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juntamente com a Espanha e os pa&#237;ses de Leste&#44; o grupo de pa&#237;ses que recruta menos de 5&#37; dos potenciais candidatos a estes programas&#44; quando a m&#233;dia europeia &#233; de 30&#37;<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a>&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">S&#227;o escassos os estudos que estimam os efeitos a longo prazo ap&#243;s PRC&#44; na manuten&#231;&#227;o das medidas preventivas institu&#237;das nas fases iniciais&#44; sobretudo na realidade portuguesa&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">A Unidade de Preven&#231;&#227;o e Reabilita&#231;&#227;o Cardiovascular &#40;UPRCV&#41; do Centro Hospitalar do Porto&#47;Hospital de Santo Ant&#243;nio &#233; atualmente coordenada por Fisiatra e Cardiologista&#44; incluindo ainda especialistas de Cirurgia Vascular&#44; Urologia&#44; Psiquiatria&#44; Endocrinologia e t&#233;cnicos de Sa&#250;de nas &#225;reas de Fisioterapia&#44; Nutri&#231;&#227;o e Enfermagem&#46; Os PRC realizados na UPRCV s&#227;o compostos por 3 fases distintas e sequenciais&#44; de acordo com as diretrizes internacionais<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a>&#46; Os doentes s&#227;o orientados para o programa atrav&#233;s de consulta externa ou do internamento de Cardiologia&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">A fase <span class="elsevierStyleSmallCaps">i</span>&#44; iniciada no internamento&#44; inclui o registo de dados anamn&#233;sicos&#44; despiste de comorbilidades e educa&#231;&#227;o dos doentes e cuidadores relativamente &#224; doen&#231;a e aos seus FRCV&#59; &#233; ainda encorajado o in&#237;cio precoce da mobiliza&#231;&#227;o ativa&#44; de forma supervisionada&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">A fase <span class="elsevierStyleSmallCaps">ii</span> inicia-se na UPRCV&#44; 2 a 3 semanas ap&#243;s a alta hospitalar&#44; com uma consulta de Medicina F&#237;sica e de Reabilita&#231;&#227;o &#40;MFR&#41;&#46; &#201; continuado o processo educativo e efetuada uma avalia&#231;&#227;o cl&#237;nica global que inclui anamnese e exame dos aparelhos cardiorrespirat&#243;rio&#44; neurol&#243;gico e musculoesquel&#233;tico&#44; bem como a sua avalia&#231;&#227;o funcional&#46; S&#227;o posteriormente agendados exames complementares de diagn&#243;stico &#40;nomeadamente&#44; prova de esfor&#231;o e estudo anal&#237;tico&#41; para posterior estratifica&#231;&#227;o do risco card&#237;aco&#44; fundamentando a prescri&#231;&#227;o do exerc&#237;cio&#44; de acordo com <span class="elsevierStyleItalic">guidelines</span> vigentes<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a>&#46; Os doentes s&#227;o ainda orientados para as consultas espec&#237;ficas que decorrem na UPRCV&#44; consoante a indica&#231;&#227;o cl&#237;nica &#40;Nutri&#231;&#227;o&#44; Psiquiatria&#44; Desabitua&#231;&#227;o Tab&#225;gica&#44; Urologia e Cirurgia Vascular&#41;&#46; Esta fase tem uma dura&#231;&#227;o habitual de 8 semanas&#44; podendo&#44; no entanto&#44; variar entre 6 e 12 semanas&#44; consoante necessidade cl&#237;nica e resposta ao exerc&#237;cio&#46; &#201; constitu&#237;da por sess&#245;es educativas semanais &#40;versando temas relacionados com os FRCV e a doen&#231;a cardiovascular&#41; e sess&#245;es de exerc&#237;cio terap&#234;utico&#46; Estas decorrem com periodicidade bissemanal&#44; com m&#233;dico Fisiatra e Cardiologista em regime presencial&#44; respeitando as recomenda&#231;&#245;es internacionais no que se refere ao n&#237;vel de supervis&#227;o e monitoriza&#231;&#227;o adequado a cada caso<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a>&#46; Adicionalmente&#44; &#233; incentivada a pr&#225;tica do exerc&#237;cio nos restantes dias da semana&#44; com base nos princ&#237;pios gerais da prescri&#231;&#227;o&#44; fomentando o seu incremento de forma segura&#46; A dura&#231;&#227;o da sess&#227;o varia entre 60 e 90<span class="elsevierStyleHsp" style=""></span>min&#44; englobando um protocolo de exerc&#237;cio constitu&#237;do por&#58; fase de aquecimento&#44; treino aer&#243;bio &#40;tapete rolante tipo <span class="elsevierStyleItalic">treadmill</span>&#44; cicloerg&#243;metro de membros inferiores e superiores&#41;&#44; treino de for&#231;a &#40;com recurso a halteres&#44; bolas medicinais e m&#225;quina de fortalecimento muscular&#41;&#44; arrefecimento e exerc&#237;cios de flexibilidade&#46; A intensidade de cada modalidade de exerc&#237;cio &#233; determinada individualmente&#44; com base no c&#225;lculo de Frequ&#234;ncia Card&#237;aca de Treino &#40;FCT&#41; atrav&#233;s do m&#233;todo de Karvonen<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a>&#44; utilizando os dados recolhidos na prova de esfor&#231;o &#40;PE&#41;&#59; &#233; complementada com a perce&#231;&#227;o subjetiva do esfor&#231;o registada na escala de Borg<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a>&#46; Cada sess&#227;o contempla uma avalia&#231;&#227;o cl&#237;nica sumarizada&#44; incluindo question&#225;rio de sintomas relevantes e o cumprimento de farmacoterapia&#46; A altera&#231;&#227;o de f&#225;rmacos ou a otimiza&#231;&#227;o de dosagens e&#47;ou posologias&#44; quando indicado&#44; &#233; realizada pelo cardiologista que integra a equipa da UPRCV&#44; sempre com o conhecimento do cardiologista assistente&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">Na fase <span class="elsevierStyleSmallCaps">iii</span>&#44; de <span class="elsevierStyleItalic">follow-up</span>&#44; o doente &#233; avaliado e orientado no sentido da manuten&#231;&#227;o do exerc&#237;cio f&#237;sico&#44; dos comportamentos saud&#225;veis e da ades&#227;o &#224; terap&#234;utica institu&#237;da&#46; O seguimento &#233; mantido em regime de consulta externa de MFR&#44; com reavalia&#231;&#227;o anal&#237;tica e funcional &#40;atrav&#233;s de PE&#41; aos 6 e 12 meses ap&#243;s o in&#237;cio da fase <span class="elsevierStyleSmallCaps">ii</span>&#44; o que permite a revis&#227;o das vari&#225;veis do treino previamente prescrito&#44; nomeadamente a sua intensidade&#44; reajustando a FCT sempre que indicado&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">O presente estudo tem como objetivo avaliar os efeitos de um PRC no controlo dos FRCV em doentes com DCI ao longo de 12 meses de <span class="elsevierStyleItalic">follow-up</span>&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">M&#233;todos</span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Popula&#231;&#227;o</span><p id="par0045" class="elsevierStylePara elsevierViewall">Foram inclu&#237;dos neste estudo os doentes com diagn&#243;stico de DCI que completaram o PRC baseado no exerc&#237;cio &#40;m&#237;nimo de 8 sess&#245;es supervisionadas&#41; durante o per&#237;odo de janeiro de 2008 a dezembro de 2009 sem perda de dados no <span class="elsevierStyleItalic">follow-up</span>&#46;</p><p id="par0050" class="elsevierStylePara elsevierViewall">Os doentes foram avaliados em 3 momentos&#58; avalia&#231;&#227;o inicial &#40;primeira consulta da fase <span class="elsevierStyleSmallCaps">ii</span> do PRC&#41; aos 3&#44; 6 e aos 12 meses&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Fatores de risco cardiovascular</span><p id="par0055" class="elsevierStylePara elsevierViewall">Os FRCV foram definidos de acordo com as <span class="elsevierStyleItalic">guidelines</span> da Sociedade Europeia de Cardiologia<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a>&#46;</p><p id="par0060" class="elsevierStylePara elsevierViewall">O registo do perfil lip&#237;dico incluiu as avalia&#231;&#245;es do colesterol total &#40;CT&#41;&#44; do colesterol das lipoprote&#237;nas de baixa densidade &#40;LDL&#41; &#40;<span class="elsevierStyleItalic">low density lipoprotein cholesterol</span> &#91;C-LDL&#93;&#41;&#44; do colesterol das lipoprote&#237;nas de alta densidade &#40;HDL&#41; &#40;<span class="elsevierStyleItalic">high density lipoprotein cholesterol</span> &#91;C-HDL&#93;&#41; e triglicer&#237;deos &#40;TG&#41;&#46; Foram considerados os seguintes valores de refer&#234;ncia<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a> CT<span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleMonospace">&#60;</span><span class="elsevierStyleHsp" style=""></span>175<span class="elsevierStyleHsp" style=""></span>mg&#47;dl&#44; C-LDL<span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleMonospace">&#60;</span><span class="elsevierStyleHsp" style=""></span>100<span class="elsevierStyleHsp" style=""></span>mg&#47;dl&#44; C- HDL<span class="elsevierStyleHsp" style=""></span>&#62;<span class="elsevierStyleHsp" style=""></span>45<span class="elsevierStyleHsp" style=""></span>mg&#47;dl e TG<span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleMonospace">&#60;</span><span class="elsevierStyleHsp" style=""></span>150<span class="elsevierStyleHsp" style=""></span>mg&#47;dl&#46; Os valores anal&#237;ticos foram obtidos ap&#243;s cumprimento de um jejum de 12<span class="elsevierStyleHsp" style=""></span>h&#46;</p><p id="par0065" class="elsevierStylePara elsevierViewall">A composi&#231;&#227;o corporal dos doentes foi avaliada atrav&#233;s do registo do peso corporal&#44; per&#237;metro abdominal &#40;PA&#41; e &#237;ndice de massa corporal &#40;IMC&#41;&#46; A obesidade foi determinada de acordo com o valor do IMC &#40;peso&#47;altura<span class="elsevierStyleSup">2</span>&#41;&#44; &#237;ndice internacionalmente utilizado para a sua classifica&#231;&#227;o&#44; sendo objetivada quando IMC &#8805;<span class="elsevierStyleHsp" style=""></span>30<span class="elsevierStyleHsp" style=""></span>kg&#47;m<span class="elsevierStyleSup">2</span>&#46; Os indiv&#237;duos com um IMC de 25 a 29&#44;9<span class="elsevierStyleHsp" style=""></span>kg&#47;m<span class="elsevierStyleSup">2</span> foram classificados como excesso de peso ou pr&#233;-obesidade&#46; Relativamente ao PA&#44; foram considerados elevados valores superiores a 80<span class="elsevierStyleHsp" style=""></span>cm para o sexo feminino e superiores a 94<span class="elsevierStyleHsp" style=""></span>cm para o sexo masculino&#46;</p><p id="par0070" class="elsevierStylePara elsevierViewall">Os valores de tens&#227;o arterial foram registados e foram considerados elevados os superiores a 130&#47;80<span class="elsevierStyleHsp" style=""></span>mmHg em 2 avalia&#231;&#245;es consecutivas&#46;</p><p id="par0075" class="elsevierStylePara elsevierViewall">Nos doentes diab&#233;ticos&#44; foram considerados os valores de glicemia capilar e hemoglobina glicosilada &#40;HbA1c&#41; no que se refere ao controlo da sua doen&#231;a&#46; Foram adotados como valores anormais glicemia capilar &#40;jejum&#41; &#8805;<span class="elsevierStyleHsp" style=""></span>110<span class="elsevierStyleHsp" style=""></span>mg&#47;dl e HbA1c<span class="elsevierStyleHsp" style=""></span>&#8805;<span class="elsevierStyleHsp" style=""></span>6&#44;5&#37;&#46;</p><p id="par0080" class="elsevierStylePara elsevierViewall">Os h&#225;bitos tab&#225;gicos foram questionados e registados&#44; sendo considerados como n&#227;o fumadores aqueles que n&#227;o tinham qualquer consumo tab&#225;gico&#46;</p><p id="par0085" class="elsevierStylePara elsevierViewall">Relativamente &#224; avalia&#231;&#227;o do n&#237;vel de atividade f&#237;sica&#44; os doentes responderam ao <span class="elsevierStyleItalic">International Physical Activity Questionnaire</span> &#40;IPAQ&#41;&#46; Este question&#225;rio foi validado para a popula&#231;&#227;o portuguesa<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a> e visa quantificar &#40;em MET&#47;min&#47;semana&#41; a atividade f&#237;sica realizada ao longo de uma semana&#44; nos diversos contextos das atividades di&#225;rias &#40;nomeadamente atividades dom&#233;sticas&#44; laborais&#44; desportivas e recreativas&#41;&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">An&#225;lise estat&#237;stica</span><p id="par0090" class="elsevierStylePara elsevierViewall">Realizou-se um estudo prospetivo com registo e an&#225;lise dos dados com recurso ao programa <span class="elsevierStyleItalic">Statistical Package for the Social Sciences</span> &#40;SPSS&#41; 17&#46;0&#46; As vari&#225;veis qualitativas foram apresentadas em percentagens e as vari&#225;veis quantitativas como m&#233;dia &#40;&#177;<span class="elsevierStyleHsp" style=""></span>desvio-padr&#227;o&#41;&#46; Os par&#226;metros quantitativos foram comparados com o teste t de <span class="elsevierStyleItalic">student</span> e os qualitativos com o teste <span class="elsevierStyleItalic">McNemar</span>&#46; Valores de p inferiores a 0&#44;05 foram considerados estatisticamente significativos&#46;</p></span></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Resultados</span><p id="par0095" class="elsevierStylePara elsevierViewall">De uma amostra total de 329 doentes&#44; foram exclu&#237;dos 73 por perda de dados durante o <span class="elsevierStyleItalic">follow-up</span>&#46;</p><p id="par0100" class="elsevierStylePara elsevierViewall">A amostra em estudo abrangeu 256 doentes&#44; sendo que a grande maioria foi orientada para PRC atrav&#233;s do internamento de Cardiologia &#40;81&#44;6&#37;&#41;&#46; A maioria dos doentes era do sexo masculino &#40;76&#44;2&#37;&#41; e a idade m&#233;dia foi de 61&#44;1 anos &#40;&#177;<span class="elsevierStyleHsp" style=""></span>10&#44;6&#41;&#44; variando entre os 30 e os 83 anos&#46; O diagn&#243;stico de admiss&#227;o mais frequente foi a s&#237;ndrome coron&#225;ria aguda &#40;SCA&#41; &#40;65&#44;3&#37;&#41; &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">Tabela 1</a>&#41;&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0105" class="elsevierStylePara elsevierViewall">A preval&#234;ncia e evolu&#231;&#227;o dos FRCV ao longo do estudo s&#227;o apresentadas de seguida &#40;<a class="elsevierStyleCrossRefs" href="#tbl0010">Tabelas 2&#8211;4</a>&#41;&#46;</p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><elsevierMultimedia ident="tbl0015"></elsevierMultimedia><elsevierMultimedia ident="tbl0020"></elsevierMultimedia><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Dislipidemia</span><p id="par0110" class="elsevierStylePara elsevierViewall">&#192; admiss&#227;o a dislipidemia&#44; revelou-se o fator de risco cardiovascular mais prevalente &#40;74&#44;2&#37;&#41; na popula&#231;&#227;o estudada&#46;</p><p id="par0115" class="elsevierStylePara elsevierViewall">No final da fase <span class="elsevierStyleSmallCaps">ii</span> do PRC &#40;3 meses&#41; observou-se uma diminui&#231;&#227;o m&#233;dia do CT de 18<span class="elsevierStyleHsp" style=""></span>mg&#47;dl &#40;10&#44;2&#37;&#44; p<span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleMonospace">&#60;</span><span class="elsevierStyleHsp" style=""></span>0&#44;001&#41;&#59; 19<span class="elsevierStyleHsp" style=""></span>mg&#47;dl de C-LDL &#40;17&#44;6&#37;&#44; p<span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleMonospace">&#60;</span><span class="elsevierStyleHsp" style=""></span>0&#44;001&#41; e 19<span class="elsevierStyleHsp" style=""></span>mg&#47;dl de TG &#40;17&#44;6&#37;&#44; p<span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleMonospace">&#60;</span><span class="elsevierStyleHsp" style=""></span>0&#44;001&#41;&#46; Esta varia&#231;&#227;o resultou numa diminui&#231;&#227;o para quase metade do n&#250;mero de doentes com CT superior a 190<span class="elsevierStyleHsp" style=""></span>mg&#47;dl &#40;26&#44;2 para 12&#44;5&#37;&#44; p<span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleMonospace">&#60;</span><span class="elsevierStyleHsp" style=""></span>0&#44;001&#41; e o n&#250;mero de doentes com C-LDL superior a 100 passou de 55&#44;1 para 32&#37; &#40;p<span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleMonospace">&#60;</span><span class="elsevierStyleHsp" style=""></span>0&#44;001&#41;&#46; Aos 6 e 12 meses manteve-se uma diminui&#231;&#227;o estatisticamente significativa nos valores de CT &#40;6&#44;8 e 5&#44;1&#37; respetivamente&#44; p<span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleMonospace">&#60;</span><span class="elsevierStyleHsp" style=""></span>0&#44;001&#41;&#44; de C-LDL &#40;13&#44;9 e 12&#37;&#44; p<span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleMonospace">&#60;</span><span class="elsevierStyleHsp" style=""></span>0&#44;001&#41; e TG &#40;14&#44;1 e 16&#44;7&#37;&#44; p<span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleMonospace">&#60;</span><span class="elsevierStyleHsp" style=""></span>0&#44;001&#41; relativamente &#224; avalia&#231;&#227;o inicial&#46;</p><p id="par0120" class="elsevierStylePara elsevierViewall">Tamb&#233;m se observou um incremento estatisticamente significativo dos n&#237;veis de C-HDL aos 3 meses &#40;doentes com C-HDL inferior a 45<span class="elsevierStyleHsp" style=""></span>mg&#47;dl diminu&#237;ram de 71&#44;9 para 38&#44;2&#37; &#91;p<span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleMonospace">&#60;</span><span class="elsevierStyleHsp" style=""></span>0&#44;001&#93;&#41;&#44; assim como aos 6 e 12 meses&#44; mantendo-se este aumento praticamente sobrepon&#237;vel ao longo de todo o estudo&#46;</p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Obesidade</span><p id="par0125" class="elsevierStylePara elsevierViewall">Um IMC superior a 25<span class="elsevierStyleHsp" style=""></span>kg&#47;m<span class="elsevierStyleSup">2</span> surge como o segundo fator de risco mais frequente na popula&#231;&#227;o estudada &#40;71&#44;5&#37;&#41;&#44; sendo que 19&#44;9&#37; dos doentes eram obesos &#40;IMC<span class="elsevierStyleHsp" style=""></span>&#8805;<span class="elsevierStyleHsp" style=""></span>30<span class="elsevierStyleHsp" style=""></span>kg&#47;m<span class="elsevierStyleSup">2</span>&#41;&#46; Aos 3 meses observou-se uma diminui&#231;&#227;o m&#233;dia do peso corporal de 2&#44;5 &#40;3&#44;3&#37;&#44; p<span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleMonospace">&#60;</span><span class="elsevierStyleHsp" style=""></span>0&#44;001&#41;&#59; diminui&#231;&#227;o m&#233;dia de 3&#44;5&#37; no IMC &#40;p<span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleMonospace">&#60;</span><span class="elsevierStyleHsp" style=""></span>0&#44;001&#41; e diminui&#231;&#227;o m&#233;dia de 3<span class="elsevierStyleHsp" style=""></span>cm no per&#237;metro abdominal &#40;3&#44;7&#37;&#44; p<span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleMonospace">&#60;</span><span class="elsevierStyleHsp" style=""></span>0&#44;001&#41; na amostra global&#46; Assim&#44; o n&#250;mero total de obesos diminuiu de 19&#44;9 para 15&#44;2&#37; &#40;p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;002&#41; e o n&#250;mero de doentes com IMC &#8805;<span class="elsevierStyleHsp" style=""></span>25<span class="elsevierStyleHsp" style=""></span>kg&#47;m<span class="elsevierStyleSup">2</span> diminuiu de 71&#44;5 para 60&#44;6&#37; &#40;p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;003&#41;&#46; No entanto&#44; apesar de se observar uma diminui&#231;&#227;o estatisticamente significativa dos valores de peso corporal em todos os momentos de avalia&#231;&#227;o&#44; esta ocorreu sobretudo aos 3 meses&#44; observando-se posteriormente apenas uma ligeira diminui&#231;&#227;o nesta percentagem &#40;2&#44;8&#37; ao final dos 6 meses e 2&#44;5&#37; aos 12 meses na amostra global&#44; comparativamente com os par&#226;metros iniciais&#41;&#46; Relativamente ao IMC&#44; a diminui&#231;&#227;o significativa verificada aos 3 meses foi praticamente anulada ao final de 6 meses &#40;0&#44;3&#37;&#44; p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;92&#41;&#44; ou seja&#44; neste per&#237;odo&#44; a diferen&#231;a verificada em rela&#231;&#227;o ao IMC inicial n&#227;o foi estatisticamente significativa&#59; verificou-se novamente uma diminui&#231;&#227;o com significado estat&#237;stico aos 12 meses p&#243;s-in&#237;cio do programa &#40;2&#44;4&#37;&#44; p<span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleMonospace">&#60;</span><span class="elsevierStyleHsp" style=""></span>0&#44;001&#41;&#44; significando que o n&#250;mero de doentes com IMC &#8805;<span class="elsevierStyleHsp" style=""></span>25<span class="elsevierStyleHsp" style=""></span>kg&#47;m<span class="elsevierStyleSup">2</span> diminuiu de 71&#44;5 para 61&#44;3&#37; &#40;p<span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleMonospace">&#60;</span><span class="elsevierStyleHsp" style=""></span>0&#44;001&#41; e o n&#250;mero total de obesos diminuiu de 19&#44;9 para 16&#44;4&#37; &#40;p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;049&#41;&#46;</p><p id="par0130" class="elsevierStylePara elsevierViewall">Este estudo revelou que&#44; inicialmente&#44; 78&#44;7&#37; das mulheres apresentavam valores de PA superior a 88<span class="elsevierStyleHsp" style=""></span>cm e que 32&#44;3&#37; dos indiv&#237;duos do sexo masculino apresentavam PA superior a 102<span class="elsevierStyleHsp" style=""></span>cm&#46; Aos 3 meses&#44; verificou-se uma diminui&#231;&#227;o estatisticamente significativa no PA de 3<span class="elsevierStyleHsp" style=""></span>cm &#40;3&#44;7&#37;&#44; p<span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleMonospace">&#60;</span><span class="elsevierStyleHsp" style=""></span>0&#44;001&#41;&#59; esta diferen&#231;a foi diminuindo ao longo dos 6 meses e 12 meses de <span class="elsevierStyleItalic">follow-up</span>&#44; embora se mantivesse estatisticamente significativa em rela&#231;&#227;o &#224; avalia&#231;&#227;o inicial&#46;</p></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Hipertens&#227;o arterial</span><p id="par0135" class="elsevierStylePara elsevierViewall">No conjunto dos nossos doentes&#44; 62&#44;5&#37; apresentavam antecedentes de hipertens&#227;o arterial &#40;HTA&#41; e&#44; no momento da primeira avalia&#231;&#227;o&#44; 25&#44;8&#37; apresentavam valores tensionais elevados&#46;</p><p id="par0140" class="elsevierStylePara elsevierViewall">Aos 3 meses&#44; apenas 4&#44;3&#37; dos doentes mantinham HTA n&#227;o controlada &#40;p<span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleMonospace">&#60;</span><span class="elsevierStyleHsp" style=""></span>0&#44;001&#41;&#44; sendo essa percentagem de 9&#44;8&#37; &#40;p<span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleMonospace">&#60;</span><span class="elsevierStyleHsp" style=""></span>0&#44;001&#41; aos 6 meses e 7&#44;8&#37; &#40;p<span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleMonospace">&#60;</span><span class="elsevierStyleHsp" style=""></span>0&#44;001&#41; aos 12 meses&#46; Assim&#44; apesar de a diminui&#231;&#227;o ser significativa sobretudo no final da fase <span class="elsevierStyleSmallCaps">ii</span>&#44; manteve-se esse significado estat&#237;stico ao longo de todo o per&#237;odo de <span class="elsevierStyleItalic">follow-up</span>&#46;</p></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Diabetes <span class="elsevierStyleItalic">mellitus</span></span><p id="par0145" class="elsevierStylePara elsevierViewall">Na nossa amostra&#44; 34&#44;4&#37; dos doentes eram diab&#233;ticos e 55&#44;7&#37; destes apresentavam valores de HbA1c superiores a 6&#44;5&#37; no in&#237;cio do estudo&#46;</p><p id="par0150" class="elsevierStylePara elsevierViewall">Aos 3 meses&#44; verificou-se uma redu&#231;&#227;o m&#233;dia de 0&#44;8&#37; na HbA1c &#40;11&#44;3&#37;&#44; p<span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleMonospace">&#60;</span><span class="elsevierStyleHsp" style=""></span>0&#44;001&#41; e uma diminui&#231;&#227;o para aproximadamente metade no n&#250;mero de doentes com HbA1c superior a 6&#44;5&#37; &#40;de 55&#44;7 para 30&#44;7&#37;&#59; p<span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleMonospace">&#60;</span><span class="elsevierStyleHsp" style=""></span>0&#44;001&#41;&#46; Aos 6 meses&#44; obteve-se uma redu&#231;&#227;o m&#233;dia de 0&#44;5&#37; no valor de HbA1c &#40;7&#44;6&#37;&#44; p<span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleMonospace">&#60;</span><span class="elsevierStyleHsp" style=""></span>0&#44;001&#41;&#44; sendo este valor de 0&#44;5&#37; &#40;7&#44;1&#37;&#44; p<span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleMonospace">&#60;</span><span class="elsevierStyleHsp" style=""></span>0&#44;001&#41; aos 12 meses de <span class="elsevierStyleItalic">follow-up</span>&#44; mantendo-se o seu significado estat&#237;stico&#46;</p></span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Tabagismo</span><p id="par0155" class="elsevierStylePara elsevierViewall">No nosso estudo&#44; 28&#44;5&#37; dos doentes eram fumadores&#46;</p><p id="par0160" class="elsevierStylePara elsevierViewall">Aos 3 meses&#44; apenas 3&#44;9&#37; dos doentes mantinham h&#225;bitos tab&#225;gicos &#40;p<span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleMonospace">&#60;</span><span class="elsevierStyleHsp" style=""></span>0&#44;001&#41;&#44; correspondendo a uma diminui&#231;&#227;o de 86&#44;3&#37; na percentagem de fumadores ativos&#46; Aos 6 meses&#44; 7&#37; dos doentes fumavam &#40;p<span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleMonospace">&#60;</span><span class="elsevierStyleHsp" style=""></span>0&#44;001&#41; e aos 12 meses&#44; mantinha-se uma percentagem de fumadores ativos sobrepon&#237;vel &#40;p<span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleMonospace">&#60;</span><span class="elsevierStyleHsp" style=""></span>0&#44;001&#41;&#46;</p></span><span id="sec0060" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Sedentarismo</span><p id="par0165" class="elsevierStylePara elsevierViewall">No in&#237;cio do estudo 46&#44;5&#37; dos indiv&#237;duos eram sedent&#225;rios&#44; constatado pelos <span class="elsevierStyleItalic">scores</span> obtidos atrav&#233;s do preenchimento do IPAQ&#46;</p><p id="par0170" class="elsevierStylePara elsevierViewall">Aos 3 meses&#44; verificou-se um aumento de mais de 200&#37; nos n&#237;veis de atividade f&#237;sica semanal &#40;2&#160;852&#44;7 MET&#47;min&#47;semana&#41;&#44; reportada atrav&#233;s do question&#225;rio empregue&#46; Assim&#44; houve uma diminui&#231;&#227;o de 46&#44;5 para 11&#37; no n&#250;mero de indiv&#237;duos sedent&#225;rios &#40;p<span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleMonospace">&#60;</span><span class="elsevierStyleHsp" style=""></span>0&#44;001&#41;&#46; Aos 6 e 12 meses&#44; observou-se um aumento de 174&#37; nos n&#237;veis de atividade f&#237;sica semanal relativamente ao in&#237;cio do estudo &#40;p<span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleMonospace">&#60;</span><span class="elsevierStyleHsp" style=""></span>0&#44;001&#41;&#44; sendo a percentagem de indiv&#237;duos sedent&#225;rios de 8&#44;6 &#40;p<span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleMonospace">&#60;</span><span class="elsevierStyleHsp" style=""></span>0&#44;001&#41; e 9&#44;8&#37; &#40;p<span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleMonospace">&#60;</span><span class="elsevierStyleHsp" style=""></span>0&#44;001&#41;&#44; respetivamente&#46;</p></span></span><span id="sec0065" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Discuss&#227;o</span><p id="par0175" class="elsevierStylePara elsevierViewall">O principal objetivo deste estudo foi avaliar os efeitos a longo prazo dos PRC baseados no exerc&#237;cio nos doentes com DCI&#46; Foram tidos em considera&#231;&#227;o todos os FRCV modific&#225;veis&#58; obesidade&#44; per&#237;metro abdominal&#44; hipertens&#227;o arterial&#44; dislipidemia&#44; diabetes&#44; tabagismo e sedentarismo&#46;</p><p id="par0180" class="elsevierStylePara elsevierViewall">No nosso estudo&#44; observou-se uma elevada percentagem de doentes com dislipidemia &#224; admiss&#227;o &#40;74&#44;2&#37;&#41;&#44; o que est&#225; de acordo com a literatura<a class="elsevierStyleCrossRefs" href="#bib0060"><span class="elsevierStyleSup">11&#44;12</span></a>&#46; A rela&#231;&#227;o entre o CT&#44; o C-LDL e C-HDL e a doen&#231;a ateroscler&#243;tica assenta em bases cient&#237;ficas inquestion&#225;veis&#46; Os triglic&#233;ridos est&#227;o tamb&#233;m relacionados com um maior risco de doen&#231;a coron&#225;ria&#59; no entanto&#44; o seu papel na doen&#231;a cardiovascular ateroscler&#243;tica n&#227;o se encontra t&#227;o bem estabelecido<a class="elsevierStyleCrossRefs" href="#bib0040"><span class="elsevierStyleSup">8&#44;13</span></a>&#46; Sabe-se hoje que o risco da hipercolesterolemia &#233; progressivo e cont&#237;nuo e que a redu&#231;&#227;o do CT em 10&#37; leva a uma diminui&#231;&#227;o da incid&#234;ncia de DCI em 25&#37;&#44; ao fim de 5 anos<a class="elsevierStyleCrossRef" href="#bib0180"><span class="elsevierStyleSup">14</span></a>&#46; No final da fase <span class="elsevierStyleSmallCaps">ii</span> do PRC &#40;3 meses&#41;&#44; a percentagem de diminui&#231;&#227;o do CT ultrapassou em m&#233;dia os 10&#37;&#44; podendo inferir-se uma redu&#231;&#227;o importante no risco CV destes doentes&#46; Na literatura h&#225; resultados controversos relativamente aos efeitos a longo prazo dos PRC na dislipidemia&#46; H&#225; estudos em que se observa uma anula&#231;&#227;o do significado estat&#237;stico nos benef&#237;cios a longo prazo obtidos relativamente &#224; dislipidemia com os PRC<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">12</span></a>&#46; Outros estudos&#44; por&#233;m&#44; est&#227;o de acordo com os nossos resultados&#44; mantendo-se os benef&#237;cios a longo prazo de forma estatisticamente significativa<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">11</span></a>&#46; Algumas das explica&#231;&#245;es que t&#234;m sido apontadas para o sucesso destes resultados s&#227;o a coexist&#234;ncia em alguns programas de apoio de Nutricionista a todos os doentes e sess&#245;es educativas&#44; sendo nestes casos os benef&#237;cios obtidos de forma mais consistente&#46; Ambas as medidas foram inclu&#237;das no nosso PRC&#46;</p><p id="par0185" class="elsevierStylePara elsevierViewall">A preval&#234;ncia da obesidade&#44; ao n&#237;vel mundial&#44; &#233; t&#227;o elevada que a OMS considerou esta doen&#231;a como a epidemia global do s&#233;culo <span class="elsevierStyleSmallCaps">xxi</span>&#46; Os &#250;ltimos dados portugueses<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">15</span></a> apontam para uma preval&#234;ncia de excesso de peso e obesidade de 53&#44;6&#37;&#46; A popula&#231;&#227;o estudada apresentava uma maior preval&#234;ncia&#44; o que &#233; indicativo do maior risco a que esta popula&#231;&#227;o est&#225; sujeita&#46; Estes resultados est&#227;o de acordo com outros estudos que verificam igualmente uma elevada taxa de excesso de peso e obesidade neste tipo de popula&#231;&#245;es<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">12</span></a>&#46;</p><p id="par0190" class="elsevierStylePara elsevierViewall">Diversos estudos t&#234;m revelado que a obesidade por si s&#243; aumenta a mortalidade cardiovascular<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">16</span></a> e que uma redu&#231;&#227;o de 5&#37; no peso corporal reduz os fatores de risco cardiovascular e uma diminui&#231;&#227;o de 10&#37; tem efeitos significativos no perfil lip&#237;dico&#44; controlo da hipertens&#227;o&#44; resist&#234;ncia &#224; insulina e dist&#250;rbios na coagula&#231;&#227;o<a class="elsevierStyleCrossRefs" href="#bib0085"><span class="elsevierStyleSup">17&#44;18</span></a>&#46;</p><p id="par0195" class="elsevierStylePara elsevierViewall">&#201; atualmente reconhecido que a gordura&#44; particularmente a visceral&#44; &#233; um &#243;rg&#227;o metabolicamente ativo que &#233; capaz de sintetizar e libertar na corrente sangu&#237;nea uma variedade de componentes que assumem um papel importante na hemostase cardiovascular<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">19</span></a>&#46; Em Portugal&#44; a maioria das mulheres tem um per&#237;metro abdominal superior a 88<span class="elsevierStyleHsp" style=""></span>cm e a percentagem de homens no mesmo escal&#227;o de risco &#233; consideravelmente menor &#40;38&#37; tem um per&#237;metro abdominal &#62;<span class="elsevierStyleHsp" style=""></span>102<span class="elsevierStyleHsp" style=""></span>cm&#41;<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">20</span></a>&#46; Os dados do nosso estudo est&#227;o de acordo com o padr&#227;o nacional de predomin&#226;ncia no sexo feminino&#46;</p><p id="par0200" class="elsevierStylePara elsevierViewall">No final da fase <span class="elsevierStyleSmallCaps">ii</span>do PRC &#40;3 meses&#41; todos estes par&#226;metros estudados sofreram uma diminui&#231;&#227;o estatisticamente significativa&#46; Resultados semelhantes podem ser encontrados na literatura<a class="elsevierStyleCrossRefs" href="#bib0105"><span class="elsevierStyleSup">21&#44;22</span></a>&#44; comprovando a efic&#225;cia deste tipo de programas na redu&#231;&#227;o dos fatores de risco&#46; Aos 6 meses e 12 meses&#44; observou-se uma diminui&#231;&#227;o importante nos benef&#237;cios obtidos&#46; H&#225; na literatura alguns estudos que apontam mesmo para uma inexist&#234;ncia de melhoria estatisticamente significativa quando s&#227;o estudados estes par&#226;metros a longo prazo<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">12</span></a>&#46; Algumas das raz&#245;es que t&#234;m sido apontadas s&#227;o a n&#227;o incorpora&#231;&#227;o de programas espec&#237;ficos para a perda de peso dentro do PRC<a class="elsevierStyleCrossRefs" href="#bib0105"><span class="elsevierStyleSup">21&#44;22</span></a>&#46; O nosso estudo incluiu aconselhamento nutricional a cada doente feito por especialista em nutri&#231;&#227;o&#44; mas&#44; efetivamente&#44; na realiza&#231;&#227;o da prescri&#231;&#227;o do exerc&#237;cio n&#227;o foram adotadas medidas espec&#237;ficas para os doentes obesos&#46;</p><p id="par0205" class="elsevierStylePara elsevierViewall">A HTA em Portugal&#44; como na maioria dos pa&#237;ses mundiais&#44; constitui um importante problema de Sa&#250;de P&#250;blica&#44; dada a sua elevada preval&#234;ncia &#40;42&#37;&#41;&#44; baixa taxa de tratamento &#40;39&#37;&#41; e o n&#250;mero reduzido &#40;11&#37;&#41; de doentes controlados<a class="elsevierStyleCrossRef" href="#bib0180"><span class="elsevierStyleSup">14</span></a>&#46;</p><p id="par0210" class="elsevierStylePara elsevierViewall">Na nossa amostra 62&#44;5&#37; dos doentes apresentavam a HTA como FRCV e&#44; no momento da primeira avalia&#231;&#227;o&#44; 25&#44;8&#37; apresentavam valores tensionais elevados&#46; Verificou-se&#44; assim&#44; que a maioria dos doentes apresentavam valores tensionais controlados no in&#237;cio do PRC&#44; o que poder&#225; dever-se ao fato de a maioria se encontrar sob terap&#234;utica anti-hipertensiva otimizada&#44; j&#225; que foram sobretudo referenciados a partir do internamento de Cardiologia&#46;</p><p id="par0215" class="elsevierStylePara elsevierViewall">Os benef&#237;cios cl&#237;nicos absolutos da redu&#231;&#227;o da PA nos doentes hipertensos assentam em evid&#234;ncias cient&#237;ficas fortes e incontroversas<a class="elsevierStyleCrossRefs" href="#bib0040"><span class="elsevierStyleSup">8&#44;14</span></a>&#46; Est&#227;o bem estabelecidos os benef&#237;cios dos PRC baseados no exerc&#237;cio no controlo da tens&#227;o arterial<a class="elsevierStyleCrossRefs" href="#bib0115"><span class="elsevierStyleSup">23&#8211;25</span></a>&#46; Ao longo do nosso estudo&#44; podemos constatar o impacto positivo do PRC na diminui&#231;&#227;o da HTA&#44; sendo esta estatisticamente significativa em todos os momentos de avalia&#231;&#227;o efetuados&#44; sendo que&#44; ao final de 12 meses de seguimento&#44; apenas 7&#44;8&#37; dos doentes n&#227;o apresentavam valores tensionais controlados&#46;</p><p id="par0220" class="elsevierStylePara elsevierViewall">De acordo com a OMS&#44; estima-se que em 2025 haja 300 milh&#245;es de diab&#233;ticos em todo o mundo&#46; Em Portugal&#44; 6&#44;5&#37; da popula&#231;&#227;o adulta sofre de diabetes &#40;este n&#250;mero n&#227;o abrange os diab&#233;ticos n&#227;o diagnosticados &#8211; mais de 300 000 pessoas &#8211; pelo que a realidade est&#225; seguramente subvalorizada&#41;<a class="elsevierStyleCrossRef" href="#bib0180"><span class="elsevierStyleSup">14</span></a>&#46; A diabetes <span class="elsevierStyleItalic">mellitus</span> &#233; um fator de risco bem estabelecido para doen&#231;a cardiovascular&#46; Apesar de os doentes diab&#233;ticos terem uma elevada probabilidade de outros fatores de risco cardiovascular cl&#225;ssicos associados&#44; tais como hipertens&#227;o arterial e dislipidemia&#44; o risco 3 a 5 vezes aumentado de doen&#231;a cardiovascular associado &#224; diabetes <span class="elsevierStyleItalic">mellitus</span> parece ser independente dos fatores de risco cardiovascular cl&#225;ssicos<a class="elsevierStyleCrossRef" href="#bib0180"><span class="elsevierStyleSup">14</span></a>&#46;</p><p id="par0225" class="elsevierStylePara elsevierViewall">No in&#237;cio do estudo&#44; 34&#44;4&#37; dos doentes tinham antecedentes de DM e mais de metade apresentavam mau controlo da sua diabetes <span class="elsevierStyleItalic">mellitus</span> &#40;HbA1c superior a 6&#44;5&#37;&#41;&#46; Estes n&#250;meros est&#227;o bem acima dos dados nacionais&#44; o que poder&#225;&#44; por um lado&#44; representar a maior preval&#234;ncia deste fator de risco dentro dos doentes com doen&#231;a coron&#225;ria e&#44; por outro lado&#44; mostrar o subdiagn&#243;stico desta patologia na popula&#231;&#227;o em geral&#46; Os benef&#237;cios do exerc&#237;cio e PRC no controlo dos valores glic&#233;micos est&#227;o bem estabelecidos na literatura<a class="elsevierStyleCrossRefs" href="#bib0130"><span class="elsevierStyleSup">26&#44;27</span></a> e&#44; no nosso estudo&#44; verificou-se uma redu&#231;&#227;o para quase metade no n&#250;mero de doentes com mau controlo glic&#233;mico&#46;</p><p id="par0230" class="elsevierStylePara elsevierViewall">O tabagismo constitui o principal fator relacionado com a diminui&#231;&#227;o da esperan&#231;a de vida&#44; sendo respons&#225;vel por mais de 50&#37; das mortes evit&#225;veis &#40;metade das quais devidas a doen&#231;a aterotromb&#243;tica&#41;&#46; Em Portugal&#44; a preval&#234;ncia de fumadores di&#225;rios&#44; com mais de 10 anos de idade&#44; &#233; de 19&#44;6&#37;<a class="elsevierStyleCrossRef" href="#bib0180"><span class="elsevierStyleSup">14</span></a>&#46; A rela&#231;&#227;o entre o consumo e&#47;ou exposi&#231;&#227;o ao tabaco e o risco de desenvolver doen&#231;a coron&#225;ria&#44; doen&#231;a cerebrovascular ou doen&#231;a vascular perif&#233;rica est&#225; bem estabelecida&#46; A incid&#234;ncia de enfarte do mioc&#225;rdio aumenta 6 vezes nas mulheres e 3 vezes nos homens que fumam pelo menos 20 cigarros por dia &#40;em compara&#231;&#227;o com os indiv&#237;duos que nunca fumaram&#41;<a class="elsevierStyleCrossRef" href="#bib0180"><span class="elsevierStyleSup">14</span></a>&#46; Os seus efeitos delet&#233;rios s&#227;o cumulativos&#44; tanto em rela&#231;&#227;o ao consumo di&#225;rio como &#224; dura&#231;&#227;o dos h&#225;bitos tab&#225;gicos &#40;tempo de exposi&#231;&#227;o&#41;&#46; O estudo INTERHEART<a class="elsevierStyleCrossRef" href="#bib0140"><span class="elsevierStyleSup">28</span></a> mostrou que existe uma forte rela&#231;&#227;o entre o n&#250;mero de cigarros consumidos e o risco de SCA&#58; um consumo de um a cinco cigarros por dia aumenta o risco em 38&#37;&#44; havendo um incremento de 900&#37; quando o consumo di&#225;rio &#233; de 40 cigarros&#46; A redu&#231;&#227;o para metade no n&#250;mero de cigarros consumidos &#233; acompanhada de uma redu&#231;&#227;o igualmente para metade no risco de SCA&#46; A cessa&#231;&#227;o tab&#225;gica torna-se assim numa prioridade no contexto da RC&#46; A motiva&#231;&#227;o para a cessa&#231;&#227;o tab&#225;gica &#233; particularmente forte aquando do diagn&#243;stico de uma doen&#231;a aterotromb&#243;tica cardiovascular ou associada &#224; realiza&#231;&#227;o de algum tratamento invasivo&#44; como&#44; por exemplo&#44; cirurgia de <span class="elsevierStyleItalic">bypass</span> coron&#225;rio&#44; angioplastia ou cirurgia vascular<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">19</span></a>&#46; Assim&#44; a reabilita&#231;&#227;o card&#237;aca representa uma importante oportunidade para a insist&#234;ncia na import&#226;ncia da cessa&#231;&#227;o tab&#225;gica&#46;</p><p id="par0235" class="elsevierStylePara elsevierViewall">No nosso estudo&#44; a percentagem de doentes fumadores diminuiu drasticamente para mais de metade ao final do <span class="elsevierStyleItalic">follow-up</span>&#46; Estes dados est&#227;o de acordo com outros estudos encontrados na literatura que demonstram uma maior taxa de cessa&#231;&#227;o tab&#225;gica nos indiv&#237;duos que participam num PRC<a class="elsevierStyleCrossRef" href="#bib0145"><span class="elsevierStyleSup">29</span></a>&#46;</p><p id="par0240" class="elsevierStylePara elsevierViewall">A atividade f&#237;sica &#233; fundamental na preven&#231;&#227;o prim&#225;ria&#44; secund&#225;ria e terci&#225;ria da maioria das doen&#231;as cr&#243;nicas e&#47;ou degenerativas mais prevalentes na popula&#231;&#227;o contempor&#226;nea&#44; sobretudo com h&#225;bitos de vida ditos ocidentais&#44; nomeadamente das causas e consequ&#234;ncias da aterosclerose<a class="elsevierStyleCrossRef" href="#bib0180"><span class="elsevierStyleSup">14</span></a>&#46; Em 1997&#44; entre 15 pa&#237;ses da Uni&#227;o Europeia&#44; a popula&#231;&#227;o portuguesa era a que apresentava preval&#234;ncia mais alta de sedentarismo &#40;87&#44;8&#37;&#41;<a class="elsevierStyleCrossRef" href="#bib0150"><span class="elsevierStyleSup">30</span></a>&#46;</p><p id="par0245" class="elsevierStylePara elsevierViewall">Ao longo do nosso estudo&#44; o n&#250;mero de doentes sedent&#225;rios reduziu de forma dr&#225;stica e&#44; ao final de um ano de <span class="elsevierStyleItalic">follow-up</span>&#44; apenas 9&#44;8&#37; se mantinham sedent&#225;rios e o aumento da atividade f&#237;sica foi traduzido num incremento de 174&#37; nos n&#237;veis de atividade f&#237;sica semanal&#46; Estes achados enfatizam a import&#226;ncia da aplica&#231;&#227;o dos PRC nestes doentes&#46;</p><p id="par0250" class="elsevierStylePara elsevierViewall">Na avalia&#231;&#227;o final da fase <span class="elsevierStyleSmallCaps">ii</span> do PRC &#40;3 meses&#41;&#44; verificou-se uma melhoria importante e estatisticamente significativa em todos os fatores de risco cardiovascular nos doentes com DCI submetidos a PRC baseados no exerc&#237;cio&#44; o que est&#225; de acordo com os resultados reportados na literatura<a class="elsevierStyleCrossRefs" href="#bib0155"><span class="elsevierStyleSup">31&#8211;35</span></a> que evidenciam de forma consistente os benef&#237;cios inerentes &#224; implementa&#231;&#227;o deste tipo de programas&#46;</p><p id="par0255" class="elsevierStylePara elsevierViewall">Observou-se&#44; globalmente&#44; uma melhoria dos par&#226;metros relativos ao controlo dos FRCV&#44; que se manteve estatisticamente significativa ao longo dos 12 meses de <span class="elsevierStyleItalic">follow-up</span>&#44; embora com diminui&#231;&#227;o dos ganhos obtidos&#46; Esta diminui&#231;&#227;o verificou-se principalmente na avalia&#231;&#227;o efetuada aos 6 meses p&#243;s-in&#237;cio do estudo&#44; o que poder&#225; ser explicado pela dissipa&#231;&#227;o da motiva&#231;&#227;o inicial associada ao evento agudo&#46; A relativa melhoria observada aos 12 meses poder&#225; resultar do refor&#231;o de h&#225;bitos comportamentais e medidas preventivas &#40;sobretudo&#44; o cumprimento de plano alimentar e exerc&#237;cio f&#237;sico&#41; realizados na consulta dos 6 meses&#44; perante a constata&#231;&#227;o do agravamento dos referidos par&#226;metros comparativamente &#224; evolu&#231;&#227;o obtida ap&#243;s fase <span class="elsevierStyleSmallCaps">ii</span> do PRC&#46;</p><p id="par0260" class="elsevierStylePara elsevierViewall">A dificuldade na manuten&#231;&#227;o dos ganhos revelou-se particularmente evidente na an&#225;lise dos dados antropom&#233;tricos&#44; j&#225; que a melhoria no IMC foi o par&#226;metro em que se verificou a pior evolu&#231;&#227;o &#40;com a melhoria obtida nos primeiros 3 meses a ser praticamente anulada nos meses subsequentes&#41;&#46; Estes resultados est&#227;o de acordo com a literatura que tem encontrado uma maior dificuldade em encontrar diferen&#231;as com significados estat&#237;stico para os par&#226;metros referidos<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">12</span></a>&#46; As principais raz&#245;es apontadas s&#227;o&#44; como previamente referido&#44; a inexist&#234;ncia de medidas espec&#237;ficas de preven&#231;&#227;o para os obesos na prescri&#231;&#227;o do exerc&#237;cio&#46;</p><p id="par0265" class="elsevierStylePara elsevierViewall">Salientamos a import&#226;ncia do estudo por incluir os efeitos a longo prazo da implementa&#231;&#227;o de programas de reabilita&#231;&#227;o card&#237;aca&#44; numa amostra consider&#225;vel de doentes&#44; abrangendo a evolu&#231;&#227;o dos FRCV&#46; Na literatura&#44; escasseiam trabalhos que apresentem investiga&#231;&#245;es semelhantes&#44; limitando-se&#44; na maioria&#44; &#224; avalia&#231;&#227;o dos fatores de risco durante um per&#237;odo de tempo mais reduzido e com an&#225;lises menos abrangentes&#46; Trata-se igualmente do primeiro estudo&#44; na realidade portuguesa&#44; a reportar resultados de PRC com 12 meses de <span class="elsevierStyleItalic">follow-up</span> e com esta dimens&#227;o populacional&#46;</p><p id="par0270" class="elsevierStylePara elsevierViewall">A inexist&#234;ncia de um grupo de controlo constitui uma limita&#231;&#227;o formal do presente estudo&#44; mas&#44; dado que a literatura tem revelado de forma consistente&#44; nos estudos comparativos <span class="elsevierStyleItalic">usual care versus</span> reabilita&#231;&#227;o card&#237;aca&#44; os benef&#237;cios da integra&#231;&#227;o em PRC<a class="elsevierStyleCrossRef" href="#bib0175"><span class="elsevierStyleSup">35</span></a>&#44; estamos convictos de que estes resultados s&#227;o atribu&#237;dos especificamente &#224; reabilita&#231;&#227;o&#46;</p></span><span id="sec0070" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Conclus&#227;o</span><p id="par0275" class="elsevierStylePara elsevierViewall">O PRC pode assim ser implementado com sucesso no tratamento dos nossos doentes&#44; verificando-se manuten&#231;&#227;o de ganhos ao longo dos meses subsequentes&#46; No entanto&#44; verifica-se uma quebra destes ganhos ap&#243;s a cessa&#231;&#227;o da fase supervisionada em regime hospitalar e&#44; como tal&#44; parece-nos importante a implementa&#231;&#227;o de novas estrat&#233;gias que mantenham a ades&#227;o dos doentes durante todo o programa&#44; nas suas diversas fases&#46; &#201; importante a elucida&#231;&#227;o dos doentes&#44; ap&#243;s a fase <span class="elsevierStyleSmallCaps">ii</span>&#44; de que os resultados obtidos se perdem frequentemente ap&#243;s esta fase se n&#227;o for mantido o rigor do cumprimento das medidas preventivas institu&#237;das&#46; Outras interven&#231;&#245;es poder&#227;o ser adotadas&#58; realiza&#231;&#227;o de uma nova sess&#227;o trimensal de exerc&#237;cio supervisionado associado a uma sess&#227;o educativa&#44; refor&#231;ando conceitos fundamentais para a preven&#231;&#227;o e promo&#231;&#227;o de sa&#250;de&#59; realiza&#231;&#227;o de telefonemas mensais e otimiza&#231;&#227;o do contacto via meios inform&#225;ticos promovendo uma maior proximidade entre o doente e a equipa do PRC&#46; &#201; igualmente essencial responsabilizar o doente pelo seu tratamento e recupera&#231;&#227;o&#44; dado que esta depender&#225; maioritariamente das suas a&#231;&#245;es&#46;</p><p id="par0280" class="elsevierStylePara elsevierViewall">Na nossa opini&#227;o&#44; este estudo refor&#231;a a relev&#226;ncia deste tipo de programas na preven&#231;&#227;o secund&#225;ria da doen&#231;a ateroscler&#243;tica e apoia a sua aplicabilidade na pr&#225;tica cl&#237;nica&#46;</p><p id="par0285" class="elsevierStylePara elsevierViewall">Real&#231;a-se&#44; assim&#44; a necessidade de aumentar a taxa de referencia&#231;&#227;o dos doentes portugueses para os PRC existentes e a necessidade de criar novos centros nacionais&#44; de forma a poderem ser proporcionados cuidados considerados essenciais na recupera&#231;&#227;o plena p&#243;s-evento agudo e na preven&#231;&#227;o da doen&#231;a cardiovascular&#46;</p></span><span id="sec0075" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Responsabilidades &#233;ticas</span><span id="sec0080" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Prote&#231;&#227;o de pessoas e animais</span><p id="par0290" class="elsevierStylePara elsevierViewall">Os autores declaram que para esta investiga&#231;&#227;o n&#227;o se realizaram experi&#234;ncias em seres humanos e&#47;ou animais&#46;</p></span><span id="sec0085" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Confidencialidade dos dados</span><p id="par0295" class="elsevierStylePara elsevierViewall">Os autores declaram ter seguido os protocolos de seu centro de trabalho acerca da publica&#231;&#227;o dos dados de pacientes e que todos os pacientes inclu&#237;dos no estudo receberam informa&#231;&#245;es suficientes e deram o seu consentimento informado por escrito para participar nesse estudo&#46;</p></span><span id="sec0090" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Direito &#224; privacidade e consentimento escrito</span><p id="par0300" class="elsevierStylePara elsevierViewall">Os autores declaram ter recebido consentimento escrito dos pacientes e&#47;ou sujeitos mencionados no artigo&#46; O autor para correspond&#234;ncia deve estar na posse deste documento&#46;</p></span></span><span id="sec0095" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Conflito de interesses</span><p id="par0305" class="elsevierStylePara elsevierViewall">Os autores declaram n&#227;o haver conflito de interesses&#46;</p></span></span>"
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        "resumen" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Os programas de reabilita&#231;&#227;o card&#237;aca visam melhorar a capacidade funcional do doente com patologia card&#237;aca&#44; assim como educar e acompanhar no controlo dos seus fatores de risco cardiovasculares&#46;</p> <span class="elsevierStyleSectionTitle">Objetivo</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Avaliar os efeitos de um programa de reabilita&#231;&#227;o card&#237;aca em doentes com doen&#231;a card&#237;aca isqu&#233;mica ao longo de 12 meses de <span class="elsevierStyleItalic">follow-up</span> no que se refere ao controlo dos fatores de risco cardiovascular&#46;</p> <span class="elsevierStyleSectionTitle">M&#233;todos</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Estudo prospetivo que inclui doentes com diagn&#243;stico de doen&#231;a card&#237;aca isqu&#233;mica que completaram programa de reabilita&#231;&#227;o card&#237;aca baseado no exerc&#237;cio entre janeiro de 2008 a dezembro de 2009&#44; sem perda de dados no <span class="elsevierStyleItalic">follow-up</span>&#46; Foram avaliados num momento inicial &#40;primeira consulta da fase <span class="elsevierStyleSmallCaps">ii</span>&#41; aos 3&#44; 6 e 12 meses depois&#44; com registo dos seguintes par&#226;metros&#58; &#237;ndice de massa corporal&#44; circometria abdominal&#44; perfil lip&#237;dico&#44; HbA1c nos doentes diab&#233;ticos&#44; tens&#227;o arterial&#44; tabagismo e n&#237;vel de atividade f&#237;sica &#40;atrav&#233;s do <span class="elsevierStyleItalic">International Physical Activity Questionnaire</span>&#41;&#46;</p> <span class="elsevierStyleSectionTitle">Resultados</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Amostra de 256 doentes &#40;76&#44;2&#37;&#59; idade m&#233;dia&#58; 67 anos&#41;&#59; a dislipidemia revelou-se o fator de risco mais prevalente &#40;74&#44;2&#37;&#41; seguido de excesso ponderal &#40;71&#44;5&#37;&#41;&#46; No final da fase <span class="elsevierStyleSmallCaps">ii</span> ocorreu uma melhoria estatisticamente significativa &#40;p<span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleMonospace">&#60;</span><span class="elsevierStyleHsp" style=""></span>0&#44;05&#41; em todos os fatores de risco estudados&#44; que se manteve aos 6 e 12 meses de <span class="elsevierStyleItalic">follow-up</span>&#44; com a exce&#231;&#227;o do IMC &#40;perda do significado estat&#237;stico na avalia&#231;&#227;o dos 6 meses&#59; p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;92&#41;&#46;</p> <span class="elsevierStyleSectionTitle">Conclus&#227;o</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Este estudo salienta a necessidade de programas de reabilita&#231;&#227;o card&#237;aca no contexto da preven&#231;&#227;o secund&#225;ria da doen&#231;a cardiovascular e a import&#226;ncia de implementar estrat&#233;gias que potenciem a manuten&#231;&#227;o dos benef&#237;cios a longo prazo&#46;</p>"
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        "resumen" => "<span class="elsevierStyleSectionTitle">Introduction</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Cardiac rehabilitation programs are designed to improve patients&#8217; functional capacity&#44; as well as to educate them and to monitor their cardiovascular risk factors&#46;</p> <span class="elsevierStyleSectionTitle">Aim</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">The study aims to evaluate the effects of cardiac rehabilitation programs in patients with coronary disease over a 12-month follow-up period with regard to control of cardiovascular risk factors&#46;</p> <span class="elsevierStyleSectionTitle">Methods</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">This was a prospective study of patients diagnosed with coronary disease who completed an exercise-based cardiac rehabilitation program between January 2008 and December 2009 and who were not lost to follow-up&#46; Patients were evaluated at an early stage &#40;first medical consultation in phase <span class="elsevierStyleSmallCaps">II</span> of the program&#41; and 3&#44; 6 and 12 months later&#44; the following parameters being assessed&#58; weight and body mass index&#44; waist circumference&#44; lipid profile&#44; HbA1c in diabetic patients&#44; blood pressure&#44; smoking status and physical activity &#40;using the International Physical Activity Questionnaire&#41;&#46;</p> <span class="elsevierStyleSectionTitle">Results</span><p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">In the sample of 256 patients &#40;76&#46;2&#37; male&#44; mean age 67 years&#41;&#44; dyslipidemia proved to be the most prevalent risk factor &#40;74&#46;2&#37;&#41;&#44; followed by overweight &#40;71&#46;5&#37;&#41;&#46; There was a statistically significant improvement &#40;p&#60;0&#44;05&#41; in all risk factors studied at the end of phase <span class="elsevierStyleSmallCaps">II</span> of the program&#44; which was maintained at 6 and 12 months of follow-up&#44; with the exception of body mass index &#40;loss of statistical significance at 6-month assessment&#44; p&#61;0&#44;92&#41;&#46;</p> <span class="elsevierStyleSectionTitle">Conclusion</span><p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">This study highlights the need for cardiac rehabilitation programs in the context of secondary prevention of cardiovascular disease and the importance of implementing strategies that promote long-term maintenance of their benefits&#46;</p>"
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>40 anos&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t\ttop\n
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                  \t\t\t\t\ttop\n
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                  \t\t\t\t\ttop\n
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                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t\ttop\n
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                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
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                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
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                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
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                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>P&#243;s-implanta&#231;&#227;o CDI&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttop\n
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                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
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                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Insufici&#234;ncia card&#237;aca&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>P&#243;s-implanta&#231;&#227;o CRT&nbsp;\t\t\t\t\t\t\n
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                  """
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                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">PA<span class="elsevierStyleHsp" style=""></span>&#9792;<span class="elsevierStyleHsp" style=""></span>80-88<span class="elsevierStyleHsp" style=""></span>cm&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">9&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">3&#44;5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">PA<span class="elsevierStyleHsp" style=""></span>&#9792;<span class="elsevierStyleHsp" style=""></span>&#62;<span class="elsevierStyleHsp" style=""></span>88<span class="elsevierStyleHsp" style=""></span>cm&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">48&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">18&#44;8&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Dislipidemia&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">190&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">74&#44;2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Hipertens&#227;o arterial&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">160&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">62&#44;5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Tabagismo&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">73&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">28&#44;5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Diabetes&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">88&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">34&#44;4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Sedentarismo&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">119&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">46&#44;5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
              ]
              "imagenFichero" => array:1 [
                0 => "xTab354863.png"
              ]
            ]
          ]
        ]
        "descripcion" => array:1 [
          "pt" => "<p id="spar0065" class="elsevierStyleSimplePara elsevierViewall">Preval&#234;ncia dos fatores de risco cardiovascular</p>"
        ]
      ]
      2 => array:7 [
        "identificador" => "tbl0015"
        "etiqueta" => "Tabela 3"
        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "tabla" => array:2 [
          "leyenda" => "<p id="spar0080" class="elsevierStyleSimplePara elsevierViewall">CT&#58; colesterol total&#59; HbA1c&#58; hemoglobina glicosilada&#59; FRCV&#58; fatores de risco cardiovascular&#59; HDL&#58; lipoprote&#237;na de alta densidade&#59; IMC&#58; &#237;ndice de massa corporal&#59; LDL&#58; lipoprote&#237;na de baixa densidade&#59; PA&#58; per&#237;metro abdominal&#59; TA&#58; tens&#227;o arterial&#59; TG&#58; triglicer&#237;deos&#46;</p>"
          "tablatextoimagen" => array:1 [
            0 => array:2 [
              "tabla" => array:1 [
                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
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                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">Fator de risco&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">Inicial &#37; &#40;n&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">3 meses &#37; &#40;n&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">Sig&#46; p&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">6 meses &#37; &#40;n&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">Sig&#46; p&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">12 meses&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">Sig&#46; p&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">IMC&#160;&#8805;<span class="elsevierStyleHsp" style=""></span>25<span class="elsevierStyleHsp" style=""></span>kg&#47;m<span class="elsevierStyleSup">2</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">71&#44;5 &#40;183&#47;256&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">60&#44;6 &#40;155&#47;256&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleMonospace">&#60;</span><span class="elsevierStyleHsp" style=""></span>0&#44;001&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">59 &#40;151&#47;256&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleMonospace">&#60;</span><span class="elsevierStyleHsp" style=""></span>0&#44;001&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">61&#44;3 &#40;157&#47;256&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleMonospace">&#60;</span><span class="elsevierStyleHsp" style=""></span>0&#44;001&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Obesidade&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">19&#44;9 &#40;51&#47;256&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">15&#44;2 &#40;39&#47;256&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#44;002&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">16 &#40;41&#47;256&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#44;013&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">16&#44;4 &#40;42&#47;256&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#44;049&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">PA &#9792;<span class="elsevierStyleHsp" style=""></span>&#62;<span class="elsevierStyleHsp" style=""></span>88 cm&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">78&#44;7 &#40;48&#47;61&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">72&#44;1 &#40;44&#47;61&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#44;125&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">67&#44;2 &#40;41&#47;61&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#44;016&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">63&#44;9 &#40;39&#47;61&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#44;008&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">PA &#9794;<span class="elsevierStyleHsp" style=""></span>&#62;<span class="elsevierStyleHsp" style=""></span>102 cm&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">32&#44;3 &#40;63&#47;195&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">20 &#40;39&#47;195&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleMonospace">&#60;</span><span class="elsevierStyleHsp" style=""></span>0&#44;001&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">24&#44;1 &#40;47&#47;195&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#44;006&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">24&#44;6 &#40;48&#47;195&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#44;004&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">TA elevada&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">25&#44;8 &#40;66&#47;256&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">4&#44;3 &#40;11&#47;256&#41;&nbsp;\t\t\t\t\t\t\n
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