Is metabolic syndrome a prognostic marker in patients at high cardiovascular risk? A long-term cohort study | Revista Portuguesa de Cardiologia (English edition)

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CAD: coronary artery disease; MS: metabolic syndrome." ] ] ] "textoCompleto" => "IntroductionCardiovascular disease (CVD) is still the leading cause of death in Europe in the general population, including Portugal, although its prevalence has fallen in recent decades.<a class="elsevierStyleCrossRefs" href="#bib0155">1–3</a> By 2015, cancer had overtaken circulatory system diseases as the leading cause of death in men.<a class="elsevierStyleCrossRef" href="#bib0165">3</a> Besides the well-established cardiovascular risk factors such as hypertension, smoking, diabetes, high low-density lipoprotein cholesterol, age and family history, a number of other risk factors have come under scrutiny in recent years. In particular, the cluster of risk factors known as metabolic syndrome (MS), which has a high prevalence worldwide, reaching almost epidemic proportions, is now a major problem, due to its demonstrated association with the development of type 2 diabetes and CVD, risk for which it increases up to two-fold. MS is particularly challenging to treat because profound changes in lifestyle, which are often difficult to implement in the general population, are needed.<a class="elsevierStyleCrossRefs" href="#bib0170">4–6</a>Several meta-analyses have demonstrated a clear association in primary prevention between MS and the occurrence of cardiovascular events during follow-up.<a class="elsevierStyleCrossRefs" href="#bib0170">4–7</a> This was also seen in the VALSIM study carried out in a Portuguese population.<a class="elsevierStyleCrossRef" href="#bib0190">8</a> In secondary prevention the results are conflicting, with some studies showing no effect and others a higher incidence of cardiovascular events, but with less than three years of follow-up.<a class="elsevierStyleCrossRefs" href="#bib0195">9,10</a>In previous studies we demonstrated that MS by itself is not associated with subclinical atherosclerosis (as assessed by common carotid intima-media thickness), but that the latter is directly associated with some of the components of the syndrome, particularly hyperinsulinemia, hyperglycemia and low high-density lipoprotein (HDL) cholesterol, an indication of the heterogeneous effects of the various components of the entity known as MS.<a class="elsevierStyleCrossRefs" href="#bib0205">11–13</a> Similarly, no direct relationship was observed with angiographically significant stable coronary artery disease (CAD), although hyperglycemia and hypertriglyceridemia did predict CAD.<a class="elsevierStyleCrossRef" href="#bib0220">14</a> In both studies, greater waist circumference paradoxically showed a protective effect.<a class="elsevierStyleCrossRefs" href="#bib0210">12,14</a>These earlier papers were based on a cross-sectional and observational study. More than five years after that analysis, the aim of the present study was to analyze the same group of patients and to determine in long-term follow-up (over five years) whether MS is associated with higher mortality or a higher incidence of cerebrovascular or cardiovascular events.MethodsThe original study included adults (age ≥18 years) admitted electively for coronary angiography between 2008 and 2010 with suspected CAD (angina and/or ischemia documented by non-invasive tests). Patients with a history of acute coronary syndrome (ACS), previous myocardial revascularization or known CAD, significant valve disease, congenital heart disease or other cardiomyopathy were excluded. In the original study, the American Heart Association/National Heart, Lung, and Blood Institute's definition of MS was used.<a class="elsevierStyleCrossRef" href="#bib0225">15</a> However, the definition of the syndrome has since been unified by several major medical societies, the main difference being that each country or region can define the limits of abdominal obesity in view of differences between ethnic groups.<a class="elsevierStyleCrossRef" href="#bib0230">16</a> We therefore used the new definition, while retaining the previously defined limits for waist circumference (≥88 cm for women and ≥102 cm for men). The other criteria are blood pressure ≥130/85 mmHg (or under drug treatment), HDL cholesterol ≤40 mg/dl in men or ≤50 mg/dl in women (or under drug treatment), triglycerides ≥150 mg/dl (or under specific treatment), and blood glucose ≥100 mg/dl (or under drug treatment).<a class="elsevierStyleCrossRefs" href="#bib0225">15,16</a> MS is defined by the presence of at least three of these criteria. Angiographically significant CAD was defined as the presence of ≥70% stenosis in any coronary vessel.Follow-up information on all patients was obtained by telephone interview with patients or family members 30 days and one year after admission by a specialist team responsible for follow-up data of patients hospitalized in the department. The same cohort was contacted again in 2017 to obtain additional follow-up information.The following events were analyzed in follow-up: all-cause mortality (defined as death from any cause); cardiovascular mortality (defined as death associated with CVD); and ACS (defined as the occurrence of angina or angina equivalent at rest with electrocardiographic changes and/or rise or fall in myocardial necrosis markers). When percutaneous coronary intervention (PCI) or coronary artery bypass grafting was performed during follow-up unrelated to the reason for initial admission, myocardial revascularization was included. Admission for heart failure was defined as hospitalization due to the onset or worsening of symptoms or signs of heart failure. Readmission was defined as cardiovascular if the patient had previously been admitted for cardiovascular symptoms, acutely or electively. Stroke/transient ischemic attack (TIA) was defined as the occurrence of new-onset neurological deficit. A composite of cardiac and cerebrovascular events (all-cause mortality, ACS, myocardial revascularization, stroke/TIA or heart failure admission) was also analyzed. The medical records of patients with events was analyzed in order to confirm the event and to classify it correctly, and if necessary further information was requested from the patient. These events were compared among patients with and without CAD and in those with and without MS. The study population was thus divided into four groups.All subjects provided their written informed consent to take part in the study, which is in accordance with the Declaration of Helsinki.Statistical analysisContinuous variables are reported as mean and standard deviation. Normality was tested using the Kolmogorov-Smirnov test. Continuous variables were compared using analysis of variance. Categorical variables are expressed as percentages and were compared with the chi-square test or Fisher's test, as appropriate.Estimates of event-free survival in follow-up were calculated by the Kaplan-Meier method and the curves were compared using the log-rank test. Cox proportional hazards analysis was used to determine the influence of MS and of angiographically significant CAD on the long-term occurrence of events and was adjusted for variables with significant impact on prognosis. Estimates of the association between predictors and events are presented as hazard ratios (HR) with 95% confidence intervals.IBM SPSS version 19.0.0.2 was used for the statistical analysis. A p-value <0.05 was considered statistically significant.ResultsThe initial study included 300 patients, four of whom were lost during follow-up. Of the 296 patients included in this analysis, 59% were male, mean age 65±9 years (38-86 years). The prevalence of MS was 55.7% and the most common component of MS was hypertension, followed by abdominal obesity, high blood glucose, low HDL cholesterol and high triglycerides (<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>). Angiographically significant CAD was detected in only 41.6% of subjects.<elsevierMultimedia ident="tbl0005"></elsevierMultimedia>In a mean follow-up of 6.9±2.2 years, 10.1% of the population suffered all-cause death, 3.7% cardiovascular death, 14.2% cardiovascular readmission and 22.0% composite outcomes (<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>). There were no statistically significant differences between any of the four groups in terms of all-cause or cardiovascular mortality (<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>; <a class="elsevierStyleCrossRefs" href="#fig0005">Figures 1 and 2</a>). However, cardiovascular readmissions and composite outcomes were more frequent in the CAD groups (<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>; <a class="elsevierStyleCrossRefs" href="#fig0015">Figures 3 and 4</a>). This difference was largely due to a higher incidence of ACS in the group with MS and CAD (<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>). Both CAD groups presented more frequent PCI and cardiovascular readmission (<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>), and CAD was associated with more events. Cardiovascular readmissions and composite outcomes were significantly more frequent in patients with CAD both in subjects without MS (log-rank p=0.001 and p=0.004, respectively) and in those with MS (log-rank p=0.007 and p=0.002, respectively). In patients with CAD, the concomitant presence of MS was associated with a tendency for higher all-cause mortality (log-rank p=0.382) and more composite outcomes (log-rank p=0.365) (<a class="elsevierStyleCrossRefs" href="#fig0005">Figures 1 and 4</a>). There was also a higher incidence of ACS, although without reaching statistical significance (log-rank p=0.094) but with a clear tendency for more events. The groups with MS had fewer admissions for heart failure. The incidence of cancer was similar in the presence or absence of MS.<elsevierMultimedia ident="tbl0010"></elsevierMultimedia><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia><elsevierMultimedia ident="fig0015"></elsevierMultimedia><elsevierMultimedia ident="fig0020"></elsevierMultimedia>In multivariate analysis, only CAD was an independent predictor of cardiovascular admission and composite outcomes, but it did not predict mortality (<a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a>). MS was not an independent predictor of any of the events considered. Age was an independent predictor of all-cause death (HR 1.1, p<0.001), cardiovascular death (HR 1.13, p=0.002), cardiovascular readmission (HR 1.05, p=0.020) and composite outcomes (HR 1.07, p<0.001). Diabetes was an independent predictor of all-cause death (HR 3.11, p=0.004) and composite outcomes (HR 1.97, p=0.012).<elsevierMultimedia ident="tbl0015"></elsevierMultimedia>DiscussionThe association between MS and cardiovascular events has been demonstrated in meta-analyses, mostly including patients in primary prevention.<a class="elsevierStyleCrossRefs" href="#bib0170">4–7</a> This association remains even after adjustment for other risk factors, proving that the increased risk is real and of epidemiological importance. The presence of MS doubles the risk of CVD, cardiovascular mortality, myocardial infarction and stroke, and increases overall mortality by 50%.<a class="elsevierStyleCrossRef" href="#bib0180">6</a> The risk for cardiovascular events in MS is thus greater than for overall mortality. Even in the absence of diabetes, MS is associated with a higher risk of cardiovascular mortality, myocardial infarction and stroke, although not significantly higher for overall mortality.<a class="elsevierStyleCrossRef" href="#bib0180">6</a>In the VALSIM study, MS was independently associated with CAD (defined as angina and/or history of myocardial infarction) and even more strongly with diabetes, which confirms its importance in the epidemiology of CVD in Portugal.<a class="elsevierStyleCrossRef" href="#bib0190">8</a> Hypertension was the MS component most strongly associated with the occurrence of CVD, although high blood glucose was also an important factor.Studies on MS in secondary prevention have shown conflicting results, some demonstrating an association with the occurrence of events and others no effect, but the follow-up in most of these studies was no longer than 36 months.<a class="elsevierStyleCrossRefs" href="#bib0195">9,10</a>An intracoronary ultrasound study showed that in subjects with MS there is a high prevalence of plaques with high lipid content that are more likely to become unstable, and that MS is an independent predictor of this type of plaque.<a class="elsevierStyleCrossRefs" href="#bib0235">17,18</a> However, more intensive pharmacological therapy in secondary prevention, particularly with statins, is known to reduce events by stabilizing atherosclerotic plaques.However, MS is a heterogeneous entity that varies according to the particular risk factors analyzed. In the MESYAS study in Spain, the risk of CVD varied depending on the component analyzed, with some MS components in isolation conferring different levels of risk.<a class="elsevierStyleCrossRef" href="#bib0245">19</a> The authors concluded that the risk associated with MS is fully explained by its individual components considered independently. Hypertriglyceridemia was the component that was associated with the greatest risk. By contrast, obesity as assessed by body mass index was not an independent risk factor for CVD, and even appeared to be protective. The cardiovascular overload associated with obesity thus appears to be mainly dependent on other metabolic risk factors such as hyperglycemia, atherogenic dyslipidemia and hypertension. Bearing in mind that MS consists of a cluster of at least three risk factors, there is considerable variation in levels of risk in patients with MS, depending on the diagnostic criteria used. If there is obesity, only two other risk factors are needed. However, in the absence of obesity, three other components are required, which represents much more significant cardiovascular risk. The particular combination of components may therefore influence the risk of developing CAD, especially if they include both high blood glucose and atherogenic dyslipidemia.Longitudinal studies have found a similar incidence of cardiovascular events in both metabolically benign obese individuals (those without metabolic syndrome or diabetes) and normal weight individuals, in contrast to the high cardiovascular risk of high-risk obese patients with clustering of cardiometabolic risk factors.<a class="elsevierStyleCrossRef" href="#bib0250">20</a> Analysis of data from three large studies (the Framingham Offspring Study, Atherosclerosis Risk In Communities and the Cardiovascular Health Study) showed that the presence of MS components, MS itself or diabetes is associated with a 2-5-fold increase in the risk of coronary events or stroke in a mean follow-up of eight years, even after adjusting for abdominal obesity,<a class="elsevierStyleCrossRef" href="#bib0255">21</a> suggesting that metabolic abnormalities are a considerably stronger predictor of cardiovascular events than abdominal obesity.In a study by Anderson et al. in patients with established CAD, high blood glucose, but not the presence of MS itself or of the other components of MS, predicted death or myocardial infarction in follow-up.<a class="elsevierStyleCrossRef" href="#bib0260">22</a> Other authors, by contrast, showed that when there is CAD, MS affects mortality and coronary events in the medium and long term.<a class="elsevierStyleCrossRefs" href="#bib0265">23,24</a> However, the latter studies were performed on non-contemporary populations (in the 1980s and 1990s), with different therapeutic approaches from those currently used and on ethnically different populations (mostly Japanese), and also used older definitions of MS. More recent studies reveal that the controversy over the influence of MS on the occurrence of events continues.<a class="elsevierStyleCrossRefs" href="#bib0195">9,10</a>In the present study, in which the treatment of CAD reflects contemporary methods, we demonstrated that MS in patients with CAD does not affect cardiovascular mortality or cardiovascular readmission. However, clear trends are apparent toward higher frequency of the composite outcomes and ACS in follow-up and fewer heart failure admissions. Age and the presence of diabetes are the predictive factors with the greatest impact.The findings on heart failure were somewhat surprising, but the literature reveals similar examples, particularly in the response to cardiac resynchronization therapy, which is better in individuals with MS.<a class="elsevierStyleCrossRefs" href="#bib0275">25–28</a> Firstly, the proportion of women in the groups with MS was greater, and previous studies report that the negative impact of MS on the survival of heart failure patients is seen mainly in men and is not observed in women.<a class="elsevierStyleCrossRef" href="#bib0290">28</a> Secondly, the effect on survival in heart failure is largely due to the presence of diabetes and hypertension and therefore depends on the particular cluster of risk factors found in the individual patient, which varies considerably, as pointed out above.<a class="elsevierStyleCrossRef" href="#bib0290">28</a> Finally, in subjects with heart failure and obesity and/or MS, it is not clear which mechanisms are at play.<a class="elsevierStyleCrossRef" href="#bib0290">28</a> Some authors suggest that the balance between anabolic and catabolic burden is altered in these patients, leading to better prognosis.<a class="elsevierStyleCrossRef" href="#bib0290">28</a> The presence of a condition that counterbalances the effects of inflammation and protein malnutrition, like overweight or moderate obesity, may be beneficial in patients with heart failure. However, the inverse association between obesity or MS and prognosis in HF described by other authors, and also seen in our study, may be the result of bias, since obese patients and/or MS patients represent a selected subgroup of heart failure patients in whom the confounding risk factors associated with worse prognosis may be less represented. In addition, the fact that these patients report symptoms and signs resulting from obesity may lead to earlier cardiac assessment and hence earlier identification of heart failure, followed by more aggressive and timely treatment, and hence better prognosis.<a class="elsevierStyleCrossRef" href="#bib0290">28</a>An important issue is that of the definition of MS, which has varied over the years, not only hampering comparisons between studies, but also with significant implications for estimates of the prevalence of the entity.<a class="elsevierStyleCrossRef" href="#bib0295">29</a> However, the risk of cardiovascular events is similar for all the different definitions, irrespective of the criteria used.<a class="elsevierStyleCrossRef" href="#bib0295">29</a> In 2009, the main medical societies involved in research into MS jointly published the harmonized definition which was used in this study.<a class="elsevierStyleCrossRef" href="#bib0230">16</a>It should also be noted that in our study only 41.6% of the sample had angiographically significant CAD. This finding is in agreement with data from other countries, such as a study based on the US National Cardiovascular Data Registry CathPCI Registry, which includes a large and representative sample of patients without previously known cardiac disease undergoing elective coronary angiography, in which this figure is even lower than in our sample.<a class="elsevierStyleCrossRef" href="#bib0300">30</a> In this study, only 37.6% of those who underwent coronary angiography presented obstructive coronary disease, defined as ≥50% stenosis of the left main coronary artery or ≥70% stenosis of a major epicardial vessel. These results demonstrate the limitations of clinical assessment in general as well as of non-invasive ischemia testing in particular.Finally, it is noteworthy that there was no apparent association with cancer in MS patients in long-term follow-up, unlike reports in previous studies.LimitationsA major limitation of the study is that the sample size is relatively small for the follow-up period and the number of events observed was also small, so the study lacked the statistical power to confirm the trends seen in the results presented. This also means that the influence of each MS component on the occurrence of cardiovascular events could not be analyzed in more detail. However, the data presented open the way for more extensive studies.ConclusionsIn long-term follow-up, the presence of CAD had a strong impact on the occurrence of events, but the presence of MS did not, which calls into question the impact of obesity and of MS in secondary prevention. However, further studies are required on larger populations, with longer follow-up and a larger number of events, in order to obtain more solid conclusions.Conflicts of interestThe authors have no conflicts of interest to declare." "textoCompletoSecciones" => array:1 [ "secciones" => array:12 [ 0 => array:3 [ "identificador" => "xres1270534" "titulo" => "Abstract" "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" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec1175804" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres1270533" "titulo" => "Resumo" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0025" "titulo" => "Introdução" ] 1 => array:2 [ "identificador" => "abst0030" "titulo" => "Métodos" ] 2 => array:2 [ "identificador" => "abst0035" "titulo" => "Resultados" ] 3 => array:2 [ "identificador" => "abst0040" "titulo" => "Conclusões" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec1175805" "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" => "Conclusions" ] 10 => array:2 [ "identificador" => "sec0040" "titulo" => "Conflicts of interest" ] 11 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2018-01-22" "fechaAceptado" => "2018-06-24" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec1175804" "palabras" => array:4 [ 0 => "Metabolic syndrome" 1 => "Coronary artery disease" 2 => "Cardiovascular events" 3 => "Prognosis" ] ] ] "pt" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palavras-chave" "identificador" => "xpalclavsec1175805" "palabras" => array:4 [ 0 => "Síndrome metabólica" 1 => "Doença coronária" 2 => "Eventos cardiovasculares" 3 => "Prognóstico" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:3 [ "titulo" => "Abstract" "resumen" => "IntroductionObese patients are at higher cardiovascular risk in primary prevention. In secondary prevention, an obesity paradox has been reported. We analyzed a cohort of individuals from a previous cross-sectional study on the impact of metabolic syndrome (MS) on coronary artery disease (CAD), aiming to assess the occurrence of cardiovascular events in a long follow-up. MethodsWe analyzed 296 individuals in a mean follow-up of 6.9±2.2 years. Subjects were divided into four groups according to the presence of MS or CAD (defined as ≥70% coronary stenosis). ResultsThe study population had a mean age of 65±9 years at the beginning of the study; 59.5% were male, 55.7% had MS and 41.6% had CAD. During follow-up 10.1% of the population suffered all-cause death, 3.7% cardiovascular death, 14.2% cardiovascular readmission and 22.0% the composite outcome (mortality, acute coronary syndrome, coronary revascularization, stroke/transient ischemic attack or heart failure admission). There were no significant differences in any type of mortality. Patients with CAD had more readmissions and composite outcomes (log-rank p<0.001 and p=0.001, respectively), but there was no difference according to the presence of MS. Only CAD was an independent predictor of cardiovascular admission (HR 3.21, 95% CI 1.66-6.21) and composite outcomes (HR 2.41, 95% CI 1.44-4.02). ConclusionsIn patients with high cardiovascular risk or established CAD, the presence of MS is not associated with cerebral or cardiac events in long-term follow-up." "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" => "IntroduçãoOs doentes com obesidade têm um maior risco de eventos cardiovasculares em prevenção primária. Em prevenção secundária tem sido descrito um paradoxo da obesidade. Foi nosso objetivo estudar uma coorte de indivíduos analisados previamente num estudo transversal sobre a relação entre síndrome metabólica (SM) e doença coronária (DC), estudando presentemente o impacto da SM na ocorrência de eventos cardiovasculares a longo-prazo. MétodosForam analisados 296 indivíduos num seguimento médio de 6,9±2,2 anos. Os indivíduos foram divididos em quatro grupos em função da presença ou ausência de SM e de DC (estenoses coronárias ≥70%). ResultadosA população analisada tinha uma idade de 65 ± 9 anos no início do estudo, 59,5% do sexo masculino, 55,7% com SM e 41,6% com DC. No seguimento, ocorreram 10,1% de mortes por todas as causas, 3,7% mortes cardiovasculares, 14,2% reinternamentos cardiovasculares e 22,0% de eventos compostos (morte, síndrome coronária aguda, revascularização coronária, acidente vascular cerebral/isquémico transitório, admissão por insuficiência cardíaca). Não se verificaram diferenças significativas em termos de mortalidade. Ambos os grupos com DC tiveram mais reinternamentos e eventos compostos (Log-rank, p<0,001 e p=0,001, respetivamente), mas sem diferenças em relação à presença de SM. A DC foi preditora independente de reinternamento cardiovascular (HR 3,21, IC 95% 1,66–6,21) e de eventos compostos (HR 2,41, IC 95% 1,44–4,02). ConclusõesEm doentes de elevado risco cardiovascular ou com doença coronária estabelecida, a presença de SM não se associou a aumento de eventos cerebrais ou cardíacos num seguimento a longo-prazo." "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0025" "titulo" => "Introdução" ] 1 => array:2 [ "identificador" => "abst0030" "titulo" => "Métodos" ] 2 => array:2 [ "identificador" => "abst0035" "titulo" => "Resultados" ] 3 => array:2 [ "identificador" => "abst0040" "titulo" => "Conclusões" ] ] ] ] "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "Please cite this article as: Timóteo AT, Mota Carmo M, Soares C, et al. Será a síndrome metabólica um marcador de prognóstico em doentes com elevado risco cardiovascular? Um estudo de coorte a longo-prazo. Rev Port Cardiol. 2019;38:325–332." ] ] "multimedia" => array:7 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1080 "Ancho" => 1501 "Tamanyo" => 66796 ] ] "descripcion" => array:1 [ "en" => "Survival curves for all-cause mortality. CAD: coronary artery disease; MS: metabolic syndrome." ] ] 1 => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 1070 "Ancho" => 1469 "Tamanyo" => 67797 ] ] "descripcion" => array:1 [ "en" => "Survival curves for cardiovascular mortality. CAD: coronary artery disease; MS: metabolic syndrome." ] ] 2 => array:7 [ "identificador" => "fig0015" "etiqueta" => "Figure 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 1087 "Ancho" => 1429 "Tamanyo" => 68944 ] ] "descripcion" => array:1 [ "en" => "Survival curves for cardiovascular admission. CAD: coronary artery disease; MS: metabolic syndrome." ] ] 3 => array:7 [ "identificador" => "fig0020" "etiqueta" => "Figure 4" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr4.jpeg" "Alto" => 1081 "Ancho" => 1465 "Tamanyo" => 69243 ] ] "descripcion" => array:1 [ "en" => "Survival curves for composite outcomes. CAD: coronary artery disease; MS: metabolic syndrome." ] ] 4 => array:8 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at1" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:2 [ "leyenda" => "BMI: body mass index; CAD: coronary artery disease; MS: metabolic syndrome; WC: waist circumference." "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="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Without MS/without CAD (n=73) \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Without MS/with CAD (n=58) \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">With MS/without CAD (n=100) \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">With MS/with CAD (n=65) \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Total (n=296) \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">p \t\t\t\t\t\t\n \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Age, years \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">63±10 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">64±9 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">64±9 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">67±8 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">64±9 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.063 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Male, % \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">54.8 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">91.4 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">42.0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">63.1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">59.6 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><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="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">BMI (kg/m2) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">27.0±3.6 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">25.3±2.3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">30.3±4.3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">29.6±4.1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">28.1±4.0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><0.001 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " colspan="7" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"></td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " colspan="7" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Risk factors, %</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Hypertension \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">72.6 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">81.0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">92.0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">95.4 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">85.8 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><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="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Smoking \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">8.2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">19.0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2.0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">12.3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">9.1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.003 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Dyslipidemia \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">58.9 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">72.4 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">75.0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">72.3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">69.9 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.122 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Diabetes \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">11.0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">24.1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">22.0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">30.8 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">21.6 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.040 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " colspan="7" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"></td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " colspan="7" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">MS components, %</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Hypertension \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">72.6 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">81.0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">92.0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">95.4 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">85.8 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><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="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">High blood glucose \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">27.4 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">39.7 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">64.0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">81.5 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">54.1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><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="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">High triglycerides \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1.4 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">13.8 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">28.0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">43.1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">22.0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><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="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Low HDL \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">15.1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">19.0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">71.0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">78.5 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">48.6 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><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="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">High WC \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">35.6 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">10.3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">91.0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">75.4 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">58.1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><0.001 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " colspan="7" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"></td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Multivessel disease, % \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">43.1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">40.0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">7.4 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><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="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Revascularization, % \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">81.0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">70.8 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">31.8 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><0.001 \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab2173407.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Demographic and clinical characteristics of the study population." ] ] 5 => array:8 [ "identificador" => "tbl0010" "etiqueta" => "Table 2" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at2" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:3 [ "leyenda" => "ACS: acute coronary syndrome; CABG: coronary artery bypass grafting; CAD: coronary artery disease; MS: metabolic syndrome; PCI: percutaneous coronary intervention; TIA: transient ischemic attack.Comparisons among patients with CAD in the presence or absence of MS:" "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="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">(%) \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Without MS/without CAD (n=73) \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Without MS/with CAD (n=58) \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">With MS/without CAD (n=100) \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">With MS/with CAD (n=65) \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Total (n=296) \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">p \t\t\t\t\t\t\n \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">All-cause mortality<a class="elsevierStyleCrossRef" href="#tblfn0005">a</a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">8.2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">8.6 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">9.0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">15.4 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">10.1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.467 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Composite outcomes<a class="elsevierStyleCrossRef" href="#tblfn0010">b</a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">12.3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">27.6 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">16.0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">36.9 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">22.0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">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="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Cardiovascular mortality \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2.7 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">5.2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">3.0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">4.6 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">3.7 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.843 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">ACS<a class="elsevierStyleCrossRef" href="#tblfn0015">c</a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1.4 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1.7 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">3.0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">10.8 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">4.1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.019 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">PCI \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1.4 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">12.1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1.0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">13.9 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">6.1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><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="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">CABG \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">3.4 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.7 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.041 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Stroke/TIA \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2.7 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">3.0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">3.1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2.4 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.622 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Cardiovascular admission \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">6.8 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">22.4 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">9.0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">23.1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">14.2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">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="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Heart failure admission<a class="elsevierStyleCrossRef" href="#tblfn0020">d</a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">5.5 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">8.6 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2.0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">3.7 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.049 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Cancer<a class="elsevierStyleCrossRef" href="#tblfn0025">e</a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">11.0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">5.2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">14.0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">12.3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">11.1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.391 \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab2173405.png" ] ] ] "notaPie" => array:5 [ 0 => array:3 [ "identificador" => "tblfn0005" "etiqueta" => "a" "nota" => "p=0.382." ] 1 => array:3 [ "identificador" => "tblfn0010" "etiqueta" => "b" "nota" => "p=0.365." ] 2 => array:3 [ "identificador" => "tblfn0015" "etiqueta" => "c" "nota" => "p=0.094." ] 3 => array:3 [ "identificador" => "tblfn0020" "etiqueta" => "d" "nota" => "p=0.050." ] 4 => array:3 [ "identificador" => "tblfn0025" "etiqueta" => "e" "nota" => "p=0.289." ] ] ] "descripcion" => array:1 [ "en" => "Events in follow-up." ] ] 6 => array:8 [ "identificador" => "tbl0015" "etiqueta" => "Table 3" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at3" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:2 [ "leyenda" => "Adjusted for age, diabetes, coronary artery disease, and metabolic syndrome.CAD: coronary artery disease; CI: confidence interval; HR: hazard ratio; MS: metabolic syndrome" "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="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">HR \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">95%CI \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">p \t\t\t\t\t\t\n \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " colspan="4" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">All-cause mortality</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">MS \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1.19 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.56-2.52 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.652 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">CAD \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1.17 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.54-2.42 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.672 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " colspan="4" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"></td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " colspan="4" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Cardiovascular mortality</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">MS \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.81 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.25-2.67 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.730 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">CAD \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1.45 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.44-4.79 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.545 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " colspan="4" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"></td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " colspan="4" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Cardiovascular admission</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">MS \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.93 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.50-1.73 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.818 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">CAD \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">3.21 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1.66-6.21 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.001 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " colspan="4" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"></td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " colspan="4" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Composite outcomes</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">MS \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1.03 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.61-1.74 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.901 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">CAD \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2.41 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1.44-4.02 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.001 \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab2173406.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Cox multivariate analysis of the predictive effect of metabolic syndrome and/or coronary artery disease for the occurrence of events." ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0015" "bibliografiaReferencia" => array:30 [ 0 => array:3 [ "identificador" => "bib0155" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Cardiovascular diseases in Europe: epidemiological update 2016" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:3 [ 0 => "N. 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Is metabolic syndrome a prognostic marker in patients at high cardiovascular risk? A long-term cohort study

Será a síndrome metabólica um marcador de prognóstico em doentes com elevado risco cardiovascular? Um estudo de coorte a longo-prazo

Ana Teresa Timóteoa,b,

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ana_timoteo@yahoo.com

Corresponding author.

, Miguel Mota Carmob, Cristina Soaresa, Rui Cruz Ferreiraa

a Serviço de Cardiologia, Hospital de Santa Marta, Centro Hospitalar Universitário Lisboa Central, Lisboa, Portugal

b Centro de Estudos de Doenças Crónicas (CEDOC), NOVA Medical School, Lisboa, Portugal

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        "titulo" => "Ser&#225; a s&#237;ndrome metab&#243;lica um marcador de progn&#243;stico em doentes com elevado risco cardiovascular&#63; Um estudo de coorte a longo-prazo"
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          "en" => "<p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">Survival curves for cardiovascular mortality&#46; CAD&#58; coronary artery disease&#59; MS&#58; metabolic syndrome&#46;</p>"
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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">Cardiovascular disease &#40;CVD&#41; is still the leading cause of death in Europe in the general population&#44; including Portugal&#44; although its prevalence has fallen in recent decades&#46;<a class="elsevierStyleCrossRefs" href="#bib0155"><span class="elsevierStyleSup">1&#8211;3</span></a> By 2015&#44; cancer had overtaken circulatory system diseases as the leading cause of death in men&#46;<a class="elsevierStyleCrossRef" href="#bib0165"><span class="elsevierStyleSup">3</span></a> Besides the well-established cardiovascular risk factors such as hypertension&#44; smoking&#44; diabetes&#44; high low-density lipoprotein cholesterol&#44; age and family history&#44; a number of other risk factors have come under scrutiny in recent years&#46; In particular&#44; the cluster of risk factors known as metabolic syndrome &#40;MS&#41;&#44; which has a high prevalence worldwide&#44; reaching almost epidemic proportions&#44; is now a major problem&#44; due to its demonstrated association with the development of type 2 diabetes and CVD&#44; risk for which it increases up to two-fold&#46; MS is particularly challenging to treat because profound changes in lifestyle&#44; which are often difficult to implement in the general population&#44; are needed&#46;<a class="elsevierStyleCrossRefs" href="#bib0170"><span class="elsevierStyleSup">4&#8211;6</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">Several meta-analyses have demonstrated a clear association in primary prevention between MS and the occurrence of cardiovascular events during follow-up&#46;<a class="elsevierStyleCrossRefs" href="#bib0170"><span class="elsevierStyleSup">4&#8211;7</span></a> This was also seen in the VALSIM study carried out in a Portuguese population&#46;<a class="elsevierStyleCrossRef" href="#bib0190"><span class="elsevierStyleSup">8</span></a> In secondary prevention the results are conflicting&#44; with some studies showing no effect and others a higher incidence of cardiovascular events&#44; but with less than three years of follow-up&#46;<a class="elsevierStyleCrossRefs" href="#bib0195"><span class="elsevierStyleSup">9&#44;10</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">In previous studies we demonstrated that MS by itself is not associated with subclinical atherosclerosis &#40;as assessed by common carotid intima-media thickness&#41;&#44; but that the latter is directly associated with some of the components of the syndrome&#44; particularly hyperinsulinemia&#44; hyperglycemia and low high-density lipoprotein &#40;HDL&#41; cholesterol&#44; an indication of the heterogeneous effects of the various components of the entity known as MS&#46;<a class="elsevierStyleCrossRefs" href="#bib0205"><span class="elsevierStyleSup">11&#8211;13</span></a> Similarly&#44; no direct relationship was observed with angiographically significant stable coronary artery disease &#40;CAD&#41;&#44; although hyperglycemia and hypertriglyceridemia did predict CAD&#46;<a class="elsevierStyleCrossRef" href="#bib0220"><span class="elsevierStyleSup">14</span></a> In both studies&#44; greater waist circumference paradoxically showed a protective effect&#46;<a class="elsevierStyleCrossRefs" href="#bib0210"><span class="elsevierStyleSup">12&#44;14</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">These earlier papers were based on a cross-sectional and observational study&#46; More than five years after that analysis&#44; the aim of the present study was to analyze the same group of patients and to determine in long-term follow-up &#40;over five years&#41; whether MS is associated with higher mortality or a higher incidence of cerebrovascular or cardiovascular events&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Methods</span><p id="par0025" class="elsevierStylePara elsevierViewall">The original study included adults &#40;age &#8805;18 years&#41; admitted electively for coronary angiography between 2008 and 2010 with suspected CAD &#40;angina and&#47;or ischemia documented by non-invasive tests&#41;&#46; Patients with a history of acute coronary syndrome &#40;ACS&#41;&#44; previous myocardial revascularization or known CAD&#44; significant valve disease&#44; congenital heart disease or other cardiomyopathy were excluded&#46; In the original study&#44; the American Heart Association&#47;National Heart&#44; Lung&#44; and Blood Institute&#39;s definition of MS was used&#46;<a class="elsevierStyleCrossRef" href="#bib0225"><span class="elsevierStyleSup">15</span></a> However&#44; the definition of the syndrome has since been unified by several major medical societies&#44; the main difference being that each country or region can define the limits of abdominal obesity in view of differences between ethnic groups&#46;<a class="elsevierStyleCrossRef" href="#bib0230"><span class="elsevierStyleSup">16</span></a> We therefore used the new definition&#44; while retaining the previously defined limits for waist circumference &#40;&#8805;88 cm for women and &#8805;102 cm for men&#41;&#46; The other criteria are blood pressure &#8805;130&#47;85 mmHg &#40;or under drug treatment&#41;&#44; HDL cholesterol &#8804;40 mg&#47;dl in men or &#8804;50 mg&#47;dl in women &#40;or under drug treatment&#41;&#44; triglycerides &#8805;150 mg&#47;dl &#40;or under specific treatment&#41;&#44; and blood glucose &#8805;100 mg&#47;dl &#40;or under drug treatment&#41;&#46;<a class="elsevierStyleCrossRefs" href="#bib0225"><span class="elsevierStyleSup">15&#44;16</span></a> MS is defined by the presence of at least three of these criteria&#46; Angiographically significant CAD was defined as the presence of &#8805;70&#37; stenosis in any coronary vessel&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">Follow-up information on all patients was obtained by telephone interview with patients or family members 30 days and one year after admission by a specialist team responsible for follow-up data of patients hospitalized in the department&#46; The same cohort was contacted again in 2017 to obtain additional follow-up information&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">The following events were analyzed in follow-up&#58; all-cause mortality &#40;defined as death from any cause&#41;&#59; cardiovascular mortality &#40;defined as death associated with CVD&#41;&#59; and ACS &#40;defined as the occurrence of angina or angina equivalent at rest with electrocardiographic changes and&#47;or rise or fall in myocardial necrosis markers&#41;&#46; When percutaneous coronary intervention &#40;PCI&#41; or coronary artery bypass grafting was performed during follow-up unrelated to the reason for initial admission&#44; myocardial revascularization was included&#46; Admission for heart failure was defined as hospitalization due to the onset or worsening of symptoms or signs of heart failure&#46; Readmission was defined as cardiovascular if the patient had previously been admitted for cardiovascular symptoms&#44; acutely or electively&#46; Stroke&#47;transient ischemic attack &#40;TIA&#41; was defined as the occurrence of new-onset neurological deficit&#46; A composite of cardiac and cerebrovascular events &#40;all-cause mortality&#44; ACS&#44; myocardial revascularization&#44; stroke&#47;TIA or heart failure admission&#41; was also analyzed&#46; The medical records of patients with events was analyzed in order to confirm the event and to classify it correctly&#44; and if necessary further information was requested from the patient&#46; These events were compared among patients with and without CAD and in those with and without MS&#46; The study population was thus divided into four groups&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">All subjects provided their written informed consent to take part in the study&#44; which is in accordance with the Declaration of Helsinki&#46;</p><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Statistical analysis</span><p id="par0045" class="elsevierStylePara elsevierViewall">Continuous variables are reported as mean and standard deviation&#46; Normality was tested using the Kolmogorov-Smirnov test&#46; Continuous variables were compared using analysis of variance&#46; Categorical variables are expressed as percentages and were compared with the chi-square test or Fisher&#39;s test&#44; as appropriate&#46;</p><p id="par0050" class="elsevierStylePara elsevierViewall">Estimates of event-free survival in follow-up were calculated by the Kaplan-Meier method and the curves were compared using the log-rank test&#46; Cox proportional hazards analysis was used to determine the influence of MS and of angiographically significant CAD on the long-term occurrence of events and was adjusted for variables with significant impact on prognosis&#46; Estimates of the association between predictors and events are presented as hazard ratios &#40;HR&#41; with 95&#37; confidence intervals&#46;</p><p id="par0055" class="elsevierStylePara elsevierViewall">IBM SPSS version 19&#46;0&#46;0&#46;2 was used for the statistical analysis&#46; A p-value &#60;0&#46;05 was considered statistically significant&#46;</p></span></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Results</span><p id="par0060" class="elsevierStylePara elsevierViewall">The initial study included 300 patients&#44; four of whom were lost during follow-up&#46; Of the 296 patients included in this analysis&#44; 59&#37; were male&#44; mean age 65&#177;9 years &#40;38-86 years&#41;&#46; The prevalence of MS was 55&#46;7&#37; and the most common component of MS was hypertension&#44; followed by abdominal obesity&#44; high blood glucose&#44; low HDL cholesterol and high triglycerides &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#41;&#46; Angiographically significant CAD was detected in only 41&#46;6&#37; of subjects&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0065" class="elsevierStylePara elsevierViewall">In a mean follow-up of 6&#46;9&#177;2&#46;2 years&#44; 10&#46;1&#37; of the population suffered all-cause death&#44; 3&#46;7&#37; cardiovascular death&#44; 14&#46;2&#37; cardiovascular readmission and 22&#46;0&#37; composite outcomes &#40;<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>&#41;&#46; There were no statistically significant differences between any of the four groups in terms of all-cause or cardiovascular mortality &#40;<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>&#59; <a class="elsevierStyleCrossRefs" href="#fig0005">Figures 1 and 2</a>&#41;&#46; However&#44; cardiovascular readmissions and composite outcomes were more frequent in the CAD groups &#40;<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>&#59; <a class="elsevierStyleCrossRefs" href="#fig0015">Figures 3 and 4</a>&#41;&#46; This difference was largely due to a higher incidence of ACS in the group with MS and CAD &#40;<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>&#41;&#46; Both CAD groups presented more frequent PCI and cardiovascular readmission &#40;<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>&#41;&#44; and CAD was associated with more events&#46; Cardiovascular readmissions and composite outcomes were significantly more frequent in patients with CAD both in subjects without MS &#40;log-rank p&#61;0&#46;001 and p&#61;0&#46;004&#44; respectively&#41; and in those with MS &#40;log-rank p&#61;0&#46;007 and p&#61;0&#46;002&#44; respectively&#41;&#46; In patients with CAD&#44; the concomitant presence of MS was associated with a tendency for higher all-cause mortality &#40;log-rank p&#61;0&#46;382&#41; and more composite outcomes &#40;log-rank p&#61;0&#46;365&#41; &#40;<a class="elsevierStyleCrossRefs" href="#fig0005">Figures 1 and 4</a>&#41;&#46; There was also a higher incidence of ACS&#44; although without reaching statistical significance &#40;log-rank p&#61;0&#46;094&#41; but with a clear tendency for more events&#46; The groups with MS had fewer admissions for heart failure&#46; The incidence of cancer was similar in the presence or absence of MS&#46;</p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia><elsevierMultimedia ident="fig0015"></elsevierMultimedia><elsevierMultimedia ident="fig0020"></elsevierMultimedia><p id="par0070" class="elsevierStylePara elsevierViewall">In multivariate analysis&#44; only CAD was an independent predictor of cardiovascular admission and composite outcomes&#44; but it did not predict mortality &#40;<a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a>&#41;&#46; MS was not an independent predictor of any of the events considered&#46; Age was an independent predictor of all-cause death &#40;HR 1&#46;1&#44; p&#60;0&#46;001&#41;&#44; cardiovascular death &#40;HR 1&#46;13&#44; p&#61;0&#46;002&#41;&#44; cardiovascular readmission &#40;HR 1&#46;05&#44; p&#61;0&#46;020&#41; and composite outcomes &#40;HR 1&#46;07&#44; p&#60;0&#46;001&#41;&#46; Diabetes was an independent predictor of all-cause death &#40;HR 3&#46;11&#44; p&#61;0&#46;004&#41; and composite outcomes &#40;HR 1&#46;97&#44; p&#61;0&#46;012&#41;&#46;</p><elsevierMultimedia ident="tbl0015"></elsevierMultimedia></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Discussion</span><p id="par0075" class="elsevierStylePara elsevierViewall">The association between MS and cardiovascular events has been demonstrated in meta-analyses&#44; mostly including patients in primary prevention&#46;<a class="elsevierStyleCrossRefs" href="#bib0170"><span class="elsevierStyleSup">4&#8211;7</span></a> This association remains even after adjustment for other risk factors&#44; proving that the increased risk is real and of epidemiological importance&#46; The presence of MS doubles the risk of CVD&#44; cardiovascular mortality&#44; myocardial infarction and stroke&#44; and increases overall mortality by 50&#37;&#46;<a class="elsevierStyleCrossRef" href="#bib0180"><span class="elsevierStyleSup">6</span></a> The risk for cardiovascular events in MS is thus greater than for overall mortality&#46; Even in the absence of diabetes&#44; MS is associated with a higher risk of cardiovascular mortality&#44; myocardial infarction and stroke&#44; although not significantly higher for overall mortality&#46;<a class="elsevierStyleCrossRef" href="#bib0180"><span class="elsevierStyleSup">6</span></a></p><p id="par0080" class="elsevierStylePara elsevierViewall">In the VALSIM study&#44; MS was independently associated with CAD &#40;defined as angina and&#47;or history of myocardial infarction&#41; and even more strongly with diabetes&#44; which confirms its importance in the epidemiology of CVD in Portugal&#46;<a class="elsevierStyleCrossRef" href="#bib0190"><span class="elsevierStyleSup">8</span></a> Hypertension was the MS component most strongly associated with the occurrence of CVD&#44; although high blood glucose was also an important factor&#46;</p><p id="par0085" class="elsevierStylePara elsevierViewall">Studies on MS in secondary prevention have shown conflicting results&#44; some demonstrating an association with the occurrence of events and others no effect&#44; but the follow-up in most of these studies was no longer than 36 months&#46;<a class="elsevierStyleCrossRefs" href="#bib0195"><span class="elsevierStyleSup">9&#44;10</span></a></p><p id="par0090" class="elsevierStylePara elsevierViewall">An intracoronary ultrasound study showed that in subjects with MS there is a high prevalence of plaques with high lipid content that are more likely to become unstable&#44; and that MS is an independent predictor of this type of plaque&#46;<a class="elsevierStyleCrossRefs" href="#bib0235"><span class="elsevierStyleSup">17&#44;18</span></a> However&#44; more intensive pharmacological therapy in secondary prevention&#44; particularly with statins&#44; is known to reduce events by stabilizing atherosclerotic plaques&#46;</p><p id="par0095" class="elsevierStylePara elsevierViewall">However&#44; MS is a heterogeneous entity that varies according to the particular risk factors analyzed&#46; In the MESYAS study in Spain&#44; the risk of CVD varied depending on the component analyzed&#44; with some MS components in isolation conferring different levels of risk&#46;<a class="elsevierStyleCrossRef" href="#bib0245"><span class="elsevierStyleSup">19</span></a> The authors concluded that the risk associated with MS is fully explained by its individual components considered independently&#46; Hypertriglyceridemia was the component that was associated with the greatest risk&#46; By contrast&#44; obesity as assessed by body mass index was not an independent risk factor for CVD&#44; and even appeared to be protective&#46; The cardiovascular overload associated with obesity thus appears to be mainly dependent on other metabolic risk factors such as hyperglycemia&#44; atherogenic dyslipidemia and hypertension&#46; Bearing in mind that MS consists of a cluster of at least three risk factors&#44; there is considerable variation in levels of risk in patients with MS&#44; depending on the diagnostic criteria used&#46; If there is obesity&#44; only two other risk factors are needed&#46; However&#44; in the absence of obesity&#44; three other components are required&#44; which represents much more significant cardiovascular risk&#46; The particular combination of components may therefore influence the risk of developing CAD&#44; especially if they include both high blood glucose and atherogenic dyslipidemia&#46;</p><p id="par0100" class="elsevierStylePara elsevierViewall">Longitudinal studies have found a similar incidence of cardiovascular events in both metabolically benign obese individuals &#40;those without metabolic syndrome or diabetes&#41; and normal weight individuals&#44; in contrast to the high cardiovascular risk of high-risk obese patients with clustering of cardiometabolic risk factors&#46;<a class="elsevierStyleCrossRef" href="#bib0250"><span class="elsevierStyleSup">20</span></a> Analysis of data from three large studies &#40;the Framingham Offspring Study&#44; Atherosclerosis Risk In Communities and the Cardiovascular Health Study&#41; showed that the presence of MS components&#44; MS itself or diabetes is associated with a 2-5-fold increase in the risk of coronary events or stroke in a mean follow-up of eight years&#44; even after adjusting for abdominal obesity&#44;<a class="elsevierStyleCrossRef" href="#bib0255"><span class="elsevierStyleSup">21</span></a> suggesting that metabolic abnormalities are a considerably stronger predictor of cardiovascular events than abdominal obesity&#46;</p><p id="par0105" class="elsevierStylePara elsevierViewall">In a study by Anderson et al&#46; in patients with established CAD&#44; high blood glucose&#44; but not the presence of MS itself or of the other components of MS&#44; predicted death or myocardial infarction in follow-up&#46;<a class="elsevierStyleCrossRef" href="#bib0260"><span class="elsevierStyleSup">22</span></a> Other authors&#44; by contrast&#44; showed that when there is CAD&#44; MS affects mortality and coronary events in the medium and long term&#46;<a class="elsevierStyleCrossRefs" href="#bib0265"><span class="elsevierStyleSup">23&#44;24</span></a> However&#44; the latter studies were performed on non-contemporary populations &#40;in the 1980s and 1990s&#41;&#44; with different therapeutic approaches from those currently used and on ethnically different populations &#40;mostly Japanese&#41;&#44; and also used older definitions of MS&#46; More recent studies reveal that the controversy over the influence of MS on the occurrence of events continues&#46;<a class="elsevierStyleCrossRefs" href="#bib0195"><span class="elsevierStyleSup">9&#44;10</span></a></p><p id="par0110" class="elsevierStylePara elsevierViewall">In the present study&#44; in which the treatment of CAD reflects contemporary methods&#44; we demonstrated that MS in patients with CAD does not affect cardiovascular mortality or cardiovascular readmission&#46; However&#44; clear trends are apparent toward higher frequency of the composite outcomes and ACS in follow-up and fewer heart failure admissions&#46; Age and the presence of diabetes are the predictive factors with the greatest impact&#46;</p><p id="par0115" class="elsevierStylePara elsevierViewall">The findings on heart failure were somewhat surprising&#44; but the literature reveals similar examples&#44; particularly in the response to cardiac resynchronization therapy&#44; which is better in individuals with MS&#46;<a class="elsevierStyleCrossRefs" href="#bib0275"><span class="elsevierStyleSup">25&#8211;28</span></a> Firstly&#44; the proportion of women in the groups with MS was greater&#44; and previous studies report that the negative impact of MS on the survival of heart failure patients is seen mainly in men and is not observed in women&#46;<a class="elsevierStyleCrossRef" href="#bib0290"><span class="elsevierStyleSup">28</span></a> Secondly&#44; the effect on survival in heart failure is largely due to the presence of diabetes and hypertension and therefore depends on the particular cluster of risk factors found in the individual patient&#44; which varies considerably&#44; as pointed out above&#46;<a class="elsevierStyleCrossRef" href="#bib0290"><span class="elsevierStyleSup">28</span></a> Finally&#44; in subjects with heart failure and obesity and&#47;or MS&#44; it is not clear which mechanisms are at play&#46;<a class="elsevierStyleCrossRef" href="#bib0290"><span class="elsevierStyleSup">28</span></a> Some authors suggest that the balance between anabolic and catabolic burden is altered in these patients&#44; leading to better prognosis&#46;<a class="elsevierStyleCrossRef" href="#bib0290"><span class="elsevierStyleSup">28</span></a> The presence of a condition that counterbalances the effects of inflammation and protein malnutrition&#44; like overweight or moderate obesity&#44; may be beneficial in patients with heart failure&#46; However&#44; the inverse association between obesity or MS and prognosis in HF described by other authors&#44; and also seen in our study&#44; may be the result of bias&#44; since obese patients and&#47;or MS patients represent a selected subgroup of heart failure patients in whom the confounding risk factors associated with worse prognosis may be less represented&#46; In addition&#44; the fact that these patients report symptoms and signs resulting from obesity may lead to earlier cardiac assessment and hence earlier identification of heart failure&#44; followed by more aggressive and timely treatment&#44; and hence better prognosis&#46;<a class="elsevierStyleCrossRef" href="#bib0290"><span class="elsevierStyleSup">28</span></a></p><p id="par0120" class="elsevierStylePara elsevierViewall">An important issue is that of the definition of MS&#44; which has varied over the years&#44; not only hampering comparisons between studies&#44; but also with significant implications for estimates of the prevalence of the entity&#46;<a class="elsevierStyleCrossRef" href="#bib0295"><span class="elsevierStyleSup">29</span></a> However&#44; the risk of cardiovascular events is similar for all the different definitions&#44; irrespective of the criteria used&#46;<a class="elsevierStyleCrossRef" href="#bib0295"><span class="elsevierStyleSup">29</span></a> In 2009&#44; the main medical societies involved in research into MS jointly published the harmonized definition which was used in this study&#46;<a class="elsevierStyleCrossRef" href="#bib0230"><span class="elsevierStyleSup">16</span></a></p><p id="par0125" class="elsevierStylePara elsevierViewall">It should also be noted that in our study only 41&#46;6&#37; of the sample had angiographically significant CAD&#46; This finding is in agreement with data from other countries&#44; such as a study based on the US National Cardiovascular Data Registry CathPCI Registry&#44; which includes a large and representative sample of patients without previously known cardiac disease undergoing elective coronary angiography&#44; in which this figure is even lower than in our sample&#46;<a class="elsevierStyleCrossRef" href="#bib0300"><span class="elsevierStyleSup">30</span></a> In this study&#44; only 37&#46;6&#37; of those who underwent coronary angiography presented obstructive coronary disease&#44; defined as &#8805;50&#37; stenosis of the left main coronary artery or &#8805;70&#37; stenosis of a major epicardial vessel&#46; These results demonstrate the limitations of clinical assessment in general as well as of non-invasive ischemia testing in particular&#46;</p><p id="par0130" class="elsevierStylePara elsevierViewall">Finally&#44; it is noteworthy that there was no apparent association with cancer in MS patients in long-term follow-up&#44; unlike reports in previous studies&#46;</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Limitations</span><p id="par0135" class="elsevierStylePara elsevierViewall">A major limitation of the study is that the sample size is relatively small for the follow-up period and the number of events observed was also small&#44; so the study lacked the statistical power to confirm the trends seen in the results presented&#46; This also means that the influence of each MS component on the occurrence of cardiovascular events could not be analyzed in more detail&#46; However&#44; the data presented open the way for more extensive studies&#46;</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Conclusions</span><p id="par0140" class="elsevierStylePara elsevierViewall">In long-term follow-up&#44; the presence of CAD had a strong impact on the occurrence of events&#44; but the presence of MS did not&#44; which calls into question the impact of obesity and of MS in secondary prevention&#46; However&#44; further studies are required on larger populations&#44; with longer follow-up and a larger number of events&#44; in order to obtain more solid conclusions&#46;</p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">Conflicts of interest</span><p id="par0145" class="elsevierStylePara elsevierViewall">The authors have no conflicts of interest to declare&#46;</p></span></span>"
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          "titulo" => "Introduction"
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            0 => array:2 [
              "identificador" => "sec0015"
              "titulo" => "Statistical analysis"
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          "titulo" => "Results"
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          "titulo" => "Limitations"
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          "titulo" => "Conclusions"
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          "identificador" => "sec0040"
          "titulo" => "Conflicts of interest"
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        11 => array:1 [
          "titulo" => "References"
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    ]
    "pdfFichero" => "main.pdf"
    "tienePdf" => true
    "fechaRecibido" => "2018-01-22"
    "fechaAceptado" => "2018-06-24"
    "PalabrasClave" => array:2 [
      "en" => array:1 [
        0 => array:4 [
          "clase" => "keyword"
          "titulo" => "Keywords"
          "identificador" => "xpalclavsec1175804"
          "palabras" => array:4 [
            0 => "Metabolic syndrome"
            1 => "Coronary artery disease"
            2 => "Cardiovascular events"
            3 => "Prognosis"
          ]
        ]
      ]
      "pt" => array:1 [
        0 => array:4 [
          "clase" => "keyword"
          "titulo" => "Palavras-chave"
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          "palabras" => array:4 [
            0 => "S&#237;ndrome metab&#243;lica"
            1 => "Doen&#231;a coron&#225;ria"
            2 => "Eventos cardiovasculares"
            3 => "Progn&#243;stico"
          ]
        ]
      ]
    ]
    "tieneResumen" => true
    "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">Obese patients are at higher cardiovascular risk in primary prevention&#46; In secondary prevention&#44; an obesity paradox has been reported&#46; We analyzed a cohort of individuals from a previous cross-sectional study on the impact of metabolic syndrome &#40;MS&#41; on coronary artery disease &#40;CAD&#41;&#44; aiming to assess the occurrence of cardiovascular events in a long follow-up&#46;</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Methods</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">We analyzed 296 individuals in a mean follow-up of 6&#46;9&#177;2&#46;2 years&#46; Subjects were divided into four groups according to the presence of MS or CAD &#40;defined as &#8805;70&#37; coronary stenosis&#41;&#46;</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Results</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">The study population had a mean age of 65&#177;9 years at the beginning of the study&#59; 59&#46;5&#37; were male&#44; 55&#46;7&#37; had MS and 41&#46;6&#37; had CAD&#46; During follow-up 10&#46;1&#37; of the population suffered all-cause death&#44; 3&#46;7&#37; cardiovascular death&#44; 14&#46;2&#37; cardiovascular readmission and 22&#46;0&#37; the composite outcome &#40;mortality&#44; acute coronary syndrome&#44; coronary revascularization&#44; stroke&#47;transient ischemic attack or heart failure admission&#41;&#46; There were no significant differences in any type of mortality&#46; Patients with CAD had more readmissions and composite outcomes &#40;log-rank p&#60;0&#46;001 and p&#61;0&#46;001&#44; respectively&#41;&#44; but there was no difference according to the presence of MS&#46; Only CAD was an independent predictor of cardiovascular admission &#40;HR 3&#46;21&#44; 95&#37; CI 1&#46;66-6&#46;21&#41; and composite outcomes &#40;HR 2&#46;41&#44; 95&#37; CI 1&#46;44-4&#46;02&#41;&#46;</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Conclusions</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">In patients with high cardiovascular risk or established CAD&#44; the presence of MS is not associated with cerebral or cardiac events in long-term follow-up&#46;</p></span>"
        "secciones" => array:4 [
          0 => array:2 [
            "identificador" => "abst0005"
            "titulo" => "Introduction"
          ]
          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">Os doentes com obesidade t&#234;m um maior risco de eventos cardiovasculares em preven&#231;&#227;o prim&#225;ria&#46; Em preven&#231;&#227;o secund&#225;ria tem sido descrito um paradoxo da obesidade&#46; Foi nosso objetivo estudar uma coorte de indiv&#237;duos analisados previamente num estudo transversal sobre a rela&#231;&#227;o entre s&#237;ndrome metab&#243;lica &#40;SM&#41; e doen&#231;a coron&#225;ria &#40;DC&#41;&#44; estudando presentemente o impacto da SM na ocorr&#234;ncia de eventos cardiovasculares a longo-prazo&#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 analisados 296 indiv&#237;duos num seguimento m&#233;dio de 6&#44;9&#177;2&#44;2 anos&#46; Os indiv&#237;duos foram divididos em quatro grupos em fun&#231;&#227;o da presen&#231;a ou aus&#234;ncia de SM e de DC &#40;estenoses coron&#225;rias &#8805;70&#37;&#41;&#46;</p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Resultados</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">A popula&#231;&#227;o analisada tinha uma idade de 65 &#177; 9 anos no in&#237;cio do estudo&#44; 59&#44;5&#37; do sexo masculino&#44; 55&#44;7&#37; com SM e 41&#44;6&#37; com DC&#46; No seguimento&#44; ocorreram 10&#44;1&#37; de mortes por todas as causas&#44; 3&#44;7&#37; mortes cardiovasculares&#44; 14&#44;2&#37; reinternamentos cardiovasculares e 22&#44;0&#37; de eventos compostos &#40;morte&#44; s&#237;ndrome coron&#225;ria aguda&#44; revasculariza&#231;&#227;o coron&#225;ria&#44; acidente vascular cerebral&#47;isqu&#233;mico transit&#243;rio&#44; admiss&#227;o por insufici&#234;ncia card&#237;aca&#41;&#46; N&#227;o se verificaram diferen&#231;as significativas em termos de mortalidade&#46; Ambos os grupos com DC tiveram mais reinternamentos e eventos compostos &#40;Log-<span class="elsevierStyleItalic">rank</span>&#44; p&#60;0&#44;001 e p&#61;0&#44;001&#44; respetivamente&#41;&#44; mas sem diferen&#231;as em rela&#231;&#227;o &#224; presen&#231;a de SM&#46; A DC foi preditora independente de reinternamento cardiovascular &#40;HR 3&#44;21&#44; IC 95&#37; 1&#44;66&#8211;6&#44;21&#41; e de eventos compostos &#40;HR 2&#44;41&#44; IC 95&#37; 1&#44;44&#8211;4&#44;02&#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">Em doentes de elevado risco cardiovascular ou com doen&#231;a coron&#225;ria estabelecida&#44; a presen&#231;a de SM n&#227;o se associou a aumento de eventos cerebrais ou card&#237;acos num seguimento a longo-prazo&#46;</p></span>"
        "secciones" => array:4 [
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            "titulo" => "M&#233;todos"
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            "identificador" => "abst0035"
            "titulo" => "Resultados"
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          3 => array:2 [
            "identificador" => "abst0040"
            "titulo" => "Conclus&#245;es"
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    "NotaPie" => array:1 [
      0 => array:2 [
        "etiqueta" => "&#9734;"
        "nota" => "<p class="elsevierStyleNotepara" id="npar0030">Please cite this article as&#58; Tim&#243;teo AT&#44; Mota Carmo M&#44; Soares C&#44; et al&#46; Ser&#225; a s&#237;ndrome metab&#243;lica um marcador de progn&#243;stico em doentes com elevado risco cardiovascular&#63; Um estudo de coorte a longo-prazo&#46; Rev Port Cardiol&#46; 2019&#59;38&#58;325&#8211;332&#46;</p>"
      ]
    ]
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        "descripcion" => array:1 [
          "en" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Survival curves for all-cause mortality&#46; CAD&#58; coronary artery disease&#59; MS&#58; metabolic syndrome&#46;</p>"
        ]
      ]
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        "etiqueta" => "Figure 2"
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        "figura" => array:1 [
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        "descripcion" => array:1 [
          "en" => "<p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">Survival curves for cardiovascular mortality&#46; CAD&#58; coronary artery disease&#59; MS&#58; metabolic syndrome&#46;</p>"
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        "identificador" => "fig0015"
        "etiqueta" => "Figure 3"
        "tipo" => "MULTIMEDIAFIGURA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "figura" => array:1 [
          0 => array:4 [
            "imagen" => "gr3.jpeg"
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        "descripcion" => array:1 [
          "en" => "<p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">Survival curves for cardiovascular admission&#46; CAD&#58; coronary artery disease&#59; MS&#58; metabolic syndrome&#46;</p>"
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      3 => array:7 [
        "identificador" => "fig0020"
        "etiqueta" => "Figure 4"
        "tipo" => "MULTIMEDIAFIGURA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "figura" => array:1 [
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          "en" => "<p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">Survival curves for composite outcomes&#46; CAD&#58; coronary artery disease&#59; MS&#58; metabolic syndrome&#46;</p>"
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        "etiqueta" => "Table 1"
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        "detalles" => array:1 [
          0 => array:3 [
            "identificador" => "at1"
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        "tabla" => array:2 [
          "leyenda" => "<p id="spar0070" class="elsevierStyleSimplePara elsevierViewall">BMI&#58; body mass index&#59; CAD&#58; coronary artery disease&#59; MS&#58; metabolic syndrome&#59; WC&#58; waist circumference&#46;</p>"
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              "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="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Without MS&#47;without CAD &#40;n&#61;73&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Without MS&#47;with CAD &#40;n&#61;58&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">With MS&#47;without CAD &#40;n&#61;100&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">With MS&#47;with CAD &#40;n&#61;65&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Total &#40;n&#61;296&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">p&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n
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                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleItalic">Age&#44; years</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t">63&#177;10&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">64&#177;9&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">67&#177;8&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">64&#177;9&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">0&#46;063&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleItalic">Male&#44; &#37;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t">54&#46;8&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">91&#46;4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t">42&#46;0&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t">63&#46;1&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t">59&#46;6&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t">&#60;0&#46;001&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleItalic">BMI &#40;kg&#47;m</span><span class="elsevierStyleSup"><span class="elsevierStyleItalic">2</span></span><span class="elsevierStyleItalic">&#41;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t">27&#46;0&#177;3&#46;6&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">25&#46;3&#177;2&#46;3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t">30&#46;3&#177;4&#46;3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">29&#46;6&#177;4&#46;1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">28&#46;1&#177;4&#46;0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t">&#60;0&#46;001&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="7" align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="\n
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                  \t\t\t\t  " colspan="7" align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleItalic">Risk factors&#44; &#37;</span></td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Hypertension&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Smoking&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Dyslipidemia&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Diabetes&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " colspan="7" align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleItalic">MS components&#44; &#37;</span></td></tr><tr title="table-row"><td class="td-with-role" title="\n
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                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Hypertension&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>High blood glucose&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>High triglycerides&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Low HDL&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">&#60;0&#46;001&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>High WC&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">&#60;0&#46;001&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td-with-role" title="\n
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                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleItalic">Multivessel disease&#44; &#37;</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">0&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">0&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">40&#46;0&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">7&#46;4&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
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                  """
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          "leyenda" => "<p id="spar0080" class="elsevierStyleSimplePara elsevierViewall">ACS&#58; acute coronary syndrome&#59; CABG&#58; coronary artery bypass grafting&#59; CAD&#58; coronary artery disease&#59; MS&#58; metabolic syndrome&#59; PCI&#58; percutaneous coronary intervention&#59; TIA&#58; transient ischemic attack&#46;</p><p id="spar0085" class="elsevierStyleSimplePara elsevierViewall">Comparisons among patients with CAD in the presence or absence of MS&#58;</p>"
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                  \t\t\t\t\ttable-head\n
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                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">&#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-head\n
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                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Without MS&#47;without CAD &#40;n&#61;73&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-head\n
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                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Without MS&#47;with CAD &#40;n&#61;58&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-head\n
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">With MS&#47;without CAD &#40;n&#61;100&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">With MS&#47;with CAD &#40;n&#61;65&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Total &#40;n&#61;296&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-head\n
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">p&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t">All-cause mortality<a class="elsevierStyleCrossRef" href="#tblfn0005"><span class="elsevierStyleSup">a</span></a>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">10&#46;1&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">0&#46;467&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t">Composite outcomes<a class="elsevierStyleCrossRef" href="#tblfn0010"><span class="elsevierStyleSup">b</span></a>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">12&#46;3&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">27&#46;6&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">16&#46;0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t">36&#46;9&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">22&#46;0&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t">0&#46;001&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t">Cardiovascular mortality&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t">3&#46;0&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t">4&#46;6&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t">3&#46;7&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t">0&#46;843&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">ACS<a class="elsevierStyleCrossRef" href="#tblfn0015"><span class="elsevierStyleSup">c</span></a>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t">1&#46;4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&#46;7&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t">3&#46;0&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">10&#46;8&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t">4&#46;1&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t">0&#46;019&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">PCI&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&#46;4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">12&#46;1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&#46;0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">13&#46;9&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">6&#46;1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t">&#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="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t">CABG&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t">0&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t">3&#46;4&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t">0&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">0&#46;7&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t">0&#46;041&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
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                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t">Stroke&#47;TIA&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t">2&#46;7&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">0&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">3&#46;0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t">3&#46;1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2&#46;4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;622&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Cardiovascular admission&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">6&#46;8&nbsp;\t\t\t\t\t\t\n
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Article information

ISSN: 21742049
Original language: English

DOI:10.1016/j.repce.2018.06.011

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Year/Month	Html	Pdf	Total

2024 November	8	4	12
2024 October	32	23	55
2024 September	39	22	61
2024 August	37	34	71
2024 July	28	29	57
2024 June	24	16	40
2024 May	32	16	48
2024 April	35	29	64
2024 March	29	22	51
2024 February	23	21	44
2024 January	34	29	63
2023 December	27	23	50
2023 November	30	31	61
2023 October	16	15	31
2023 September	31	24	55
2023 August	23	14	37
2023 July	26	13	39
2023 June	20	12	32
2023 May	39	25	64
2023 April	42	5	47
2023 March	56	17	73
2023 February	30	16	46
2023 January	28	12	40
2022 December	61	21	82
2022 November	44	30	74
2022 October	58	26	84
2022 September	28	27	55
2022 August	20	30	50
2022 July	31	39	70
2022 June	18	25	43
2022 May	22	24	46
2022 April	22	35	57
2022 March	27	46	73
2022 February	33	34	67
2022 January	26	23	49
2021 December	23	24	47
2021 November	51	27	78
2021 October	36	39	75
2021 September	37	30	67
2021 August	21	22	43
2021 July	16	20	36
2021 June	22	11	33
2021 May	19	35	54
2021 April	63	31	94
2021 March	32	22	54
2021 February	32	17	49
2021 January	36	17	53
2020 December	34	16	50
2020 November	30	17	47
2020 October	23	14	37
2020 September	36	15	51
2020 August	21	11	32
2020 July	15	8	23
2020 June	23	22	45
2020 May	26	8	34
2020 April	15	13	28
2020 March	22	11	33
2020 February	40	29	69
2020 January	10	9	19
2019 December	38	18	56
2019 November	16	7	23
2019 October	22	9	31
2019 September	35	24	59
2019 August	23	5	28
2019 July	27	20	47
2019 June	4	3	7

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