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the burden of CVD morbidity is expected to grow further&#44; weighing heavily not only on healthcare systems and patients&#8217; quality of life but also on work productivity&#44; as well as increasing the need for informal care of people with CVD&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">To our knowledge&#44; existing information on productivity losses after CVD in Portugal is very limited&#46;<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">5</span></a> In a multi-country study&#44; the direct and indirect costs of cardiovascular disease in Portugal for 2003 were estimated at around &#8364;1762 million&#44; of which &#8364;969 million was healthcare costs&#46;<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">6</span></a> A more recent study conducted in the European Union in 2017 estimated the overall cost of CVD in Portugal at &#8364;2&#46;8 billion a year&#44; with direct healthcare costs accounting for 42&#37; of total costs&#44; work productivity losses for 27&#37; and informal care for the remaining 31&#37;&#46;<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">7</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">The aim of the current study was to estimate productivity loss and indirect costs for patients and caregivers in the first year after an acute coronary syndrome &#40;ACS&#41; or stroke in Portugal&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Methods</span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Study design and population</span><p id="par0020" class="elsevierStylePara elsevierViewall">Portugal was one of the seven European countries &#40;the others were Belgium&#44; France&#44; Poland&#44; Spain&#44; Switzerland&#44; and the UK&#41; that participated in a multi-country cross-sectional study of patient and caregiver productivity loss and indirect costs following ACS or stroke in Europe&#46; The results of this multi-country study are published elsewhere&#46;<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">8</span></a> Patients were recruited during a routine consultation at a cardiologist&#39;s or neurologist&#39;s clinic between September 2016 and November 2017&#46; Inclusion criteria were hospitalization for ACS &#40;myocardial infarction &#91;MI&#93; or unstable angina&#41; or stroke 3-12 months prior to the recruitment visit&#44; having a paid job&#44; and receiving lipid-modifying therapy at the time of the hospitalization for the cardiovascular event &#40;CVE&#41;&#46; To assess absenteeism and presenteeism at work&#44; patients had to be back to work for at least four weeks prior to recruitment&#46; Patients who participated in a clinical trial at the time of recruitment or were treated with evolocumab were excluded from the study&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">Patients who were able to return to work after an event were recruited in four clinical centers located in different parts of Portugal&#46; Patients who were unemployed at the time of their event or those who did not return to work were not included in the analyses&#46; The objective was to recruit 33 ACS and 33 stroke patients&#44; to achieve a 34&#37; precision in the cost estimate&#44; assuming that sample mean and standard deviation &#40;SD&#41; are equal&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">The study received approval from the appropriate hospital ethics committees and the Portuguese Data Protection Authority &#40;CNPD&#41;&#46; All participants provided written informed consent&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Data collection</span><p id="par0035" class="elsevierStylePara elsevierViewall">Patient absenteeism&#44; presenteeism and caregiver time were assessed using the IMTA Productivity Cost Questionnaire &#40;iPCQ&#41;&#44; a validated questionnaire developed by the Institute for Medical Technology Assessment&#44; Erasmus University Rotterdam&#44; The Netherlands&#44; to collect productivity loss data&#46;<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">9</span></a> This questionnaire has a four-week recall period to overcome recall bias and robust costing methodology&#44; and can be completed in about 10<span class="elsevierStyleHsp" style=""></span>minutes&#44; minimizing the additional burden to patients&#46; Two additional questions were added to the iPCQ to assess absenteeism due to the index CVE hospitalization and sick leave immediately after discharge&#46; The questions were reviewed by the iMTA team that developed the original questionnaire in order to maintain the integrity of the tool&#46; The modified questionnaire was translated into Portuguese using forward-backward translation&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">Demographic and clinical characteristics were abstracted by the recruiting physician from patients&#8217; medical records and provided via an electronic case report form &#40;eCRF&#41;&#46; This eCRF also included data that enabled the length of the index hospitalization to be cross-checked against the data reported by the patient&#46; Conflicting or implausible responses were reconciled directly with the recruiting centers&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Analysis</span><p id="par0045" class="elsevierStylePara elsevierViewall">To estimate annual patient productivity loss&#44; the reported time loss for four weeks was prorated to the rest of the year and combined with the productive time lost due to the index hospitalization and sick leave&#46; Similarly&#44; annual caregiver loss was prorated from the reported loss for the four weeks preceding recruitment&#46; Lost productive time during the year was calculated based on patient-reported working hours per day and considering Portuguese annual leave and bank holidays &#40;a mean of 36 days in total&#41;&#46; All calculations were performed at the patient level and summarized by ACS and stroke&#46;</p><p id="par0050" class="elsevierStylePara elsevierViewall">Productivity loss was valued using the human capital approach for the patient &#40;i&#46;e&#46; assuming that each worker is irreplaceable for society so that all productive time lost by the worker is lost to society&#41; and the opportunity cost for the caregiver &#40;i&#46;e&#46; forgone production&#41;&#46;<a class="elsevierStyleCrossRefs" href="#bib0095"><span class="elsevierStyleSup">4&#44;10</span></a> Each hour lost was multiplied by the Portuguese labor cost taken from Eurostat&#46; To obtain 2018 values&#44; labor costs from 2012 to 2017 were projected using the geometric average &#40;&#8364;14&#46;27&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">11</span></a></p><p id="par0055" class="elsevierStylePara elsevierViewall">The friction cost method &#40;i&#46;e&#46; assuming that workers are replaceable and it takes a certain &#8216;friction&#8217; period to find and train a replacement&#59; after this friction period productivity losses are no longer incurred by society&#41; was used in a sensitivity analysis with a friction period of three months&#46;<a class="elsevierStyleCrossRef" href="#bib0135"><span class="elsevierStyleSup">12</span></a></p><p id="par0060" class="elsevierStylePara elsevierViewall">Descriptive statistics were expressed as frequency and percentage for categorical variables and mean &#40;standard deviation&#41; unless otherwise specified and ranges for continuous variables&#46; Missing clinical values were not replaced&#59; missing numbers of days lost were assumed to equal zero&#46;</p><p id="par0065" class="elsevierStylePara elsevierViewall">All analyses were performed using SAS&#174; Statistical software &#40;SAS Institute&#44; Cary&#44; NC&#41; version 9&#46;4&#46;</p></span></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Results</span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Population characteristics</span><p id="par0070" class="elsevierStylePara elsevierViewall">Four centers participated in the study&#58; one in Faro&#44; two in the Greater Lisbon area&#44; and the fourth in Braga&#46; A total of 39 patients with ACS and 31 patients with stroke were included across the four centers&#46; The baseline characteristics of the study population are shown in <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0075" class="elsevierStylePara elsevierViewall">The mean age of ACS patients was 51 &#40;7&#46;5&#41; years&#44; 80&#37; were men&#44; 85&#37; lived in urban areas and 56&#37; were white-collar workers&#46; Almost 95&#37; of patients with ACS had an MI&#46; However&#44; the left ventricular election fraction of the MI patients was well preserved &#40;mean 55&#37;&#41;&#46; All ACS patients had dyslipidemia&#44; 54&#37; were current smokers and 13&#37; had type 2 diabetes&#46; More than 40&#37; of ACS patients had a history of a prior CV event&#46; Patients were recruited on average seven months after their CVE&#46; The ACS patients worked on average 37&#46;1 &#40;9&#46;6&#41; hours over 5&#46;0 &#40;0&#46;9&#41; days per week&#59; mean duration of a work day was 7&#46;5 &#40;2&#46;1&#41; hours&#46;</p><p id="par0080" class="elsevierStylePara elsevierViewall">The mean age of stroke patients was 50 &#40;8&#46;5&#41; years and 81&#37; were men&#44; 77&#37; lived in urban areas and 52&#37; were white-collar workers&#46; All these patients suffered an ischemic stroke&#46; In most cases the stroke had relatively little impact on mobility &#40;77&#46;4&#37; of patients had modified Ranking scale &#91;mRS&#93; score &#8804;1&#41;&#46; Seventy-four per cent of patients were hypertensive&#44; 23&#37; had type 2 diabetes and 9&#37; had a history of prior CVEs&#46; Stroke patients were recruited on average seven months after their CVE&#46; These patients worked on average 37&#46;8 &#40;13&#46;5&#41; hours over 5&#46;4 &#40;0&#46;7&#41; days per week&#59; mean duration of a work day was 7&#46;0 &#40;2&#46;3&#41; hours&#46;</p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">Productive time lost</span><p id="par0085" class="elsevierStylePara elsevierViewall">The mean productivity loss by patients and caregivers during the first year after an ACS was 47&#46;3 &#40;62&#46;2&#41; work days&#59; after a stroke patients and caregivers lost a mean of 76&#46;4 &#40;101&#46;2&#41; work days &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Figure 1</a>&#41;&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0090" class="elsevierStylePara elsevierViewall">ACS patients lost a mean of 37&#46;3 &#40;38&#46;5&#41; work days due to absenteeism and presenteeism&#59; caregivers lost an additional 10 &#40;42&#46;5&#41; days helping an ACS patient&#46; Stroke patients lost a mean of 64&#46;7 &#40;78&#46;2&#41; work days due to absenteeism and presenteeism and an additional 11&#46;7 &#40;37&#46;9&#41; work days were lost by caregivers helping a stroke patient&#46;</p><p id="par0095" class="elsevierStylePara elsevierViewall">On average&#44; 82&#37; of the time lost by ACS patients was due to absenteeism caused by the index hospitalization and initial sick leave&#46; In stroke patients the index hospitalization and initial sick leave accounted for 73&#37; of lost productive time&#46; Presenteeism accounted for 4&#37; &#40;1&#46;6 work days&#41; in ACS patients and 11&#37; &#40;7&#46;1 work days&#41; in stroke patients &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Figure 1</a>&#41;&#46;</p></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0105">Indirect costs</span><p id="par0100" class="elsevierStylePara elsevierViewall">In the first year after the index CVE&#44; the mean total indirect cost associated with patients&#8217; and caregivers&#8217; productivity loss was &#8364;5403 &#40;&#8364;7095&#41; for ACS and &#8364;8726 &#40;&#8364;11<span class="elsevierStyleHsp" style=""></span>558&#41; for stroke &#40;<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>&#41;&#46; Of those&#44; &#8364;4259 &#40;&#8364;4394&#41; and &#8364;7386 &#40;&#8364;8927&#41;&#44; respectively&#44; were lost by ACS and stroke patients&#46; Caregivers&#8217; indirect costs were &#8364;1144 &#40;&#8364;4847&#41; for ACS and &#8364;1340 &#40;&#8364;4322&#41; for stroke&#44; respectively&#46; Although the absolute numbers were slightly lower&#44; the patterns of lost productivity remained unchanged when the friction cost method was used &#40;<a class="elsevierStyleCrossRef" href="#sec0085">Supplementary Table S1</a>&#41;&#46;</p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia></span></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0110">Discussion</span><p id="par0105" class="elsevierStylePara elsevierViewall">In our study we observed substantial productivity losses and indirect costs in the first year following a CVE in Portugal&#44; with 47 work days lost by patients and caregivers after an ACS and 76 work days after a stroke&#44; and mean total indirect costs of &#8364;5403 and &#8364;8726&#44; respectively&#46;</p><p id="par0110" class="elsevierStylePara elsevierViewall">About 80&#37; of productive time in ACS patients was lost due to the patient&#39;s absence immediately following the CVE&#46; This is much more than the average of 60&#37; that was observed in the other six European countries that participated in this study&#46;<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">4</span></a> Once Portuguese patients returned to work they continued to lose productive time due to absenteeism &#40;five work days for ACS and 11 work days for stroke patients&#41; and presenteeism &#40;two work days for ACS and seven work days for stroke patients&#41;&#46; The loss of productive time observed in Portuguese patients was considerably lower than the average time lost in the other six countries in the project&#46; After returning to work Portuguese ACS patients lost on average seven work days during the first year after the event&#44; while stroke patients lost 18 work days&#46; The corresponding losses in the other six European countries were 24 work days for ACS and 22 work days for stroke patients&#46; A possible explanation for the lower productivity loss compared to France&#44; Poland&#44; Spain&#44; Switzerland and the UK could be the proportion of blue-collar workers in the Portuguese sample &#40;45&#37; in Portugal vs&#46; 26&#37; in the other six countries&#41;&#46; Blue-collar workers may be more concerned about losing their job for being on sick leave for too long or being unproductive&#46; However&#44; it should be noted that unemployment in Portugal&#44; although higher than in Switzerland&#44; UK&#44; Poland and Belgium&#44; is much lower than in France and Spain&#44; where such low productivity losses were not seen after returning to work&#46;<a class="elsevierStyleCrossRef" href="#bib0140"><span class="elsevierStyleSup">13</span></a> ACS patients in Portugal tended to lose less productive time due to the initial hospitalization and sick leave compared to the other participating countries &#40;31 vs&#46; 37 days&#41;&#46; Portuguese stroke patients&#44; on the other hand&#44; lost more time than did stoke patients in the other six countries that participated in the project &#40;47 days vs&#46; 31 days&#41;&#46;</p><p id="par0115" class="elsevierStylePara elsevierViewall">The considerable presenteeism that we observed in stroke patients could be explained by cognitive problems and fatigue after the event that are not considered in the mRS score&#46; Although the Portuguese stroke population had the same proportion of stroke patients with mRS &#8804; 1 as did the other countries in the project &#40;77&#37;&#41;&#44; the distribution of patients between mRS &#61; 0 and mRS &#61; 1 was different&#46; In the Portuguese population 55&#37; had mRS&#61;1 whereas in the overall study this population comprised a mean of 38&#37;&#46; This could explain the longer initial hospitalization and sick leave and longer period of absenteeism in Portuguese patients&#46;</p><p id="par0120" class="elsevierStylePara elsevierViewall">According to the 2016 literature review by Gordois et al&#46;&#44; very little information is available in Portugal on indirect costs in general and on cardiovascular disease in particular&#46;<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">5</span></a> Gouveia Pinto reported that the estimated cost of MI for the first 12 weeks was &#8364;5450&#44; which is very close to what we observed in ACS patients &#40;&#8364;5403&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0145"><span class="elsevierStyleSup">14</span></a> For stroke our estimate of indirect costs seems to be double the direct cost as reported by Miguel et al&#46; &#40;&#8364;8726 vs&#46; &#8364;4136&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0150"><span class="elsevierStyleSup">15</span></a></p><p id="par0125" class="elsevierStylePara elsevierViewall">An important strength of our study is that&#44; unlike most indirect costs studies&#44; which focus on retrospective investigation of databases or administrative records&#44; we collected information directly from CVE patients to capture information on absenteeism after return to work&#44; presenteeism&#44; and caregiver help&#46; We used the most recent validated tool &#40;iPCQ&#41; specifically designed for assessing productivity losses over the previous four weeks &#8211; the longest period that can be assessed without recall bias having a significant effect&#46;<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">9</span></a></p><p id="par0130" class="elsevierStylePara elsevierViewall">We recruited ACS and stroke patients who were still of working age&#44; were employed prior to their event and were able to return to work afterward&#46; This population is expected to be healthier and younger than the overall population of ACS and stroke patients&#46; Therefore&#44; our study provides a conservative estimate of productivity losses in ACS and stroke patients&#59; the burden of productivity loss and indirect costs in the overall population of ACS and stroke patients is likely higher&#44; as patients with more severe ACS and stroke may take more than 12 months to return to work &#40;for example because they require longer rehabilitation&#41; or in fact never return to work due to acquired disability&#46;</p><p id="par0135" class="elsevierStylePara elsevierViewall">The main study limitations are typical of all cross-sectional studies with patient-reported data&#46; Our patients were recruited from four different centers&#46; Although every attempt was made to select centers in different regions across the country&#44; most of the centers served urban populations&#44; leading to the possibility of rural populations being under-represented&#46; These factors may limit the generalizability of our results to a broader ACS and stroke population in Portugal&#46;</p><p id="par0140" class="elsevierStylePara elsevierViewall">Prorating was based on individual absenteeism&#44; presenteeism and caregiver loss patterns over the previous four weeks and assumed to remain constant between return to work and the end of the year&#46; We analyzed the distribution of patients who were recruited within six months of the event and those who were recruited 6-12 months after the event&#44; and found no difference in productivity loss patterns depending on the time elapsed since the event&#46;</p><p id="par0145" class="elsevierStylePara elsevierViewall">By focusing on employed patients only&#44; we did not take into account caregiver time in patients who were unemployed or did not return to work&#46; Since the overall population of MI and stroke patients does include these patients and their caregivers&#44; the estimates for overall caregiver productivity losses are likely to be higher&#46;</p><p id="par0150" class="elsevierStylePara elsevierViewall">Concerning wages&#44; salary-related differences between genders and age groups could have been considered to refine this value&#46; However&#44; given that this analysis was part of a multi-country project we opted to use the same source &#40;Eurostat&#41; for all the different countries&#44; with the associated limitations&#46;</p><p id="par0155" class="elsevierStylePara elsevierViewall">For this analysis&#44; a validated questionnaire &#40;iPCQ&#41; was used and instructions for users on how to translate the answers into costs were followed&#46; For caregivers it is not known whether they were employed&#44; and if so&#44; whether they performed their caregiving tasks during working time&#46;</p></span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0115">Conclusion</span><p id="par0160" class="elsevierStylePara elsevierViewall">Our findings suggest that ACS and stroke were associated with substantial productivity loss and indirect costs in Portugal&#46; ACS patients lost a mean of 17&#37; of their work days during the first year after the event and stroke patients lost 27&#37; of work days&#46; In addition&#44; caregivers lost 4&#37; and 5&#37; of their annual productive time helping ACS and stroke patients&#44; respectively&#46; In Portugal&#44; productivity loss in terms of work days lost associated with ACS was lower than in the other six European countries that participated in the study&#46; Productivity loss in Portuguese stroke patients was similar to that observed in the other participating countries&#46;</p><p id="par0165" class="elsevierStylePara elsevierViewall">The associated indirect costs&#44; &#8364;5403 for ACS and &#8364;8726 for stroke&#44; are comparable to the direct medical costs of these conditions as reported in earlier studies&#44; and therefore potentially double the total cost of ACS and stroke from a societal perspective&#46; Similar relationships between direct and indirect costs of ACS and stroke were found in all seven European countries that participated in the study&#46;</p></span><span id="sec0060" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0120">Data sharing statement</span><p id="par0170" class="elsevierStylePara elsevierViewall">Qualified researchers may request data from Amgen clinical studies&#46; Complete details are available at <a href="http://www.amgen.com/datasharing">http&#58;&#47;&#47;www&#46;amgen&#46;com&#47;datasharing</a>&#46;</p></span><span id="sec0065" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0125">Authors&#8217; contributions</span><p id="par0175" class="elsevierStylePara elsevierViewall">NM&#44; HP&#44; SR&#44; AGF&#44; ADA&#58; contributed to patient recruitment&#44; interpreted the results&#44; critically reviewed the manuscript&#46;</p><p id="par0180" class="elsevierStylePara elsevierViewall">ES&#44; LG&#44; MR&#44; RM&#58; developed the study concept and design&#44; coordinated the centers and patient recruitment&#44; supervised the analyses&#44; critically reviewed the manuscript&#46;</p><p id="par0185" class="elsevierStylePara elsevierViewall">LG&#58; wrote the study protocol&#44; programmed the analyses&#46;</p><p id="par0190" class="elsevierStylePara elsevierViewall">MR&#58; drafted the manuscript&#46;</p></span><span id="sec0070" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0130">Funding</span><p id="par0195" class="elsevierStylePara elsevierViewall">This study was funded by <span class="elsevierStyleGrantSponsor" id="gs1">Amgen &#40;Europe&#41; GmbH</span>&#46;</p></span><span id="sec0075" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0135">Conflicts of interest</span><p id="par0200" class="elsevierStylePara elsevierViewall">ES is a full-time employee at Amgen &#40;Europe&#41; GmbH and owns Amgen stock options&#46; RM is a full-time employee at Amgen Biofarmac&#234;utica Lda &#40;Portugal&#41;&#46; IQVIA&#44; employer of LG and MR&#44; received consulting fees from Amgen &#40;Europe&#41; GmbH&#46;</p></span></span>"
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        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Objectives</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">To present the Portuguese results of a multi-country cross-sectional survey aiming to estimate productivity loss in the first year after an acute coronary syndrome &#40;ACS&#41; or stroke&#46;</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Methods</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Patients previously hospitalized for ACS or stroke were enrolled during a routine cardiology&#47;neurology visit 3-12 months after the index event and &#8805;4 weeks after returning to work&#46; Productivity loss for the patient and the caregiver in the previous four weeks were reported by the patient using the validated iMTA Productivity Cost Questionnaire &#40;iPCQ&#41;&#46; Hours lost were converted into eight-hour work days and prorated to one year&#44; combined with initial hospitalization and sick leave&#44; and valued according to Portuguese labor costs&#46;</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Results</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">The analysis included 39 employed patients with ACS &#40;mean age 51 years&#44; 80&#37; men&#44; 95&#37; with myocardial infarction&#44; mean left ventricular ejection fraction 55&#37;&#41; and 31 with stroke &#40;mean age 50 years&#44; 80&#37; men&#44; all ischemic&#44; 77&#37; with modified Rankin Scale 0-1&#41;&#59; 41&#37; of ACS and 10&#37; of stroke patients had a history of cardiovascular disease&#46; Mean &#40;SD&#41; productivity loss for patients and caregivers was 47 &#40;62&#41; work days for ACS and 76 &#40;101&#41; work days for stroke&#46; ACS patients lost 37 &#40;39&#41; and caregivers lost 10 &#40;42&#41; work days&#46; Stroke patients and caregivers lost 65 &#40;78&#41; and 12 &#40;38&#41; work days&#44; respectively&#46; Total mean indirect cost per case was &#8364;5403 &#40;&#8364;7095&#41; and &#8364;8726 &#40;&#8364;11<span class="elsevierStyleHsp" style=""></span>558&#41; for employed patients with ACS and stroke&#44; respectively&#46;</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Conclusions</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">The annual proportions of productive time lost by employed patients due to ACS and stroke in Portugal were 17&#37; and 27&#37;&#44; respectively&#46; Caregivers of these patients lost about 5&#37; of their annual productive time&#46;</p></span>"
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        "resumen" => "<span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Objetivo</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Apresentar os resultados portugueses de um estudo de corte transversal desenvolvido em v&#225;rios pa&#237;ses que estima a perda de produtividade no primeiro ano ap&#243;s eventos de s&#237;ndrome coron&#225;ria aguda &#40;SCA&#41; ou de acidente vascular cerebral &#40;AVC&#41;&#46;</p></span> <span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">M&#233;todo</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Doentes previamente hospitalizados por SCA ou AVC foram recrutados em consultas de cardiologia e neurologia 3-12 meses ap&#243;s &#237;ndice de hospitaliza&#231;&#227;o por evento e quatro semanas ap&#243;s regresso ao trabalho&#46; Perda de produtividade de doentes e cuidadores foi reportada pelos doentes nas quatro semanas anteriores utilizando o validado <span class="elsevierStyleItalic">iMTA Productivity Cost Questionnaire</span> &#40;iPCQ&#41;&#46; Horas perdidas foram convertidas em dias de trabalho com dura&#231;&#227;o de oito horas e dimensionados a um ano&#44; combinadas com hospitaliza&#231;&#227;o inicial e baixa m&#233;dica e valorados segundo o custo laboral em Portugal&#46;</p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Resultados</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">A an&#225;lise incluiu doentes empregados&#44; dos quais 39 sofreram SCA &#40;51 anos&#44; 80&#37; homens&#44; 95&#37; enfarte do mioc&#225;rdio&#44; 55&#37; fra&#231;&#227;o de eje&#231;&#227;o ventricular esquerda&#41; e 31 sofreram AVC &#40;50 anos&#44; 80&#37; homens&#44; 100&#37; doen&#231;as isqu&#233;micas do cora&#231;&#227;o&#44; 77&#37; escala 0-1 modificada de Rankin&#41;&#59; 41&#37; dos doentes com SCA e 10&#37; dos doentes com AVC tinham hist&#243;ria de doen&#231;as cardiovasculares&#46; A produtividade perdida m&#233;dia &#40;DP&#41; para doentes e cuidadores&#44; em dias de trabalho&#44; foi 47 &#40;62&#41; para SCA e 76 &#40;101&#41; para AVC&#46; Doentes e cuidadores de SCA perderam 37 &#40;39&#41; e 10 &#40;42&#41; dias de trabalho&#44; respetivamente&#46; Doentes e cuidadores de AVC perderam 65 &#40;78&#41; e 12 &#40;38&#41; dias de trabalho&#44; respetivamente&#46; O custo total indireto foi &#8364;5&#44;403 &#40;&#8364;7&#44;095&#41; e &#8364;8&#44;726 &#40;&#8364;11&#44;558&#41; por doente empregado com SCA e AVC&#44; respetivamente&#46;</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Conclus&#227;o</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">Em Portugal&#44; as propor&#231;&#245;es anuais de tempo produtivo perdido para doentes empregados ap&#243;s SCA e AVC foram&#44; respetivamente&#44; 17&#37; e 27&#37;&#46; Cuidadores destes doentes perderam cerca de 5&#37; do seu tempo produtivo anual&#46;</p></span>"
        "secciones" => array:4 [
          0 => array:2 [
            "identificador" => "abst0025"
            "titulo" => "Objetivo"
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          1 => array:2 [
            "identificador" => "abst0030"
            "titulo" => "M&#233;todo"
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          2 => array:2 [
            "identificador" => "abst0035"
            "titulo" => "Resultados"
          ]
          3 => array:2 [
            "identificador" => "abst0040"
            "titulo" => "Conclus&#227;o"
          ]
        ]
      ]
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    "apendice" => array:1 [
      0 => array:1 [
        "seccion" => array:1 [
          0 => array:4 [
            "apendice" => "<p id="par0215" class="elsevierStylePara elsevierViewall"><elsevierMultimedia ident="upi0005"></elsevierMultimedia></p>"
            "etiqueta" => "Appendix A"
            "titulo" => "Supplementary data"
            "identificador" => "sec0085"
          ]
        ]
      ]
    ]
    "multimedia" => array:4 [
      0 => array:7 [
        "identificador" => "fig0005"
        "etiqueta" => "Figure 1"
        "tipo" => "MULTIMEDIAFIGURA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "figura" => array:1 [
          0 => array:4 [
            "imagen" => "gr1.jpeg"
            "Alto" => 1275
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            "Tamanyo" => 154306
          ]
        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Mean patient and caregiver annual work days lost due to acute coronary syndrome and stroke&#46; ACS&#58; acute coronary syndrome&#46;</p>"
        ]
      ]
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        "identificador" => "tbl0005"
        "etiqueta" => "Table 1"
        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "detalles" => array:1 [
          0 => array:3 [
            "identificador" => "at1"
            "detalle" => "Table "
            "rol" => "short"
          ]
        ]
        "tabla" => array:2 [
          "tablatextoimagen" => array:1 [
            0 => array:2 [
              "tabla" => array:1 [
                0 => """
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">ACS &#40;n&#61;39&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleItalic">Gender&#44; male&#44; n &#40;&#37;&#41;</span>&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">31 &#40;79&#46;5&#37;&#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">25 &#40;80&#46;7&#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 ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Age&#44; years&#44; mean &#40;SD&#41;</span>&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">51&#46;3 &#40;7&#46;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="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">49&#46;9 &#40;8&#46;5&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Urban residence&#44; n &#40;&#37;&#41;</span>&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">33 &#40;84&#46;6&#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="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">24 &#40;77&#46;4&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="3" align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="3" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Education level and employment&#44; n &#40;&#37;&#41;</span></td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Below secondary&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">18 &#40;46&#46;2&#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="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">9 &#40;29&#46;0&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Secondary&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="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">17 &#40;43&#46;6&#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="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">15 &#40;48&#46;4&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Higher education&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
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                  \t\t\t\t">4 &#40;10&#46;3&#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="left" valign="\n
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                  \t\t\t\t">4 &#40;12&#46;9&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>White collar &#40;office employee&#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="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">22 &#40;56&#46;4&#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="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">16 &#40;51&#46;6&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Blue collar &#40;manual worker&#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="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">17 &#40;43&#46;6&#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="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">15 &#40;48&#46;4&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="3" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="3" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Type of ACS&#44; n &#40;&#37;&#41;</span></td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Myocardial infarction&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="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">37 &#40;94&#46;9&#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="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">NA&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Unstable angina&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="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2 &#40;5&#46;1&#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="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">NA&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="3" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">LVEF&#44; &#37;&#44; mean &#40;SD&#41;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">54&#46;5 &#40;11&#46;4&#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="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">NA&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="3" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Revascularization&#44; n &#40;&#37;&#41;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">35 &#40;89&#46;7&#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="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">NA&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>CABG&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="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1 &#40;2&#46;6&#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="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">NA&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>PCI&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">34 &#40;87&#46;2&#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="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">NA&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="3" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="3" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Type of stroke</span></td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Ischemic&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="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">NA&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="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">31 &#40;100&#46;0&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="3" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="3" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">mRS at discharge&#44; n &#40;&#37;&#41;</span></td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">NA&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="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">7 &#40;22&#46;6&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">NA&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="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">17 &#40;54&#46;8&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>2&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="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">NA&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="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">5 &#40;16&#46;1&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>3&#43;&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="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">NA&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="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2 &#40;6&#46;5&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="3" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="3" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">CV risk factors&#44; n &#40;&#37;&#41;</span></td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>BMI&#44; kg&#47;m<span class="elsevierStyleSup">2</span>&#44; mean &#40;SD&#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="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">26&#46;5 &#40;4&#46;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="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">26&#46;8 &#40;3&#46;9&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Current smoker&#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="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">21 &#40;53&#46;9&#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="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">9 &#40;29&#46;0&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Type 2 diabetes&#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="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">5 &#40;12&#46;8&#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="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">7 &#40;22&#46;6&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Dyslipidemia&#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="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">39 &#40;100&#46;0&#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="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">31 &#40;100&#46;0&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>LDL-C &#8805;70 mg&#47;dl &#40;1&#46;8 mmol&#47;l&#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="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">36 &#40;92&#46;3&#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="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">27 &#40;87&#46;1&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>LDL-C &#8805;100 mg&#47;dl &#40;2&#46;5 mmol&#47;l&#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="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">28 &#40;71&#46;8&#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="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">26 &#40;83&#46;9&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Receiving high-intensity statin therapy<a class="elsevierStyleCrossRef" href="#tblfn0005"><span class="elsevierStyleSup">a</span></a>&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="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">30 &#40;76&#46;9&#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="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">17 &#40;54&#46;8&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Hypertension&#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="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">34 &#40;87&#46;2&#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="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">22 &#40;71&#46;0&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>SBP &#8805;140 mmHg&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="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">8 &#40;20&#46;5&#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="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">3 &#40;9&#46;7&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Previous CVE or established CV disease&#44; n &#40;&#37;&#41;<a class="elsevierStyleCrossRef" href="#tblfn0010"><span class="elsevierStyleSup">b</span></a>&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="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">16 &#40;41&#46;0&#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="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">3 &#40;9&#46;7&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="3" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">CCI score&#44; mean &#40;SD&#41;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&#46;4 &#40;1&#46;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="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&#46;5 &#40;1&#46;2&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">CCI score &#8805;2&#44; n &#40;&#37;&#41;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">10 &#40;25&#46;6&#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="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">8 &#40;25&#46;8&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Time since CVE&#44; months&#44; mean &#40;SD&#41;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">7&#46;4 &#40;2&#46;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="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">6&#46;5 &#40;3&#46;0&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Index CVE hospitalization&#44; days&#44; mean &#40;SD&#41;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">4&#46;6 &#40;4&#46;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="left" valign="\n
                  \t\t\t\t\ttop\n
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Original Article
Patient and caregiver productivity loss and indirect costs associated with cardiovascular events in Portugal
Perda de produtividade e custos indiretos de doentes e cuidadores associados a eventos cardiovasculares em Portugal
Nuno Marquesa, Laetitia Gerlierb, Mafalda Ramosb,
Autor para correspondência
mafalda.ramos@iqvia.com

Corresponding author.
, Helder Pereirac, Sérgia Rochad, Ana Catarina Fonsecae, Ana Andréf, Ricardo Melog, Eduard Sidelnikovh
a Department of Cardiology, Centro Hospitalar e Universitário do Algarve, Faro, Portugal
b IQVIA, Zaventem, Belgium
c Department of Cardiology, Hospital Garcia de Orta, Almada, Portugal
d Department of Cardiology, Hospital de Braga, Braga, Portugal
e Department of Neurology, Hospital de Santa Maria, Universidade de Lisboa, Lisboa, Portugal
f Department of Neurology, Centro Hospitalar e Universitário do Algarve, Faro, Portugal
g Amgen SA, Portugal
h Amgen (Europe) GmbH, Rotkreuz, Switzerland
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          "en" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Mean patient and caregiver annual work days lost due to acute coronary syndrome and stroke&#46; ACS&#58; acute coronary syndrome&#46;</p>"
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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Cardiovascular disease &#40;CVD&#41; is responsible for about one third of global mortality every year&#44; with 18 million CVD deaths in 2015 worldwide&#44; of which 15 million deaths were due to ischemic heart disease and stroke&#46;<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">1</span></a> CVD was responsible for 29&#37; of the 107<span class="elsevierStyleHsp" style=""></span>000 deaths in Portugal in 2016&#46;<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">2</span></a> Although mortality from CVD in Portugal has decreased by more than 40&#37; over the last 10 years&#44;<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">3</span></a> the number of patients discharged from the hospital having survived an event is not decreasing and therefore there are more patients alive with a history of the disease&#46;<a class="elsevierStyleCrossRefs" href="#bib0090"><span class="elsevierStyleSup">3&#44;4</span></a> Thus&#44; the burden of CVD morbidity is expected to grow further&#44; weighing heavily not only on healthcare systems and patients&#8217; quality of life but also on work productivity&#44; as well as increasing the need for informal care of people with CVD&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">To our knowledge&#44; existing information on productivity losses after CVD in Portugal is very limited&#46;<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">5</span></a> In a multi-country study&#44; the direct and indirect costs of cardiovascular disease in Portugal for 2003 were estimated at around &#8364;1762 million&#44; of which &#8364;969 million was healthcare costs&#46;<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">6</span></a> A more recent study conducted in the European Union in 2017 estimated the overall cost of CVD in Portugal at &#8364;2&#46;8 billion a year&#44; with direct healthcare costs accounting for 42&#37; of total costs&#44; work productivity losses for 27&#37; and informal care for the remaining 31&#37;&#46;<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">7</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">The aim of the current study was to estimate productivity loss and indirect costs for patients and caregivers in the first year after an acute coronary syndrome &#40;ACS&#41; or stroke in Portugal&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Methods</span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Study design and population</span><p id="par0020" class="elsevierStylePara elsevierViewall">Portugal was one of the seven European countries &#40;the others were Belgium&#44; France&#44; Poland&#44; Spain&#44; Switzerland&#44; and the UK&#41; that participated in a multi-country cross-sectional study of patient and caregiver productivity loss and indirect costs following ACS or stroke in Europe&#46; The results of this multi-country study are published elsewhere&#46;<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">8</span></a> Patients were recruited during a routine consultation at a cardiologist&#39;s or neurologist&#39;s clinic between September 2016 and November 2017&#46; Inclusion criteria were hospitalization for ACS &#40;myocardial infarction &#91;MI&#93; or unstable angina&#41; or stroke 3-12 months prior to the recruitment visit&#44; having a paid job&#44; and receiving lipid-modifying therapy at the time of the hospitalization for the cardiovascular event &#40;CVE&#41;&#46; To assess absenteeism and presenteeism at work&#44; patients had to be back to work for at least four weeks prior to recruitment&#46; Patients who participated in a clinical trial at the time of recruitment or were treated with evolocumab were excluded from the study&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">Patients who were able to return to work after an event were recruited in four clinical centers located in different parts of Portugal&#46; Patients who were unemployed at the time of their event or those who did not return to work were not included in the analyses&#46; The objective was to recruit 33 ACS and 33 stroke patients&#44; to achieve a 34&#37; precision in the cost estimate&#44; assuming that sample mean and standard deviation &#40;SD&#41; are equal&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">The study received approval from the appropriate hospital ethics committees and the Portuguese Data Protection Authority &#40;CNPD&#41;&#46; All participants provided written informed consent&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Data collection</span><p id="par0035" class="elsevierStylePara elsevierViewall">Patient absenteeism&#44; presenteeism and caregiver time were assessed using the IMTA Productivity Cost Questionnaire &#40;iPCQ&#41;&#44; a validated questionnaire developed by the Institute for Medical Technology Assessment&#44; Erasmus University Rotterdam&#44; The Netherlands&#44; to collect productivity loss data&#46;<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">9</span></a> This questionnaire has a four-week recall period to overcome recall bias and robust costing methodology&#44; and can be completed in about 10<span class="elsevierStyleHsp" style=""></span>minutes&#44; minimizing the additional burden to patients&#46; Two additional questions were added to the iPCQ to assess absenteeism due to the index CVE hospitalization and sick leave immediately after discharge&#46; The questions were reviewed by the iMTA team that developed the original questionnaire in order to maintain the integrity of the tool&#46; The modified questionnaire was translated into Portuguese using forward-backward translation&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">Demographic and clinical characteristics were abstracted by the recruiting physician from patients&#8217; medical records and provided via an electronic case report form &#40;eCRF&#41;&#46; This eCRF also included data that enabled the length of the index hospitalization to be cross-checked against the data reported by the patient&#46; Conflicting or implausible responses were reconciled directly with the recruiting centers&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Analysis</span><p id="par0045" class="elsevierStylePara elsevierViewall">To estimate annual patient productivity loss&#44; the reported time loss for four weeks was prorated to the rest of the year and combined with the productive time lost due to the index hospitalization and sick leave&#46; Similarly&#44; annual caregiver loss was prorated from the reported loss for the four weeks preceding recruitment&#46; Lost productive time during the year was calculated based on patient-reported working hours per day and considering Portuguese annual leave and bank holidays &#40;a mean of 36 days in total&#41;&#46; All calculations were performed at the patient level and summarized by ACS and stroke&#46;</p><p id="par0050" class="elsevierStylePara elsevierViewall">Productivity loss was valued using the human capital approach for the patient &#40;i&#46;e&#46; assuming that each worker is irreplaceable for society so that all productive time lost by the worker is lost to society&#41; and the opportunity cost for the caregiver &#40;i&#46;e&#46; forgone production&#41;&#46;<a class="elsevierStyleCrossRefs" href="#bib0095"><span class="elsevierStyleSup">4&#44;10</span></a> Each hour lost was multiplied by the Portuguese labor cost taken from Eurostat&#46; To obtain 2018 values&#44; labor costs from 2012 to 2017 were projected using the geometric average &#40;&#8364;14&#46;27&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">11</span></a></p><p id="par0055" class="elsevierStylePara elsevierViewall">The friction cost method &#40;i&#46;e&#46; assuming that workers are replaceable and it takes a certain &#8216;friction&#8217; period to find and train a replacement&#59; after this friction period productivity losses are no longer incurred by society&#41; was used in a sensitivity analysis with a friction period of three months&#46;<a class="elsevierStyleCrossRef" href="#bib0135"><span class="elsevierStyleSup">12</span></a></p><p id="par0060" class="elsevierStylePara elsevierViewall">Descriptive statistics were expressed as frequency and percentage for categorical variables and mean &#40;standard deviation&#41; unless otherwise specified and ranges for continuous variables&#46; Missing clinical values were not replaced&#59; missing numbers of days lost were assumed to equal zero&#46;</p><p id="par0065" class="elsevierStylePara elsevierViewall">All analyses were performed using SAS&#174; Statistical software &#40;SAS Institute&#44; Cary&#44; NC&#41; version 9&#46;4&#46;</p></span></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Results</span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Population characteristics</span><p id="par0070" class="elsevierStylePara elsevierViewall">Four centers participated in the study&#58; one in Faro&#44; two in the Greater Lisbon area&#44; and the fourth in Braga&#46; A total of 39 patients with ACS and 31 patients with stroke were included across the four centers&#46; The baseline characteristics of the study population are shown in <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0075" class="elsevierStylePara elsevierViewall">The mean age of ACS patients was 51 &#40;7&#46;5&#41; years&#44; 80&#37; were men&#44; 85&#37; lived in urban areas and 56&#37; were white-collar workers&#46; Almost 95&#37; of patients with ACS had an MI&#46; However&#44; the left ventricular election fraction of the MI patients was well preserved &#40;mean 55&#37;&#41;&#46; All ACS patients had dyslipidemia&#44; 54&#37; were current smokers and 13&#37; had type 2 diabetes&#46; More than 40&#37; of ACS patients had a history of a prior CV event&#46; Patients were recruited on average seven months after their CVE&#46; The ACS patients worked on average 37&#46;1 &#40;9&#46;6&#41; hours over 5&#46;0 &#40;0&#46;9&#41; days per week&#59; mean duration of a work day was 7&#46;5 &#40;2&#46;1&#41; hours&#46;</p><p id="par0080" class="elsevierStylePara elsevierViewall">The mean age of stroke patients was 50 &#40;8&#46;5&#41; years and 81&#37; were men&#44; 77&#37; lived in urban areas and 52&#37; were white-collar workers&#46; All these patients suffered an ischemic stroke&#46; In most cases the stroke had relatively little impact on mobility &#40;77&#46;4&#37; of patients had modified Ranking scale &#91;mRS&#93; score &#8804;1&#41;&#46; Seventy-four per cent of patients were hypertensive&#44; 23&#37; had type 2 diabetes and 9&#37; had a history of prior CVEs&#46; Stroke patients were recruited on average seven months after their CVE&#46; These patients worked on average 37&#46;8 &#40;13&#46;5&#41; hours over 5&#46;4 &#40;0&#46;7&#41; days per week&#59; mean duration of a work day was 7&#46;0 &#40;2&#46;3&#41; hours&#46;</p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">Productive time lost</span><p id="par0085" class="elsevierStylePara elsevierViewall">The mean productivity loss by patients and caregivers during the first year after an ACS was 47&#46;3 &#40;62&#46;2&#41; work days&#59; after a stroke patients and caregivers lost a mean of 76&#46;4 &#40;101&#46;2&#41; work days &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Figure 1</a>&#41;&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0090" class="elsevierStylePara elsevierViewall">ACS patients lost a mean of 37&#46;3 &#40;38&#46;5&#41; work days due to absenteeism and presenteeism&#59; caregivers lost an additional 10 &#40;42&#46;5&#41; days helping an ACS patient&#46; Stroke patients lost a mean of 64&#46;7 &#40;78&#46;2&#41; work days due to absenteeism and presenteeism and an additional 11&#46;7 &#40;37&#46;9&#41; work days were lost by caregivers helping a stroke patient&#46;</p><p id="par0095" class="elsevierStylePara elsevierViewall">On average&#44; 82&#37; of the time lost by ACS patients was due to absenteeism caused by the index hospitalization and initial sick leave&#46; In stroke patients the index hospitalization and initial sick leave accounted for 73&#37; of lost productive time&#46; Presenteeism accounted for 4&#37; &#40;1&#46;6 work days&#41; in ACS patients and 11&#37; &#40;7&#46;1 work days&#41; in stroke patients &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Figure 1</a>&#41;&#46;</p></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0105">Indirect costs</span><p id="par0100" class="elsevierStylePara elsevierViewall">In the first year after the index CVE&#44; the mean total indirect cost associated with patients&#8217; and caregivers&#8217; productivity loss was &#8364;5403 &#40;&#8364;7095&#41; for ACS and &#8364;8726 &#40;&#8364;11<span class="elsevierStyleHsp" style=""></span>558&#41; for stroke &#40;<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>&#41;&#46; Of those&#44; &#8364;4259 &#40;&#8364;4394&#41; and &#8364;7386 &#40;&#8364;8927&#41;&#44; respectively&#44; were lost by ACS and stroke patients&#46; Caregivers&#8217; indirect costs were &#8364;1144 &#40;&#8364;4847&#41; for ACS and &#8364;1340 &#40;&#8364;4322&#41; for stroke&#44; respectively&#46; Although the absolute numbers were slightly lower&#44; the patterns of lost productivity remained unchanged when the friction cost method was used &#40;<a class="elsevierStyleCrossRef" href="#sec0085">Supplementary Table S1</a>&#41;&#46;</p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia></span></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0110">Discussion</span><p id="par0105" class="elsevierStylePara elsevierViewall">In our study we observed substantial productivity losses and indirect costs in the first year following a CVE in Portugal&#44; with 47 work days lost by patients and caregivers after an ACS and 76 work days after a stroke&#44; and mean total indirect costs of &#8364;5403 and &#8364;8726&#44; respectively&#46;</p><p id="par0110" class="elsevierStylePara elsevierViewall">About 80&#37; of productive time in ACS patients was lost due to the patient&#39;s absence immediately following the CVE&#46; This is much more than the average of 60&#37; that was observed in the other six European countries that participated in this study&#46;<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">4</span></a> Once Portuguese patients returned to work they continued to lose productive time due to absenteeism &#40;five work days for ACS and 11 work days for stroke patients&#41; and presenteeism &#40;two work days for ACS and seven work days for stroke patients&#41;&#46; The loss of productive time observed in Portuguese patients was considerably lower than the average time lost in the other six countries in the project&#46; After returning to work Portuguese ACS patients lost on average seven work days during the first year after the event&#44; while stroke patients lost 18 work days&#46; The corresponding losses in the other six European countries were 24 work days for ACS and 22 work days for stroke patients&#46; A possible explanation for the lower productivity loss compared to France&#44; Poland&#44; Spain&#44; Switzerland and the UK could be the proportion of blue-collar workers in the Portuguese sample &#40;45&#37; in Portugal vs&#46; 26&#37; in the other six countries&#41;&#46; Blue-collar workers may be more concerned about losing their job for being on sick leave for too long or being unproductive&#46; However&#44; it should be noted that unemployment in Portugal&#44; although higher than in Switzerland&#44; UK&#44; Poland and Belgium&#44; is much lower than in France and Spain&#44; where such low productivity losses were not seen after returning to work&#46;<a class="elsevierStyleCrossRef" href="#bib0140"><span class="elsevierStyleSup">13</span></a> ACS patients in Portugal tended to lose less productive time due to the initial hospitalization and sick leave compared to the other participating countries &#40;31 vs&#46; 37 days&#41;&#46; Portuguese stroke patients&#44; on the other hand&#44; lost more time than did stoke patients in the other six countries that participated in the project &#40;47 days vs&#46; 31 days&#41;&#46;</p><p id="par0115" class="elsevierStylePara elsevierViewall">The considerable presenteeism that we observed in stroke patients could be explained by cognitive problems and fatigue after the event that are not considered in the mRS score&#46; Although the Portuguese stroke population had the same proportion of stroke patients with mRS &#8804; 1 as did the other countries in the project &#40;77&#37;&#41;&#44; the distribution of patients between mRS &#61; 0 and mRS &#61; 1 was different&#46; In the Portuguese population 55&#37; had mRS&#61;1 whereas in the overall study this population comprised a mean of 38&#37;&#46; This could explain the longer initial hospitalization and sick leave and longer period of absenteeism in Portuguese patients&#46;</p><p id="par0120" class="elsevierStylePara elsevierViewall">According to the 2016 literature review by Gordois et al&#46;&#44; very little information is available in Portugal on indirect costs in general and on cardiovascular disease in particular&#46;<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">5</span></a> Gouveia Pinto reported that the estimated cost of MI for the first 12 weeks was &#8364;5450&#44; which is very close to what we observed in ACS patients &#40;&#8364;5403&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0145"><span class="elsevierStyleSup">14</span></a> For stroke our estimate of indirect costs seems to be double the direct cost as reported by Miguel et al&#46; &#40;&#8364;8726 vs&#46; &#8364;4136&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0150"><span class="elsevierStyleSup">15</span></a></p><p id="par0125" class="elsevierStylePara elsevierViewall">An important strength of our study is that&#44; unlike most indirect costs studies&#44; which focus on retrospective investigation of databases or administrative records&#44; we collected information directly from CVE patients to capture information on absenteeism after return to work&#44; presenteeism&#44; and caregiver help&#46; We used the most recent validated tool &#40;iPCQ&#41; specifically designed for assessing productivity losses over the previous four weeks &#8211; the longest period that can be assessed without recall bias having a significant effect&#46;<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">9</span></a></p><p id="par0130" class="elsevierStylePara elsevierViewall">We recruited ACS and stroke patients who were still of working age&#44; were employed prior to their event and were able to return to work afterward&#46; This population is expected to be healthier and younger than the overall population of ACS and stroke patients&#46; Therefore&#44; our study provides a conservative estimate of productivity losses in ACS and stroke patients&#59; the burden of productivity loss and indirect costs in the overall population of ACS and stroke patients is likely higher&#44; as patients with more severe ACS and stroke may take more than 12 months to return to work &#40;for example because they require longer rehabilitation&#41; or in fact never return to work due to acquired disability&#46;</p><p id="par0135" class="elsevierStylePara elsevierViewall">The main study limitations are typical of all cross-sectional studies with patient-reported data&#46; Our patients were recruited from four different centers&#46; Although every attempt was made to select centers in different regions across the country&#44; most of the centers served urban populations&#44; leading to the possibility of rural populations being under-represented&#46; These factors may limit the generalizability of our results to a broader ACS and stroke population in Portugal&#46;</p><p id="par0140" class="elsevierStylePara elsevierViewall">Prorating was based on individual absenteeism&#44; presenteeism and caregiver loss patterns over the previous four weeks and assumed to remain constant between return to work and the end of the year&#46; We analyzed the distribution of patients who were recruited within six months of the event and those who were recruited 6-12 months after the event&#44; and found no difference in productivity loss patterns depending on the time elapsed since the event&#46;</p><p id="par0145" class="elsevierStylePara elsevierViewall">By focusing on employed patients only&#44; we did not take into account caregiver time in patients who were unemployed or did not return to work&#46; Since the overall population of MI and stroke patients does include these patients and their caregivers&#44; the estimates for overall caregiver productivity losses are likely to be higher&#46;</p><p id="par0150" class="elsevierStylePara elsevierViewall">Concerning wages&#44; salary-related differences between genders and age groups could have been considered to refine this value&#46; However&#44; given that this analysis was part of a multi-country project we opted to use the same source &#40;Eurostat&#41; for all the different countries&#44; with the associated limitations&#46;</p><p id="par0155" class="elsevierStylePara elsevierViewall">For this analysis&#44; a validated questionnaire &#40;iPCQ&#41; was used and instructions for users on how to translate the answers into costs were followed&#46; For caregivers it is not known whether they were employed&#44; and if so&#44; whether they performed their caregiving tasks during working time&#46;</p></span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0115">Conclusion</span><p id="par0160" class="elsevierStylePara elsevierViewall">Our findings suggest that ACS and stroke were associated with substantial productivity loss and indirect costs in Portugal&#46; ACS patients lost a mean of 17&#37; of their work days during the first year after the event and stroke patients lost 27&#37; of work days&#46; In addition&#44; caregivers lost 4&#37; and 5&#37; of their annual productive time helping ACS and stroke patients&#44; respectively&#46; In Portugal&#44; productivity loss in terms of work days lost associated with ACS was lower than in the other six European countries that participated in the study&#46; Productivity loss in Portuguese stroke patients was similar to that observed in the other participating countries&#46;</p><p id="par0165" class="elsevierStylePara elsevierViewall">The associated indirect costs&#44; &#8364;5403 for ACS and &#8364;8726 for stroke&#44; are comparable to the direct medical costs of these conditions as reported in earlier studies&#44; and therefore potentially double the total cost of ACS and stroke from a societal perspective&#46; Similar relationships between direct and indirect costs of ACS and stroke were found in all seven European countries that participated in the study&#46;</p></span><span id="sec0060" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0120">Data sharing statement</span><p id="par0170" class="elsevierStylePara elsevierViewall">Qualified researchers may request data from Amgen clinical studies&#46; Complete details are available at <a href="http://www.amgen.com/datasharing">http&#58;&#47;&#47;www&#46;amgen&#46;com&#47;datasharing</a>&#46;</p></span><span id="sec0065" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0125">Authors&#8217; contributions</span><p id="par0175" class="elsevierStylePara elsevierViewall">NM&#44; HP&#44; SR&#44; AGF&#44; ADA&#58; contributed to patient recruitment&#44; interpreted the results&#44; critically reviewed the manuscript&#46;</p><p id="par0180" class="elsevierStylePara elsevierViewall">ES&#44; LG&#44; MR&#44; RM&#58; developed the study concept and design&#44; coordinated the centers and patient recruitment&#44; supervised the analyses&#44; critically reviewed the manuscript&#46;</p><p id="par0185" class="elsevierStylePara elsevierViewall">LG&#58; wrote the study protocol&#44; programmed the analyses&#46;</p><p id="par0190" class="elsevierStylePara elsevierViewall">MR&#58; drafted the manuscript&#46;</p></span><span id="sec0070" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0130">Funding</span><p id="par0195" class="elsevierStylePara elsevierViewall">This study was funded by <span class="elsevierStyleGrantSponsor" id="gs1">Amgen &#40;Europe&#41; GmbH</span>&#46;</p></span><span id="sec0075" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0135">Conflicts of interest</span><p id="par0200" class="elsevierStylePara elsevierViewall">ES is a full-time employee at Amgen &#40;Europe&#41; GmbH and owns Amgen stock options&#46; RM is a full-time employee at Amgen Biofarmac&#234;utica Lda &#40;Portugal&#41;&#46; IQVIA&#44; employer of LG and MR&#44; received consulting fees from Amgen &#40;Europe&#41; GmbH&#46;</p></span></span>"
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          "identificador" => "sec0075"
          "titulo" => "Conflicts of interest"
        ]
        13 => array:2 [
          "identificador" => "xack516828"
          "titulo" => "Acknowledgments"
        ]
        14 => array:1 [
          "titulo" => "References"
        ]
      ]
    ]
    "pdfFichero" => "main.pdf"
    "tienePdf" => true
    "fechaRecibido" => "2019-11-04"
    "fechaAceptado" => "2020-05-05"
    "PalabrasClave" => array:2 [
      "en" => array:1 [
        0 => array:4 [
          "clase" => "keyword"
          "titulo" => "Keywords"
          "identificador" => "xpalclavsec1343149"
          "palabras" => array:6 [
            0 => "Cardiovascular disease"
            1 => "Productivity"
            2 => "Absenteeism"
            3 => "Presenteeism"
            4 => "Caregivers"
            5 => "Cost of illness"
          ]
        ]
      ]
      "pt" => array:1 [
        0 => array:4 [
          "clase" => "keyword"
          "titulo" => "Palavras-chave"
          "identificador" => "xpalclavsec1343150"
          "palabras" => array:6 [
            0 => "Doen&#231;a cardiovascular"
            1 => "Produtividade"
            2 => "Absentismo"
            3 => "Presentismo"
            4 => "Cuidadores"
            5 => "Custo da doen&#231;a"
          ]
        ]
      ]
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    "tieneResumen" => true
    "resumen" => array:2 [
      "en" => array:3 [
        "titulo" => "Abstract"
        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Objectives</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">To present the Portuguese results of a multi-country cross-sectional survey aiming to estimate productivity loss in the first year after an acute coronary syndrome &#40;ACS&#41; or stroke&#46;</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Methods</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Patients previously hospitalized for ACS or stroke were enrolled during a routine cardiology&#47;neurology visit 3-12 months after the index event and &#8805;4 weeks after returning to work&#46; Productivity loss for the patient and the caregiver in the previous four weeks were reported by the patient using the validated iMTA Productivity Cost Questionnaire &#40;iPCQ&#41;&#46; Hours lost were converted into eight-hour work days and prorated to one year&#44; combined with initial hospitalization and sick leave&#44; and valued according to Portuguese labor costs&#46;</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Results</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">The analysis included 39 employed patients with ACS &#40;mean age 51 years&#44; 80&#37; men&#44; 95&#37; with myocardial infarction&#44; mean left ventricular ejection fraction 55&#37;&#41; and 31 with stroke &#40;mean age 50 years&#44; 80&#37; men&#44; all ischemic&#44; 77&#37; with modified Rankin Scale 0-1&#41;&#59; 41&#37; of ACS and 10&#37; of stroke patients had a history of cardiovascular disease&#46; Mean &#40;SD&#41; productivity loss for patients and caregivers was 47 &#40;62&#41; work days for ACS and 76 &#40;101&#41; work days for stroke&#46; ACS patients lost 37 &#40;39&#41; and caregivers lost 10 &#40;42&#41; work days&#46; Stroke patients and caregivers lost 65 &#40;78&#41; and 12 &#40;38&#41; work days&#44; respectively&#46; Total mean indirect cost per case was &#8364;5403 &#40;&#8364;7095&#41; and &#8364;8726 &#40;&#8364;11<span class="elsevierStyleHsp" style=""></span>558&#41; for employed patients with ACS and stroke&#44; respectively&#46;</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Conclusions</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">The annual proportions of productive time lost by employed patients due to ACS and stroke in Portugal were 17&#37; and 27&#37;&#44; respectively&#46; Caregivers of these patients lost about 5&#37; of their annual productive time&#46;</p></span>"
        "secciones" => array:4 [
          0 => array:2 [
            "identificador" => "abst0005"
            "titulo" => "Objectives"
          ]
          1 => array:2 [
            "identificador" => "abst0010"
            "titulo" => "Methods"
          ]
          2 => array:2 [
            "identificador" => "abst0015"
            "titulo" => "Results"
          ]
          3 => array:2 [
            "identificador" => "abst0020"
            "titulo" => "Conclusions"
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      "pt" => array:3 [
        "titulo" => "Resumo"
        "resumen" => "<span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Objetivo</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Apresentar os resultados portugueses de um estudo de corte transversal desenvolvido em v&#225;rios pa&#237;ses que estima a perda de produtividade no primeiro ano ap&#243;s eventos de s&#237;ndrome coron&#225;ria aguda &#40;SCA&#41; ou de acidente vascular cerebral &#40;AVC&#41;&#46;</p></span> <span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">M&#233;todo</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Doentes previamente hospitalizados por SCA ou AVC foram recrutados em consultas de cardiologia e neurologia 3-12 meses ap&#243;s &#237;ndice de hospitaliza&#231;&#227;o por evento e quatro semanas ap&#243;s regresso ao trabalho&#46; Perda de produtividade de doentes e cuidadores foi reportada pelos doentes nas quatro semanas anteriores utilizando o validado <span class="elsevierStyleItalic">iMTA Productivity Cost Questionnaire</span> &#40;iPCQ&#41;&#46; Horas perdidas foram convertidas em dias de trabalho com dura&#231;&#227;o de oito horas e dimensionados a um ano&#44; combinadas com hospitaliza&#231;&#227;o inicial e baixa m&#233;dica e valorados segundo o custo laboral em Portugal&#46;</p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Resultados</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">A an&#225;lise incluiu doentes empregados&#44; dos quais 39 sofreram SCA &#40;51 anos&#44; 80&#37; homens&#44; 95&#37; enfarte do mioc&#225;rdio&#44; 55&#37; fra&#231;&#227;o de eje&#231;&#227;o ventricular esquerda&#41; e 31 sofreram AVC &#40;50 anos&#44; 80&#37; homens&#44; 100&#37; doen&#231;as isqu&#233;micas do cora&#231;&#227;o&#44; 77&#37; escala 0-1 modificada de Rankin&#41;&#59; 41&#37; dos doentes com SCA e 10&#37; dos doentes com AVC tinham hist&#243;ria de doen&#231;as cardiovasculares&#46; A produtividade perdida m&#233;dia &#40;DP&#41; para doentes e cuidadores&#44; em dias de trabalho&#44; foi 47 &#40;62&#41; para SCA e 76 &#40;101&#41; para AVC&#46; Doentes e cuidadores de SCA perderam 37 &#40;39&#41; e 10 &#40;42&#41; dias de trabalho&#44; respetivamente&#46; Doentes e cuidadores de AVC perderam 65 &#40;78&#41; e 12 &#40;38&#41; dias de trabalho&#44; respetivamente&#46; O custo total indireto foi &#8364;5&#44;403 &#40;&#8364;7&#44;095&#41; e &#8364;8&#44;726 &#40;&#8364;11&#44;558&#41; por doente empregado com SCA e AVC&#44; respetivamente&#46;</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Conclus&#227;o</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">Em Portugal&#44; as propor&#231;&#245;es anuais de tempo produtivo perdido para doentes empregados ap&#243;s SCA e AVC foram&#44; respetivamente&#44; 17&#37; e 27&#37;&#46; Cuidadores destes doentes perderam cerca de 5&#37; do seu tempo produtivo anual&#46;</p></span>"
        "secciones" => array:4 [
          0 => array:2 [
            "identificador" => "abst0025"
            "titulo" => "Objetivo"
          ]
          1 => array:2 [
            "identificador" => "abst0030"
            "titulo" => "M&#233;todo"
          ]
          2 => array:2 [
            "identificador" => "abst0035"
            "titulo" => "Resultados"
          ]
          3 => array:2 [
            "identificador" => "abst0040"
            "titulo" => "Conclus&#227;o"
          ]
        ]
      ]
    ]
    "apendice" => array:1 [
      0 => array:1 [
        "seccion" => array:1 [
          0 => array:4 [
            "apendice" => "<p id="par0215" class="elsevierStylePara elsevierViewall"><elsevierMultimedia ident="upi0005"></elsevierMultimedia></p>"
            "etiqueta" => "Appendix A"
            "titulo" => "Supplementary data"
            "identificador" => "sec0085"
          ]
        ]
      ]
    ]
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      0 => array:7 [
        "identificador" => "fig0005"
        "etiqueta" => "Figure 1"
        "tipo" => "MULTIMEDIAFIGURA"
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          0 => array:4 [
            "imagen" => "gr1.jpeg"
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        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Mean patient and caregiver annual work days lost due to acute coronary syndrome and stroke&#46; ACS&#58; acute coronary syndrome&#46;</p>"
        ]
      ]
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        "identificador" => "tbl0005"
        "etiqueta" => "Table 1"
        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "detalles" => array:1 [
          0 => array:3 [
            "identificador" => "at1"
            "detalle" => "Table "
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        "tabla" => array:2 [
          "tablatextoimagen" => array:1 [
            0 => array:2 [
              "tabla" => array:1 [
                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">ACS &#40;n&#61;39&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">31 &#40;79&#46;5&#37;&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">25 &#40;80&#46;7&#37;&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleItalic">Age&#44; years&#44; mean &#40;SD&#41;</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">51&#46;3 &#40;7&#46;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">49&#46;9 &#40;8&#46;5&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">33 &#40;84&#46;6&#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="left" valign="\n
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                  \t\t\t\t">24 &#40;77&#46;4&#37;&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleItalic">Education level and employment&#44; n &#40;&#37;&#41;</span></td></tr><tr title="table-row"><td class="td-with-role" title="\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Below secondary&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">18 &#40;46&#46;2&#37;&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">9 &#40;29&#46;0&#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 ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Secondary&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">17 &#40;43&#46;6&#37;&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">15 &#40;48&#46;4&#37;&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">4 &#40;12&#46;9&#37;&#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">22 &#40;56&#46;4&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">16 &#40;51&#46;6&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t">17 &#40;43&#46;6&#37;&#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">15 &#40;48&#46;4&#37;&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleItalic">Type of ACS&#44; n &#40;&#37;&#41;</span></td></tr><tr title="table-row"><td class="td-with-role" title="\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">37 &#40;94&#46;9&#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="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">NA&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Unstable angina&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
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                  \t\t\t\t">2 &#40;5&#46;1&#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="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">NA&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="3" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">LVEF&#44; &#37;&#44; mean &#40;SD&#41;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">54&#46;5 &#40;11&#46;4&#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="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">NA&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="3" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Revascularization&#44; n &#40;&#37;&#41;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">35 &#40;89&#46;7&#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="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">NA&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>CABG&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="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1 &#40;2&#46;6&#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="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">NA&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>PCI&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">34 &#40;87&#46;2&#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="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">NA&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="3" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="3" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Type of stroke</span></td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Ischemic&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="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">NA&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="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">31 &#40;100&#46;0&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="3" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="3" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">mRS at discharge&#44; n &#40;&#37;&#41;</span></td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">NA&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="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">7 &#40;22&#46;6&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">NA&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="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">17 &#40;54&#46;8&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>2&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="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">NA&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="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">5 &#40;16&#46;1&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>3&#43;&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="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">NA&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="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2 &#40;6&#46;5&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="3" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="3" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">CV risk factors&#44; n &#40;&#37;&#41;</span></td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>BMI&#44; kg&#47;m<span class="elsevierStyleSup">2</span>&#44; mean &#40;SD&#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="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">26&#46;5 &#40;4&#46;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="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">26&#46;8 &#40;3&#46;9&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Current smoker&#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="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">21 &#40;53&#46;9&#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="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">9 &#40;29&#46;0&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Type 2 diabetes&#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="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">5 &#40;12&#46;8&#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="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">7 &#40;22&#46;6&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Dyslipidemia&#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="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">39 &#40;100&#46;0&#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="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">31 &#40;100&#46;0&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>LDL-C &#8805;70 mg&#47;dl &#40;1&#46;8 mmol&#47;l&#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="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">36 &#40;92&#46;3&#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="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">27 &#40;87&#46;1&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>LDL-C &#8805;100 mg&#47;dl &#40;2&#46;5 mmol&#47;l&#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="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">28 &#40;71&#46;8&#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="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">26 &#40;83&#46;9&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Receiving high-intensity statin therapy<a class="elsevierStyleCrossRef" href="#tblfn0005"><span class="elsevierStyleSup">a</span></a>&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="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">30 &#40;76&#46;9&#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="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">17 &#40;54&#46;8&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Hypertension&#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="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">34 &#40;87&#46;2&#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="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">22 &#40;71&#46;0&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>SBP &#8805;140 mmHg&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="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">8 &#40;20&#46;5&#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="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">3 &#40;9&#46;7&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Previous CVE or established CV disease&#44; n &#40;&#37;&#41;<a class="elsevierStyleCrossRef" href="#tblfn0010"><span class="elsevierStyleSup">b</span></a>&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="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">16 &#40;41&#46;0&#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="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">3 &#40;9&#46;7&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="3" align="left" valign="\n
                  \t\t\t\t\ttop\n
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                  \t\t\t\t">1&#46;4 &#40;1&#46;1&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">1&#46;5 &#40;1&#46;2&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">10 &#40;25&#46;6&#37;&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">7&#46;4 &#40;2&#46;5&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">0 &#40;0&#46;0&#37;&#41;&nbsp;\t\t\t\t\t\t\n
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        "titulo" => "Acknowledgments"
        "texto" => "<p id="par0205" class="elsevierStylePara elsevierViewall">The authors would like to thank to all study investigators&#44; study nurses and patients who participated in the study&#58; Dr Ana Marques &#40;Hospital Garcia de Orta&#44; Lisbon&#41;&#44; Dr Pedro Nascimento Alves &#40;Hospital de Santa Maria&#44; Lisbon&#41;&#44; Dr Jo&#227;o Diogo Pinto &#40;Hospital De Braga&#41;&#44; Dr Dina Bento &#40;Hospital De Faro&#41;&#59; Tim Kanters at iMTA for his methodological input on the study design and analyses&#59; and iMTA in general for granting permission to use and translate the iPCQ questionnaire for our study&#46; The authors would also like to thank David Gomez and Mark Lamotte for their ongoing support&#46;</p>"
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ISSN: 08702551
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