Pulse pressure can predict mortality in advanced heart failure | Revista Portuguesa de Cardiologia (English edition)

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array:19 [ "idiomaDefecto" => true "cabecera" => "Original Article" "titulo" => "Pulse pressure can predict mortality in advanced heart failure" "tieneTextoCompleto" => true "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "225" "paginaFinal" => "228" ] ] "autores" => array:1 [ 0 => array:4 [ "autoresLista" => "Ana Rita Ferreira, Sofia Mendes, Luís Leite, Sílvia Monteiro, Mariano Pego" "autores" => array:5 [ 0 => array:4 [ "nombre" => "Ana Rita" "apellidos" => "Ferreira" "email" => array:1 [ 0 => "ritafmup@gmail.com" ] "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "*" "identificador" => "cor0005" ] ] ] 1 => array:2 [ "nombre" => "Sofia" "apellidos" => "Mendes" ] 2 => array:2 [ "nombre" => "Luís" "apellidos" => "Leite" ] 3 => array:2 [ "nombre" => "Sílvia" "apellidos" => "Monteiro" ] 4 => array:2 [ "nombre" => "Mariano" "apellidos" => "Pego" ] ] "afiliaciones" => array:1 [ 0 => array:2 [ "entidad" => "Serviço de Cardiologia A, Centro Hospitalar e Universitário de 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wall elastic properties.<a class="elsevierStyleCrossRef" href="#bib0040">1</a>In a young healthy person, each stroke volume received into the central vessels is accommodated by a stretching of these vessels in systole followed by subsequent elastic recoil in late systole and diastole. This is known as arterial compliance and has the effect of maintaining central and peripheral BP within a relatively narrow range. With aging, there is a disruption and fragmentation of the elastic lamellae of the central arteries, as well as alteration of the collagen-to-elastin ratio, leading to arterial stiffness, loss of compliance, and increased pulse wave velocity and therefore increased PP.<a class="elsevierStyleCrossRef" href="#bib0045">2</a>An elevated PP consistently predicts increased cardiovascular (CV) risk, including for coronary heart disease, chronic heart failure (HF) and CV mortality.<a class="elsevierStyleCrossRefs" href="#bib0050">3,4</a>The prognostic value of PP in patients with chronic HF is less clear. The SOLVD investigators found that a high PP predicted adverse outcome, especially in patients in New York Heart Association (NYHA) class II or III.<a class="elsevierStyleCrossRef" href="#bib0060">5</a> In contrast, in patients hospitalized with acute HF, low PP appeared to be an independent predictor of mortality. A low PP (≤40 mmHg) may represent a decrease in cardiac output and reflect a reduction of stroke volume due to left ventricular dysfunction.The aim of this study was to assess whether PP can be used as a prognostic marker in advanced HF (NYHA class III or IV).MethodsWe retrospectively studied 914 patients in NYHA class III–IV hospitalized in a single advanced HF unit between January 2003 and August 2012.Detailed histories of the patients including demographic characteristics, CV risk factors and medication were recorded.Serum lipid, glucose, creatinine, sodium, potassium, and brain natriuretic peptide levels were measured by routine laboratory methods.PP was calculated as the difference between systolic and diastolic BP at admission, and the patients were divided into two groups (group 1: PP >40 mmHg and group 2: PP ≤40 mmHg).Median follow-up was 666±50 days for the occurrence of CV death (sudden cardiac death or death due to decompensated HF, acute coronary syndrome or arrhythmia) and heart transplantation.Statistical analysisAll analyses were performed with SPSS 16.0. Continuous variables were presented as mean ± standard error of the mean. Continuous variables according to NYHA class or PP group were analyzed by means.The Student's t test or Mann-Whitney test was used for binary dependent variables. A p value <0.05 was considered statistically significant.Differences between survival curves were calculated using univariate log-rank survival analysis.ResultsDuring follow-up 914 patients in NYHA class III–IV were hospitalized, 520 in group 1 and 394 in group 2. Median follow-up was nearly two years.Patients’ baseline characteristics are presented in <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>.<elsevierMultimedia ident="tbl0005"></elsevierMultimedia>There were no significant differences between patients with lower and higher PP. Mean age was similar and most patients were male in both groups. There were also no differences in medication or CV risk factors.The most important difference between the groups was in left ventricular dysfunction, which was greater in patients with lower PP. Length of hospital stay was greater in group 2, although without statistically significant difference.On Kaplan-Meier analysis (<a class="elsevierStyleCrossRef" href="#fig0005">Figure 1</a>), group 2 had higher mortality (38 vs. 24 patients, log-rank p=0.002).<elsevierMultimedia ident="fig0005"></elsevierMultimedia>DiscussionOur study showed that low PP predicted CV death in patients with advanced HF. Furthermore, low PP was closely associated with worsening left ventricular ejection fraction (LVEF).<a class="elsevierStyleCrossRef" href="#bib0050">3</a>PP has been previously correlated with arterial compliance and with hemodynamic factors such as stroke volume and peak aortic blood flow. Left ventricular systolic dysfunction reduces stroke volume and therefore also PP and systolic BP. Several studies have shown a positive correlation between low PP and diminished cardiac index (<2.2 l/min/m2). Voors et al. reported a positive and independent association between low PP and low LVEF, and our results confirm these observations.<a class="elsevierStyleCrossRef" href="#bib0055">4</a>There are well recognized factors that affect mortality in HF, such as older age, diabetes, renal failure, higher NYHA class, low LVEF, low peak oxygen consumption, low plasma sodium levels and high natriuretic peptides. In our study low PP and low LVEF were the most important predictors of CV death.<a class="elsevierStyleCrossRef" href="#bib0055">4</a>The data on the relationship between PP and HF prognosis are limited and controversial. In two large trials, high PP predicted adverse CV outcomes in mild HF patients. The SAVE investigators<a class="elsevierStyleCrossRef" href="#bib0060">5</a> showed that higher PP predicted worse outcome in patients with asymptomatic LV systolic dysfunction, and the SOLVD investigators<a class="elsevierStyleCrossRef" href="#bib0065">6</a> reported that high PP was an independent predictor of total CV death in patients with mild HF. Other investigators showed that low PP independently predicted higher CV mortality in patients with advanced and decompensated HF, but not in patients with mild HF. Voors et al.<a class="elsevierStyleCrossRef" href="#bib0055">4</a> proposed that low PP indicated decreased cardiac function. In another study PP only appeared to be an independent predictor of CV death in non-ischemic HF.The differences between findings on the prognostic value of PP may be due to different characteristics of the study populations. In mild HF, a high PP is probably the result of vascular stiffening or decreased aortic elasticity, which indicates atherosclerosis and therefore a poorer prognosis, whereas in advanced HF, low PP indicates decreased cardiac function and an associated worse prognosis, as demonstrated in our study.<a class="elsevierStyleCrossRefs" href="#bib0055">4,5</a>ConclusionPP is easily calculated and can provide a clinical prognostic indicator in patients hospitalized for advanced HF.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 no patient data appear in this article.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." 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PP rises markedly after the fifth decade of life. High PP is a risk factor for the development of coronary heart disease and heart failure. The aim of this study was to assess whether PP can be used as a prognostic marker in advanced heart failure. MethodsWe retrospectively studied patients in NYHA class III–IV who were hospitalized in a single heart failure unit between January 2003 and August 2012. Demographic characteristics, laboratory tests, and cardiovascular risk factors were recorded. PP was calculated as the difference between systolic and diastolic BP at admission, and the patients were divided into two groups (group 1: PP >40 mmHg and group 2: PP ≤40 mmHg). Median follow-up was 666±50 days for the occurrence of cardiovascular death and heart transplantation. ResultsDuring follow-up 914 patients in NYHA class III–IV were hospitalized, 520 in group 1 and 394 in group 2. The most important difference between the groups was in left ventricular dysfunction, which was greater in patients with lower PP. On Kaplan-Meier analysis, group 2 had higher mortality (38 vs. 24 patients, log-rank p=0.002). ConclusionsPP is easily calculated, and enables prediction of cardiovascular death in patients with advanced heart failure." "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Introduction" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Methods" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Results" ] 3 => array:2 [ "identificador" => "abst0020" "titulo" => "Conclusions" ] ] ] "pt" => array:3 [ "titulo" => "Resumo" "resumen" => "IntroduçãoA pressão de pulso (PP) é a diferença entre os valores da pressão arterial sistólica e diastólica (BP). A PP sobe acentuadamente após a quinta década de vida, sendo considerada um fator de risco para o desenvolvimento de doenças cardiovasculares. O objetivo do estudo foi avaliar se a PP pode ser usada como um marcador de prognóstico em doentes com insuficiência cardíaca avançada. MétodosForam estudados, retrospetivamente, 914 doentes em classe III-IV de NYHA, que foram internados numa unidade de insuficiência cardíaca, entre janeiro de 2003 e agosto de 2012. Foram recolhidos: características demográficas, análises laboratoriais e fatores de risco cardiovascular dos doentes incluídos. A PP foi calculada como a diferença entre a BP na admissão e os doentes foram divididos em dois grupos (PP > 40 mmHg e PP = 40 mmHg). O tempo médio de follow-up foi de 666 ± 50 dias. Os endpoints considerados foram a morte por causa cardiovascular e o transplante cardíaco. ResultadosDurante o follow-up foram internados 914 doentes, sendo divididos em dois grupos: grupo I: PP > 40 mmHg (520 pacientes); grupo II: PP = 40 mmHg (394 pacientes). A diferença mais importante entre os grupos foi a depressão da função ventricular esquerda mais acentuada no grupo de doentes com PP menor. Na análise KaplanMeyer, o grupo II (PP = 40 mmHg) apresentou maior mortalidade (38 pacientes versus 24 pacientes, log-rank P = 0,002). ConclusõesA PP é um parâmetro facilmente calculado que se correlaciona com o prognóstico dos doentes com insuficiência cardíaca avançada." 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"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">Group 1: PP >40 mmHg (n=520) \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">Group 2: PP ≤40 mmHg (n=394) \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-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">PP (mean ± SEM) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">33.5 (0.3) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">55.5 (0.4) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top"><0.005 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Age, years (mean; range) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">61 (14) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">58 (14) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">NS \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Male, n (%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">71.3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">74.4 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">NS \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Female, n (%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">28.7 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">25.6 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">NS \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">LVEF, % (mean ± SEM) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">30 (13.1) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">25 (10.5) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top"><0.001 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Heart rate, bpm (mean ± SEM) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">81 (17) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">75 (13) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">NS \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">BNP, pg/ml (mean ± SEM) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">830 (742) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1121 (866) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">NS \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Chronic HF (n) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">403 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">313 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">NS \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Acute HF (n) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">80 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">41 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">NS \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Cardiogenic shock (n) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">20 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">8 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">NS \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Right HF (n) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">22 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">18 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">NS \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Hospital stay, days (mean ± SEM) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">9 (8) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">10 (9) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">NS \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Hypertension (%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">64.5 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">58.8 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">NS \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; 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Pulse pressure can predict mortality in advanced heart failure

Pressão de pulso pode ser um preditor de mortalidade na insuficiência cardíaca avançada

Ana Rita Ferreira

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ritafmup@gmail.com

Corresponding author.

, Sofia Mendes, Luís Leite, Sílvia Monteiro, Mariano Pego

Serviço de Cardiologia A, Centro Hospitalar e Universitário de Coimbra, Hospitais da Universidade de Coimbra, Coimbra, Portugal

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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">Pulse pressure &#40;PP&#41; is the difference between systolic and diastolic blood pressure &#40;BP&#41; and is dependent on stroke volume and arterial wall elastic properties&#46;<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">1</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">In a young healthy person&#44; each stroke volume received into the central vessels is accommodated by a stretching of these vessels in systole followed by subsequent elastic recoil in late systole and diastole&#46; This is known as arterial compliance and has the effect of maintaining central and peripheral BP within a relatively narrow range&#46; With aging&#44; there is a disruption and fragmentation of the elastic lamellae of the central arteries&#44; as well as alteration of the collagen-to-elastin ratio&#44; leading to arterial stiffness&#44; loss of compliance&#44; and increased pulse wave velocity and therefore increased PP&#46;<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">2</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">An elevated PP consistently predicts increased cardiovascular &#40;CV&#41; risk&#44; including for coronary heart disease&#44; chronic heart failure &#40;HF&#41; and CV mortality&#46;<a class="elsevierStyleCrossRefs" href="#bib0050"><span class="elsevierStyleSup">3&#44;4</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">The prognostic value of PP in patients with chronic HF is less clear&#46; The SOLVD investigators found that a high PP predicted adverse outcome&#44; especially in patients in New York Heart Association &#40;NYHA&#41; class II or III&#46;<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">5</span></a> In contrast&#44; in patients hospitalized with acute HF&#44; low PP appeared to be an independent predictor of mortality&#46; A low PP &#40;&#8804;40 mmHg&#41; may represent a decrease in cardiac output and reflect a reduction of stroke volume due to left ventricular dysfunction&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">The aim of this study was to assess whether PP can be used as a prognostic marker in advanced HF &#40;NYHA class III or IV&#41;&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Methods</span><p id="par0030" class="elsevierStylePara elsevierViewall">We retrospectively studied 914 patients in NYHA class III&#8211;IV hospitalized in a single advanced HF unit between January 2003 and August 2012&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">Detailed histories of the patients including demographic characteristics&#44; CV risk factors and medication were recorded&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">Serum lipid&#44; glucose&#44; creatinine&#44; sodium&#44; potassium&#44; and brain natriuretic peptide levels were measured by routine laboratory methods&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">PP was calculated as the difference between systolic and diastolic BP at admission&#44; and the patients were divided into two groups &#40;group 1&#58; PP &#62;40 mmHg and group 2&#58; PP &#8804;40 mmHg&#41;&#46;</p><p id="par0050" class="elsevierStylePara elsevierViewall">Median follow-up was 666&#177;50 days for the occurrence of CV death &#40;sudden cardiac death or death due to decompensated HF&#44; acute coronary syndrome or arrhythmia&#41; and heart transplantation&#46;</p><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Statistical analysis</span><p id="par0055" class="elsevierStylePara elsevierViewall">All analyses were performed with SPSS 16&#46;0&#46; Continuous variables were presented as mean &#177; standard error of the mean&#46; Continuous variables according to NYHA class or PP group were analyzed by means&#46;</p><p id="par0060" class="elsevierStylePara elsevierViewall">The Student&#39;s t test or Mann-Whitney test was used for binary dependent variables&#46; A p value &#60;0&#46;05 was considered statistically significant&#46;</p><p id="par0065" class="elsevierStylePara elsevierViewall">Differences between survival curves were calculated using univariate log-rank survival analysis&#46;</p></span></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Results</span><p id="par0070" class="elsevierStylePara elsevierViewall">During follow-up 914 patients in NYHA class III&#8211;IV were hospitalized&#44; 520 in group 1 and 394 in group 2&#46; Median follow-up was nearly two years&#46;</p><p id="par0075" class="elsevierStylePara elsevierViewall">Patients&#8217; baseline characteristics are presented in <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0080" class="elsevierStylePara elsevierViewall">There were no significant differences between patients with lower and higher PP&#46; Mean age was similar and most patients were male in both groups&#46; There were also no differences in medication or CV risk factors&#46;</p><p id="par0085" class="elsevierStylePara elsevierViewall">The most important difference between the groups was in left ventricular dysfunction&#44; which was greater in patients with lower PP&#46; Length of hospital stay was greater in group 2&#44; although without statistically significant difference&#46;</p><p id="par0090" class="elsevierStylePara elsevierViewall">On Kaplan-Meier analysis &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Figure 1</a>&#41;&#44; group 2 had higher mortality &#40;38 vs&#46; 24 patients&#44; log-rank p&#61;0&#46;002&#41;&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Discussion</span><p id="par0095" class="elsevierStylePara elsevierViewall">Our study showed that low PP predicted CV death in patients with advanced HF&#46; Furthermore&#44; low PP was closely associated with worsening left ventricular ejection fraction &#40;LVEF&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">3</span></a></p><p id="par0100" class="elsevierStylePara elsevierViewall">PP has been previously correlated with arterial compliance and with hemodynamic factors such as stroke volume and peak aortic blood flow&#46; Left ventricular systolic dysfunction reduces stroke volume and therefore also PP and systolic BP&#46; Several studies have shown a positive correlation between low PP and diminished cardiac index &#40;&#60;2&#46;2 l&#47;min&#47;m<span class="elsevierStyleSup">2</span>&#41;&#46; Voors et al&#46; reported a positive and independent association between low PP and low LVEF&#44; and our results confirm these observations&#46;<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">4</span></a></p><p id="par0105" class="elsevierStylePara elsevierViewall">There are well recognized factors that affect mortality in HF&#44; such as older age&#44; diabetes&#44; renal failure&#44; higher NYHA class&#44; low LVEF&#44; low peak oxygen consumption&#44; low plasma sodium levels and high natriuretic peptides&#46; In our study low PP and low LVEF were the most important predictors of CV death&#46;<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">4</span></a></p><p id="par0110" class="elsevierStylePara elsevierViewall">The data on the relationship between PP and HF prognosis are limited and controversial&#46; In two large trials&#44; high PP predicted adverse CV outcomes in mild HF patients&#46; The SAVE investigators<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">5</span></a> showed that higher PP predicted worse outcome in patients with asymptomatic LV systolic dysfunction&#44; and the SOLVD investigators<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">6</span></a> reported that high PP was an independent predictor of total CV death in patients with mild HF&#46; Other investigators showed that low PP independently predicted higher CV mortality in patients with advanced and decompensated HF&#44; but not in patients with mild HF&#46; Voors et al&#46;<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">4</span></a> proposed that low PP indicated decreased cardiac function&#46; In another study PP only appeared to be an independent predictor of CV death in non-ischemic HF&#46;</p><p id="par0115" class="elsevierStylePara elsevierViewall">The differences between findings on the prognostic value of PP may be due to different characteristics of the study populations&#46; In mild HF&#44; a high PP is probably the result of vascular stiffening or decreased aortic elasticity&#44; which indicates atherosclerosis and therefore a poorer prognosis&#44; whereas in advanced HF&#44; low PP indicates decreased cardiac function and an associated worse prognosis&#44; as demonstrated in our study&#46;<a class="elsevierStyleCrossRefs" href="#bib0055"><span class="elsevierStyleSup">4&#44;5</span></a></p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Conclusion</span><p id="par0120" class="elsevierStylePara elsevierViewall">PP is easily calculated and can provide a clinical prognostic indicator in patients hospitalized for advanced HF&#46;</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Ethical disclosures</span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">Protection of human and animal subjects</span><p id="par0125" class="elsevierStylePara elsevierViewall">The authors declare that no experiments were performed on humans or animals for this study&#46;</p></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0105">Confidentiality of data</span><p id="par0130" class="elsevierStylePara elsevierViewall">The authors declare that no patient data appear in this article&#46;</p></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0110">Right to privacy and informed consent</span><p id="par0135" class="elsevierStylePara elsevierViewall">The authors declare that no patient data appear in this article&#46;</p></span></span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0115">Conflicts of interest</span><p id="par0140" class="elsevierStylePara elsevierViewall">The authors have no conflicts of interest to declare&#46;</p></span></span>"
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          "titulo" => "References"
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    "pdfFichero" => "main.pdf"
    "tienePdf" => true
    "fechaRecibido" => "2015-07-18"
    "fechaAceptado" => "2015-11-21"
    "PalabrasClave" => array:2 [
      "en" => array:1 [
        0 => array:4 [
          "clase" => "keyword"
          "titulo" => "Keywords"
          "identificador" => "xpalclavsec818750"
          "palabras" => array:3 [
            0 => "Pulse pressure"
            1 => "Heart failure"
            2 => "Left ventricular dysfunction"
          ]
        ]
      ]
      "pt" => array:1 [
        0 => array:4 [
          "clase" => "keyword"
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          "palabras" => array:3 [
            0 => "Press&#227;o de pulso"
            1 => "Insufici&#234;ncia card&#237;aca"
            2 => "Disfun&#231;&#227;o ventricular esquerda"
          ]
        ]
      ]
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    "resumen" => array:2 [
      "en" => array:3 [
        "titulo" => "Abstract"
        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Introduction</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Pulse pressure &#40;PP&#41; is the difference between systolic and diastolic blood pressure &#40;BP&#41;&#46; PP rises markedly after the fifth decade of life&#46; High PP is a risk factor for the development of coronary heart disease and heart failure&#46; The aim of this study was to assess whether PP can be used as a prognostic marker in advanced heart failure&#46;</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Methods</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">We retrospectively studied patients in NYHA class III&#8211;IV who were hospitalized in a single heart failure unit between January 2003 and August 2012&#46; Demographic characteristics&#44; laboratory tests&#44; and cardiovascular risk factors were recorded&#46; PP was calculated as the difference between systolic and diastolic BP at admission&#44; and the patients were divided into two groups &#40;group 1&#58; PP &#62;40 mmHg and group 2&#58; PP &#8804;40 mmHg&#41;&#46; Median follow-up was 666&#177;50 days for the occurrence of cardiovascular death and heart transplantation&#46;</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Results</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">During follow-up 914 patients in NYHA class III&#8211;IV were hospitalized&#44; 520 in group 1 and 394 in group 2&#46; The most important difference between the groups was in left ventricular dysfunction&#44; which was greater in patients with lower PP&#46; On Kaplan-Meier analysis&#44; group 2 had higher mortality &#40;38 vs&#46; 24 patients&#44; log-rank p&#61;0&#46;002&#41;&#46;</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Conclusions</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">PP is easily calculated&#44; and enables prediction of cardiovascular death in patients with advanced heart failure&#46;</p></span>"
        "secciones" => array:4 [
          0 => array:2 [
            "identificador" => "abst0005"
            "titulo" => "Introduction"
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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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            "identificador" => "abst0020"
            "titulo" => "Conclusions"
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      "pt" => array:3 [
        "titulo" => "Resumo"
        "resumen" => "<span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Introdu&#231;&#227;o</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">A press&#227;o de pulso &#40;PP&#41; &#233; a diferen&#231;a entre os valores da press&#227;o arterial sist&#243;lica e diast&#243;lica &#40;BP&#41;&#46; A PP sobe acentuadamente ap&#243;s a quinta d&#233;cada de vida&#44; sendo considerada um fator de risco para o desenvolvimento de doen&#231;as cardiovasculares&#46; O objetivo do estudo foi avaliar se a PP pode ser usada como um marcador de progn&#243;stico em doentes com insufici&#234;ncia card&#237;aca avan&#231;ada&#46;</p></span> <span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">M&#233;todos</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Foram estudados&#44; retrospetivamente&#44; 914 doentes em classe III-IV de NYHA&#44; que foram internados numa unidade de insufici&#234;ncia card&#237;aca&#44; entre janeiro de 2003 e agosto de 2012&#46; Foram recolhidos&#58; caracter&#237;sticas demogr&#225;ficas&#44; an&#225;lises laboratoriais e fatores de risco cardiovascular dos doentes inclu&#237;dos&#46; A PP foi calculada como a diferen&#231;a entre a BP na admiss&#227;o e os doentes foram divididos em dois grupos &#40;PP &#62; 40 mmHg e PP &#61; 40 mmHg&#41;&#46; O tempo m&#233;dio de <span class="elsevierStyleItalic">follow-up</span> foi de 666 &#177; 50 dias&#46; Os <span class="elsevierStyleItalic">endpoints</span> considerados foram a morte por causa cardiovascular e o transplante card&#237;aco&#46;</p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Resultados</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Durante o <span class="elsevierStyleItalic">follow-up</span> foram internados 914 doentes&#44; sendo divididos em dois grupos&#58; grupo I&#58; PP &#62; 40 mmHg &#40;520 pacientes&#41;&#59; grupo II&#58; PP &#61; 40 mmHg &#40;394 pacientes&#41;&#46; A diferen&#231;a mais importante entre os grupos foi a depress&#227;o da fun&#231;&#227;o ventricular esquerda mais acentuada no grupo de doentes com PP menor&#46; Na an&#225;lise KaplanMeyer&#44; o grupo II &#40;PP &#61; 40 mmHg&#41; apresentou maior mortalidade &#40;38 pacientes <span class="elsevierStyleItalic">versus</span> 24 pacientes&#44; <span class="elsevierStyleItalic">log-rank</span> P &#61; 0&#44;002&#41;&#46;</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Conclus&#245;es</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">A PP &#233; um par&#226;metro facilmente calculado que se correlaciona com o progn&#243;stico dos doentes com insufici&#234;ncia card&#237;aca avan&#231;ada&#46;</p></span>"
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          "en" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Kaplan-Meier analysis showing that group 2 had higher mortality&#46;</p>"
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          "leyenda" => "<p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">BNP&#58; brain natriuretic peptide&#59; HF&#58; heart failure&#59; LVEF&#58; left ventricular ejection fraction&#59; PP&#58; pulse pressure&#59; SEM&#58; standard error of the mean&#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">Group 1&#58; PP &#62;40 mmHg &#40;n&#61;520&#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">Group 2&#58; PP &#8804;40 mmHg &#40;n&#61;394&#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-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">PP &#40;mean &#177; SEM&#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;5 &#40;0&#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">55&#46;5 &#40;0&#46;4&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#60;0&#46;005&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Age&#44; years &#40;mean&#59; range&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">61 &#40;14&#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 &#40;14&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">NS&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Male&#44; n &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">71&#46;3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">74&#46;4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">NS&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Female&#44; n &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">28&#46;7&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">25&#46;6&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">NS&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">LVEF&#44; &#37; &#40;mean &#177; SEM&#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 &#40;13&#46;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">25 &#40;10&#46;5&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#60;0&#46;001&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Heart rate&#44; bpm &#40;mean &#177; SEM&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">81 &#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">75 &#40;13&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">NS&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">BNP&#44; pg&#47;ml &#40;mean &#177; SEM&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">830 &#40;742&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1121 &#40;866&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">NS&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Chronic HF &#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">403&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">313&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">NS&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Acute HF &#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">80&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">41&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">NS&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Cardiogenic shock &#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">20&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">8&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">NS&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Right HF &#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">22&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">18&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">NS&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Hospital stay&#44; days &#40;mean &#177; SEM&#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 &#40;8&#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 &#40;9&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">NS&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Hypertension &#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">64&#46;5&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&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">NS&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Dyslipidemia &#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">74&#46;4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">85&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">NS&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Type 2 diabetes &#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">48&#46;4&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;2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">NS&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
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          "en" => "<p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">Demographic characteristics&#46;</p>"
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      "titulo" => "References"
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        0 => array:2 [
          "identificador" => "bibs0005"
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                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "ESH&#47;ESC Guidelines for the management of arterial hypertension"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:3 [
                            0 => "G&#46; Mancia"
                            1 => "R&#46; Fagard"
                            2 => "K&#46; Narkiewicz"
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                      ]
                    ]
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                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1093/eurheartj/eht151"
                      "Revista" => array:6 [
                        "tituloSerie" => "Eur Heart J"
                        "fecha" => "2013"
                        "volumen" => "34"
                        "paginaInicial" => "2159"
                        "paginaFinal" => "2219"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/23771844"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            1 => array:3 [
              "identificador" => "bib0045"
              "etiqueta" => "2"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Pulse pressure&#58; why is it important&#63;"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:2 [
                            0 => "A&#46;F&#46; Malone"
                            1 => "D&#46;N&#46; Reddan"
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                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.3747/pdi.2010.00002"
                      "Revista" => array:6 [
                        "tituloSerie" => "Perit Dial Int"
                        "fecha" => "2010"
                        "volumen" => "30"
                        "paginaInicial" => "265"
                        "paginaFinal" => "268"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/20424194"
                            "web" => "Medline"
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                    0 => array:2 [
                      "titulo" => "Low pulse pressure as a predictor of death in patients with mild to advanced heart failure"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:3 [
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Article information

ISSN: 21742049
Original language: English

DOI:10.1016/j.repce.2015.11.018

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Year/Month	Html	Pdf	Total

2024 November	5	3	8
2024 October	43	29	72
2024 September	53	24	77
2024 August	53	26	79
2024 July	48	31	79
2024 June	41	28	69
2024 May	39	19	58
2024 April	36	19	55
2024 March	66	32	98
2024 February	46	49	95
2024 January	57	39	96
2023 December	41	26	67
2023 November	52	29	81
2023 October	49	14	63
2023 September	37	24	61
2023 August	29	18	47
2023 July	44	18	62
2023 June	44	9	53
2023 May	66	25	91
2023 April	30	3	33
2023 March	51	23	74
2023 February	56	18	74
2023 January	42	11	53
2022 December	40	21	61
2022 November	62	17	79
2022 October	73	18	91
2022 September	57	31	88
2022 August	67	28	95
2022 July	52	31	83
2022 June	48	16	64
2022 May	38	21	59
2022 April	45	24	69
2022 March	47	28	75
2022 February	57	29	86
2022 January	82	24	106
2021 December	43	23	66
2021 November	52	34	86
2021 October	93	43	136
2021 September	57	34	91
2021 August	64	41	105
2021 July	61	35	96
2021 June	61	20	81
2021 May	75	45	120
2021 April	104	75	179
2021 March	88	33	121
2021 February	94	26	120
2021 January	72	17	89
2020 December	92	11	103
2020 November	92	22	114
2020 October	95	11	106
2020 September	118	23	141
2020 August	79	12	91
2020 July	124	14	138
2020 June	130	9	139
2020 May	166	6	172
2020 April	238	26	264
2020 March	228	20	248
2020 February	324	19	343
2020 January	303	9	312
2019 December	336	17	353
2019 November	661	53	714
2019 October	1312	123	1435
2019 September	1212	58	1270
2019 August	679	32	711
2019 July	430	30	460
2019 June	607	36	643
2019 May	763	30	793
2019 April	745	47	792
2019 March	574	30	604
2019 February	362	20	382
2019 January	261	7	268
2018 December	215	14	229
2018 November	121	11	132
2018 October	214	20	234
2018 September	62	15	77
2018 August	51	3	54
2018 July	36	5	41
2018 June	57	11	68
2018 May	32	7	39
2018 April	32	13	45
2018 March	42	8	50
2018 February	29	4	33
2018 January	16	8	24
2017 December	43	5	48
2017 November	18	9	27
2017 October	26	15	41
2017 September	26	9	35
2017 August	30	14	44
2017 July	23	16	39
2017 June	28	9	37
2017 May	29	18	47
2017 April	11	7	18
2017 March	14	23	37
2017 February	24	4	28
2017 January	19	8	27
2016 December	29	4	33
2016 November	17	5	22
2016 October	22	16	38
2016 September	33	11	44
2016 August	8	0	8
2016 July	23	14	37
2016 June	19	33	52
2016 May	15	30	45
2016 April	9	6	15

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