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          "en" => "<p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">Effect of metformin monotherapy on BMI&#46; BMI0&#58; BMI before initiation of metformin monotherapy&#59; BMI3&#58; BMI after three months of metformin monotherapy&#59; BMI&#58; body mass index&#46;</p>"
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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0060">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Visceral adipose tissue &#40;VAT&#41;&#44; anatomically located around certain organs&#44; is now accepted as an endocrine organ which secretes various adipokines that influence both nearby and distant tissues&#46; Imbalance between pro- and anti-inflammatory adipokines secreted from VAT contributes to the pathogenesis of certain cardiovascular and metabolic disorders&#44; including insulin resistance&#46;<a class="elsevierStyleCrossRef" href="#bib0150"><span class="elsevierStyleSup">1</span></a> Epicardial adipose tissue &#40;EAT&#41;&#44; an organ-specific VAT&#44; is mainly found in the atrioventricular and interventricular grooves and along the major branches of the coronary arteries&#44; and to a lesser extent around the atria&#44; over the free wall of the right ventricle and over the apex of the left ventricle&#46;<a class="elsevierStyleCrossRef" href="#bib0155"><span class="elsevierStyleSup">2</span></a> Evidence is accumulating that bioactive molecules secreted by EAT can directly affect intima-media thickness and regulate vasomotor function&#46;<a class="elsevierStyleCrossRef" href="#bib0160"><span class="elsevierStyleSup">3</span></a> Furthermore&#44; there is emerging evidence that EAT has a direct association with coronary atherosclerosis&#46;<a class="elsevierStyleCrossRef" href="#bib0165"><span class="elsevierStyleSup">4</span></a> In view of the putative proatherogenic effect of EAT&#44; several clinical trials have shown a positive correlation between EAT thickness and coronary atherosclerosis&#46;<a class="elsevierStyleCrossRefs" href="#bib0170"><span class="elsevierStyleSup">5&#8211;7</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">Although its exact mechanism of action is unknown&#44; metformin is regarded as the gold standard treatment for type 2 diabetes&#46;<a class="elsevierStyleCrossRef" href="#bib0185"><span class="elsevierStyleSup">8</span></a> Beside its glucose-lowering effect&#44; metformin also has a favorable effect on body weight&#44; primarily due to reduction of VAT&#46;<a class="elsevierStyleCrossRef" href="#bib0190"><span class="elsevierStyleSup">9</span></a> In this study&#44; we investigated the effects of metformin on EAT thickness and body mass index &#40;BMI&#41; in type 2 diabetes patients&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Methods</span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Study population</span><p id="par0015" class="elsevierStylePara elsevierViewall">In this prospective observational study&#44; we analyzed consecutive patients referred to the internal medicine outpatient clinic between September 1&#44; 2015 and May 31&#44; 2016&#46; Patients with BMI &#60;20 or &#62;35 kg&#47;m<span class="elsevierStyleSup">2</span> or poor echocardiographic window were excluded&#46; A total of 47 newly diagnosed type 2 diabetes patients prescribed metformin monotherapy were selected&#46; Clinical and demographic features of the selected patients were recorded&#46; All patients were informed about the study and written consent was obtained&#46; The study was approved by the local ethics committee&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Study protocol</span><p id="par0020" class="elsevierStylePara elsevierViewall">Before initiation of metformin monotherapy&#44; the BMI of all recruited patients was calculated &#40;BMI0&#41; and all underwent transthoracic echocardiography to assess EAT thickness &#40;EAT0&#41;&#46; Metformin 1000 mg twice daily was prescribed to all participants&#46; After three months of metformin monotherapy&#44; BMI was recalculated &#40;BMI3&#41; and transthoracic echocardiographic studies were repeated to measure EAT thickness &#40;EAT3&#41;&#44; and the resulting data were statistically analyzed&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Measurement of epicardial adipose tissue thickness</span><p id="par0025" class="elsevierStylePara elsevierViewall">All included patients underwent detailed two-dimensional &#40;2D&#41;&#44; M-mode&#44; Doppler&#44; and tissue Doppler transthoracic echocardiography using standard techniques before beginning metformin monotherapy and after three months of treatment&#46; The echocardiograms were performed by two experienced cardiologists who were blinded to the subjects&#8217; clinical and demographic data&#46; Each subject underwent 2D-guided M-mode transthoracic echocardiography using commercially available equipment &#40;Aplio 500&#44; Toshiba&#44; Irvine&#44; CA&#41;&#46; Standard parasternal and apical views were obtained in left lateral decubitus position&#46; EAT was visualized as echo-free space between the outer wall of the myocardium and the visceral layer of the pericardium &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Figure 1</a>&#41;&#46; EAT thickness was measured perpendicularly on the free wall of the right ventricle during three cardiac cycles at end-diastole&#46; Parasternal long- and short-axis views provided the most accurate measurement of EAT in the right ventricle&#44; with optimal cursor beam orientation in each view&#46; Maximum EAT thickness was measured at the point on the free wall of the right ventricle along the midline of the ultrasound beam perpendicular to the aortic annulus&#44; used as an anatomic landmark for this view&#46; For midventricular parasternal short-axis assessment&#44; maximum EAT thickness was measured on the right ventricular free wall along the midline of the ultrasound beam&#44; perpendicular to the ventricular septum at midchordal and tip of the papillary muscle level&#44; as anatomic landmarks&#46; The mean values from three cardiac cycles in each echocardiographic view were analyzed&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Statistical analysis</span><p id="par0030" class="elsevierStylePara elsevierViewall">The statistical analysis was conducted using SPSS software&#44; version 16&#46;0 &#40;IBM&#44; Chicago&#44; IL&#41;&#46; Data were expressed as mean &#177; standard deviation for continuous variables and as counts and percentage for categorical variables&#46; The Student&#39;s t test was used to compare continuous variables&#44; while the chi-square and Fisher&#39;s exact tests were used to compare categorical variables&#46; Correlations of continuous variables were assessed using Pearson correlation analysis&#46; Values 0-0&#46;3 indicated weak&#44; 0&#46;3-0&#46;7 indicated intermediate&#44; and 0&#46;7-1&#46;0 indicated strong correlation&#46; A p value &#60;0&#46;05 was considered statistically significant&#46;</p></span></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Results</span><p id="par0035" class="elsevierStylePara elsevierViewall">Seven patients were excluded due to metformin intolerance during the follow-up period&#44; and so a total of 40 patients were analyzed&#46; Of the study population&#44; 23 &#40;57&#46;5&#37;&#41; were male and mean age was 48&#46;6&#177;1&#46;99 years&#46; Fourteen patients &#40;35&#37;&#41; had hypertension&#44; 12 &#40;30&#37;&#41; had hyperlipidemia and 13 &#40;32&#46;5&#37;&#41; were smokers&#46; Mean fasting blood glucose was 280&#46;38&#177;14&#46;88 mg&#47;dl before beginning metformin monotherapy&#44; falling to 129&#46;01&#177;17&#46;00 mg&#47;dl after three months of therapy&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">EAT thickness was significantly decreased after three months of metformin monotherapy &#40;EAT0&#61; 5&#46;07&#177;1&#46;33 mm vs&#46; EAT3&#61;4&#46;76&#177;1&#46;32 mm&#59; p&#60;0&#46;001&#41; &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Figure 2</a>&#41;&#46;</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0045" class="elsevierStylePara elsevierViewall">Furthermore&#44; BMI was also significantly decreased after three months of metformin monotherapy &#40;BMI0&#61;28&#46;27&#177;2&#46;71 vs&#46; BMI3&#61;27&#46;29&#177;2&#46;10&#59; p&#60;0&#46;0001&#41; &#40;<a class="elsevierStyleCrossRef" href="#fig0015">Figure 3</a>&#41;&#46;</p><elsevierMultimedia ident="fig0015"></elsevierMultimedia><p id="par0050" class="elsevierStylePara elsevierViewall">We also analyzed the correlation between the decrease in EAT &#40;formulated as EAT0 - EAT3&#41; and mean fasting blood glucose level before beginning metformin monotherapy and BMI0&#46; A statistically non-significant positive correlation was found between decrease in EAT and mean fasting blood glucose before beginning therapy &#40;r&#61;0&#46;19&#59; p&#61;0&#46;056&#41; and BMI0 &#40;r&#61;0&#46;17&#59; p&#61;0&#46;053&#41;&#46;</p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Discussion</span><p id="par0055" class="elsevierStylePara elsevierViewall">In this study we demonstrated that metformin monotherapy significantly decreases EAT thickness and BMI as early as the third month of therapy&#46;</p><p id="par0060" class="elsevierStylePara elsevierViewall">Because of its vital endocrine function and close anatomical relation to the coronary arteries&#44; many studies have set out to determine the effects of EAT on cardiovascular disease&#46; Mahabadi et al&#46; showed the existence of a relation between cardiovascular risk factors&#44; myocardial infarction and EAT thickness&#44;<a class="elsevierStyleCrossRef" href="#bib0195"><span class="elsevierStyleSup">10</span></a> while Cavalcante et al&#46; found a significant association between subclinical coronary atherosclerosis&#44; metabolic syndrome&#44; diastolic dysfunction and EAT thickness&#46;<a class="elsevierStyleCrossRef" href="#bib0200"><span class="elsevierStyleSup">11</span></a> In a recently published study&#44; Abazid et al&#46; also concluded that higher EAT volume is associated with greater coronary artery calcification&#44;<a class="elsevierStyleCrossRef" href="#bib0205"><span class="elsevierStyleSup">12</span></a> and Wu et al&#46; showed that EAT thickness is positively correlated with obstructive coronary artery disease &#40;CAD&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0210"><span class="elsevierStyleSup">13</span></a></p><p id="par0065" class="elsevierStylePara elsevierViewall">Although the exact mechanism is unknown&#44; several hypotheses have been put forward to explain this relation&#46; EAT is a metabolically active fat depot which is rich in proinflammatory and proatherogenic cytokines including interleukin &#40;IL&#41;-1&#946;&#44; IL-6&#44; and tumor necrosis factor &#40;TNF&#41;-&#945;&#46;<a class="elsevierStyleCrossRef" href="#bib0215"><span class="elsevierStyleSup">14</span></a> In a recent study&#44; Vrselja et al&#46; demonstrated that TNF-&#945; levels were increased in CAD patients&#46;<a class="elsevierStyleCrossRef" href="#bib0220"><span class="elsevierStyleSup">15</span></a> Furthermore&#44; Eiras et al&#46; postulated that the extent of CAD was associated with the expression of IL-6 mRNA in EAT&#46;<a class="elsevierStyleCrossRef" href="#bib0225"><span class="elsevierStyleSup">16</span></a></p><p id="par0070" class="elsevierStylePara elsevierViewall">EAT shares the same embryologic origin as mesenteric and omental fat&#46;<a class="elsevierStyleCrossRefs" href="#bib0230"><span class="elsevierStyleSup">17&#44;18</span></a> They all encase viscera in close contact&#44; with no fascial barrier&#46;<a class="elsevierStyleCrossRef" href="#bib0240"><span class="elsevierStyleSup">19</span></a> Hence it has been suggested that EAT may have endocrine and paracrine effects on the adjacent coronary arterial wall that could result in atherosclerotic plaque development&#46;<a class="elsevierStyleCrossRefs" href="#bib0245"><span class="elsevierStyleSup">20&#8211;22</span></a> These findings highlight the potential role of increased EAT thickness in atherosclerosis&#46; It could therefore be postulated that decreased EAT would produce less proinflammatory and proatherogenic cytokines and be less likely to cause atherosclerosis&#46;</p><p id="par0075" class="elsevierStylePara elsevierViewall">Metformin is now accepted as the first-line drug for use as monotherapy in type 2 diabetes patients&#46; It is thought to affect certain aspects of the body&#39;s metabolism&#46; It inhibits hepatic gluconeogenesis&#44; augments peripheral glucose uptake&#44; and reduces insulin demand&#46;<a class="elsevierStyleCrossRef" href="#bib0185"><span class="elsevierStyleSup">8</span></a> Various studies have also investigated the effect of metformin on body weight and visceral adipose tissue&#46; In a recent study&#44; Alfaras et al&#46; showed in mice that metformin significantly reduces body weight within the first weeks of treatment&#44; without affecting food consumption or energy expenditure&#46;<a class="elsevierStyleCrossRef" href="#bib0260"><span class="elsevierStyleSup">23</span></a> Yanovski et al&#46; showed that metformin significantly reduced body weight in children with insulin resistance&#44;<a class="elsevierStyleCrossRef" href="#bib0265"><span class="elsevierStyleSup">24</span></a> while Tokubuchi et al&#46; demonstrated that metformin treatment caused significant reductions in visceral fat mass&#44; probably through a potential shift of fuel resource into fat oxidation and upregulation of thermogenesis&#46;<a class="elsevierStyleCrossRef" href="#bib0270"><span class="elsevierStyleSup">25</span></a></p><p id="par0080" class="elsevierStylePara elsevierViewall">Although there have been many studies on the effects of metformin on body weight and VAT&#44; there is hardly any data about its effect on EAT&#46; In our study&#44; we showed that metformin significantly reduces BMI and EAT thickness&#46; Magnetic resonance imaging &#40;MRI&#41; and computed tomography &#40;CT&#41; are the gold-standard techniques for quantifying EAT volume&#46; Due to the difficulty in standardizing localization of the measurement site&#44; reference values for EAT assessed by CT are uncertain&#46;<a class="elsevierStyleCrossRef" href="#bib0275"><span class="elsevierStyleSup">26</span></a> Iacobellis et al&#46; were the first to propose that transthoracic echocardiography could be an easy and reliable imaging method for EAT prediction&#46;<a class="elsevierStyleCrossRef" href="#bib0280"><span class="elsevierStyleSup">27</span></a> MRI and transthoracic echocardiography provide comparable results for detection of EAT volume&#46;<a class="elsevierStyleCrossRef" href="#bib0285"><span class="elsevierStyleSup">28</span></a> Hence measurement of EAT by transthoracic echocardiography is practical&#44; cost-effective&#44; safe&#44; rapid&#44; and well correlated to gold-standard techniques&#46;<a class="elsevierStyleCrossRef" href="#bib0290"><span class="elsevierStyleSup">29</span></a></p></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">Study limitations</span><p id="par0085" class="elsevierStylePara elsevierViewall">As this is the first study to investigate the effect of metformin on EAT thickness&#44; it is subject to some limitations&#44; the main ones being its relatively small sample size and the lack of data on inflammatory markers&#46; Due to financial constraints we were unable to analyze the possible effects of inflammation on the results&#46; Larger-scale and more detailed studies should be designed to clarify the exact mechanisms underlying the favorable effects of metformin on EAT thickness and BMI&#46;</p></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0105">Conclusion</span><p id="par0090" class="elsevierStylePara elsevierViewall">To the best of our knowledge&#44; our study demonstrates for the first time in the literature that metformin significantly reduces EAT thickness in newly diagnosed type 2 diabetes&#46; Because EAT volume is closely related to atherosclerosis&#44; it could be concluded that EAT is a modifiable risk factor for atherosclerosis and that metformin could significantly reduce the frequency of coronary atherosclerosis&#46; Metformin could even become the aspirin of the 21st century&#46; Further studies on a larger scale are needed to support these findings&#46;</p></span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0110">Conflicts of interest</span><p id="par0095" class="elsevierStylePara elsevierViewall">The authors have no conflicts of interest to declare&#46;</p></span></span>"
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              "identificador" => "sec0025"
              "titulo" => "Measurement of epicardial adipose tissue thickness"
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              "titulo" => "Statistical analysis"
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    "fechaRecibido" => "2018-03-04"
    "fechaAceptado" => "2018-08-01"
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          "clase" => "keyword"
          "titulo" => "Keywords"
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            0 => "Adipose tissue"
            1 => "Coronary atherosclerosis"
            2 => "Type 2 diabetes"
            3 => "Metformin"
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        ]
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          "palabras" => array:4 [
            0 => "Tecido adiposo"
            1 => "Aterosclerose coron&#225;ria"
            2 => "Diabetes tipo 2"
            3 => "Metformina"
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      "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">Imbalance between pro- and anti-inflammatory cytokines secreted from visceral adipose tissue &#40;VAT&#41; contributes to the pathogenesis of certain cardiovascular and metabolic disorders&#44; including insulin resistance&#46; Epicardial adipose tissue &#40;EAT&#41; is a form of VAT mainly concentrated along the coronary arteries&#46; It has been shown in various studies that EAT thickness is positively correlated with cardiovascular disease&#46; Due to its high worldwide prevalence&#44; prevention and management of type 2 diabetes &#40;T2D&#41; has become a major public health challenge&#46; Metformin&#44; the most widely prescribed drug to treat T2D&#44; has favorable effects on VAT and body weight&#46; As metformin decreases VAT mass&#44; in this prospective study we analyzed the possible positive effect of metformin on EAT mass&#44; which is organ-specific VAT&#44; and body mass index &#40;BMI&#41;&#46;</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Methods</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Subjects were selected from patients admitted to the internal medicine outpatient clinic&#46; Newly diagnosed T2D patients treated with metformin monotherapy were analyzed and 40 patients were included&#46; EAT thickness in the included patients was measured echocardiographically&#46; BMI and EAT thickness were analyzed at the beginning &#40;BMI0 and EAT0&#41; and after three months of metformin monotherapy &#40;BMI3 and EAT3&#41;&#46;</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Results</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">There was a statistically significant decrease in EAT thickness after three months of metformin monotherapy &#40;EAT0&#61;5&#46;07&#177;1&#46;33 mm vs&#46; EAT3&#61;4&#46;76&#177;1&#46;32 mm&#59; p&#60;0&#46;001&#41;&#46; Furthermore&#44; BMI was also significantly decreased &#40;BMI0&#61;28&#46;27&#177;2&#46;71 vs&#46; BMI3&#61;27&#46;29&#177;2&#46;10&#59; p&#60;0&#46;0001&#41;&#46;</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Conclusions</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">In this study we show that metformin monotherapy significantly decreases EAT thickness and BMI in T2D patients&#46; This suggests that metformin could reduce the frequency of coronary atherosclerosis&#46;</p></span>"
        "secciones" => array:4 [
          0 => array:2 [
            "identificador" => "abst0005"
            "titulo" => "Introduction"
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          1 => array:2 [
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            "titulo" => "Methods"
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          2 => array:2 [
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            "titulo" => "Results"
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            "titulo" => "Conclusions"
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      "pt" => array:3 [
        "titulo" => "Resumo"
        "resumen" => "<span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Objetivos</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">O desequil&#237;brio entre as citocinas pro e anti-inflamat&#243;rias segregadas pelo tecido adiposo visceral &#40;TAV&#41; contribui para a patog&#233;nese de certas doen&#231;as cardiovasculares e metab&#243;licas&#44; incluindo a resist&#234;ncia &#224; insulina&#46; O tecido adiposo epic&#225;rdico &#40;EAT&#41; &#233; o TAV&#44; concentrado principalmente ao longo das art&#233;rias coron&#225;rias&#46; &#201; previamente demonstrado em v&#225;rios estudos que a espessura do EAT est&#225; positivamente correlacionada com a frequ&#234;ncia de doen&#231;a cardiovascular&#46; Devido &#224; alta preval&#234;ncia mundial&#44; a preven&#231;&#227;o e tratamento da diabetes <span class="elsevierStyleItalic">mellitus</span> tipo 2 &#40;DM2&#41; tornou-se um grande desafio para a sa&#250;de p&#250;blica&#46; A metformina&#44; o medicamento mais amplamente prescrito para o tratamento da DM2&#44; tem efeitos favor&#225;veis no TAV e no peso corporal&#46; Como a metformina diminui a massa do TAV&#44; neste estudo prospetivo&#44; analisamos o poss&#237;vel efeito positivo da metformina na massa do EAT&#44; que &#233; o TAV do &#243;rg&#227;o e o &#237;ndice de massa corporal&#46;</p></span> <span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">M&#233;todos</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Os indiv&#237;duos foram selecionados dos doentes admitidos no ambulat&#243;rio de medicina interna&#46; Doentes rec&#233;m-diagnosticados com DM2 tratados com metformina em monoterapia foram investigados&#46; Foram inclu&#237;dos 40 doentes&#46; A espessura do EAT dos doentes inclu&#237;dos foi medida por ecocardiografia&#46; A espessura do IMC e do EAT no in&#237;cio e tr&#234;s meses ap&#243;s a monoterapia com metformina foi analisada&#46;</p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Resultados</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Houve redu&#231;&#227;o estatisticamente significativa na espessura do EAT ap&#243;s tr&#234;s meses de monoterap&#234;utica com metformina &#40;EAT0&#61;5&#44;07&#177;1&#44;33 mm <span class="elsevierStyleItalic">versus</span> EAT3&#61;4&#44;76&#177;1&#44;32 mm&#59; p&#60;0&#44;001&#41;&#46; Al&#233;m disso&#44; o IMC tamb&#233;m diminuiu significativamente &#40;IMC0&#61;28&#44;27&#177;2&#44;71 <span class="elsevierStyleItalic">versus</span> IMC3&#61;27&#44;29&#177;2&#44;10&#59; p&#60;0&#44;0001&#41;&#46;</p><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">Conclus&#245;es Neste estudo&#44; verific&#225;mos que a metformina em monoterapia diminui significativamente a espessura do EAT e o IMC nos doentes com DM2&#44; pelo que se pode concluir que a metformina pode reduzir a frequ&#234;ncia de aterosclerose coron&#225;ria&#46;</p></span>"
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      "seccion" => array:1 [
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                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Vasocrine signalling from perivascular fat&#58; a mechanism linking insulin resistance to vascular disease"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:3 [
                            0 => "J&#46;S&#46; Yudkin"
                            1 => "E&#46; Eringa"
                            2 => "C&#46;D&#46; Stehouwer"
                          ]
                        ]
                      ]
                    ]
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                      "doi" => "10.1016/S0140-6736(05)66585-3"
                      "Revista" => array:6 [
                        "tituloSerie" => "Lancet"
                        "fecha" => "2005"
                        "volumen" => "365"
                        "paginaInicial" => "1817"
                        "paginaFinal" => "1820"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/15910955"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            1 => array:3 [
              "identificador" => "bib0155"
              "etiqueta" => "2"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Epicardial adipose tissue&#58; anatomic&#44; biomolecular and clinical relationships with the heart"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:3 [
                            0 => "G&#46; Iacobellis"
                            1 => "D&#46; Corradi"
                            2 => "A&#46;M&#46; Sharma"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1038/ncpcardio0319"
                      "Revista" => array:6 [
                        "tituloSerie" => "Nat Clin Pract Cardiovasc Med"
                        "fecha" => "2005"
                        "volumen" => "2"
                        "paginaInicial" => "536"
                        "paginaFinal" => "543"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/16186852"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            2 => array:3 [
              "identificador" => "bib0160"
              "etiqueta" => "3"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Human epicardial adipose tissue&#58; a review"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:2 [
                            0 => "H&#46;S&#46; Sacks"
                            1 => "J&#46;N&#46; Fain"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1016/j.ahj.2007.03.019"
                      "Revista" => array:6 [
                        "tituloSerie" => "Am Heart J"
                        "fecha" => "2007"
                        "volumen" => "153"
                        "paginaInicial" => "907"
                        "paginaFinal" => "917"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/17540190"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            3 => array:3 [
              "identificador" => "bib0165"
              "etiqueta" => "4"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Association of epicardial adipose tissue with coronary atherosclerosis is region-specific and independent of conventional risk factors and intra-abdominal adiposity"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:3 [
                            0 => "T&#46;D&#46; Wang"
                            1 => "W&#46;J&#46; Lee"
                            2 => "F&#46;Y&#46; Shih"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1016/j.atherosclerosis.2010.07.055"
                      "Revista" => array:6 [
                        "tituloSerie" => "Atherosclerosis"
                        "fecha" => "2010"
                        "volumen" => "213"
                        "paginaInicial" => "279"
                        "paginaFinal" => "287"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/20801451"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
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              "identificador" => "bib0170"
              "etiqueta" => "5"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Clinical significance of epicardial fat measured using cardiac multislice computed tomography"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:3 [
                            0 => "S&#46; Sarin"
                            1 => "C&#46; Wenger"
                            2 => "A&#46; Marwaha"
                          ]
                        ]
                      ]
                    ]
                  ]
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                    0 => array:2 [
                      "doi" => "10.1016/j.amjcard.2008.04.058"
                      "Revista" => array:7 [
                        "tituloSerie" => "Am J Cardiol"
                        "fecha" => "2008"
                        "volumen" => "102"
                        "paginaInicial" => "767"
                        "paginaFinal" => "771"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/18774004"
                            "web" => "Medline"
                          ]
                        ]
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                          "pii" => "S0140673613622199"
                          "estado" => "S300"
                          "issn" => "01406736"
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                    ]
                  ]
                ]
              ]
            ]
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              "identificador" => "bib0175"
              "etiqueta" => "6"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "The association of pericardial fat with incident coronary heart disease&#58; the Multi Ethnic Study of Atherosclerosis &#40;MESA&#41;"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:3 [
                            0 => "J&#46; Ding"
                            1 => "F&#46;C&#46; Hsu"
                            2 => "T&#46;B&#46; Harris"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.3945/ajcn.2008.27358"
                      "Revista" => array:6 [
                        "tituloSerie" => "Am J Clin Nutr"
                        "fecha" => "2009"
                        "volumen" => "90"
                        "paginaInicial" => "499"
                        "paginaFinal" => "504"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/19571212"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            6 => array:3 [
              "identificador" => "bib0180"
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              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Subepicardial adipose tissue and the presence and severity of coronary artery disease"
                      "autores" => array:1 [
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                          "autores" => array:3 [
                            0 => "N&#46; Chaowalit"
                            1 => "V&#46;K&#46; Somers"
                            2 => "P&#46;A&#46; Pellikka"
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                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1016/j.atherosclerosis.2005.08.004"
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                        "tituloSerie" => "Atherosclerosis"
                        "fecha" => "2006"
                        "volumen" => "186"
                        "paginaInicial" => "354"
                        "paginaFinal" => "359"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/16183065"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
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              "identificador" => "bib0185"
              "etiqueta" => "8"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
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                      "titulo" => "Metformin &#8211; a new old drug"
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                          "autores" => array:3 [
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                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.5603/EP.2017.0050"
                      "Revista" => array:6 [
                        "tituloSerie" => "Endokrynol Pol"
                        "fecha" => "2017"
                        "volumen" => "68"
                        "paginaInicial" => "482"
                        "paginaFinal" => "496"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/28819951"
                            "web" => "Medline"
                          ]
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                ]
              ]
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                      "titulo" => "Selective decrease in visceral fat is associated with weight loss during metformin treatment in African Americans with type 2 diabetes"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:3 [
                            0 => "R&#46; Kurukulasuriya"
                            1 => "M&#46;A&#46; Banerji"
                            2 => "R&#46; Chaiken"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:4 [
                        "tituloSerie" => "Diabetes"
                        "fecha" => "1999"
                        "volumen" => "48"
                        "paginaInicial" => "315"
                      ]
                    ]
                  ]
                ]
              ]
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            9 => array:3 [
              "identificador" => "bib0195"
              "etiqueta" => "10"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Association of epicardial fat with cardiovascular risk factors and incident myocardial infarction in the general population&#58; the Heinz Nixdorf Recall Study"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:3 [
                            0 => "A&#46;A&#46; Mahabadi"
                            1 => "M&#46;H&#46; Berg"
                            2 => "N&#46; Lehmann"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1016/j.jacc.2012.11.062"
                      "Revista" => array:6 [
                        "tituloSerie" => "J Am Coll Cardiol"
                        "fecha" => "2013"
                        "volumen" => "61"
                        "paginaInicial" => "1388"
                        "paginaFinal" => "1395"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/23433560"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            10 => array:3 [
              "identificador" => "bib0200"
              "etiqueta" => "11"
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                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Association of epicardial fat&#44; hypertension&#44; subclinical coronary artery disease&#44; and metabolic syndrome with left ventricular diastolic dysfunction"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:3 [
                            0 => "J&#46;L&#46; Cavalcante"
                            1 => "B&#46;K&#46; Tamarappoo"
                            2 => "R&#46; Hachamovitch"
                          ]
                        ]
                      ]
                    ]
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                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1016/j.amjcard.2012.07.045"
                      "Revista" => array:6 [
                        "tituloSerie" => "Am J Cardiol"
                        "fecha" => "2012"
                        "volumen" => "110"
                        "paginaInicial" => "1793"
                        "paginaFinal" => "1798"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/22980968"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            11 => array:3 [
              "identificador" => "bib0205"
              "etiqueta" => "12"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Relation between epicardial fat and subclinical atherosclerosis in asymptomatic individuals"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:3 [
                            0 => "R&#46;M&#46; Abazid"
                            1 => "O&#46;A&#46; Smettei"
                            2 => "M&#46;O&#46; Kattea"
                          ]
                        ]
                      ]
                    ]
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                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1097/RTI.0000000000000296"
                      "Revista" => array:6 [
                        "tituloSerie" => "J Thorac Imaging"
                        "fecha" => "2017"
                        "volumen" => "32"
                        "paginaInicial" => "378"
                        "paginaFinal" => "382"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/28817459"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            12 => array:3 [
              "identificador" => "bib0210"
              "etiqueta" => "13"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "The relation of location-specific epicardial adipose tissue thickness and obstructive coronary artery disease&#58; systemic review and meta-analysis of observational studies"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:3 [
                            0 => "F&#46;Z&#46; Wu"
                            1 => "K&#46;J&#46; Chou"
                            2 => "Y&#46;L&#46; Huang"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1186/1471-2261-14-62"
                      "Revista" => array:5 [
                        "tituloSerie" => "BMC Cardiovasc Disord"
                        "fecha" => "2014"
                        "volumen" => "14"
                        "paginaInicial" => "62"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/24884458"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            13 => array:3 [
              "identificador" => "bib0215"
              "etiqueta" => "14"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Association of epicardial adipose tissue and high-risk plaque characteristics&#58; a systematic review and meta-analysis"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:3 [
                            0 => "N&#46; Nerlekar"
                            1 => "A&#46;J&#46; Brown"
                            2 => "R&#46;G&#46; Muthalaly"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:3 [
                        "tituloSerie" => "J Am Heart Assoc"
                        "fecha" => "2017"
                        "volumen" => "6"
                      ]
                    ]
                  ]
                ]
              ]
            ]
            14 => array:3 [
              "identificador" => "bib0220"
              "etiqueta" => "15"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Transcardial gradient of adiponectin&#44; interleukin-6 and tumor necrosis factor-&#945; in overweight coronary artery disease patients"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:3 [
                            0 => "Z&#46; Vrselja"
                            1 => "M&#46; &#352;ram"
                            2 => "D&#46; Andrijevic"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1016/j.cyto.2015.09.009"
                      "Revista" => array:6 [
                        "tituloSerie" => "Cytokine"
                        "fecha" => "2015"
                        "volumen" => "76"
                        "paginaInicial" => "321"
                        "paginaFinal" => "327"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/26385653"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            15 => array:3 [
              "identificador" => "bib0225"
              "etiqueta" => "16"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Extension of coronary artery disease is associated with increased IL-6 and decreased adiponectin gene expression in epicardial adipose tissue"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:3 [
                            0 => "S&#46; Eiras"
                            1 => "E&#46; Teijeira-Fern&#225;ndez"
                            2 => "L&#46;G&#46; Shamagian"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1016/j.cyto.2008.05.006"
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                        "tituloSerie" => "Cytokine"
                        "fecha" => "2008"
                        "volumen" => "43"
                        "paginaInicial" => "174"
                        "paginaFinal" => "180"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/18562207"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            16 => array:3 [
              "identificador" => "bib0230"
              "etiqueta" => "17"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Association of pericardial fat and coronary high-risk lesions as determined by cardiac CT"
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                        0 => array:2 [
                          "etal" => true
                          "autores" => array:3 [
                            0 => "C&#46;L&#46; Schlett"
                            1 => "M&#46; Ferencik"
                            2 => "M&#46;F&#46; Kriegel"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1016/j.atherosclerosis.2012.02.029"
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                        "tituloSerie" => "Atherosclerosis"
                        "fecha" => "2012"
                        "volumen" => "222"
                        "paginaInicial" => "129"
                        "paginaFinal" => "134"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/22417843"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            17 => array:3 [
              "identificador" => "bib0235"
              "etiqueta" => "18"
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                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Relationship of epicardial fat volume to coronary plaque&#44; severe coronary stenosis&#44; and high-risk coronary plaque features assessed by coronary CT angiography"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:3 [
                            0 => "R&#46; Rajani"
                            1 => "H&#46; Shmilovich"
                            2 => "R&#46; Nakazato"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1016/j.jcct.2013.02.003"
                      "Revista" => array:6 [
                        "tituloSerie" => "J Cardiovasc Comput Tomogr"
                        "fecha" => "2013"
                        "volumen" => "7"
                        "paginaInicial" => "125"
                        "paginaFinal" => "132"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/23622507"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            18 => array:3 [
              "identificador" => "bib0240"
              "etiqueta" => "19"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Epicardial and perivascular adipose tissues and their influence on cardiovascular disease&#58; basic mechanisms and clinical associations"
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                        0 => array:2 [
                          "etal" => false
                          "autores" => array:2 [
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                            1 => "M&#46;P&#46; Czech"
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                    ]
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                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1161/JAHA.113.000582"
                      "Revista" => array:6 [
                        "tituloSerie" => "J Am Heart Assoc"
                        "fecha" => "2014"
                        "volumen" => "3"
                        "paginaInicial" => "e000582"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/24595191"
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                        "itemHostRev" => array:3 [
                          "pii" => "S2213858717302395"
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                          "issn" => "22138587"
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                    ]
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                ]
              ]
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              "identificador" => "bib0245"
              "etiqueta" => "20"
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                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Relationship between epicardial fat and quantitative coronary artery plaque progression&#58; insights from computer tomography coronary angiography"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:3 [
                            0 => "P&#46;J&#46; Psaltis"
                            1 => "A&#46;H&#46; Talman"
                            2 => "K&#46; Munnur"
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                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:5 [
                        "tituloSerie" => "Int J Cardiovasc Imaging"
                        "fecha" => "2016"
                        "volumen" => "32"
                        "paginaInicial" => "317"
                        "paginaFinal" => "328"
                      ]
                    ]
                  ]
                ]
              ]
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            20 => array:3 [
              "identificador" => "bib0250"
              "etiqueta" => "21"
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                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Epicardial adipose tissue volume and adipocytokine imbalance are strongly linked to human coronary atherosclerosis"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:3 [
                            0 => "M&#46; Shimabukuro"
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                            2 => "M&#46; Tabata"
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                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1161/ATVBAHA.112.300829"
                      "Revista" => array:6 [
                        "tituloSerie" => "Arterioscler Thromb Vasc Biol"
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                        "volumen" => "33"
                        "paginaInicial" => "1077"
                        "paginaFinal" => "1084"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/23471228"
                            "web" => "Medline"
                          ]
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                      ]
                    ]
                  ]
                ]
              ]
            ]
            21 => array:3 [
              "identificador" => "bib0255"
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                0 => array:2 [
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                    0 => array:2 [
                      "titulo" => "Eccentric atherosclerotic plaques with positive remodelling have a pericardial distribution&#58; a permissive role of epicardial fat&#63; A three-dimensional intravascular ultrasound study of left anterior descending artery lesions"
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                        0 => array:2 [
                          "etal" => false
                          "autores" => array:1 [
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                    0 => array:2 [
                      "doi" => "10.1016/s0195-668x(02)00426-8"
                      "Revista" => array:6 [
                        "tituloSerie" => "Eur Heart J"
                        "fecha" => "2003"
                        "volumen" => "24"
                        "paginaInicial" => "329"
                        "paginaFinal" => "336"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/12581680"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
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            22 => array:3 [
              "identificador" => "bib0260"
              "etiqueta" => "23"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Health benefits of late-onset metformin treatment every other week in mice"
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                          "etal" => true
                          "autores" => array:3 [
                            0 => "I&#46; Alfaras"
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                            2 => "H&#46; Mora"
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                    ]
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                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1038/s41514-017-0018-7"
                      "Revista" => array:5 [
                        "tituloSerie" => "NPJ Aging Mech Dis"
                        "fecha" => "2017"
                        "volumen" => "3"
                        "paginaInicial" => "16"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/29167747"
                            "web" => "Medline"
                          ]
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                    ]
                  ]
                ]
              ]
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            23 => array:3 [
              "identificador" => "bib0265"
              "etiqueta" => "24"
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                0 => array:2 [
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                    0 => array:2 [
                      "titulo" => "Effects of metformin on body weight and body composition in obese insulin-resistant children&#58; a randomized clinical trial"
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                        0 => array:2 [
                          "etal" => true
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                        ]
                      ]
                    ]
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                    0 => array:2 [
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                        "tituloSerie" => "Diabetes"
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                        "paginaInicial" => "477"
                        "paginaFinal" => "485"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/21228310"
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                          "issn" => "01406736"
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                ]
              ]
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              "identificador" => "bib0270"
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                0 => array:2 [
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                    0 => array:2 [
                      "titulo" => "Beneficial effects of metformin on energy metabolism and visceral fat volume through a possible mechanism of fatty acid oxidation in human subjects and rats"
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                    0 => array:2 [
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                        "tituloSerie" => "PLOS ONE"
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                        "volumen" => "12"
                        "paginaInicial" => "e0171293"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/28158227"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
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                ]
              ]
            ]
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              "identificador" => "bib0275"
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              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Relation of epicardial and pericoronary fat to coronary atherosclerosis and coronary artery calcium in patients undergoing coronary angiography"
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                        0 => array:2 [
                          "etal" => true
                          "autores" => array:3 [
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                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1016/j.amjcard.2008.04.002"
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                        "tituloSerie" => "Am J Cardiol"
                        "fecha" => "2008"
                        "volumen" => "102"
                        "paginaInicial" => "380"
                        "paginaFinal" => "385"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/18678291"
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              ]
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              "identificador" => "bib0280"
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                0 => array:2 [
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                    0 => array:2 [
                      "titulo" => "Epicardial fat from echocardiography&#58; a new method for visceral adipose tissue prediction"
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                    ]
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Original Article
Metformin monotherapy significantly decreases epicardial adipose tissue thickness in newly diagnosed type 2 diabetes patients
A monoterapia com metformina diminiu significativamente a espessura do tecido adiposo epicárdico nos doentes recentemente diagnosticados com diabetes tipo 2
Murat Ziyreka,
Corresponding author
muziyrek@yahoo.com

Corresponding author.
, Serkan Kahramana, Emrah Ozdemirb, Ali Doganb
a Silivri State Hospital, Department of Cardiology, Turkey
b Yeniyüzyıl University, Faculty of Medicine, Department of Cardiology, Turkey
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          "en" => "<p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">Effect of metformin monotherapy on BMI&#46; BMI0&#58; BMI before initiation of metformin monotherapy&#59; BMI3&#58; BMI after three months of metformin monotherapy&#59; BMI&#58; body mass index&#46;</p>"
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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0060">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Visceral adipose tissue &#40;VAT&#41;&#44; anatomically located around certain organs&#44; is now accepted as an endocrine organ which secretes various adipokines that influence both nearby and distant tissues&#46; Imbalance between pro- and anti-inflammatory adipokines secreted from VAT contributes to the pathogenesis of certain cardiovascular and metabolic disorders&#44; including insulin resistance&#46;<a class="elsevierStyleCrossRef" href="#bib0150"><span class="elsevierStyleSup">1</span></a> Epicardial adipose tissue &#40;EAT&#41;&#44; an organ-specific VAT&#44; is mainly found in the atrioventricular and interventricular grooves and along the major branches of the coronary arteries&#44; and to a lesser extent around the atria&#44; over the free wall of the right ventricle and over the apex of the left ventricle&#46;<a class="elsevierStyleCrossRef" href="#bib0155"><span class="elsevierStyleSup">2</span></a> Evidence is accumulating that bioactive molecules secreted by EAT can directly affect intima-media thickness and regulate vasomotor function&#46;<a class="elsevierStyleCrossRef" href="#bib0160"><span class="elsevierStyleSup">3</span></a> Furthermore&#44; there is emerging evidence that EAT has a direct association with coronary atherosclerosis&#46;<a class="elsevierStyleCrossRef" href="#bib0165"><span class="elsevierStyleSup">4</span></a> In view of the putative proatherogenic effect of EAT&#44; several clinical trials have shown a positive correlation between EAT thickness and coronary atherosclerosis&#46;<a class="elsevierStyleCrossRefs" href="#bib0170"><span class="elsevierStyleSup">5&#8211;7</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">Although its exact mechanism of action is unknown&#44; metformin is regarded as the gold standard treatment for type 2 diabetes&#46;<a class="elsevierStyleCrossRef" href="#bib0185"><span class="elsevierStyleSup">8</span></a> Beside its glucose-lowering effect&#44; metformin also has a favorable effect on body weight&#44; primarily due to reduction of VAT&#46;<a class="elsevierStyleCrossRef" href="#bib0190"><span class="elsevierStyleSup">9</span></a> In this study&#44; we investigated the effects of metformin on EAT thickness and body mass index &#40;BMI&#41; in type 2 diabetes patients&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Methods</span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Study population</span><p id="par0015" class="elsevierStylePara elsevierViewall">In this prospective observational study&#44; we analyzed consecutive patients referred to the internal medicine outpatient clinic between September 1&#44; 2015 and May 31&#44; 2016&#46; Patients with BMI &#60;20 or &#62;35 kg&#47;m<span class="elsevierStyleSup">2</span> or poor echocardiographic window were excluded&#46; A total of 47 newly diagnosed type 2 diabetes patients prescribed metformin monotherapy were selected&#46; Clinical and demographic features of the selected patients were recorded&#46; All patients were informed about the study and written consent was obtained&#46; The study was approved by the local ethics committee&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Study protocol</span><p id="par0020" class="elsevierStylePara elsevierViewall">Before initiation of metformin monotherapy&#44; the BMI of all recruited patients was calculated &#40;BMI0&#41; and all underwent transthoracic echocardiography to assess EAT thickness &#40;EAT0&#41;&#46; Metformin 1000 mg twice daily was prescribed to all participants&#46; After three months of metformin monotherapy&#44; BMI was recalculated &#40;BMI3&#41; and transthoracic echocardiographic studies were repeated to measure EAT thickness &#40;EAT3&#41;&#44; and the resulting data were statistically analyzed&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Measurement of epicardial adipose tissue thickness</span><p id="par0025" class="elsevierStylePara elsevierViewall">All included patients underwent detailed two-dimensional &#40;2D&#41;&#44; M-mode&#44; Doppler&#44; and tissue Doppler transthoracic echocardiography using standard techniques before beginning metformin monotherapy and after three months of treatment&#46; The echocardiograms were performed by two experienced cardiologists who were blinded to the subjects&#8217; clinical and demographic data&#46; Each subject underwent 2D-guided M-mode transthoracic echocardiography using commercially available equipment &#40;Aplio 500&#44; Toshiba&#44; Irvine&#44; CA&#41;&#46; Standard parasternal and apical views were obtained in left lateral decubitus position&#46; EAT was visualized as echo-free space between the outer wall of the myocardium and the visceral layer of the pericardium &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Figure 1</a>&#41;&#46; EAT thickness was measured perpendicularly on the free wall of the right ventricle during three cardiac cycles at end-diastole&#46; Parasternal long- and short-axis views provided the most accurate measurement of EAT in the right ventricle&#44; with optimal cursor beam orientation in each view&#46; Maximum EAT thickness was measured at the point on the free wall of the right ventricle along the midline of the ultrasound beam perpendicular to the aortic annulus&#44; used as an anatomic landmark for this view&#46; For midventricular parasternal short-axis assessment&#44; maximum EAT thickness was measured on the right ventricular free wall along the midline of the ultrasound beam&#44; perpendicular to the ventricular septum at midchordal and tip of the papillary muscle level&#44; as anatomic landmarks&#46; The mean values from three cardiac cycles in each echocardiographic view were analyzed&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Statistical analysis</span><p id="par0030" class="elsevierStylePara elsevierViewall">The statistical analysis was conducted using SPSS software&#44; version 16&#46;0 &#40;IBM&#44; Chicago&#44; IL&#41;&#46; Data were expressed as mean &#177; standard deviation for continuous variables and as counts and percentage for categorical variables&#46; The Student&#39;s t test was used to compare continuous variables&#44; while the chi-square and Fisher&#39;s exact tests were used to compare categorical variables&#46; Correlations of continuous variables were assessed using Pearson correlation analysis&#46; Values 0-0&#46;3 indicated weak&#44; 0&#46;3-0&#46;7 indicated intermediate&#44; and 0&#46;7-1&#46;0 indicated strong correlation&#46; A p value &#60;0&#46;05 was considered statistically significant&#46;</p></span></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Results</span><p id="par0035" class="elsevierStylePara elsevierViewall">Seven patients were excluded due to metformin intolerance during the follow-up period&#44; and so a total of 40 patients were analyzed&#46; Of the study population&#44; 23 &#40;57&#46;5&#37;&#41; were male and mean age was 48&#46;6&#177;1&#46;99 years&#46; Fourteen patients &#40;35&#37;&#41; had hypertension&#44; 12 &#40;30&#37;&#41; had hyperlipidemia and 13 &#40;32&#46;5&#37;&#41; were smokers&#46; Mean fasting blood glucose was 280&#46;38&#177;14&#46;88 mg&#47;dl before beginning metformin monotherapy&#44; falling to 129&#46;01&#177;17&#46;00 mg&#47;dl after three months of therapy&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">EAT thickness was significantly decreased after three months of metformin monotherapy &#40;EAT0&#61; 5&#46;07&#177;1&#46;33 mm vs&#46; EAT3&#61;4&#46;76&#177;1&#46;32 mm&#59; p&#60;0&#46;001&#41; &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Figure 2</a>&#41;&#46;</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0045" class="elsevierStylePara elsevierViewall">Furthermore&#44; BMI was also significantly decreased after three months of metformin monotherapy &#40;BMI0&#61;28&#46;27&#177;2&#46;71 vs&#46; BMI3&#61;27&#46;29&#177;2&#46;10&#59; p&#60;0&#46;0001&#41; &#40;<a class="elsevierStyleCrossRef" href="#fig0015">Figure 3</a>&#41;&#46;</p><elsevierMultimedia ident="fig0015"></elsevierMultimedia><p id="par0050" class="elsevierStylePara elsevierViewall">We also analyzed the correlation between the decrease in EAT &#40;formulated as EAT0 - EAT3&#41; and mean fasting blood glucose level before beginning metformin monotherapy and BMI0&#46; A statistically non-significant positive correlation was found between decrease in EAT and mean fasting blood glucose before beginning therapy &#40;r&#61;0&#46;19&#59; p&#61;0&#46;056&#41; and BMI0 &#40;r&#61;0&#46;17&#59; p&#61;0&#46;053&#41;&#46;</p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Discussion</span><p id="par0055" class="elsevierStylePara elsevierViewall">In this study we demonstrated that metformin monotherapy significantly decreases EAT thickness and BMI as early as the third month of therapy&#46;</p><p id="par0060" class="elsevierStylePara elsevierViewall">Because of its vital endocrine function and close anatomical relation to the coronary arteries&#44; many studies have set out to determine the effects of EAT on cardiovascular disease&#46; Mahabadi et al&#46; showed the existence of a relation between cardiovascular risk factors&#44; myocardial infarction and EAT thickness&#44;<a class="elsevierStyleCrossRef" href="#bib0195"><span class="elsevierStyleSup">10</span></a> while Cavalcante et al&#46; found a significant association between subclinical coronary atherosclerosis&#44; metabolic syndrome&#44; diastolic dysfunction and EAT thickness&#46;<a class="elsevierStyleCrossRef" href="#bib0200"><span class="elsevierStyleSup">11</span></a> In a recently published study&#44; Abazid et al&#46; also concluded that higher EAT volume is associated with greater coronary artery calcification&#44;<a class="elsevierStyleCrossRef" href="#bib0205"><span class="elsevierStyleSup">12</span></a> and Wu et al&#46; showed that EAT thickness is positively correlated with obstructive coronary artery disease &#40;CAD&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0210"><span class="elsevierStyleSup">13</span></a></p><p id="par0065" class="elsevierStylePara elsevierViewall">Although the exact mechanism is unknown&#44; several hypotheses have been put forward to explain this relation&#46; EAT is a metabolically active fat depot which is rich in proinflammatory and proatherogenic cytokines including interleukin &#40;IL&#41;-1&#946;&#44; IL-6&#44; and tumor necrosis factor &#40;TNF&#41;-&#945;&#46;<a class="elsevierStyleCrossRef" href="#bib0215"><span class="elsevierStyleSup">14</span></a> In a recent study&#44; Vrselja et al&#46; demonstrated that TNF-&#945; levels were increased in CAD patients&#46;<a class="elsevierStyleCrossRef" href="#bib0220"><span class="elsevierStyleSup">15</span></a> Furthermore&#44; Eiras et al&#46; postulated that the extent of CAD was associated with the expression of IL-6 mRNA in EAT&#46;<a class="elsevierStyleCrossRef" href="#bib0225"><span class="elsevierStyleSup">16</span></a></p><p id="par0070" class="elsevierStylePara elsevierViewall">EAT shares the same embryologic origin as mesenteric and omental fat&#46;<a class="elsevierStyleCrossRefs" href="#bib0230"><span class="elsevierStyleSup">17&#44;18</span></a> They all encase viscera in close contact&#44; with no fascial barrier&#46;<a class="elsevierStyleCrossRef" href="#bib0240"><span class="elsevierStyleSup">19</span></a> Hence it has been suggested that EAT may have endocrine and paracrine effects on the adjacent coronary arterial wall that could result in atherosclerotic plaque development&#46;<a class="elsevierStyleCrossRefs" href="#bib0245"><span class="elsevierStyleSup">20&#8211;22</span></a> These findings highlight the potential role of increased EAT thickness in atherosclerosis&#46; It could therefore be postulated that decreased EAT would produce less proinflammatory and proatherogenic cytokines and be less likely to cause atherosclerosis&#46;</p><p id="par0075" class="elsevierStylePara elsevierViewall">Metformin is now accepted as the first-line drug for use as monotherapy in type 2 diabetes patients&#46; It is thought to affect certain aspects of the body&#39;s metabolism&#46; It inhibits hepatic gluconeogenesis&#44; augments peripheral glucose uptake&#44; and reduces insulin demand&#46;<a class="elsevierStyleCrossRef" href="#bib0185"><span class="elsevierStyleSup">8</span></a> Various studies have also investigated the effect of metformin on body weight and visceral adipose tissue&#46; In a recent study&#44; Alfaras et al&#46; showed in mice that metformin significantly reduces body weight within the first weeks of treatment&#44; without affecting food consumption or energy expenditure&#46;<a class="elsevierStyleCrossRef" href="#bib0260"><span class="elsevierStyleSup">23</span></a> Yanovski et al&#46; showed that metformin significantly reduced body weight in children with insulin resistance&#44;<a class="elsevierStyleCrossRef" href="#bib0265"><span class="elsevierStyleSup">24</span></a> while Tokubuchi et al&#46; demonstrated that metformin treatment caused significant reductions in visceral fat mass&#44; probably through a potential shift of fuel resource into fat oxidation and upregulation of thermogenesis&#46;<a class="elsevierStyleCrossRef" href="#bib0270"><span class="elsevierStyleSup">25</span></a></p><p id="par0080" class="elsevierStylePara elsevierViewall">Although there have been many studies on the effects of metformin on body weight and VAT&#44; there is hardly any data about its effect on EAT&#46; In our study&#44; we showed that metformin significantly reduces BMI and EAT thickness&#46; Magnetic resonance imaging &#40;MRI&#41; and computed tomography &#40;CT&#41; are the gold-standard techniques for quantifying EAT volume&#46; Due to the difficulty in standardizing localization of the measurement site&#44; reference values for EAT assessed by CT are uncertain&#46;<a class="elsevierStyleCrossRef" href="#bib0275"><span class="elsevierStyleSup">26</span></a> Iacobellis et al&#46; were the first to propose that transthoracic echocardiography could be an easy and reliable imaging method for EAT prediction&#46;<a class="elsevierStyleCrossRef" href="#bib0280"><span class="elsevierStyleSup">27</span></a> MRI and transthoracic echocardiography provide comparable results for detection of EAT volume&#46;<a class="elsevierStyleCrossRef" href="#bib0285"><span class="elsevierStyleSup">28</span></a> Hence measurement of EAT by transthoracic echocardiography is practical&#44; cost-effective&#44; safe&#44; rapid&#44; and well correlated to gold-standard techniques&#46;<a class="elsevierStyleCrossRef" href="#bib0290"><span class="elsevierStyleSup">29</span></a></p></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">Study limitations</span><p id="par0085" class="elsevierStylePara elsevierViewall">As this is the first study to investigate the effect of metformin on EAT thickness&#44; it is subject to some limitations&#44; the main ones being its relatively small sample size and the lack of data on inflammatory markers&#46; Due to financial constraints we were unable to analyze the possible effects of inflammation on the results&#46; Larger-scale and more detailed studies should be designed to clarify the exact mechanisms underlying the favorable effects of metformin on EAT thickness and BMI&#46;</p></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0105">Conclusion</span><p id="par0090" class="elsevierStylePara elsevierViewall">To the best of our knowledge&#44; our study demonstrates for the first time in the literature that metformin significantly reduces EAT thickness in newly diagnosed type 2 diabetes&#46; Because EAT volume is closely related to atherosclerosis&#44; it could be concluded that EAT is a modifiable risk factor for atherosclerosis and that metformin could significantly reduce the frequency of coronary atherosclerosis&#46; Metformin could even become the aspirin of the 21st century&#46; Further studies on a larger scale are needed to support these findings&#46;</p></span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0110">Conflicts of interest</span><p id="par0095" class="elsevierStylePara elsevierViewall">The authors have no conflicts of interest to declare&#46;</p></span></span>"
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          "identificador" => "xres1244374"
          "titulo" => "Abstract"
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          "titulo" => "Keywords"
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            0 => array:2 [
              "identificador" => "sec0015"
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              "identificador" => "sec0020"
              "titulo" => "Study protocol"
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            2 => array:2 [
              "identificador" => "sec0025"
              "titulo" => "Measurement of epicardial adipose tissue thickness"
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            3 => array:2 [
              "identificador" => "sec0030"
              "titulo" => "Statistical analysis"
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    "fechaRecibido" => "2018-03-04"
    "fechaAceptado" => "2018-08-01"
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        0 => array:4 [
          "clase" => "keyword"
          "titulo" => "Keywords"
          "identificador" => "xpalclavsec1153967"
          "palabras" => array:4 [
            0 => "Adipose tissue"
            1 => "Coronary atherosclerosis"
            2 => "Type 2 diabetes"
            3 => "Metformin"
          ]
        ]
      ]
      "pt" => array:1 [
        0 => array:4 [
          "clase" => "keyword"
          "titulo" => "Palavras-chave"
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          "palabras" => array:4 [
            0 => "Tecido adiposo"
            1 => "Aterosclerose coron&#225;ria"
            2 => "Diabetes tipo 2"
            3 => "Metformina"
          ]
        ]
      ]
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    "resumen" => array:2 [
      "en" => array:3 [
        "titulo" => "Abstract"
        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Introduction</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Imbalance between pro- and anti-inflammatory cytokines secreted from visceral adipose tissue &#40;VAT&#41; contributes to the pathogenesis of certain cardiovascular and metabolic disorders&#44; including insulin resistance&#46; Epicardial adipose tissue &#40;EAT&#41; is a form of VAT mainly concentrated along the coronary arteries&#46; It has been shown in various studies that EAT thickness is positively correlated with cardiovascular disease&#46; Due to its high worldwide prevalence&#44; prevention and management of type 2 diabetes &#40;T2D&#41; has become a major public health challenge&#46; Metformin&#44; the most widely prescribed drug to treat T2D&#44; has favorable effects on VAT and body weight&#46; As metformin decreases VAT mass&#44; in this prospective study we analyzed the possible positive effect of metformin on EAT mass&#44; which is organ-specific VAT&#44; and body mass index &#40;BMI&#41;&#46;</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Methods</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Subjects were selected from patients admitted to the internal medicine outpatient clinic&#46; Newly diagnosed T2D patients treated with metformin monotherapy were analyzed and 40 patients were included&#46; EAT thickness in the included patients was measured echocardiographically&#46; BMI and EAT thickness were analyzed at the beginning &#40;BMI0 and EAT0&#41; and after three months of metformin monotherapy &#40;BMI3 and EAT3&#41;&#46;</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Results</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">There was a statistically significant decrease in EAT thickness after three months of metformin monotherapy &#40;EAT0&#61;5&#46;07&#177;1&#46;33 mm vs&#46; EAT3&#61;4&#46;76&#177;1&#46;32 mm&#59; p&#60;0&#46;001&#41;&#46; Furthermore&#44; BMI was also significantly decreased &#40;BMI0&#61;28&#46;27&#177;2&#46;71 vs&#46; BMI3&#61;27&#46;29&#177;2&#46;10&#59; p&#60;0&#46;0001&#41;&#46;</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Conclusions</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">In this study we show that metformin monotherapy significantly decreases EAT thickness and BMI in T2D patients&#46; This suggests that metformin could reduce the frequency of coronary atherosclerosis&#46;</p></span>"
        "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"
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        ]
      ]
      "pt" => array:3 [
        "titulo" => "Resumo"
        "resumen" => "<span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Objetivos</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">O desequil&#237;brio entre as citocinas pro e anti-inflamat&#243;rias segregadas pelo tecido adiposo visceral &#40;TAV&#41; contribui para a patog&#233;nese de certas doen&#231;as cardiovasculares e metab&#243;licas&#44; incluindo a resist&#234;ncia &#224; insulina&#46; O tecido adiposo epic&#225;rdico &#40;EAT&#41; &#233; o TAV&#44; concentrado principalmente ao longo das art&#233;rias coron&#225;rias&#46; &#201; previamente demonstrado em v&#225;rios estudos que a espessura do EAT est&#225; positivamente correlacionada com a frequ&#234;ncia de doen&#231;a cardiovascular&#46; Devido &#224; alta preval&#234;ncia mundial&#44; a preven&#231;&#227;o e tratamento da diabetes <span class="elsevierStyleItalic">mellitus</span> tipo 2 &#40;DM2&#41; tornou-se um grande desafio para a sa&#250;de p&#250;blica&#46; A metformina&#44; o medicamento mais amplamente prescrito para o tratamento da DM2&#44; tem efeitos favor&#225;veis no TAV e no peso corporal&#46; Como a metformina diminui a massa do TAV&#44; neste estudo prospetivo&#44; analisamos o poss&#237;vel efeito positivo da metformina na massa do EAT&#44; que &#233; o TAV do &#243;rg&#227;o e o &#237;ndice de massa corporal&#46;</p></span> <span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">M&#233;todos</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Os indiv&#237;duos foram selecionados dos doentes admitidos no ambulat&#243;rio de medicina interna&#46; Doentes rec&#233;m-diagnosticados com DM2 tratados com metformina em monoterapia foram investigados&#46; Foram inclu&#237;dos 40 doentes&#46; A espessura do EAT dos doentes inclu&#237;dos foi medida por ecocardiografia&#46; A espessura do IMC e do EAT no in&#237;cio e tr&#234;s meses ap&#243;s a monoterapia com metformina foi analisada&#46;</p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Resultados</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Houve redu&#231;&#227;o estatisticamente significativa na espessura do EAT ap&#243;s tr&#234;s meses de monoterap&#234;utica com metformina &#40;EAT0&#61;5&#44;07&#177;1&#44;33 mm <span class="elsevierStyleItalic">versus</span> EAT3&#61;4&#44;76&#177;1&#44;32 mm&#59; p&#60;0&#44;001&#41;&#46; Al&#233;m disso&#44; o IMC tamb&#233;m diminuiu significativamente &#40;IMC0&#61;28&#44;27&#177;2&#44;71 <span class="elsevierStyleItalic">versus</span> IMC3&#61;27&#44;29&#177;2&#44;10&#59; p&#60;0&#44;0001&#41;&#46;</p><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">Conclus&#245;es Neste estudo&#44; verific&#225;mos que a metformina em monoterapia diminui significativamente a espessura do EAT e o IMC nos doentes com DM2&#44; pelo que se pode concluir que a metformina pode reduzir a frequ&#234;ncia de aterosclerose coron&#225;ria&#46;</p></span>"
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        "nota" => "<p class="elsevierStyleNotepara" id="npar0005">This work was presented as an oral presentation at the 32nd Turkish National Cardiology Congress &#40;October 20-23&#44; 2016&#41;&#46;</p>"
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          "en" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Measurement of EAT thickness&#46; &#40;A&#41; Parasternal long-axis view&#59; &#40;B&#41; parasternal short-axis view&#46; Ao&#58; aorta&#59; EAT&#58; epicardial adipose tissue&#59; LV&#58; left ventricle&#59; RV&#58; right ventricle&#46;</p>"
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      "seccion" => array:1 [
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                    0 => array:2 [
                      "titulo" => "Vasocrine signalling from perivascular fat&#58; a mechanism linking insulin resistance to vascular disease"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:3 [
                            0 => "J&#46;S&#46; Yudkin"
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                            2 => "C&#46;D&#46; Stehouwer"
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                      ]
                    ]
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                      "doi" => "10.1016/S0140-6736(05)66585-3"
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                        "tituloSerie" => "Lancet"
                        "fecha" => "2005"
                        "volumen" => "365"
                        "paginaInicial" => "1817"
                        "paginaFinal" => "1820"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/15910955"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
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              "identificador" => "bib0155"
              "etiqueta" => "2"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Epicardial adipose tissue&#58; anatomic&#44; biomolecular and clinical relationships with the heart"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:3 [
                            0 => "G&#46; Iacobellis"
                            1 => "D&#46; Corradi"
                            2 => "A&#46;M&#46; Sharma"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1038/ncpcardio0319"
                      "Revista" => array:6 [
                        "tituloSerie" => "Nat Clin Pract Cardiovasc Med"
                        "fecha" => "2005"
                        "volumen" => "2"
                        "paginaInicial" => "536"
                        "paginaFinal" => "543"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/16186852"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            2 => array:3 [
              "identificador" => "bib0160"
              "etiqueta" => "3"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Human epicardial adipose tissue&#58; a review"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:2 [
                            0 => "H&#46;S&#46; Sacks"
                            1 => "J&#46;N&#46; Fain"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1016/j.ahj.2007.03.019"
                      "Revista" => array:6 [
                        "tituloSerie" => "Am Heart J"
                        "fecha" => "2007"
                        "volumen" => "153"
                        "paginaInicial" => "907"
                        "paginaFinal" => "917"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/17540190"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
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              "identificador" => "bib0165"
              "etiqueta" => "4"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Association of epicardial adipose tissue with coronary atherosclerosis is region-specific and independent of conventional risk factors and intra-abdominal adiposity"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:3 [
                            0 => "T&#46;D&#46; Wang"
                            1 => "W&#46;J&#46; Lee"
                            2 => "F&#46;Y&#46; Shih"
                          ]
                        ]
                      ]
                    ]
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                    0 => array:2 [
                      "doi" => "10.1016/j.atherosclerosis.2010.07.055"
                      "Revista" => array:6 [
                        "tituloSerie" => "Atherosclerosis"
                        "fecha" => "2010"
                        "volumen" => "213"
                        "paginaInicial" => "279"
                        "paginaFinal" => "287"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/20801451"
                            "web" => "Medline"
                          ]
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                ]
              ]
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              "identificador" => "bib0170"
              "etiqueta" => "5"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Clinical significance of epicardial fat measured using cardiac multislice computed tomography"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:3 [
                            0 => "S&#46; Sarin"
                            1 => "C&#46; Wenger"
                            2 => "A&#46; Marwaha"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1016/j.amjcard.2008.04.058"
                      "Revista" => array:7 [
                        "tituloSerie" => "Am J Cardiol"
                        "fecha" => "2008"
                        "volumen" => "102"
                        "paginaInicial" => "767"
                        "paginaFinal" => "771"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/18774004"
                            "web" => "Medline"
                          ]
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                          "pii" => "S0140673613622199"
                          "estado" => "S300"
                          "issn" => "01406736"
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                  ]
                ]
              ]
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            5 => array:3 [
              "identificador" => "bib0175"
              "etiqueta" => "6"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "The association of pericardial fat with incident coronary heart disease&#58; the Multi Ethnic Study of Atherosclerosis &#40;MESA&#41;"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:3 [
                            0 => "J&#46; Ding"
                            1 => "F&#46;C&#46; Hsu"
                            2 => "T&#46;B&#46; Harris"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.3945/ajcn.2008.27358"
                      "Revista" => array:6 [
                        "tituloSerie" => "Am J Clin Nutr"
                        "fecha" => "2009"
                        "volumen" => "90"
                        "paginaInicial" => "499"
                        "paginaFinal" => "504"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/19571212"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
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            6 => array:3 [
              "identificador" => "bib0180"
              "etiqueta" => "7"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Subepicardial adipose tissue and the presence and severity of coronary artery disease"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:3 [
                            0 => "N&#46; Chaowalit"
                            1 => "V&#46;K&#46; Somers"
                            2 => "P&#46;A&#46; Pellikka"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1016/j.atherosclerosis.2005.08.004"
                      "Revista" => array:6 [
                        "tituloSerie" => "Atherosclerosis"
                        "fecha" => "2006"
                        "volumen" => "186"
                        "paginaInicial" => "354"
                        "paginaFinal" => "359"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/16183065"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            7 => array:3 [
              "identificador" => "bib0185"
              "etiqueta" => "8"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Metformin &#8211; a new old drug"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:3 [
                            0 => "M&#46;P&#46; Wr&#243;bel"
                            1 => "B&#46; Marek"
                            2 => "D&#46; Kajdaniuk"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.5603/EP.2017.0050"
                      "Revista" => array:6 [
                        "tituloSerie" => "Endokrynol Pol"
                        "fecha" => "2017"
                        "volumen" => "68"
                        "paginaInicial" => "482"
                        "paginaFinal" => "496"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/28819951"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            8 => array:3 [
              "identificador" => "bib0190"
              "etiqueta" => "9"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Selective decrease in visceral fat is associated with weight loss during metformin treatment in African Americans with type 2 diabetes"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:3 [
                            0 => "R&#46; Kurukulasuriya"
                            1 => "M&#46;A&#46; Banerji"
                            2 => "R&#46; Chaiken"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:4 [
                        "tituloSerie" => "Diabetes"
                        "fecha" => "1999"
                        "volumen" => "48"
                        "paginaInicial" => "315"
                      ]
                    ]
                  ]
                ]
              ]
            ]
            9 => array:3 [
              "identificador" => "bib0195"
              "etiqueta" => "10"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Association of epicardial fat with cardiovascular risk factors and incident myocardial infarction in the general population&#58; the Heinz Nixdorf Recall Study"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:3 [
                            0 => "A&#46;A&#46; Mahabadi"
                            1 => "M&#46;H&#46; Berg"
                            2 => "N&#46; Lehmann"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1016/j.jacc.2012.11.062"
                      "Revista" => array:6 [
                        "tituloSerie" => "J Am Coll Cardiol"
                        "fecha" => "2013"
                        "volumen" => "61"
                        "paginaInicial" => "1388"
                        "paginaFinal" => "1395"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/23433560"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            10 => array:3 [
              "identificador" => "bib0200"
              "etiqueta" => "11"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Association of epicardial fat&#44; hypertension&#44; subclinical coronary artery disease&#44; and metabolic syndrome with left ventricular diastolic dysfunction"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:3 [
                            0 => "J&#46;L&#46; Cavalcante"
                            1 => "B&#46;K&#46; Tamarappoo"
                            2 => "R&#46; Hachamovitch"
                          ]
                        ]
                      ]
                    ]
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                    0 => array:2 [
                      "doi" => "10.1016/j.amjcard.2012.07.045"
                      "Revista" => array:6 [
                        "tituloSerie" => "Am J Cardiol"
                        "fecha" => "2012"
                        "volumen" => "110"
                        "paginaInicial" => "1793"
                        "paginaFinal" => "1798"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/22980968"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
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            11 => array:3 [
              "identificador" => "bib0205"
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              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Relation between epicardial fat and subclinical atherosclerosis in asymptomatic individuals"
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                        0 => array:2 [
                          "etal" => true
                          "autores" => array:3 [
                            0 => "R&#46;M&#46; Abazid"
                            1 => "O&#46;A&#46; Smettei"
                            2 => "M&#46;O&#46; Kattea"
                          ]
                        ]
                      ]
                    ]
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                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1097/RTI.0000000000000296"
                      "Revista" => array:6 [
                        "tituloSerie" => "J Thorac Imaging"
                        "fecha" => "2017"
                        "volumen" => "32"
                        "paginaInicial" => "378"
                        "paginaFinal" => "382"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/28817459"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            12 => array:3 [
              "identificador" => "bib0210"
              "etiqueta" => "13"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "The relation of location-specific epicardial adipose tissue thickness and obstructive coronary artery disease&#58; systemic review and meta-analysis of observational studies"
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                        0 => array:2 [
                          "etal" => true
                          "autores" => array:3 [
                            0 => "F&#46;Z&#46; Wu"
                            1 => "K&#46;J&#46; Chou"
                            2 => "Y&#46;L&#46; Huang"
                          ]
                        ]
                      ]
                    ]
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                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1186/1471-2261-14-62"
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                        "tituloSerie" => "BMC Cardiovasc Disord"
                        "fecha" => "2014"
                        "volumen" => "14"
                        "paginaInicial" => "62"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/24884458"
                            "web" => "Medline"
                          ]
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                    ]
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                ]
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            13 => array:3 [
              "identificador" => "bib0215"
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                0 => array:2 [
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                    0 => array:2 [
                      "titulo" => "Association of epicardial adipose tissue and high-risk plaque characteristics&#58; a systematic review and meta-analysis"
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                        0 => array:2 [
                          "etal" => true
                          "autores" => array:3 [
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                            2 => "R&#46;G&#46; Muthalaly"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:3 [
                        "tituloSerie" => "J Am Heart Assoc"
                        "fecha" => "2017"
                        "volumen" => "6"
                      ]
                    ]
                  ]
                ]
              ]
            ]
            14 => array:3 [
              "identificador" => "bib0220"
              "etiqueta" => "15"
              "referencia" => array:1 [
                0 => array:2 [
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                    0 => array:2 [
                      "titulo" => "Transcardial gradient of adiponectin&#44; interleukin-6 and tumor necrosis factor-&#945; in overweight coronary artery disease patients"
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                        0 => array:2 [
                          "etal" => true
                          "autores" => array:3 [
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                        ]
                      ]
                    ]
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                  "host" => array:1 [
                    0 => array:2 [
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                        "tituloSerie" => "Cytokine"
                        "fecha" => "2015"
                        "volumen" => "76"
                        "paginaInicial" => "321"
                        "paginaFinal" => "327"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/26385653"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
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                ]
              ]
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            15 => array:3 [
              "identificador" => "bib0225"
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              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Extension of coronary artery disease is associated with increased IL-6 and decreased adiponectin gene expression in epicardial adipose tissue"
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                        0 => array:2 [
                          "etal" => true
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                        ]
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                    0 => array:2 [
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                        "tituloSerie" => "Cytokine"
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                        "volumen" => "43"
                        "paginaInicial" => "174"
                        "paginaFinal" => "180"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/18562207"
                            "web" => "Medline"
                          ]
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                ]
              ]
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            16 => array:3 [
              "identificador" => "bib0230"
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              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Association of pericardial fat and coronary high-risk lesions as determined by cardiac CT"
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                          "autores" => array:3 [
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                        ]
                      ]
                    ]
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                  "host" => array:1 [
                    0 => array:2 [
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                        "tituloSerie" => "Atherosclerosis"
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                        "paginaInicial" => "129"
                        "paginaFinal" => "134"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/22417843"
                            "web" => "Medline"
                          ]
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                      ]
                    ]
                  ]
                ]
              ]
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              "identificador" => "bib0235"
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                0 => array:2 [
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                    0 => array:2 [
                      "titulo" => "Relationship of epicardial fat volume to coronary plaque&#44; severe coronary stenosis&#44; and high-risk coronary plaque features assessed by coronary CT angiography"
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                          "etal" => true
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                      ]
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                    0 => array:2 [
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                        "tituloSerie" => "J Cardiovasc Comput Tomogr"
                        "fecha" => "2013"
                        "volumen" => "7"
                        "paginaInicial" => "125"
                        "paginaFinal" => "132"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/23622507"
                            "web" => "Medline"
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                ]
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            18 => array:3 [
              "identificador" => "bib0240"
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                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Epicardial and perivascular adipose tissues and their influence on cardiovascular disease&#58; basic mechanisms and clinical associations"
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                          "etal" => false
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                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1161/JAHA.113.000582"
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                        "tituloSerie" => "J Am Heart Assoc"
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                        "volumen" => "3"
                        "paginaInicial" => "e000582"
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                          0 => array:2 [
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              "identificador" => "bib0245"
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                0 => array:2 [
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                    0 => array:2 [
                      "titulo" => "Relationship between epicardial fat and quantitative coronary artery plaque progression&#58; insights from computer tomography coronary angiography"
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                          "autores" => array:3 [
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                            2 => "K&#46; Munnur"
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                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:5 [
                        "tituloSerie" => "Int J Cardiovasc Imaging"
                        "fecha" => "2016"
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                        "paginaInicial" => "317"
                        "paginaFinal" => "328"
                      ]
                    ]
                  ]
                ]
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                0 => array:2 [
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                    0 => array:2 [
                      "titulo" => "Epicardial adipose tissue volume and adipocytokine imbalance are strongly linked to human coronary atherosclerosis"
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                          "etal" => true
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                            2 => "M&#46; Tabata"
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                    ]
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                  "host" => array:1 [
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                        "tituloSerie" => "Arterioscler Thromb Vasc Biol"
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                        "paginaInicial" => "1077"
                        "paginaFinal" => "1084"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/23471228"
                            "web" => "Medline"
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                ]
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              "identificador" => "bib0255"
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                      "titulo" => "Eccentric atherosclerotic plaques with positive remodelling have a pericardial distribution&#58; a permissive role of epicardial fat&#63; A three-dimensional intravascular ultrasound study of left anterior descending artery lesions"
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                        "tituloSerie" => "Eur Heart J"
                        "fecha" => "2003"
                        "volumen" => "24"
                        "paginaInicial" => "329"
                        "paginaFinal" => "336"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/12581680"
                            "web" => "Medline"
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                  ]
                ]
              ]
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            22 => array:3 [
              "identificador" => "bib0260"
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              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Health benefits of late-onset metformin treatment every other week in mice"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:3 [
                            0 => "I&#46; Alfaras"
                            1 => "S&#46;J&#46; Mitchell"
                            2 => "H&#46; Mora"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1038/s41514-017-0018-7"
                      "Revista" => array:5 [
                        "tituloSerie" => "NPJ Aging Mech Dis"
                        "fecha" => "2017"
                        "volumen" => "3"
                        "paginaInicial" => "16"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/29167747"
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                      "titulo" => "Effects of metformin on body weight and body composition in obese insulin-resistant children&#58; a randomized clinical trial"
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                        0 => array:2 [
                          "etal" => true
                          "autores" => array:3 [
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                            2 => "C&#46;G&#46; Salaita"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.2337/db10-1185"
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                        "tituloSerie" => "Diabetes"
                        "fecha" => "2011"
                        "volumen" => "60"
                        "paginaInicial" => "477"
                        "paginaFinal" => "485"
                        "link" => array:1 [
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                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/21228310"
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                0 => array:2 [
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                    0 => array:2 [
                      "titulo" => "Beneficial effects of metformin on energy metabolism and visceral fat volume through a possible mechanism of fatty acid oxidation in human subjects and rats"
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                        0 => array:2 [
                          "etal" => true
                          "autores" => array:3 [
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                    0 => array:2 [
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                        "volumen" => "12"
                        "paginaInicial" => "e0171293"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/28158227"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
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              "etiqueta" => "26"
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                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Relation of epicardial and pericoronary fat to coronary atherosclerosis and coronary artery calcium in patients undergoing coronary angiography"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:3 [
                            0 => "P&#46;M&#46; Gorter"
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                            2 => "Y&#46; van der Graaf"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1016/j.amjcard.2008.04.002"
                      "Revista" => array:7 [
                        "tituloSerie" => "Am J Cardiol"
                        "fecha" => "2008"
                        "volumen" => "102"
                        "paginaInicial" => "380"
                        "paginaFinal" => "385"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/18678291"
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                          ]
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                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Epicardial fat from echocardiography&#58; a new method for visceral adipose tissue prediction"
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                        0 => array:2 [
                          "etal" => true
                          "autores" => array:3 [
                            0 => "G&#46; Iacobellis"
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                            2 => "M&#46;C&#46; Ribaudo"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1038/oby.2003.45"
                      "Revista" => array:7 [
                        "tituloSerie" => "Obes Res"
                        "fecha" => "2003"
                        "volumen" => "11"
                        "paginaInicial" => "304"
                        "paginaFinal" => "310"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/12582228"
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                          "issn" => "22138587"
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                    ]
                  ]
                ]
              ]
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                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Pericardial rather than epicardial fat is a cardiometabolic risk marker&#58; an MRI vs echo study"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:3 [
                            0 => "R&#46; Sicari"
                            1 => "A&#46;M&#46; Sironi"
                            2 => "R&#46; Petz"
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                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1016/j.echo.2011.06.013"
                      "Revista" => array:6 [
                        "tituloSerie" => "J Am Soc Echocardiogr"
                        "fecha" => "2011"
                        "volumen" => "24"
                        "paginaInicial" => "1156"
                        "paginaFinal" => "1162"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/21795020"
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                      ]
                    ]
                  ]
                ]
              ]
            ]
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              "referencia" => array:1 [
                0 => array:2 [
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                    0 => array:2 [
                      "titulo" => "Epicardial adipose tissue imaged by magnetic resonance imaging&#58; an important risk marker of cardiovascular disease"
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                          "etal" => false
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                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1136/hrt.2005.074872"
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                        "tituloSerie" => "Heart"
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                        "volumen" => "92"
                        "paginaInicial" => "962"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/16775103"
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ISSN: 21742049
Original language: English
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