Clinical characteristics and prognosis of heart failure in elderly patients | Revista Portuguesa de Cardiologia (English edition)

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"luciamartinezbrana@gmail.com" ] "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "*" "identificador" => "cor0005" ] ] ] 1 => array:2 [ "nombre" => "Lara" "apellidos" => "Mateo-Mosquera" ] 2 => array:2 [ "nombre" => "María" "apellidos" => "Bermúdez-Ramos" ] 3 => array:2 [ "nombre" => "María de los Ángeles" "apellidos" => "Valcárcel García" ] 4 => array:2 [ "nombre" => "Lorena" "apellidos" => "Fernández Hernández" ] 5 => array:2 [ "nombre" => "Álvaro" "apellidos" => "Hermida Ameijeiras" ] 6 => array:2 [ "nombre" => "Francisco Luis" "apellidos" => "Lado Lado" ] ] "afiliaciones" => array:1 [ 0 => array:2 [ "entidad" => "Department of Internal Medicine, Department of Medicine, University Clinical Hospital of Santiago de Compostela, Spain" "identificador" => "aff0005" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 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Moreover, HF is the primary cause of hospitalization in patients aged 65 or over, accounting for 2–2.5% of the total number of annual hospital admissions.<a class="elsevierStyleCrossRef" href="#bib0230">2</a> Furthermore, the readmission rate following a first hospitalization for HF is high, increasing from 38% in the first month<a class="elsevierStyleCrossRef" href="#bib0235">3</a> to 43% at 6–12 months.<a class="elsevierStyleCrossRef" href="#bib0240">4</a>The prevalence of HF is on the rise due not only to the improved prognosis of patients with ischemic heart disease (IHD) or hypertension, but also to the progressive aging of the population. The census for the Spanish population for the last two decades showed an increase of nearly 50% in life expectancy of 1–2 years in the population aged from 77 to 87 years.<a class="elsevierStyleCrossRef" href="#bib0230">2</a> Moreover, the prevalence of HF is estimated at 6.8% in people aged 45 years or older, and 16.1% in people older than 75,<a class="elsevierStyleCrossRef" href="#bib0245">5</a> and it is precisely in the latter population that the incidence and prevalence of heart failure with preserved ejection fraction (HFPEF) rises.<a class="elsevierStyleCrossRef" href="#bib0250">6</a>Though the survival of HF patients has improved in recent years, prognosis continues to be poor, with 50% mortality five years after diagnosis.<a class="elsevierStyleCrossRef" href="#bib0255">7</a> Most clinical trials are on patients with heart failure with reduced ejection fraction (HFREF), and it is in this population that current therapies have shown to improve life expectancy.<a class="elsevierStyleCrossRef" href="#bib0260">8</a> In contrast, the findings on HFPEF remain inconclusive, which underscores the need for further studies on these patients, who are the most prevalent among elderly populations, as most internal medicine departments can attest.<a class="elsevierStyleCrossRef" href="#bib0265">9</a>Few studies have compared the clinical characteristics of elderly patients with HFREF in comparison to those with HFPEF. The aim of this study was to assess prevalence, clinical characteristics, and medium-term prognosis of a group of elderly HFPEF patients in comparison to elderly HFREF patients who were followed in an internal medicine unit.MethodsThis was a retrospective observational study of a cohort of 301 patients who were followed in an internal medicine unit HF unit in a tertiary referral hospital in north-eastern Spain with an estimated catchment population of 400 000.<a class="elsevierStyleCrossRef" href="#bib0270">10</a> Patients were consecutively included for study between January 1, 2007 and December 31, 2010, and their vital status was checked to determine whether they were alive on December 31, 2012. Patients were referred from primary health care, emergency departments, and cardiology and internal medicine wards.Only patients aged 18 years or older were included in the study. HF was diagnosed according to the clinical practice guidelines of the European Cardiology Society<a class="elsevierStyleCrossRef" href="#bib0275">11</a> and the American College of Cardiology/American Heart Association,<a class="elsevierStyleCrossRef" href="#bib0280">12</a> based on the presence of HF symptoms and signs.At the time of inclusion and during follow-up, data were collected on sociodemographic, clinical, laboratory, electrocardiographic, and echocardiographic variables, New York Heart Association (NYHA) functional class, and treatment.Left ventricular ejection fraction (LVEF) was measured using the Teichholz formula and the subjective scoring of the echocardiographer. Patients were assigned to one of two groups: preserved ejection fraction with LVEF ≥50%, or reduced ejection fraction with LVEF <50%.Hypertension was defined as blood pressure >140/90 mmHg or less if under directed treatment, anemia as hemoglobin <12 g/dl for women and <13 g/dl for men,<a class="elsevierStyleCrossRef" href="#bib0285">13</a> and chronic renal disease as a glomerular filtration rate <60 ml/min/m2 using the 4-variable Modification of Diet in Renal Disease formula.The etiology of HF was determined on the basis of the following criteria: ischemic, when the patient was diagnosed with IHD; valvular, when there was moderate valvulopathy with no IHD; hypertensive, when there was known hypertension but no evidence of other significant heart disease; dilated cardiomyopathy, as defined by LVEF <50% with no other known cardiac cause (including heavy drinking, idiopathic etiology, etc.); cor pulmonale, right heart failure without left ventricular dysfunction.Statistical analysisQualitative variables were expressed as absolute frequencies and percentages and quantitative variables were expressed as mean ± standard deviation. The statistical analysis was performed using SPSS for Windows, version 15. Descriptive statistical analysis was based on frequency tables of categorical variables using the chi-square test to compare the significance of association between qualitative variables. The Student's t test for independent samples was used to compare quantitative variables. A value of p<0.05 (two-sided) was used as the nominal level of statistical significance. Survival curves between the HFREF and HFPEF patient groups were constructed using the Kaplan-Meier method and compared using the log-rank test.ResultsA total of 301 patients were assessed, of whom 165 (54.8%) were women. For various reasons (including non-compliance with follow-up and unfavorable clinical conditions), LVEF was not assessed echocardiographically in 38 patients (12.7%). Of the 263 (87.4%) patients in whom LVEF was assessed echocardiographically, 190 (72.2%) had HFPEF and 73 (27.8%) had HFREF. The characteristics of the two groups are shown in <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>.<elsevierMultimedia ident="tbl0005"></elsevierMultimedia>Patients’ mean age was similar in the two groups (80.1 and 79.9 years; p=0.905), with a predominance of women in the HFPEF group (60.5% women, 42.5% men). Analysis of cardiovascular risk factors such as hypertension and diabetes, other comorbidities including chronic obstructive pulmonary disease, anemia, atrial fibrillation, and chronic renal disease, and NYHA functional class revealed no statistically significant differences.Regarding etiology, hypertensive heart disease was the main cause in the HFPEF group, whereas IHD and dilated cardiomyopathy were the main causes in the HFREF group.Data on patient referral source, pharmacological treatment for LVEF, and follow-up are shown in <a class="elsevierStyleCrossRefs" href="#tbl0025">Tables 2–4</a>, respectively.Most referrals from internal medicine wards had HFPEF, whereas most referrals from cardiology wards had HFREF (<a class="elsevierStyleCrossRef" href="#tbl0025">Table 2</a>). Comparison of treatments during follow-up showed no significant differences in the use of angiotensin-converting enzyme (ACE) inhibitors, angiotensin receptor blockers (ARBs), and aldosterone antagonists (AA). HFREF patients were prescribed more beta-blockers than HFPEF patients (<a class="elsevierStyleCrossRef" href="#tbl0045">Table 3</a>). The mean follow-up was 10 months. No statistically significant differences in survival rates, follow-up or causes of ending of the observation period were found between the groups according to LVEF (<a class="elsevierStyleCrossRef" href="#fig0005">Figure 1</a>).<elsevierMultimedia ident="tbl0025"></elsevierMultimedia><elsevierMultimedia ident="tbl0045"></elsevierMultimedia><elsevierMultimedia ident="tbl0065"></elsevierMultimedia><elsevierMultimedia ident="fig0005"></elsevierMultimedia>DiscussionThis study confirmed that HFPEF is more frequent in elderly patients. In our series 72.2% of HFPEF patients had a mean age >80 years. In other studies, its frequency varies considerably, with 51.8% of cases at a mean age of 72.4 years,<a class="elsevierStyleCrossRef" href="#bib0265">9</a> and 40% at a mean age of 66 years.<a class="elsevierStyleCrossRef" href="#bib0290">14</a> These differences are in all likelihood due to differences in age, as the patients in this study were older than in most series in the recent literature, which would account for the lower percentages of patients with preserved LVEF.<a class="elsevierStyleCrossRefs" href="#bib0290">14–20</a> In contrast, other studies including very elderly patients report mean ages similar to those observed in our study, e.g. mean age 80±10 years<a class="elsevierStyleCrossRef" href="#bib0325">21</a> or close to 79 years.<a class="elsevierStyleCrossRef" href="#bib0330">22</a> However, two other Spanish studies, GALICAP<a class="elsevierStyleCrossRef" href="#bib0305">17</a> and INCA,<a class="elsevierStyleCrossRef" href="#bib0310">18</a> which included younger patients than in our study (mean age 76 and 71 years, respectively), found a prevalence of HFPEF similar to that observed in this study: 61.4 and 61.7%, respectively. Likewise, similar results have been obtained in studies undertaken in other countries, such as a prospective study in France, where 61% of the population aged over 80 years had preserved LVEF, falling to 53% below this age group,<a class="elsevierStyleCrossRef" href="#bib0335">23</a> which is similar to the findings of the present study. In contrast, in a Japanese registry of younger patients (mean age 71 years) hospitalized due to HF, only 26% had LVEF >50%,<a class="elsevierStyleCrossRef" href="#bib0340">24</a> a similar prevalence to that recorded in another Japanese registry during the years 2000–2004.<a class="elsevierStyleCrossRef" href="#bib0345">25</a>Though 12.7% of patients were not echocardiographically assessed in our study, this percentage was lower than in other series, even when patients managed by cardiologists were included in the series.<a class="elsevierStyleCrossRefs" href="#bib0350">26,27</a> However, other studies have demonstrated that the number of patients without an echocardiogram is relevant in the elderly and in women, since these subgroups present the highest frequency of HFPEF, which suggests that in all probability the true prevalence is underestimated.As for gender, in this series women predominated in the HFPEF group (60.5% vs. 42.5% men), which is in accordance with most previous studies on these patients.<a class="elsevierStyleCrossRefs" href="#bib0265">9,28</a> With respect to etiology, a significant difference was observed between the groups: hypertensive heart disease was the most frequent etiology in the HFPEF group, whereas IHD was the most frequent etiology in the HFREF group, and it is widely acknowledged that the two types of HF differ in their epidemiological characteristics. Thus, HFPEF patients tend to be older and predominantly women, and the main etiology is hypertensive, with less heart disease and atrial fibrillation as concomitant pathologies.<a class="elsevierStyleCrossRefs" href="#bib0360">28,29</a> Analysis of NYHA functional class showed no significant differences in cardiovascular risk factors or other comorbidities between the groups.In terms of drug treatment, 32% of patients received ACE inhibitors, 47% ARBs (ACE inhibitors and ARBs 79%), 25% AA, and 54% beta-blockers (BBs). According to other studies, these drug groups can be considered an optimum complement to HF treatment, since they increase survival in HF patients with reduced LVEF. Thus, in an observational retrospective study on compliance with treatment guidelines in elderly Korean HF patients (mean age 76 years, of whom 64% were older than 75 years) by Kim et al.,<a class="elsevierStyleCrossRef" href="#bib0370">30</a> 32% were treated with BBs, 55% with ACE inhibitors or ARBs, and 7% with AA. The type and proportion of drugs administered in our population was similar to other studies.<a class="elsevierStyleCrossRefs" href="#bib0265">9,15,31</a>Few studies have assessed the different drug treatments for the two types of HF. As expected, in this study BBs were employed more in HFREF patients, but no significant differences were found between the groups in other treatments. By contrast, a study on 12 000 patients found ACE inhibitors and BBs were employed more in the HFPEF group.<a class="elsevierStyleCrossRef" href="#bib0265">9</a>Despite the lack of evidence for the use of AA in HFPEF, these drugs were prescribed in a high percentage of our patients (22.8%) compared with other studies<a class="elsevierStyleCrossRef" href="#bib0370">30</a> in order to control congestive symptoms.Though a wide spectrum of drug groups (ACE inhibitors, ARBs, BBs, and AA) are known to reduce morbidity and mortality in HFREF patients, findings on the benefits of certain HFPEF drug treatments remain inconclusive, which would explain the lack of specific treatment guidelines for these patients.<a class="elsevierStyleCrossRefs" href="#bib0380">32–34</a>With regard to prognosis, there is disagreement in recent reviews in the literature as to whether the prognosis of HFPEF patients is similar, worse or better than in HFREF patients.<a class="elsevierStyleCrossRefs" href="#bib0395">35–37</a> Few studies have compared prognosis in the two groups, and fewer still in HFPEF, and the results have been contradictory. While the prognosis of HFPEF patients appears to be better than in HFREF patients,<a class="elsevierStyleCrossRefs" href="#bib0365">29,38,39</a> an observational study on 478 HF patients with atrial fibrillation showed similar mortality for both HFPEF and HFREF (50% vs. 48%, p=0.74) at five years.<a class="elsevierStyleCrossRef" href="#bib0420">40</a> Likewise, other studies have reported similar prognosis in the two groups,<a class="elsevierStyleCrossRefs" href="#bib0425">41,42</a> as was the case in our series, in which no significant differences were found.In terms of mortality, it is generally believed that prognosis for HFREF is worse than for HFPEF, independently of other factors such as female gender, age, atrial fibrillation, chronic renal disease, functional class (NYHA III or IV), and pulmonary hypertension.<a class="elsevierStyleCrossRefs" href="#bib0395">35,43</a> In the present series, no significant differences were found in terms of prognosis, but mortality was slightly higher in HFPEF patients, which may be due to other factors such as those mentioned above. Moreover, no significant differences were found between the groups in chronic renal disease, functional class, or age. Given that no differences in mortality between the groups were observed, i.e., the factors under assessment were evenly distributed in both groups, it would be plausible to expect mortality also to be similar.In order to improve prognosis, an integrated approach to elderly HF patients is recommended, ideally in specialized units with multidisciplinary teams, as is the case of our specialized HF unit, in which the characteristics of patients are different from those treated by cardiologists (younger and predominantly with HFREF).In our catchment area, a heart failure protocol was recently designed,<a class="elsevierStyleCrossRef" href="#bib0440">44</a> with the consensus of different specialists (internists and cardiologists), primary health care, emergency departments, and nursing. The protocol defines the roles of and interaction between the different health care professionals involved in treating and managing HF patients, as well as highlighting the importance of educating patients, health staff, and carers as to treatment compliance and of close and continued follow-up in accordance with the clinical practice guidelines, in order to improve the prognosis and quality of life of these patients.LimitationsOne of the limitations of this study is that all of the patients included in the sample were followed by the internal medicine department, and patients followed by cardiologists were excluded. This may have led to bias in the selection process, given that these patients were older and had less coronary disease. Nevertheless, it results in greater homogeneity in clinical management and treatment in internal medicine departments and in primary health care, both of which are traditionally involved in the management of elderly patients with more comorbidities.The follow-up period was quite short (10 months) due to the age of our patients; almost half of our sample (42%) died or dropped out during this period. Nevertheless, we would point out that the follow-up was probably sufficiently long, given the characteristics of our cohort.A further limitation is the exclusion of the nearly 13% of patients who were not echocardiographically assessed.ConclusionIn this study, most patients presented HFPEF. The clinical characteristics of this group were similar to those of the HFREF group. As in other studies, women and hypertensive etiology were predominant in the HFPEF group. HFREF patients were more likely to receive BBs, and dilated cardiomyopathy predominated. No significant differences in mortality were observed between the groups. Our experience shows that an integrated multidisciplinary approach enhances the treatment, management, and follow-up of HF patients. However, few studies have focused on HFPEF patients, and even fewer have included patients from internists in specialized HF units, which underscores the need for further prospective studies to explore new improved therapeutic strategies.Ethical disclosuresProtection of human and animal subjectsThe authors declare that no experiments were performed on humans or animals for this study.Confidentiality of dataThe authors declare that they have followed the protocols of their work center on the publication of patient data.Right to privacy and informed consentThe authors declare that no patient data appear in this article.Conflicts of interestThe authors have no conflicts of interest to declare." "textoCompletoSecciones" => array:1 [ "secciones" => array:13 [ 0 => array:3 [ "identificador" => "xres538922" "titulo" => "Abstract" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Objectives" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Methods" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Results" ] 3 => array:2 [ "identificador" => "abst0020" "titulo" => "Conclusion" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec558592" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres538923" "titulo" => "Resumo" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0025" "titulo" => "Introdução e objetivos" ] 1 => array:2 [ "identificador" => "abst0030" "titulo" => "Materiais e métodos" ] 2 => array:2 [ "identificador" => "abst0035" "titulo" => "Resultados" ] 3 => array:2 [ "identificador" => "abst0040" "titulo" => "Conclusão" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec558591" "titulo" => "Palavras-chave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:3 [ "identificador" => "sec0010" "titulo" => "Methods" "secciones" => array:1 [ 0 => array:2 [ "identificador" => "sec0015" "titulo" => "Statistical analysis" ] ] ] 6 => array:2 [ "identificador" => "sec0020" "titulo" => "Results" ] 7 => array:2 [ "identificador" => "sec0025" "titulo" => "Discussion" ] 8 => array:2 [ "identificador" => "sec0030" "titulo" => "Limitations" ] 9 => array:2 [ "identificador" => "sec0035" "titulo" => "Conclusion" ] 10 => array:3 [ "identificador" => "sec0040" "titulo" => "Ethical disclosures" "secciones" => array:3 [ 0 => array:2 [ "identificador" => "sec0045" "titulo" => "Protection of human and animal subjects" ] 1 => array:2 [ "identificador" => "sec0050" "titulo" => "Confidentiality of data" ] 2 => array:2 [ "identificador" => "sec0055" "titulo" => "Right to privacy and informed consent" ] ] ] 11 => array:2 [ "identificador" => "sec0060" "titulo" => "Conflicts of interest" ] 12 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2014-07-31" "fechaAceptado" => "2015-02-25" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec558592" "palabras" => array:5 [ 0 => "Heart failure" 1 => "Preserved ejection fraction" 2 => "Reduced ejection fraction" 3 => "Elderly" 4 => "Survival" ] ] ] "pt" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palavras-chave" "identificador" => "xpalclavsec558591" "palabras" => array:5 [ 0 => "Insuficiência cardíaca" 1 => "Insuficiência cardíaca com fração de ejeção preservada" 2 => "Insuficiência cardíaca com fração de ejeção dimuída" 3 => "Idosos" 4 => "Sobrevivência" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:3 [ "titulo" => "Abstract" "resumen" => "ObjectivesThe aim of this study was to assess prevalence, clinical characteristics, and prognosis in elderly patients with heart failure with preserved ejection fraction (HFPEF) compared to patients with heart failure with reduced ejection fraction (HFREF) who were followed in an internal medicine unit. MethodsIn this retrospective observational study, the sample consisted of 301 patients followed in an internal medicine referral unit between January 2007 and December 2010. All patients were checked to determine their vital status on 31 December 2012. Survival was analyzed using Kaplan-Meier curves, and compared using the log-rank test. ResultsOf the 301 patients, 165 (54.8%) were women. In the 263 cases (87.4%) who underwent echocardiographic assessment, 190 (72.2%) had HFPEF and 73 (27.8%) had HFREF. Mean age was similar in the two groups (80.1 and 79.9 years; p=0.905), with a predominance of women in the HFPEF group (60.5% women, 42.5% men; p=0.025). The main etiology was hypertensive heart disease in the HFPEF group. Regarding treatment, more beta-blockers were administered in the HFREF group. No statistically significant differences were observed between the groups in terms of cardiovascular risk factors, comorbidities, NYHA functional class, or mortality. ConclusionClinical characteristics were similar for both HFPEF and HFREF patients. Women were predominant in the HFPEF group, as was hypertensive etiology. No significant differences in mortality were observed between the groups." "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Objectives" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Methods" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Results" ] 3 => array:2 [ "identificador" => "abst0020" "titulo" => "Conclusion" ] ] ] "pt" => array:3 [ "titulo" => "Resumo" "resumen" => "Introdução e objetivosO objetivo do estudo é analisar a prevalência, as características clínicas e o prognóstico dum grupo de doentes idosos com diagnóstico de insuficiência cardíaca com fração de ejeção preservada (IC/FEP) seguidos numa consulta especializada e compará-los com os doentes que apresentam fração de ejeção dimuída (IC/FED). Materiais e métodosEstudo retrospetivo observacional incluindo 301 doentes, seguidos numa consulta especializada de Medicina Interna, no período entre janeiro de 2007 e dezembro de 2010 cujo status vital foi determinado a 31 de dezembro de 2012. Para a análise de sobrevivência foram utilizadas as curvas de Kaplan-Meier e na comparação foi utilizado o teste de Log-rank. Resultados301 doentes foram estudados, sendo 165 (54,8%) do sexo feminino. Nos 263 (87,4%) casos nos quais foi realizado o estudo ecocardiográfico, 190 (72,2%) correspondiam a doentes com diagnóstico de IC/FEP e 73 (27,8%) de IC/FED. A idade média foi similar nos dois grupos (80,3 e 79,9 anos, p 0,905), sendo maior a percentagem de mulheres (60,5% face a 42,5%, p 0,025) e com predomínio de etiologia hipertensiva no grupo com IC/FEP. Quanto ao tratamento, o uso de betabloqueantes foi maior no grupo com IC/FED. Não foram encontradas diferenças significativas entre ambos os grupos relativamente a fatores de risco cardiovascular, comorbilidades, classe funcional ou mortalidade. ConclusãoAs caraterísticas clínicas dos doentes com IC/FEP e com IC/FED são similares. No grupo de IC/FEP predominam os doentes do sexo feminino e a etiologia hipertensiva. Não foram observadas diferenças na mortalidade entre ambos os grupos." "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0025" "titulo" => "Introdução e objetivos" ] 1 => array:2 [ "identificador" => "abst0030" "titulo" => "Materiais e métodos" ] 2 => array:2 [ "identificador" => "abst0035" "titulo" => "Resultados" ] 3 => array:2 [ "identificador" => "abst0040" "titulo" => "Conclusão" ] ] ] ] "multimedia" => array:5 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 850 "Ancho" => 992 "Tamanyo" => 54356 ] ] "descripcion" => array:1 [ "en" => "Follow-up survival curve for patients with heart failure with preserved ejection fraction and heart failure with reduced ejection fraction." ] ] 1 => array:7 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "tabla" => array:2 [ "leyenda" => "COPD: chronic obstructive pulmonary disease; DCM: dilated cardiomyopathy; LVEF: left ventricular ejection fraction; NYHA: New York Heart Association." "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " align="" valign="top" scope="col" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Overall (n=301) \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">LVEF ≥50% (n=190) \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">LVEF <50% (n=73) \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">p \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Women, % (n) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">54.8 (165) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">60.5 (115) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">42.5 (31) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.025 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Age, years (P25;75) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">80.3 (75.2;84.3) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">80.1 (74.6;84.3) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">79.9 (74.0;84.2) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.905 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">COPD, % (n) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">30.2 (91) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">31.6 (60) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">28.8 (21) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.773 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Diabetes, % (n) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">32.2 (97) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">33.2 (63) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">30.1 (22) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.892 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Hypertension, % (n) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">81.4 (245) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">84.2 (160) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">76.7 (56) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.259 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Anemia, % (n) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">46.8 (141) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">45.3 (85) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">47.9 (35) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.692 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Renal failure, % (n) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">58.8 (177) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">57.4 (109) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">58.9 (43) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.629 \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"></td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="5" align="left" valign="top">NYHA class, % (n)</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">I \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">27.8 (83) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">26.5 (50) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">30.1 (22) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.792 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">II \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">42.5 (127) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">41.8 (79) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">46.6 (34) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.792 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">III \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">29.1 (87) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">30.7 (58) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">23.3 (17) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.792 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">IV \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.7 (2) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1.1 (2) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.792 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Atrial fibrillation, % (n) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">55.1 (66) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">55.8 (106) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">56.2 (41) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.791 \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"></td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="5" align="left" valign="top">Etiology, % (n)</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Hypertensive \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">67.8 (198) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">70.5 (129) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">57.5 (42) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.003 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Ischemic \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">12.0 (35) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">10.4 (19) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">17.8 (13) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.003 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Valvular \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">8.6 (25) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">9.8 (18) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">5.5 (4) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.003 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">DCM \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">4.5 (13) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1.1 (2) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">12.3 (9) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.003 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Cor pulmonale \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">5.1 (15) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">7.1 (13) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2.7 (2) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.003 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Other \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2.1 (6) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1.1 (2) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">4.1 (3) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.003 \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab866170.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Clinical characteristics of patients according to left ventricular ejection fraction." ] ] 2 => array:7 [ "identificador" => "tbl0025" "etiqueta" => "Table 2" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "tabla" => array:2 [ "leyenda" => "LVEF: left ventricular ejection fraction." "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " align="" valign="top" scope="col" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Overall (n=301) \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">LVEF ≥50% (n=190) \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">LVEF <50% (n=73) \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">p \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry " colspan="5" align="left" valign="top">Source of referral % (n)</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Primary care \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1.0 (3) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.5 (1) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2.8 (2) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.032 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Emergency \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">22.7 (68) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">19.6 (37) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">23.6 (17) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.032 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Cardiology \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">3.3 (10) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">3.2 (6) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">5.6 (4) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.032 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Internal medicine \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">68.9 (206) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">73 (138) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">66.7 (48) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.032 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Other \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">4.0 (12) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">3.7 (7) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1.4 (1) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.032 \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab866169.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Source of patient referrals." ] ] 3 => array:7 [ "identificador" => "tbl0045" "etiqueta" => "Table 3" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "tabla" => array:2 [ "leyenda" => "ACE: angiotensin-converting enzyme; ARBs: angiotensin receptor blockers." "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " align="" valign="top" scope="col" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Overall (n=301) \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">LVEF ≥50% (n=190) \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">LVEF <50% (n=73) \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">p \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry " colspan="5" align="left" valign="top">Treatment, % (n)</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">ACE inhibitors \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">32.1 (84) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">32.9 (55) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">29.2 (19) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.910 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">ARBs \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">46.6 (122) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">46.1 (77) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">50.8 (27) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.256 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Spironolactone \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">24.8 (65) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">22.8 (38) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">32.3 (21) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.570 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Beta-blockers \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">53.5 (139) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">48.2 (80) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">67.2 (43) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.028 \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab866171.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Pharmacological treatment according to left ventricular ejection fraction." ] ] 4 => array:7 [ "identificador" => "tbl0065" "etiqueta" => "Table 4" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "tabla" => array:2 [ "leyenda" => "LVEF: left ventricular ejection fraction." "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Variables \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Overall (n=301) \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">LVEF ≥50% (n=190) \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">LVEF <50% (n=73) \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">p \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Follow-up, months (SD) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">10 (11.9) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">10.5 (12.3) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">12 (11.2) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.946 \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"></td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="5" align="left" valign="top">End of observational period, % (n)</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Follow-up \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">37.5 (113) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">37.9 (72) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">38.4 (28) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.465 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Discharge to cardiology clinic \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">5.3 (16) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">4.7 (9) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">4.1 (3) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.465 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Discharge to health care unit \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">14.3 (43) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">28.4 (54) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">32.9 (24) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.465 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Deceased \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">12.0 (36) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">13.7 (26) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">8.2 (6) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.465 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Lost to follow-up \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">30.9 (93) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">28.4 (54) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">32.9 (24) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.465 \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"></td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Intervention, % (n) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">87.0 (262) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">87.9 (167) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">89 (65) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.274 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Mortality, % (n) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">47.8 (144) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">51.1 (97) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">39.7 (29) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.257 \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab866172.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Follow-up and mortality." ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:44 [ 0 => array:3 [ "identificador" => "bib0225" 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Clinical characteristics and prognosis of heart failure in elderly patients

Lucía Martínez-Braña

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luciamartinezbrana@gmail.com

Corresponding author.

, Lara Mateo-Mosquera, María Bermúdez-Ramos, María de los Ángeles Valcárcel García, Lorena Fernández Hernández, Álvaro Hermida Ameijeiras, Francisco Luis Lado Lado

Department of Internal Medicine, Department of Medicine, University Clinical Hospital of Santiago de Compostela, Spain

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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Heart failure &#40;HF&#41; continues to be a major burden on public health systems&#44; with high morbidity and mortality and spiraling costs&#44; which account for 1&#8211;2&#37; of the annual health budget of most developed nations&#46;<a class="elsevierStyleCrossRef" href="#bib0225"><span class="elsevierStyleSup">1</span></a> In Spain&#44; it is the third leading cause of death from cardiovascular disease&#59; ischemic heart disease and cerebrovascular disease are the leading causes&#44; with estimated mortality of 4&#46;2&#37; and 4&#46;4&#37; for the years 2010 and 2011&#44; respectively&#46; Moreover&#44; HF is the primary cause of hospitalization in patients aged 65 or over&#44; accounting for 2&#8211;2&#46;5&#37; of the total number of annual hospital admissions&#46;<a class="elsevierStyleCrossRef" href="#bib0230"><span class="elsevierStyleSup">2</span></a> Furthermore&#44; the readmission rate following a first hospitalization for HF is high&#44; increasing from 38&#37; in the first month<a class="elsevierStyleCrossRef" href="#bib0235"><span class="elsevierStyleSup">3</span></a> to 43&#37; at 6&#8211;12 months&#46;<a class="elsevierStyleCrossRef" href="#bib0240"><span class="elsevierStyleSup">4</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">The prevalence of HF is on the rise due not only to the improved prognosis of patients with ischemic heart disease &#40;IHD&#41; or hypertension&#44; but also to the progressive aging of the population&#46; The census for the Spanish population for the last two decades showed an increase of nearly 50&#37; in life expectancy of 1&#8211;2 years in the population aged from 77 to 87 years&#46;<a class="elsevierStyleCrossRef" href="#bib0230"><span class="elsevierStyleSup">2</span></a> Moreover&#44; the prevalence of HF is estimated at 6&#46;8&#37; in people aged 45 years or older&#44; and 16&#46;1&#37; in people older than 75&#44;<a class="elsevierStyleCrossRef" href="#bib0245"><span class="elsevierStyleSup">5</span></a> and it is precisely in the latter population that the incidence and prevalence of heart failure with preserved ejection fraction &#40;HFPEF&#41; rises&#46;<a class="elsevierStyleCrossRef" href="#bib0250"><span class="elsevierStyleSup">6</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">Though the survival of HF patients has improved in recent years&#44; prognosis continues to be poor&#44; with 50&#37; mortality five years after diagnosis&#46;<a class="elsevierStyleCrossRef" href="#bib0255"><span class="elsevierStyleSup">7</span></a> Most clinical trials are on patients with heart failure with reduced ejection fraction &#40;HFREF&#41;&#44; and it is in this population that current therapies have shown to improve life expectancy&#46;<a class="elsevierStyleCrossRef" href="#bib0260"><span class="elsevierStyleSup">8</span></a> In contrast&#44; the findings on HFPEF remain inconclusive&#44; which underscores the need for further studies on these patients&#44; who are the most prevalent among elderly populations&#44; as most internal medicine departments can attest&#46;<a class="elsevierStyleCrossRef" href="#bib0265"><span class="elsevierStyleSup">9</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">Few studies have compared the clinical characteristics of elderly patients with HFREF in comparison to those with HFPEF&#46; The aim of this study was to assess prevalence&#44; clinical characteristics&#44; and medium-term prognosis of a group of elderly HFPEF patients in comparison to elderly HFREF patients who were followed in an internal medicine unit&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Methods</span><p id="par0025" class="elsevierStylePara elsevierViewall">This was a retrospective observational study of a cohort of 301 patients who were followed in an internal medicine unit HF unit in a tertiary referral hospital in north-eastern Spain with an estimated catchment population of 400 000&#46;<a class="elsevierStyleCrossRef" href="#bib0270"><span class="elsevierStyleSup">10</span></a> Patients were consecutively included for study between January 1&#44; 2007 and December 31&#44; 2010&#44; and their vital status was checked to determine whether they were alive on December 31&#44; 2012&#46; Patients were referred from primary health care&#44; emergency departments&#44; and cardiology and internal medicine wards&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">Only patients aged 18 years or older were included in the study&#46; HF was diagnosed according to the clinical practice guidelines of the European Cardiology Society<a class="elsevierStyleCrossRef" href="#bib0275"><span class="elsevierStyleSup">11</span></a> and the American College of Cardiology&#47;American Heart Association&#44;<a class="elsevierStyleCrossRef" href="#bib0280"><span class="elsevierStyleSup">12</span></a> based on the presence of HF symptoms and signs&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">At the time of inclusion and during follow-up&#44; data were collected on sociodemographic&#44; clinical&#44; laboratory&#44; electrocardiographic&#44; and echocardiographic variables&#44; New York Heart Association &#40;NYHA&#41; functional class&#44; and treatment&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">Left ventricular ejection fraction &#40;LVEF&#41; was measured using the Teichholz formula and the subjective scoring of the echocardiographer&#46; Patients were assigned to one of two groups&#58; preserved ejection fraction with LVEF &#8805;50&#37;&#44; or reduced ejection fraction with LVEF &#60;50&#37;&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">Hypertension was defined as blood pressure &#62;140&#47;90 mmHg or less if under directed treatment&#44; anemia as hemoglobin &#60;12 g&#47;dl for women and &#60;13 g&#47;dl for men&#44;<a class="elsevierStyleCrossRef" href="#bib0285"><span class="elsevierStyleSup">13</span></a> and chronic renal disease as a glomerular filtration rate &#60;60 ml&#47;min&#47;m<span class="elsevierStyleSup">2</span> using the 4-variable Modification of Diet in Renal Disease formula&#46;</p><p id="par0050" class="elsevierStylePara elsevierViewall">The etiology of HF was determined on the basis of the following criteria&#58; ischemic&#44; when the patient was diagnosed with IHD&#59; valvular&#44; when there was moderate valvulopathy with no IHD&#59; hypertensive&#44; when there was known hypertension but no evidence of other significant heart disease&#59; dilated cardiomyopathy&#44; as defined by LVEF &#60;50&#37; with no other known cardiac cause &#40;including heavy drinking&#44; idiopathic etiology&#44; etc&#46;&#41;&#59; cor pulmonale&#44; right heart failure without left ventricular dysfunction&#46;</p><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Statistical analysis</span><p id="par0055" class="elsevierStylePara elsevierViewall">Qualitative variables were expressed as absolute frequencies and percentages and quantitative variables were expressed as mean &#177; standard deviation&#46; The statistical analysis was performed using SPSS for Windows&#44; version 15&#46; Descriptive statistical analysis was based on frequency tables of categorical variables using the chi-square test to compare the significance of association between qualitative variables&#46; The Student&#39;s t test for independent samples was used to compare quantitative variables&#46; A value of p&#60;0&#46;05 &#40;two-sided&#41; was used as the nominal level of statistical significance&#46; Survival curves between the HFREF and HFPEF patient groups were constructed using the Kaplan-Meier method and compared using the log-rank test&#46;</p></span></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Results</span><p id="par0060" class="elsevierStylePara elsevierViewall">A total of 301 patients were assessed&#44; of whom 165 &#40;54&#46;8&#37;&#41; were women&#46; For various reasons &#40;including non-compliance with follow-up and unfavorable clinical conditions&#41;&#44; LVEF was not assessed echocardiographically in 38 patients &#40;12&#46;7&#37;&#41;&#46; Of the 263 &#40;87&#46;4&#37;&#41; patients in whom LVEF was assessed echocardiographically&#44; 190 &#40;72&#46;2&#37;&#41; had HFPEF and 73 &#40;27&#46;8&#37;&#41; had HFREF&#46; The characteristics of the two groups are shown in <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0065" class="elsevierStylePara elsevierViewall">Patients&#8217; mean age was similar in the two groups &#40;80&#46;1 and 79&#46;9 years&#59; p&#61;0&#46;905&#41;&#44; with a predominance of women in the HFPEF group &#40;60&#46;5&#37; women&#44; 42&#46;5&#37; men&#41;&#46; Analysis of cardiovascular risk factors such as hypertension and diabetes&#44; other comorbidities including chronic obstructive pulmonary disease&#44; anemia&#44; atrial fibrillation&#44; and chronic renal disease&#44; and NYHA functional class revealed no statistically significant differences&#46;</p><p id="par0070" class="elsevierStylePara elsevierViewall">Regarding etiology&#44; hypertensive heart disease was the main cause in the HFPEF group&#44; whereas IHD and dilated cardiomyopathy were the main causes in the HFREF group&#46;</p><p id="par0075" class="elsevierStylePara elsevierViewall">Data on patient referral source&#44; pharmacological treatment for LVEF&#44; and follow-up are shown in <a class="elsevierStyleCrossRefs" href="#tbl0025">Tables 2&#8211;4</a>&#44; respectively&#46;Most referrals from internal medicine wards had HFPEF&#44; whereas most referrals from cardiology wards had HFREF &#40;<a class="elsevierStyleCrossRef" href="#tbl0025">Table 2</a>&#41;&#46; Comparison of treatments during follow-up showed no significant differences in the use of angiotensin-converting enzyme &#40;ACE&#41; inhibitors&#44; angiotensin receptor blockers &#40;ARBs&#41;&#44; and aldosterone antagonists &#40;AA&#41;&#46; HFREF patients were prescribed more beta-blockers than HFPEF patients &#40;<a class="elsevierStyleCrossRef" href="#tbl0045">Table 3</a>&#41;&#46; The mean follow-up was 10 months&#46; No statistically significant differences in survival rates&#44; follow-up or causes of ending of the observation period were found between the groups according to LVEF &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Figure 1</a>&#41;&#46;</p><elsevierMultimedia ident="tbl0025"></elsevierMultimedia><elsevierMultimedia ident="tbl0045"></elsevierMultimedia><elsevierMultimedia ident="tbl0065"></elsevierMultimedia><elsevierMultimedia ident="fig0005"></elsevierMultimedia></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Discussion</span><p id="par0085" class="elsevierStylePara elsevierViewall">This study confirmed that HFPEF is more frequent in elderly patients&#46; In our series 72&#46;2&#37; of HFPEF patients had a mean age &#62;80 years&#46; In other studies&#44; its frequency varies considerably&#44; with 51&#46;8&#37; of cases at a mean age of 72&#46;4 years&#44;<a class="elsevierStyleCrossRef" href="#bib0265"><span class="elsevierStyleSup">9</span></a> and 40&#37; at a mean age of 66 years&#46;<a class="elsevierStyleCrossRef" href="#bib0290"><span class="elsevierStyleSup">14</span></a> These differences are in all likelihood due to differences in age&#44; as the patients in this study were older than in most series in the recent literature&#44; which would account for the lower percentages of patients with preserved LVEF&#46;<a class="elsevierStyleCrossRefs" href="#bib0290"><span class="elsevierStyleSup">14&#8211;20</span></a> In contrast&#44; other studies including very elderly patients report mean ages similar to those observed in our study&#44; e&#46;g&#46; mean age 80&#177;10 years<a class="elsevierStyleCrossRef" href="#bib0325"><span class="elsevierStyleSup">21</span></a> or close to 79 years&#46;<a class="elsevierStyleCrossRef" href="#bib0330"><span class="elsevierStyleSup">22</span></a> However&#44; two other Spanish studies&#44; GALICAP<a class="elsevierStyleCrossRef" href="#bib0305"><span class="elsevierStyleSup">17</span></a> and INCA&#44;<a class="elsevierStyleCrossRef" href="#bib0310"><span class="elsevierStyleSup">18</span></a> which included younger patients than in our study &#40;mean age 76 and 71 years&#44; respectively&#41;&#44; found a prevalence of HFPEF similar to that observed in this study&#58; 61&#46;4 and 61&#46;7&#37;&#44; respectively&#46; Likewise&#44; similar results have been obtained in studies undertaken in other countries&#44; such as a prospective study in France&#44; where 61&#37; of the population aged over 80 years had preserved LVEF&#44; falling to 53&#37; below this age group&#44;<a class="elsevierStyleCrossRef" href="#bib0335"><span class="elsevierStyleSup">23</span></a> which is similar to the findings of the present study&#46; In contrast&#44; in a Japanese registry of younger patients &#40;mean age 71 years&#41; hospitalized due to HF&#44; only 26&#37; had LVEF &#62;50&#37;&#44;<a class="elsevierStyleCrossRef" href="#bib0340"><span class="elsevierStyleSup">24</span></a> a similar prevalence to that recorded in another Japanese registry during the years 2000&#8211;2004&#46;<a class="elsevierStyleCrossRef" href="#bib0345"><span class="elsevierStyleSup">25</span></a></p><p id="par0090" class="elsevierStylePara elsevierViewall">Though 12&#46;7&#37; of patients were not echocardiographically assessed in our study&#44; this percentage was lower than in other series&#44; even when patients managed by cardiologists were included in the series&#46;<a class="elsevierStyleCrossRefs" href="#bib0350"><span class="elsevierStyleSup">26&#44;27</span></a> However&#44; other studies have demonstrated that the number of patients without an echocardiogram is relevant in the elderly and in women&#44; since these subgroups present the highest frequency of HFPEF&#44; which suggests that in all probability the true prevalence is underestimated&#46;</p><p id="par0095" class="elsevierStylePara elsevierViewall">As for gender&#44; in this series women predominated in the HFPEF group &#40;60&#46;5&#37; vs&#46; 42&#46;5&#37; men&#41;&#44; which is in accordance with most previous studies on these patients&#46;<a class="elsevierStyleCrossRefs" href="#bib0265"><span class="elsevierStyleSup">9&#44;28</span></a> With respect to etiology&#44; a significant difference was observed between the groups&#58; hypertensive heart disease was the most frequent etiology in the HFPEF group&#44; whereas IHD was the most frequent etiology in the HFREF group&#44; and it is widely acknowledged that the two types of HF differ in their epidemiological characteristics&#46; Thus&#44; HFPEF patients tend to be older and predominantly women&#44; and the main etiology is hypertensive&#44; with less heart disease and atrial fibrillation as concomitant pathologies&#46;<a class="elsevierStyleCrossRefs" href="#bib0360"><span class="elsevierStyleSup">28&#44;29</span></a> Analysis of NYHA functional class showed no significant differences in cardiovascular risk factors or other comorbidities between the groups&#46;</p><p id="par0100" class="elsevierStylePara elsevierViewall">In terms of drug treatment&#44; 32&#37; of patients received ACE inhibitors&#44; 47&#37; ARBs &#40;ACE inhibitors and ARBs 79&#37;&#41;&#44; 25&#37; AA&#44; and 54&#37; beta-blockers &#40;BBs&#41;&#46; According to other studies&#44; these drug groups can be considered an optimum complement to HF treatment&#44; since they increase survival in HF patients with reduced LVEF&#46; Thus&#44; in an observational retrospective study on compliance with treatment guidelines in elderly Korean HF patients &#40;mean age 76 years&#44; of whom 64&#37; were older than 75 years&#41; by Kim et al&#46;&#44;<a class="elsevierStyleCrossRef" href="#bib0370"><span class="elsevierStyleSup">30</span></a> 32&#37; were treated with BBs&#44; 55&#37; with ACE inhibitors or ARBs&#44; and 7&#37; with AA&#46; The type and proportion of drugs administered in our population was similar to other studies&#46;<a class="elsevierStyleCrossRefs" href="#bib0265"><span class="elsevierStyleSup">9&#44;15&#44;31</span></a></p><p id="par0105" class="elsevierStylePara elsevierViewall">Few studies have assessed the different drug treatments for the two types of HF&#46; As expected&#44; in this study BBs were employed more in HFREF patients&#44; but no significant differences were found between the groups in other treatments&#46; By contrast&#44; a study on 12 000 patients found ACE inhibitors and BBs were employed more in the HFPEF group&#46;<a class="elsevierStyleCrossRef" href="#bib0265"><span class="elsevierStyleSup">9</span></a></p><p id="par0110" class="elsevierStylePara elsevierViewall">Despite the lack of evidence for the use of AA in HFPEF&#44; these drugs were prescribed in a high percentage of our patients &#40;22&#46;8&#37;&#41; compared with other studies<a class="elsevierStyleCrossRef" href="#bib0370"><span class="elsevierStyleSup">30</span></a> in order to control congestive symptoms&#46;</p><p id="par0115" class="elsevierStylePara elsevierViewall">Though a wide spectrum of drug groups &#40;ACE inhibitors&#44; ARBs&#44; BBs&#44; and AA&#41; are known to reduce morbidity and mortality in HFREF patients&#44; findings on the benefits of certain HFPEF drug treatments remain inconclusive&#44; which would explain the lack of specific treatment guidelines for these patients&#46;<a class="elsevierStyleCrossRefs" href="#bib0380"><span class="elsevierStyleSup">32&#8211;34</span></a>With regard to prognosis&#44; there is disagreement in recent reviews in the literature as to whether the prognosis of HFPEF patients is similar&#44; worse or better than in HFREF patients&#46;<a class="elsevierStyleCrossRefs" href="#bib0395"><span class="elsevierStyleSup">35&#8211;37</span></a> Few studies have compared prognosis in the two groups&#44; and fewer still in HFPEF&#44; and the results have been contradictory&#46; While the prognosis of HFPEF patients appears to be better than in HFREF patients&#44;<a class="elsevierStyleCrossRefs" href="#bib0365"><span class="elsevierStyleSup">29&#44;38&#44;39</span></a> an observational study on 478 HF patients with atrial fibrillation showed similar mortality for both HFPEF and HFREF &#40;50&#37; vs&#46; 48&#37;&#44; p&#61;0&#46;74&#41; at five years&#46;<a class="elsevierStyleCrossRef" href="#bib0420"><span class="elsevierStyleSup">40</span></a> Likewise&#44; other studies have reported similar prognosis in the two groups&#44;<a class="elsevierStyleCrossRefs" href="#bib0425"><span class="elsevierStyleSup">41&#44;42</span></a> as was the case in our series&#44; in which no significant differences were found&#46;</p><p id="par0120" class="elsevierStylePara elsevierViewall">In terms of mortality&#44; it is generally believed that prognosis for HFREF is worse than for HFPEF&#44; independently of other factors such as female gender&#44; age&#44; atrial fibrillation&#44; chronic renal disease&#44; functional class &#40;NYHA III or IV&#41;&#44; and pulmonary hypertension&#46;<a class="elsevierStyleCrossRefs" href="#bib0395"><span class="elsevierStyleSup">35&#44;43</span></a> In the present series&#44; no significant differences were found in terms of prognosis&#44; but mortality was slightly higher in HFPEF patients&#44; which may be due to other factors such as those mentioned above&#46; Moreover&#44; no significant differences were found between the groups in chronic renal disease&#44; functional class&#44; or age&#46; Given that no differences in mortality between the groups were observed&#44; i&#46;e&#46;&#44; the factors under assessment were evenly distributed in both groups&#44; it would be plausible to expect mortality also to be similar&#46;</p><p id="par0125" class="elsevierStylePara elsevierViewall">In order to improve prognosis&#44; an integrated approach to elderly HF patients is recommended&#44; ideally in specialized units with multidisciplinary teams&#44; as is the case of our specialized HF unit&#44; in which the characteristics of patients are different from those treated by cardiologists &#40;younger and predominantly with HFREF&#41;&#46;</p><p id="par0130" class="elsevierStylePara elsevierViewall">In our catchment area&#44; a heart failure protocol was recently designed&#44;<a class="elsevierStyleCrossRef" href="#bib0440"><span class="elsevierStyleSup">44</span></a> with the consensus of different specialists &#40;internists and cardiologists&#41;&#44; primary health care&#44; emergency departments&#44; and nursing&#46; The protocol defines the roles of and interaction between the different health care professionals involved in treating and managing HF patients&#44; as well as highlighting the importance of educating patients&#44; health staff&#44; and carers as to treatment compliance and of close and continued follow-up in accordance with the clinical practice guidelines&#44; in order to improve the prognosis and quality of life of these patients&#46;</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Limitations</span><p id="par0135" class="elsevierStylePara elsevierViewall">One of the limitations of this study is that all of the patients included in the sample were followed by the internal medicine department&#44; and patients followed by cardiologists were excluded&#46; This may have led to bias in the selection process&#44; given that these patients were older and had less coronary disease&#46; Nevertheless&#44; it results in greater homogeneity in clinical management and treatment in internal medicine departments and in primary health care&#44; both of which are traditionally involved in the management of elderly patients with more comorbidities&#46;</p><p id="par0140" class="elsevierStylePara elsevierViewall">The follow-up period was quite short &#40;10 months&#41; due to the age of our patients&#59; almost half of our sample &#40;42&#37;&#41; died or dropped out during this period&#46; Nevertheless&#44; we would point out that the follow-up was probably sufficiently long&#44; given the characteristics of our cohort&#46;</p><p id="par0145" class="elsevierStylePara elsevierViewall">A further limitation is the exclusion of the nearly 13&#37; of patients who were not echocardiographically assessed&#46;</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Conclusion</span><p id="par0150" class="elsevierStylePara elsevierViewall">In this study&#44; most patients presented HFPEF&#46; The clinical characteristics of this group were similar to those of the HFREF group&#46; As in other studies&#44; women and hypertensive etiology were predominant in the HFPEF group&#46; HFREF patients were more likely to receive BBs&#44; and dilated cardiomyopathy predominated&#46; No significant differences in mortality were observed between the groups&#46; Our experience shows that an integrated multidisciplinary approach enhances the treatment&#44; management&#44; and follow-up of HF patients&#46; However&#44; few studies have focused on HFPEF patients&#44; and even fewer have included patients from internists in specialized HF units&#44; which underscores the need for further prospective studies to explore new improved therapeutic strategies&#46;</p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">Ethical disclosures</span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0105">Protection of human and animal subjects</span><p id="par0155" class="elsevierStylePara elsevierViewall">The authors declare that no experiments were performed on humans or animals for this study&#46;</p></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0110">Confidentiality of data</span><p id="par0160" class="elsevierStylePara elsevierViewall">The authors declare that they have followed the protocols of their work center on the publication of patient data&#46;</p></span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0115">Right to privacy and informed consent</span><p id="par0165" class="elsevierStylePara elsevierViewall">The authors declare that no patient data appear in this article&#46;</p></span></span><span id="sec0060" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0120">Conflicts of interest</span><p id="par0170" class="elsevierStylePara elsevierViewall">The authors have no conflicts of interest to declare&#46;</p></span></span>"
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              "titulo" => "Introdu&#231;&#227;o e objetivos"
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    "fechaRecibido" => "2014-07-31"
    "fechaAceptado" => "2015-02-25"
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            0 => "Heart failure"
            1 => "Preserved ejection fraction"
            2 => "Reduced ejection fraction"
            3 => "Elderly"
            4 => "Survival"
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          "titulo" => "Palavras-chave"
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            0 => "Insufici&#234;ncia card&#237;aca"
            1 => "Insufici&#234;ncia card&#237;aca com fra&#231;&#227;o de eje&#231;&#227;o preservada"
            2 => "Insufici&#234;ncia card&#237;aca com fra&#231;&#227;o de eje&#231;&#227;o dimu&#237;da"
            3 => "Idosos"
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        "titulo" => "Abstract"
        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Objectives</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">The aim of this study was to assess prevalence&#44; clinical characteristics&#44; and prognosis in elderly patients with heart failure with preserved ejection fraction &#40;HFPEF&#41; compared to patients with heart failure with reduced ejection fraction &#40;HFREF&#41; who were followed in an internal medicine unit&#46;</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Methods</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">In this retrospective observational study&#44; the sample consisted of 301 patients followed in an internal medicine referral unit between January 2007 and December 2010&#46; All patients were checked to determine their vital status on 31 December 2012&#46; Survival was analyzed using Kaplan-Meier curves&#44; and compared using the log-rank test&#46;</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Results</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Of the 301 patients&#44; 165 &#40;54&#46;8&#37;&#41; were women&#46; In the 263 cases &#40;87&#46;4&#37;&#41; who underwent echocardiographic assessment&#44; 190 &#40;72&#46;2&#37;&#41; had HFPEF and 73 &#40;27&#46;8&#37;&#41; had HFREF&#46; Mean age was similar in the two groups &#40;80&#46;1 and 79&#46;9 years&#59; p&#61;0&#46;905&#41;&#44; with a predominance of women in the HFPEF group &#40;60&#46;5&#37; women&#44; 42&#46;5&#37; men&#59; p&#61;0&#46;025&#41;&#46; The main etiology was hypertensive heart disease in the HFPEF group&#46; Regarding treatment&#44; more beta-blockers were administered in the HFREF group&#46; No statistically significant differences were observed between the groups in terms of cardiovascular risk factors&#44; comorbidities&#44; NYHA functional class&#44; or mortality&#46;</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Conclusion</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Clinical characteristics were similar for both HFPEF and HFREF patients&#46; Women were predominant in the HFPEF group&#44; as was hypertensive etiology&#46; No significant differences in mortality were observed between the groups&#46;</p></span>"
        "secciones" => array:4 [
          0 => array:2 [
            "identificador" => "abst0005"
            "titulo" => "Objectives"
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          1 => array:2 [
            "identificador" => "abst0010"
            "titulo" => "Methods"
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          2 => array:2 [
            "identificador" => "abst0015"
            "titulo" => "Results"
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        "titulo" => "Resumo"
        "resumen" => "<span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Introdu&#231;&#227;o e objetivos</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">O objetivo do estudo &#233; analisar a preval&#234;ncia&#44; as caracter&#237;sticas cl&#237;nicas e o progn&#243;stico dum grupo de doentes idosos com diagn&#243;stico de insufici&#234;ncia card&#237;aca com fra&#231;&#227;o de eje&#231;&#227;o preservada &#40;IC&#47;FEP&#41; seguidos numa consulta especializada e compar&#225;-los com os doentes que apresentam fra&#231;&#227;o de eje&#231;&#227;o dimu&#237;da &#40;IC&#47;FED&#41;&#46;</p></span> <span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Materiais e m&#233;todos</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Estudo retrospetivo observacional incluindo 301 doentes&#44; seguidos numa consulta especializada de Medicina Interna&#44; no per&#237;odo entre janeiro de 2007 e dezembro de 2010 cujo <span class="elsevierStyleItalic">status</span> vital foi determinado a 31 de dezembro de 2012&#46; Para a an&#225;lise de sobreviv&#234;ncia foram utilizadas as curvas de Kaplan-Meier e na compara&#231;&#227;o foi utilizado o teste de Log-rank&#46;</p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Resultados</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">301 doentes foram estudados&#44; sendo 165 &#40;54&#44;8&#37;&#41; do sexo feminino&#46; Nos 263 &#40;87&#44;4&#37;&#41; casos nos quais foi realizado o estudo ecocardiogr&#225;fico&#44; 190 &#40;72&#44;2&#37;&#41; correspondiam a doentes com diagn&#243;stico de IC&#47;FEP e 73 &#40;27&#44;8&#37;&#41; de IC&#47;FED&#46; A idade m&#233;dia foi similar nos dois grupos &#40;80&#44;3 e 79&#44;9 anos&#44; p 0&#44;905&#41;&#44; sendo maior a percentagem de mulheres &#40;60&#44;5&#37; face a 42&#44;5&#37;&#44; p 0&#44;025&#41; e com predom&#237;nio de etiologia hipertensiva no grupo com IC&#47;FEP&#46; Quanto ao tratamento&#44; o uso de betabloqueantes foi maior no grupo com IC&#47;FED&#46; N&#227;o foram encontradas diferen&#231;as significativas entre ambos os grupos relativamente a fatores de risco cardiovascular&#44; comorbilidades&#44; classe funcional ou mortalidade&#46;</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Conclus&#227;o</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">As carater&#237;sticas cl&#237;nicas dos doentes com IC&#47;FEP e com IC&#47;FED s&#227;o similares&#46; No grupo de IC&#47;FEP predominam os doentes do sexo feminino e a etiologia hipertensiva&#46; N&#227;o foram observadas diferen&#231;as na mortalidade entre ambos os grupos&#46;</p></span>"
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          "en" => "<p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">Follow-up survival curve for patients with heart failure with preserved ejection fraction and heart failure with reduced ejection fraction&#46;</p>"
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          "leyenda" => "<p id="spar0080" class="elsevierStyleSimplePara elsevierViewall">COPD&#58; chronic obstructive pulmonary disease&#59; DCM&#58; dilated cardiomyopathy&#59; LVEF&#58; left ventricular ejection fraction&#59; NYHA&#58; New York Heart Association&#46;</p>"
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                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " align="" valign="top" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Overall &#40;n&#61;301&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">LVEF &#8805;50&#37; &#40;n&#61;190&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">LVEF &#60;50&#37; &#40;n&#61;73&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">p&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleItalic">Women&#44; &#37; &#40;n&#41;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">54&#46;8 &#40;165&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">60&#46;5 &#40;115&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">42&#46;5 &#40;31&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;025&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleItalic">Age&#44; years &#40;P25&#59;75&#41;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">80&#46;3 &#40;75&#46;2&#59;84&#46;3&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">80&#46;1 &#40;74&#46;6&#59;84&#46;3&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">79&#46;9 &#40;74&#46;0&#59;84&#46;2&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;905&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleItalic">COPD&#44; &#37; &#40;n&#41;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">30&#46;2 &#40;91&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">31&#46;6 &#40;60&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">28&#46;8 &#40;21&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;773&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleItalic">Diabetes&#44; &#37; &#40;n&#41;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">32&#46;2 &#40;97&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">33&#46;2 &#40;63&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">30&#46;1 &#40;22&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;892&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleItalic">Hypertension&#44; &#37; &#40;n&#41;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">81&#46;4 &#40;245&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">84&#46;2 &#40;160&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">76&#46;7 &#40;56&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;259&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleItalic">Anemia&#44; &#37; &#40;n&#41;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">46&#46;8 &#40;141&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">45&#46;3 &#40;85&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">47&#46;9 &#40;35&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;692&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleItalic">Renal failure&#44; &#37; &#40;n&#41;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">58&#46;8 &#40;177&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">57&#46;4 &#40;109&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">58&#46;9 &#40;43&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;629&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">NYHA class&#44; &#37; &#40;n&#41;</span></td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>I&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">27&#46;8 &#40;83&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">26&#46;5 &#40;50&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">30&#46;1 &#40;22&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;792&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>II&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">42&#46;5 &#40;127&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">41&#46;8 &#40;79&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">46&#46;6 &#40;34&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;792&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>III&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">29&#46;1 &#40;87&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">30&#46;7 &#40;58&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">23&#46;3 &#40;17&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;792&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>IV&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;7 &#40;2&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1&#46;1 &#40;2&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;792&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Atrial fibrillation&#44; &#37; &#40;n&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">55&#46;1 &#40;66&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">55&#46;8 &#40;106&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">56&#46;2 &#40;41&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;791&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">Etiology&#44; &#37; &#40;n&#41;</span></td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Hypertensive&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">67&#46;8 &#40;198&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">70&#46;5 &#40;129&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">57&#46;5 &#40;42&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;003&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Ischemic&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">12&#46;0 &#40;35&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">10&#46;4 &#40;19&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">17&#46;8 &#40;13&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;003&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Valvular&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">8&#46;6 &#40;25&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">9&#46;8 &#40;18&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">5&#46;5 &#40;4&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;003&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>DCM&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">4&#46;5 &#40;13&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1&#46;1 &#40;2&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">12&#46;3 &#40;9&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;003&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Cor pulmonale&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">5&#46;1 &#40;15&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">7&#46;1 &#40;13&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">2&#46;7 &#40;2&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;003&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Other&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">2&#46;1 &#40;6&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1&#46;1 &#40;2&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">4&#46;1 &#40;3&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;003&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
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                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " align="" valign="top" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Overall &#40;n&#61;301&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">LVEF &#8805;50&#37; &#40;n&#61;190&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">LVEF &#60;50&#37; &#40;n&#61;73&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">p&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry  " colspan="5" align="left" valign="top"><span class="elsevierStyleItalic">Source of referral &#37; &#40;n&#41;</span></td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Primary care&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1&#46;0 &#40;3&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;5 &#40;1&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">2&#46;8 &#40;2&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;032&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Emergency&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">22&#46;7 &#40;68&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">19&#46;6 &#40;37&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">23&#46;6 &#40;17&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;032&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Cardiology&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">3&#46;3 &#40;10&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">3&#46;2 &#40;6&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">5&#46;6 &#40;4&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;032&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Internal medicine&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">68&#46;9 &#40;206&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">73 &#40;138&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">66&#46;7 &#40;48&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;032&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Other&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">4&#46;0 &#40;12&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">3&#46;7 &#40;7&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1&#46;4 &#40;1&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;032&nbsp;\t\t\t\t\t\t\n
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          "en" => "<p id="spar0085" class="elsevierStyleSimplePara elsevierViewall">Source of patient referrals&#46;</p>"
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                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Overall &#40;n&#61;301&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">LVEF &#8805;50&#37; &#40;n&#61;190&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">p&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry  " colspan="5" align="left" valign="top"><span class="elsevierStyleItalic">Treatment&#44; &#37; &#40;n&#41;</span></td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>ACE inhibitors&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">32&#46;1 &#40;84&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">32&#46;9 &#40;55&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">29&#46;2 &#40;19&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;910&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>ARBs&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">46&#46;1 &#40;77&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">50&#46;8 &#40;27&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;256&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Spironolactone&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">22&#46;8 &#40;38&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">32&#46;3 &#40;21&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;570&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">48&#46;2 &#40;80&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">67&#46;2 &#40;43&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;028&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Overall &#40;n&#61;301&#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="char" valign="top">10&#46;5 &#40;12&#46;3&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">12 &#40;11&#46;2&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;946&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">End of observational period&#44; &#37; &#40;n&#41;</span></td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Follow-up&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">37&#46;5 &#40;113&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">37&#46;9 &#40;72&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">38&#46;4 &#40;28&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;465&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Discharge to cardiology clinic&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">4&#46;7 &#40;9&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">4&#46;1 &#40;3&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;465&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">28&#46;4 &#40;54&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">32&#46;9 &#40;24&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;465&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">13&#46;7 &#40;26&#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="char" valign="top">0&#46;465&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">28&#46;4 &#40;54&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">32&#46;9 &#40;24&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;465&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  " align="left" valign="top"><span class="elsevierStyleItalic">Intervention&#44; &#37; &#40;n&#41;</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">87&#46;9 &#40;167&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">89 &#40;65&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;274&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">51&#46;1 &#40;97&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">39&#46;7 &#40;29&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;257&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
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          "en" => "<p id="spar0135" class="elsevierStyleSimplePara elsevierViewall">Follow-up and mortality&#46;</p>"
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      "titulo" => "References"
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        0 => array:2 [
          "identificador" => "bibs0005"
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            0 => array:3 [
              "identificador" => "bib0225"
              "etiqueta" => "1"
              "referencia" => array:1 [
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                  "contribucion" => array:1 [
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                  "host" => array:1 [
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                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/24776334"
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              "identificador" => "bib0230"
              "etiqueta" => "2"
              "referencia" => array:1 [
                0 => array:1 [
                  "referenciaCompleta" => "Instituto Nacional de Estad&#237;stica &#40;National Statistics Institute&#41;&#46; &#91;Internet&#93;&#46; Available at&#58; <a href="http://www.ine.es/jaxi/tabla.do">http&#58;&#47;&#47;www&#46;ine&#46;es&#47;jaxi&#47;tabla&#46;do</a> &#91;accessed 05&#46;12&#46;13&#93;&#46;"
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            ]
            2 => array:3 [
              "identificador" => "bib0235"
              "etiqueta" => "3"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Managing congestive heart failure using home telehealth"
                      "autores" => array:1 [
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                          "etal" => false
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            3 => array:3 [
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                  "contribucion" => array:1 [
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                      "titulo" => "Predictive factors for readmission in heart failure patients"
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                            1 => "L&#46; San Vicente"
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                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Prevalence of heart failure in the Spanish general population aged over 45 years&#46; The PRICE Study"
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                        0 => array:2 [
                          "etal" => true
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                            0 => "M&#46; Anguita S&#225;nchez"
                            1 => "M&#46;G&#46; Crespo Leiro"
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                  "host" => array:1 [
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Article information

ISSN: 21742049
Original language: English

DOI:10.1016/j.repce.2015.07.006

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2023 October	24	23	47
2023 September	20	17	37
2023 August	21	18	39
2023 July	13	9	22
2023 June	15	8	23
2023 May	28	24	52
2023 April	14	1	15
2023 March	16	18	34
2023 February	21	15	36
2023 January	17	14	31
2022 December	19	19	38
2022 November	23	20	43
2022 October	29	22	51
2022 September	17	24	41
2022 August	18	27	45
2022 July	31	29	60
2022 June	21	30	51
2022 May	18	23	41
2022 April	23	31	54
2022 March	28	34	62
2022 February	15	29	44
2022 January	27	28	55
2021 December	11	32	43
2021 November	23	34	57
2021 October	28	35	63
2021 September	19	39	58
2021 August	22	23	45
2021 July	20	26	46
2021 June	22	18	40
2021 May	30	34	64
2021 April	55	61	116
2021 March	47	18	65
2021 February	51	17	68
2021 January	29	10	39
2020 December	32	11	43
2020 November	21	14	35
2020 October	9	16	25
2020 September	42	9	51
2020 August	17	9	26
2020 July	24	6	30
2020 June	31	15	46
2020 May	33	6	39
2020 April	33	10	43
2020 March	29	5	34
2020 February	51	17	68
2020 January	25	8	33
2019 December	40	3	43
2019 November	25	12	37
2019 October	32	8	40
2019 September	21	12	33
2019 August	33	10	43
2019 July	25	7	32
2019 June	23	25	48
2019 May	26	11	37
2019 April	21	14	35
2019 March	25	9	34
2019 February	25	8	33
2019 January	17	7	24
2018 December	49	11	60
2018 November	136	8	144
2018 October	384	15	399
2018 September	112	16	128
2018 August	40	10	50
2018 July	38	6	44
2018 June	57	9	66
2018 May	77	7	84
2018 April	75	8	83
2018 March	99	13	112
2018 February	68	2	70
2018 January	108	5	113
2017 December	78	15	93
2017 November	32	8	40
2017 October	32	12	44
2017 September	27	14	41
2017 August	28	13	41
2017 July	29	12	41
2017 June	29	14	43
2017 May	32	18	50
2017 April	25	6	31
2017 March	36	8	44
2017 February	26	5	31
2017 January	29	4	33
2016 December	31	11	42
2016 November	16	3	19
2016 October	42	7	49
2016 September	37	6	43
2016 August	13	2	15
2016 July	22	11	33
2016 June	18	3	21
2016 May	21	5	26
2016 April	7	3	10
2016 March	34	4	38
2016 February	34	20	54
2016 January	32	16	48
2015 December	20	10	30
2015 November	37	12	49
2015 October	36	19	55
2015 September	39	7	46
2015 August	28	20	48

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