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respetivamente&#41;&#44; desde o internamento por evento cardiovascular at&#233; ao momento em que o indiv&#237;duo se torne totalmente respons&#225;vel pela manuten&#231;&#227;o das estrat&#233;gias educativas&#46;</p><p id="par0155" class="elsevierStylePara elsevierViewall">Os doentes com diabetes <span class="elsevierStyleItalic">mellitus</span> &#40;DM&#41; t&#234;m um risco de doen&#231;a cardiovascular&#44; especialmente DC&#44; duas a quatro vezes superior a n&#227;o diab&#233;ticos e a sua presen&#231;a duplica a taxa de mortalidade por evento cardiovascular&#44; mesmo ap&#243;s ajustes para outros FRCV<a class="elsevierStyleCrossRefs" href="#bib0040"><span class="elsevierStyleSup">8&#44;9</span></a>&#46;</p><p id="par0160" class="elsevierStylePara elsevierViewall">A Organiza&#231;&#227;o Mundial de Sa&#250;de declarou a DM como um problema de sa&#250;de p&#250;blica&#44; sendo essencial a promo&#231;&#227;o de medidas de educa&#231;&#227;o para a sa&#250;de&#44; j&#225; que a previs&#227;o para 2030 &#233; de 366 milh&#245;es de diab&#233;ticos em todo o mundo<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a>&#46; Em Portugal&#44; 11&#44;7&#37; da popula&#231;&#227;o entre os 20 e os 79 anos tem diabetes<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">11</span></a>&#46;</p><p id="par0165" class="elsevierStylePara elsevierViewall">Apesar da mortalidade por eventos coron&#225;rios ter diminu&#237;do nas &#250;ltimas d&#233;cadas na popula&#231;&#227;o em geral&#44; consequ&#234;ncia do melhor controlo de alguns FRCV e de terap&#234;uticas mais eficazes para a doen&#231;a card&#237;aca&#44; tal n&#227;o se verificou em indiv&#237;duos diab&#233;ticos<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">12</span></a>&#46;</p><p id="par0170" class="elsevierStylePara elsevierViewall">A abordagem global do doente diab&#233;tico em termos da redu&#231;&#227;o do risco cardiovascular inclui dieta adequada&#44; controlo dos FRCV concomitantes&#44; exerc&#237;cio f&#237;sico regular e interven&#231;&#227;o farmacol&#243;gica<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">13</span></a>&#46; Estas estrat&#233;gias ir&#227;o levar a respostas metab&#243;licas e end&#243;crinas favor&#225;veis&#44; que a m&#233;dio e longo prazo se traduzem em redu&#231;&#227;o da hemoglobina glicada &#40;HbA1c&#41;&#44; diminui&#231;&#227;o da intoler&#226;ncia &#224; glicose&#44; diminui&#231;&#227;o da resist&#234;ncia &#224; insulina&#44; aumento do consumo muscular de glicose&#44; redu&#231;&#227;o do tecido adiposo e aumento da toler&#226;ncia ao exerc&#237;cio&#46; Estes benef&#237;cios&#44; no seu conjunto&#44; atrasam a evolu&#231;&#227;o de complica&#231;&#245;es micro e macrovasculares associadas &#224; DM&#44; reduzindo&#44; assim&#44; o risco cardiovascular e promovendo a melhoria da qualidade de vida<a class="elsevierStyleCrossRefs" href="#bib0035"><span class="elsevierStyleSup">7&#44;13&#44;14</span></a>&#46;</p><p id="par0175" class="elsevierStylePara elsevierViewall">Dos doentes referenciados para PRC&#44; 20&#8208;30&#37; t&#234;m DM<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">15</span></a>&#44; contudo&#44; existem poucos estudos que avaliem especificamente a efic&#225;cia dos PRC em doentes diab&#233;ticos&#44; apesar destes programas poderem ser especialmente importantes nesta popula&#231;&#227;o de doentes&#46;</p><p id="par0180" class="elsevierStylePara elsevierViewall">O presente estudo tem como objetivo avaliar os efeitos de um PRC &#40;fase <span class="elsevierStyleSmallCaps">II</span>&#41; em doentes coron&#225;rios com DM tipo 2 e comparar os seus resultados no que se refere ao controlo de FRCV e ganhos na capacidade funcional com doentes coron&#225;rios n&#227;o diab&#233;ticos&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">M&#233;todos</span><p id="par0185" class="elsevierStylePara elsevierViewall">Foi realizado um estudo unic&#234;ntrico&#44; observacional&#44; prospetivo&#44; do tipo coorte&#44; integrando 818 doentes com diagn&#243;stico de doen&#231;a card&#237;aca isqu&#233;mica &#40;DCI&#41;&#44; consecutivamente orientados para PRC na Unidade de Preven&#231;&#227;o e de Reabilita&#231;&#227;o Cardiovascular &#40;UPRCV&#41; do Hospital de Santo Ant&#243;nio&#44; Centro Hospitalar do Porto&#44; entre janeiro de 2009 e junho de 2013&#46; Da amostra inicial foram exclu&#237;dos 136 doentes&#58; 91 por abandono do PRC &#40;desist&#234;ncia&#41;&#59; nove por intercorr&#234;ncias cl&#237;nicas que impossibilitaram o cumprimento de um m&#237;nimo de oito sess&#245;es do programa &#40;dois por reinternamento para ICP&#59; um por SCA&#59; seis por les&#245;es musculosquel&#233;ticas&#41;&#59; 36 por perda de dados no per&#237;odo de <span class="elsevierStyleItalic">follow&#8208;up</span>&#44; nomeadamente valores anal&#237;ticos ou dados antropom&#233;tricos&#44; que impossibilitavam a an&#225;lise estat&#237;stica&#46; Foram assim inclu&#237;dos 682 doentes&#44; que iniciaram o PRC nos primeiros tr&#234;s meses p&#243;s&#8208;evento&#44; independentemente do diagn&#243;stico de admiss&#227;o&#46; Para a realiza&#231;&#227;o do estudo consideraram&#8208;se dois grupos de doentes&#58; grupo dos diab&#233;ticos &#40;GD&#41; e dos n&#227;o diab&#233;ticos &#40;GND&#41;&#46; Foram inclu&#237;dos no GD os doentes com hist&#243;ria pr&#233;via de DM tipo 2 &#40;confirmada no processo cl&#237;nico&#41; ou sob medica&#231;&#227;o antidiab&#233;tica &#40;antidiab&#233;ticos orais ou insulinoterapia&#41;&#46;</p><p id="par0190" class="elsevierStylePara elsevierViewall">Estabeleceram&#8208;se dois momentos de avalia&#231;&#227;o&#58; in&#237;cio do PRC e tr&#234;s meses depois&#46; Na avalia&#231;&#227;o inicial procedeu&#8208;se &#224; realiza&#231;&#227;o da hist&#243;ria cl&#237;nica &#40;recolha de dados sociodemogr&#225;ficos&#44; antecedentes pessoais e familiares&#41; e ao exame f&#237;sico dos sistemas cardiovascular&#44; musculosquel&#233;tico e neurol&#243;gico&#46; Nos dois momentos de avalia&#231;&#227;o foram ainda recolhidos dados relativos ao perfil de risco&#44; nomeadamente&#44; medi&#231;&#227;o de press&#227;o arterial&#59; dados antropom&#233;tricos incluindo &#237;ndice de massa corporal &#40;IMC&#41; &#40;kg&#47;m<span class="elsevierStyleSup">2</span>&#41; e per&#237;metro abdominal &#40;PA&#41;&#59; registo de h&#225;bitos tab&#225;gicos&#44; de valores de glicose&#44; HbA1c e do perfil lip&#237;dico &#40;obtido ap&#243;s cumprimento de um per&#237;odo de 12 horas de jejum&#41; incluindo colesterol total &#40;CT&#41;&#44; colesterol das lipoprote&#237;nas de baixa densidade &#40;LDL&#41; &#40;<span class="elsevierStyleItalic">low density lipoprotein cholesterol</span> &#91;c&#8208;LDL&#93;&#41;&#44; colesterol das lipoprote&#237;nas de alta densidade &#40;HDL&#41; &#40;<span class="elsevierStyleItalic">high density lipoprotein cholesterol</span> &#91;c&#8208;HDL&#93;&#41; e triglicer&#237;deos &#40;TG&#41;&#46;</p><p id="par0195" class="elsevierStylePara elsevierViewall">Foram considerados os seguintes valores de refer&#234;ncia como normais&#58; press&#227;o arterial inferior a 130&#47;80<span class="elsevierStyleHsp" style=""></span>mmHg em duas avalia&#231;&#245;es consecutivas&#59; IMC de 18&#8208;24&#44;9 kg&#47;m<span class="elsevierStyleSup">2</span> &#40;valores de 25&#8208;29&#44;9<span class="elsevierStyleHsp" style=""></span>kg&#47;m<span class="elsevierStyleSup">2</span> foram classificados como excesso de peso e IMC &#8805;<span class="elsevierStyleHsp" style=""></span>30 kg&#47;m<span class="elsevierStyleSup">2</span> foram classificados como obesidade&#41;&#59; PA inferior a 80<span class="elsevierStyleHsp" style=""></span>cm para o sexo feminino e inferior a 94<span class="elsevierStyleHsp" style=""></span>cm para o masculino&#59; glicemia capilar &#40;jejum&#41; &#60;<span class="elsevierStyleHsp" style=""></span>110<span class="elsevierStyleHsp" style=""></span>mg&#47;dL e HbA1c<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>6&#44;5&#37;&#59; CT &#60;<span class="elsevierStyleHsp" style=""></span>190<span class="elsevierStyleHsp" style=""></span>mg&#47;dl&#44; C&#8208;LDL &#60;<span class="elsevierStyleHsp" style=""></span>100<span class="elsevierStyleHsp" style=""></span>mg&#47;dl&#44; C&#8208;HDL &#62;<span class="elsevierStyleHsp" style=""></span>45<span class="elsevierStyleHsp" style=""></span>mg&#47;dl para o sexo masculino e C&#8208;HDL<span class="elsevierStyleHsp" style=""></span>&#62;<span class="elsevierStyleHsp" style=""></span>40<span class="elsevierStyleHsp" style=""></span>mg&#47;dl para o sexo feminino e TG<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>150<span class="elsevierStyleHsp" style=""></span>mg&#47;dl&#46;</p><p id="par0200" class="elsevierStylePara elsevierViewall">A avalia&#231;&#227;o do n&#237;vel de atividade f&#237;sica foi efetuada atrav&#233;s do <span class="elsevierStyleItalic">International Physical Activity Questionnaire</span> &#40;IPAQ&#41;&#44; validado para a popula&#231;&#227;o portuguesa<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">16</span></a> e que visa quantificar &#40;em equivalentes metab&#243;licos &#91;MET&#93;&#42;minuto&#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; Consideraram&#8208;se as seguintes categorias&#58; sedentarismo &#40;valores inferiores a 600<span class="elsevierStyleHsp" style=""></span>MET&#42;minuto&#47;semana&#41;&#59; atividade f&#237;sica moderada &#40;600&#8208;3&#46;000<span class="elsevierStyleHsp" style=""></span>MET&#42;minuto&#47;semana&#41;&#59; atividade f&#237;sica vigorosa &#40;valores superiores a 3&#46;000<span class="elsevierStyleHsp" style=""></span>MET&#42;minuto&#47;semana&#41;&#46;</p><p id="par0205" class="elsevierStylePara elsevierViewall">Nos mesmos per&#237;odos&#44; todos doentes realizaram prova de esfor&#231;o &#40;PE&#41; em tapete rolante motorizado&#44; sob medica&#231;&#227;o habitual&#44; determinando par&#226;metros de resposta cronotr&#243;pica e hemodin&#226;mica&#46; A capacidade funcional m&#225;xima foi estimada em MET obtidos na PE&#44; calculados atrav&#233;s de equa&#231;&#245;es metab&#243;licas do <span class="elsevierStyleItalic">American College of Sports Medicine</span> para marcha em tapete rolante<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a>&#44; e foi tamb&#233;m registado o tempo de esfor&#231;o total da PE&#46;</p><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Programa de reabilita&#231;&#227;o</span><p id="par0210" class="elsevierStylePara elsevierViewall">O PRC incluiu aconselhamento individual sobre estrat&#233;gias para controlo dos FRCV&#44; sess&#245;es de educa&#231;&#227;o para a sa&#250;de em grupo e sess&#245;es de exerc&#237;cio f&#237;sico supervisionado&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Exerc&#237;cio f&#237;sico supervisionado</span><p id="par0215" class="elsevierStylePara elsevierViewall">Todos os doentes integraram um programa de exerc&#237;cio f&#237;sico supervisionado por m&#233;dicos &#40;cardiologista e fisiatra&#41; e por fisioterapeuta&#44; durante 8&#8208;12 semanas&#44; com periodicidade bissemanal&#46; A dura&#231;&#227;o do PRC foi determinada de acordo com a estratifica&#231;&#227;o do risco card&#237;aco&#44; aus&#234;ncia de intercorr&#234;ncias durante o mesmo e a disponibilidade do doente &#40;dist&#226;ncia &#224; &#225;rea de resid&#234;ncia e necessidade de retomar a atividade laboral&#41;&#46;</p><p id="par0220" class="elsevierStylePara elsevierViewall">Cada sess&#227;o&#44; com dura&#231;&#227;o entre 60&#8208;90 minutos&#44; englobou um protocolo de exerc&#237;cio constitu&#237;do por&#58; fase de aquecimento&#44; treino aer&#243;bico &#40;exerc&#237;cio em tapete rolante&#44; cicloerg&#243;metro de membros superiores e inferiores&#41;&#44; treino de for&#231;a &#40;com recurso a bandas el&#225;sticas&#44; halteres&#44; bolas medicinais e aparelhos de fortalecimento muscular&#41; e fase de relaxamento e exerc&#237;cios de flexibilidade&#46; A intensidade do exerc&#237;cio aer&#243;bico foi determinada individualmente&#44; com base no c&#225;lculo de frequ&#234;ncia card&#237;aca de treino atrav&#233;s do m&#233;todo de Karvonen<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">17</span></a>&#44; utilizando os dados recolhidos na PE&#59; foi complementada com a perce&#231;&#227;o subjetiva do esfor&#231;o registada na escala de Borg<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a>&#46;</p><p id="par0225" class="elsevierStylePara elsevierViewall">Previamente a cada sess&#227;o de exerc&#237;cio foi realizada uma avalia&#231;&#227;o cl&#237;nica sum&#225;ria que incluiu o question&#225;rio de sintomas relevantes e cumprimento da farmacoterapia&#44; e foram medidos os valores de frequ&#234;ncia card&#237;aca e press&#227;o arterial basais&#44; assim como valores de glicemia capilar no caso dos doentes diab&#233;ticos&#46; No decorrer de cada sess&#227;o foi registada de forma cont&#237;nua a frequ&#234;ncia card&#237;aca atrav&#233;s de monitoriza&#231;&#227;o eletrocardiogr&#225;fica por telemetria ou por cardiofrequenc&#237;metro&#44; de acordo com 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="#bib0035"><span class="elsevierStyleSup">7</span></a>&#46;</p><p id="par0230" class="elsevierStylePara elsevierViewall">Adicionalmente&#44; foi incentivada em todos os doentes a pr&#225;tica do exerc&#237;cio f&#237;sico nos restantes dias da semana&#44; ao encontro &#224;s recomenda&#231;&#245;es no contexto da preven&#231;&#227;o secund&#225;ria<a class="elsevierStyleCrossRefs" href="#bib0035"><span class="elsevierStyleSup">7&#44;17</span></a>&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Educa&#231;&#227;o para a sa&#250;de</span><p id="par0235" class="elsevierStylePara elsevierViewall">Periodicamente foram realizadas sess&#245;es de grupo&#44; envolvendo os doentes e os seus familiares&#44; onde foram abordados e discutidos diversos temas como &#171;Doen&#231;a Coron&#225;ria&#187;&#44; &#171;Nutri&#231;&#227;o&#187;&#44; &#171;Stress&#187; e &#171;Exerc&#237;cio F&#237;sico&#187;&#46;</p><p id="par0240" class="elsevierStylePara elsevierViewall">Sempre que houve indica&#231;&#227;o cl&#237;nica os doentes foram orientados para consultas espec&#237;ficas na UPRCV&#44; nomeadamente Consulta de Endocrinologia&#44; Psiquiatria&#44; Desabitua&#231;&#227;o Tab&#225;gica&#44; Urologia ou Cirurgia Vascular&#46; Todos os doentes diab&#233;ticos foram avaliados em Consulta de Nutri&#231;&#227;o&#44; onde lhes foi prescrito um plano alimentar individualizado&#46;</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">An&#225;lise estat&#237;stica</span><p id="par0245" class="elsevierStylePara elsevierViewall">O processamento estat&#237;stico dos dados foi efetuado com recurso ao programa <span class="elsevierStyleItalic">Statistical Package for the Social Sciences</span> &#40;SPSS&#41; vers&#227;o 17&#46;0&#46; Os dados s&#227;o apresentados como m&#233;dia &#40;desvio padr&#227;o &#91;DP&#93;&#41;&#44; para vari&#225;veis cont&#237;nuas com distribui&#231;&#227;o normal&#44; e mediana &#40;intervalo interquartis &#91;P25&#8208;P75&#93;&#41;&#44; para vari&#225;veis cont&#237;nuas com distribui&#231;&#227;o n&#227;o normal&#46; Os doentes foram categorizados em dois grupos&#58; GD e GND&#46; Diferen&#231;as intragrupo foram avaliadas usando teste t de <span class="elsevierStyleItalic">Student</span> para amostras emparelhadas para vari&#225;veis cont&#237;nuas de distribui&#231;&#227;o normal e o teste de <span class="elsevierStyleItalic">Wilcoxon</span> para vari&#225;veis cont&#237;nuas de distribui&#231;&#227;o n&#227;o&#8208;normal&#46; A diferen&#231;a entre os grupos na resposta ao programa foi avaliada usando o teste t de <span class="elsevierStyleItalic">Student</span> para compara&#231;&#227;o de m&#233;dias e o teste de <span class="elsevierStyleItalic">Mann&#8208;Whitney</span> para compara&#231;&#227;o de medianas&#46; As vari&#225;veis categ&#243;ricas foram comparadas usando o teste <span class="elsevierStyleItalic">McNemar</span> para diferen&#231;as intragrupo e o teste de <span class="elsevierStyleItalic">Qui&#8208;quadrado</span> para diferen&#231;as entre grupos&#46;</p><p id="par0250" class="elsevierStylePara elsevierViewall">Valores de p inferiores a 0&#44;05 foram considerados estatisticamente significativos&#46;</p></span></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">Resultados</span><p id="par0255" class="elsevierStylePara elsevierViewall">A amostra em estudo abrangeu 682 doentes &#40;253 diab&#233;ticos e 429 n&#227;o diab&#233;ticos&#41;&#46; Ambos os grupos apresentavam maior propor&#231;&#227;o de doentes do sexo masculino &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">Tabela 1</a>&#41;&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0260" class="elsevierStylePara elsevierViewall">Os doentes diab&#233;ticos eram significativamente mais idosos &#40;m&#233;dia &#91;DP&#58; 61&#44;6 &#91;9&#44;1&#93; anos <span class="elsevierStyleItalic">versus</span> 58&#44;6 &#91;11&#44;0&#93; anos&#44; p<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#44;001&#41; e apresentavam pior perfil de risco cardiovascular &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">Tabela 1</a>&#41;&#58; maior preval&#234;ncia de excesso ponderal &#40;80&#44;6 <span class="elsevierStyleItalic">versus</span> 60&#44;1&#37;&#44; p<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#44;001&#41;&#44; com valores significativamente superiores de IMC e de PA&#59; maior preval&#234;ncia de dislipidemia &#40;76&#44;3 <span class="elsevierStyleItalic">versus</span> 64&#44;3&#37;&#44; p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;004&#41; com valores significativamente superiores de TG e valores inferiores de colesterol HDL&#59; maior preval&#234;ncia de hipertens&#227;o arterial &#40;HTA&#41; &#40;70&#44;4 <span class="elsevierStyleItalic">versus</span> 52&#44;4&#37;&#44; p<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#44;001&#41; e de sedentarismo &#40;61&#44;3 <span class="elsevierStyleItalic">versus</span> 49&#44;7&#37;&#44; p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;013&#41;&#46; Apresentavam&#44; contudo&#44; menor preval&#234;ncia de h&#225;bitos tab&#225;gicos &#40;21&#44;7 <span class="elsevierStyleItalic">versus</span> 37&#44;1&#37;&#44; p<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#44;001&#41;&#46; Relativamente &#224; capacidade funcional&#44; esta era significativamente menor nos diab&#233;ticos &#40;7&#44;9 &#91;2&#44;1&#93; MET <span class="elsevierStyleItalic">versus</span> 9&#44;1 &#91;2&#44;4&#93; MET&#44; p<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#44;001&#59; tempo de PE&#58; 0&#58;06&#58;51 &#91;0&#58;02&#58;08&#93; min&#58;seg <span class="elsevierStyleItalic">versus</span> 0&#58;08&#58;22 &#91;0&#58;02&#58;43&#93; min&#58;seg&#44; p<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#44;001&#41;&#46;</p><p id="par0265" class="elsevierStylePara elsevierViewall">O diagn&#243;stico de admiss&#227;o mais frequente foi em ambos os grupos a SCA&#46; A caracteriza&#231;&#227;o completa da amostra na admiss&#227;o para PRC &#233; apresentada na <a class="elsevierStyleCrossRef" href="#tbl0005">Tabela 1</a>&#46;</p><p id="par0270" class="elsevierStylePara elsevierViewall">A evolu&#231;&#227;o dos FRCV ao longo do estudo para o GD e GND est&#225; sumarizada nas <a class="elsevierStyleCrossRef" href="#tbl0010">Tabela 2</a> e<a class="elsevierStyleCrossRef" href="#tbl0015">Tabela 3</a>&#46; A <a class="elsevierStyleCrossRef" href="#tbl0020">Tabela 4</a> apresenta a compara&#231;&#227;o da evolu&#231;&#227;o dos FRCV entre os dois grupos&#46; Na <a class="elsevierStyleCrossRef" href="#tbl0025">Tabela 5</a> est&#225; representada a evolu&#231;&#227;o da capacidade funcional em cada um dos grupos de doentes&#44; bem como a compara&#231;&#227;o entre grupos&#46;</p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><elsevierMultimedia ident="tbl0015"></elsevierMultimedia><elsevierMultimedia ident="tbl0020"></elsevierMultimedia><elsevierMultimedia ident="tbl0025"></elsevierMultimedia><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0105">Obesidade</span><p id="par0275" class="elsevierStylePara elsevierViewall">O excesso ponderal constituiu o FRCV mais prevalente no grupo dos doentes diab&#233;ticos &#40;80&#44;6&#37;&#41;&#44; sendo que 22&#44;9&#37; destes eram obesos&#46;</p><p id="par0280" class="elsevierStylePara elsevierViewall">Entre o in&#237;cio e o fim do PRC&#44; ambos os grupos melhoraram significativamente nos par&#226;metros antropom&#233;tricos &#40;<a class="elsevierStyleCrossRef" href="#tbl0010">Tabela 2</a> e <a class="elsevierStyleCrossRef" href="#tbl0015">Tabela 3</a>&#41;&#46;</p><p id="par0285" class="elsevierStylePara elsevierViewall">A melhoria verificada foi semelhante nos dois grupos em rela&#231;&#227;o ao PA &#40;p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;058&#41;&#44; mas n&#227;o relativamente ao IMC&#44; em que a diminui&#231;&#227;o m&#233;dia nos valores do IMC foi em termos absolutos significativamente superior nos n&#227;o diab&#233;ticos &#40;p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;008&#41;&#46;</p></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0110">Hipertens&#227;o arterial</span><p id="par0290" class="elsevierStylePara elsevierViewall">Na admiss&#227;o para PRC&#44; 70&#44;4&#37; dos diab&#233;ticos e 52&#44;4&#37; dos n&#227;o diab&#233;ticos apresentavam antecedentes de HTA&#46; No momento da primeira avalia&#231;&#227;o 28&#44;1&#37; dos diab&#233;ticos e 21&#44;0&#37; dos n&#227;o diab&#233;ticos apresentavam valores tensionais elevados&#46; Com o PRC verificou&#8208;se em ambos os grupos uma diminui&#231;&#227;o significativa no n&#250;mero de doentes que apresentavam valores tensionais n&#227;o controlados &#40;diminui&#231;&#227;o de 70&#44;4&#37;&#44; p<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#44;001 nos diab&#233;ticos e de 80&#44;0&#37;&#44; p<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#44;001 nos n&#227;o diab&#233;ticos&#41;&#44; sendo que essa diminui&#231;&#227;o n&#227;o foi significativamente diferente nos dois grupos &#40;p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;195&#41;&#46;</p></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0115">Dislipidemia</span><p id="par0295" class="elsevierStylePara elsevierViewall">A dislipidemia era o FRCV mais prevalente nos n&#227;o diab&#233;ticos &#40;64&#44;3&#37;&#41;&#46;</p><p id="par0300" class="elsevierStylePara elsevierViewall">No final da fase <span class="elsevierStyleSmallCaps">II</span> do PRC verificou&#8208;se em ambos os grupos uma melhoria no perfil lip&#237;dico&#44; traduzida quer por uma diminui&#231;&#227;o significativa nos valores de CT&#44; C&#8208;LDL e TG quer por um aumento significativo nos valores do C&#8208;HDL &#40;<a class="elsevierStyleCrossRef" href="#tbl0010">Tabela 2</a> e <a class="elsevierStyleCrossRef" href="#tbl0015">Tabela 3</a>&#41;&#46;</p><p id="par0305" class="elsevierStylePara elsevierViewall">As varia&#231;&#245;es nos v&#225;rios par&#226;metros do perfil lip&#237;dico com o PRC foram semelhantes nos dois grupos&#44; exceto a diminui&#231;&#227;o no valor de TG&#44; que foi&#44; em termos absolutos&#44; significativamente superior nos diab&#233;ticos &#40;p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;039&#41;&#46;</p></span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0120">Tabagismo</span><p id="par0310" class="elsevierStylePara elsevierViewall">Na admiss&#227;o&#44; 21&#44;7&#37; dos diab&#233;ticos e 37&#44;1&#37; dos n&#227;o diab&#233;ticos eram fumadores&#46; No final da fase <span class="elsevierStyleSmallCaps">II</span> verificou&#8208;se uma diminui&#231;&#227;o de cerca de 90&#44;0&#37; no n&#250;mero de diab&#233;ticos fumadores &#40;p<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#44;001&#41; e de 83&#44;6&#37; nos n&#227;o diab&#233;ticos fumadores &#40;p<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#44;001&#41;&#44; tendo sido essa diminui&#231;&#227;o semelhante em ambos os grupos &#40;p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;266&#41;&#46;</p><p id="par0315" class="elsevierStylePara elsevierViewall">Relativamente ao n&#250;mero de cigarros fumados por dia&#44; observou&#8208;se igualmente uma diminui&#231;&#227;o significativa &#40;<a class="elsevierStyleCrossRef" href="#tbl0010">Tabela 2</a> e <a class="elsevierStyleCrossRef" href="#tbl0015">Tabela 3</a>&#41;&#44; sendo que essa diminui&#231;&#227;o n&#227;o foi significativamente diferente entre os dois grupos &#40;p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;194&#41;&#46;</p></span><span id="sec0060" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0125">Diabetes <span class="elsevierStyleItalic">mellitus</span></span><p id="par0320" class="elsevierStylePara elsevierViewall">Com o PRC&#44; os doentes diab&#233;ticos demonstraram melhoria no controlo da DM&#44; que se refletiu por uma diminui&#231;&#227;o significativa nos valores de glicemia em jejum e de HbA1c &#40;<a class="elsevierStyleCrossRef" href="#tbl0010">Tabela 2</a>&#41;&#46;</p></span><span id="sec0065" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0130">Sedentarismo</span><p id="par0325" class="elsevierStylePara elsevierViewall">No in&#237;cio do estudo 61&#44;3&#37; dos diab&#233;ticos e 49&#44;7&#37; dos n&#227;o diab&#233;ticos eram sedent&#225;rios&#44; constatado pelos <span class="elsevierStyleItalic">scores</span> obtidos atrav&#233;s do IPAQ&#46;</p><p id="par0330" class="elsevierStylePara elsevierViewall">Ambos os grupos demonstraram um aumento significativo no seu padr&#227;o habitual de atividade f&#237;sica&#44; expresso como o aumento da atividade f&#237;sica semanal medida pelo IPAQ entre o in&#237;cio e o final do PRC &#40;<a class="elsevierStyleCrossRef" href="#tbl0010">Tabela 2</a> e <a class="elsevierStyleCrossRef" href="#tbl0015">Tabela 3</a>&#41;&#46;</p><p id="par0335" class="elsevierStylePara elsevierViewall">O aumento verificado nos valores de IPAQ foi semelhante nos dois grupos &#40;p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;628&#41;&#46;</p></span><span id="sec0070" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0135">Capacidade funcional</span><p id="par0340" class="elsevierStylePara elsevierViewall">No in&#237;cio do estudo&#44; os diab&#233;ticos apresentavam uma pior capacidade funcional &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">Tabela 1</a>&#41;&#46; No final do PRC&#44; ambos os grupos apresentaram uma melhoria significativa na capacidade funcional &#40;equivalentes metab&#243;licos&#58; &#43;<span class="elsevierStyleHsp" style=""></span>1&#44;3 &#91;1&#44;2&#93; MET&#44; p<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#44;001 GD <span class="elsevierStyleItalic">versus</span> &#43;<span class="elsevierStyleHsp" style=""></span>1&#44;5 &#91;1&#44;2&#93; MET&#44; p<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#44;001 GND&#59; tempo de esfor&#231;o&#58; &#43;<span class="elsevierStyleHsp" style=""></span>0&#58;01&#58;32 &#91;0&#58;01&#58;22&#93; min&#58;seg&#44; p<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#44;001 GD <span class="elsevierStyleItalic">versus</span> &#43;<span class="elsevierStyleHsp" style=""></span>0&#58;01&#58;51 &#91;0&#58;02&#58;56&#93; min&#58;seg&#44; p<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#44;001 GND&#41; &#40;<a class="elsevierStyleCrossRef" href="#tbl0025">Tabela 5</a>&#41;&#46; Comparando os dois grupos&#44; a melhoria verificada na capacidade funcional foi significativamente menor nos diab&#233;ticos em termos de equivalentes metab&#243;licos &#40;p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;042&#41;&#46; Relativamente ao aumento no tempo de esfor&#231;o&#44; embora este tamb&#233;m tenha sido menor nos diab&#233;ticos&#44; esta diferen&#231;a n&#227;o adquiriu significado estat&#237;stico &#40;p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;107&#41; &#40;<a class="elsevierStyleCrossRef" href="#tbl0025">Tabela 5</a>&#41;&#46;</p></span></span><span id="sec0075" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0140">Discuss&#227;o</span><p id="par0345" class="elsevierStylePara elsevierViewall">As altera&#231;&#245;es metab&#243;licas que caracterizam a DM&#44; como a hiperglicemia&#44; o aumento de &#225;cidos gordos livres e a resist&#234;ncia &#224; insulina&#44; conduzem a altera&#231;&#245;es moleculares&#44; como a diminui&#231;&#227;o da disponibilidade de &#243;xido n&#237;trico ou o aumento do <span class="elsevierStyleItalic">stress</span> oxidativo&#44; que levam &#224; disfun&#231;&#227;o vascular<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">18</span></a>&#46; Tudo isto contribui para acelerar o processo de aterosclerose e consequentemente para o aumento do risco cardiovascular em doentes diab&#233;ticos&#46;</p><p id="par0350" class="elsevierStylePara elsevierViewall">Em 1997&#44; a Organiza&#231;&#227;o Mundial de Sa&#250;de considerou o excesso de peso e a obesidade como &#171;uma epidemia em escalada&#187; relacionando&#8208;os com cinco das dez principais causas de morte nos pa&#237;ses industrializados incluindo a DM&#44; a DCI&#44; os acidentes vasculares cerebrais&#44; a aterosclerose e alguns tipos de cancro<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">19</span></a>&#46; De facto&#44; a obesidade associa&#8208;se a um aumento do risco de DC&#44; provavelmente devido ao perfil metab&#243;lico adverso relacionado com o aumento de gordura visceral que desempenha um papel central na resist&#234;ncia perif&#233;rica &#224; a&#231;&#227;o da insulina<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">20</span></a>&#46;</p><p id="par0355" class="elsevierStylePara elsevierViewall">Na popula&#231;&#227;o em estudo&#44; o excesso de peso e a obesidade apresentavam uma elevada preval&#234;ncia&#44; principalmente nos doentes com DM tipo 2&#46; O estilo de vida sedent&#225;rio de 61&#44;3&#37; dos diab&#233;ticos poder&#225; ser tamb&#233;m um dos fatores a contribuir para o excesso ponderal encontrado&#46;</p><p id="par0360" class="elsevierStylePara elsevierViewall">No final da fase <span class="elsevierStyleSmallCaps">II</span> do PRC verificou&#8208;se uma diminui&#231;&#227;o significativa nos valores de IMC e do PA nos dois grupos ao contr&#225;rio de outros estudos<a class="elsevierStyleCrossRefs" href="#bib0105"><span class="elsevierStyleSup">21&#44;22</span></a> em que a diminui&#231;&#227;o no IMC n&#227;o foi significativa nos diab&#233;ticos&#46; Isto poder&#225; ter ocorrido devido &#224; avalia&#231;&#227;o e aconselhamento nutricional individualizado&#44; por especialista em nutri&#231;&#227;o&#44; proporcionado durante o nosso PRC&#46; Al&#233;m disso&#44; todos os doentes receberam um plano de treino individualizado&#44; embora sem ado&#231;&#227;o de medidas espec&#237;ficas para os doentes obesos na prescri&#231;&#227;o do exerc&#237;cio&#46;</p><p id="par0365" class="elsevierStylePara elsevierViewall">A HTA e a DM tipo 2 surgem frequentemente associadas&#44; sendo que a presen&#231;a de HTA aumenta o risco cardiovascular&#44; j&#225; por si aumentado&#44; em doentes diab&#233;ticos&#46; Assim&#44; a preval&#234;ncia de HTA em diab&#233;ticos &#233; superior &#224; da popula&#231;&#227;o em geral&#44; com uma preval&#234;ncia de 40&#8208;60&#37; entre os 45&#8208;75 anos<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">23</span></a>&#46; Na nossa amostra&#44; 70&#44;4&#37; dos diab&#233;ticos e 52&#44;4&#37; dos n&#227;o diab&#233;ticos apresentavam HTA&#44; o que est&#225; de acordo com outros estudos<a class="elsevierStyleCrossRefs" href="#bib0120"><span class="elsevierStyleSup">24&#44;25</span></a>&#46;</p><p id="par0370" class="elsevierStylePara elsevierViewall">O tratamento da HTA em doentes diab&#233;ticos constitui uma medida preventiva absolutamente crucial&#44; j&#225; que poder&#225; reduzir as complica&#231;&#245;es micro e macrovasculares&#44; devendo o n&#237;vel&#8208;alvo de press&#227;o arterial ser mais baixo do que em doentes n&#227;o diab&#233;ticos<a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">26</span></a>&#46; Por cada diminui&#231;&#227;o de 10<span class="elsevierStyleHsp" style=""></span>mmHg na press&#227;o arterial sist&#243;lica&#44; verifica&#8208;se uma diminui&#231;&#227;o de cerca de 12&#37; na ocorr&#234;ncia de qualquer complica&#231;&#227;o relacionada com a DM&#44; nomeadamente doen&#231;a cardiovascular<a class="elsevierStyleCrossRef" href="#bib0135"><span class="elsevierStyleSup">27</span></a>&#46;</p><p id="par0375" class="elsevierStylePara elsevierViewall">No momento da primeira avalia&#231;&#227;o&#44; 28&#44;1&#37; dos doentes diab&#233;ticos e 21&#44;0&#37; dos doentes n&#227;o diab&#233;ticos apresentavam valores tensionais elevados&#46; Verificou&#8208;se&#44; assim&#44; que a maioria dos doentes apresentava valores tensionais controlados no in&#237;cio do PRC&#44; o que poder&#225; dever&#8208;se ao facto da maioria se encontrar sob terap&#234;utica anti&#8208;hipertensiva otimizada&#44; j&#225; que foram sobretudo referenciados a partir do internamento de cardiologia&#46; Ao longo do estudo observou&#8208;se uma diminui&#231;&#227;o estatisticamente significativa no n&#250;mero de doentes com HTA n&#227;o controlada&#46; Os benef&#237;cios decorrentes da pr&#225;tica regular de exerc&#237;cio f&#237;sico aer&#243;bico na diminui&#231;&#227;o da press&#227;o arterial em doentes hipertensos est&#227;o bem documentados na literatura<a class="elsevierStyleCrossRefs" href="#bib0140"><span class="elsevierStyleSup">28&#44;29</span></a>&#46; Contudo&#44; os mecanismos fisiopatol&#243;gicos respons&#225;veis pelos efeitos anti&#8208;hipertensivos do exerc&#237;cio permanecem controversos&#58; alguns estudos referem uma diminui&#231;&#227;o na resist&#234;ncia total perif&#233;rica&#44; na atividade simp&#225;tica e nos n&#237;veis plasm&#225;ticos de noroadrenalina<a class="elsevierStyleCrossRefs" href="#bib0145"><span class="elsevierStyleSup">29&#44;30</span></a>&#59; segundo outros&#44; ocorrer&#225; um aumento na resist&#234;ncia total perif&#233;rica no per&#237;odo de recupera&#231;&#227;o p&#243;s&#8208;exerc&#237;cio&#44; associado a uma diminui&#231;&#227;o significativa do d&#233;bito card&#237;aco<a class="elsevierStyleCrossRefs" href="#bib0145"><span class="elsevierStyleSup">29&#44;31</span></a>&#59; a melhoria na fun&#231;&#227;o endotelial com o exerc&#237;cio poder&#225; tamb&#233;m contribuir para a sua resposta anti&#8208;hipertensiva<a class="elsevierStyleCrossRefs" href="#bib0145"><span class="elsevierStyleSup">29&#44;32</span></a>&#46;</p><p id="par0380" class="elsevierStylePara elsevierViewall">Em doentes com DM tipo 2 o perfil lip&#237;dico caracteriza&#8208;se geralmente por hipertrigliceridemia e diminui&#231;&#227;o do C&#8208;HDL&#46; A concentra&#231;&#227;o do C&#8208;LDL frequentemente n&#227;o &#233; muito diferente daquela apresentada por indiv&#237;duos n&#227;o diab&#233;ticos&#46; Contudo&#44; nos diab&#233;ticos as part&#237;culas das LDL s&#227;o geralmente pequenas e densas&#44; tornando&#8208;as altamente aterog&#233;nicas&#44; pelo que mesmo que as concentra&#231;&#245;es de C&#8208;LDL sejam id&#234;nticas &#224;s de n&#227;o diab&#233;ticos as taxas de DC ser&#227;o superiores nos diab&#233;ticos<a class="elsevierStyleCrossRef" href="#bib0165"><span class="elsevierStyleSup">33</span></a>&#46;</p><p id="par0385" class="elsevierStylePara elsevierViewall">O tratamento adequado da dislipidemia poder&#225; determinar redu&#231;&#245;es significativas na morbilidade e mortalidade cardiovascular em doentes diab&#233;ticos<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">20</span></a>&#46; Estudos demonstraram que por cada 1&#37; de aumento nos n&#237;veis de C&#8208;HDL&#44; a progress&#227;o da DCI diminui cerca de 3&#37;<a class="elsevierStyleCrossRef" href="#bib0170"><span class="elsevierStyleSup">34</span></a>&#46; Numa meta&#8208;an&#225;lise&#44; em que foram avaliados os efeitos do exerc&#237;cio f&#237;sico aer&#243;bico no perfil lip&#237;dico de doentes com DM tipo 2 relativamente a um grupo controlo&#44; verificou&#8208;se que os doentes que praticavam exerc&#237;cio apresentavam uma melhoria de todos os par&#226;metros do perfil lip&#237;dico&#44; embora apenas a diminui&#231;&#227;o nos n&#237;veis de C&#8208;LDL tivesse sido estatisticamente significativa<a class="elsevierStyleCrossRef" href="#bib0175"><span class="elsevierStyleSup">35</span></a>&#46; Na popula&#231;&#227;o estudada&#44; os diab&#233;ticos apresentavam maior preval&#234;ncia de dislipidemia e valores significativamente superiores de TG e inferiores de C&#8208;HDL&#46;</p><p id="par0390" class="elsevierStylePara elsevierViewall">Ao longo do estudo constatou&#8208;se uma evolu&#231;&#227;o favor&#225;vel de todos os par&#226;metros do perfil lip&#237;dico nos dois grupos&#44; sendo que a diminui&#231;&#227;o verificada nos n&#237;veis de TG foi significativamente maior nos diab&#233;ticos&#46; Isto poder&#225; ser explicado pelo facto da abordagem inicial para a hipertrigliceridemia ser a melhoria do controlo da glicemia<a class="elsevierStyleCrossRef" href="#bib0180"><span class="elsevierStyleSup">36</span></a>&#44; o que ocorreu de forma significativa nos diab&#233;ticos&#46; Por outro lado&#44; todos os doentes diab&#233;ticos inclu&#237;dos no estudo receberam aconselhamento nutricional individualizado&#44; onde foi salientada a import&#226;ncia de reduzirem o consumo de gorduras saturadas&#44; de acordo com o preconizado pela <span class="elsevierStyleItalic">American Diabetes Association</span><a class="elsevierStyleCrossRef" href="#bib0180"><span class="elsevierStyleSup">36</span></a>&#46;</p><p id="par0395" class="elsevierStylePara elsevierViewall">O tabagismo&#44; por si s&#243;&#44; constitui um fator de risco muito importante e independente para as complica&#231;&#245;es micro e macrovasculares nos diab&#233;ticos&#44; especialmente em mulheres&#44; pelo que a cessa&#231;&#227;o tab&#225;gica tem um impacto muito superior nestes doentes relativamente a n&#227;o diab&#233;ticos<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">13</span></a>&#46;</p><p id="par0400" class="elsevierStylePara elsevierViewall">No final do nosso estudo verificou&#8208;se em ambos os grupos uma enorme diminui&#231;&#227;o quer na percentagem de fumadores ativos quer no n&#250;mero de cigarros fumados por dia naqueles que mantiveram os h&#225;bitos tab&#225;gicos&#44; o que vem real&#231;ar a import&#226;ncia dos PRC no incentivo &#224; cessa&#231;&#227;o tab&#225;gica&#46; Contudo&#44; &#233; necess&#225;rio prud&#234;ncia na interpreta&#231;&#227;o destes resultados devido ao tempo curto de seguimento do estudo&#44; inferior ao per&#237;odo m&#237;nimo de seis meses de cessa&#231;&#227;o tab&#225;gica&#46;</p><p id="par0405" class="elsevierStylePara elsevierViewall">Um controlo adequado dos n&#237;veis de glicemia em doentes diab&#233;ticos &#233; fundamental para a redu&#231;&#227;o do risco de doen&#231;a cardiovascular&#44; j&#225; que existe uma rela&#231;&#227;o exponencial entre os n&#237;veis de glicemia em jejum e a incid&#234;ncia de eventos cardiovasculares<a class="elsevierStyleCrossRef" href="#bib0185"><span class="elsevierStyleSup">37</span></a>&#46;</p><p id="par0410" class="elsevierStylePara elsevierViewall">Na popula&#231;&#227;o estudada&#44; constatou&#8208;se uma diminui&#231;&#227;o significativa nos valores de glicemia em jejum e de HbA1c nos diab&#233;ticos&#44; o que traduz um melhor controlo da diabetes com o PRC&#46; O exerc&#237;cio f&#237;sico aer&#243;bico estruturado ou o treino de for&#231;a diminuem o valor de HbA1c em cerca de 0&#44;4&#8208;0&#44;6&#37;<a class="elsevierStyleCrossRefs" href="#bib0190"><span class="elsevierStyleSup">38&#44;39</span></a>&#46; Por cada 1&#37; de diminui&#231;&#227;o no valor de HbA1c verifica&#8208;se uma diminui&#231;&#227;o de 15&#8208;20&#37; na incid&#234;ncia de eventos cardiovasculares <span class="elsevierStyleItalic">major</span><a class="elsevierStyleCrossRef" href="#bib0200"><span class="elsevierStyleSup">40</span></a>&#46; Os benef&#237;cios no controlo da glicemia ser&#227;o ainda superiores com a associa&#231;&#227;o do exerc&#237;cio aer&#243;bico e do treino de for&#231;a<a class="elsevierStyleCrossRef" href="#bib0205"><span class="elsevierStyleSup">41</span></a>&#46;</p><p id="par0415" class="elsevierStylePara elsevierViewall">N&#237;veis elevados de atividade f&#237;sica em diab&#233;ticos reduzem o risco cardiovascular e a mortalidade em cerca de 20&#8208;30&#37; por cada 4&#46;184<span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleMonospace">k</span>j&#47;wk de energia despendida<a class="elsevierStyleCrossRef" href="#bib0210"><span class="elsevierStyleSup">42</span></a>&#46;</p><p id="par0420" class="elsevierStylePara elsevierViewall">Os n&#237;veis de atividade f&#237;sica semanal foram avaliados atrav&#233;s do IPAQ e aumentaram significativamente e em propor&#231;&#227;o semelhante em ambos os grupos&#46; Estes resultados contrariam o esperado&#44; pois sabe&#8208;se que a grande maioria dos indiv&#237;duos com DM tipo 2 s&#227;o fisicamente mais inativos comparativamente a indiv&#237;duos n&#227;o diab&#233;ticos&#44; provavelmente devido &#224; maior incid&#234;ncia de limita&#231;&#245;es f&#237;sicas&#44; &#224; menor toler&#226;ncia ao esfor&#231;o e &#224; maior perce&#231;&#227;o de desconforto durante o exerc&#237;cio nos diab&#233;ticos<a class="elsevierStyleCrossRef" href="#bib0215"><span class="elsevierStyleSup">43</span></a>&#46; Deste modo&#44; &#233; fundamental a cria&#231;&#227;o de estrat&#233;gias que promovam o aumento dos n&#237;veis de atividade f&#237;sica&#46;</p><p id="par0425" class="elsevierStylePara elsevierViewall">Na popula&#231;&#227;o estudada&#44; os diab&#233;ticos apresentavam uma menor capacidade funcional&#44; avaliada em MET&#44; relativamente aos n&#227;o diab&#233;ticos&#44; o que est&#225; de acordo com outros estudos<a class="elsevierStyleCrossRefs" href="#bib0105"><span class="elsevierStyleSup">21&#44;22&#44;24&#44;44&#8211;46</span></a>&#46; Doentes diab&#233;ticos&#44; mesmo sem nenhuma complica&#231;&#227;o&#44; apresentam uma diminui&#231;&#227;o no consumo m&#225;ximo de O<span class="elsevierStyleInf">2</span> &#40;VO<span class="elsevierStyleInf">2</span> m&#225;ximo&#41; em rela&#231;&#227;o &#224; idade e ao IMC<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">24</span></a>&#46; A hiperglicemia associa&#8208;se a um aumento da rigidez de grandes vasos como a aorta&#44; comprometendo assim o fluxo sangu&#237;neo coron&#225;rio&#44; a capacidade de trabalho do mioc&#225;rdio e consequentemente a capacidade global de exerc&#237;cio<a class="elsevierStyleCrossRef" href="#bib0220"><span class="elsevierStyleSup">44</span></a>&#46; Para a menor capacidade funcional dos diab&#233;ticos contribui n&#227;o s&#243; um perfil antropom&#233;trico mais desfavor&#225;vel&#44; mas tamb&#233;m a disfun&#231;&#227;o do ventr&#237;culo esquerdo e o d&#233;fice na regula&#231;&#227;o auton&#243;mica card&#237;aca<a class="elsevierStyleCrossRef" href="#bib0220"><span class="elsevierStyleSup">44</span></a>&#46;</p><p id="par0430" class="elsevierStylePara elsevierViewall">Ao longo do PRC&#44; ambos os grupos melhoraram significativamente a sua capacidade funcional&#44; embora essa melhoria tenha sido menor nos diab&#233;ticos&#46; Na literatura existem resultados contradit&#243;rios relativamente a ganhos na capacidade funcional em diab&#233;ticos e n&#227;o diab&#233;ticos&#46; Alguns estudos est&#227;o de acordo com os nossos resultados e demonstram uma melhoria significativa na capacidade funcional dos diab&#233;ticos&#44; mas menor relativamente a n&#227;o diab&#233;ticos<a class="elsevierStyleCrossRefs" href="#bib0225"><span class="elsevierStyleSup">45&#44;46</span></a>&#46; Outros&#44; por&#233;m&#44; referem ganhos na capacidade funcional significativos e semelhantes nos dois grupos de doentes<a class="elsevierStyleCrossRefs" href="#bib0105"><span class="elsevierStyleSup">21&#44;22&#44;24&#44;44&#44;47</span></a>&#46; Esta discrep&#226;ncia de resultados poder&#225; dever&#8208;se a v&#225;rios fatores como diferen&#231;as nas caracter&#237;sticas basais dos participantes &#40;idade&#44; medica&#231;&#227;o&#44; gravidade da doen&#231;a&#44; preval&#234;ncia de comorbilidades&#44; intensidade do exerc&#237;cio&#41; ou diferen&#231;as no grau de ades&#227;o ao programa de exerc&#237;cio ou na dura&#231;&#227;o do mesmo&#46;</p><p id="par0435" class="elsevierStylePara elsevierViewall">Nos estudos que defendem uma melhoria menos acentuada da capacidade funcional com o PRC em diab&#233;ticos&#44; as raz&#245;es apontadas permanecem pouco claras&#44; mas admite&#8208;se que a hiperglicemia possa desempenhar um papel importante<a class="elsevierStyleCrossRef" href="#bib0240"><span class="elsevierStyleSup">48</span></a>&#46; Outros mecanismos poder&#227;o tamb&#233;m contribuir para essa menor melhoria na capacidade funcional dos diab&#233;ticos&#46; A insulina &#233; um importante regulador das prote&#237;nas musculares&#44; estimulando a s&#237;ntese de prote&#237;nas mitocondriais&#46; Os doentes com DM tipo 2 apresentam geralmente um compromisso no funcionamento mitocondrial ao n&#237;vel do m&#250;sculo&#8208;esquel&#233;tico&#46; Uma vez que a atividade muscular perif&#233;rica &#233; o principal fator determinante da capacidade de exerc&#237;cio&#44; um compromisso no seu funcionamento pode estar envolvido na resposta muscular alterada ao exerc&#237;cio<a class="elsevierStyleCrossRef" href="#bib0240"><span class="elsevierStyleSup">48</span></a>&#46; Al&#233;m disso&#44; 42&#37; dos diab&#233;ticos sem evid&#234;ncia cl&#237;nica de doen&#231;a vascular perif&#233;rica apresentam d&#233;fices significativos na perfus&#227;o dos m&#250;sculos dos membros inferiores&#44; provavelmente devido &#224; doen&#231;a microvascular&#44; o que poder&#225; tamb&#233;m diminuir o efeito da reabilita&#231;&#227;o card&#237;aca na capacidade funcional<a class="elsevierStyleCrossRef" href="#bib0245"><span class="elsevierStyleSup">49</span></a>&#46;</p><p id="par0440" class="elsevierStylePara elsevierViewall">Neste trabalho&#44; que inclui uma amostra consider&#225;vel de doentes&#44; observou&#8208;se globalmente uma melhoria de todos os par&#226;metros relativos ao controlo dos FRCV&#44; bem como da capacidade funcional&#44; e verificou&#8208;se que os benef&#237;cios alcan&#231;ados com o PRC foram semelhantes nos diab&#233;ticos e n&#227;o diab&#233;ticos em termos de redu&#231;&#227;o do risco cardiovascular&#46;</p><p id="par0445" class="elsevierStylePara elsevierViewall">Real&#231;amos a sua import&#226;ncia por se tratar do primeiro estudo&#44; na realidade portuguesa&#44; a comparar os resultados do PRC entre doentes diab&#233;ticos e n&#227;o diab&#233;ticos e com uma grande dimens&#227;o populacional&#46;</p><p id="par0450" class="elsevierStylePara elsevierViewall">O processo de aprendizagem desenvolvido durante as diversas sess&#245;es do PRC promove o autocontrolo da diabetes&#44; a autodisciplina na manuten&#231;&#227;o de estilos de vida saud&#225;veis&#44; conjuntamente&#44; com a autovigil&#226;ncia de complica&#231;&#245;es&#47;consequ&#234;ncias decorrentes da pr&#225;tica de exerc&#237;cio f&#237;sico na condi&#231;&#227;o cl&#237;nica do doente diab&#233;tico&#46;</p><span id="sec0080" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0145">Limita&#231;&#245;es do estudo</span><p id="par0455" class="elsevierStylePara elsevierViewall">A inexist&#234;ncia de um grupo controlo que permita ter em considera&#231;&#227;o o efeito da evolu&#231;&#227;o natural da doen&#231;a constitui uma limita&#231;&#227;o do estudo&#44; mas dado que a literatura tem revelado de forma consistente 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="#bib0250"><span class="elsevierStyleSup">50</span></a>&#44; estamos convictos que os resultados favor&#225;veis encontrados nos dois grupos s&#227;o atribu&#237;dos especificamente ao PRC&#46;</p><p id="par0460" class="elsevierStylePara elsevierViewall">Por outro lado&#44; o per&#237;odo de <span class="elsevierStyleItalic">follow&#8208;up</span> &#233; reduzido &#40;tr&#234;s meses&#41;&#44; sendo por isso importante realizar uma avalia&#231;&#227;o a longo prazo&#46;</p></span></span><span id="sec0085" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0150">Conclus&#245;es</span><p id="par0465" class="elsevierStylePara elsevierViewall">A preval&#234;ncia de doentes diab&#233;ticos em PRC parece estar a aumentar e esta tend&#234;ncia dever&#225; manter&#8208;se no futuro&#44; tendo em conta as previs&#245;es de uma crescente preval&#234;ncia da DM&#46;</p><p id="par0470" class="elsevierStylePara elsevierViewall">Os resultados deste estudo demonstraram que doentes com DM tipo 2 podem beneficiar com um PRC e alcan&#231;ar resultados compar&#225;veis a doentes n&#227;o diab&#233;ticos em termos de melhoria do perfil de risco cardiovascular&#46;</p><p id="par0475" class="elsevierStylePara elsevierViewall">Os diab&#233;ticos t&#234;m um risco acrescido de futuros eventos cardiovasculares e por isso requerem uma preven&#231;&#227;o secund&#225;ria mais agressiva&#46; Alertamos para a import&#226;ncia da referencia&#231;&#227;o sistem&#225;tica destes doentes para os PRC&#44; dados os seus benef&#237;cios&#44; contribuindo assim para a melhoria da qualidade de vida do doente diab&#233;tico&#46;</p></span><span id="sec0090" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0155">Conflito de interesses</span><p id="par0480" class="elsevierStylePara elsevierViewall">Os autores declaram n&#227;o haver conflito de interesses&#46;</p></span></span>"
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              "titulo" => "Programa de reabilita&#231;&#227;o"
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              "titulo" => "Exerc&#237;cio f&#237;sico supervisionado"
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              "titulo" => "Educa&#231;&#227;o para a sa&#250;de"
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              "titulo" => "An&#225;lise estat&#237;stica"
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              "titulo" => "Obesidade"
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            1 => array:2 [
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              "titulo" => "Hipertens&#227;o arterial"
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              "titulo" => "Dislipidemia"
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              "titulo" => "Tabagismo"
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              "titulo" => "Diabetes mellitus"
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              "titulo" => "Sedentarismo"
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          "titulo" => "Bibliografia"
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    "fechaRecibido" => "2013-11-02"
    "fechaAceptado" => "2014-01-27"
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            0 => "Reabilita&#231;&#227;o card&#237;aca"
            1 => "Diabetes <span class="elsevierStyleItalic">mellitus</span>"
            2 => "Doen&#231;a card&#237;aca isqu&#233;mica"
            3 => "Fatores de risco cardiovascular"
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            0 => "Cardiac rehabilitation"
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            2 => "Ischemic heart disease"
            3 => "Cardiovascular risk factors"
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    "resumen" => array:2 [
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        "titulo" => "Resumo"
        "resumen" => "<span class="elsevierStyleSectionTitle" id="sect0010">Introdu&#231;&#227;o e objetivos</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Doentes diab&#233;ticos t&#234;m um risco de doen&#231;a cardiovascular duas a quatro vezes superior a n&#227;o diab&#233;ticos&#46; Os objetivos do estudo s&#227;o&#58; avaliar os efeitos de um programa de reabilita&#231;&#227;o card&#237;aca &#40;fase <span class="elsevierStyleSmallCaps">II</span>&#41; em doentes coron&#225;rios diab&#233;ticos e comparar os seus resultados em termos de controlo de fatores de risco cardiovasculares e ganhos na capacidade funcional com doentes coron&#225;rios n&#227;o diab&#233;ticos&#46;</p> <span class="elsevierStyleSectionTitle" id="sect0015">M&#233;todos</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Estudo prospetivo integrando doentes com doen&#231;a card&#237;aca isqu&#233;mica orientados para programa de reabilita&#231;&#227;o card&#237;aca entre janeiro de 2009 e junho de 2013&#46; Consideraram&#8208;se dois grupos&#58; diab&#233;ticos e n&#227;o diab&#233;ticos&#46; Foram avaliados na primeira consulta da fase <span class="elsevierStyleSmallCaps">II</span> e tr&#234;s meses depois&#44; com registo dos seguintes par&#226;metros&#58; &#237;ndice de massa corporal&#44; per&#237;metro abdominal&#44; perfil lip&#237;dico&#44; hemoglobina glicada e glicose nos diab&#233;ticos&#44; press&#227;o arterial&#44; tabagismo&#44; n&#237;vel de atividade f&#237;sica &#40;atrav&#233;s do <span class="elsevierStyleItalic">International Physical Activity Questionnaire</span>&#41; e capacidade funcional &#40;alcan&#231;ada em prova de esfor&#231;o&#41;&#46;</p> <span class="elsevierStyleSectionTitle" id="sect0020">Resultados</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Amostra de 682 doentes &#40;253 diab&#233;ticos e 429 n&#227;o diab&#233;ticos&#41;&#46; Os diab&#233;ticos eram significativamente mais idosos&#44; apresentavam pior perfil de risco cardiovascular &#40;maior preval&#234;ncia de excesso ponderal&#44; dislipidemia&#44; hipertens&#227;o arterial e sedentarismo&#41; e menor capacidade funcional&#46; No final da fase <span class="elsevierStyleSmallCaps">II</span> ocorreu uma melhoria estatisticamente significativa &#40;p &#60;<span class="elsevierStyleHsp" style=""></span>0&#44;05&#41; em todos os fatores de risco e na capacidade funcional&#44; que foi semelhante nos dois grupos com exce&#231;&#227;o do &#237;ndice de massa corporal&#44; dos triglicer&#237;deos e da capacidade funcional&#46;</p> <span class="elsevierStyleSectionTitle" id="sect0025">Conclus&#245;es</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Doentes diab&#233;ticos podem beneficiar com um programa de reabilita&#231;&#227;o card&#237;aca e alcan&#231;ar resultados compar&#225;veis a n&#227;o diab&#233;ticos&#46;</p>"
      ]
      "en" => array:2 [
        "titulo" => "Abstract"
        "resumen" => "<span class="elsevierStyleSectionTitle" id="sect0035">Introduction and Aims</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Diabetic patients have a 2&#8208;4 times higher risk of cardiovascular disease than non&#8208;diabetic individuals&#46; The aims of this study are to evaluate the effects of a cardiac rehabilitation program &#40;phase II&#41; in patients with diabetes and coronary disease and to compare the results with regard to control of cardiovascular risk factors and improvement in functional capacity with coronary patients without diabetes&#46;</p> <span class="elsevierStyleSectionTitle" id="sect0040">Methods</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">This was a prospective study of patients diagnosed with ischemic heart disease referred for a cardiac rehabilitation program between January 2009 and June 2013&#46; The population was divided into two groups&#58; diabetic and non&#8208;diabetic&#46; Patients were assessed at the beginning of phase II and three months later and the following parameters were recorded&#58; body mass index&#44; waist circumference&#44; lipid profile&#44; blood glucose and glycated hemoglobin in diabetic patients&#44; blood pressure&#44; smoking&#44; physical activity level &#40;using the International Physical Activity Questionnaire&#41; and functional capacity &#40;on treadmill stress testing&#41;&#46;</p> <span class="elsevierStyleSectionTitle" id="sect0045">Results</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">The study population consisted of 682 patients &#40;253 diabetic and 429 non&#8208;diabetic&#41;&#46; Diabetic patients were significantly older&#44; had a worse cardiovascular risk profile &#40;higher prevalence of overweight&#44; dyslipidemia&#44; hypertension and sedentary lifestyle&#41; and lower functional capacity&#46; At the end of phase II&#44; there was a statistically significant improvement &#40;p&#60;0&#46;05&#41; in all risk factors and functional capacity&#44; which was similar in both groups&#44; except for body mass index&#44; triglycerides and functional capacity&#46;</p> <span class="elsevierStyleSectionTitle" id="sect0050">Conclusions</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">Diabetic patients may benefit from a cardiac rehabilitation program and achieve comparable results to non&#8208;diabetic patients&#46;</p>"
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        "identificador" => "nom0005"
        "titulo" => "<span class="elsevierStyleSectionTitle" id="sect0065">Lista de Abreviaturas</span>"
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              0 => array:2 [
                "termino" => "<span class="elsevierStyleVsp" style="height:0.5px"></span>CABG"
                "descripcion" => "<p id="par0005" class="elsevierStylePara elsevierViewall">Cirurgia de <span class="elsevierStyleItalic">By&#8208;pass</span> Coron&#225;rio</p>"
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              1 => array:2 [
                "termino" => "<span class="elsevierStyleVsp" style="height:0.5px"></span>C&#8208;HDL"
                "descripcion" => "<p id="par0010" class="elsevierStylePara elsevierViewall">Colesterol das lipoprote&#237;nas de alta densidade</p>"
              ]
              2 => array:2 [
                "termino" => "<span class="elsevierStyleVsp" style="height:0.5px"></span>C&#8208;LDL"
                "descripcion" => "<p id="par0015" class="elsevierStylePara elsevierViewall">Colesterol das lipoprote&#237;nas de baixa densidade</p>"
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              3 => array:2 [
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                "descripcion" => "<p id="par0020" class="elsevierStylePara elsevierViewall">Colesterol total</p>"
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              4 => array:2 [
                "termino" => "<span class="elsevierStyleVsp" style="height:0.5px"></span>DC"
                "descripcion" => "<p id="par0025" class="elsevierStylePara elsevierViewall">Doen&#231;a coron&#225;ria</p>"
              ]
              5 => array:2 [
                "termino" => "<span class="elsevierStyleVsp" style="height:0.5px"></span>DCI"
                "descripcion" => "<p id="par0030" class="elsevierStylePara elsevierViewall">Doen&#231;a card&#237;aca isqu&#233;mica</p>"
              ]
              6 => array:2 [
                "termino" => "<span class="elsevierStyleVsp" style="height:0.5px"></span>DM"
                "descripcion" => "<p id="par0035" class="elsevierStylePara elsevierViewall">Diabetes <span class="elsevierStyleItalic">mellitus</span></p>"
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              7 => array:2 [
                "termino" => "<span class="elsevierStyleVsp" style="height:0.5px"></span>DP"
                "descripcion" => "<p id="par0040" class="elsevierStylePara elsevierViewall">Desvio Padr&#227;o</p>"
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              8 => array:2 [
                "termino" => "<span class="elsevierStyleVsp" style="height:0.5px"></span>FRCV"
                "descripcion" => "<p id="par0045" class="elsevierStylePara elsevierViewall">Fatores de risco cardiovascular</p>"
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              9 => array:2 [
                "termino" => "<span class="elsevierStyleVsp" style="height:0.5px"></span>GD"
                "descripcion" => "<p id="par0050" class="elsevierStylePara elsevierViewall">Grupo dos diab&#233;ticos</p>"
              ]
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>&#8208; IMC &#40;kg&#47;m<span class="elsevierStyleSup">2</span>&#41;&#44; m&#233;dia &#40;DP&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>&#8208; Per&#237;metro abdominal &#40;cm&#41;&#44; m&#233;dia &#40;DP&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>&#8208; CT &#40;mg&#47;dL&#41;&#44; m&#233;dia &#40;DP&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>&#8208; C&#8208;LDL &#40;mg&#47;dL&#41;&#44; m&#233;dia &#40;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"><span class="elsevierStyleHsp" style=""></span>&#8208; C&#8208;HDL &#40;mg&#47;dL&#41;&#44; P50 &#40;P25&#59; P75&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">CT &#40;mg&#47;dL&#41;&#44; m&#233;dia &#40;DP&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">C&#8208;LDL &#40;mg&#47;dL&#41;&#44; m&#233;dia &#40;DP&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">C&#8208;HDL &#40;mg&#47;dL&#41;&#44; P50 &#40;P25&#59; P75&#41;&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">37&#44;0 &#40;31&#44;0&#59; 45&#44;0&#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">&#43;3&#44;0 &#40;&#8722;2&#44;0&#59; 8&#44;0&#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="char" valign="\n
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                  \t\t\t\t">&#60;<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">Triglicer&#237;deos &#40;mg&#47;dL&#41;&#44; P50 &#40;P25&#59; P75&#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
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                  \t\t\t\t">143&#44;0 &#40;107&#44;0&#59; 207&#44;5&#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
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                  \t\t\t\t">&#8722;24&#44;0 &#40;&#8722;64&#44;0&#59; 6&#44;5&#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">&#60;<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
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">Fumadores&#44; n &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">55 &#40;21&#44;7&#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="char" valign="\n
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                  \t\t\t\t">&#8595;90&#44;9&#37;&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">&#60;<span class="elsevierStyleHsp" style=""></span>0&#44;001&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">N&#46;&#176; cigarros&#47;dia&#44; P50 &#40;P25&#59; P75&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">20&#44;0 &#40;15&#44;0&#59; 30&#44;0&#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">&#8722;20&#44;0 &#40;&#8722;30&#44;0&#59; &#8722;10&#44;0&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">&#60;<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="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Glicose &#40;mg&#47;dL&#41;&#44; P50 &#40;P25&#59; P75&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">129&#44;0 &#40;106&#44;0&#59; 173&#44;5&#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
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                  \t\t\t\t">&#8722;14&#44;0 &#40;&#8722;45&#44;0&#59; 0&#44;0&#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">&#60;<span class="elsevierStyleHsp" style=""></span>0&#44;001&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">HbA1c &#40;&#37;&#41;&#44; P50 &#40;P25&#59; P75&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t">6&#44;6 &#40;5&#44;9&#59; 8&#44;1&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#8722;0&#44;45 &#40;&#8722;1&#44;0&#59; &#8722;0&#44;2&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">IPAQ &#40;MET&#42;minuto&#47;semana&#41;&#44; P50 &#40;P25&#59; P75&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">&#43;1&#46;283&#44;0 &#40;693&#44;0&#59; 1&#46;923&#44;0&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">&#60;<span class="elsevierStyleHsp" style=""></span>0&#44;001&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t" style="border-bottom: 2px solid black">Avalia&#231;&#227;o pr&#233;&#8208;PRC&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t" style="border-bottom: 2px solid black">p&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">95&#44;1 &#40;9&#44;5&#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">&#8722;2&#44;8 &#40;3&#44;8&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">&#60;<span class="elsevierStyleHsp" style=""></span>0&#44;001&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">Press&#227;o arterial elevada&#44; n &#40;&#37;&#41;&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">90 &#40;21&#44;0&#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">&#8595;80&#44;0&#37;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">&#60;<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">CT &#40;mg&#47;dL&#41;&#44; m&#233;dia &#40;DP&#41;&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">177&#44;1 &#40;39&#44;0&#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">&#8722;20&#44;8 &#40;39&#44;5&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">C&#8208;LDL &#40;mg&#47;dL&#41;&#44; m&#233;dia &#40;DP&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">&#8722;21&#44;0 &#40;32&#44;4&#41;&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">&#60;<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="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">C&#8208;HDL &#40;mg&#47;dL&#41;&#44; P50 &#40;P25&#59; P75&#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">39&#44;0 &#40;32&#44;0&#59; 47&#44;0&#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">&#43;4&#44;0 &#40;&#8722;1&#44;0&#59; 9&#44;0&#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;<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">Triglicer&#237;deos &#40;mg&#47;dL&#41;&#44; P50 &#40;P25&#59; P75&#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">122&#44;0 &#40;98&#44;5&#59; 166&#44;0&#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
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                  \t\t\t\t">Fumadores&#44; n&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  " align="left" valign="\n
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                  \t\t\t\t">N&#46;&#176; cigarros&#47;dia&#44; P50 &#40;P25&#59; P75&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">20&#44;0 &#40;10&#44;0&#59; 30&#44;0&#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">IPAQ &#40;MET&#42;minuto&#47;semana&#41;&#44; P50 &#40;P25&#59; P75&#41;&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">&#8722;2&#44;3 &#40;3&#44;1&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">&#8722;2&#44;8 &#40;3&#44;8&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">0&#44;058&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">Press&#227;o arterial elevada&#44; &#37;&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">&#8595; 70&#44;4&#37;&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">&#8595; 80&#44;0&#37;&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">CT &#40;mg&#47;dL&#41;&#44; m&#233;dia &#40;DP&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t">&#8722;21&#44;5 &#40;41&#44;3&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">&#8722;20&#44;8 &#40;39&#44;5&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">0&#44;806&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">C&#8208;LDL &#40;mg&#47;dL&#41;&#44; m&#233;dia &#40;DP&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">&#8722;20&#44;1 &#40;33&#44;2&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">&#8722;21&#44;0 &#40;32&#44;4&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">0&#44;60&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">C&#8208;HDL &#40;mg&#47;dL&#41;&#44; P50 &#40;P25&#59; P75&#41;&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">&#43;3&#44;0 &#40;&#8722;2&#44;0&#59; 8&#44;0&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">&#43;4&#44;0 &#40;&#8722;1&#44;0&#59; 9&#44;0&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">0&#44;148&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">Triglicer&#237;deos &#40;mg&#47;dL&#41;&#44; P50 &#40;P25&#59; P75&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">&#8722;24&#44;0 &#40;&#8722;64&#44;0&#59; 6&#44;5&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">&#8722;16&#44;0 &#40;&#8722;44&#44;0&#59; 7&#44;5&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">0&#44;039&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">Fumadores&#44; &#37;&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">&#8595; 90&#44;9&#37;&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">&#8595; 83&#44;6&#37;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t">0&#44;266&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
                  \t\t\t\t\ttop\n
                  \t\t\t\t">N&#46;&#176; cigarros&#47;dia&#44; P50 &#40;P25&#59; P75&#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">&#8722;20&#44;0 &#40;&#8722;30&#44;0&#59; &#8722;10&#44;0&#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="char" valign="\n
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                  \t\t\t\t">&#8722;20&#44;0 &#40;&#8722;25&#44;0&#59; &#8722;10&#44;0&#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="char" valign="\n
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                  \t\t\t\t">0&#44;194&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">IPAQ &#40;METs&#47;min&#47;sem&#41;&#44; P50 &#40;P25&#59; P75&#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="char" valign="\n
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                  \t\t\t\t">1&#46;283&#44;0 &#40;693&#44;0&#59; 1&#46;923&#44;0&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">1&#46;380&#44;0 &#40;597&#44;0&#59; 2&#46;289&#44;5&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t">0&#44;628&nbsp;\t\t\t\t\t\t\n
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          "pt" => "<p id="spar0075" class="elsevierStyleSimplePara elsevierViewall">Compara&#231;&#227;o da evolu&#231;&#227;o dos FRCV com o programa de reabilita&#231;&#227;o card&#237;aca entre doentes diab&#233;ticos e n&#227;o diab&#233;ticos</p>"
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          "pt" => "<p id="spar0085" class="elsevierStyleSimplePara elsevierViewall">Compara&#231;&#227;o da capacidade funcional&#44; antes e ap&#243;s o PRC em cada um dos grupos e compara&#231;&#227;o entre os dois grupos</p>"
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Artigo Original
Reabilitação cardíaca em doentes coronários com diabetes mellitus tipo 2: Estudo comparativo
Cardiac rehabilitation in patients with type 2 diabetes mellitus and coronary disease: A comparative study
Sofia Tostea,
Autor para correspondência
sofiatoste@gmail.com

Autor para correspondência.
, Sofia Viamontea,
Autor para correspondência
sofiaviamonte@gmail.com

Autor para correspondência.
, Ana Barreirab, Preza Fernandesb, José Lopes Gomesb, Severo Torresb
a Serviço de Fisiatria, 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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10339
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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Introdu&#231;&#227;o</span><p id="par0135" class="elsevierStylePara elsevierViewall">Os Programas de Reabilita&#231;&#227;o Card&#237;aca &#40;PRC&#41; s&#227;o programas de interven&#231;&#227;o multidisciplinar que t&#234;m como objetivo possibilitar ao doente alcan&#231;ar e manter o seu m&#225;ximo potencial f&#237;sico e psicossocial<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a>&#46;</p><p id="par0140" class="elsevierStylePara elsevierViewall">Os PRC constituem atualmente uma valiosa op&#231;&#227;o terap&#234;utica ao proporcionarem m&#250;ltiplos benef&#237;cios&#44; nomeadamente a promo&#231;&#227;o de estilos de vida saud&#225;veis com controlo de fatores de risco cardiovascular &#40;FRCV&#41;&#44; al&#237;vio sintom&#225;tico&#44; otimiza&#231;&#227;o da capacidade funcional e diminui&#231;&#227;o da incid&#234;ncia de novos eventos cardiovasculares&#44; contribuindo para um retorno a uma vida mais produtiva e satisfat&#243;ria<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a>&#46; Estudos referem uma diminui&#231;&#227;o na taxa de mortalidade por enfarte do mioc&#225;rdio de cerca de 25&#37; em doentes submetidos a PRC&#44; relativamente a doentes que n&#227;o realizam programa<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">3&#44;4</span></a>&#46; Apesar disso&#44; em Portugal os PRC continuam a ser pouco utilizados e de acordo com dados dos Grupos de Diagn&#243;stico Homog&#233;neos &#40;GDH&#41; de 2007 e do inqu&#233;rito nacional do Grupo de Estudo de Fisiopatologia do Esfor&#231;o e Reabilita&#231;&#227;o Card&#237;aca &#40;GEFERC&#41; da Sociedade Portuguesa de Cardiologia 2007&#44; a percentagem de doentes com enfarte do mioc&#225;rdio submetidos a PRC foi de 3&#37;&#44; sendo esta percentagem ainda menor para outras patologias<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a>&#46; Em 2007&#44; Portugal era o pen&#250;ltimo pa&#237;s da Europa em termos de reabilita&#231;&#227;o card&#237;aca&#44; tendo&#44; no entanto&#44; duplicado em rela&#231;&#227;o aos n&#250;meros de 2004<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a>&#46;</p><p id="par0145" class="elsevierStylePara elsevierViewall">As indica&#231;&#245;es cl&#237;nicas para integra&#231;&#227;o em PRC incluem&#58; s&#237;ndrome coron&#225;ria aguda &#40;SCA&#41;&#44; angina est&#225;vel&#44; procedimentos de revasculariza&#231;&#227;o como interven&#231;&#227;o coron&#225;ria percut&#226;nea &#40;ICP&#41; ou cirurgia de <span class="elsevierStyleItalic">bypass</span> coron&#225;rio &#40;CABG&#41;&#44; cirurgia valvular&#44; insufici&#234;ncia card&#237;aca compensada&#44; transplante card&#237;aco e controlo de FRCV em doentes de elevado risco de doen&#231;a coron&#225;ria &#40;DC&#41;<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#44;2</span></a>&#46;</p><p id="par0150" class="elsevierStylePara elsevierViewall">Os PRC s&#227;o constitu&#237;dos por tr&#234;s ou quatro fases &#40;de acordo com as recomenda&#231;&#245;es europeias<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> ou americanas<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a>&#44; respetivamente&#41;&#44; desde o internamento por evento cardiovascular at&#233; ao momento em que o indiv&#237;duo se torne totalmente respons&#225;vel pela manuten&#231;&#227;o das estrat&#233;gias educativas&#46;</p><p id="par0155" class="elsevierStylePara elsevierViewall">Os doentes com diabetes <span class="elsevierStyleItalic">mellitus</span> &#40;DM&#41; t&#234;m um risco de doen&#231;a cardiovascular&#44; especialmente DC&#44; duas a quatro vezes superior a n&#227;o diab&#233;ticos e a sua presen&#231;a duplica a taxa de mortalidade por evento cardiovascular&#44; mesmo ap&#243;s ajustes para outros FRCV<a class="elsevierStyleCrossRefs" href="#bib0040"><span class="elsevierStyleSup">8&#44;9</span></a>&#46;</p><p id="par0160" class="elsevierStylePara elsevierViewall">A Organiza&#231;&#227;o Mundial de Sa&#250;de declarou a DM como um problema de sa&#250;de p&#250;blica&#44; sendo essencial a promo&#231;&#227;o de medidas de educa&#231;&#227;o para a sa&#250;de&#44; j&#225; que a previs&#227;o para 2030 &#233; de 366 milh&#245;es de diab&#233;ticos em todo o mundo<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a>&#46; Em Portugal&#44; 11&#44;7&#37; da popula&#231;&#227;o entre os 20 e os 79 anos tem diabetes<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">11</span></a>&#46;</p><p id="par0165" class="elsevierStylePara elsevierViewall">Apesar da mortalidade por eventos coron&#225;rios ter diminu&#237;do nas &#250;ltimas d&#233;cadas na popula&#231;&#227;o em geral&#44; consequ&#234;ncia do melhor controlo de alguns FRCV e de terap&#234;uticas mais eficazes para a doen&#231;a card&#237;aca&#44; tal n&#227;o se verificou em indiv&#237;duos diab&#233;ticos<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">12</span></a>&#46;</p><p id="par0170" class="elsevierStylePara elsevierViewall">A abordagem global do doente diab&#233;tico em termos da redu&#231;&#227;o do risco cardiovascular inclui dieta adequada&#44; controlo dos FRCV concomitantes&#44; exerc&#237;cio f&#237;sico regular e interven&#231;&#227;o farmacol&#243;gica<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">13</span></a>&#46; Estas estrat&#233;gias ir&#227;o levar a respostas metab&#243;licas e end&#243;crinas favor&#225;veis&#44; que a m&#233;dio e longo prazo se traduzem em redu&#231;&#227;o da hemoglobina glicada &#40;HbA1c&#41;&#44; diminui&#231;&#227;o da intoler&#226;ncia &#224; glicose&#44; diminui&#231;&#227;o da resist&#234;ncia &#224; insulina&#44; aumento do consumo muscular de glicose&#44; redu&#231;&#227;o do tecido adiposo e aumento da toler&#226;ncia ao exerc&#237;cio&#46; Estes benef&#237;cios&#44; no seu conjunto&#44; atrasam a evolu&#231;&#227;o de complica&#231;&#245;es micro e macrovasculares associadas &#224; DM&#44; reduzindo&#44; assim&#44; o risco cardiovascular e promovendo a melhoria da qualidade de vida<a class="elsevierStyleCrossRefs" href="#bib0035"><span class="elsevierStyleSup">7&#44;13&#44;14</span></a>&#46;</p><p id="par0175" class="elsevierStylePara elsevierViewall">Dos doentes referenciados para PRC&#44; 20&#8208;30&#37; t&#234;m DM<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">15</span></a>&#44; contudo&#44; existem poucos estudos que avaliem especificamente a efic&#225;cia dos PRC em doentes diab&#233;ticos&#44; apesar destes programas poderem ser especialmente importantes nesta popula&#231;&#227;o de doentes&#46;</p><p id="par0180" class="elsevierStylePara elsevierViewall">O presente estudo tem como objetivo avaliar os efeitos de um PRC &#40;fase <span class="elsevierStyleSmallCaps">II</span>&#41; em doentes coron&#225;rios com DM tipo 2 e comparar os seus resultados no que se refere ao controlo de FRCV e ganhos na capacidade funcional com doentes coron&#225;rios n&#227;o diab&#233;ticos&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">M&#233;todos</span><p id="par0185" class="elsevierStylePara elsevierViewall">Foi realizado um estudo unic&#234;ntrico&#44; observacional&#44; prospetivo&#44; do tipo coorte&#44; integrando 818 doentes com diagn&#243;stico de doen&#231;a card&#237;aca isqu&#233;mica &#40;DCI&#41;&#44; consecutivamente orientados para PRC na Unidade de Preven&#231;&#227;o e de Reabilita&#231;&#227;o Cardiovascular &#40;UPRCV&#41; do Hospital de Santo Ant&#243;nio&#44; Centro Hospitalar do Porto&#44; entre janeiro de 2009 e junho de 2013&#46; Da amostra inicial foram exclu&#237;dos 136 doentes&#58; 91 por abandono do PRC &#40;desist&#234;ncia&#41;&#59; nove por intercorr&#234;ncias cl&#237;nicas que impossibilitaram o cumprimento de um m&#237;nimo de oito sess&#245;es do programa &#40;dois por reinternamento para ICP&#59; um por SCA&#59; seis por les&#245;es musculosquel&#233;ticas&#41;&#59; 36 por perda de dados no per&#237;odo de <span class="elsevierStyleItalic">follow&#8208;up</span>&#44; nomeadamente valores anal&#237;ticos ou dados antropom&#233;tricos&#44; que impossibilitavam a an&#225;lise estat&#237;stica&#46; Foram assim inclu&#237;dos 682 doentes&#44; que iniciaram o PRC nos primeiros tr&#234;s meses p&#243;s&#8208;evento&#44; independentemente do diagn&#243;stico de admiss&#227;o&#46; Para a realiza&#231;&#227;o do estudo consideraram&#8208;se dois grupos de doentes&#58; grupo dos diab&#233;ticos &#40;GD&#41; e dos n&#227;o diab&#233;ticos &#40;GND&#41;&#46; Foram inclu&#237;dos no GD os doentes com hist&#243;ria pr&#233;via de DM tipo 2 &#40;confirmada no processo cl&#237;nico&#41; ou sob medica&#231;&#227;o antidiab&#233;tica &#40;antidiab&#233;ticos orais ou insulinoterapia&#41;&#46;</p><p id="par0190" class="elsevierStylePara elsevierViewall">Estabeleceram&#8208;se dois momentos de avalia&#231;&#227;o&#58; in&#237;cio do PRC e tr&#234;s meses depois&#46; Na avalia&#231;&#227;o inicial procedeu&#8208;se &#224; realiza&#231;&#227;o da hist&#243;ria cl&#237;nica &#40;recolha de dados sociodemogr&#225;ficos&#44; antecedentes pessoais e familiares&#41; e ao exame f&#237;sico dos sistemas cardiovascular&#44; musculosquel&#233;tico e neurol&#243;gico&#46; Nos dois momentos de avalia&#231;&#227;o foram ainda recolhidos dados relativos ao perfil de risco&#44; nomeadamente&#44; medi&#231;&#227;o de press&#227;o arterial&#59; dados antropom&#233;tricos incluindo &#237;ndice de massa corporal &#40;IMC&#41; &#40;kg&#47;m<span class="elsevierStyleSup">2</span>&#41; e per&#237;metro abdominal &#40;PA&#41;&#59; registo de h&#225;bitos tab&#225;gicos&#44; de valores de glicose&#44; HbA1c e do perfil lip&#237;dico &#40;obtido ap&#243;s cumprimento de um per&#237;odo de 12 horas de jejum&#41; incluindo colesterol total &#40;CT&#41;&#44; colesterol das lipoprote&#237;nas de baixa densidade &#40;LDL&#41; &#40;<span class="elsevierStyleItalic">low density lipoprotein cholesterol</span> &#91;c&#8208;LDL&#93;&#41;&#44; colesterol das lipoprote&#237;nas de alta densidade &#40;HDL&#41; &#40;<span class="elsevierStyleItalic">high density lipoprotein cholesterol</span> &#91;c&#8208;HDL&#93;&#41; e triglicer&#237;deos &#40;TG&#41;&#46;</p><p id="par0195" class="elsevierStylePara elsevierViewall">Foram considerados os seguintes valores de refer&#234;ncia como normais&#58; press&#227;o arterial inferior a 130&#47;80<span class="elsevierStyleHsp" style=""></span>mmHg em duas avalia&#231;&#245;es consecutivas&#59; IMC de 18&#8208;24&#44;9 kg&#47;m<span class="elsevierStyleSup">2</span> &#40;valores de 25&#8208;29&#44;9<span class="elsevierStyleHsp" style=""></span>kg&#47;m<span class="elsevierStyleSup">2</span> foram classificados como excesso de peso e IMC &#8805;<span class="elsevierStyleHsp" style=""></span>30 kg&#47;m<span class="elsevierStyleSup">2</span> foram classificados como obesidade&#41;&#59; PA inferior a 80<span class="elsevierStyleHsp" style=""></span>cm para o sexo feminino e inferior a 94<span class="elsevierStyleHsp" style=""></span>cm para o masculino&#59; glicemia capilar &#40;jejum&#41; &#60;<span class="elsevierStyleHsp" style=""></span>110<span class="elsevierStyleHsp" style=""></span>mg&#47;dL e HbA1c<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>6&#44;5&#37;&#59; CT &#60;<span class="elsevierStyleHsp" style=""></span>190<span class="elsevierStyleHsp" style=""></span>mg&#47;dl&#44; C&#8208;LDL &#60;<span class="elsevierStyleHsp" style=""></span>100<span class="elsevierStyleHsp" style=""></span>mg&#47;dl&#44; C&#8208;HDL &#62;<span class="elsevierStyleHsp" style=""></span>45<span class="elsevierStyleHsp" style=""></span>mg&#47;dl para o sexo masculino e C&#8208;HDL<span class="elsevierStyleHsp" style=""></span>&#62;<span class="elsevierStyleHsp" style=""></span>40<span class="elsevierStyleHsp" style=""></span>mg&#47;dl para o sexo feminino e TG<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>150<span class="elsevierStyleHsp" style=""></span>mg&#47;dl&#46;</p><p id="par0200" class="elsevierStylePara elsevierViewall">A avalia&#231;&#227;o do n&#237;vel de atividade f&#237;sica foi efetuada atrav&#233;s do <span class="elsevierStyleItalic">International Physical Activity Questionnaire</span> &#40;IPAQ&#41;&#44; validado para a popula&#231;&#227;o portuguesa<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">16</span></a> e que visa quantificar &#40;em equivalentes metab&#243;licos &#91;MET&#93;&#42;minuto&#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; Consideraram&#8208;se as seguintes categorias&#58; sedentarismo &#40;valores inferiores a 600<span class="elsevierStyleHsp" style=""></span>MET&#42;minuto&#47;semana&#41;&#59; atividade f&#237;sica moderada &#40;600&#8208;3&#46;000<span class="elsevierStyleHsp" style=""></span>MET&#42;minuto&#47;semana&#41;&#59; atividade f&#237;sica vigorosa &#40;valores superiores a 3&#46;000<span class="elsevierStyleHsp" style=""></span>MET&#42;minuto&#47;semana&#41;&#46;</p><p id="par0205" class="elsevierStylePara elsevierViewall">Nos mesmos per&#237;odos&#44; todos doentes realizaram prova de esfor&#231;o &#40;PE&#41; em tapete rolante motorizado&#44; sob medica&#231;&#227;o habitual&#44; determinando par&#226;metros de resposta cronotr&#243;pica e hemodin&#226;mica&#46; A capacidade funcional m&#225;xima foi estimada em MET obtidos na PE&#44; calculados atrav&#233;s de equa&#231;&#245;es metab&#243;licas do <span class="elsevierStyleItalic">American College of Sports Medicine</span> para marcha em tapete rolante<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a>&#44; e foi tamb&#233;m registado o tempo de esfor&#231;o total da PE&#46;</p><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Programa de reabilita&#231;&#227;o</span><p id="par0210" class="elsevierStylePara elsevierViewall">O PRC incluiu aconselhamento individual sobre estrat&#233;gias para controlo dos FRCV&#44; sess&#245;es de educa&#231;&#227;o para a sa&#250;de em grupo e sess&#245;es de exerc&#237;cio f&#237;sico supervisionado&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Exerc&#237;cio f&#237;sico supervisionado</span><p id="par0215" class="elsevierStylePara elsevierViewall">Todos os doentes integraram um programa de exerc&#237;cio f&#237;sico supervisionado por m&#233;dicos &#40;cardiologista e fisiatra&#41; e por fisioterapeuta&#44; durante 8&#8208;12 semanas&#44; com periodicidade bissemanal&#46; A dura&#231;&#227;o do PRC foi determinada de acordo com a estratifica&#231;&#227;o do risco card&#237;aco&#44; aus&#234;ncia de intercorr&#234;ncias durante o mesmo e a disponibilidade do doente &#40;dist&#226;ncia &#224; &#225;rea de resid&#234;ncia e necessidade de retomar a atividade laboral&#41;&#46;</p><p id="par0220" class="elsevierStylePara elsevierViewall">Cada sess&#227;o&#44; com dura&#231;&#227;o entre 60&#8208;90 minutos&#44; englobou um protocolo de exerc&#237;cio constitu&#237;do por&#58; fase de aquecimento&#44; treino aer&#243;bico &#40;exerc&#237;cio em tapete rolante&#44; cicloerg&#243;metro de membros superiores e inferiores&#41;&#44; treino de for&#231;a &#40;com recurso a bandas el&#225;sticas&#44; halteres&#44; bolas medicinais e aparelhos de fortalecimento muscular&#41; e fase de relaxamento e exerc&#237;cios de flexibilidade&#46; A intensidade do exerc&#237;cio aer&#243;bico foi determinada individualmente&#44; com base no c&#225;lculo de frequ&#234;ncia card&#237;aca de treino atrav&#233;s do m&#233;todo de Karvonen<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">17</span></a>&#44; utilizando os dados recolhidos na PE&#59; foi complementada com a perce&#231;&#227;o subjetiva do esfor&#231;o registada na escala de Borg<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a>&#46;</p><p id="par0225" class="elsevierStylePara elsevierViewall">Previamente a cada sess&#227;o de exerc&#237;cio foi realizada uma avalia&#231;&#227;o cl&#237;nica sum&#225;ria que incluiu o question&#225;rio de sintomas relevantes e cumprimento da farmacoterapia&#44; e foram medidos os valores de frequ&#234;ncia card&#237;aca e press&#227;o arterial basais&#44; assim como valores de glicemia capilar no caso dos doentes diab&#233;ticos&#46; No decorrer de cada sess&#227;o foi registada de forma cont&#237;nua a frequ&#234;ncia card&#237;aca atrav&#233;s de monitoriza&#231;&#227;o eletrocardiogr&#225;fica por telemetria ou por cardiofrequenc&#237;metro&#44; de acordo com 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="#bib0035"><span class="elsevierStyleSup">7</span></a>&#46;</p><p id="par0230" class="elsevierStylePara elsevierViewall">Adicionalmente&#44; foi incentivada em todos os doentes a pr&#225;tica do exerc&#237;cio f&#237;sico nos restantes dias da semana&#44; ao encontro &#224;s recomenda&#231;&#245;es no contexto da preven&#231;&#227;o secund&#225;ria<a class="elsevierStyleCrossRefs" href="#bib0035"><span class="elsevierStyleSup">7&#44;17</span></a>&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Educa&#231;&#227;o para a sa&#250;de</span><p id="par0235" class="elsevierStylePara elsevierViewall">Periodicamente foram realizadas sess&#245;es de grupo&#44; envolvendo os doentes e os seus familiares&#44; onde foram abordados e discutidos diversos temas como &#171;Doen&#231;a Coron&#225;ria&#187;&#44; &#171;Nutri&#231;&#227;o&#187;&#44; &#171;Stress&#187; e &#171;Exerc&#237;cio F&#237;sico&#187;&#46;</p><p id="par0240" class="elsevierStylePara elsevierViewall">Sempre que houve indica&#231;&#227;o cl&#237;nica os doentes foram orientados para consultas espec&#237;ficas na UPRCV&#44; nomeadamente Consulta de Endocrinologia&#44; Psiquiatria&#44; Desabitua&#231;&#227;o Tab&#225;gica&#44; Urologia ou Cirurgia Vascular&#46; Todos os doentes diab&#233;ticos foram avaliados em Consulta de Nutri&#231;&#227;o&#44; onde lhes foi prescrito um plano alimentar individualizado&#46;</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">An&#225;lise estat&#237;stica</span><p id="par0245" class="elsevierStylePara elsevierViewall">O processamento estat&#237;stico dos dados foi efetuado com recurso ao programa <span class="elsevierStyleItalic">Statistical Package for the Social Sciences</span> &#40;SPSS&#41; vers&#227;o 17&#46;0&#46; Os dados s&#227;o apresentados como m&#233;dia &#40;desvio padr&#227;o &#91;DP&#93;&#41;&#44; para vari&#225;veis cont&#237;nuas com distribui&#231;&#227;o normal&#44; e mediana &#40;intervalo interquartis &#91;P25&#8208;P75&#93;&#41;&#44; para vari&#225;veis cont&#237;nuas com distribui&#231;&#227;o n&#227;o normal&#46; Os doentes foram categorizados em dois grupos&#58; GD e GND&#46; Diferen&#231;as intragrupo foram avaliadas usando teste t de <span class="elsevierStyleItalic">Student</span> para amostras emparelhadas para vari&#225;veis cont&#237;nuas de distribui&#231;&#227;o normal e o teste de <span class="elsevierStyleItalic">Wilcoxon</span> para vari&#225;veis cont&#237;nuas de distribui&#231;&#227;o n&#227;o&#8208;normal&#46; A diferen&#231;a entre os grupos na resposta ao programa foi avaliada usando o teste t de <span class="elsevierStyleItalic">Student</span> para compara&#231;&#227;o de m&#233;dias e o teste de <span class="elsevierStyleItalic">Mann&#8208;Whitney</span> para compara&#231;&#227;o de medianas&#46; As vari&#225;veis categ&#243;ricas foram comparadas usando o teste <span class="elsevierStyleItalic">McNemar</span> para diferen&#231;as intragrupo e o teste de <span class="elsevierStyleItalic">Qui&#8208;quadrado</span> para diferen&#231;as entre grupos&#46;</p><p id="par0250" class="elsevierStylePara elsevierViewall">Valores de p inferiores a 0&#44;05 foram considerados estatisticamente significativos&#46;</p></span></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">Resultados</span><p id="par0255" class="elsevierStylePara elsevierViewall">A amostra em estudo abrangeu 682 doentes &#40;253 diab&#233;ticos e 429 n&#227;o diab&#233;ticos&#41;&#46; Ambos os grupos apresentavam maior propor&#231;&#227;o de doentes do sexo masculino &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">Tabela 1</a>&#41;&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0260" class="elsevierStylePara elsevierViewall">Os doentes diab&#233;ticos eram significativamente mais idosos &#40;m&#233;dia &#91;DP&#58; 61&#44;6 &#91;9&#44;1&#93; anos <span class="elsevierStyleItalic">versus</span> 58&#44;6 &#91;11&#44;0&#93; anos&#44; p<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#44;001&#41; e apresentavam pior perfil de risco cardiovascular &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">Tabela 1</a>&#41;&#58; maior preval&#234;ncia de excesso ponderal &#40;80&#44;6 <span class="elsevierStyleItalic">versus</span> 60&#44;1&#37;&#44; p<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#44;001&#41;&#44; com valores significativamente superiores de IMC e de PA&#59; maior preval&#234;ncia de dislipidemia &#40;76&#44;3 <span class="elsevierStyleItalic">versus</span> 64&#44;3&#37;&#44; p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;004&#41; com valores significativamente superiores de TG e valores inferiores de colesterol HDL&#59; maior preval&#234;ncia de hipertens&#227;o arterial &#40;HTA&#41; &#40;70&#44;4 <span class="elsevierStyleItalic">versus</span> 52&#44;4&#37;&#44; p<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#44;001&#41; e de sedentarismo &#40;61&#44;3 <span class="elsevierStyleItalic">versus</span> 49&#44;7&#37;&#44; p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;013&#41;&#46; Apresentavam&#44; contudo&#44; menor preval&#234;ncia de h&#225;bitos tab&#225;gicos &#40;21&#44;7 <span class="elsevierStyleItalic">versus</span> 37&#44;1&#37;&#44; p<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#44;001&#41;&#46; Relativamente &#224; capacidade funcional&#44; esta era significativamente menor nos diab&#233;ticos &#40;7&#44;9 &#91;2&#44;1&#93; MET <span class="elsevierStyleItalic">versus</span> 9&#44;1 &#91;2&#44;4&#93; MET&#44; p<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#44;001&#59; tempo de PE&#58; 0&#58;06&#58;51 &#91;0&#58;02&#58;08&#93; min&#58;seg <span class="elsevierStyleItalic">versus</span> 0&#58;08&#58;22 &#91;0&#58;02&#58;43&#93; min&#58;seg&#44; p<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#44;001&#41;&#46;</p><p id="par0265" class="elsevierStylePara elsevierViewall">O diagn&#243;stico de admiss&#227;o mais frequente foi em ambos os grupos a SCA&#46; A caracteriza&#231;&#227;o completa da amostra na admiss&#227;o para PRC &#233; apresentada na <a class="elsevierStyleCrossRef" href="#tbl0005">Tabela 1</a>&#46;</p><p id="par0270" class="elsevierStylePara elsevierViewall">A evolu&#231;&#227;o dos FRCV ao longo do estudo para o GD e GND est&#225; sumarizada nas <a class="elsevierStyleCrossRef" href="#tbl0010">Tabela 2</a> e<a class="elsevierStyleCrossRef" href="#tbl0015">Tabela 3</a>&#46; A <a class="elsevierStyleCrossRef" href="#tbl0020">Tabela 4</a> apresenta a compara&#231;&#227;o da evolu&#231;&#227;o dos FRCV entre os dois grupos&#46; Na <a class="elsevierStyleCrossRef" href="#tbl0025">Tabela 5</a> est&#225; representada a evolu&#231;&#227;o da capacidade funcional em cada um dos grupos de doentes&#44; bem como a compara&#231;&#227;o entre grupos&#46;</p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><elsevierMultimedia ident="tbl0015"></elsevierMultimedia><elsevierMultimedia ident="tbl0020"></elsevierMultimedia><elsevierMultimedia ident="tbl0025"></elsevierMultimedia><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0105">Obesidade</span><p id="par0275" class="elsevierStylePara elsevierViewall">O excesso ponderal constituiu o FRCV mais prevalente no grupo dos doentes diab&#233;ticos &#40;80&#44;6&#37;&#41;&#44; sendo que 22&#44;9&#37; destes eram obesos&#46;</p><p id="par0280" class="elsevierStylePara elsevierViewall">Entre o in&#237;cio e o fim do PRC&#44; ambos os grupos melhoraram significativamente nos par&#226;metros antropom&#233;tricos &#40;<a class="elsevierStyleCrossRef" href="#tbl0010">Tabela 2</a> e <a class="elsevierStyleCrossRef" href="#tbl0015">Tabela 3</a>&#41;&#46;</p><p id="par0285" class="elsevierStylePara elsevierViewall">A melhoria verificada foi semelhante nos dois grupos em rela&#231;&#227;o ao PA &#40;p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;058&#41;&#44; mas n&#227;o relativamente ao IMC&#44; em que a diminui&#231;&#227;o m&#233;dia nos valores do IMC foi em termos absolutos significativamente superior nos n&#227;o diab&#233;ticos &#40;p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;008&#41;&#46;</p></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0110">Hipertens&#227;o arterial</span><p id="par0290" class="elsevierStylePara elsevierViewall">Na admiss&#227;o para PRC&#44; 70&#44;4&#37; dos diab&#233;ticos e 52&#44;4&#37; dos n&#227;o diab&#233;ticos apresentavam antecedentes de HTA&#46; No momento da primeira avalia&#231;&#227;o 28&#44;1&#37; dos diab&#233;ticos e 21&#44;0&#37; dos n&#227;o diab&#233;ticos apresentavam valores tensionais elevados&#46; Com o PRC verificou&#8208;se em ambos os grupos uma diminui&#231;&#227;o significativa no n&#250;mero de doentes que apresentavam valores tensionais n&#227;o controlados &#40;diminui&#231;&#227;o de 70&#44;4&#37;&#44; p<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#44;001 nos diab&#233;ticos e de 80&#44;0&#37;&#44; p<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#44;001 nos n&#227;o diab&#233;ticos&#41;&#44; sendo que essa diminui&#231;&#227;o n&#227;o foi significativamente diferente nos dois grupos &#40;p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;195&#41;&#46;</p></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0115">Dislipidemia</span><p id="par0295" class="elsevierStylePara elsevierViewall">A dislipidemia era o FRCV mais prevalente nos n&#227;o diab&#233;ticos &#40;64&#44;3&#37;&#41;&#46;</p><p id="par0300" class="elsevierStylePara elsevierViewall">No final da fase <span class="elsevierStyleSmallCaps">II</span> do PRC verificou&#8208;se em ambos os grupos uma melhoria no perfil lip&#237;dico&#44; traduzida quer por uma diminui&#231;&#227;o significativa nos valores de CT&#44; C&#8208;LDL e TG quer por um aumento significativo nos valores do C&#8208;HDL &#40;<a class="elsevierStyleCrossRef" href="#tbl0010">Tabela 2</a> e <a class="elsevierStyleCrossRef" href="#tbl0015">Tabela 3</a>&#41;&#46;</p><p id="par0305" class="elsevierStylePara elsevierViewall">As varia&#231;&#245;es nos v&#225;rios par&#226;metros do perfil lip&#237;dico com o PRC foram semelhantes nos dois grupos&#44; exceto a diminui&#231;&#227;o no valor de TG&#44; que foi&#44; em termos absolutos&#44; significativamente superior nos diab&#233;ticos &#40;p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;039&#41;&#46;</p></span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0120">Tabagismo</span><p id="par0310" class="elsevierStylePara elsevierViewall">Na admiss&#227;o&#44; 21&#44;7&#37; dos diab&#233;ticos e 37&#44;1&#37; dos n&#227;o diab&#233;ticos eram fumadores&#46; No final da fase <span class="elsevierStyleSmallCaps">II</span> verificou&#8208;se uma diminui&#231;&#227;o de cerca de 90&#44;0&#37; no n&#250;mero de diab&#233;ticos fumadores &#40;p<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#44;001&#41; e de 83&#44;6&#37; nos n&#227;o diab&#233;ticos fumadores &#40;p<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#44;001&#41;&#44; tendo sido essa diminui&#231;&#227;o semelhante em ambos os grupos &#40;p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;266&#41;&#46;</p><p id="par0315" class="elsevierStylePara elsevierViewall">Relativamente ao n&#250;mero de cigarros fumados por dia&#44; observou&#8208;se igualmente uma diminui&#231;&#227;o significativa &#40;<a class="elsevierStyleCrossRef" href="#tbl0010">Tabela 2</a> e <a class="elsevierStyleCrossRef" href="#tbl0015">Tabela 3</a>&#41;&#44; sendo que essa diminui&#231;&#227;o n&#227;o foi significativamente diferente entre os dois grupos &#40;p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;194&#41;&#46;</p></span><span id="sec0060" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0125">Diabetes <span class="elsevierStyleItalic">mellitus</span></span><p id="par0320" class="elsevierStylePara elsevierViewall">Com o PRC&#44; os doentes diab&#233;ticos demonstraram melhoria no controlo da DM&#44; que se refletiu por uma diminui&#231;&#227;o significativa nos valores de glicemia em jejum e de HbA1c &#40;<a class="elsevierStyleCrossRef" href="#tbl0010">Tabela 2</a>&#41;&#46;</p></span><span id="sec0065" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0130">Sedentarismo</span><p id="par0325" class="elsevierStylePara elsevierViewall">No in&#237;cio do estudo 61&#44;3&#37; dos diab&#233;ticos e 49&#44;7&#37; dos n&#227;o diab&#233;ticos eram sedent&#225;rios&#44; constatado pelos <span class="elsevierStyleItalic">scores</span> obtidos atrav&#233;s do IPAQ&#46;</p><p id="par0330" class="elsevierStylePara elsevierViewall">Ambos os grupos demonstraram um aumento significativo no seu padr&#227;o habitual de atividade f&#237;sica&#44; expresso como o aumento da atividade f&#237;sica semanal medida pelo IPAQ entre o in&#237;cio e o final do PRC &#40;<a class="elsevierStyleCrossRef" href="#tbl0010">Tabela 2</a> e <a class="elsevierStyleCrossRef" href="#tbl0015">Tabela 3</a>&#41;&#46;</p><p id="par0335" class="elsevierStylePara elsevierViewall">O aumento verificado nos valores de IPAQ foi semelhante nos dois grupos &#40;p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;628&#41;&#46;</p></span><span id="sec0070" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0135">Capacidade funcional</span><p id="par0340" class="elsevierStylePara elsevierViewall">No in&#237;cio do estudo&#44; os diab&#233;ticos apresentavam uma pior capacidade funcional &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">Tabela 1</a>&#41;&#46; No final do PRC&#44; ambos os grupos apresentaram uma melhoria significativa na capacidade funcional &#40;equivalentes metab&#243;licos&#58; &#43;<span class="elsevierStyleHsp" style=""></span>1&#44;3 &#91;1&#44;2&#93; MET&#44; p<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#44;001 GD <span class="elsevierStyleItalic">versus</span> &#43;<span class="elsevierStyleHsp" style=""></span>1&#44;5 &#91;1&#44;2&#93; MET&#44; p<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#44;001 GND&#59; tempo de esfor&#231;o&#58; &#43;<span class="elsevierStyleHsp" style=""></span>0&#58;01&#58;32 &#91;0&#58;01&#58;22&#93; min&#58;seg&#44; p<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#44;001 GD <span class="elsevierStyleItalic">versus</span> &#43;<span class="elsevierStyleHsp" style=""></span>0&#58;01&#58;51 &#91;0&#58;02&#58;56&#93; min&#58;seg&#44; p<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#44;001 GND&#41; &#40;<a class="elsevierStyleCrossRef" href="#tbl0025">Tabela 5</a>&#41;&#46; Comparando os dois grupos&#44; a melhoria verificada na capacidade funcional foi significativamente menor nos diab&#233;ticos em termos de equivalentes metab&#243;licos &#40;p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;042&#41;&#46; Relativamente ao aumento no tempo de esfor&#231;o&#44; embora este tamb&#233;m tenha sido menor nos diab&#233;ticos&#44; esta diferen&#231;a n&#227;o adquiriu significado estat&#237;stico &#40;p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;107&#41; &#40;<a class="elsevierStyleCrossRef" href="#tbl0025">Tabela 5</a>&#41;&#46;</p></span></span><span id="sec0075" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0140">Discuss&#227;o</span><p id="par0345" class="elsevierStylePara elsevierViewall">As altera&#231;&#245;es metab&#243;licas que caracterizam a DM&#44; como a hiperglicemia&#44; o aumento de &#225;cidos gordos livres e a resist&#234;ncia &#224; insulina&#44; conduzem a altera&#231;&#245;es moleculares&#44; como a diminui&#231;&#227;o da disponibilidade de &#243;xido n&#237;trico ou o aumento do <span class="elsevierStyleItalic">stress</span> oxidativo&#44; que levam &#224; disfun&#231;&#227;o vascular<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">18</span></a>&#46; Tudo isto contribui para acelerar o processo de aterosclerose e consequentemente para o aumento do risco cardiovascular em doentes diab&#233;ticos&#46;</p><p id="par0350" class="elsevierStylePara elsevierViewall">Em 1997&#44; a Organiza&#231;&#227;o Mundial de Sa&#250;de considerou o excesso de peso e a obesidade como &#171;uma epidemia em escalada&#187; relacionando&#8208;os com cinco das dez principais causas de morte nos pa&#237;ses industrializados incluindo a DM&#44; a DCI&#44; os acidentes vasculares cerebrais&#44; a aterosclerose e alguns tipos de cancro<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">19</span></a>&#46; De facto&#44; a obesidade associa&#8208;se a um aumento do risco de DC&#44; provavelmente devido ao perfil metab&#243;lico adverso relacionado com o aumento de gordura visceral que desempenha um papel central na resist&#234;ncia perif&#233;rica &#224; a&#231;&#227;o da insulina<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">20</span></a>&#46;</p><p id="par0355" class="elsevierStylePara elsevierViewall">Na popula&#231;&#227;o em estudo&#44; o excesso de peso e a obesidade apresentavam uma elevada preval&#234;ncia&#44; principalmente nos doentes com DM tipo 2&#46; O estilo de vida sedent&#225;rio de 61&#44;3&#37; dos diab&#233;ticos poder&#225; ser tamb&#233;m um dos fatores a contribuir para o excesso ponderal encontrado&#46;</p><p id="par0360" class="elsevierStylePara elsevierViewall">No final da fase <span class="elsevierStyleSmallCaps">II</span> do PRC verificou&#8208;se uma diminui&#231;&#227;o significativa nos valores de IMC e do PA nos dois grupos ao contr&#225;rio de outros estudos<a class="elsevierStyleCrossRefs" href="#bib0105"><span class="elsevierStyleSup">21&#44;22</span></a> em que a diminui&#231;&#227;o no IMC n&#227;o foi significativa nos diab&#233;ticos&#46; Isto poder&#225; ter ocorrido devido &#224; avalia&#231;&#227;o e aconselhamento nutricional individualizado&#44; por especialista em nutri&#231;&#227;o&#44; proporcionado durante o nosso PRC&#46; Al&#233;m disso&#44; todos os doentes receberam um plano de treino individualizado&#44; embora sem ado&#231;&#227;o de medidas espec&#237;ficas para os doentes obesos na prescri&#231;&#227;o do exerc&#237;cio&#46;</p><p id="par0365" class="elsevierStylePara elsevierViewall">A HTA e a DM tipo 2 surgem frequentemente associadas&#44; sendo que a presen&#231;a de HTA aumenta o risco cardiovascular&#44; j&#225; por si aumentado&#44; em doentes diab&#233;ticos&#46; Assim&#44; a preval&#234;ncia de HTA em diab&#233;ticos &#233; superior &#224; da popula&#231;&#227;o em geral&#44; com uma preval&#234;ncia de 40&#8208;60&#37; entre os 45&#8208;75 anos<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">23</span></a>&#46; Na nossa amostra&#44; 70&#44;4&#37; dos diab&#233;ticos e 52&#44;4&#37; dos n&#227;o diab&#233;ticos apresentavam HTA&#44; o que est&#225; de acordo com outros estudos<a class="elsevierStyleCrossRefs" href="#bib0120"><span class="elsevierStyleSup">24&#44;25</span></a>&#46;</p><p id="par0370" class="elsevierStylePara elsevierViewall">O tratamento da HTA em doentes diab&#233;ticos constitui uma medida preventiva absolutamente crucial&#44; j&#225; que poder&#225; reduzir as complica&#231;&#245;es micro e macrovasculares&#44; devendo o n&#237;vel&#8208;alvo de press&#227;o arterial ser mais baixo do que em doentes n&#227;o diab&#233;ticos<a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">26</span></a>&#46; Por cada diminui&#231;&#227;o de 10<span class="elsevierStyleHsp" style=""></span>mmHg na press&#227;o arterial sist&#243;lica&#44; verifica&#8208;se uma diminui&#231;&#227;o de cerca de 12&#37; na ocorr&#234;ncia de qualquer complica&#231;&#227;o relacionada com a DM&#44; nomeadamente doen&#231;a cardiovascular<a class="elsevierStyleCrossRef" href="#bib0135"><span class="elsevierStyleSup">27</span></a>&#46;</p><p id="par0375" class="elsevierStylePara elsevierViewall">No momento da primeira avalia&#231;&#227;o&#44; 28&#44;1&#37; dos doentes diab&#233;ticos e 21&#44;0&#37; dos doentes n&#227;o diab&#233;ticos apresentavam valores tensionais elevados&#46; Verificou&#8208;se&#44; assim&#44; que a maioria dos doentes apresentava valores tensionais controlados no in&#237;cio do PRC&#44; o que poder&#225; dever&#8208;se ao facto da maioria se encontrar sob terap&#234;utica anti&#8208;hipertensiva otimizada&#44; j&#225; que foram sobretudo referenciados a partir do internamento de cardiologia&#46; Ao longo do estudo observou&#8208;se uma diminui&#231;&#227;o estatisticamente significativa no n&#250;mero de doentes com HTA n&#227;o controlada&#46; Os benef&#237;cios decorrentes da pr&#225;tica regular de exerc&#237;cio f&#237;sico aer&#243;bico na diminui&#231;&#227;o da press&#227;o arterial em doentes hipertensos est&#227;o bem documentados na literatura<a class="elsevierStyleCrossRefs" href="#bib0140"><span class="elsevierStyleSup">28&#44;29</span></a>&#46; Contudo&#44; os mecanismos fisiopatol&#243;gicos respons&#225;veis pelos efeitos anti&#8208;hipertensivos do exerc&#237;cio permanecem controversos&#58; alguns estudos referem uma diminui&#231;&#227;o na resist&#234;ncia total perif&#233;rica&#44; na atividade simp&#225;tica e nos n&#237;veis plasm&#225;ticos de noroadrenalina<a class="elsevierStyleCrossRefs" href="#bib0145"><span class="elsevierStyleSup">29&#44;30</span></a>&#59; segundo outros&#44; ocorrer&#225; um aumento na resist&#234;ncia total perif&#233;rica no per&#237;odo de recupera&#231;&#227;o p&#243;s&#8208;exerc&#237;cio&#44; associado a uma diminui&#231;&#227;o significativa do d&#233;bito card&#237;aco<a class="elsevierStyleCrossRefs" href="#bib0145"><span class="elsevierStyleSup">29&#44;31</span></a>&#59; a melhoria na fun&#231;&#227;o endotelial com o exerc&#237;cio poder&#225; tamb&#233;m contribuir para a sua resposta anti&#8208;hipertensiva<a class="elsevierStyleCrossRefs" href="#bib0145"><span class="elsevierStyleSup">29&#44;32</span></a>&#46;</p><p id="par0380" class="elsevierStylePara elsevierViewall">Em doentes com DM tipo 2 o perfil lip&#237;dico caracteriza&#8208;se geralmente por hipertrigliceridemia e diminui&#231;&#227;o do C&#8208;HDL&#46; A concentra&#231;&#227;o do C&#8208;LDL frequentemente n&#227;o &#233; muito diferente daquela apresentada por indiv&#237;duos n&#227;o diab&#233;ticos&#46; Contudo&#44; nos diab&#233;ticos as part&#237;culas das LDL s&#227;o geralmente pequenas e densas&#44; tornando&#8208;as altamente aterog&#233;nicas&#44; pelo que mesmo que as concentra&#231;&#245;es de C&#8208;LDL sejam id&#234;nticas &#224;s de n&#227;o diab&#233;ticos as taxas de DC ser&#227;o superiores nos diab&#233;ticos<a class="elsevierStyleCrossRef" href="#bib0165"><span class="elsevierStyleSup">33</span></a>&#46;</p><p id="par0385" class="elsevierStylePara elsevierViewall">O tratamento adequado da dislipidemia poder&#225; determinar redu&#231;&#245;es significativas na morbilidade e mortalidade cardiovascular em doentes diab&#233;ticos<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">20</span></a>&#46; Estudos demonstraram que por cada 1&#37; de aumento nos n&#237;veis de C&#8208;HDL&#44; a progress&#227;o da DCI diminui cerca de 3&#37;<a class="elsevierStyleCrossRef" href="#bib0170"><span class="elsevierStyleSup">34</span></a>&#46; Numa meta&#8208;an&#225;lise&#44; em que foram avaliados os efeitos do exerc&#237;cio f&#237;sico aer&#243;bico no perfil lip&#237;dico de doentes com DM tipo 2 relativamente a um grupo controlo&#44; verificou&#8208;se que os doentes que praticavam exerc&#237;cio apresentavam uma melhoria de todos os par&#226;metros do perfil lip&#237;dico&#44; embora apenas a diminui&#231;&#227;o nos n&#237;veis de C&#8208;LDL tivesse sido estatisticamente significativa<a class="elsevierStyleCrossRef" href="#bib0175"><span class="elsevierStyleSup">35</span></a>&#46; Na popula&#231;&#227;o estudada&#44; os diab&#233;ticos apresentavam maior preval&#234;ncia de dislipidemia e valores significativamente superiores de TG e inferiores de C&#8208;HDL&#46;</p><p id="par0390" class="elsevierStylePara elsevierViewall">Ao longo do estudo constatou&#8208;se uma evolu&#231;&#227;o favor&#225;vel de todos os par&#226;metros do perfil lip&#237;dico nos dois grupos&#44; sendo que a diminui&#231;&#227;o verificada nos n&#237;veis de TG foi significativamente maior nos diab&#233;ticos&#46; Isto poder&#225; ser explicado pelo facto da abordagem inicial para a hipertrigliceridemia ser a melhoria do controlo da glicemia<a class="elsevierStyleCrossRef" href="#bib0180"><span class="elsevierStyleSup">36</span></a>&#44; o que ocorreu de forma significativa nos diab&#233;ticos&#46; Por outro lado&#44; todos os doentes diab&#233;ticos inclu&#237;dos no estudo receberam aconselhamento nutricional individualizado&#44; onde foi salientada a import&#226;ncia de reduzirem o consumo de gorduras saturadas&#44; de acordo com o preconizado pela <span class="elsevierStyleItalic">American Diabetes Association</span><a class="elsevierStyleCrossRef" href="#bib0180"><span class="elsevierStyleSup">36</span></a>&#46;</p><p id="par0395" class="elsevierStylePara elsevierViewall">O tabagismo&#44; por si s&#243;&#44; constitui um fator de risco muito importante e independente para as complica&#231;&#245;es micro e macrovasculares nos diab&#233;ticos&#44; especialmente em mulheres&#44; pelo que a cessa&#231;&#227;o tab&#225;gica tem um impacto muito superior nestes doentes relativamente a n&#227;o diab&#233;ticos<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">13</span></a>&#46;</p><p id="par0400" class="elsevierStylePara elsevierViewall">No final do nosso estudo verificou&#8208;se em ambos os grupos uma enorme diminui&#231;&#227;o quer na percentagem de fumadores ativos quer no n&#250;mero de cigarros fumados por dia naqueles que mantiveram os h&#225;bitos tab&#225;gicos&#44; o que vem real&#231;ar a import&#226;ncia dos PRC no incentivo &#224; cessa&#231;&#227;o tab&#225;gica&#46; Contudo&#44; &#233; necess&#225;rio prud&#234;ncia na interpreta&#231;&#227;o destes resultados devido ao tempo curto de seguimento do estudo&#44; inferior ao per&#237;odo m&#237;nimo de seis meses de cessa&#231;&#227;o tab&#225;gica&#46;</p><p id="par0405" class="elsevierStylePara elsevierViewall">Um controlo adequado dos n&#237;veis de glicemia em doentes diab&#233;ticos &#233; fundamental para a redu&#231;&#227;o do risco de doen&#231;a cardiovascular&#44; j&#225; que existe uma rela&#231;&#227;o exponencial entre os n&#237;veis de glicemia em jejum e a incid&#234;ncia de eventos cardiovasculares<a class="elsevierStyleCrossRef" href="#bib0185"><span class="elsevierStyleSup">37</span></a>&#46;</p><p id="par0410" class="elsevierStylePara elsevierViewall">Na popula&#231;&#227;o estudada&#44; constatou&#8208;se uma diminui&#231;&#227;o significativa nos valores de glicemia em jejum e de HbA1c nos diab&#233;ticos&#44; o que traduz um melhor controlo da diabetes com o PRC&#46; O exerc&#237;cio f&#237;sico aer&#243;bico estruturado ou o treino de for&#231;a diminuem o valor de HbA1c em cerca de 0&#44;4&#8208;0&#44;6&#37;<a class="elsevierStyleCrossRefs" href="#bib0190"><span class="elsevierStyleSup">38&#44;39</span></a>&#46; Por cada 1&#37; de diminui&#231;&#227;o no valor de HbA1c verifica&#8208;se uma diminui&#231;&#227;o de 15&#8208;20&#37; na incid&#234;ncia de eventos cardiovasculares <span class="elsevierStyleItalic">major</span><a class="elsevierStyleCrossRef" href="#bib0200"><span class="elsevierStyleSup">40</span></a>&#46; Os benef&#237;cios no controlo da glicemia ser&#227;o ainda superiores com a associa&#231;&#227;o do exerc&#237;cio aer&#243;bico e do treino de for&#231;a<a class="elsevierStyleCrossRef" href="#bib0205"><span class="elsevierStyleSup">41</span></a>&#46;</p><p id="par0415" class="elsevierStylePara elsevierViewall">N&#237;veis elevados de atividade f&#237;sica em diab&#233;ticos reduzem o risco cardiovascular e a mortalidade em cerca de 20&#8208;30&#37; por cada 4&#46;184<span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleMonospace">k</span>j&#47;wk de energia despendida<a class="elsevierStyleCrossRef" href="#bib0210"><span class="elsevierStyleSup">42</span></a>&#46;</p><p id="par0420" class="elsevierStylePara elsevierViewall">Os n&#237;veis de atividade f&#237;sica semanal foram avaliados atrav&#233;s do IPAQ e aumentaram significativamente e em propor&#231;&#227;o semelhante em ambos os grupos&#46; Estes resultados contrariam o esperado&#44; pois sabe&#8208;se que a grande maioria dos indiv&#237;duos com DM tipo 2 s&#227;o fisicamente mais inativos comparativamente a indiv&#237;duos n&#227;o diab&#233;ticos&#44; provavelmente devido &#224; maior incid&#234;ncia de limita&#231;&#245;es f&#237;sicas&#44; &#224; menor toler&#226;ncia ao esfor&#231;o e &#224; maior perce&#231;&#227;o de desconforto durante o exerc&#237;cio nos diab&#233;ticos<a class="elsevierStyleCrossRef" href="#bib0215"><span class="elsevierStyleSup">43</span></a>&#46; Deste modo&#44; &#233; fundamental a cria&#231;&#227;o de estrat&#233;gias que promovam o aumento dos n&#237;veis de atividade f&#237;sica&#46;</p><p id="par0425" class="elsevierStylePara elsevierViewall">Na popula&#231;&#227;o estudada&#44; os diab&#233;ticos apresentavam uma menor capacidade funcional&#44; avaliada em MET&#44; relativamente aos n&#227;o diab&#233;ticos&#44; o que est&#225; de acordo com outros estudos<a class="elsevierStyleCrossRefs" href="#bib0105"><span class="elsevierStyleSup">21&#44;22&#44;24&#44;44&#8211;46</span></a>&#46; Doentes diab&#233;ticos&#44; mesmo sem nenhuma complica&#231;&#227;o&#44; apresentam uma diminui&#231;&#227;o no consumo m&#225;ximo de O<span class="elsevierStyleInf">2</span> &#40;VO<span class="elsevierStyleInf">2</span> m&#225;ximo&#41; em rela&#231;&#227;o &#224; idade e ao IMC<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">24</span></a>&#46; A hiperglicemia associa&#8208;se a um aumento da rigidez de grandes vasos como a aorta&#44; comprometendo assim o fluxo sangu&#237;neo coron&#225;rio&#44; a capacidade de trabalho do mioc&#225;rdio e consequentemente a capacidade global de exerc&#237;cio<a class="elsevierStyleCrossRef" href="#bib0220"><span class="elsevierStyleSup">44</span></a>&#46; Para a menor capacidade funcional dos diab&#233;ticos contribui n&#227;o s&#243; um perfil antropom&#233;trico mais desfavor&#225;vel&#44; mas tamb&#233;m a disfun&#231;&#227;o do ventr&#237;culo esquerdo e o d&#233;fice na regula&#231;&#227;o auton&#243;mica card&#237;aca<a class="elsevierStyleCrossRef" href="#bib0220"><span class="elsevierStyleSup">44</span></a>&#46;</p><p id="par0430" class="elsevierStylePara elsevierViewall">Ao longo do PRC&#44; ambos os grupos melhoraram significativamente a sua capacidade funcional&#44; embora essa melhoria tenha sido menor nos diab&#233;ticos&#46; Na literatura existem resultados contradit&#243;rios relativamente a ganhos na capacidade funcional em diab&#233;ticos e n&#227;o diab&#233;ticos&#46; Alguns estudos est&#227;o de acordo com os nossos resultados e demonstram uma melhoria significativa na capacidade funcional dos diab&#233;ticos&#44; mas menor relativamente a n&#227;o diab&#233;ticos<a class="elsevierStyleCrossRefs" href="#bib0225"><span class="elsevierStyleSup">45&#44;46</span></a>&#46; Outros&#44; por&#233;m&#44; referem ganhos na capacidade funcional significativos e semelhantes nos dois grupos de doentes<a class="elsevierStyleCrossRefs" href="#bib0105"><span class="elsevierStyleSup">21&#44;22&#44;24&#44;44&#44;47</span></a>&#46; Esta discrep&#226;ncia de resultados poder&#225; dever&#8208;se a v&#225;rios fatores como diferen&#231;as nas caracter&#237;sticas basais dos participantes &#40;idade&#44; medica&#231;&#227;o&#44; gravidade da doen&#231;a&#44; preval&#234;ncia de comorbilidades&#44; intensidade do exerc&#237;cio&#41; ou diferen&#231;as no grau de ades&#227;o ao programa de exerc&#237;cio ou na dura&#231;&#227;o do mesmo&#46;</p><p id="par0435" class="elsevierStylePara elsevierViewall">Nos estudos que defendem uma melhoria menos acentuada da capacidade funcional com o PRC em diab&#233;ticos&#44; as raz&#245;es apontadas permanecem pouco claras&#44; mas admite&#8208;se que a hiperglicemia possa desempenhar um papel importante<a class="elsevierStyleCrossRef" href="#bib0240"><span class="elsevierStyleSup">48</span></a>&#46; Outros mecanismos poder&#227;o tamb&#233;m contribuir para essa menor melhoria na capacidade funcional dos diab&#233;ticos&#46; A insulina &#233; um importante regulador das prote&#237;nas musculares&#44; estimulando a s&#237;ntese de prote&#237;nas mitocondriais&#46; Os doentes com DM tipo 2 apresentam geralmente um compromisso no funcionamento mitocondrial ao n&#237;vel do m&#250;sculo&#8208;esquel&#233;tico&#46; Uma vez que a atividade muscular perif&#233;rica &#233; o principal fator determinante da capacidade de exerc&#237;cio&#44; um compromisso no seu funcionamento pode estar envolvido na resposta muscular alterada ao exerc&#237;cio<a class="elsevierStyleCrossRef" href="#bib0240"><span class="elsevierStyleSup">48</span></a>&#46; Al&#233;m disso&#44; 42&#37; dos diab&#233;ticos sem evid&#234;ncia cl&#237;nica de doen&#231;a vascular perif&#233;rica apresentam d&#233;fices significativos na perfus&#227;o dos m&#250;sculos dos membros inferiores&#44; provavelmente devido &#224; doen&#231;a microvascular&#44; o que poder&#225; tamb&#233;m diminuir o efeito da reabilita&#231;&#227;o card&#237;aca na capacidade funcional<a class="elsevierStyleCrossRef" href="#bib0245"><span class="elsevierStyleSup">49</span></a>&#46;</p><p id="par0440" class="elsevierStylePara elsevierViewall">Neste trabalho&#44; que inclui uma amostra consider&#225;vel de doentes&#44; observou&#8208;se globalmente uma melhoria de todos os par&#226;metros relativos ao controlo dos FRCV&#44; bem como da capacidade funcional&#44; e verificou&#8208;se que os benef&#237;cios alcan&#231;ados com o PRC foram semelhantes nos diab&#233;ticos e n&#227;o diab&#233;ticos em termos de redu&#231;&#227;o do risco cardiovascular&#46;</p><p id="par0445" class="elsevierStylePara elsevierViewall">Real&#231;amos a sua import&#226;ncia por se tratar do primeiro estudo&#44; na realidade portuguesa&#44; a comparar os resultados do PRC entre doentes diab&#233;ticos e n&#227;o diab&#233;ticos e com uma grande dimens&#227;o populacional&#46;</p><p id="par0450" class="elsevierStylePara elsevierViewall">O processo de aprendizagem desenvolvido durante as diversas sess&#245;es do PRC promove o autocontrolo da diabetes&#44; a autodisciplina na manuten&#231;&#227;o de estilos de vida saud&#225;veis&#44; conjuntamente&#44; com a autovigil&#226;ncia de complica&#231;&#245;es&#47;consequ&#234;ncias decorrentes da pr&#225;tica de exerc&#237;cio f&#237;sico na condi&#231;&#227;o cl&#237;nica do doente diab&#233;tico&#46;</p><span id="sec0080" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0145">Limita&#231;&#245;es do estudo</span><p id="par0455" class="elsevierStylePara elsevierViewall">A inexist&#234;ncia de um grupo controlo que permita ter em considera&#231;&#227;o o efeito da evolu&#231;&#227;o natural da doen&#231;a constitui uma limita&#231;&#227;o do estudo&#44; mas dado que a literatura tem revelado de forma consistente 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="#bib0250"><span class="elsevierStyleSup">50</span></a>&#44; estamos convictos que os resultados favor&#225;veis encontrados nos dois grupos s&#227;o atribu&#237;dos especificamente ao PRC&#46;</p><p id="par0460" class="elsevierStylePara elsevierViewall">Por outro lado&#44; o per&#237;odo de <span class="elsevierStyleItalic">follow&#8208;up</span> &#233; reduzido &#40;tr&#234;s meses&#41;&#44; sendo por isso importante realizar uma avalia&#231;&#227;o a longo prazo&#46;</p></span></span><span id="sec0085" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0150">Conclus&#245;es</span><p id="par0465" class="elsevierStylePara elsevierViewall">A preval&#234;ncia de doentes diab&#233;ticos em PRC parece estar a aumentar e esta tend&#234;ncia dever&#225; manter&#8208;se no futuro&#44; tendo em conta as previs&#245;es de uma crescente preval&#234;ncia da DM&#46;</p><p id="par0470" class="elsevierStylePara elsevierViewall">Os resultados deste estudo demonstraram que doentes com DM tipo 2 podem beneficiar com um PRC e alcan&#231;ar resultados compar&#225;veis a doentes n&#227;o diab&#233;ticos em termos de melhoria do perfil de risco cardiovascular&#46;</p><p id="par0475" class="elsevierStylePara elsevierViewall">Os diab&#233;ticos t&#234;m um risco acrescido de futuros eventos cardiovasculares e por isso requerem uma preven&#231;&#227;o secund&#225;ria mais agressiva&#46; Alertamos para a import&#226;ncia da referencia&#231;&#227;o sistem&#225;tica destes doentes para os PRC&#44; dados os seus benef&#237;cios&#44; contribuindo assim para a melhoria da qualidade de vida do doente diab&#233;tico&#46;</p></span><span id="sec0090" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0155">Conflito de interesses</span><p id="par0480" class="elsevierStylePara elsevierViewall">Os autores declaram n&#227;o haver conflito de interesses&#46;</p></span></span>"
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        "resumen" => "<span class="elsevierStyleSectionTitle" id="sect0010">Introdu&#231;&#227;o e objetivos</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Doentes diab&#233;ticos t&#234;m um risco de doen&#231;a cardiovascular duas a quatro vezes superior a n&#227;o diab&#233;ticos&#46; Os objetivos do estudo s&#227;o&#58; avaliar os efeitos de um programa de reabilita&#231;&#227;o card&#237;aca &#40;fase <span class="elsevierStyleSmallCaps">II</span>&#41; em doentes coron&#225;rios diab&#233;ticos e comparar os seus resultados em termos de controlo de fatores de risco cardiovasculares e ganhos na capacidade funcional com doentes coron&#225;rios n&#227;o diab&#233;ticos&#46;</p> <span class="elsevierStyleSectionTitle" id="sect0015">M&#233;todos</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Estudo prospetivo integrando doentes com doen&#231;a card&#237;aca isqu&#233;mica orientados para programa de reabilita&#231;&#227;o card&#237;aca entre janeiro de 2009 e junho de 2013&#46; Consideraram&#8208;se dois grupos&#58; diab&#233;ticos e n&#227;o diab&#233;ticos&#46; Foram avaliados na primeira consulta da fase <span class="elsevierStyleSmallCaps">II</span> e tr&#234;s meses depois&#44; com registo dos seguintes par&#226;metros&#58; &#237;ndice de massa corporal&#44; per&#237;metro abdominal&#44; perfil lip&#237;dico&#44; hemoglobina glicada e glicose nos diab&#233;ticos&#44; press&#227;o arterial&#44; tabagismo&#44; n&#237;vel de atividade f&#237;sica &#40;atrav&#233;s do <span class="elsevierStyleItalic">International Physical Activity Questionnaire</span>&#41; e capacidade funcional &#40;alcan&#231;ada em prova de esfor&#231;o&#41;&#46;</p> <span class="elsevierStyleSectionTitle" id="sect0020">Resultados</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Amostra de 682 doentes &#40;253 diab&#233;ticos e 429 n&#227;o diab&#233;ticos&#41;&#46; Os diab&#233;ticos eram significativamente mais idosos&#44; apresentavam pior perfil de risco cardiovascular &#40;maior preval&#234;ncia de excesso ponderal&#44; dislipidemia&#44; hipertens&#227;o arterial e sedentarismo&#41; e menor capacidade funcional&#46; No final da fase <span class="elsevierStyleSmallCaps">II</span> ocorreu uma melhoria estatisticamente significativa &#40;p &#60;<span class="elsevierStyleHsp" style=""></span>0&#44;05&#41; em todos os fatores de risco e na capacidade funcional&#44; que foi semelhante nos dois grupos com exce&#231;&#227;o do &#237;ndice de massa corporal&#44; dos triglicer&#237;deos e da capacidade funcional&#46;</p> <span class="elsevierStyleSectionTitle" id="sect0025">Conclus&#245;es</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Doentes diab&#233;ticos podem beneficiar com um programa de reabilita&#231;&#227;o card&#237;aca e alcan&#231;ar resultados compar&#225;veis a n&#227;o diab&#233;ticos&#46;</p>"
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        "titulo" => "Abstract"
        "resumen" => "<span class="elsevierStyleSectionTitle" id="sect0035">Introduction and Aims</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Diabetic patients have a 2&#8208;4 times higher risk of cardiovascular disease than non&#8208;diabetic individuals&#46; The aims of this study are to evaluate the effects of a cardiac rehabilitation program &#40;phase II&#41; in patients with diabetes and coronary disease and to compare the results with regard to control of cardiovascular risk factors and improvement in functional capacity with coronary patients without diabetes&#46;</p> <span class="elsevierStyleSectionTitle" id="sect0040">Methods</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">This was a prospective study of patients diagnosed with ischemic heart disease referred for a cardiac rehabilitation program between January 2009 and June 2013&#46; The population was divided into two groups&#58; diabetic and non&#8208;diabetic&#46; Patients were assessed at the beginning of phase II and three months later and the following parameters were recorded&#58; body mass index&#44; waist circumference&#44; lipid profile&#44; blood glucose and glycated hemoglobin in diabetic patients&#44; blood pressure&#44; smoking&#44; physical activity level &#40;using the International Physical Activity Questionnaire&#41; and functional capacity &#40;on treadmill stress testing&#41;&#46;</p> <span class="elsevierStyleSectionTitle" id="sect0045">Results</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">The study population consisted of 682 patients &#40;253 diabetic and 429 non&#8208;diabetic&#41;&#46; Diabetic patients were significantly older&#44; had a worse cardiovascular risk profile &#40;higher prevalence of overweight&#44; dyslipidemia&#44; hypertension and sedentary lifestyle&#41; and lower functional capacity&#46; At the end of phase II&#44; there was a statistically significant improvement &#40;p&#60;0&#46;05&#41; in all risk factors and functional capacity&#44; which was similar in both groups&#44; except for body mass index&#44; triglycerides and functional capacity&#46;</p> <span class="elsevierStyleSectionTitle" id="sect0050">Conclusions</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">Diabetic patients may benefit from a cardiac rehabilitation program and achieve comparable results to non&#8208;diabetic patients&#46;</p>"
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                "termino" => "<span class="elsevierStyleVsp" style="height:0.5px"></span>CABG"
                "descripcion" => "<p id="par0005" class="elsevierStylePara elsevierViewall">Cirurgia de <span class="elsevierStyleItalic">By&#8208;pass</span> Coron&#225;rio</p>"
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                "descripcion" => "<p id="par0010" class="elsevierStylePara elsevierViewall">Colesterol das lipoprote&#237;nas de alta densidade</p>"
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              2 => array:2 [
                "termino" => "<span class="elsevierStyleVsp" style="height:0.5px"></span>C&#8208;LDL"
                "descripcion" => "<p id="par0015" class="elsevierStylePara elsevierViewall">Colesterol das lipoprote&#237;nas de baixa densidade</p>"
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              3 => array:2 [
                "termino" => "<span class="elsevierStyleVsp" style="height:0.5px"></span>CT"
                "descripcion" => "<p id="par0020" class="elsevierStylePara elsevierViewall">Colesterol total</p>"
              ]
              4 => array:2 [
                "termino" => "<span class="elsevierStyleVsp" style="height:0.5px"></span>DC"
                "descripcion" => "<p id="par0025" class="elsevierStylePara elsevierViewall">Doen&#231;a coron&#225;ria</p>"
              ]
              5 => array:2 [
                "termino" => "<span class="elsevierStyleVsp" style="height:0.5px"></span>DCI"
                "descripcion" => "<p id="par0030" class="elsevierStylePara elsevierViewall">Doen&#231;a card&#237;aca isqu&#233;mica</p>"
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              6 => array:2 [
                "termino" => "<span class="elsevierStyleVsp" style="height:0.5px"></span>DM"
                "descripcion" => "<p id="par0035" class="elsevierStylePara elsevierViewall">Diabetes <span class="elsevierStyleItalic">mellitus</span></p>"
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                "termino" => "<span class="elsevierStyleVsp" style="height:0.5px"></span>DP"
                "descripcion" => "<p id="par0040" class="elsevierStylePara elsevierViewall">Desvio Padr&#227;o</p>"
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              8 => array:2 [
                "termino" => "<span class="elsevierStyleVsp" style="height:0.5px"></span>FRCV"
                "descripcion" => "<p id="par0045" class="elsevierStylePara elsevierViewall">Fatores de risco cardiovascular</p>"
              ]
              9 => array:2 [
                "termino" => "<span class="elsevierStyleVsp" style="height:0.5px"></span>GD"
                "descripcion" => "<p id="par0050" class="elsevierStylePara elsevierViewall">Grupo dos diab&#233;ticos</p>"
              ]
              10 => array:2 [
                "termino" => "<span class="elsevierStyleVsp" style="height:0.5px"></span>GND"
                "descripcion" => "<p id="par0055" class="elsevierStylePara elsevierViewall">Grupo dos n&#227;o diab&#233;ticos</p>"
              ]
              11 => array:2 [
                "termino" => "<span class="elsevierStyleVsp" style="height:0.5px"></span>HbA1c"
                "descripcion" => "<p id="par0060" class="elsevierStylePara elsevierViewall">Hemoglobina glicada</p>"
              ]
              12 => array:2 [
                "termino" => "<span class="elsevierStyleVsp" style="height:0.5px"></span>HTA"
                "descripcion" => "<p id="par0065" class="elsevierStylePara elsevierViewall">Hipertens&#227;o Arterial</p>"
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              13 => array:2 [
                "termino" => "<span class="elsevierStyleVsp" style="height:0.5px"></span>ICP"
                "descripcion" => "<p id="par0070" class="elsevierStylePara elsevierViewall">Interven&#231;&#227;o Coron&#225;ria Percut&#226;nea</p>"
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                "termino" => "<span class="elsevierStyleVsp" style="height:0.5px"></span>IMC"
                "descripcion" => "<p id="par0075" class="elsevierStylePara elsevierViewall">&#205;ndice de massa corporal</p>"
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              15 => array:2 [
                "termino" => "<span class="elsevierStyleVsp" style="height:0.5px"></span>IPAQ"
                "descripcion" => "<p id="par0080" class="elsevierStylePara elsevierViewall">International Physical Activity Questionnaire</p>"
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                "termino" => "<span class="elsevierStyleVsp" style="height:0.5px"></span>MET"
                "descripcion" => "<p id="par0085" class="elsevierStylePara elsevierViewall">Metabolic equivalent</p>"
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                "descripcion" => "<p id="par0095" class="elsevierStylePara elsevierViewall">Per&#237;metro abdominal</p>"
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                "descripcion" => "<p id="par0100" class="elsevierStylePara elsevierViewall">Prova de esfor&#231;o</p>"
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                "termino" => "<span class="elsevierStyleVsp" style="height:0.5px"></span>PRC"
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                "descripcion" => "<p id="par0110" class="elsevierStylePara elsevierViewall">S&#237;ndrome Coron&#225;ria Aguda</p>"
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                "termino" => "<span class="elsevierStyleVsp" style="height:0.5px"></span>Seg"
                "descripcion" => "<p id="par0115" class="elsevierStylePara elsevierViewall">Segundos</p>"
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                "descripcion" => "<p id="par0120" class="elsevierStylePara elsevierViewall">Statistical Package for the Social Science</p>"
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                "termino" => "<span class="elsevierStyleVsp" style="height:0.5px"></span>TG"
                "descripcion" => "<p id="par0125" class="elsevierStylePara elsevierViewall">Triglicer&#237;deos</p>"
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              25 => array:2 [
                "termino" => "UPRCV"
                "descripcion" => "<p id="par0130" class="elsevierStylePara elsevierViewall">Unidade de Preven&#231;&#227;o e Reabilita&#231;&#227;o Cardiovascular</p>"
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                  \t\t\t\t">159 &#40;37&#44;1&#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"><span class="elsevierStyleHsp" style=""></span>&#8208; Sedentarismo&#44; n &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>&#8208; Per&#237;metro abdominal &#40;cm&#41;&#44; m&#233;dia &#40;DP&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">Press&#227;o arterial elevada&#44; n &#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-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">71 &#40;28&#44;1&#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">&#8595;70&#44;4&#37;&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;<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">CT &#40;mg&#47;dL&#41;&#44; m&#233;dia &#40;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-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">178&#44;0 &#40;44&#44;2&#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">&#8722;21&#44;5 &#40;41&#44;3&#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;<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
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                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">C&#8208;LDL &#40;mg&#47;dL&#41;&#44; m&#233;dia &#40;DP&#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="char" valign="\n
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                  \t\t\t\t">109&#44;4 &#40;34&#44;6&#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
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                  \t\t\t\t">&#8722;20&#44;1 &#40;33&#44;2&#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="char" valign="\n
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                  \t\t\t\t">&#60;<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">C&#8208;HDL &#40;mg&#47;dL&#41;&#44; P50 &#40;P25&#59; P75&#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">37&#44;0 &#40;31&#44;0&#59; 45&#44;0&#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">&#43;3&#44;0 &#40;&#8722;2&#44;0&#59; 8&#44;0&#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;<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">Triglicer&#237;deos &#40;mg&#47;dL&#41;&#44; P50 &#40;P25&#59; P75&#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">143&#44;0 &#40;107&#44;0&#59; 207&#44;5&#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">&#8722;24&#44;0 &#40;&#8722;64&#44;0&#59; 6&#44;5&#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;<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
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                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Fumadores&#44; n &#40;&#37;&#41;&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">55 &#40;21&#44;7&#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="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#8595;90&#44;9&#37;&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">&#60;<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
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                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">N&#46;&#176; cigarros&#47;dia&#44; P50 &#40;P25&#59; P75&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t">20&#44;0 &#40;15&#44;0&#59; 30&#44;0&#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
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                  \t\t\t\t">&#8722;20&#44;0 &#40;&#8722;30&#44;0&#59; &#8722;10&#44;0&#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">&#60;<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">Glicose &#40;mg&#47;dL&#41;&#44; P50 &#40;P25&#59; P75&#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
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                  \t\t\t\t">129&#44;0 &#40;106&#44;0&#59; 173&#44;5&#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">&#8722;14&#44;0 &#40;&#8722;45&#44;0&#59; 0&#44;0&#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="char" valign="\n
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                  \t\t\t\t">&#60;<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
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                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">HbA1c &#40;&#37;&#41;&#44; P50 &#40;P25&#59; P75&#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">6&#44;6 &#40;5&#44;9&#59; 8&#44;1&#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">&#8722;0&#44;45 &#40;&#8722;1&#44;0&#59; &#8722;0&#44;2&#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">&#60;<span class="elsevierStyleHsp" style=""></span>0&#44;001&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">IPAQ &#40;MET&#42;minuto&#47;semana&#41;&#44; P50 &#40;P25&#59; P75&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">346&#44;0 &#40;0&#44;0&#59; 1&#46;006&#44;0&#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">&#43;1&#46;283&#44;0 &#40;693&#44;0&#59; 1&#46;923&#44;0&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">&#60;<span class="elsevierStyleHsp" style=""></span>0&#44;001&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">Avalia&#231;&#227;o pr&#233;&#8208;PRC&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t" style="border-bottom: 2px solid black">Diferen&#231;a p&#243;s&#8208;pr&#233;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t" style="border-bottom: 2px solid black">p&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">26&#44;3 &#40;3&#44;9&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">&#8722;0&#44;9 &#40;1&#44;2&#41;&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">PA &#40;cm&#41;&#44; m&#233;dia &#40;DP&#41;&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">95&#44;1 &#40;9&#44;5&#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
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                  \t\t\t\t">&#8722;2&#44;8 &#40;3&#44;8&#41;&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">&#60;<span class="elsevierStyleHsp" style=""></span>0&#44;001&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">Press&#227;o arterial elevada&#44; n &#40;&#37;&#41;&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">90 &#40;21&#44;0&#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">&#8595;80&#44;0&#37;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t">&#60;<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="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">CT &#40;mg&#47;dL&#41;&#44; m&#233;dia &#40;DP&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t">177&#44;1 &#40;39&#44;0&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t">C&#8208;HDL &#40;mg&#47;dL&#41;&#44; P50 &#40;P25&#59; P75&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">Triglicer&#237;deos &#40;mg&#47;dL&#41;&#44; P50 &#40;P25&#59; P75&#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">N&#46;&#176; cigarros&#47;dia&#44; P50 &#40;P25&#59; P75&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">CT &#40;mg&#47;dL&#41;&#44; m&#233;dia &#40;DP&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">&#8722;21&#44;5 &#40;41&#44;3&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">&#8722;20&#44;8 &#40;39&#44;5&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">C&#8208;LDL &#40;mg&#47;dL&#41;&#44; m&#233;dia &#40;DP&#41;&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">C&#8208;HDL &#40;mg&#47;dL&#41;&#44; P50 &#40;P25&#59; P75&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttop\n
                  \t\t\t\t">Triglicer&#237;deos &#40;mg&#47;dL&#41;&#44; P50 &#40;P25&#59; P75&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">&#8722;16&#44;0 &#40;&#8722;44&#44;0&#59; 7&#44;5&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">0&#44;039&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">Fumadores&#44; &#37;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">&#8595; 90&#44;9&#37;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">&#8595; 83&#44;6&#37;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t" style="border-bottom: 2px solid black">Diferen&#231;a p&#243;s&#8208;pr&#233;&nbsp;\t\t\t\t\t\t\n
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                0 => array:2 [
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                      "titulo" => "Meta&#8208;analysis&#58; secondary prevention programs for patients with coronary artery disease"
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                          "autores" => array:3 [
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                      "Revista" => array:6 [
                        "tituloSerie" => "Ann Intern Med&#46;"
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                      "titulo" => "Cardiac rehabilitation and survival in patients with left ventricular systolic dysfunction"
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                          "autores" => array:3 [
                            0 => "D&#46;J&#46; Whellan"
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Informação do artigo
ISSN: 08702551
Idioma original: Português
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2024 Setembro 86 32 118
2024 Agosto 82 44 126
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2024 Junho 56 20 76
2024 Maio 67 21 88
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2023 Maro 50 29 79
2023 Fevereiro 36 19 55
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2022 Julho 95 38 133
2022 Junho 43 42 85
2022 Maio 40 29 69
2022 Abril 51 34 85
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2022 Janeiro 47 32 79
2021 Dezembro 35 36 71
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2021 Outubro 41 33 74
2021 Setembro 34 28 62
2021 Agosto 22 28 50
2021 Julho 29 24 53
2021 Junho 42 17 59
2021 Maio 24 16 40
2021 Abril 55 30 85
2021 Maro 55 7 62
2021 Fevereiro 54 13 67
2021 Janeiro 30 9 39
2020 Dezembro 50 17 67
2020 Novembro 33 14 47
2020 Outubro 26 10 36
2020 Setembro 31 17 48
2020 Agosto 33 5 38
2020 Julho 35 8 43
2020 Junho 32 8 40
2020 Maio 49 12 61
2020 Abril 57 8 65
2020 Maro 67 10 77
2020 Fevereiro 96 33 129
2020 Janeiro 51 9 60
2019 Dezembro 50 6 56
2019 Novembro 54 7 61
2019 Outubro 66 14 80
2019 Setembro 84 17 101
2019 Agosto 60 15 75
2019 Julho 63 6 69
2019 Junho 58 21 79
2019 Maio 84 21 105
2019 Abril 61 16 77
2019 Maro 49 12 61
2019 Fevereiro 63 15 78
2019 Janeiro 57 23 80
2018 Dezembro 89 17 106
2018 Novembro 241 18 259
2018 Outubro 521 29 550
2018 Setembro 108 8 116
2018 Agosto 171 9 180
2018 Julho 50 12 62
2018 Junho 85 11 96
2018 Maio 156 20 176
2018 Abril 176 6 182
2018 Maro 198 18 216
2018 Fevereiro 154 5 159
2018 Janeiro 178 11 189
2017 Dezembro 240 15 255
2017 Novembro 63 12 75
2017 Outubro 52 16 68
2017 Setembro 43 12 55
2017 Agosto 49 10 59
2017 Julho 45 8 53
2017 Junho 45 17 62
2017 Maio 49 12 61
2017 Abril 27 3 30
2017 Maro 44 1 45
2017 Fevereiro 82 10 92
2017 Janeiro 87 8 95
2016 Dezembro 30 12 42
2016 Novembro 36 18 54
2016 Outubro 51 10 61
2016 Setembro 52 13 65
2016 Agosto 22 16 38
2016 Julho 29 23 52
2016 Junho 14 30 44
2016 Maio 1 9 10
2016 Abril 21 3 24
2016 Maro 49 27 76
2016 Fevereiro 70 20 90
2016 Janeiro 41 5 46
2015 Dezembro 57 10 67
2015 Novembro 49 9 58
2015 Outubro 55 15 70
2015 Setembro 45 16 61
2015 Agosto 37 11 48
2015 Julho 29 15 44
2015 Junho 26 4 30
2015 Maio 65 13 78
2015 Abril 27 14 41
2015 Maro 34 10 44
2015 Fevereiro 26 13 39
2015 Janeiro 26 18 44
2014 Dezembro 41 32 73
2014 Novembro 109 69 178
2014 Outubro 21 9 30
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