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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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Artigo Original
Efeitos a longo prazo de um programa de reabilitação cardíaca no controlo dos fatores de risco cardiovasculares
Long-term effects of a cardiac rehabilitation program in the control of cardiovascular risk factors
Sandra Magalhãesa,
Autor para correspondência
mag.sandra@gmail.com

Autor para correspondência.
, Sofia Viamontea, Maria Miguel Ribeiroa, Ana Barreirab, Preza Fernandesb, Severo Torresb, José Lopes Gomesb
a Serviço de Medicina Física e de Reabilitação, Hospital de Santo António, Centro Hospitalar do Porto, Porto, Portugal
b Serviço de Cardiologia, Hospital de Santo António, Centro Hospitalar do Porto, Porto, Portugal
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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Introdu&#231;&#227;o</span><p id="par0005" class="elsevierStylePara elsevierViewall">Em Portugal&#44; as doen&#231;as cardiovasculares lideram as taxas de morbilidade e mortalidade&#44; o que torna evidente a import&#226;ncia da doen&#231;a ateroscler&#243;tica no panorama de Sa&#250;de P&#250;blica e a necessidade de se implementarem medidas que visem a sua preven&#231;&#227;o prim&#225;ria e secund&#225;ria<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a>&#46; Os programas de reabilita&#231;&#227;o card&#237;aca &#40;PRC&#41; foram criados para promover uma recupera&#231;&#227;o precoce ap&#243;s evento agudo&#44; orientada para a reintegra&#231;&#227;o social plena&#46; T&#234;m como objetivos&#58; informa&#231;&#227;o do doente sobre a sua patologia&#44; educa&#231;&#227;o relativamente a formas de preven&#231;&#227;o visando o controlo dos fatores de risco cardiovascular &#40;FRCV&#41;&#44; prescri&#231;&#227;o de exerc&#237;cio f&#237;sico de acordo com a estratifica&#231;&#227;o de risco cardiovascular e melhoria da capacidade funcional dos doentes e da sua qualidade de vida<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a>&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">Na &#250;ltima d&#233;cada&#44; acumulou-se evid&#234;ncia cient&#237;fica do benef&#237;cio dos PRC institu&#237;dos na doen&#231;a card&#237;aca isqu&#233;mica &#40;DCI&#41;&#44; demonstrando redu&#231;&#227;o da taxa de mortalidade de 20 a 30&#37; em rela&#231;&#227;o aos doentes que n&#227;o realizam programas de reabilita&#231;&#227;o<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">3&#8211;7</span></a>&#46; Apesar das melhorias evidenciadas&#44; os dados portugueses do inqu&#233;rito de 2007 da Associa&#231;&#227;o Europeia de Preven&#231;&#227;o e Reabilita&#231;&#227;o Cardiovascular indicam que integramos&#44; 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; 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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; 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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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        9 => array:3 [
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          "titulo" => "Responsabilidades &#233;ticas"
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            0 => array:2 [
              "identificador" => "sec0080"
              "titulo" => "Prote&#231;&#227;o de pessoas e animais"
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            1 => array:2 [
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              "titulo" => "Confidencialidade dos dados"
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            2 => array:2 [
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              "titulo" => "Direito &#224; privacidade e consentimento escrito"
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          "identificador" => "sec0095"
          "titulo" => "Conflito de interesses"
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        11 => array:1 [
          "titulo" => "Bibliografia"
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    "pdfFichero" => "main.pdf"
    "tienePdf" => true
    "fechaRecibido" => "2012-05-15"
    "fechaAceptado" => "2012-08-02"
    "PalabrasClave" => array:2 [
      "pt" => array:1 [
        0 => array:4 [
          "clase" => "keyword"
          "titulo" => "Palavras-chave"
          "identificador" => "xpalclavsec238225"
          "palabras" => array:3 [
            0 => "Reabilita&#231;&#227;o card&#237;aca"
            1 => "Doen&#231;a card&#237;aca isqu&#233;mica"
            2 => "Fatores de risco cardiovascular"
          ]
        ]
      ]
      "en" => array:1 [
        0 => array:4 [
          "clase" => "keyword"
          "titulo" => "Keywords"
          "identificador" => "xpalclavsec238226"
          "palabras" => array:3 [
            0 => "Cardiac rehabilitation"
            1 => "Coronary disease"
            2 => "Cardiovascular risk factors"
          ]
        ]
      ]
    ]
    "tieneResumen" => true
    "resumen" => array:2 [
      "pt" => array:2 [
        "titulo" => "Resumo"
        "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>"
      ]
      "en" => array:2 [
        "titulo" => "Abstract"
        "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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        "tabla" => array:2 [
          "leyenda" => "<p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">CABG&#58; cirurgia de <span class="elsevierStyleItalic">by-pass</span> coron&#225;rio&#59; CDI&#58; cardioversor-desfibrilhador implant&#225;vel&#59; CRT&#58; cardiac resynchronization therapy&#59; SCA&#58; s&#237;ndrome coron&#225;ria aguda&#46;</p>"
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Internamento&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">209&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Consulta externa&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">47&nbsp;\t\t\t\t\t\t\n
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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">9&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">3&#44;5&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>40-59 anos&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">101&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t">39&#44;5&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>60-79 anos&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t">143&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t">55&#44;9&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>&#8805;<span class="elsevierStyleHsp" style=""></span>80 anos&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">3&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">1&#44;1&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">195&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t">76&#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
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Feminino&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t">61&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t">23&#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
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                  \t\t\t\t  " colspan="3" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>SCA&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">167&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t">65&#44;3&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
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>P&#243;s-angioplastia&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">38&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t">14&#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
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                  \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  " align="char" valign="\n
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                  \t\t\t\t">15&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">5&#44;9&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>P&#243;s-CABG&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">16&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t">6&#44;3&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"><span class="elsevierStyleHsp" style=""></span>Angina <span class="elsevierStyleItalic">pectoris</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">13&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">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"><span class="elsevierStyleHsp" style=""></span>Insufici&#234;ncia card&#237;aca&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">6&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2&#44;3&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"><span class="elsevierStyleHsp" style=""></span>P&#243;s-implanta&#231;&#227;o CRT&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&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;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  " colspan="3" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleVsp" style="height:0.5px"></span></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="elsevierStyleItalic">Total</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">256&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="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
              ]
              "imagenFichero" => array:1 [
                0 => "xTab354866.png"
              ]
            ]
          ]
        ]
        "descripcion" => array:1 [
          "pt" => "<p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">Caracteriza&#231;&#227;o da amostra</p>"
        ]
      ]
      1 => array:7 [
        "identificador" => "tbl0010"
        "etiqueta" => "Tabela 2"
        "tipo" => "MULTIMEDIATABLA"
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        "tabla" => array:2 [
          "leyenda" => "<p id="spar0070" class="elsevierStyleSimplePara elsevierViewall">IMC&#58; &#237;ndice de massa corporal&#59; PA&#58; per&#237;metro abdominal&#46;</p>"
          "tablatextoimagen" => array:1 [
            0 => array:2 [
              "tabla" => array:1 [
                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">&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">n&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">&#37;&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<span class="elsevierStyleHsp" style=""></span>&#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
                  \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">183&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">71&#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">25<span class="elsevierStyleHsp" style=""></span>kg&#47;m<span class="elsevierStyleSup">2</span><span class="elsevierStyleHsp" style=""></span>&#62;<span class="elsevierStyleHsp" style=""></span>IMC<span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleMonospace">&#60;</span><span class="elsevierStyleHsp" style=""></span>30<span class="elsevierStyleHsp" style=""></span>kg&#47;m<span class="elsevierStyleSup">2</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">131&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">51&#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">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>&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">51&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">19&#44;9&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>&#9794;<span class="elsevierStyleHsp" style=""></span>94-102<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">76&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">29&#44;7&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>&#9794;<span class="elsevierStyleHsp" style=""></span>&#62;<span class="elsevierStyleHsp" style=""></span>102<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">63&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&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>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
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><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">Fator de risco&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">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
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                  \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"><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"><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">9&#44;8 &#40;25&#47;256&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">CT<span class="elsevierStyleHsp" style=""></span>&#8805;<span class="elsevierStyleHsp" style=""></span>175<span class="elsevierStyleHsp" style=""></span>mg&#47;dL&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">18&#44;8 &#40;48&#47;256&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">LDL<span class="elsevierStyleHsp" style=""></span>&#8805;<span class="elsevierStyleHsp" style=""></span>100<span class="elsevierStyleHsp" style=""></span>mg&#47;dL&nbsp;\t\t\t\t\t\t\n
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                  \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"><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">HDL<span class="elsevierStyleHsp" style=""></span>&#8804;<span class="elsevierStyleHsp" style=""></span>45<span class="elsevierStyleHsp" style=""></span>mg&#47;dL&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">71&#44;9 &#40;184&#47;256&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">38&#44;2 &#40;149&#47;256&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">52 &#40;133&#47;256&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\tvoid\n
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                  \t\t\t\t  " align="" valign="\n
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                  \t\t\t\t" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t" style="border-bottom: 2px solid black">Dif&#46; m&#233;dia &#40;&#177;&#160;DP&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t" style="border-bottom: 2px solid black">Dif&#46; m&#233;dia &#40;&#37;&#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
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                  \t\t\t\t" style="border-bottom: 2px solid black">Sig&#46; p&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">Dif&#46; m&#233;dia &#40;&#177;&#160;DP&#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">Dif&#46; m&#233;dia &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t" style="border-bottom: 2px solid black">Sig&#46; p&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">Dif&#46; m&#233;dia &#40;&#177;&#160;DP&#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">Dif&#46; m&#233;dia &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">Sig&#46; p&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">Peso &#40;kg&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">&#8595;&#160;3&#44;3&nbsp;\t\t\t\t\t\t\n
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Informação do artigo
ISSN: 08702551
Idioma original: Português
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Ano/Mês Html Pdf Total
2024 Novembro 33 6 39
2024 Outubro 205 43 248
2024 Setembro 178 31 209
2024 Agosto 192 56 248
2024 Julho 107 35 142
2024 Junho 145 24 169
2024 Maio 158 39 197
2024 Abril 94 34 128
2024 Maro 98 32 130
2024 Fevereiro 74 22 96
2024 Janeiro 76 40 116
2023 Dezembro 62 25 87
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2023 Outubro 66 24 90
2023 Setembro 48 23 71
2023 Agosto 44 15 59
2023 Julho 78 12 90
2023 Junho 64 13 77
2023 Maio 105 36 141
2023 Abril 68 13 81
2023 Maro 87 36 123
2023 Fevereiro 72 24 96
2023 Janeiro 82 41 123
2022 Dezembro 62 31 93
2022 Novembro 74 38 112
2022 Outubro 79 32 111
2022 Setembro 74 48 122
2022 Agosto 77 36 113
2022 Julho 70 47 117
2022 Junho 62 46 108
2022 Maio 59 64 123
2022 Abril 64 47 111
2022 Maro 58 54 112
2022 Fevereiro 53 42 95
2022 Janeiro 61 46 107
2021 Dezembro 51 42 93
2021 Novembro 75 45 120
2021 Outubro 55 59 114
2021 Setembro 27 30 57
2021 Agosto 32 31 63
2021 Julho 28 33 61
2021 Junho 37 35 72
2021 Maio 35 39 74
2021 Abril 78 42 120
2021 Maro 94 36 130
2021 Fevereiro 73 21 94
2021 Janeiro 62 10 72
2020 Dezembro 35 12 47
2020 Novembro 49 26 75
2020 Outubro 30 12 42
2020 Setembro 34 9 43
2020 Agosto 22 18 40
2020 Julho 43 23 66
2020 Junho 45 23 68
2020 Maio 27 35 62
2020 Abril 49 27 76
2020 Maro 42 11 53
2020 Fevereiro 76 18 94
2020 Janeiro 28 9 37
2019 Dezembro 38 8 46
2019 Novembro 24 11 35
2019 Outubro 37 10 47
2019 Setembro 19 8 27
2019 Agosto 17 6 23
2019 Julho 46 8 54
2019 Junho 22 8 30
2019 Maio 38 8 46
2019 Abril 29 14 43
2019 Maro 71 12 83
2019 Fevereiro 81 14 95
2019 Janeiro 39 3 42
2018 Dezembro 58 10 68
2018 Novembro 49 1 50
2018 Outubro 112 21 133
2018 Setembro 41 15 56
2018 Agosto 33 10 43
2018 Julho 23 7 30
2018 Junho 71 12 83
2018 Maio 81 11 92
2018 Abril 54 15 69
2018 Maro 91 13 104
2018 Fevereiro 75 10 85
2018 Janeiro 67 6 73
2017 Dezembro 55 17 72
2017 Novembro 55 16 71
2017 Outubro 60 19 79
2017 Setembro 40 9 49
2017 Agosto 55 12 67
2017 Julho 35 16 51
2017 Junho 41 22 63
2017 Maio 61 19 80
2017 Abril 49 3 52
2017 Maro 42 38 80
2017 Fevereiro 91 7 98
2017 Janeiro 78 7 85
2016 Dezembro 33 9 42
2016 Novembro 26 24 50
2016 Outubro 58 9 67
2016 Setembro 83 16 99
2016 Agosto 31 9 40
2016 Julho 30 28 58
2016 Junho 2 37 39
2016 Maio 5 27 32
2016 Abril 102 4 106
2016 Maro 163 39 202
2016 Fevereiro 183 44 227
2016 Janeiro 119 19 138
2015 Dezembro 116 28 144
2015 Novembro 165 29 194
2015 Outubro 123 27 150
2015 Setembro 108 28 136
2015 Agosto 86 23 109
2015 Julho 93 17 110
2015 Junho 103 13 116
2015 Maio 100 20 120
2015 Abril 91 20 111
2015 Maro 112 15 127
2015 Fevereiro 80 12 92
2015 Janeiro 80 17 97
2014 Dezembro 69 12 81
2014 Novembro 108 15 123
2014 Outubro 134 19 153
2014 Setembro 76 25 101
2014 Agosto 73 23 96
2014 Julho 89 24 113
2014 Junho 85 24 109
2014 Maio 104 24 128
2014 Abril 72 30 102
2014 Maro 107 31 138
2014 Fevereiro 135 29 164
2014 Janeiro 134 37 171
2013 Dezembro 121 40 161
2013 Novembro 151 47 198
2013 Outubro 163 29 192
2013 Setembro 137 34 171
2013 Agosto 108 50 158
2013 Julho 111 35 146
2013 Junho 76 33 109
2013 Maio 155 70 225
2013 Abril 228 132 360
2013 Maro 71 49 120
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