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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">En vista de la importancia que reviste la hipertensi&#243;n arterial como problema de salud p&#250;blica en relaci&#243;n con la morbimortalidad cardiovascular&#44; muchos investigadores han tratado de buscar tambi&#233;n asociaciones entre incrementos exagerados de la presi&#243;n arterial con el ejercicio y el desarrollo posterior de hipertensi&#243;n arterial en reposo<a class="elsevierStyleCrossRefs" href="#bib0210"><span class="elsevierStyleSup">1&#8211;7</span></a>&#44; de da&#241;o en &#243;rganos diana y de mortalidad y eventos cardiovasculares graves en personas con<a class="elsevierStyleCrossRefs" href="#bib0245"><span class="elsevierStyleSup">8&#8211;10</span></a> y sin enfermedad coronaria<a class="elsevierStyleCrossRefs" href="#bib0220"><span class="elsevierStyleSup">3&#44;11&#8211;13</span></a>&#44; aunque con resultados discrepantes&#46; Adem&#225;s&#44; es frecuente que en los estudios que han evaluado el valor pron&#243;stico de la respuesta hipertensiva con el ejercicio se hayan excluido las mujeres<a class="elsevierStyleCrossRefs" href="#bib0250"><span class="elsevierStyleSup">9&#44;13&#8211;15</span></a>&#44; no teniendo en cuenta&#44; por tanto&#44; las particularidades de sexo en la determinaci&#243;n del valor pron&#243;stico de esta variable &#40;limit&#225;ndose a extrapolar los resultados de los varones a las mujeres&#41;&#44; por lo que la informaci&#243;n disponible en la literatura sobre este subgrupo de pacientes es limitada&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">Nuestro prop&#243;sito fue analizar la relaci&#243;n entre una elevaci&#243;n extrema de la presi&#243;n arterial &#40;PA&#41; con el ejercicio &#40;igual o superior al percentil 95 de la muestra&#41; con la mortalidad y eventos cardiovasculares y cerebrovasculares graves&#44; en mujeres con enfermedad coronaria conocida o sospechada&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">M&#233;todos</span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Pacientes</span><p id="par0015" class="elsevierStylePara elsevierViewall">La muestra se constituy&#243; con 3&#46;942 mujeres&#44; pertenecientes al &#225;rea sanitaria de referencia de un hospital de tercer nivel&#44; sometidas a ecocardiograf&#237;a de ejercicio en la unidad de imagen y funci&#243;n card&#237;aca&#44; entre el 1 de marzo de 1995 y el 28 de junio de 2013&#46; Incluy&#243; a mujeres de edad &#8805;<span class="elsevierStyleHsp" style=""></span>18 a&#241;os y fueron excluidas del estudio las pacientes tratadas con bloqueadores beta en las 48<span class="elsevierStyleHsp" style=""></span>horas previas al test<a class="elsevierStyleCrossRef" href="#bib0285"><span class="elsevierStyleSup">16</span></a> y aquellas en las que se constat&#243; una ausencia de incremento de la PA con el ejercicio por encima de su valor basal&#44; es decir&#44; no aument&#243; o incluso disminuy&#243; con el ejercicio en relaci&#243;n con los valores en reposo &#40;por su bien conocido valor pron&#243;stico negativo&#41;<a class="elsevierStyleCrossRef" href="#bib0290"><span class="elsevierStyleSup">17</span></a>&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Datos cl&#237;nicos</span><p id="par0020" class="elsevierStylePara elsevierViewall">Los datos demogr&#225;ficos y cl&#237;nicos fueron introducidos en una base de datos en el momento de la realizaci&#243;n del estudio&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">La diabetes mellitus&#44; la hipertensi&#243;n arterial y la hipercolesterolemia se definieron de acuerdo a la historia previa conocida de enfermedad y&#47;o los antecedentes de tratamiento farmacol&#243;gico con antidiab&#233;ticos&#44; antihipertensivos o hipolipidemiantes respectivamente&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">Las razones cl&#237;nicas por las que se indic&#243; el ecocardiograma de ejercicio incluyeron dolor tor&#225;cico&#44; disnea y pruebas evaluativas en pacientes asintom&#225;ticos&#46; Los pacientes referidos para la evaluaci&#243;n de dolor tor&#225;cico se clasificaron como enfermos con angina t&#237;pica&#44; angina probable&#47;at&#237;pica o dolor tor&#225;cico de origen no isqu&#233;mico de acuerdo a la escala de Diamond<a class="elsevierStyleCrossRef" href="#bib0295"><span class="elsevierStyleSup">18</span></a>&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">La historia previa de cardiopat&#237;a isqu&#233;mica se defini&#243; como el antecedente de infarto agudo de miocardio &#40;IM&#41;&#44; revascularizaci&#243;n coronaria o documentaci&#243;n angiogr&#225;fica previa de estenosis coronaria significativa &#40;&#8805;<span class="elsevierStyleHsp" style=""></span>50&#37; del di&#225;metro del tronco coronario izquierdo o &#8805;<span class="elsevierStyleHsp" style=""></span>70&#37; del di&#225;metro de cualquier otra arteria coronaria epic&#225;rdica&#41;&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">Con respecto a los datos electrocardiogr&#225;ficos basales se recogi&#243; el ritmo del paciente &#40;sinusal&#44; fibrilaci&#243;n auricular&#41;&#44; as&#237; como aquellos hallazgos que pudiesen dificultar la interpretabilidad del mismo &#40;el ECG basal se consider&#243; no interpretable en presencia de bloqueo de rama izquierda&#44; ritmo de marcapasos&#44; hipertrofia ventricular izquierda con patr&#243;n de sobrecarga&#44; tratamiento con digoxina&#44; s&#237;ndrome de preexcitaci&#243;n u otras alteraciones de la repolarizaci&#243;n&#41;&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Prueba de esfuerzo</span><p id="par0045" class="elsevierStylePara elsevierViewall">Todos los pacientes fueron sometidos a ecocardiograf&#237;a de ejercicio sobre cinta rodante utilizando distintos protocolos en funci&#243;n de las caracter&#237;sticas de los pacientes&#46;</p><p id="par0050" class="elsevierStylePara elsevierViewall">Se obtuvieron datos de frecuencia card&#237;aca &#40;FC&#41;&#44; PA &#40;por el m&#233;todo auscultatorio&#41; y electrocardiograma de 12 derivaciones previo al ejercicio y en cada estadio del protocolo&#44; como es habitual en la ergometr&#237;a convencional&#46;</p><p id="par0055" class="elsevierStylePara elsevierViewall">Para la realizaci&#243;n del test los pacientes cumplieron un protocolo de ejercicio en cinta rodante hasta alcanzar uno de los siguientes objetivos&#58; agotamiento f&#237;sico&#44; angina severa&#44; arritmia significativa con compromiso hemodin&#225;mico del paciente&#44; hipertensi&#243;n severa &#40;PA sist&#243;lica<span class="elsevierStyleHsp" style=""></span>&#62;<span class="elsevierStyleHsp" style=""></span>240<span class="elsevierStyleHsp" style=""></span>mm<span class="elsevierStyleHsp" style=""></span>Hg o PA di&#225;st&#243;lica<span class="elsevierStyleHsp" style=""></span>&#62;<span class="elsevierStyleHsp" style=""></span>110<span class="elsevierStyleHsp" style=""></span>mm<span class="elsevierStyleHsp" style=""></span>Hg&#41; o una respuesta hipotensiva con el ejercicio &#40;descenso de la PA sist&#243;lica<span class="elsevierStyleHsp" style=""></span>&#62;<span class="elsevierStyleHsp" style=""></span>20<span class="elsevierStyleHsp" style=""></span>mm<span class="elsevierStyleHsp" style=""></span>Hg desde el valor basal&#41;&#46;</p><p id="par0060" class="elsevierStylePara elsevierViewall">El incremento exagerado de la PA sist&#243;lica &#40;PAS&#41; con el ejercicio &#40;IEPASE&#41; se defini&#243; como la diferencia entre la PAS pico y la PAS basal&#44; y se categoriz&#243; de acuerdo al percentil 95 de la poblaci&#243;n del estudio &#40;70<span class="elsevierStyleHsp" style=""></span>mm<span class="elsevierStyleHsp" style=""></span>Hg&#41;&#46;</p><p id="par0065" class="elsevierStylePara elsevierViewall">Se consideraron alteraciones electrocardiogr&#225;ficas isqu&#233;micas durante el test la aparici&#243;n de un ascenso o un descenso del segmento ST horizontal o descendente &#8805;<span class="elsevierStyleHsp" style=""></span>1<span class="elsevierStyleHsp" style=""></span>mm a 80<span class="elsevierStyleHsp" style=""></span>mseg del punto J en &#8805;<span class="elsevierStyleHsp" style=""></span>1 derivaci&#243;n en pacientes con electrocardiograma interpretable&#46;</p><p id="par0070" class="elsevierStylePara elsevierViewall">El test subm&#225;ximo se defini&#243; como la incapacidad en alcanzar el 85&#37; de la FC m&#225;xima te&#243;rica&#46;</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Ecocardiograf&#237;a de ejercicio</span><p id="par0075" class="elsevierStylePara elsevierViewall">Se realiz&#243; un ecocardiograma bidimensional en las proyecciones apicales y paraesternales est&#225;ndar en 3 tiempos&#58; en situaci&#243;n basal&#44; en pico de ejercicio con el paciente todav&#237;a deambulando sobre la cinta e inmediatamente tras el ejercicio<a class="elsevierStyleCrossRef" href="#bib0300"><span class="elsevierStyleSup">19</span></a>&#46; Todas las im&#225;genes fueron almacenadas en un disco &#243;ptico&#46; Se codific&#243; la motilidad segmentaria siguiendo el modelo de 16 segmentos del ventr&#237;culo izquierdo utilizando una escala de 4 puntos con los siguientes valores&#58; motilidad normal<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>1&#44; hipocinesia<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>2&#44; acinesia<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>3&#44; discinesia<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>4&#46; Se calcul&#243; el &#237;ndice de motilidad segmentaria &#40;IMS&#41; basal y durante el ejercicio como el cociente entre el sumatorio de las puntuaciones y el n&#250;mero total de segmentos&#46; Se calcul&#243; tambi&#233;n la diferencia entre el IMS en ejercicio y en reposo &#40;&#916;IMS&#41; y se defini&#243; isquemia como el desarrollo de anomal&#237;as de la contractilidad segmentaria de nueva aparici&#243;n o empeoramiento de las ya existentes &#40;&#916;IMS<span class="elsevierStyleHsp" style=""></span>&#62;<span class="elsevierStyleHsp" style=""></span>0&#41;&#44; excepto el empeoramiento de acinesia a discinesia<a class="elsevierStyleCrossRef" href="#bib0305"><span class="elsevierStyleSup">20</span></a> y la hipocinesia aislada del segmento inferobasal<a class="elsevierStyleCrossRef" href="#bib0310"><span class="elsevierStyleSup">21</span></a>&#46;</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Seguimiento</span><p id="par0080" class="elsevierStylePara elsevierViewall">Los datos del seguimiento fueron obtenidos a partir de la revisi&#243;n de la historia cl&#237;nica electr&#243;nica y de las bases de datos hospitalarias y fueron facilitados en su mayor parte por el departamento de tecnolog&#237;as de la informaci&#243;n de nuestro centro&#46; Los estados vitales&#44; as&#237; como las causas de muerte&#44; fueron contrastados con la informaci&#243;n proporcionada por el Registro gallego de mortalidad&#44; atendiendo en todo momento a las normas de manejo de informaci&#243;n confidencial al uso&#46;</p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">Objetivos</span><p id="par0085" class="elsevierStylePara elsevierViewall">Los objetivos del estudio fueron mortalidad global&#44; muerte de origen cardiaco&#44; IM no fatal&#44; accidente cerebrovascular &#40;ACV&#41; e intervenciones de revascularizaci&#243;n coronaria durante el seguimiento&#46; El estudio cuenta con la aprobaci&#243;n del Comit&#233; &#233;tico de investigaci&#243;n cl&#237;nica de Galicia&#46;</p></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0105">An&#225;lisis estad&#237;stico</span><p id="par0090" class="elsevierStylePara elsevierViewall">Las variables categ&#243;ricas se expresaron como porcentajes y la comparaci&#243;n entre grupos se realiz&#243; con el test de Chi cuadrado&#46; Las variables continuas se expresaron como media<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>desviaci&#243;n est&#225;ndar o como mediana<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>rango intercuart&#237;lico&#44; previa comprobaci&#243;n de la distribuci&#243;n de la variable&#44; y las diferencias entre grupos fueron contrastadas mediante el test de la &#171;t&#187; de Student &#40;en variables con distribuci&#243;n param&#233;trica&#41; o el test de Mann-Whitney &#40;en variables con distribuci&#243;n no param&#233;trica&#41;&#46;</p><p id="par0095" class="elsevierStylePara elsevierViewall">La supervivencia fue evaluada mediante el m&#233;todo de Kaplan-Meier&#44; y las curvas de supervivencia fueron comparadas mediante el test de rangos logar&#237;tmicos&#46; Las tasas anuales de eventos fueron calculadas en funci&#243;n del cociente entre n&#250;mero de eventos y el producto del n&#250;mero de casos por el seguimiento medio&#46;</p><p id="par0100" class="elsevierStylePara elsevierViewall">El valor pron&#243;stico de la IPASE se determin&#243; mediante an&#225;lisis de regresi&#243;n de Cox&#46; En todos los modelos multivariantes fueron consideradas las siguientes covariables&#58; edad&#44; diabetes&#44; h&#225;bito tab&#225;quico&#44; hipertensi&#243;n arterial&#44; hipercolesterolemia&#44; IECA&#47;ARA-II&#44; diur&#233;ticos&#44; nitritos&#44; antagonistas del calcio&#44; antecedentes familiares de enfermedad coronaria&#44; IM previo&#44; antecedentes de revascularizaci&#243;n coronaria&#44; fibrilaci&#243;n auricular&#44; fracci&#243;n de eyecci&#243;n del ventr&#237;culo izquierdo basal&#44; PA basal&#44; FC en pico de ejercicio&#44; capacidad funcional &#40;METS&#41;&#44; presencia de angina durante el ejercicio&#44; IMS en pico de ejercicio y resultado de la ergometr&#237;a&#46;</p><p id="par0105" class="elsevierStylePara elsevierViewall">El an&#225;lisis estad&#237;stico se realiz&#243; mediante el paquete SPSS versi&#243;n 25&#46;0 &#40;SPSS&#44; Chicago&#44; Illinois&#44; EE&#46; UU&#46;&#41;&#46;</p></span></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0110">Resultados</span><p id="par0110" class="elsevierStylePara elsevierViewall">La mediana de seguimiento fue de 3&#44;5 a&#241;os&#44; con un rango intercuart&#237;lico de 0&#44;8-8 a&#241;os&#46;</p><p id="par0115" class="elsevierStylePara elsevierViewall">El estudio incluy&#243; a 3&#46;942 mujeres con una media de edad de 63&#44;5<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>11&#44;6 a&#241;os&#44; de las cuales 332 &#40;8&#44;4&#37;&#41; desarrollaron IEPASE durante la realizaci&#243;n del test &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">tabla 1</a>&#41;&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0120" class="elsevierStylePara elsevierViewall">La edad fue ligeramente superior en las mujeres sin IEPASE&#46; Las pacientes con IEPASE presentaron mayor prevalencia de diabetes mellitus&#46; No observamos diferencias significativas en la prevalencia de hipertensi&#243;n&#44; hipercolesterolemia ni historia de enfermedad coronaria&#46;</p><p id="par0125" class="elsevierStylePara elsevierViewall">Las pacientes que desarrollaron IEPASE presentaron una mayor capacidad funcional y una menor probabilidad de test subm&#225;ximo y de isquemia ecocardiogr&#225;fica durante el ejercicio&#46; No hubo diferencias significativas en relaci&#243;n con la PA en reposo entre ambos subgrupos de mujeres &#40;<a class="elsevierStyleCrossRef" href="#tbl0010">tabla 2</a>&#41;&#46;</p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><p id="par0130" class="elsevierStylePara elsevierViewall">Durante el seguimiento hubo un total de 458 muertes &#40;162 de origen card&#237;aca&#41;&#44; 212<span class="elsevierStyleHsp" style=""></span>IM&#44; 89<span class="elsevierStyleHsp" style=""></span>ACV y 345 intervenciones de revascularizaci&#243;n coronaria&#46; La tasa anual de mortalidad global fue significativamente inferior en el subgrupo de pacientes con IEPASE &#40;0&#44;15&#37; vs&#46; 2&#44;3&#37;&#44; p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;02&#41;&#44; tambi&#233;n la tasa anual de mortalidad card&#237;aca &#40;0&#44;01&#37; vs&#46; 0&#44;2&#37;&#44; p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;015&#41;&#46; No observamos diferencias significativas en las tasas de IM&#44; ACV y de intervenciones de revascularizaci&#243;n coronaria&#44; que fueron&#44; respectivamente&#44; del 1&#44;1&#37;&#44; 0&#44;43&#37; y 2&#44;24&#37; en pacientes con IEPASE y del 0&#44;09&#37;&#44; 0&#44;05&#37; y 0&#44;13&#37; en aquellas mujeres sin IEPASE &#40;p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;66&#59; p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;57&#59; p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;19&#44; respectivamente&#41; &#40;<a class="elsevierStyleCrossRef" href="#fig0005">fig&#46; 1</a>&#41;&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0135" class="elsevierStylePara elsevierViewall">En un an&#225;lisis univariado la capacidad funcional &#40;METS&#41;&#44; la presencia de un de test subm&#225;ximo y la FC en pico de ejercicio resultaron predictores de mortalidad&#44; IM e intervenciones de revascularizaci&#243;n coronaria&#46; La capacidad funcional y la FC m&#225;xima tambi&#233;n resultaron predictores de ACV &#40;<a class="elsevierStyleCrossRef" href="#tbl0015">tabla 3</a>&#41;&#46;</p><elsevierMultimedia ident="tbl0015"></elsevierMultimedia><p id="par0140" class="elsevierStylePara elsevierViewall">Tras ajuste multivariante el IEPASE no result&#243; predictor de mortalidad &#40;ni global ni card&#237;aca&#41; ni de eventos cardiovasculares ni cerebrovasculares en las mujeres estudiadas &#40;<a class="elsevierStyleCrossRef" href="#tbl0020">tabla 4</a>&#41;&#46;</p><elsevierMultimedia ident="tbl0020"></elsevierMultimedia></span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0115">Discusi&#243;n</span><p id="par0145" class="elsevierStylePara elsevierViewall">En nuestro estudio la IEPASE no result&#243; predictora de mortalidad ni de eventos cardiovasculares ni cerebrovasculares graves en una poblaci&#243;n de mujeres sometidas a ecocardiograf&#237;a de ejercicio&#46;</p><p id="par0150" class="elsevierStylePara elsevierViewall">El valor pron&#243;stico de la IEPASE resulta a&#250;n hoy controvertido&#59; sin embargo&#44; la idea de que la respuesta hipertensiva con el ejercicio pueda asociarse de forma independiente a mortalidad y eventos cardiovasculares se baraja desde hace m&#225;s de 20 a&#241;os&#44; tras las publicaciones de algunos estudios que determinaron una asociaci&#243;n entre la respuesta hipertensiva con el ejercicio y una mayor incidencia futura de hipertensi&#243;n<a class="elsevierStyleCrossRefs" href="#bib0210"><span class="elsevierStyleSup">1&#8211;7</span></a> y de eventos cardiovasculares<a class="elsevierStyleCrossRefs" href="#bib0220"><span class="elsevierStyleSup">3&#44;11&#8211;13&#44;22&#44;23</span></a> en individuos sanos con PA basal normal&#46; Sin embargo&#44; otros investigadores intentaron encontrar una relaci&#243;n entre la respuesta exagerada de la PA con el ejercicio en pacientes sanos y la presencia de una hipertensi&#243;n enmascarada&#44; fracasando en la b&#250;squeda<a class="elsevierStyleCrossRef" href="#bib0325"><span class="elsevierStyleSup">24</span></a>&#46; M&#225;s recientemente Schultz et al&#46; concluyeron&#44; bas&#225;ndose en una revisi&#243;n de 12 estudios longitudinales que inclu&#237;an un total de 46&#46;314 pacientes sin enfermedad coronaria&#44; que la IEPASE a intensidades moderadas de ejercicio constituye un factor de riesgo independiente de eventos cardiovasculares y mortalidad<a class="elsevierStyleCrossRef" href="#bib0330"><span class="elsevierStyleSup">25</span></a>&#46;</p><p id="par0155" class="elsevierStylePara elsevierViewall">Las investigaciones en relaci&#243;n con la posible asociaci&#243;n entre respuesta hipertensiva con el ejercicio y desarrollo de ACV en el seguimiento son m&#225;s limitadas&#46; Por un lado&#44; Kurl et al&#46;<a class="elsevierStyleCrossRef" href="#bib0280"><span class="elsevierStyleSup">15</span></a> determinaron que aquellos sujetos sanos con una elevaci&#243;n de la PAS igual o superior a 19&#44;7<span class="elsevierStyleHsp" style=""></span>mm<span class="elsevierStyleHsp" style=""></span>Hg&#47;min con el ejercicio presentan una incidencia mayor de ACV durante el seguimiento&#44; en comparaci&#243;n con los sujetos que hab&#237;an experimentado un aumento no superior a 16&#44;1<span class="elsevierStyleHsp" style=""></span>mm<span class="elsevierStyleHsp" style=""></span>Hg&#47;min de ejercicio&#46; Estudios posteriores en pacientes con enfermedad coronaria conocida arrojaron resultados discrepantes<a class="elsevierStyleCrossRef" href="#bib0335"><span class="elsevierStyleSup">26</span></a>&#46;</p><p id="par0160" class="elsevierStylePara elsevierViewall">Por lo general&#44; los estudios en pacientes con enfermedad coronaria conocida o sospechada han reportado resultados conflictivos<a class="elsevierStyleCrossRefs" href="#bib0245"><span class="elsevierStyleSup">8&#44;27&#8211;29</span></a>&#44; por lo que resulta pertinente analizar cu&#225;les podr&#237;an ser los motivos de las discrepancias entre las distintas investigaciones&#46;</p><p id="par0165" class="elsevierStylePara elsevierViewall">En el transcurso de una prueba de esfuerzo&#44; la respuesta tensional esperada en un sujeto sano es de un aumento de la PAS progresiva&#44; a medida que aumenta la carga de trabajo&#44; mientras la PA diast&#243;lica se mantiene o desciende ligeramente&#46; El incremento de la PAS con el ejercicio es el resultado del aumento del gasto card&#237;aco&#44; motivado a su vez por el incremento de la FC y del volumen sist&#243;lico&#46; De forma simult&#225;nea&#44; la respuesta simp&#225;tica determina una redistribuci&#243;n del flujo sangu&#237;neo hacia las zonas activas&#44; con mayores necesidades metab&#243;licas&#44; produci&#233;ndose una vasodilataci&#243;n en los vasos que irrigan a los m&#250;sculos implicados en la actividad y una vasoconstricci&#243;n en las zonas inactivas&#44; lo cual explicar&#237;a el ligero descenso de la PA diast&#243;lica durante el ejercicio&#46; Si bien un aumento del gasto card&#237;aco podr&#237;a ser favorable para el paciente desde el punto de vista pron&#243;stico&#44; un aumento de las resistencias vasculares perif&#233;ricas no esperable en circunstancias de estr&#233;s f&#237;sico ser&#237;a&#44; sin duda&#44; indicador de peor pron&#243;stico<a class="elsevierStyleCrossRef" href="#bib0355"><span class="elsevierStyleSup">30</span></a>&#46;</p><p id="par0170" class="elsevierStylePara elsevierViewall">Los mecanismos fisiopatol&#243;gicos que explican la respuesta hipertensiva con el ejercicio no est&#225;n totalmente esclarecidos&#46; Aunque presumiblemente la etiolog&#237;a de la respuesta hipertensiva con el ejercicio sea multifactorial&#44; un posible factor causal podr&#237;a ser la rigidez arterial provocada por el proceso del envejecimiento o por alg&#250;n proceso patol&#243;gico<a class="elsevierStyleCrossRefs" href="#bib0360"><span class="elsevierStyleSup">31&#44;32</span></a>&#59; esta rigidez arterial estar&#237;a presente en pacientes normotensos con riesgo de futura hipertensi&#243;n arterial&#46; En la misma l&#237;nea&#44; otros autores<a class="elsevierStyleCrossRefs" href="#bib0370"><span class="elsevierStyleSup">33&#8211;36</span></a> hallaron una asociaci&#243;n entre el da&#241;o en la funci&#243;n endotelial y la respuesta de la PA durante el ejercicio&#46; La reducci&#243;n de la distensibilidad a&#243;rtica<a class="elsevierStyleCrossRefs" href="#bib0390"><span class="elsevierStyleSup">37&#44;38</span></a> o la incapacidad de las arterias perif&#233;ricas para dilatarse y acomodarse a un flujo sangu&#237;neo aumentado durante el ejercicio tambi&#233;n fueron se&#241;aladas como posibles causas de incremento exagerado de la PA durante el ejercicio<a class="elsevierStyleCrossRef" href="#bib0400"><span class="elsevierStyleSup">39</span></a>&#46; Otros estudios apuntan a la presencia de arterioesclerosis incipiente como factor instigador de un respuesta tensional exagerada con el ejercicio<a class="elsevierStyleCrossRefs" href="#bib0375"><span class="elsevierStyleSup">34&#44;40</span></a>&#44; y a aumentos de la angiotensina <span class="elsevierStyleSmallCaps">ii</span> durante el ejercicio en pacientes con respuesta hipertensiva<a class="elsevierStyleCrossRef" href="#bib0410"><span class="elsevierStyleSup">41</span></a>&#46;</p><p id="par0175" class="elsevierStylePara elsevierViewall">En nuestro estudio los pacientes con IEPASE presentaron una menor probabilidad de test subm&#225;ximos y una mayor frecuencia card&#237;aca en el pico de esfuerzo&#44; as&#237; como una fracci&#243;n de eyecci&#243;n del ventr&#237;culo izquierdo mayor&#44; tanto en reposo como en pico de ejercicio&#44; menor porcentaje de alteraciones basales de la contractilidad segmentaria y de isquemia ecocardiogr&#225;fica y una mejor capacidad funcional&#44; factores todos ellos que explicar&#237;an un mayor gasto card&#237;aco y&#44; por tanto&#44; la significativa menor mortalidad global de las pacientes con IEPASE &#40;relaci&#243;n que desaparece tras ajustar por estos factores&#41;&#46;</p><p id="par0180" class="elsevierStylePara elsevierViewall">Nuestro inter&#233;s se centr&#243;&#44; por tanto&#44; en evaluar el comportamiento de incrementos extremos de la PA con el ejercicio en mujeres&#46; Como hemos podido comprobar&#44; las mujeres&#44; con frecuencia&#44; han sido excluidas en los estudios de valor pron&#243;stico de la respuesta hipertensiva con el ejercicio&#44; de manera que la informaci&#243;n sobre el comportamiento de esta variable en el sexo femenino es limitada&#44; extrapol&#225;ndose generalmente los resultados de estudios en hombres a las mujeres sin tener en cuenta las diferencias de sexo&#46;</p><span id="sec0060" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0120">Limitaciones</span><p id="par0185" class="elsevierStylePara elsevierViewall">Nuestro estudio presenta las limitaciones propias de los estudios observacionales&#44; retrospectivos y unic&#233;ntricos&#46; Estos resultados solo son aplicables a mujeres referidas a pruebas de esfuerzo en tapiz rodante por motivos cl&#237;nicos&#44; por lo que no pueden ser extrapolados a otros subgrupos de sujetos&#46; A pesar de la exclusi&#243;n de pacientes tratados con bloqueadores beta en las 48<span class="elsevierStyleHsp" style=""></span>horas previas al test&#44; no se puede descartar un efecto residual de estos f&#225;rmacos en los pacientes&#46; Algunas variables importantes&#44; como el peso&#44; la terapia con anticoagulantes o el tama&#241;o de la aur&#237;cula izquierda no estaban disponibles para su an&#225;lisis en nuestro estudio&#46;</p></span></span><span id="sec0065" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0125">Conclusiones</span><p id="par0190" class="elsevierStylePara elsevierViewall">En nuestro estudio el incremento extremo de la PA con el ejercicio no se asoci&#243; de forma independiente a mortalidad&#44; ni eventos cardiovasculares ni cerebrovasculares graves en mujeres con enfermedad coronaria conocida o sospechada sometidas a ecocardiograf&#237;a de ejercicio en cinta rodante&#46;</p></span><span id="sec0070" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0130">Financiaci&#243;n</span><p id="par0195" class="elsevierStylePara elsevierViewall">Uni&#243;n Europea a trav&#233;s del Fondo europeo de desarrollo regional &#40;FEDER&#41;&#46;</p></span><span id="sec0075" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0135">Conflicto de intereses</span><p id="par0200" class="elsevierStylePara elsevierViewall">Los autores declaran no tener ning&#250;n conflicto de intereses</p></span></span>"
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          "titulo" => "Abstract"
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            0 => array:2 [
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              "titulo" => "Background and objectives"
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    "fechaRecibido" => "2019-02-25"
    "fechaAceptado" => "2019-05-18"
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        "titulo" => "Resumen"
        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Fundamento y objetivos</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">La asociaci&#243;n entre un incremento exagerado de la presi&#243;n arterial sist&#243;lica con el ejercicio &#40;IEPASE&#41; y la probabilidad de eventos cardiovasculares es controvertida y poco estudiada en poblaci&#243;n femenina&#46; Nuestro prop&#243;sito fue determinar la posible asociaci&#243;n de un IEPASE con mortalidad y eventos cardiovasculares en mujeres referidas a ecocardiograf&#237;a de ejercicio por enfermedad coronaria conocida o sospechada&#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">Se realiz&#243; ecocardiograf&#237;a de ejercicio a 3&#46;942 mujeres con enfermedad coronaria conocida o sospechada&#46; El IEPASE se defini&#243; como un incremento de la presi&#243;n arterial sist&#243;lica con el ejercicio &#8805;<span class="elsevierStyleHsp" style=""></span>70<span class="elsevierStyleHsp" style=""></span>mm<span class="elsevierStyleHsp" style=""></span>Hg&#46; Los objetivos fueron mortalidad global y card&#237;aca&#44; infarto agudo de miocardio &#40;IM&#41;&#44; accidente cerebrovascular &#40;ACV&#41; e intervenciones de revascularizaci&#243;n coronaria&#46;</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Resultados</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Trescientas treinta y dos mujeres desarrollaron IEPASE durante los test&#46; En el seguimiento se registraron un total de 458 muertes &#40;162 de origen card&#237;aco&#41;&#44; 212 IM&#44; 89 ACV y 345 intervenciones de revascularizaci&#243;n coronaria&#46; La tasa anual de mortalidad global y cardiaca fue inferior en el subgrupo de pacientes con IEPASE &#40;0&#44;15&#37; vs&#46; 2&#44;3&#37;&#44; p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;02 y 0&#44;01&#37; vs&#46; 0&#44;2&#37;&#44; p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;015&#44; respectivamente&#41;&#46; No observamos diferencias significativas en las tasas de IM&#44; ACV y de intervenciones de revascularizaci&#243;n coronaria&#44; que fueron&#44; respectivamente&#44; del 1&#44;1&#37;&#44; 0&#44;43&#37; y 2&#44;24&#37; en pacientes con IEPASE y del 0&#44;09&#37;&#44; 0&#44;05&#37; y 0&#44;13&#37; en aquellas mujeres sin IEPASE &#40;p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;66&#59; p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;57&#59; p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;19&#44; respectivamente&#41;&#44; Tras un ajuste multivariante el IEPASE no result&#243; predictor de mortalidad ni de eventos cardiovasculares&#46;</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Conclusiones</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">El IEPASE no se asoci&#243; con mortalidad ni eventos cardiovasculares graves en mujeres con enfermedad coronaria conocida o sospechada&#46;</p></span>"
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          0 => array:2 [
            "identificador" => "abst0005"
            "titulo" => "Fundamento y objetivos"
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          1 => array:2 [
            "identificador" => "abst0010"
            "titulo" => "Pacientes y m&#233;todos"
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          2 => array:2 [
            "identificador" => "abst0015"
            "titulo" => "Resultados"
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        "resumen" => "<span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Background and objectives</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">The association between an exaggerated systolic blood pressure increase with exercise &#40;EBPIE&#41; and the probability of cardiovascular events is controversial and poorly studied in the female population&#46; Our aim was to determine the possible association between EBPIE on one hand and mortality and cardiovascular events on the other in women referred for exercise echocardiography due to known or suspected coronary artery disease&#46;</p></span> <span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Patients and methods</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">A total of 3942 women with known or suspected coronary artery disease underwent exercise echocardiography&#46; We defined EBPIE as a &#8805;<span class="elsevierStyleHsp" style=""></span>70<span class="elsevierStyleHsp" style=""></span>mm Hg increase in systolic blood pressure with exercise&#46; The study endpoints were overall and cardiac mortality&#44; acute myocardial infarction &#40;MI&#41;&#44; stroke and coronary revascularisation procedures&#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 332 women developed EBPIE during the test&#46; During the follow-up&#44; 458 deaths &#40;162 of cardiac origin&#41;&#44; 212 MIs&#44; 89 strokes and 345 coronary revascularisation procedures were recorded&#46; The annual rates of overall and cardiac mortality were lower in the patient subgroup with EBPIE &#40;0&#46;15&#37; vs&#46; 2&#46;3&#37;&#44; <span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>&#46;02 and 0&#46;01&#37; vs&#46; 0&#46;2&#37;&#44; <span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>&#46;015&#44; respectively&#41;&#46; There were no significant differences in the rates of MI&#44; stroke and the need for coronary revascularisation procedures&#44; which occurred in 1&#46;1&#37;&#44; 0&#46;43&#37; and 2&#46;24&#37; of the patients with EBPIE&#44; respectively&#44; and occurred in 0&#46;09&#37;&#44; 0&#46;05&#37; and 0&#46;13&#37; of the women without EBPIE &#40;<span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>&#46;66&#59; <span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>&#46;57&#59; <span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>&#46;19&#44; respectively&#41;&#46; After a multivariate adjustment&#44; EBPIE was not a predictor of mortality or cardiovascular events&#46;</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Conclusions</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">EBPIE is not associated with mortality or severe cardiovascular events in women with known or suspected coronary artery disease&#46;</p></span>"
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          "es" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Curvas de Kaplan-Meier de mortalidad &#40;A&#41;&#44; infarto de miocardio &#40;B&#41;&#44; accidente cerebrovascular &#40;C&#41; y revascularizaci&#243;n coronaria &#40;D&#41;&#44; estratificadas seg&#250;n el desarrollo de un incremento exagerado de la presi&#243;n arterial sist&#243;lica con el ejercicio &#40;IEPASE&#41;&#46;</p>"
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          "leyenda" => "<p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">ARA-II&#58; antagonistas de los receptores de la angiotensina <span class="elsevierStyleSmallCaps">ii</span>&#59; ECG&#58; electrocardiograma&#59; EE&#58; ecocardiograf&#237;a de ejercicio&#59; IECA&#58; inhibidores de la enzima conversora de la angiotensina&#59; IEPASE&#58; incremento de la tensi&#243;n arterial sist&#243;lica con el ejercicio igual o mayor a 70<span class="elsevierStyleHsp" style=""></span>mm<span class="elsevierStyleHsp" style=""></span>Hg&#59; IM&#58; infarto de miocardio&#46;</p>"
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Muestra &#40;n<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>3&#46;942&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">No IEPASE &#40;n<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>3&#46;610&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">IEPASE &#40;n<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>332&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">63&#44;4<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>11&#44;6&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>&#8804;<span class="elsevierStyleHsp" style=""></span>30 d&#237;as antes de la EE&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>&#62;<span class="elsevierStyleHsp" style=""></span>30 d&#237;as antes de la EE&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleItalic">Revascularizaci&#243;n coronaria&#44; n &#40;&#37;&#41;</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Percut&#225;nea&#44; n &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Quir&#250;rgica&#44; n &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
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                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t">0&#44;24&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t">24&#44;4<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>5&#44;3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t\ttop\n
                  \t\t\t\t">32&#44;4<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>4&#44;8&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t\ttop\n
                  \t\t\t\t"><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="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>&#37; de FC m&#225;xima te&#243;rica&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t\ttop\n
                  \t\t\t\t">94&#44;9<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>10&#44;8&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">97&#44;1<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>10&#44;3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><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="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Test subm&#225;ximo&#44; n &#40;&#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">531 &#40;14&#44;7&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">28 &#40;8&#44;4&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#44;002&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Angina durante el test&#44; n &#40;&#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">389 &#40;10&#44;8&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">32 &#40;9&#44;6&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#44;52&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Cambios isqu&#233;micos en ECG&#44; n &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">410 &#40;11&#44;4&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">39 &#40;11&#44;7&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#44;83&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Capacidad funcional&#44; METS&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
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                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">9<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>2&#44;3&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"><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="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="4" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="4" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">FEVI&#44; &#37;</span></td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Reposo&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">60<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>7&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">61&#44;4<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>5&#44;2&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttop\n
                  \t\t\t\t"><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="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Pico&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><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="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Alteraciones basales de la contractilidad segmentaria&#44; &#37;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t">390 &#40;10&#44;8&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">17 &#40;5&#44;1&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">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="\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>Isquemia ecocardiogr&#225;fica&#44; n &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">635 &#40;17&#44;6&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">41 &#40;12&#44;3&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#44;02&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="4" align="left" valign="\n
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                  \t\t\t\t  " colspan="4" align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Reposo&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">1&#44;1<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>0&#44;2&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">0&#44;001&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">1&#44;1<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>0&#44;2&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>&#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">1&#44;89 &#40;1&#44;15-2&#44;42&#41; p<span class="elsevierStyleHsp" style=""></span>&#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-head\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  " align="left" valign="\n
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                  \t\t\t\t">0&#44;66 &#40;0&#44;32-1&#44;36&#41; p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;26&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
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                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t\ttop\n
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                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
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Vol. 220. Núm. 4.
Páginas 228-235 (mayo 2020)
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Vol. 220. Núm. 4.
Páginas 228-235 (mayo 2020)
Original
Un incremento exagerado de la presión arterial con el ejercicio no predice mortalidad ni eventos cardiovasculares graves en mujeres referidas a ecocardiografía de ejercicio por razones clínicas
An exaggerated increase in blood pressure with exercise does not predict mortality or severe cardiovascular events in women referred for exercise echocardiography for clinical reasons
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M.C. Bouzas-Mosqueraa,
Autor para correspondencia
carmen.bouzas@uclm.es

Autor para correspondencia.
, A. Bouzas Mosquerab, J. Peteirob, B. Espina-Jerezc, P. Domínguez-Isabelc, S. Gómez Cantarinoa
a Departamento de Enfermería, Fisioterapia y Terapia Ocupacional, Universidad de Castilla la Mancha, Toledo, España
b Departamento de Cardiología, Complexo Hospitalario Universitario de A Coruña, La Coruña, España
c Universidad de Castilla la Mancha, Toledo, España
Contenido relacionado
Rev Clin Esp. 2020;220:246-710.1016/j.rce.2019.07.002
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Estadísticas
Figuras (1)
Tablas (4)
Tabla 1. Características basales de los pacientes de acuerdo al desarrollo de IEPASE
Tabla 2. Resultados de la ecocardiografía de ejercicio de acuerdo a la aparición de IEPASE
Tabla 3. Predictores univariados de eventos cardiovasculares en el seguimiento
Tabla 4. Predictores multivariados de mortalidad y eventos cardiovasculares
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Resumen
Fundamento y objetivos

La asociación entre un incremento exagerado de la presión arterial sistólica con el ejercicio (IEPASE) y la probabilidad de eventos cardiovasculares es controvertida y poco estudiada en población femenina. Nuestro propósito fue determinar la posible asociación de un IEPASE con mortalidad y eventos cardiovasculares en mujeres referidas a ecocardiografía de ejercicio por enfermedad coronaria conocida o sospechada.

Pacientes y métodos

Se realizó ecocardiografía de ejercicio a 3.942 mujeres con enfermedad coronaria conocida o sospechada. El IEPASE se definió como un incremento de la presión arterial sistólica con el ejercicio ≥70mmHg. Los objetivos fueron mortalidad global y cardíaca, infarto agudo de miocardio (IM), accidente cerebrovascular (ACV) e intervenciones de revascularización coronaria.

Resultados

Trescientas treinta y dos mujeres desarrollaron IEPASE durante los test. En el seguimiento se registraron un total de 458 muertes (162 de origen cardíaco), 212 IM, 89 ACV y 345 intervenciones de revascularización coronaria. La tasa anual de mortalidad global y cardiaca fue inferior en el subgrupo de pacientes con IEPASE (0,15% vs. 2,3%, p=0,02 y 0,01% vs. 0,2%, p=0,015, respectivamente). No observamos diferencias significativas en las tasas de IM, ACV y de intervenciones de revascularización coronaria, que fueron, respectivamente, del 1,1%, 0,43% y 2,24% en pacientes con IEPASE y del 0,09%, 0,05% y 0,13% en aquellas mujeres sin IEPASE (p=0,66; p=0,57; p=0,19, respectivamente), Tras un ajuste multivariante el IEPASE no resultó predictor de mortalidad ni de eventos cardiovasculares.

Conclusiones

El IEPASE no se asoció con mortalidad ni eventos cardiovasculares graves en mujeres con enfermedad coronaria conocida o sospechada.

Palabras clave:
Ejercicio
Respuesta hipertensiva
Pronóstico
Mujeres
Abstract
Background and objectives

The association between an exaggerated systolic blood pressure increase with exercise (EBPIE) and the probability of cardiovascular events is controversial and poorly studied in the female population. Our aim was to determine the possible association between EBPIE on one hand and mortality and cardiovascular events on the other in women referred for exercise echocardiography due to known or suspected coronary artery disease.

Patients and methods

A total of 3942 women with known or suspected coronary artery disease underwent exercise echocardiography. We defined EBPIE as a ≥70mm Hg increase in systolic blood pressure with exercise. The study endpoints were overall and cardiac mortality, acute myocardial infarction (MI), stroke and coronary revascularisation procedures.

Results

A total of 332 women developed EBPIE during the test. During the follow-up, 458 deaths (162 of cardiac origin), 212 MIs, 89 strokes and 345 coronary revascularisation procedures were recorded. The annual rates of overall and cardiac mortality were lower in the patient subgroup with EBPIE (0.15% vs. 2.3%, P=.02 and 0.01% vs. 0.2%, P=.015, respectively). There were no significant differences in the rates of MI, stroke and the need for coronary revascularisation procedures, which occurred in 1.1%, 0.43% and 2.24% of the patients with EBPIE, respectively, and occurred in 0.09%, 0.05% and 0.13% of the women without EBPIE (P=.66; P=.57; P=.19, respectively). After a multivariate adjustment, EBPIE was not a predictor of mortality or cardiovascular events.

Conclusions

EBPIE is not associated with mortality or severe cardiovascular events in women with known or suspected coronary artery disease.

Keywords:
Exercise
Hypertensive response
Prognosis
Women

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