI&#46; El diagn&#243;stico se realiz&#243; sobre la base de los criterios universales de infarto de miocardio<a class="elsevierStyleCrossRefs" href="#bib0375"><span class="elsevierStyleSup">22&#44;23</span></a>&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Variables estudiadas</span><p id="par0030" class="elsevierStylePara elsevierViewall">Se incluyeron al ingreso&#58; <span class="elsevierStyleItalic">1&#41;</span> variables demogr&#225;ficas como edad y sexo&#59; <span class="elsevierStyleItalic">2&#41;</span> presencia de factores de riesgo cardiovascular&#58; tabaquismo &#40;distinguiendo entre h&#225;bito activo o extabaquismo&#41;&#44; diabetes mellitus&#44; hipertensi&#243;n&#44; dislipidemia&#44; obesidad&#44; historia familiar de cardiopat&#237;a isqu&#233;mica&#59; <span class="elsevierStyleItalic">3&#41;</span> antecedentes m&#233;dicos de inter&#233;s&#58; historia previa de angina&#44; infarto agudo de miocardio&#44; lesiones coronarias conocidas&#44; insuficiencia cardiaca&#44; accidente cerebrovascular&#44; arritmias&#44; enfermedad vascular perif&#233;rica&#44; broncopat&#237;a cr&#243;nica&#44; e insuficiencia renal&#44; y <span class="elsevierStyleItalic">4&#41;</span> presentaci&#243;n del SCA en forma de elevaci&#243;n del ST o en su ausencia&#44; localizaci&#243;n anterior del infarto o presencia de Killip &#8805; 2 al ingreso&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">Durante el curso hospitalario se recogieron los siguientes eventos&#58; reinfarto&#44; bloqueo auriculoventricular o asistolia&#44; taquicardia ventricular&#44; fibrilaci&#243;n ventricular&#44; necesidad de ventilaci&#243;n mec&#225;nica&#44; shock&#44; accidente cerebrovascular y mortalidad tanto durante la estancia en la UCI como hospitalaria&#46; La variable principal de valoraci&#243;n fue la mortalidad hospitalaria&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">Los pacientes se clasificaron en 3 grupos&#58; fumadores activos&#44; exfumadores y no fumadores&#46; Se defini&#243; como exfumador a aquel paciente que hab&#237;a abandonado el h&#225;bito tab&#225;quico al menos 3 meses antes de su ingreso&#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">El an&#225;lisis estad&#237;stico se realiz&#243; con el paquete inform&#225;tico Stata 13&#46;1 &#40;Statacorp&#44; Texas&#44; EE&#46; UU&#46;&#44; 2013&#41;&#46; Las variables categ&#243;ricas se expresan como n&#250;meros absolutos y porcentajes&#44; y las variables continuas como media<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>desviaci&#243;n est&#225;ndar&#46; Las diferencias en las caracter&#237;sticas demogr&#225;ficas y cl&#237;nicas&#44; y los eventos intrahospitalarios entre los 3 grupos &#40;fumadores&#44; no fumadores y exfumadores&#41; se evaluaron con el test de la chi al cuadrado para variables categ&#243;ricas y el test de ANOVA para las variables continuas&#44; estableciendo como nivel de significaci&#243;n estad&#237;stica un valor de p<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#44;05 bilateral&#46;</p><p id="par0050" class="elsevierStylePara elsevierViewall">Se analiz&#243; la influencia del h&#225;bito tab&#225;quico o de la condici&#243;n exfumador en la mortalidad mediante 2 an&#225;lisis multivariados&#46; En primer lugar&#44; se realiz&#243; un c&#225;lculo de probabilidad inversa ponderada aumentada &#40;augmented inverse probability weights &#91;AIPW&#93;&#41;&#44; con un modelo log&#237;stico de medias ponderadas&#46; El AIPW es un m&#233;todo que combina el ajuste mediante regresi&#243;n y el ajuste de medias ponderado inverso&#46; Para confirmar los resultados&#44; se repiti&#243; la estimaci&#243;n del efecto mediante un an&#225;lisis de propensi&#243;n &#40;propensity matching score&#41;&#44; igualmente con un modelo log&#237;stico&#46; En el an&#225;lisis de propensi&#243;n con Stata cada paciente se compara con otro lo m&#225;s similar posible en cuanto a las variables independientes&#44; con la &#250;nica diferencia del &#171;tratamiento&#187; &#40;fumador o exfumador&#41;<a class="elsevierStyleCrossRefs" href="#bib0385"><span class="elsevierStyleSup">24-26</span></a>&#46; Ambos an&#225;lisis se realizaron de forma independiente para cada una de las condiciones&#44; fumador y exfumador&#46;</p><p id="par0055" class="elsevierStylePara elsevierViewall">En ambos an&#225;lisis se presenta el efecto medio estimado en la poblaci&#243;n&#44; expresado en unidades porcentuales&#44; como un coeficiente que expresa la reducci&#243;n o aumento de la mortalidad&#46; Como variables independientes para ponderar el efecto de los &#171;tratamientos&#187; &#40;fumador o exfumador&#41; sobre la mortalidad&#44; se incluyeron las caracter&#237;sticas cl&#237;nicas cuya distribuci&#243;n fue significativamente diferente entre los grupos de fumadores&#44; exfumadores y no fumadores&#58; edad&#44; sexo&#44; ST elevado&#44; diabetes&#44; dislipidemia&#44; hipertensi&#243;n arterial&#44; historia familiar&#44; angina previa&#44; infarto previo&#44; historia de insuficiencia cardiaca&#44; ictus&#44; insuficiencia renal&#44; vasculopat&#237;a&#44; fibrilaci&#243;n auricular previas&#44; enfermedad pulmonar obstructiva cr&#243;nica y Killip<span class="elsevierStyleHsp" style=""></span>&#8805;<span class="elsevierStyleHsp" style=""></span>2 al ingreso &#40;<a class="elsevierStyleCrossRef" href="#sec0065">anexo 1</a>&#41;&#46;</p></span></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Resultados</span><p id="par0060" class="elsevierStylePara elsevierViewall">De los 42&#46;827 pacientes incluidos&#44; 14&#46;285 &#40;33&#44;3&#37;&#41; eran fumadores activos&#44; 9&#46;155 &#40;21&#44;4&#37;&#41; exfumadores y 19&#46;387 &#40;45&#44;4&#37;&#41; no fumadores&#46; Los pacientes con SCA y ST elevado fueron 25&#46;633 &#40;59&#44;9&#37;&#41;&#44; sin ST elevado 16&#46;851 &#40;39&#44;3&#37;&#41;&#44; y sin definir 343 &#40;0&#44;8&#37;&#41;&#46;</p><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">Caracter&#237;sticas basales</span><p id="par0065" class="elsevierStylePara elsevierViewall">Las caracter&#237;sticas basales de los pacientes incluidos en el estudio se detallan en la <a class="elsevierStyleCrossRef" href="#tbl0005">tabla 1</a>&#46; En comparaci&#243;n con los no fumadores&#44; los pacientes fumadores eran m&#225;s j&#243;venes y&#44; en mayor proporci&#243;n&#44; varones&#46; Adem&#225;s&#44; presentaban menos comorbilidades&#44; y ten&#237;an menos antecedentes personales de cardiopat&#237;a isqu&#233;mica&#44; insuficiencia cardiaca&#44; arritmias e insuficiencia renal&#46; Ten&#237;an&#44; en cambio&#44; m&#225;s antecedentes familiares de cardiopat&#237;a isqu&#233;mica y m&#225;s enfermedad pulmonar obstructiva cr&#243;nica&#46; Entre los fumadores la forma de presentaci&#243;n m&#225;s frecuente fue la elevaci&#243;n del ST y con menor frecuencia presentaban un Killip<span class="elsevierStyleHsp" style=""></span>&#8805;<span class="elsevierStyleHsp" style=""></span>2&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0070" class="elsevierStylePara elsevierViewall">Por otra parte&#44; en comparaci&#243;n con los no fumadores&#44; el grupo de exfumadores era 2 a&#241;os m&#225;s joven y mayoritariamente varones&#46; Presentaban menos diabetes&#44; hipertensi&#243;n o arritmias previas&#44; pero m&#225;s dislipidemia&#44; infarto o angina previa&#44; vasculopat&#237;a perif&#233;rica&#44; insuficiencia renal&#44; broncopat&#237;a cr&#243;nica e historia familiar de cardiopat&#237;a isqu&#233;mica&#46;</p></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0105">Eventos hospitalarios</span><p id="par0075" class="elsevierStylePara elsevierViewall">En el an&#225;lisis no ajustado&#44; la mortalidad en la UCI y hospitalaria fue significativamente mayor en el grupo de no fumadores&#44; seguida de los exfumadores&#44; apreci&#225;ndose una menor tasa de mortalidad en los fumadores &#40;<a class="elsevierStyleCrossRef" href="#tbl0010">tabla 2</a>&#41;&#46; Tanto los fumadores como los exfumadores presentaron menos frecuentemente shock cardiog&#233;nico&#44; bloqueo aur&#237;culo-ventricular o necesidad de ventilaci&#243;n mec&#225;nica&#46; El grupo fumador present&#243; con mayor frecuencia fibrilaci&#243;n ventricular&#46;</p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><p id="par0080" class="elsevierStylePara elsevierViewall">El an&#225;lisis del efecto del tabaquismo previo &#40;exfumador&#41; sobre la mortalidad&#44; ajustado a las otras variables&#44; mostr&#243; una diferencia no significativa con respecto a los fumadores&#44; tanto con el an&#225;lisis de probabilidad inversa como con el de propensi&#243;n&#44; con una diferencia de mortalidad en la poblaci&#243;n de &#8211;0&#44;3 y<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>0&#44;4&#37;&#44; respectivamente&#46; En cambio&#44; la cualidad de exfumador supuso una reducci&#243;n significativa de la mortalidad en ambos test&#44; de 2&#44;2&#37; en el an&#225;lisis de probabilidad inversa &#40;p<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#44;001&#41; y del 2&#44;1&#37; en el an&#225;lisis de propensi&#243;n &#40;p 0&#44;005&#41; &#40;<a class="elsevierStyleCrossRef" href="#tbl0015">tabla 3</a>&#41;&#46;</p><elsevierMultimedia ident="tbl0015"></elsevierMultimedia></span></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0110">Discusi&#243;n</span><p id="par0085" class="elsevierStylePara elsevierViewall">Numerosos estudios han demostrado la asociaci&#243;n entre tabaquismo y morbilidad cardiovascular&#44; incluyendo el aumento de riesgo de un evento coronario agudo y muerte s&#250;bita cardiaca<a class="elsevierStyleCrossRefs" href="#bib0400"><span class="elsevierStyleSup">27-29</span></a>&#46; Adem&#225;s&#44; el cese del h&#225;bito tab&#225;quico se ha asociado a una disminuci&#243;n significativa de la mortalidad por todas las causas en pacientes con cardiopat&#237;a isqu&#233;mica<a class="elsevierStyleCrossRef" href="#bib0315"><span class="elsevierStyleSup">10</span></a>&#46; Sin embargo&#44; en pacientes con SCA&#44; diversos trabajos han observado que los fumadores tienen un mejor pron&#243;stico que los no fumadores&#46; Para aclarar esta paradoja se han propuesto varias explicaciones&#44; como una menor edad&#44; menor carga de comorbilidades asociadas y una menor extensi&#243;n de las lesiones coronarias en los paciente fumadores<a class="elsevierStyleCrossRefs" href="#bib0415"><span class="elsevierStyleSup">30&#44;31</span></a>&#46;</p><p id="par0090" class="elsevierStylePara elsevierViewall">La edad es el factor pron&#243;stico m&#225;s importante a corto plazo en el SCA<a class="elsevierStyleCrossRefs" href="#bib0425"><span class="elsevierStyleSup">32-35</span></a>&#46; No obstante&#44; en un estudio en el que se evalu&#243; la paradoja del tabaco entre paciente j&#243;venes con SCA&#44; aquellos que eran fumadores tuvieron una mortalidad hospitalaria y a los 8 meses superior al del grupo de no fumadores<a class="elsevierStyleCrossRef" href="#bib0445"><span class="elsevierStyleSup">36</span></a>&#46; Esto difiere de otros trabajos en los que tras ajustar mediante an&#225;lisis multivariado entre ambos grupos seg&#250;n la edad&#44; este supuesto factor pron&#243;stico observado entre los fumadores desaparec&#237;a por completo<a class="elsevierStyleCrossRefs" href="#bib0325"><span class="elsevierStyleSup">12-15</span></a>&#46; Estas discrepancias entre estudios pueden ser debidas a diferencias metodol&#243;gicas&#44; tales como la selecci&#243;n de pacientes&#44; el tama&#241;o muestral o las variables incluidas en el an&#225;lisis multivariado&#46;</p><p id="par0095" class="elsevierStylePara elsevierViewall">En nuestro registro tambi&#233;n observamos una menor edad entre el grupo de pacientes fumadores&#46; Esta diferencia de edad podr&#237;a justificar parcialmente la menor tasa de mortalidad en dicho grupo&#44; ya que al corregir las caracter&#237;sticas basales de los grupos por otros factores relacionados con el pron&#243;stico&#44; desaparec&#237;a el efecto protector del tabaquismo&#46; Sin embargo&#44; en un an&#225;lisis mediante regresi&#243;n log&#237;stica incluyendo m&#250;ltiples covariables previamente publicado por el Grupo ARIAM&#44; el tabaquismo previo segu&#237;a siendo &#171;protector&#187; a corto plazo<a class="elsevierStyleCrossRef" href="#bib0450"><span class="elsevierStyleSup">37</span></a>&#46;</p><p id="par0100" class="elsevierStylePara elsevierViewall">Barbash et al&#46; estudiaron a 2&#46;400 pacientes reclutados para el subestudio angiogr&#225;fico del GUSTO-I y demostraron que los fumadores presentaban menos frecuentemente afectaci&#243;n multivaso&#44; mientras que ten&#237;an m&#225;s infartos cuya arteria responsable era la coronaria derecha que los no fumadores<a class="elsevierStyleCrossRef" href="#bib0365"><span class="elsevierStyleSup">20</span></a>&#46; En consonancia&#44; los datos de otros estudios angiogr&#225;ficos y epidemiol&#243;gicos sugieren que el infarto agudo de miocardio en fumadores ocurre en un periodo relativamente temprano del proceso de ateroesclerosis coronaria&#46; Adem&#225;s&#44; el estado de hipercoagulabilidad que asocian los fumadores activos&#44; debido a un aumento de hematocrito&#44; fibrin&#243;geno y trombina&#44; y una mayor activaci&#243;n plaquetaria&#44; se ha propuesto para explicar las diferencias pron&#243;sticas en los fumadores<a class="elsevierStyleCrossRefs" href="#bib0325"><span class="elsevierStyleSup">12&#44;31</span></a>&#46; La evidencia acumulada apoya que el infarto de miocardio en fumadores ocurre sobre lesiones menos graves que en no fumadores&#44; con un mecanismo trombog&#233;nico predominante<a class="elsevierStyleCrossRef" href="#bib0420"><span class="elsevierStyleSup">31</span></a>&#46; Esto podr&#237;a explicar la mejor respuesta al tratamiento trombol&#237;tico que tambi&#233;n se ha descrito en trabajos previos<a class="elsevierStyleCrossRefs" href="#bib0335"><span class="elsevierStyleSup">14&#44;19&#44;31&#44;38</span></a>&#46;</p><p id="par0105" class="elsevierStylePara elsevierViewall">Recientemente se ha investigado la interacci&#243;n entre clopidogrel y tabaco&#46; El tabaquismo ha demostrado inducir el citocromo P4501A2&#44; causando una mejora en la respuesta al clopidogrel en los fumadores<a class="elsevierStyleCrossRef" href="#bib0460"><span class="elsevierStyleSup">39</span></a>&#46; El estudio CHARISMA &#40;The Clopidogrel for High Atherotrombotic Risk and Ischaemic Stabilization&#44; Management and Avoidance&#41; compar&#243; clopidogrel 75<span class="elsevierStyleHsp" style=""></span>mg al d&#237;a versus placebo en pacientes con perfil de alto riesgo&#44; mostrando una reducci&#243;n significativa de la mortalidad en fumadores&#44; sin alcanzar dicho efecto en no fumadores<a class="elsevierStyleCrossRef" href="#bib0465"><span class="elsevierStyleSup">40</span></a>&#46; Adem&#225;s&#44; el ensayo CLARITY-TIMI 28 &#40;Clopidogrel as Adjunctive Reperfusion Therapy-Thrombolysis in Myocardial Infarction 28&#41; compar&#243; el efecto de clopidogrel con variables angiogr&#225;ficas y cl&#237;nicas en pacientes con SCA y elevaci&#243;n de ST&#44; mostrando que el antiagregante era significativamente m&#225;s efectivo en reducir la tasa de muerte cardiovascular&#44; infarto de miocardio o revascularizaci&#243;n urgente entre los pacientes fumadores<a class="elsevierStyleCrossRef" href="#bib0470"><span class="elsevierStyleSup">41</span></a>&#46;</p><p id="par0110" class="elsevierStylePara elsevierViewall">Tambi&#233;n se ha descrito un pico de marcadores m&#225;s precoz entre los pacientes fumadores tras presentar un evento coronario agudo&#44; lo que se podr&#237;a relacionar con una menor afectaci&#243;n en la microcirculaci&#243;n coronaria<a class="elsevierStyleCrossRef" href="#bib0475"><span class="elsevierStyleSup">42</span></a>&#46; Esta teor&#237;a tambi&#233;n se podr&#237;a apoyar en el hecho de que en los pacientes con SCA y elevaci&#243;n de ST sin antecedente de tabaquismo se ha objetivado una menor resoluci&#243;n del segmento ST tras la reperfusi&#243;n<a class="elsevierStyleCrossRefs" href="#bib0480"><span class="elsevierStyleSup">43&#44;44</span></a>&#46; Heeschen et al&#46; describieron en un modelo animal con ratones un mayor desarrollo de circulaci&#243;n colateral tras la administraci&#243;n de nicotina<a class="elsevierStyleCrossRef" href="#bib0490"><span class="elsevierStyleSup">45</span></a>&#46; En el mismo sentido&#44; Ruixing et al&#46; evidenciaron la capacidad de la administraci&#243;n intramuscular de nicotina para promover angiog&#233;nesis intramioc&#225;rdica<a class="elsevierStyleCrossRef" href="#bib0495"><span class="elsevierStyleSup">46</span></a>&#46; Por lo tanto&#44; el tabaquismo podr&#237;a aumentar la circulaci&#243;n colateral y prevenir el da&#241;o de la microcirculaci&#243;n despu&#233;s de la terapia de reperfusi&#243;n y esto podr&#237;a explicar por qu&#233; hay un menor n&#250;mero de pacientes con insuficiencia cardiaca en el grupo fumador durante el seguimiento&#46;</p><p id="par0115" class="elsevierStylePara elsevierViewall">Al igual que nuestro trabajo&#44; varios estudios han constatado que el efecto protector del tabaquismo sobre el SCA se explica por otras variables pron&#243;sticas<a class="elsevierStyleCrossRefs" href="#bib0330"><span class="elsevierStyleSup">13&#44;15&#44;47</span></a>&#46; En el presente estudio aplicamos una metodolog&#237;a potente y novedosa de an&#225;lisis multivariado&#44; con un estudio de propensi&#243;n en el que se incluy&#243; a todos los pacientes en la estimaci&#243;n del efecto del tabaquismo sobre la mortalidad&#46; Esto demostr&#243; que las covariables s&#237; explican esta aparente paradoja en el caso de los fumadores activos&#46;</p><p id="par0120" class="elsevierStylePara elsevierViewall">Otra conclusi&#243;n que podemos extraer de nuestro trabajo es que el pron&#243;stico de un paciente con SCA es mejor entre aquellos que han abandonado el h&#225;bito tab&#225;quico&#44; de manera similar a lo observado en otros estudios previos<a class="elsevierStyleCrossRefs" href="#bib0315"><span class="elsevierStyleSup">10&#44;48</span></a>&#46; Sin embargo&#44; se desconoce las bases fisiopatol&#243;gicas de este efecto beneficioso<a class="elsevierStyleCrossRef" href="#bib0510"><span class="elsevierStyleSup">49</span></a>&#46; Se ha postulado que el abandono previo del tabaco se asocia a una disminuci&#243;n del tama&#241;o de las plaquetas<a class="elsevierStyleCrossRef" href="#bib0510"><span class="elsevierStyleSup">49</span></a> y a una elevaci&#243;n de los niveles de adiponectina<a class="elsevierStyleCrossRef" href="#bib0515"><span class="elsevierStyleSup">50</span></a>&#44; que podr&#237;an condicionar una mejor evoluci&#243;n de un SCA posterior al abandono del tabaco&#46; Numerosos trabajos han comunicado el efecto beneficioso de dejar de fumar entre la poblaci&#243;n general&#44; as&#237; como en pacientes con antecedentes de cardiopat&#237;a isqu&#233;mica<a class="elsevierStyleCrossRefs" href="#bib0315"><span class="elsevierStyleSup">10&#44;51&#44;52</span></a>&#46; Por otra parte&#44; van Berkel et al&#46;<a class="elsevierStyleCrossRef" href="#bib0530"><span class="elsevierStyleSup">53</span></a> revisaron los datos publicados sobre el impacto del cese del tabaquismo y encontraron que el riesgo relativo de mortalidad entre exfumadores y fumadores activos variaba entre 0&#44;13 y 0&#44;72&#46;</p><p id="par0125" class="elsevierStylePara elsevierViewall">En nuestro estudio&#44; tras incluir en el an&#225;lisis multivariado un importante n&#250;mero de variables que diferencian a los fumadores de los no fumadores ingresados por un SCA&#44; el tabaquismo no tuvo efecto protector&#46; En contraste&#44; el abandono previo del tabaco s&#237; que tuvo una influencia significativa&#44; con una reducci&#243;n de mortalidad en la poblaci&#243;n analizada de m&#225;s del 1&#44;5&#37; en t&#233;rminos absolutos&#46; Por todo ello&#44; como se&#241;alan Andrikopoulos et al&#46;<a class="elsevierStyleCrossRef" href="#bib0330"><span class="elsevierStyleSup">13</span></a> el t&#233;rmino paradoja del tabaco deber&#237;a evitarse&#44; puesto que no existe una paradoja real y su uso podr&#237;a inducir al error en la poblaci&#243;n general de un supuesto beneficio del tabaco en el contexto del SCA&#46;</p><p id="par0130" class="elsevierStylePara elsevierViewall">Este estudio tiene limitaciones&#46; Si bien el registro ARIAM est&#225; dise&#241;ado para incluir todos los pacientes ingresados en una UCI&#44; la introducci&#243;n de cada caso es manual&#44; por lo que depende de la voluntariedad de los investigadores&#46; Esto&#44; al igual que el requisito de ser ingresado en una UCI&#44; puede introducir sesgos de selecci&#243;n de pacientes&#46; Nuestro estudio tiene las limitaciones de todos los registros observacionales&#46; La metodolog&#237;a estad&#237;stica aplicada es una versi&#243;n del an&#225;lisis multivariado y de propensi&#243;n de gran potencia&#44; que aprovecha la informaci&#243;n de todos los pacientes para aproximar el resultado al de un modelo experimental&#44; pero se basa en estimaciones matem&#225;ticas a partir de las variables incluidas&#46; No podemos asegurar que haya otras variables no incluidas que pudieran hacer variar significativamente los resultados&#46;</p><p id="par0135" class="elsevierStylePara elsevierViewall">En resumen&#44; la paradoja del tabaco en pacientes que ingresan por SCA es un hallazgo que puede quedar explicado al ajustar las caracter&#237;sticas basales por otros factores pron&#243;sticos&#46; El abandono previo del h&#225;bito tab&#225;quico se asocia a un mejor pron&#243;stico cuando se ingresa por un SCA&#46; Por tanto&#44; debemos recalcar la importancia de evitar este h&#225;bito nocivo en la poblaci&#243;n general&#44; as&#237; como procurar el abandono del mismo entre los fumadores activos&#46;</p></span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0115">Conflicto de intereses</span><p id="par0140" class="elsevierStylePara elsevierViewall">Los autores declaran no tener ning&#250;n conflicto de intereses&#46;</p></span></span>"
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    "fechaRecibido" => "2015-10-19"
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        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Objetivo</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">La paradoja del tabaco es un fen&#243;meno insuficientemente explicado en estudios previos&#46; Este estudio analiza el papel pron&#243;stico del tabaquismo previo o activo en pacientes con s&#237;ndrome coronario agudo&#46;</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">M&#233;todos</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Obtuvimos los datos del registro ARIAM&#44; entre 2001 y 2012&#46; Se incluy&#243; a 42&#46;827 pacientes con s&#237;ndrome coronario agudo &#40;edad media 65<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>13 a&#241;os&#44; 26&#44;4&#37; mujeres&#41;&#46; Se analiz&#243; la influencia del h&#225;bito tab&#225;quico o de la condici&#243;n de exfumador en la mortalidad mediante an&#225;lisis multivariados&#46;</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Resultados</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Los fumadores eran m&#225;s j&#243;venes&#44; m&#225;s frecuentemente hombres&#44; ten&#237;an menos diabetes&#44; hipertensi&#243;n e historia previa de insuficiencia cardiaca&#44; ictus&#44; arritmia e insuficiencia renal&#44; as&#237; como m&#225;s frecuentemente elevaci&#243;n del ST e historia familiar&#46; Los exfumadores presentaban m&#225;s dislipidemia e historia de angina&#44; infarto de miocardio&#44; cardiopat&#237;a isqu&#233;mica&#44; vasculopat&#237;a perif&#233;rica y broncopat&#237;a cr&#243;nica&#46; Fumadores y exfumadores desarrollaron menos frecuentemente shock cardiog&#233;nico &#40;fumadores 4&#44;2&#37;&#44; exfumadores 4&#44;7&#37; y no fumadores 6&#44;9&#37;&#44; p<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#44;001&#41;&#46; La mortalidad hospitalaria fue del 7&#44;8&#37; en los no fumadores&#44; un 4&#44;9&#37; en los exfumadores y un 3&#44;1&#37; en los fumadores &#40;p<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#44;001&#41;&#46; En el an&#225;lisis multivariado&#44; el car&#225;cter fumador perdi&#243; su influencia en el pron&#243;stico &#40;&#8211;0&#44;26&#37;&#44; p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;52 mediante c&#225;lculo de probabilidad inversa&#59; y &#43;0&#44;26&#37;&#44; p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;691 mediante an&#225;lisis de propensi&#243;n&#41;&#46; Sin embargo&#44; el car&#225;cter exfumador mostr&#243; una reducci&#243;n significativa de la mortalidad en ambos test &#40;&#8211;2&#44;4&#37; en el an&#225;lisis de probabilidad inversa&#44; p<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#44;001&#44; y &#8211;1&#44;5&#37; en el an&#225;lisis de propensi&#243;n&#44; p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;005&#41;&#46;</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Conclusiones</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">La paradoja del tabaco es un hallazgo que puede explicarse por otros factores pron&#243;sticos&#46; El abandono del h&#225;bito tab&#225;quico previo a un ingreso por s&#237;ndrome coronario agudo se asocia a un mejor pron&#243;stico&#46;</p></span>"
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        "resumen" => "<span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Objective</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">The tobacco paradox is a phenomenon insufficiently explained by previous studies&#46; This study analyses the prognostic role of prior or active smoking in patients with acute coronary syndrome&#46;</p></span> <span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Methods</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">We obtained data from the ARIAM registry&#44; between 2001 and 2012&#46; The study included 42&#44;827 patients with acute coronary syndrome &#40;mean age&#44; 65<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>13 years&#59; 26&#46;4&#37; women&#41;&#46; The influence of smoking and that of being an ex-smoker on mortality was analysed using a multivariate analysis&#46;</p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Results</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">The smokers were younger&#44; were more often men&#44; had less diabetes&#44; hypertension and prior history of heart failure&#44; stroke&#44; arrhythmia and renal failure and more frequently had ST-elevation and a family history of smoking&#46; The ex-smokers had more dyslipidaemia and history of angina&#44; myocardial infarction&#44; ischemic heart disease&#44; peripheral vasculopathy and chronic bronchial disease&#46; Smokers and ex-smokers less frequently developed cardiogenic shock &#40;smokers 4&#46;2&#37;&#44; ex-smokers 4&#46;7&#37; and nonsmokers 6&#46;9&#37;&#44; <span class="elsevierStyleItalic">P</span>&#60;&#46;001&#41;&#46; Hospital mortality was 7&#46;8&#37; for the nonsmokers&#44; 4&#46;9&#37; for the ex-smokers and 3&#46;1&#37; for the smokers <span class="elsevierStyleItalic">&#40;P</span>&#60;&#46;001&#41;&#46; In the multivariate analysis&#44; the smoker factor lost its influence in the prognosis &#40;&#8211;0&#46;26&#37;&#44; p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>&#46;52 using an inverse probability calculation&#59; and<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>0&#46;26&#37;&#44; <span class="elsevierStyleItalic">P</span>&#61;&#46;691 using a propensity analysis&#41;&#46; However&#44; the exsmoker factor showed a significant reduction in mortality in both tests &#40;-2&#46;4&#37; in the inverse probability analysis&#44; <span class="elsevierStyleItalic">P</span>&#60;&#46;001&#59; and &#8211;1&#46;5&#37; in the propensity analysis&#44; <span class="elsevierStyleItalic">P</span>&#61;&#46;005&#41;&#46;</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Conclusions</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">The tobacco paradox is a finding that could be explained by other prognostic factors&#46; Smoking cessation prior to hospitalization for acute coronary syndrome is associated with a better prognosis&#46;</p></span>"
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                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Edad&#44; a&#241;os<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>DE&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">57<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>11&#44;4<a class="elsevierStyleCrossRef" href="#tblfn0015"><span class="elsevierStyleSup">c</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">67<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>10&#44;8<a class="elsevierStyleCrossRef" href="#tblfn0015"><span class="elsevierStyleSup">c</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">69<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>11&#44;1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">p<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#44;001&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="5" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="5" align="left" valign="top"><span class="elsevierStyleItalic">Factores de riesgo cardiovascular</span></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Diabetes mellitus&#44; n &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">3&#46;111 &#40;34&#37;&#41;<a class="elsevierStyleCrossRef" href="#tblfn0015"><span class="elsevierStyleSup">c</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">7&#46;779 &#40;40&#44;1&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">p<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#44;001&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Dislipidemia&#44; n &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">5&#46;288 &#40;37&#37;&#41;<a class="elsevierStyleCrossRef" href="#tblfn0005"><span class="elsevierStyleSup">a</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">4&#46;032 &#40;44&#37;&#41;<a class="elsevierStyleCrossRef" href="#tblfn0015"><span class="elsevierStyleSup">c</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">7&#46;441 &#40;38&#44;4&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">p<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#44;001&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>HTA&#44; n &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">5&#46;423 &#40;38&#37;&#41;<a class="elsevierStyleCrossRef" href="#tblfn0015"><span class="elsevierStyleSup">c</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">5&#46;050 &#40;55&#44;2&#37;&#41;<a class="elsevierStyleCrossRef" href="#tblfn0015"><span class="elsevierStyleSup">c</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">11&#46;977 &#40;61&#44;8&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">p<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#44;001&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Obesidad&#44; n &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">1&#46;595 &#40;11&#44;2&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">1&#46;035 &#40;11&#44;3&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">2&#46;104 &#40;10&#44;9&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;456&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Historia familiar&#44; n &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">1&#46;859 &#40;13&#37;&#41;<a class="elsevierStyleCrossRef" href="#tblfn0015"><span class="elsevierStyleSup">c</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">773 &#40;8&#44;4&#37;&#41;<a class="elsevierStyleCrossRef" href="#tblfn0015"><span class="elsevierStyleSup">c</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">1&#46;335 &#40;6&#44;9&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">p<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#44;001&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="5" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="5" align="left" valign="top"><span class="elsevierStyleItalic">Antecedentes</span></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Angina&#44; n &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">2&#46;468 &#40;17&#44;3&#37;&#41;<a class="elsevierStyleCrossRef" href="#tblfn0015"><span class="elsevierStyleSup">c</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">2&#46;813 &#40;30&#44;7&#37;&#41;<a class="elsevierStyleCrossRef" href="#tblfn0015"><span class="elsevierStyleSup">c</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">5&#46;077 &#40;26&#44;2&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">p<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#44;001&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>IAM&#44; n &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">1&#46;642 &#40;11&#44;5&#37;&#41;<a class="elsevierStyleCrossRef" href="#tblfn0015"><span class="elsevierStyleSup">c</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">2&#46;544 &#40;27&#44;8&#37;&#41;<a class="elsevierStyleCrossRef" href="#tblfn0015"><span class="elsevierStyleSup">c</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">3&#46;380 &#40;17&#44;4&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">p<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#44;001&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Lesiones coronarias&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">513 &#40;3&#44;6&#37;&#41;<a class="elsevierStyleCrossRef" href="#tblfn0015"><span class="elsevierStyleSup">c</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">831 &#40;9&#44;1&#37;&#41;<a class="elsevierStyleCrossRef" href="#tblfn0015"><span class="elsevierStyleSup">c</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">1&#46;139 &#40;5&#44;9&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">p<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#44;001&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>IC&#44; n &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">245 &#40;1&#44;7&#37;&#41;<a class="elsevierStyleCrossRef" href="#tblfn0015"><span class="elsevierStyleSup">c</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">577 &#40;6&#44;3&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">1&#46;159 &#40;6&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">p<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#44;001&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>AVC&#44; n &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">464 &#40;3&#44;2&#37;&#41;<a class="elsevierStyleCrossRef" href="#tblfn0015"><span class="elsevierStyleSup">c</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">596 &#40;6&#44;5&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">1&#46;336 &#40;6&#44;9&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">p<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#44;001&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Arritmia&#44; n &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">337 &#40;2&#44;4&#37;&#41;<a class="elsevierStyleCrossRef" href="#tblfn0015"><span class="elsevierStyleSup">c</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">663 &#40;7&#44;2&#37;&#41;<a class="elsevierStyleCrossRef" href="#tblfn0010"><span class="elsevierStyleSup">b</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">1&#46;598 &#40;8&#44;2&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">p<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#44;001&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Vasculopat&#237;a&#44; n &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">635 &#40;4&#44;4&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">767 &#40;8&#44;4&#37;&#41;<a class="elsevierStyleCrossRef" href="#tblfn0015"><span class="elsevierStyleSup">c</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">778 &#40;4&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">p<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#44;001&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>EPOC&#44; n &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">728 &#40;8&#37;&#41;<a class="elsevierStyleCrossRef" href="#tblfn0015"><span class="elsevierStyleSup">c</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">501 &#40;2&#44;6&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">p<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#44;001&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>IR&#44; n &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">393 &#40;2&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">p<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#44;001&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="5" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="5" align="left" valign="top"><span class="elsevierStyleItalic">Forma presentaci&#243;n</span></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>ST elevado&#44; n &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">10&#46;763 &#40;56&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">p<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#44;001&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Killip<span class="elsevierStyleHsp" style=""></span>&#62;<span class="elsevierStyleHsp" style=""></span>2 al ingreso&#44; n &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">2&#46;090 &#40;15&#37;&#41;<a class="elsevierStyleCrossRef" href="#tblfn0015"><span class="elsevierStyleSup">c</span></a>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">4&#46;980 &#40;26&#44;4&#37;&#41;&nbsp;\t\t\t\t\t\t\n
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Vol. 216. Núm. 6.
Páginas 301-307 (agosto - septiembre 2016)
Original
La paradoja del tabaco en el síndrome coronario agudo. El abandono previo del hábito tabáquico como marcador de mejor pronóstico a corto plazo
The tobacco paradox in acute coronary syndrome. The prior cessation of smoking as a marker of a better short-term prognosis
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P. Bastos-Amadora, M. Almendro-Deliaa, B. Muñoz-Caleroa, E. Blanco-Ponceb, A. Recio-Mayoralb, A. Reina-Toralb, J.M. Cruz-Fernandezc, A. García-Alcántarac, R. Hidalgo-Urbanoa, J.C. García-Rubiraa,
Autor para correspondencia
grubira1@gmail.com

Autor para correspondencia.
, Grupo SCA plataforma Ariam-Andalucía
a Unidad de Gestión de Cardiología, Hospitales Universitarios Virgen Macarena-Virgen del Rocío, Sevilla, España
b Unidad de Cuidados Intensivos, Hospital Virgen de las Nieves, Granada, España
c Unidad de Cuidados Intensivos, Hospital Virgen de la Victoria, Málaga, España
Contenido relacionado
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Estadísticas
Tablas (3)
Tabla 1. Características basales de la población de estudio
Tabla 2. Eventos en el seguimiento intrahospitalario
Tabla 3. Análisis multivariado del efecto de fumador y exfumador sobre la mortalidad
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Material adicional (2)
Resumen
Objetivo

La paradoja del tabaco es un fenómeno insuficientemente explicado en estudios previos. Este estudio analiza el papel pronóstico del tabaquismo previo o activo en pacientes con síndrome coronario agudo.

Métodos

Obtuvimos los datos del registro ARIAM, entre 2001 y 2012. Se incluyó a 42.827 pacientes con síndrome coronario agudo (edad media 65±13 años, 26,4% mujeres). Se analizó la influencia del hábito tabáquico o de la condición de exfumador en la mortalidad mediante análisis multivariados.

Resultados

Los fumadores eran más jóvenes, más frecuentemente hombres, tenían menos diabetes, hipertensión e historia previa de insuficiencia cardiaca, ictus, arritmia e insuficiencia renal, así como más frecuentemente elevación del ST e historia familiar. Los exfumadores presentaban más dislipidemia e historia de angina, infarto de miocardio, cardiopatía isquémica, vasculopatía periférica y broncopatía crónica. Fumadores y exfumadores desarrollaron menos frecuentemente shock cardiogénico (fumadores 4,2%, exfumadores 4,7% y no fumadores 6,9%, p<0,001). La mortalidad hospitalaria fue del 7,8% en los no fumadores, un 4,9% en los exfumadores y un 3,1% en los fumadores (p<0,001). En el análisis multivariado, el carácter fumador perdió su influencia en el pronóstico (–0,26%, p=0,52 mediante cálculo de probabilidad inversa; y +0,26%, p=0,691 mediante análisis de propensión). Sin embargo, el carácter exfumador mostró una reducción significativa de la mortalidad en ambos test (–2,4% en el análisis de probabilidad inversa, p<0,001, y –1,5% en el análisis de propensión, p=0,005).

Conclusiones

La paradoja del tabaco es un hallazgo que puede explicarse por otros factores pronósticos. El abandono del hábito tabáquico previo a un ingreso por síndrome coronario agudo se asocia a un mejor pronóstico.

Palabras clave:
Síndrome coronario agudo
Infarto agudo de miocardio
Tabaquismo
Abandono tabaquismo
Factores de riesgo
Pronóstico
Abstract
Objective

The tobacco paradox is a phenomenon insufficiently explained by previous studies. This study analyses the prognostic role of prior or active smoking in patients with acute coronary syndrome.

Methods

We obtained data from the ARIAM registry, between 2001 and 2012. The study included 42,827 patients with acute coronary syndrome (mean age, 65±13 years; 26.4% women). The influence of smoking and that of being an ex-smoker on mortality was analysed using a multivariate analysis.

Results

The smokers were younger, were more often men, had less diabetes, hypertension and prior history of heart failure, stroke, arrhythmia and renal failure and more frequently had ST-elevation and a family history of smoking. The ex-smokers had more dyslipidaemia and history of angina, myocardial infarction, ischemic heart disease, peripheral vasculopathy and chronic bronchial disease. Smokers and ex-smokers less frequently developed cardiogenic shock (smokers 4.2%, ex-smokers 4.7% and nonsmokers 6.9%, P<.001). Hospital mortality was 7.8% for the nonsmokers, 4.9% for the ex-smokers and 3.1% for the smokers (P<.001). In the multivariate analysis, the smoker factor lost its influence in the prognosis (–0.26%, p=.52 using an inverse probability calculation; and+0.26%, P=.691 using a propensity analysis). However, the exsmoker factor showed a significant reduction in mortality in both tests (-2.4% in the inverse probability analysis, P<.001; and –1.5% in the propensity analysis, P=.005).

Conclusions

The tobacco paradox is a finding that could be explained by other prognostic factors. Smoking cessation prior to hospitalization for acute coronary syndrome is associated with a better prognosis.

Keywords:
Acute coronary syndrome
Acute myocardial infarction
Smoking
Smoking cessation
Risk factors
Prognosis

Artículo

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