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          "en" => "<p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">Suggested therapeutic regimen for the management of hypertension&#46;<a class="elsevierStyleCrossRef" href="#bib0480"><span class="elsevierStyleSup">31</span></a><span class="elsevierStyleSup">a</span>CKD is defined as eGFR&#60;60 ml&#47;min&#47;1&#46;72 m<span class="elsevierStyleSup">2</span> with or without proteinuria&#59; <span class="elsevierStyleSup">b</span>preferential use of loop diuretics if eGFR&#60;30 ml&#47;min&#47;1&#46;72 m<span class="elsevierStyleSup">2</span>&#44; due to thiazide diuretics or similar being much less effective when eGFR is reduced to these levels&#59; <span class="elsevierStyleSup">c</span>caution&#58; risk of hyperkalemia with spironolactone&#44; especially when eGFR is less than 45 ml&#47;min&#47;1&#46;72 m<span class="elsevierStyleSup">2</span> or when basal kalemia &#8805;4&#46;5 mmol&#47;L&#46; ACEi&#58; angiotensin converting enzyme inhibitor&#59; AMI&#58; acute myocardial infarction&#59; ARB&#58; angiotensin receptor blocker&#59; BP&#58; blood pressure&#59; CCB&#58; calcium channel blocker&#59; CKD&#58; chronic kidney disease&#59; eGFR&#58; estimated glomerular filtration rate&#59; HF&#58; heart failure&#46;</p>"
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a well-defined functional network with the different levels of care is of the utmost importance&#44; which is only possible with the intervention and cooperation of all institutional and political structures&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">Hospital referral&#44; when judicious&#44; facilitates the timely diagnosis and treatment of potentially serious situations&#44; and if appropriate to local access limitations&#44; contributes to the correct clinical prioritization&#44; being also a tool for updating all the professionals involved&#46;<a class="elsevierStyleCrossRef" href="#bib0350"><span class="elsevierStyleSup">5</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">In this document&#44; we present general guidelines for the referral of patients with cardiovascular pathologies to a cardiology hospital consultation&#46; Additionally&#44; suggestions are made for the initial clinical approach within PHC&#44; with the objective of promoting a more efficient differential diagnosis and follow-up&#44; taking into account the limitations of access of PHC to some diagnostic exams and the context of the Portuguese national referral network&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Methods</span><p id="par0020" class="elsevierStylePara elsevierViewall">A modified Metaplan<a class="elsevierStyleCrossRefs" href="#bib0355"><span class="elsevierStyleSup">6&#44;7</span></a> methodology was used and divided into two phases&#58; 1&#41; in the first phase a panel of four specialists in Cardiology and 3 specialists in General and Family Medicine convened&#46; After a presentation by the moderator&#44; the panel discussed and defined which cardiovascular diseases were to be addressed in this document&#59; 2&#41; in the second phase&#44; and based on the previous discussion&#44; on current clinical guidelines&#44; and on relevant scientific papers in the field&#44; each chapter was developed by a Cardiologist and a General Practitioner &#40;GP&#41;&#46; 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including typical signs and symptoms of HF&#44; as well as the classification of HF according to left ventricular ejection fraction &#40;LVEF&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0375"><span class="elsevierStyleSup">10</span></a></p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par1875" class="elsevierStylePara elsevierViewall">In case of suspected HF&#44; the diagnosis should be performed as soon as possible&#44; ideally with evaluation of the results within a timeframe not exceeding two weeks to one month&#46;<a class="elsevierStyleCrossRef" href="#bib0380"><span class="elsevierStyleSup">11</span></a></p><p id="par1880" class="elsevierStylePara elsevierViewall">Classification of HF based on function and cardiac structural changes is shown in <a class="elsevierStyleCrossRef" href="#tbl0055">Table 1</a>&#46;</p><elsevierMultimedia ident="tbl0055"></elsevierMultimedia></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Diagnosis - initial investigation</span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0060">Laboratory evaluation<a class="elsevierStyleCrossRef" href="#bib0375"><span class="elsevierStyleSup">10</span></a></span><p id="par0055" class="elsevierStylePara elsevierViewall"><ul class="elsevierStyleList" id="lis0015"><li class="elsevierStyleListItem" id="lsti0025"><span class="elsevierStyleLabel">&#8226;</span><p id="par0060" class="elsevierStylePara elsevierViewall">Complete blood count&#44; renal&#44; hepatic and thyroid function&#44; lipid profile&#44; creatine kinase&#44; HbA1c and glycemia &#40;described in this document as baseline laboratory evaluation&#41;&#59;</p></li><li class="elsevierStyleListItem" id="lsti0030"><span class="elsevierStyleLabel">&#8226;</span><p id="par0065" class="elsevierStylePara elsevierViewall">Ferritin&#44; &#37; transferrin saturation &#40;&#40;iron&#47;total iron-binding capacity&#41;x100&#41;&#59;</p></li><li class="elsevierStyleListItem" id="lsti0035"><span class="elsevierStyleLabel">&#8226;</span><p id="par0070" class="elsevierStylePara elsevierViewall">Natriuretic peptides&#44; according to <a class="elsevierStyleCrossRef" href="#fig0005">Figure 1</a>&#44; if available&#59;</p></li><li class="elsevierStyleListItem" id="lsti0040"><span class="elsevierStyleLabel">&#8226;</span><p id="par0075" class="elsevierStylePara elsevierViewall">Urine sediment&#46;</p></li></ul></p></span></span></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Treatment</span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Approach to heart failure with reduced ejection fraction</span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Non-pharmacological measures<a class="elsevierStyleCrossRef" href="#bib0385"><span class="elsevierStyleSup">12</span></a></span><p id="par0080" class="elsevierStylePara elsevierViewall"><ul class="elsevierStyleList" id="lis0020"><li class="elsevierStyleListItem" id="lsti0045"><span class="elsevierStyleLabel">&#8226;</span><p id="par0085" class="elsevierStylePara elsevierViewall">Control of risk factors and lifestyle modification&#59;</p></li><li class="elsevierStyleListItem" id="lsti0050"><span class="elsevierStyleLabel">&#8226;</span><p id="par0090" class="elsevierStylePara elsevierViewall">Influenza and anti-pneumococcal vaccination&#59;</p></li><li class="elsevierStyleListItem" id="lsti0055"><span class="elsevierStyleLabel">&#8226;</span><p id="par0095" class="elsevierStylePara elsevierViewall">Daily weight monitoring and self-monitoring of symptoms&#59;</p></li><li class="elsevierStyleListItem" id="lsti0060"><span class="elsevierStyleLabel">&#8226;</span><p id="par0100" class="elsevierStylePara elsevierViewall">Avoid the use of potential harmful medication &#40;e&#46;g&#46;&#44; non-steroidal anti-inflammatory drugs &#40;NSAIDs&#41;&#44; COX-2 inhibitors&#41;&#46;</p></li></ul></p></span><span id="sec0060" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Pharmacological therapy</span><p id="par0110" class="elsevierStylePara elsevierViewall">The prognostic-modifying therapy of the patient with HF should include angiotensin receptor-neprilysin inhibitors &#40;ARNI&#41;&#47;angiotensin converting enzyme inhibitor &#40;ACEi&#41;&#44; beta blockers &#40;BB&#41;&#44; mineralocorticoid receptor antagonists &#8211; spironolactone or eplerenone &#40;MRA&#41; and sodium-glucose cotransporter 2 inhibitors &#8211; dapagliflozin or empagliflozin &#40;SGLT2i&#41;&#44; as soon as possible&#44; in order to reduce mortality&#44; hospitalizations for HF&#44; and symptoms&#46;<a class="elsevierStyleCrossRefs" href="#bib0365"><span class="elsevierStyleSup">8&#44;10</span></a><ul class="elsevierStyleList" id="lis0030"><li class="elsevierStyleListItem" id="lsti0070"><span class="elsevierStyleLabel">&#8728;</span><p id="par0115" class="elsevierStylePara elsevierViewall">ACEi or ARBs should be replaced by an ARNI in suitable patients &#40;i&#46;e&#46;&#44; patients that remain symptomatic&#41;&#46;</p></li><li class="elsevierStyleListItem" id="lsti0075"><span class="elsevierStyleLabel">&#8728;</span><p id="par0120" class="elsevierStylePara elsevierViewall">If an ACEi is to be substituted by an ARNI&#44; the ARNI should only be initiated 36 hours after ACEi discontinuation&#46;<a class="elsevierStyleCrossRef" href="#bib0375"><span class="elsevierStyleSup">10</span></a></p></li><li class="elsevierStyleListItem" id="lsti0080"><span class="elsevierStyleLabel">&#8728;</span><p id="par0125" class="elsevierStylePara elsevierViewall">Initiation of dapagliflozin and empagliflozin is not recommended in patients with an eGFR &#60;25 and &#60;20 mL&#47;min&#47;1&#46;73 m<span class="elsevierStyleSup">2</span>&#44; respectively&#46; In the case of dapagliflozin if the level of eGFR falls below 25 mL&#47;min&#47;1&#46;73 m<span class="elsevierStyleSup">2</span> after initiation&#44; there is no need for treatment discontinuation&#46;<a class="elsevierStyleCrossRefs" href="#bib0390"><span class="elsevierStyleSup">13&#8211;15</span></a></p></li><li class="elsevierStyleListItem" id="lsti0085"><span class="elsevierStyleLabel">&#8728;</span><p id="par0130" class="elsevierStylePara elsevierViewall">ARNI&#47;ACEi&#47;ARBs or MRAs should be prescribed with caution for patients with an eGFR&#60;30 ml&#47;min&#46;</p></li></ul></p><p id="par0135" class="elsevierStylePara elsevierViewall">In patients with signs and&#47;or symptoms of congestion&#44; loop diuretics&#44; such as furosemide&#44; are recommended to improve and reduce symptoms and enhance exercise ability&#46;<a class="elsevierStyleCrossRef" href="#bib0375"><span class="elsevierStyleSup">10</span></a></p><p id="par0140" class="elsevierStylePara elsevierViewall">Ivabradine should be considered in symptomatic patients with LVEF&#8804;35&#37; at sinus rhythm&#44; and with a heart rate &#40;HR&#41; at rest of &#8805;70 beats per minute &#40;bpm&#41;&#44; despite treatment with BB or ACEi&#47;ARB&#47;MRA&#44; or until evaluation by the cardiologist in case of contraindication for the use of BB&#46;<a class="elsevierStyleCrossRef" href="#bib0375"><span class="elsevierStyleSup">10</span></a></p><p id="par0145" class="elsevierStylePara elsevierViewall">Vericiguat and digoxin may be considered in patients with worsening HF or who remain symptomatic&#44; respectively&#44; after cardiological evaluation&#46;<a class="elsevierStyleCrossRef" href="#bib0375"><span class="elsevierStyleSup">10</span></a></p></span><span id="sec0065" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Devices in HF</span><p id="par0155" class="elsevierStylePara elsevierViewall">In certain patients&#44; an implantable cardioverter-defibrillator &#40;ICD&#41; is recommended to reduce the risk of sudden death and all-cause mortality&#46;<a class="elsevierStyleCrossRef" href="#bib0405"><span class="elsevierStyleSup">16</span></a></p><p id="par0160" class="elsevierStylePara elsevierViewall">Cardiac resynchronization therapy &#40;CRT&#41; improves cardiac performance in selected patients&#44; improves symptoms and well-being&#44; and reduces morbidity and mortality&#46;<a class="elsevierStyleCrossRef" href="#bib0410"><span class="elsevierStyleSup">17</span></a></p></span><span id="sec0070" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Comorbidities</span><p id="par0165" class="elsevierStylePara elsevierViewall"><ul class="elsevierStyleList" id="lis0040"><li class="elsevierStyleListItem" id="lsti0115"><span class="elsevierStyleLabel">&#8226;</span><p id="par0170" class="elsevierStylePara elsevierViewall">Anemia and&#47;or iron deficiency</p></li></ul><ul class="elsevierStyleList" id="lis0045"><li class="elsevierStyleListItem" id="lsti0120"><span class="elsevierStyleLabel">&#8728;</span><p id="par0175" class="elsevierStylePara elsevierViewall">Intravenous iron replacement with iron carboxymaltosis<a class="elsevierStyleCrossRef" href="#bib0415"><span class="elsevierStyleSup">18</span></a>&#59;</p></li><li class="elsevierStyleListItem" id="lsti0125"><span class="elsevierStyleLabel">&#8728;</span><p id="par0180" class="elsevierStylePara elsevierViewall">Do not use oral replacement therapy&#46;<a class="elsevierStyleCrossRef" href="#bib0415"><span class="elsevierStyleSup">18</span></a></p></li></ul><ul class="elsevierStyleList" id="lis0555"><li class="elsevierStyleListItem" id="lsti0130"><span class="elsevierStyleLabel">&#8226;</span><p id="par0185" class="elsevierStylePara elsevierViewall">Atrial fibrillation</p></li></ul><ul class="elsevierStyleList" id="lis0050"><li class="elsevierStyleListItem" id="lsti0135"><span class="elsevierStyleLabel">&#8728;</span><p id="par0190" class="elsevierStylePara elsevierViewall">See chapter dedicated to AF&#59;</p></li><li class="elsevierStyleListItem" id="lsti0140"><span class="elsevierStyleLabel">&#8728;</span><p id="par0195" class="elsevierStylePara elsevierViewall">Diltiazem or verapamil should not be used&#46;<a class="elsevierStyleCrossRef" href="#bib0375"><span class="elsevierStyleSup">10</span></a></p></li></ul><ul class="elsevierStyleList" id="lis0560"><li class="elsevierStyleListItem" id="lsti0145"><span class="elsevierStyleLabel">&#8226;</span><p id="par0200" class="elsevierStylePara elsevierViewall">Type 2 diabetes</p></li></ul><ul class="elsevierStyleList" id="lis0055"><li class="elsevierStyleListItem" id="lsti0150"><span class="elsevierStyleLabel">&#8728;</span><p id="par0205" class="elsevierStylePara elsevierViewall">1<span class="elsevierStyleSup">st</span> line&#58; SGLT2i &#40;reduction in risk of hospitalization for HF&#41;<a class="elsevierStyleCrossRef" href="#bib0420"><span class="elsevierStyleSup">19</span></a>&#59;</p></li><li class="elsevierStyleListItem" id="lsti0155"><span class="elsevierStyleLabel">&#8728;</span><p id="par0210" class="elsevierStylePara elsevierViewall">Metformin can be considered if the glomerular filtration rate &#40;GFR&#41; &#62;30 ml&#47;min&#47;1&#46;73 m<a class="elsevierStyleCrossRefs" href="#bib0335"><span class="elsevierStyleSup">2&#44;20</span></a>&#59;</p></li><li class="elsevierStyleListItem" id="lsti0160"><span class="elsevierStyleLabel">&#8728;</span><p id="par0215" class="elsevierStylePara elsevierViewall">The use of glitazone is not recommended&#46;<a class="elsevierStyleCrossRef" href="#bib0430"><span class="elsevierStyleSup">21</span></a></p></li></ul><ul class="elsevierStyleList" id="lis0565"><li class="elsevierStyleListItem" id="lsti0165"><span class="elsevierStyleLabel">&#8226;</span><p id="par0220" class="elsevierStylePara elsevierViewall">Lung diseases</p></li></ul><ul class="elsevierStyleList" id="lis0060"><li class="elsevierStyleListItem" id="lsti0170"><span class="elsevierStyleLabel">&#8728;</span><p id="par0225" class="elsevierStylePara elsevierViewall">Beta blockers are only relatively contraindicated in asthma&#44; but not in chronic obstructive pulmonary disease &#40;COPD&#41;<a class="elsevierStyleCrossRef" href="#bib0435"><span class="elsevierStyleSup">22</span></a>&#59;</p></li></ul><ul class="elsevierStyleList" id="lis0765"><li class="elsevierStyleListItem" id="lsti0175"><span class="elsevierStyleLabel">-</span><p id="par0230" class="elsevierStylePara elsevierViewall">Preferable&#58; bisoprolol or nebivolol&#59; carvedilol can also be used<a class="elsevierStyleCrossRefs" href="#bib0370"><span class="elsevierStyleSup">9&#44;22</span></a></p></li></ul><ul class="elsevierStyleList" id="lis0065"><li class="elsevierStyleListItem" id="lsti0180"><span class="elsevierStyleLabel">&#8728;</span><p id="par0235" class="elsevierStylePara elsevierViewall">Inhaled corticosteroids are preferable to oral corticosteroids<a class="elsevierStyleCrossRefs" href="#bib0370"><span class="elsevierStyleSup">9&#44;23</span></a>&#59;</p></li><li class="elsevierStyleListItem" id="lsti0185"><span class="elsevierStyleLabel">&#8728;</span><p id="par0240" class="elsevierStylePara elsevierViewall">Noninvasive ventilation can be added to conventional therapy&#46;<a class="elsevierStyleCrossRef" href="#bib0370"><span class="elsevierStyleSup">9</span></a></p></li></ul><ul class="elsevierStyleList" id="lis0575"><li class="elsevierStyleListItem" id="lsti0190"><span class="elsevierStyleLabel">&#8226;</span><p id="par0245" class="elsevierStylePara elsevierViewall">Depression</p></li></ul><ul class="elsevierStyleList" id="lis0070"><li class="elsevierStyleListItem" id="lsti0195"><span class="elsevierStyleLabel"><span class="elsevierStyleBold">&#8728;</span></span><p id="par0250" class="elsevierStylePara elsevierViewall">Sertraline and escitalopram can be used<a class="elsevierStyleCrossRefs" href="#bib0445"><span class="elsevierStyleSup">24&#44;25</span></a>&#59;</p></li><li class="elsevierStyleListItem" id="lsti0200"><span class="elsevierStyleLabel"><span class="elsevierStyleBold">&#8728;</span></span><p id="par0255" class="elsevierStylePara elsevierViewall">Tricyclic antidepressants are not recommended&#46;<a class="elsevierStyleCrossRefs" href="#bib0370"><span class="elsevierStyleSup">9&#44;26</span></a></p></li></ul></p></span></span><span id="sec0075" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Approach to heart failure with mildly reduced ejection fraction</span><p id="par0260" class="elsevierStylePara elsevierViewall"><ul class="elsevierStyleList" id="lis0075"><li class="elsevierStyleListItem" id="lsti0205"><span class="elsevierStyleLabel">&#8226;</span><p id="par0265" class="elsevierStylePara elsevierViewall">Pharmacological therapy</p></li></ul><ul class="elsevierStyleList" id="lis0080"><li class="elsevierStyleListItem" id="lsti0210"><span class="elsevierStyleLabel">&#8728;</span><p id="par0270" class="elsevierStylePara elsevierViewall">Loop diuretics should be used to relieve congestion<a class="elsevierStyleCrossRef" href="#bib0460"><span class="elsevierStyleSup">27</span></a>&#59;</p></li><li class="elsevierStyleListItem" id="lsti0215"><span class="elsevierStyleLabel">&#8728;</span><p id="par0275" class="elsevierStylePara elsevierViewall">The use of ARNI&#44; ACEi&#47;ARB&#44; BB and MRA can be considered to reduce the risk of hospitalization due to HF or death&#46;<a class="elsevierStyleCrossRef" href="#bib0375"><span class="elsevierStyleSup">10</span></a></p></li></ul><ul class="elsevierStyleList" id="lis0580"><li class="elsevierStyleListItem" id="lsti0220"><span class="elsevierStyleLabel"><span class="elsevierStyleBold">&#8226;</span></span><p id="par0280" class="elsevierStylePara elsevierViewall">Identify and treat comorbidities&#46;</p></li></ul></p></span><span id="sec0080" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">Approach to heart failure with preserved ejection fraction</span><p id="par0285" class="elsevierStylePara elsevierViewall"><ul class="elsevierStyleList" id="lis0085"><li class="elsevierStyleListItem" id="lsti0225"><span class="elsevierStyleLabel">&#8226;</span><p id="par0290" class="elsevierStylePara elsevierViewall">Pharmacological therapy</p></li></ul><ul class="elsevierStyleList" id="lis0090"><li class="elsevierStyleListItem" id="lsti0230"><span class="elsevierStyleLabel">&#8728;</span><p id="par0295" class="elsevierStylePara elsevierViewall">Loop diuretics should be used to relieve congestion&#46;<a class="elsevierStyleCrossRef" href="#bib0460"><span class="elsevierStyleSup">27</span></a></p></li></ul><ul class="elsevierStyleList" id="lis0585"><li class="elsevierStyleListItem" id="lsti0235"><span class="elsevierStyleLabel"><span class="elsevierStyleBold">&#8226;</span></span><p id="par0300" class="elsevierStylePara elsevierViewall">Identify and treat comorbidities &#40;e&#46;g&#46;&#58; obesity&#44; hypertension &#40;HT&#41;&#44; obstructive sleep apnea syndrome &#40;OSAS&#41;&#44; coronary artery disease &#40;CAD&#41;&#44; type 2 diabetes&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0375"><span class="elsevierStyleSup">10</span></a></p></li></ul></p></span></span><span id="sec0085" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0105">Criteria for referral to a cardiology consultation &#40;or internal medicine&#44; depending on local resources&#41;</span><span id="sec0090" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0110">Heart failure with reduced or mildly reduced LVEF &#40;&#8804;49&#37;&#41;<a class="elsevierStyleCrossRef" href="#bib0465"><span class="elsevierStyleSup">28</span></a></span><p id="par0305" class="elsevierStylePara elsevierViewall"><ul class="elsevierStyleList" id="lis0095"><li class="elsevierStyleListItem" id="lsti0240"><span class="elsevierStyleLabel">&#8728;</span><p id="par0310" class="elsevierStylePara elsevierViewall">Patients with <span class="elsevierStyleItalic">de novo</span> HF&#59;</p></li><li class="elsevierStyleListItem" id="lsti0245"><span class="elsevierStyleLabel">&#8728;</span><p id="par0315" class="elsevierStylePara elsevierViewall">Patients with LVEF&#60;50&#37;&#46;</p></li></ul></p><p id="par0320" class="elsevierStylePara elsevierViewall">The decision of referral to a hospital consultation should not result in a delay in the initiation&#47;optimization of prognostic-modifying therapy &#40;see recommended therapies mentioned&#41;&#44; which is useful for the cardiovascular protection of the patient while waiting for a hospital consultation&#46;</p></span><span id="sec0095" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0115">Heart failure with preserved LVEF &#40;&#8805;50&#37;&#41;<a class="elsevierStyleCrossRef" href="#bib0465"><span class="elsevierStyleSup">28</span></a></span><p id="par0325" class="elsevierStylePara elsevierViewall"><ul class="elsevierStyleList" id="lis0100"><li class="elsevierStyleListItem" id="lsti0250"><span class="elsevierStyleLabel">&#8728;</span><p id="par0330" class="elsevierStylePara elsevierViewall">Patients with preserved LVEF&#44; who have had &#62;2 hospitalizations&#47;visits to the emergency department &#40;ER&#41; in one year&#44; after excluding non-compliance with medication and lifestyle measures&#59;</p></li><li class="elsevierStyleListItem" id="lsti0255"><span class="elsevierStyleLabel">&#8728;</span><p id="par0335" class="elsevierStylePara elsevierViewall">Patients with suspected restrictive&#47;infiltrative disease &#40;e&#46;g&#46;&#44; cardiac amyloidosis&#41;&#59;</p></li><li class="elsevierStyleListItem" id="lsti0260"><span class="elsevierStyleLabel">&#8728;</span><p id="par0340" class="elsevierStylePara elsevierViewall">Patients with suspected hypertrophic cardiomyopathy&#59;</p></li><li class="elsevierStyleListItem" id="lsti0265"><span class="elsevierStyleLabel">&#8728;</span><p id="par0345" class="elsevierStylePara elsevierViewall">Patients with moderate&#47;severe pulmonary HT&#46;</p></li></ul></p></span></span><span id="sec0100" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0120">Criteria for returning to primary healthcare and follow-up plan</span><span id="sec0105" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0125">Criteria for returning in heart failure with reduced or mildly reduced LVEF &#40;&#8804;49&#37;&#41;</span><p id="par0350" class="elsevierStylePara elsevierViewall"><ul class="elsevierStyleList" id="lis0105"><li class="elsevierStyleListItem" id="lsti0270"><span class="elsevierStyleLabel">&#8226;</span><p id="par0355" class="elsevierStylePara elsevierViewall">Patients with LVEF&#62;35&#37;&#44; without devices&#44; under maximum optimized therapy&#44; without hospitalizations&#47;decompensation episodes &#62;1 year&#44; with a concluded etiological evaluation&#46;</p></li></ul></p></span><span id="sec0110" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0130">Criteria for returning in heart failure with preserved LVEF &#40;&#8805;50&#37;&#41;</span><p id="par0360" class="elsevierStylePara elsevierViewall"><ul class="elsevierStyleList" id="lis0110"><li class="elsevierStyleListItem" id="lsti0275"><span class="elsevierStyleLabel">&#8226;</span><p id="par0365" class="elsevierStylePara elsevierViewall">Patients without indication for further investigation and without indication for specific intervention&#46;</p></li></ul></p></span><span id="sec0115" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0135">Heart failure follow-up plan in primary healthcare</span><p id="par0370" class="elsevierStylePara elsevierViewall"><ul class="elsevierStyleList" id="lis0115"><li class="elsevierStyleListItem" id="lsti0280"><span class="elsevierStyleLabel">&#8226;</span><p id="par0375" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">Before</span> the hospital consultation&#58;</p></li></ul><ul class="elsevierStyleList" id="lis0120"><li class="elsevierStyleListItem" id="lsti0285"><span class="elsevierStyleLabel">&#8728;</span><p id="par0380" class="elsevierStylePara elsevierViewall">Clinical&#44; analytical and electrocardiogram &#40;ECG&#41; reassessment when titrating disease modifying drugs&#59;</p></li><li class="elsevierStyleListItem" id="lsti0290"><span class="elsevierStyleLabel">&#8728;</span><p id="par0385" class="elsevierStylePara elsevierViewall">Repeat transthoracic echocardiogram &#40;TTE&#41; after three to six months of maximum optimized therapy&#46;</p></li></ul><ul class="elsevierStyleList" id="lis0590"><li class="elsevierStyleListItem" id="lsti0295"><span class="elsevierStyleLabel">&#8226;</span><p id="par0390" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">After</span> discharge from hospital consultation&#58;</p></li></ul><ul class="elsevierStyleList" id="lis0125"><li class="elsevierStyleListItem" id="lsti0300"><span class="elsevierStyleLabel">&#8728;</span><p id="par0395" class="elsevierStylePara elsevierViewall">Medical consultation and laboratory reassessment every six months&#59;</p></li><li class="elsevierStyleListItem" id="lsti0305"><span class="elsevierStyleLabel">&#8728;</span><p id="par0400" class="elsevierStylePara elsevierViewall">Annual ECG reassessment&#59;</p></li><li class="elsevierStyleListItem" id="lsti0310"><span class="elsevierStyleLabel">&#8728;</span><p id="par0405" class="elsevierStylePara elsevierViewall">In case the patient&#39;s clinical condition worsens&#44; reassess ECG and TTE&#46;</p></li></ul><ul class="elsevierStyleList" id="lis0595"><li class="elsevierStyleListItem" id="lsti0315"><span class="elsevierStyleLabel">&#8226;</span><p id="par0410" class="elsevierStylePara elsevierViewall">In case of complications or worsening of the clinical condition&#44; consider the possibility of contacting the referral center&#46;</p></li></ul></p></span></span></span><span id="sec0120" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0140">Hypertension</span><span id="sec0125" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0145">Definition</span><p id="par0420" class="elsevierStylePara elsevierViewall">Hypertension is defined as a systolic blood pressure &#40;SBP&#41;&#8805;140 mmHg and&#47;or diastolic blood pressure &#40;DBP&#41;&#8805;90 mmHg&#44; at the doctor&#39;s office&#46;<a class="elsevierStyleCrossRefs" href="#bib0470"><span class="elsevierStyleSup">29&#44;30</span></a></p></span><span id="sec0130" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0150">Evaluation and risk stratification of hypertensive patients in primary healthcare</span><p id="par0425" class="elsevierStylePara elsevierViewall">Once the diagnosis of HT has been confirmed&#44; the patients&#8217; assessment should meet the following objectives<a class="elsevierStyleCrossRef" href="#bib0475"><span class="elsevierStyleSup">30</span></a>&#58;<ul class="elsevierStyleList" id="lis0135"><li class="elsevierStyleListItem" id="lsti0325"><span class="elsevierStyleLabel">&#8226;</span><p id="par0430" class="elsevierStylePara elsevierViewall">Identify signs of secondary HT&#59;</p></li><li class="elsevierStyleListItem" id="lsti0330"><span class="elsevierStyleLabel">&#8226;</span><p id="par0435" class="elsevierStylePara elsevierViewall">Detect target organ damage&#59;</p></li><li class="elsevierStyleListItem" id="lsti0335"><span class="elsevierStyleLabel">&#8226;</span><p id="par0440" class="elsevierStylePara elsevierViewall">Assist in cardiovascular risk stratification&#59;</p></li><li class="elsevierStyleListItem" id="lsti0340"><span class="elsevierStyleLabel">&#8226;</span><p id="par0445" class="elsevierStylePara elsevierViewall">Assess the existence of other associated pathologies that may influence the prognosis and treatment of HT&#46;</p></li></ul></p><p id="par0450" class="elsevierStylePara elsevierViewall">In PHC&#44; the GP should perform a clinical history and complete objective examination&#44; as well as request relevant tests&#46;<a class="elsevierStyleCrossRef" href="#bib0470"><span class="elsevierStyleSup">29</span></a></p><span id="sec0135" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0155">Cardiovascular risk assessment</span><p id="par0455" class="elsevierStylePara elsevierViewall">The cardiovascular &#40;CV&#41; risk associated with the different HT stages is described in <a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>&#46;</p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia></span><span id="sec0140" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0160">Diagnosis</span><p id="par0460" class="elsevierStylePara elsevierViewall">Recommended exams to diagnose HT are summarized in <a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a>&#46;</p><elsevierMultimedia ident="tbl0015"></elsevierMultimedia></span></span><span id="sec0145" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0165">TREATMENT</span><p id="par0465" class="elsevierStylePara elsevierViewall">A suggested treatment algorithm for HT is presented in <a class="elsevierStyleCrossRef" href="#fig0010">Figure 2</a>&#46;</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><span id="sec0150" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0170">Therapeutic goals &#40;in the doctor&#39;s office&#41;<a class="elsevierStyleCrossRef" href="#bib0480"><span class="elsevierStyleSup">31</span></a>&#58;</span><p id="par0470" class="elsevierStylePara elsevierViewall"><ul class="elsevierStyleList" id="lis0140"><li class="elsevierStyleListItem" id="lsti0345"><span class="elsevierStyleLabel">&#8226;</span><p id="par0475" class="elsevierStylePara elsevierViewall">18&#8211;65 years&#58;</p></li></ul><ul class="elsevierStyleList" id="lis0145"><li class="elsevierStyleListItem" id="lsti0350"><span class="elsevierStyleLabel">&#8728;</span><p id="par0480" class="elsevierStylePara elsevierViewall">Initial goal&#58; blood pressure &#40;BP&#41; &#60;140&#47;90 mmHg&#59;</p></li><li class="elsevierStyleListItem" id="lsti0355"><span class="elsevierStyleLabel">&#8728;</span><p id="par0485" class="elsevierStylePara elsevierViewall">If well tolerated&#44; SBP should be between 120&#8211;130 mmHg and DBP between 70<span class="elsevierStyleBold">&#8211;</span>79 mmHg&#59;</p></li></ul><ul class="elsevierStyleList" id="lis0600"><li class="elsevierStyleListItem" id="lsti0360"><span class="elsevierStyleLabel">&#8226;</span><p id="par0490" class="elsevierStylePara elsevierViewall">&#62;65 years&#58;</p></li></ul><ul class="elsevierStyleList" id="lis0150"><li class="elsevierStyleListItem" id="lsti0365"><span class="elsevierStyleLabel">&#8728;</span><p id="par0495" class="elsevierStylePara elsevierViewall">SBP 130&#8211;140 mmHg and DBP 70&#8211;79 mmHg&#44; regardless of CVD history&#46;</p></li></ul></p></span></span><span id="sec0155" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0175">When and how to refer to a hospital consultation</span><span id="sec0160" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0180">Referral criteria<a class="elsevierStyleCrossRefs" href="#bib0475"><span class="elsevierStyleSup">30&#44;31</span></a></span><p id="par0500" class="elsevierStylePara elsevierViewall"><ul class="elsevierStyleList" id="lis0155"><li class="elsevierStyleListItem" id="lsti0370"><span class="elsevierStyleLabel">&#8226;</span><p id="par0505" class="elsevierStylePara elsevierViewall">Refractory HT &#40;uncontrolled&#44; with SBP&#62;140 mmHg and&#47;or DBP&#62;90 mmHg&#44; despite treatment with three antihypertensives from different drug classes at maximum tolerated doses&#44; one of which is a diuretic&#41;&#59;</p></li><li class="elsevierStyleListItem" id="lsti0375"><span class="elsevierStyleLabel">&#8226;</span><p id="par0510" class="elsevierStylePara elsevierViewall">HT in young patients &#40;&#60;35 years&#41;&#59;</p></li><li class="elsevierStyleListItem" id="lsti0380"><span class="elsevierStyleLabel">&#8226;</span><p id="par0515" class="elsevierStylePara elsevierViewall">White coat HT and masked according to clinical judgment&#44; of high and very high cardiovascular risk according to SCORE and for diagnostic clarification&#59;</p></li><li class="elsevierStyleListItem" id="lsti0385"><span class="elsevierStyleLabel">&#8226;</span><p id="par0520" class="elsevierStylePara elsevierViewall">Suspected secondary HT&#44; according to the following criteria&#58;</p></li></ul><ul class="elsevierStyleList" id="lis0160"><li class="elsevierStyleListItem" id="lsti0390"><span class="elsevierStyleLabel">&#8728;</span><p id="par0525" class="elsevierStylePara elsevierViewall">Young patients &#40;&#60;40 years&#41; with grade 2 HT or onset of any degree of HT in childhood&#59;</p></li><li class="elsevierStyleListItem" id="lsti0395"><span class="elsevierStyleLabel">&#8728;</span><p id="par0530" class="elsevierStylePara elsevierViewall">Acute worsening of the BP profile in patients&#44; complying with therapy&#44; with previously documented stable normotension or severe HT &#40;grade 3&#41; or hypertensive emergency&#59;</p></li><li class="elsevierStyleListItem" id="lsti0400"><span class="elsevierStyleLabel">&#8728;</span><p id="par0535" class="elsevierStylePara elsevierViewall">Refractory HT&#59;</p></li><li class="elsevierStyleListItem" id="lsti0405"><span class="elsevierStyleLabel">&#8728;</span><p id="par0540" class="elsevierStylePara elsevierViewall">Presence of relevant target organ damage&#59;</p></li><li class="elsevierStyleListItem" id="lsti0410"><span class="elsevierStyleLabel">&#8728;</span><p id="par0545" class="elsevierStylePara elsevierViewall">Clinical or biochemical characteristics suggestive of endocrine causes of chronic kidney disease &#40;CKD&#41; or HT &#40;in this context it may be important to also refer to the respective medical specialties&#41;&#59;</p></li><li class="elsevierStyleListItem" id="lsti0415"><span class="elsevierStyleLabel">&#8728;</span><p id="par0550" class="elsevierStylePara elsevierViewall">Clinical features suggestive of obstructive sleep apnea &#40;excessive daytime sleepiness&#44; loud snoring&#44; observed episodes of interrupted breathing during sleep&#44; abrupt awakenings accompanied by gasping or choking&#44; waking with a dry mouth or sore throat&#44; morning headache&#44; difficulty concentrating during the day&#41;&#59;</p></li><li class="elsevierStyleListItem" id="lsti0420"><span class="elsevierStyleLabel">&#8728;</span><p id="par0555" class="elsevierStylePara elsevierViewall">Symptoms suggestive of pheochromocytoma or family history of pheochromocytoma&#46;</p></li></ul></p></span></span><span id="sec0165" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0185">Follow-up plan in primary healthcare</span><span id="sec0170" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0190">Criteria for returning to PHC<a class="elsevierStyleCrossRef" href="#bib0480"><span class="elsevierStyleSup">31</span></a></span><p id="par0560" class="elsevierStylePara elsevierViewall"><ul class="elsevierStyleList" id="lis0165"><li class="elsevierStyleListItem" id="lsti0425"><span class="elsevierStyleLabel">&#8226;</span><p id="par0565" class="elsevierStylePara elsevierViewall">Properly controlled BP&#46;</p></li></ul></p></span><span id="sec0175" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0195">Follow-up<a class="elsevierStyleCrossRef" href="#bib0480"><span class="elsevierStyleSup">31</span></a></span><p id="par0570" class="elsevierStylePara elsevierViewall"><ul class="elsevierStyleList" id="lis0170"><li class="elsevierStyleListItem" id="lsti0430"><span class="elsevierStyleLabel">&#8226;</span><p id="par0575" class="elsevierStylePara elsevierViewall">Lifestyle modification &#40;healthy diet and physical activity&#41;&#46;</p></li><li class="elsevierStyleListItem" id="lsti0435"><span class="elsevierStyleLabel">&#8226;</span><p id="par0580" class="elsevierStylePara elsevierViewall">Initial BP reduction in 1&#8211;2 weeks&#44; which may continue to decrease over two months&#46;</p></li><li class="elsevierStyleListItem" id="lsti0440"><span class="elsevierStyleLabel">&#8226;</span><p id="par0585" class="elsevierStylePara elsevierViewall">Initial reassessment in the first month and follow-up dependent on the severity and comorbidities&#44; with a maximum interval of six months &#40;in medical and&#47;or nursing consultation&#41;&#46;</p></li><li class="elsevierStyleListItem" id="lsti0445"><span class="elsevierStyleLabel">&#8226;</span><p id="par0590" class="elsevierStylePara elsevierViewall">Procedures for surveillance in general practice&#58;</p></li></ul><ul class="elsevierStyleList" id="lis0175"><li class="elsevierStyleListItem" id="lsti0450"><span class="elsevierStyleLabel">&#8728;</span><p id="par0595" class="elsevierStylePara elsevierViewall">Demonstrate BP control&#44; compliance and tolerance to treatment&#59;</p></li><li class="elsevierStyleListItem" id="lsti0455"><span class="elsevierStyleLabel">&#8728;</span><p id="par0600" class="elsevierStylePara elsevierViewall">Assess target organ damage&#59;</p></li><li class="elsevierStyleListItem" id="lsti0460"><span class="elsevierStyleLabel">&#8728;</span><p id="par0605" class="elsevierStylePara elsevierViewall">Assess persistence and&#47;or emergence of new cardiovascular risk factors&#59;</p></li><li class="elsevierStyleListItem" id="lsti0465"><span class="elsevierStyleLabel">&#8728;</span><p id="par0610" class="elsevierStylePara elsevierViewall">Reinforce recommendations for lifestyle changes&#59;</p></li><li class="elsevierStyleListItem" id="lsti0470"><span class="elsevierStyleLabel">&#8728;</span><p id="par0615" class="elsevierStylePara elsevierViewall">Regular exams&#58;</p></li></ul><ul class="elsevierStyleList" id="lis0180"><li class="elsevierStyleListItem" id="lsti0475"><span class="elsevierStyleLabel">&#8226;</span><p id="par0620" class="elsevierStylePara elsevierViewall">Glycemia&#44; lipid profile&#44; uricemia&#44; creatinine&#44; microalbuminuria&#58; annually&#46;</p></li><li class="elsevierStyleListItem" id="lsti0480"><span class="elsevierStyleLabel">&#8226;</span><p id="par0625" class="elsevierStylePara elsevierViewall">ECG every two years if the previous one is normal&#46;</p></li><li class="elsevierStyleListItem" id="lsti0485"><span class="elsevierStyleLabel"><span class="elsevierStyleBold">&#8226;</span></span><p id="par0630" class="elsevierStylePara elsevierViewall">Potassium&#58; after one month of treatment and annually if the patient is treated with diuretic&#47;ACEi&#47;ARB&#47;spironolactone&#46;</p></li></ul></p></span></span></span><span id="sec0180" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0200">Syncope</span><span id="sec0185" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0205">Definition</span><p id="par0640" class="elsevierStylePara elsevierViewall">Transient loss of consciousness due to cerebral hypoperfusion&#44; characterized by sudden onset of short duration and spontaneous and complete recovery&#44; accompanied by loss of postural tone<a class="elsevierStyleCrossRef" href="#bib0485"><span class="elsevierStyleSup">32</span></a>&#59;</p><p id="par1885" class="elsevierStylePara elsevierViewall">Presyncope are the signs and symptoms &#40;dizziness&#44; blurred vision&#44; nausea&#44; paleness&#44; warmth&#44; perspiration&#44; others&#41; that precede loss of consciousness in syncope<a class="elsevierStyleCrossRef" href="#bib0485"><span class="elsevierStyleSup">32</span></a>&#59;</p><p id="par1890" class="elsevierStylePara elsevierViewall">Syncope is very common in the community and 20&#8211;50&#37; of the adult population will have at least one syncope throughout life&#46;<a class="elsevierStyleCrossRef" href="#bib0485"><span class="elsevierStyleSup">32</span></a></p></span><span id="sec0190" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0210">Initial approach to the patient and assessment in primary health care</span><p id="par0660" class="elsevierStylePara elsevierViewall">Given the very different prognosis of the various forms of syncope&#44; an accurate diagnosis is fundamental&#46; After excluding other forms of non-syncope transient loss of consciousness&#44; such as convulsion or psychogenic forms&#44; syncope can be divided into three major etiological groups&#58; reflex&#44; due to orthostatic hypotension&#44; or cardiac&#46;<a class="elsevierStyleCrossRef" href="#bib0490"><span class="elsevierStyleSup">33</span></a></p><p id="par1895" class="elsevierStylePara elsevierViewall">Approximately 10&#8211;20&#37; of patients may remain without an etiological diagnosis&#46;<a class="elsevierStyleCrossRef" href="#bib0495"><span class="elsevierStyleSup">34</span></a> Up to one third of these patients will experience recurrence of syncope&#46;<a class="elsevierStyleCrossRef" href="#bib0500"><span class="elsevierStyleSup">35</span></a></p><span id="sec0195" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0215">Clinical history and physical examination</span><p id="par0675" class="elsevierStylePara elsevierViewall">With a careful clinical history and physical examination&#44; which should include an orthostatic test &#40;BP measurement in decubitus and orthostatism&#41; and carotid sinus massage in patients over 40 years &#40;usually performed in a hospital setting&#41;&#44; up to 85&#37; of all patients may have an etiological diagnosis &#40;see <a class="elsevierStyleCrossRef" href="#tbl0020">Table 4</a>&#41;&#46;<a class="elsevierStyleCrossRefs" href="#bib0490"><span class="elsevierStyleSup">33&#44;36</span></a></p><elsevierMultimedia ident="tbl0020"></elsevierMultimedia><p id="par1900" class="elsevierStylePara elsevierViewall">In the context of PHC&#44; the approach in terms of initial diagnostic exams will include&#58;<a class="elsevierStyleCrossRef" href="#bib0490"><span class="elsevierStyleSup">33</span></a><ul class="elsevierStyleList" id="lis0200"><li class="elsevierStyleListItem" id="lsti0525"><span class="elsevierStyleLabel">&#8728;</span><p id="par0685" class="elsevierStylePara elsevierViewall">Basic laboratory evaluation&#59;</p></li><li class="elsevierStyleListItem" id="lsti0530"><span class="elsevierStyleLabel">&#8728;</span><p id="par0690" class="elsevierStylePara elsevierViewall">ECG&#59;</p></li><li class="elsevierStyleListItem" id="lsti0535"><span class="elsevierStyleLabel">&#8728;</span><p id="par0695" class="elsevierStylePara elsevierViewall">24 h Holter&#59;</p></li><li class="elsevierStyleListItem" id="lsti0540"><span class="elsevierStyleLabel">&#8728;</span><p id="par0700" class="elsevierStylePara elsevierViewall">TTE with Doppler study&#44; particularly in the presence of known previous heart disease or when there are data suggestive of structural heart disease or cardiac syncope &#40;see <a class="elsevierStyleCrossRef" href="#tbl0020">Table 4</a>&#41;&#59;</p></li><li class="elsevierStyleListItem" id="lsti0545"><span class="elsevierStyleLabel">&#8728;</span><p id="par0705" class="elsevierStylePara elsevierViewall">Stress test&#44; if there are complaints of angina or syncope on exertion &#40;preferably performed in a hospital setting&#41;&#46;</p></li></ul></p><p id="par0710" class="elsevierStylePara elsevierViewall">Dizziness is also common&#46; It is a heterogeneous symptom&#44; including feeling dizzy &#40;sense of motion&#44; accompanied by nausea&#44; vomiting&#44; paleness and diaphoresis&#41;&#44; presyncope &#40;perception of an imminent episode of fainting accompanied by paleness&#44; diaphoresis and nausea&#41; and imbalance &#40;loss of balance without feeling of movement&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0510"><span class="elsevierStyleSup">37</span></a> The most frequent causes include peripheral vertigo&#44; labyrinthitis&#44; Meni&#232;re disease&#44; central vestibular causes&#44; psychiatric diseases&#44; hyperventilation and multifactorial causes&#46; The prognosis of dizziness is usually favorable&#44; unlike that of cardiac syncope&#46;<a class="elsevierStyleCrossRef" href="#bib0510"><span class="elsevierStyleSup">37</span></a></p></span></span><span id="sec0200" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0220">When to refer to cardiology</span><span id="sec0205" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0225">Referral criteria &#40;cardiology consultation&#41;</span><p id="par0715" class="elsevierStylePara elsevierViewall"><ul class="elsevierStyleList" id="lis0205"><li class="elsevierStyleListItem" id="lsti0555"><span class="elsevierStyleLabel">&#8226;</span><p id="par0720" class="elsevierStylePara elsevierViewall">Syncope suggestive of cardiac etiology&#58;</p></li></ul><ul class="elsevierStyleList" id="lis0210"><li class="elsevierStyleListItem" id="lsti0560"><span class="elsevierStyleLabel">&#8728;</span><p id="par0725" class="elsevierStylePara elsevierViewall">Based on clinical criteria or after suggestive findings in diagnostic exams available in PHC &#40;ECG&#44; TTE&#44; stress test&#44; laboratory tests&#41; &#40;see <a class="elsevierStyleCrossRef" href="#tbl0020">Table 4</a>&#41;&#59;</p></li></ul><ul class="elsevierStyleList" id="lis0605"><li class="elsevierStyleListItem" id="lsti0565"><span class="elsevierStyleLabel">&#8226;</span><p id="par0730" class="elsevierStylePara elsevierViewall">Recurrent syncope&#44; even if of unlikely cardiac etiology&#59;</p></li><li class="elsevierStyleListItem" id="lsti0570"><span class="elsevierStyleLabel">&#8226;</span><p id="par0735" class="elsevierStylePara elsevierViewall">Syncope in patients with pacemakers or other devices&#59;</p></li><li class="elsevierStyleListItem" id="lsti0575"><span class="elsevierStyleLabel">&#8226;</span><p id="par0740" class="elsevierStylePara elsevierViewall">Syncope of unlikely cardiac etiology&#44; but in patients with high risk professions &#40;heavy-duty drivers&#44; divers&#44; etc&#46;&#41;&#46;</p></li></ul></p></span><span id="sec0210" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0230">Referral criteria &#40;emergency department&#41;</span><p id="par0745" class="elsevierStylePara elsevierViewall"><ul class="elsevierStyleList" id="lis0215"><li class="elsevierStyleListItem" id="lsti0580"><span class="elsevierStyleLabel">&#8226;</span><p id="par0750" class="elsevierStylePara elsevierViewall">Syncope and<a class="elsevierStyleCrossRef" href="#bib0490"><span class="elsevierStyleSup">33</span></a>&#58;</p></li></ul><ul class="elsevierStyleList" id="lis0220"><li class="elsevierStyleListItem" id="lsti0585"><span class="elsevierStyleLabel">&#8728;</span><p id="par0755" class="elsevierStylePara elsevierViewall">Documented 2<span class="elsevierStyleSup">nd</span> or 3<span class="elsevierStyleSup">rd</span> degree AV block &#40;ECG or Holter&#41;&#59;</p></li><li class="elsevierStyleListItem" id="lsti0590"><span class="elsevierStyleLabel">&#8728;</span><p id="par0760" class="elsevierStylePara elsevierViewall">Documented alternating branch block &#40;ECG or Holter&#41;&#59;</p></li><li class="elsevierStyleListItem" id="lsti0595"><span class="elsevierStyleLabel">&#8728;</span><p id="par0765" class="elsevierStylePara elsevierViewall">Trifascicular block &#40;ECG or Holter&#41;&#59;</p></li><li class="elsevierStyleListItem" id="lsti0600"><span class="elsevierStyleLabel">&#8728;</span><p id="par0770" class="elsevierStylePara elsevierViewall">Severe aortic stenosis&#59;</p></li><li class="elsevierStyleListItem" id="lsti0605"><span class="elsevierStyleLabel">&#8728;</span><p id="par0775" class="elsevierStylePara elsevierViewall">Severe depression of left ventricular function&#59;</p></li><li class="elsevierStyleListItem" id="lsti0610"><span class="elsevierStyleLabel">&#8728;</span><p id="par0780" class="elsevierStylePara elsevierViewall">Severe pulmonary HT&#59;</p></li><li class="elsevierStyleListItem" id="lsti0615"><span class="elsevierStyleLabel">&#8728;</span><p id="par0785" class="elsevierStylePara elsevierViewall">ICD shock&#59;</p></li><li class="elsevierStyleListItem" id="lsti0620"><span class="elsevierStyleLabel">&#8728;</span><p id="par0790" class="elsevierStylePara elsevierViewall">Suspected acute coronary syndrome &#40;ACS&#41;&#59;</p></li><li class="elsevierStyleListItem" id="lsti0625"><span class="elsevierStyleLabel">&#8728;</span><p id="par0795" class="elsevierStylePara elsevierViewall">Suspected pulmonary thromboembolism&#59;</p></li><li class="elsevierStyleListItem" id="lsti0630"><span class="elsevierStyleLabel">&#8728;</span><p id="par0800" class="elsevierStylePara elsevierViewall">Suspected dissection of the aorta&#59;</p></li><li class="elsevierStyleListItem" id="lsti0635"><span class="elsevierStyleLabel">&#8728;</span><p id="par0805" class="elsevierStylePara elsevierViewall">Traumatic brain injury&#46;</p></li></ul></p></span></span><span id="sec0215" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0235">Follow-up plan in primary health care and discharge criteria from the cardiology consultation</span><p id="par0815" class="elsevierStylePara elsevierViewall">After evaluation in an external hospital consultation &#40;often involving neurology and psychiatry&#41;&#44; a final diagnosis is normally achieved in approximately 80&#37; of patients&#44; and this will determine the therapeutic approach&#46;<a class="elsevierStyleCrossRef" href="#bib0515"><span class="elsevierStyleSup">38</span></a></p><span id="sec0220" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0240">Criteria for return to primary healthcare<a class="elsevierStyleCrossRef" href="#bib0490"><span class="elsevierStyleSup">33</span></a></span><p id="par0820" class="elsevierStylePara elsevierViewall"><ul class="elsevierStyleList" id="lis0230"><li class="elsevierStyleListItem" id="lsti0645"><span class="elsevierStyleLabel">&#8226;</span><p id="par0825" class="elsevierStylePara elsevierViewall">Cardiac syncope&#58;</p></li></ul><ul class="elsevierStyleList" id="lis0235"><li class="elsevierStyleListItem" id="lsti0650"><span class="elsevierStyleLabel">&#8728;</span><p id="par0830" class="elsevierStylePara elsevierViewall">Treated with implantable devices &#40;follow-up at devices consultation&#41;&#59;</p></li><li class="elsevierStyleListItem" id="lsti0655"><span class="elsevierStyleLabel">&#8728;</span><p id="par0835" class="elsevierStylePara elsevierViewall">Treated by ablation&#44; surgery or pharmacological control &#40;may be discharged or followed-up in a specific consultation&#44; depending on the situation&#44; but only after a period of at least one year without symptoms&#41;&#46;</p></li></ul><ul class="elsevierStyleList" id="lis0610"><li class="elsevierStyleListItem" id="lsti0660"><span class="elsevierStyleLabel">&#8226;</span><p id="par0840" class="elsevierStylePara elsevierViewall">Syncope of unknown etiology with implanted event recording device &#40;follow-up at device consultation&#41;&#59;</p></li><li class="elsevierStyleListItem" id="lsti0665"><span class="elsevierStyleLabel">&#8226;</span><p id="par0845" class="elsevierStylePara elsevierViewall">Reflex syncope without indication for pacemaker implantation and with clinical improvement after the establishment of general and&#47;or pharmacological measures&#59;</p></li><li class="elsevierStyleListItem" id="lsti0670"><span class="elsevierStyleLabel">&#8226;</span><p id="par0850" class="elsevierStylePara elsevierViewall">Syncope due to orthostatic hypotension and with clinical improvement after the establishment of general and&#47;or pharmacological measures&#46;</p></li></ul></p></span><span id="sec0225" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0245">Follow-up<a class="elsevierStyleCrossRef" href="#bib0490"><span class="elsevierStyleSup">33</span></a></span><p id="par0855" class="elsevierStylePara elsevierViewall"><ul class="elsevierStyleList" id="lis0240"><li class="elsevierStyleListItem" id="lsti0675"><span class="elsevierStyleLabel">&#8226;</span><p id="par0860" class="elsevierStylePara elsevierViewall">The therapeutic approach to most patients with syncope of non-cardiac etiology &#40;reflex or due to orthostatic hypotension&#41; involves reassurance&#44; general measures and adjustment of established therapy&#59;</p></li><li class="elsevierStyleListItem" id="lsti0680"><span class="elsevierStyleLabel">&#8226;</span><p id="par0865" class="elsevierStylePara elsevierViewall">The follow-up is based on the evaluation of the response to these measures over time&#59;</p></li><li class="elsevierStyleListItem" id="lsti0685"><span class="elsevierStyleLabel">&#8226;</span><p id="par0870" class="elsevierStylePara elsevierViewall">Patients with syncope of non-cardiac etiology &#40;reflex or due to orthostatic hypotension&#41; or of unknown etiology may have syncope recurrences&#59;</p></li></ul><ul class="elsevierStyleList" id="lis0245"><li class="elsevierStyleListItem" id="lsti0690"><span class="elsevierStyleLabel">&#8728;</span><p id="par0875" class="elsevierStylePara elsevierViewall">In these cases&#44; the approach is summarized in <a class="elsevierStyleCrossRef" href="#tbl0025">Table 5</a>&#46; Some of the approaches can be addressed in PHC&#46;</p><elsevierMultimedia ident="tbl0025"></elsevierMultimedia></li></ul><ul class="elsevierStyleList" id="lis0615"><li class="elsevierStyleListItem" id="lsti0695"><span class="elsevierStyleLabel">&#8226;</span><p id="par0880" class="elsevierStylePara elsevierViewall">Patients with recurrent syncope despite the initial approach or who have begun high risk professions should be re-referred for consultation&#46;</p></li></ul></p></span></span></span><span id="sec0230" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0250">Valve diseases</span><p id="par0885" class="elsevierStylePara elsevierViewall">The definition and the main points in the diagnosis of valve diseases&#44; as well as the referral criteria and follow-up plan are presented in <a class="elsevierStyleCrossRef" href="#tbl0030">Table 6</a>&#46;</p><elsevierMultimedia ident="tbl0030"></elsevierMultimedia></span><span id="sec0235" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0255">Chronic coronary syndromes</span><span id="sec0240" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0260">Definition</span><p id="par0890" class="elsevierStylePara elsevierViewall">Atherosclerotic CAD is a chronic progressive disease associated with a continuous high risk of long-term cardiovascular events&#46;<a class="elsevierStyleCrossRef" href="#bib0520"><span class="elsevierStyleSup">39</span></a> The risk of instability increases with insufficient control of cardiovascular risk factors&#44; suboptimal lifestyle modifications&#44; poor adherence to medical therapy or the presence of large areas of myocardial ischemia&#46;<a class="elsevierStyleCrossRefs" href="#bib0520"><span class="elsevierStyleSup">39&#44;40</span></a></p></span><span id="sec0245" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0265">Diagnosis</span><span id="sec0250" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0270">Evaluating signs and symptoms<a class="elsevierStyleCrossRefs" href="#bib0530"><span class="elsevierStyleSup">41&#44;42</span></a></span><p id="par0895" class="elsevierStylePara elsevierViewall"><ul class="elsevierStyleList" id="lis0250"><li class="elsevierStyleListItem" id="lsti0700"><span class="elsevierStyleLabel">&#8226;</span><p id="par0900" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleUnderline">Typical angina</span>&#58; presence of the three characteristics&#58;</p></li></ul><ul class="elsevierStyleList" id="lis0255"><li class="elsevierStyleListItem" id="lsti0705"><span class="elsevierStyleLabel">&#8728;</span><p id="par0905" class="elsevierStylePara elsevierViewall">chest pain or discomfort &#40;feels like pressure or squeezing&#41;&#59;</p></li><li class="elsevierStyleListItem" id="lsti0710"><span class="elsevierStyleLabel">&#8728;</span><p id="par0910" class="elsevierStylePara elsevierViewall">precipitated by physical exertion&#59;</p></li><li class="elsevierStyleListItem" id="lsti0715"><span class="elsevierStyleLabel">&#8728;</span><p id="par0915" class="elsevierStylePara elsevierViewall">relieved at rest or with nitrates&#46;</p></li></ul><ul class="elsevierStyleList" id="lis0620"><li class="elsevierStyleListItem" id="lsti0720"><span class="elsevierStyleLabel">&#8226;</span><p id="par0920" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleUnderline">Atypical angina&#58;</span> presence of two of the previous characteristics&#59;</p></li><li class="elsevierStyleListItem" id="lsti0725"><span class="elsevierStyleLabel">&#8226;</span><p id="par0925" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleUnderline">Non-anginous chest pain&#58;</span> presence of one or none of the previous characteristics&#59;</p></li><li class="elsevierStyleListItem" id="lsti0730"><span class="elsevierStyleLabel">&#8226;</span><p id="par0930" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleUnderline">Assess</span>&#58; precipitating factors &#40;severe anemia&#44; poorly controlled HT&#44; dysrhythmias&#44; hyperthyroidism&#44; smoking or contraceptive use&#41;&#44; atherosclerotic disease in other territories &#40;cerebral&#44; carotid and lower limbs&#41; and erectile dysfunction&#46;</p></li></ul></p></span><span id="sec0255" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0275">Initial exams<a class="elsevierStyleCrossRef" href="#bib0535"><span class="elsevierStyleSup">42</span></a></span><p id="par0935" class="elsevierStylePara elsevierViewall"><ul class="elsevierStyleList" id="lis0260"><li class="elsevierStyleListItem" id="lsti0735"><span class="elsevierStyleLabel">&#8226;</span><p id="par0940" class="elsevierStylePara elsevierViewall">Basic laboratory evaluation&#59;</p></li><li class="elsevierStyleListItem" id="lsti0740"><span class="elsevierStyleLabel">&#8226;</span><p id="par0945" class="elsevierStylePara elsevierViewall">ECG at rest&#59;</p></li><li class="elsevierStyleListItem" id="lsti0745"><span class="elsevierStyleLabel">&#8226;</span><p id="par0950" class="elsevierStylePara elsevierViewall">Chest X-ray &#40;symptoms of heart failure or lung disease&#41;&#59;</p></li><li class="elsevierStyleListItem" id="lsti0750"><span class="elsevierStyleLabel">&#8226;</span><p id="par0955" class="elsevierStylePara elsevierViewall">TTE&#46;</p></li></ul></p></span><span id="sec0260" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0280">Assess the pre-test probability and clinical probability of obstructive coronary artery disease<a class="elsevierStyleCrossRef" href="#bib0535"><span class="elsevierStyleSup">42</span></a></span><p id="par0960" class="elsevierStylePara elsevierViewall"><ul class="elsevierStyleList" id="lis0265"><li class="elsevierStyleListItem" id="lsti0755"><span class="elsevierStyleLabel">&#8226;</span><p id="par0965" class="elsevierStylePara elsevierViewall">When CAD is suspected&#44; determine the pre-test probability &#40;PTP&#41;&#46; PTPs of CAD according to age and to nature of symptoms are presented in <a class="elsevierStyleCrossRef" href="#tbl0035">Table 7</a>&#59;</p><elsevierMultimedia ident="tbl0035"></elsevierMultimedia></li><li class="elsevierStyleListItem" id="lsti0760"><span class="elsevierStyleLabel">&#8226;</span><p id="par0970" class="elsevierStylePara elsevierViewall">In patients with low PTP &#40;5&#8211;15&#37;&#41;&#44; the presence of other determinants of increased risk&#44; such as cardiovascular risk factors&#44; changes in ECG at rest&#44; left ventricular dysfunction&#44; abnormal stress test and coronary calcification should be considered&#46;</p></li></ul></p></span><span id="sec0265" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0285">Selection of coronary artery disease diagnostic exam<a class="elsevierStyleCrossRefs" href="#bib0535"><span class="elsevierStyleSup">42&#44;43</span></a></span><p id="par0975" class="elsevierStylePara elsevierViewall">First-line exams in patients with intermediate probability &#40;PTP&#62;15&#37;&#41;&#58;<ul class="elsevierStyleList" id="lis0270"><li class="elsevierStyleListItem" id="lsti0765"><span class="elsevierStyleLabel">I&#46;</span><p id="par0980" class="elsevierStylePara elsevierViewall">Non-invasive functional imaging for the determination of ischemia&#58;</p></li></ul><ul class="elsevierStyleList" id="lis0275"><li class="elsevierStyleListItem" id="lsti0770"><span class="elsevierStyleLabel">&#8226;</span><p id="par0985" class="elsevierStylePara elsevierViewall">Myocardial perfusion scintigraphy &#40;MPS&#41;&#59;</p></li><li class="elsevierStyleListItem" id="lsti0775"><span class="elsevierStyleLabel">&#8226;</span><p id="par0990" class="elsevierStylePara elsevierViewall">Stress TTE&#46;</p></li></ul><ul class="elsevierStyleList" id="lis0625"><li class="elsevierStyleListItem" id="lsti0780"><span class="elsevierStyleLabel">II&#46;</span><p id="par0995" class="elsevierStylePara elsevierViewall">Anatomical evaluation with computed tomography coronary angiogram &#40;CTCA&#41;</p></li></ul></p><p id="par1000" class="elsevierStylePara elsevierViewall">The stress test has a low performance in the confirmation or exclusion of the disease&#46;</p><p id="par1005" class="elsevierStylePara elsevierViewall">In the case of high clinical probability of CAD&#44; persistence of symptoms under medical therapy&#44; typical angina at low level of exertion or high risk of cardiovascular events &#8211; invasive coronary angiography may be indicated &#40;refer to urgent cardiology consultation&#41;&#46;</p></span></span><span id="sec0270" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0290">Action plan in primary health care</span><span id="sec0275" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0295">Non-pharmacological measures<a class="elsevierStyleCrossRef" href="#bib0545"><span class="elsevierStyleSup">44</span></a>&#58;</span><p id="par1010" class="elsevierStylePara elsevierViewall"><ul class="elsevierStyleList" id="lis0285"><li class="elsevierStyleListItem" id="lsti0795"><span class="elsevierStyleLabel">&#8226;</span><p id="par1015" class="elsevierStylePara elsevierViewall">Lifestyle modification and aggressive control of all cardiovascular risk factors&#46;</p></li></ul></p></span><span id="sec0280" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0300">Pharmacological measures<a class="elsevierStyleCrossRefs" href="#bib0535"><span class="elsevierStyleSup">42&#44;44</span></a>&#58;</span><p id="par1020" class="elsevierStylePara elsevierViewall"><ul class="elsevierStyleList" id="lis0290"><li class="elsevierStyleListItem" id="lsti0800"><span class="elsevierStyleLabel"><span class="elsevierStyleBold">&#8226;</span></span><p id="par1025" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">Anti-angina therapy&#58;</span></p></li></ul><ul class="elsevierStyleList" id="lis0295"><li class="elsevierStyleListItem" id="lsti0805"><span class="elsevierStyleLabel">&#8728;</span><p id="par1030" class="elsevierStylePara elsevierViewall">1st line&#58; BB at maximum tolerated dose &#40;MTD&#41;&#59;</p></li><li class="elsevierStyleListItem" id="lsti0810"><span class="elsevierStyleLabel">&#8728;</span><p id="par1035" class="elsevierStylePara elsevierViewall">2nd line&#58; CCB&#44; ivabradine&#44; nicorandil&#44; ranolazine&#44; trimetazidine and long-acting nitrates &#40;nitroglycerin&#44; isosorbide dinitrate and isosorbide mononitrate&#41;&#46;</p></li></ul><ul class="elsevierStyleList" id="lis0630"><li class="elsevierStyleListItem" id="lsti0815"><span class="elsevierStyleLabel"><span class="elsevierStyleBold">&#8226;</span></span><p id="par1040" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">Antithrombotic therapy&#58;</span></p></li></ul><ul class="elsevierStyleList" id="lis0300"><li class="elsevierStyleListItem" id="lsti0820"><span class="elsevierStyleLabel">&#8728;</span><p id="par1045" class="elsevierStylePara elsevierViewall">Before hospital referral&#58;</p></li></ul><ul class="elsevierStyleList" id="lis0305"><li class="elsevierStyleListItem" id="lsti0825"><span class="elsevierStyleLabel">&#8226;</span><p id="par1050" class="elsevierStylePara elsevierViewall">If ischemia was unequivocally demonstrated and the patient has an appropriate clinical risk profile&#44; aspirin can be started&#59;</p></li></ul><ul class="elsevierStyleList" id="lis0635"><li class="elsevierStyleListItem" id="lsti0830"><span class="elsevierStyleLabel">&#8728;</span><p id="par1055" class="elsevierStylePara elsevierViewall">After elective angioplasty&#58;</p></li></ul><ul class="elsevierStyleList" id="lis0310"><li class="elsevierStyleListItem" id="lsti0835"><span class="elsevierStyleLabel">&#8226;</span><p id="par1060" class="elsevierStylePara elsevierViewall">Aspirin &#40;ASA&#41; 100 and clopidogrel 75 for at least 6 months&#59; in case of high hemorrhagic risk&#58; 1&#8211;3 months&#59;</p></li></ul><ul class="elsevierStyleList" id="lis0640"><li class="elsevierStyleListItem" id="lsti0840"><span class="elsevierStyleLabel">&#8728;</span><p id="par1065" class="elsevierStylePara elsevierViewall">After acute coronary syndrome&#58;</p></li></ul><ul class="elsevierStyleList" id="lis0315"><li class="elsevierStyleListItem" id="lsti0845"><span class="elsevierStyleLabel">&#8226;</span><p id="par1070" class="elsevierStylePara elsevierViewall">Dual antiplatelet therapy &#40;ASA&#43;ticagrelor 90 mg or prasugrel 10 mg&#59; if unavailable or contraindicated&#44; clopidogrel&#41;&#59;</p></li></ul><ul class="elsevierStyleList" id="lis0645"><li class="elsevierStyleListItem" id="lsti0850"><span class="elsevierStyleLabel">&#8226;</span><p id="par1075" class="elsevierStylePara elsevierViewall">For at least 12 months&#59;</p></li><li class="elsevierStyleListItem" id="lsti0855"><span class="elsevierStyleLabel">&#8226;</span><p id="par1080" class="elsevierStylePara elsevierViewall">Long-term extension with ticagrelor 60 mg in patients at high &#40;IIa&#41; or moderate &#40;IIb&#41; risk of ischemic events&#58; diffuse multivessel CAD associated with comorbidities &#40;diabetes&#44; recurrent myocardial infarction &#40;MI&#41;&#44; peripheral artery disease&#44; or CKD&#41;&#44; without high hemorrhagic risk and who tolerate dual antiplatelet therapy during the first year&#59;</p></li><li class="elsevierStyleListItem" id="lsti0860"><span class="elsevierStyleLabel">&#8226;</span><p id="par1085" class="elsevierStylePara elsevierViewall">Alternatively to DAPT&#44; may consider intensification with rivaroxaban 2&#46;5 mg therapy in combination with aspirin in patients who had an myocardial infarction at least one year before or in cases of CCS with multivessel CAD&#59;</p></li></ul><ul class="elsevierStyleList" id="lis0650"><li class="elsevierStyleListItem" id="lsti0865"><span class="elsevierStyleLabel">&#8226;</span><p id="par1090" class="elsevierStylePara elsevierViewall">In patients with indication for long-term oral anticoagulation therapy &#40;AF&#41;&#58;</p></li></ul><ul class="elsevierStyleList" id="lis0655"><li class="elsevierStyleListItem" id="lsti0870"><span class="elsevierStyleLabel">&#8728;</span><p id="par1095" class="elsevierStylePara elsevierViewall">Hospitalization&#58; Aspirin&#43;clopidogrel&#43;anticoagulant&#59;</p></li><li class="elsevierStyleListItem" id="lsti0875"><span class="elsevierStyleLabel">&#8728;</span><p id="par1100" class="elsevierStylePara elsevierViewall">First year&#58; Clopidogrel&#43;oral anticoagulant &#40;direct oral anticoagulant &#40;DOAC&#41;&#41;&#59;</p></li><li class="elsevierStyleListItem" id="lsti0880"><span class="elsevierStyleLabel">&#8728;</span><p id="par1105" class="elsevierStylePara elsevierViewall">&#62;12 months&#58; oral anticoagulant &#40;DOAC&#41;&#46;</p></li></ul><ul class="elsevierStyleList" id="lis0660"><li class="elsevierStyleListItem" id="lsti0885"><span class="elsevierStyleLabel"><span class="elsevierStyleBold">&#8226;</span></span><p id="par1110" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">Hypolipemic therapy&#58;</span></p></li></ul><ul class="elsevierStyleList" id="lis0320"><li class="elsevierStyleListItem" id="lsti0890"><span class="elsevierStyleLabel">&#8728;</span><p id="par1115" class="elsevierStylePara elsevierViewall">Therapeutic goals&#58;</p></li></ul><ul class="elsevierStyleList" id="lis0325"><li class="elsevierStyleListItem" id="lsti0895"><span class="elsevierStyleLabel">&#8226;</span><p id="par1120" class="elsevierStylePara elsevierViewall">LDL-c&#60;55 mg&#47;dL and reduction of at least 50&#37; relative to baseline&#59;</p></li><li class="elsevierStyleListItem" id="lsti0900"><span class="elsevierStyleLabel">&#8226;</span><p id="par1125" class="elsevierStylePara elsevierViewall">In the presence of second event within two years&#58; LDL-c&#60;40 mg&#47;dL&#59;</p></li></ul><ul class="elsevierStyleList" id="lis0665"><li class="elsevierStyleListItem" id="lsti0905"><span class="elsevierStyleLabel">&#8728;</span><p id="par1130" class="elsevierStylePara elsevierViewall">Recommended drugs&#58; statins at MTD&#44; ezetimibe and proprotein convertase subtilisin&#47;kexin type 9 &#40;PCSK9&#41; &#40;available at hospital level&#41;</p></li></ul><ul class="elsevierStyleList" id="lis0670"><li class="elsevierStyleListItem" id="lsti0910"><span class="elsevierStyleLabel"><span class="elsevierStyleBold">&#8226;</span></span><p id="par1135" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">Antihypertensive therapy&#58;</span></p></li></ul><ul class="elsevierStyleList" id="lis0330"><li class="elsevierStyleListItem" id="lsti0915"><span class="elsevierStyleLabel">&#8728;</span><p id="par1140" class="elsevierStylePara elsevierViewall">Therapeutic goal&#58; BP&#60;130 mmHg&#44; if tolerated&#59;</p></li><li class="elsevierStyleListItem" id="lsti0920"><span class="elsevierStyleLabel">&#8728;</span><p id="par1145" class="elsevierStylePara elsevierViewall">Recommended drugs&#58; BB and&#47;or ACEi&#59; if necessary add other drugs&#59;</p></li></ul><ul class="elsevierStyleList" id="lis0675"><li class="elsevierStyleListItem" id="lsti0925"><span class="elsevierStyleLabel"><span class="elsevierStyleBold">&#8226;</span></span><p id="par1150" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">Antidiabetic therapy&#58;</span></p></li></ul><ul class="elsevierStyleList" id="lis0335"><li class="elsevierStyleListItem" id="lsti0930"><span class="elsevierStyleLabel">&#8728;</span><p id="par1155" class="elsevierStylePara elsevierViewall">1<span class="elsevierStyleSup">st</span> line&#58; SGLT2i and GLP-1 analogues&#44; due to their impact on the reduction of CV events&#46;</p></li></ul></p></span></span><span id="sec0285" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0305">When and how to refer to cardiology</span><span id="sec0290" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0310">Referral criteria</span><span id="sec0295" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0315">Referral to the emergency department<a class="elsevierStyleCrossRef" href="#bib0535"><span class="elsevierStyleSup">42</span></a>&#58;</span><p id="par1160" class="elsevierStylePara elsevierViewall"><ul class="elsevierStyleList" id="lis0340"><li class="elsevierStyleListItem" id="lsti0935"><span class="elsevierStyleLabel">&#8226;</span><p id="par1165" class="elsevierStylePara elsevierViewall">Suspected ACS&#59;</p></li></ul></p></span><span id="sec0300" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0320">Referral for cardiology consultation&#58;</span><p id="par1170" class="elsevierStylePara elsevierViewall"><ul class="elsevierStyleList" id="lis0345"><li class="elsevierStyleListItem" id="lsti0940"><span class="elsevierStyleLabel">&#8226;</span><p id="par1175" class="elsevierStylePara elsevierViewall">Initial clinical evaluation suggestive of high risk events&#58;</p></li></ul><ul class="elsevierStyleList" id="lis0350"><li class="elsevierStyleListItem" id="lsti0945"><span class="elsevierStyleLabel">&#8728;</span><p id="par1180" class="elsevierStylePara elsevierViewall">High clinical probability of CAD&#59;</p></li><li class="elsevierStyleListItem" id="lsti0950"><span class="elsevierStyleLabel">&#8728;</span><p id="par1185" class="elsevierStylePara elsevierViewall">Persistence of symptoms under optimized medical therapy&#59;</p></li><li class="elsevierStyleListItem" id="lsti0955"><span class="elsevierStyleLabel">&#8728;</span><p id="par1190" class="elsevierStylePara elsevierViewall">Typical angina at low level of exertion &#40;in the context of daily life activities&#41;&#59;</p></li><li class="elsevierStyleListItem" id="lsti0960"><span class="elsevierStyleLabel">&#8728;</span><p id="par1195" class="elsevierStylePara elsevierViewall">Carotid disease or symptomatic peripheral artery disease in patients with ischemic cardiopathy&#59;</p></li></ul><ul class="elsevierStyleList" id="lis0680"><li class="elsevierStyleListItem" id="lsti0965"><span class="elsevierStyleLabel"><span class="elsevierStyleBold">&#8226;</span></span><p id="par1200" class="elsevierStylePara elsevierViewall">Significant <span class="elsevierStyleItalic">de novo</span> ischemia &#40;MPS with ischemic area &#8805;10&#37; of the myocardium&#41;&#59;</p></li><li class="elsevierStyleListItem" id="lsti0970"><span class="elsevierStyleLabel">&#8226;</span><p id="par1205" class="elsevierStylePara elsevierViewall">Significant lesions in CTCA &#40;CAD RADS &#62;3&#58; severe coronary stenosis &#91;70-99&#37;&#41;&#93;&#44; left main &#62;50&#37; or 3-vessel obstructive &#91;&#8805;70&#37;&#93; disease&#44; total coronary occlusion &#91;100&#37;&#93;&#41;&#46;</p></li><li class="elsevierStyleListItem" id="lsti0975"><span class="elsevierStyleLabel"><span class="elsevierStyleBold">&#8226;</span></span><p id="par1210" class="elsevierStylePara elsevierViewall">Left ventricular dysfunction &#40;LVEF&#60;50&#37;&#41;&#46;</p></li></ul></p></span></span><span id="sec0305" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0325">Important information to be included in the consultation request</span><p id="par1215" class="elsevierStylePara elsevierViewall"><ul class="elsevierStyleList" id="lis0355"><li class="elsevierStyleListItem" id="lsti0980"><span class="elsevierStyleLabel">&#8226;</span><p id="par1220" class="elsevierStylePara elsevierViewall">Signs&#44; symptoms&#44; cardiovascular risk factors and comorbidities&#59;</p></li><li class="elsevierStyleListItem" id="lsti0985"><span class="elsevierStyleLabel">&#8226;</span><p id="par1225" class="elsevierStylePara elsevierViewall">Results of exams&#59;</p></li><li class="elsevierStyleListItem" id="lsti0990"><span class="elsevierStyleLabel">&#8226;</span><p id="par1230" class="elsevierStylePara elsevierViewall">Response to established therapy&#46;</p></li></ul></p></span></span><span id="sec0310" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0330">Follow-up plan in primary healthcare</span><span id="sec0315" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0335">Criteria of return to PHC</span><p id="par1235" class="elsevierStylePara elsevierViewall">Patients with controlled cardiovascular symptoms and risk factors after diagnosis and therapeutic optimization by a cardiologist&#46;</p></span><span id="sec0320" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0340">Follow-up</span><p id="par1240" class="elsevierStylePara elsevierViewall">After initial diagnosis or CV event&#44; consultation at three and six months&#44; annually thereafter<a class="elsevierStyleCrossRef" href="#bib0535"><span class="elsevierStyleSup">42</span></a>&#58;<ul class="elsevierStyleList" id="lis0360"><li class="elsevierStyleListItem" id="lsti0995"><span class="elsevierStyleLabel">&#8226;</span><p id="par1245" class="elsevierStylePara elsevierViewall">Clinical evaluation&#44; lifestyle modification&#44; cardiovascular RF control and adherence to therapy&#59;</p></li><li class="elsevierStyleListItem" id="lsti1000"><span class="elsevierStyleLabel">&#8226;</span><p id="par1250" class="elsevierStylePara elsevierViewall">Routine exams&#58;</p></li></ul><ul class="elsevierStyleList" id="lis0365"><li class="elsevierStyleListItem" id="lsti1005"><span class="elsevierStyleLabel">&#8226;</span><p id="par1255" class="elsevierStylePara elsevierViewall">Basic laboratory evaluation&#59;</p></li><li class="elsevierStyleListItem" id="lsti1010"><span class="elsevierStyleLabel">&#8226;</span><p id="par1260" class="elsevierStylePara elsevierViewall">ECG at rest&#59;</p></li></ul><ul class="elsevierStyleList" id="lis0685"><li class="elsevierStyleListItem" id="lsti1015"><span class="elsevierStyleLabel">&#8226;</span><p id="par1265" class="elsevierStylePara elsevierViewall">TTE&#58; 1 year &#40;if previously abnormal&#41; or periodically &#40;every 3&#8211;5 years&#41;&#59;</p></li><li class="elsevierStyleListItem" id="lsti1020"><span class="elsevierStyleLabel">&#8226;</span><p id="par1270" class="elsevierStylePara elsevierViewall">Non-invasive imaging exam&#58; change in the level of symptoms or periodically &#40;every 3-5 years&#41; for ischemia assessment&#46;</p></li></ul></p></span></span></span><span id="sec0325" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0345">Arrhythmias and palpitations</span><span id="sec0330" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0350">Definition</span><p id="par1275" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">Bradycardia</span> is characterized by a HR &#60;60 bpm and can be caused by a dysfunction in the sinus node&#44; an atrioventricular block or a block in conduction&#46; <span class="elsevierStyleBold">Tachycardia</span> is characterized by a HR &#62;100 bpm and can be ventricular or supraventricular&#46;</p><p id="par1280" class="elsevierStylePara elsevierViewall">Palpitations result from an unconfortable perception of the heartbeat by the patient&#46; Two types of palpitations are identified&#58;<ul class="elsevierStyleList" id="lis0370"><li class="elsevierStyleListItem" id="lsti1025"><span class="elsevierStyleLabel">&#8226;</span><p id="par1285" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">Normal palpitations</span> &#8211; they occur due to exercise&#44; emotion&#44; stress&#44; or after ingestion of substances that increase adrenergic activity or decrease vagal activity&#59;</p></li><li class="elsevierStyleListItem" id="lsti1030"><span class="elsevierStyleLabel">&#8226;</span><p id="par1290" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">Abnormal palpitations</span> &#8211; they occur for no reason and can be fast or strong&#47;slow&#46; These palpitations may indicate cardiac arrhythmia&#46; However&#44; most people who have electrical conduction disturbances experience syncope&#44; and chest pain&#44; rather than palpitations&#46;<a class="elsevierStyleCrossRefs" href="#bib0550"><span class="elsevierStyleSup">45&#8211;49</span></a></p></li></ul></p></span><span id="sec0335" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0355">Differential diagnosis</span><span id="sec0340" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0360">Exams to be requested in an outpatient context</span><span id="sec0345" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0365">Laboratory evaluation&#58;</span><p id="par1295" class="elsevierStylePara elsevierViewall"><ul class="elsevierStyleList" id="lis0375"><li class="elsevierStyleListItem" id="lsti1035"><span class="elsevierStyleLabel">&#8226;</span><p id="par1300" class="elsevierStylePara elsevierViewall">Baseline laboratory assessment plus evaluation of the thyroid function and of potassium and magnesium levels<a class="elsevierStyleCrossRef" href="#bib0575"><span class="elsevierStyleSup">50</span></a>&#59;</p></li></ul></p></span><span id="sec0350" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0370">ECG at rest and Holter&#58;</span><p id="par1305" class="elsevierStylePara elsevierViewall"><ul class="elsevierStyleList" id="lis0380"><li class="elsevierStyleListItem" id="lsti1040"><span class="elsevierStyleLabel">&#8226;</span><p id="par1310" class="elsevierStylePara elsevierViewall">Immediate electrocardiographic monitoring if arrhythmic syncope is suspected&#46;<a class="elsevierStyleCrossRefs" href="#bib0575"><span class="elsevierStyleSup">50&#44;51</span></a></p></li></ul></p></span><span id="sec0355" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0375">Treadmill stress test to assess chronotropic incompetence or onset of conduction disorders on exertion<a class="elsevierStyleCrossRefs" href="#bib0575"><span class="elsevierStyleSup">50&#44;52</span></a>&#59;</span><span id="sec0360" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0380">Refer to TTE&#58;</span><p id="par1315" class="elsevierStylePara elsevierViewall"><ul class="elsevierStyleList" id="lis0385"><li class="elsevierStyleListItem" id="lsti1045"><span class="elsevierStyleLabel">&#8226;</span><p id="par1320" class="elsevierStylePara elsevierViewall">If there is known previous heart disease or when data are suggestive of structural and functional left ventricular &#40;LV&#41; heart disease&#46;<a class="elsevierStyleCrossRefs" href="#bib0575"><span class="elsevierStyleSup">50&#44;53</span></a></p></li></ul></p></span></span></span></span><span id="sec0365" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0385">Action plan in primary health care</span><span id="sec0370" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0390">Non-pharmacological and pharmacological treatment</span><p id="par1325" class="elsevierStylePara elsevierViewall"><ul class="elsevierStyleList" id="lis0390"><li class="elsevierStyleListItem" id="lsti1050"><span class="elsevierStyleLabel">&#8226;</span><p id="par1330" class="elsevierStylePara elsevierViewall">Bradycardia&#58; the dose of drugs that may be inducing bradycardia should be adjusted and secondary causes&#44; such as hypothyroidism&#44; should be excluded&#46;<a class="elsevierStyleCrossRef" href="#bib0565"><span class="elsevierStyleSup">48</span></a></p></li><li class="elsevierStyleListItem" id="lsti1055"><span class="elsevierStyleLabel">&#8226;</span><p id="par1335" class="elsevierStylePara elsevierViewall">In the context of supraventricular tachyarrhythmias&#44; antiarrhythmic drugs may play an important role in their control&#44; particularly in atrial fibrillation &#40;AF&#41; and in some specific arrhythmias&#46;<a class="elsevierStyleCrossRefs" href="#bib0565"><span class="elsevierStyleSup">48&#44;50</span></a></p></li><li class="elsevierStyleListItem" id="lsti1060"><span class="elsevierStyleLabel">&#8226;</span><p id="par1340" class="elsevierStylePara elsevierViewall">With the exception of BB&#44; currently available antiarrhythmic drugs are not effective in the primary treatment of patients with potentially fatal ventricular arrhythmias or in preventing sudden cardiac death&#46; Each drug has significant potential to cause adverse events&#44; including pro-arrhythmia&#46;<a class="elsevierStyleCrossRef" href="#bib0575"><span class="elsevierStyleSup">50</span></a></p></li></ul></p></span></span><span id="sec0375" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0395">When and how to refer to cardiology</span><span id="sec0380" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0400">Referral criteria</span><p id="par1345" class="elsevierStylePara elsevierViewall"><ul class="elsevierStyleList" id="lis0395"><li class="elsevierStyleListItem" id="lsti1065"><span class="elsevierStyleLabel">&#8226;</span><p id="par1350" class="elsevierStylePara elsevierViewall">Ventricular or supraventicular extrasystole&#58;</p></li></ul><ul class="elsevierStyleList" id="lis0400"><li class="elsevierStyleListItem" id="lsti1070"><span class="elsevierStyleLabel">&#8728;</span><p id="par1355" class="elsevierStylePara elsevierViewall">Evidence of cardiopathy associated with systolic LV dysfunction&#44; myocardial ischemia&#44; valve pathology&#44; or cardiomyopathies&#59;</p></li><li class="elsevierStyleListItem" id="lsti1075"><span class="elsevierStyleLabel">&#8728;</span><p id="par1360" class="elsevierStylePara elsevierViewall">Typical ECG abnormalities &#40;Wolff-Parkison-White&#44; long QT&#44; Brugada&#41;&#59;</p></li><li class="elsevierStyleListItem" id="lsti1080"><span class="elsevierStyleLabel">&#8728;</span><p id="par1365" class="elsevierStylePara elsevierViewall">Intense associated symptomatology&#59;</p></li><li class="elsevierStyleListItem" id="lsti1085"><span class="elsevierStyleLabel">&#8728;</span><p id="par1370" class="elsevierStylePara elsevierViewall">Complex or frequent ventricular premature beats &#40;&#62;5000 EVs&#47;24 h&#41;&#59;</p></li><li class="elsevierStyleListItem" id="lsti1090"><span class="elsevierStyleLabel">&#8728;</span><p id="par1375" class="elsevierStylePara elsevierViewall">Supraventricular premature beats &#40;&#8805;10&#47;hour&#41; in patients who remain symptomatic after a first therapeutic approach with a beta-blocker or at risk of developing AF&#46;</p></li></ul><ul class="elsevierStyleList" id="lis0690"><li class="elsevierStyleListItem" id="lsti1095"><span class="elsevierStyleLabel">&#8226;</span><p id="par1380" class="elsevierStylePara elsevierViewall">Bradycardia&#58;</p></li></ul><ul class="elsevierStyleList" id="lis0405"><li class="elsevierStyleListItem" id="lsti1100"><span class="elsevierStyleLabel">&#8728;</span><p id="par1385" class="elsevierStylePara elsevierViewall">In the context of syncope &#40;see syncope&#39;s chapter&#41;&#59;</p></li><li class="elsevierStyleListItem" id="lsti1105"><span class="elsevierStyleLabel">&#8728;</span><p id="par1390" class="elsevierStylePara elsevierViewall">When associated with dizziness or tiredness&#59;</p></li><li class="elsevierStyleListItem" id="lsti1110"><span class="elsevierStyleLabel">&#8728;</span><p id="par1395" class="elsevierStylePara elsevierViewall">Patients with pacemakers &#8211; for regular follow-up &#40;if they have missed the follow-up at device consultation&#41;&#46;</p></li></ul><ul class="elsevierStyleList" id="lis0695"><li class="elsevierStyleListItem" id="lsti1115"><span class="elsevierStyleLabel">&#8226;</span><p id="par1400" class="elsevierStylePara elsevierViewall">Supraventricular tachycardias&#58;</p></li></ul><ul class="elsevierStyleList" id="lis0410"><li class="elsevierStyleListItem" id="lsti1120"><span class="elsevierStyleLabel">&#8728;</span><p id="par1405" class="elsevierStylePara elsevierViewall">Documented and maintained supraventricular paroxysmal tachycardia&#59;</p></li><li class="elsevierStyleListItem" id="lsti1125"><span class="elsevierStyleLabel">&#8728;</span><p id="par1410" class="elsevierStylePara elsevierViewall">If associated with the presence of Wolff-Parkinson-White pattern&#59;</p></li><li class="elsevierStyleListItem" id="lsti1130"><span class="elsevierStyleLabel">&#8728;</span><p id="par1415" class="elsevierStylePara elsevierViewall">Atria flutter or AF &#40;see AF&#39;s chapter&#41;&#46;</p></li></ul><ul class="elsevierStyleList" id="lis0700"><li class="elsevierStyleListItem" id="lsti1135"><span class="elsevierStyleLabel">&#8226;</span><p id="par1420" class="elsevierStylePara elsevierViewall">Ventricular tachycardias on Holter&#58;</p></li></ul><ul class="elsevierStyleList" id="lis0415"><li class="elsevierStyleListItem" id="lsti1140"><span class="elsevierStyleLabel">&#8728;</span><p id="par1425" class="elsevierStylePara elsevierViewall">Sustained ventricular tachycardias &#40;&#62;30 seconds or symptomatic&#41; &#8211; refer to the emergency department&#59;</p></li><li class="elsevierStyleListItem" id="lsti1145"><span class="elsevierStyleLabel">&#8728;</span><p id="par1430" class="elsevierStylePara elsevierViewall">Non-sustained ventricular tachycardia&#44; even if asymptomatic&#44; if&#58;</p></li></ul><ul class="elsevierStyleList" id="lis0420"><li class="elsevierStyleListItem" id="lsti1150"><span class="elsevierStyleLabel">&#8226;</span><p id="par1435" class="elsevierStylePara elsevierViewall">Typical ECG abnormalities &#40;Wolff-Parkison-White&#44; long QT&#44; Brugada&#41;&#46;</p></li><li class="elsevierStyleListItem" id="lsti1155"><span class="elsevierStyleLabel">&#8226;</span><p id="par1440" class="elsevierStylePara elsevierViewall">Cardiac structural changes &#40;depressed function&#44; CAD&#44; valve disease&#44; myocardiopathy&#44; family history of sudden death&#41;&#46;</p></li></ul><ul class="elsevierStyleList" id="lis0705"><li class="elsevierStyleListItem" id="lsti1160"><span class="elsevierStyleLabel">&#8226;</span><p id="par1445" class="elsevierStylePara elsevierViewall">Palpitations&#58;</p></li></ul><ul class="elsevierStyleList" id="lis0425"><li class="elsevierStyleListItem" id="lsti1165"><span class="elsevierStyleLabel">&#8728;</span><p id="par1450" class="elsevierStylePara elsevierViewall">Patients with frequent or persistent palpitations&#59;</p></li><li class="elsevierStyleListItem" id="lsti1170"><span class="elsevierStyleLabel">&#8728;</span><p id="par1455" class="elsevierStylePara elsevierViewall">Sustained rapid palpitations&#59;</p></li><li class="elsevierStyleListItem" id="lsti1175"><span class="elsevierStyleLabel">&#8728;</span><p id="par1460" class="elsevierStylePara elsevierViewall">Significant associated symptoms&#58;</p></li></ul><ul class="elsevierStyleList" id="lis0430"><li class="elsevierStyleListItem" id="lsti1180"><span class="elsevierStyleLabel">&#8226;</span><p id="par1465" class="elsevierStylePara elsevierViewall">Pre-syncope&#47;syncope &#40;consider the situation context&#41;&#59;</p></li><li class="elsevierStyleListItem" id="lsti1185"><span class="elsevierStyleLabel">&#8226;</span><p id="par1470" class="elsevierStylePara elsevierViewall">Shortness of breath&#59;</p></li><li class="elsevierStyleListItem" id="lsti1190"><span class="elsevierStyleLabel">&#8226;</span><p id="par1475" class="elsevierStylePara elsevierViewall">Chest pain&#59;</p></li></ul><ul class="elsevierStyleList" id="lis0710"><li class="elsevierStyleListItem" id="lsti1195"><span class="elsevierStyleLabel">&#8728;</span><p id="par1480" class="elsevierStylePara elsevierViewall">Family history of recurrent syncope or sudden death&#59;</p></li><li class="elsevierStyleListItem" id="lsti1200"><span class="elsevierStyleLabel">&#8728;</span><p id="par1485" class="elsevierStylePara elsevierViewall">ECG or echocardiographic anomalies &#40;see above&#41;&#46;</p></li></ul></p></span></span><span id="sec0385" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0405">Follow-up plan in primary health care and re-referral criteria to cardiology consultation after discharge</span><p id="par1495" class="elsevierStylePara elsevierViewall">Follow-up will depend on the type of arrhythmia&#44; whether there is concomitant hospital follow-up&#44; whether a device has been implanted &#40;which requires specific follow-up&#41;&#44; or whether an antiarrhythmic drug has been prescribed&#46;<a class="elsevierStyleCrossRef" href="#bib0575"><span class="elsevierStyleSup">50</span></a></p></span></span><span id="sec0390" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0410">Atrial fibrillation</span><span id="sec0395" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0415">Definition</span><p id="par1505" class="elsevierStylePara elsevierViewall">Supraventricular arrhythmia&#44; characterized by irregular RR intervals and absence of P-wave on ECG &#40;duration&#62;30 s&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0595"><span class="elsevierStyleSup">54</span></a></p></span><span id="sec0400" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0420">Evaluation of the patient with atrial fibrillation in primary health care</span><p id="par1510" class="elsevierStylePara elsevierViewall"><ul class="elsevierStyleList" id="lis0445"><li class="elsevierStyleListItem" id="lsti1215"><span class="elsevierStyleLabel">&#8226;</span><p id="par1515" class="elsevierStylePara elsevierViewall">Clinical history&#44; comorbidities&#44; AF pattern&#44; thromboembolic risk&#44; symptoms<a class="elsevierStyleCrossRef" href="#bib0600"><span class="elsevierStyleSup">55</span></a>&#59;</p></li><li class="elsevierStyleListItem" id="lsti1220"><span class="elsevierStyleLabel">&#8226;</span><p id="par1520" class="elsevierStylePara elsevierViewall">Modified European Heart Rhythm Association scale of symptoms &#40;<a class="elsevierStyleCrossRef" href="#tbl0040">Table 8</a>&#41;<a class="elsevierStyleCrossRef" href="#bib0605"><span class="elsevierStyleSup">56</span></a>&#59;</p><elsevierMultimedia ident="tbl0040"></elsevierMultimedia></li><li class="elsevierStyleListItem" id="lsti1225"><span class="elsevierStyleLabel">&#8226;</span><p id="par1525" class="elsevierStylePara elsevierViewall">12-lead ECG<a class="elsevierStyleCrossRef" href="#bib0595"><span class="elsevierStyleSup">54</span></a>&#59;</p></li><li class="elsevierStyleListItem" id="lsti1230"><span class="elsevierStyleLabel">&#8226;</span><p id="par1530" class="elsevierStylePara elsevierViewall">Baseline laboratory evaluation plus ionogram and thyroid hormone levels<a class="elsevierStyleCrossRef" href="#bib0595"><span class="elsevierStyleSup">54</span></a>&#59;</p></li><li class="elsevierStyleListItem" id="lsti1235"><span class="elsevierStyleLabel">&#8226;</span><p id="par1535" class="elsevierStylePara elsevierViewall">TTE&#58; assessment of left atrium dimensions&#44; structural cardiopathy&#59;<a class="elsevierStyleCrossRef" href="#bib0595"><span class="elsevierStyleSup">54</span></a></p></li><li class="elsevierStyleListItem" id="lsti1240"><span class="elsevierStyleLabel">&#8226;</span><p id="par1540" class="elsevierStylePara elsevierViewall">Holter<a class="elsevierStyleCrossRef" href="#bib0595"><span class="elsevierStyleSup">54</span></a>&#59;</p></li><li class="elsevierStyleListItem" id="lsti1245"><span class="elsevierStyleLabel">&#8226;</span><p id="par1545" class="elsevierStylePara elsevierViewall">Non-invasive ischemia test &#40;MPS&#44; coronary angio-CT&#41; &#8211; in patients with suspected CAD<a class="elsevierStyleCrossRef" href="#bib0595"><span class="elsevierStyleSup">54</span></a>&#59;</p></li><li class="elsevierStyleListItem" id="lsti1250"><span class="elsevierStyleLabel">&#8226;</span><p id="par1550" class="elsevierStylePara elsevierViewall">Brain CT &#8211; in patients with suspected stroke&#46;<a class="elsevierStyleCrossRef" href="#bib0595"><span class="elsevierStyleSup">54</span></a></p></li></ul></p></span><span id="sec0405" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0425">Classification<a class="elsevierStyleCrossRef" href="#bib0595"><span class="elsevierStyleSup">54</span></a></span><p id="par1555" class="elsevierStylePara elsevierViewall"><ul class="elsevierStyleList" id="lis0450"><li class="elsevierStyleListItem" id="lsti1255"><span class="elsevierStyleLabel">&#8226;</span><p id="par1560" class="elsevierStylePara elsevierViewall">Paroxysmal AF&#58; ends spontaneously or with intervention up to seven days&#59;</p></li><li class="elsevierStyleListItem" id="lsti1260"><span class="elsevierStyleLabel">&#8226;</span><p id="par1565" class="elsevierStylePara elsevierViewall">Persistent AF&#58; AF lasting &#62;7 days&#44; including episodes terminated by electrical or pharmacological cardioversion&#59;</p></li><li class="elsevierStyleListItem" id="lsti1265"><span class="elsevierStyleLabel">&#8226;</span><p id="par1570" class="elsevierStylePara elsevierViewall">Long-term persistent AF&#58; continuous AF with duration &#8805;1 year&#44; subject to rhythm control strategy&#59;</p></li><li class="elsevierStyleListItem" id="lsti1270"><span class="elsevierStyleLabel">&#8226;</span><p id="par1575" class="elsevierStylePara elsevierViewall">Permanent AF&#58; long-term continuous AF under heart rate control strategy &#40;where the possibility of conversion to sinus rhythm is excluded&#41;&#46;</p></li></ul></p></span><span id="sec0410" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0430">Action plan in primary health care</span><span id="sec0415" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0435">Integrated approach to patient-centered atrial fibrillation<a class="elsevierStyleCrossRef" href="#bib0595"><span class="elsevierStyleSup">54</span></a></span><p id="par1580" class="elsevierStylePara elsevierViewall"><ul class="elsevierStyleList" id="lis0455"><li class="elsevierStyleListItem" id="lsti1275"><span class="elsevierStyleLabel">&#8226;</span><p id="par1585" class="elsevierStylePara elsevierViewall">A - Anticoagulation</p></li></ul><ul class="elsevierStyleList" id="lis0460"><li class="elsevierStyleListItem" id="lsti1280"><span class="elsevierStyleLabel">i&#46;</span><p id="par1590" class="elsevierStylePara elsevierViewall">Stroke risk assessment&#44; according to <a class="elsevierStyleCrossRef" href="#tbl0045">Table 9</a><a class="elsevierStyleCrossRef" href="#bib0610"><span class="elsevierStyleSup">57</span></a></p><elsevierMultimedia ident="tbl0045"></elsevierMultimedia></li></ul><ul class="elsevierStyleList" id="lis0465"><li class="elsevierStyleListItem" id="lsti1285"><span class="elsevierStyleLabel">&#8728;</span><p id="par1595" class="elsevierStylePara elsevierViewall">CHA<span class="elsevierStyleInf">2</span>DS<span class="elsevierStyleInf">2</span>-VASc <span class="elsevierStyleBold">score 0 in men and 1 in women</span>&#58;</p></li></ul><ul class="elsevierStyleList" id="lis0470"><li class="elsevierStyleListItem" id="lsti1290"><span class="elsevierStyleLabel">a&#46;</span><p id="par1600" class="elsevierStylePara elsevierViewall">No indication for antithrombotic therapy&#59;</p></li></ul><ul class="elsevierStyleList" id="lis0715"><li class="elsevierStyleListItem" id="lsti1295"><span class="elsevierStyleLabel">&#8728;</span><p id="par1605" class="elsevierStylePara elsevierViewall">CHA<span class="elsevierStyleInf">2</span>DS<span class="elsevierStyleInf">2</span>-VASc&#61;<span class="elsevierStyleBold">1 in men or &#61;2 in women</span>&#58;</p></li></ul><ul class="elsevierStyleList" id="lis0475"><li class="elsevierStyleListItem" id="lsti1300"><span class="elsevierStyleLabel">a&#46;</span><p id="par1610" class="elsevierStylePara elsevierViewall">Oral anticoagulant &#40;OAC&#41; should be considered &#40;IIa&#41;&#59;</p></li></ul><ul class="elsevierStyleList" id="lis0720"><li class="elsevierStyleListItem" id="lsti1305"><span class="elsevierStyleLabel">&#8728;</span><p id="par1615" class="elsevierStylePara elsevierViewall">CHA<span class="elsevierStyleInf">2</span>DS<span class="elsevierStyleInf">2</span>-VASc <span class="elsevierStyleBold">&#8805;2 in men or &#8805;3 in women</span>&#58;</p></li></ul><ul class="elsevierStyleList" id="lis0480"><li class="elsevierStyleListItem" id="lsti1310"><span class="elsevierStyleLabel">a&#46;</span><p id="par1620" class="elsevierStylePara elsevierViewall">OAC is recommended &#40;Ia&#41;&#59;</p></li></ul><ul class="elsevierStyleList" id="lis0725"><li class="elsevierStyleListItem" id="lsti1315"><span class="elsevierStyleLabel">ii&#46;</span><p id="par1625" class="elsevierStylePara elsevierViewall">Hemorrhagic risk assessment&#44; according to <a class="elsevierStyleCrossRef" href="#tbl0045">Table 9</a><a class="elsevierStyleCrossRef" href="#bib0615"><span class="elsevierStyleSup">58</span></a></p></li></ul><ul class="elsevierStyleList" id="lis0485"><li class="elsevierStyleListItem" id="lsti1320"><span class="elsevierStyleLabel">&#8728;</span><p id="par1630" class="elsevierStylePara elsevierViewall">Identify modifiable hemorrhagic risk factor&#59;</p></li><li class="elsevierStyleListItem" id="lsti1325"><span class="elsevierStyleLabel">&#8728;</span><p id="par1635" class="elsevierStylePara elsevierViewall">HAS-BLED&#8805;3&#58;</p></li></ul><ul class="elsevierStyleList" id="lis0490"><li class="elsevierStyleListItem" id="lsti1330"><span class="elsevierStyleLabel">a&#46;</span><p id="par1640" class="elsevierStylePara elsevierViewall">Control all modifiable hemorrhagic RF&#59;</p></li><li class="elsevierStyleListItem" id="lsti1335"><span class="elsevierStyleLabel">b&#46;</span><p id="par1645" class="elsevierStylePara elsevierViewall">Regular patient evaluation&#59;</p></li><li class="elsevierStyleListItem" id="lsti1340"><span class="elsevierStyleLabel"><span class="elsevierStyleBold">c&#46;</span></span><p id="par1650" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">No reason to discontinue or to not initiate anticoagulation&#46;</span></p></li></ul><ul class="elsevierStyleList" id="lis0730"><li class="elsevierStyleListItem" id="lsti1345"><span class="elsevierStyleLabel">iii&#46;</span><p id="par1655" class="elsevierStylePara elsevierViewall">Treatment selection<a class="elsevierStyleCrossRef" href="#bib0595"><span class="elsevierStyleSup">54</span></a></p></li></ul><ul class="elsevierStyleList" id="lis0495"><li class="elsevierStyleListItem" id="lsti1350"><span class="elsevierStyleLabel">&#8728;</span><p id="par1660" class="elsevierStylePara elsevierViewall">DOACs are recommended as 1<span class="elsevierStyleSup">st</span> line</p></li><li class="elsevierStyleListItem" id="lsti1355"><span class="elsevierStyleLabel">&#8728;</span><p id="par1665" class="elsevierStylePara elsevierViewall">Vitamin K antagonist &#8211; as DOAC are contraindicated in patients with&#58;</p></li></ul><ul class="elsevierStyleList" id="lis0500"><li class="elsevierStyleListItem" id="lsti1360"><span class="elsevierStyleLabel">a&#46;</span><p id="par1670" class="elsevierStylePara elsevierViewall">Mechanical valve prostheses&#59;</p></li><li class="elsevierStyleListItem" id="lsti1365"><span class="elsevierStyleLabel">b&#46;</span><p id="par1675" class="elsevierStylePara elsevierViewall">Moderate-severe mitral stenosis&#46;</p></li></ul><ul class="elsevierStyleList" id="lis0735"><li class="elsevierStyleListItem" id="lsti1370"><span class="elsevierStyleLabel">&#8226;</span><p id="par1680" class="elsevierStylePara elsevierViewall">B - Symptom control<a class="elsevierStyleCrossRef" href="#bib0595"><span class="elsevierStyleSup">54</span></a></p></li></ul><ul class="elsevierStyleList" id="lis0505"><li class="elsevierStyleListItem" id="lsti1375"><span class="elsevierStyleLabel">i&#46;</span><p id="par1685" class="elsevierStylePara elsevierViewall">Heart rate control&#58;</p></li></ul><ul class="elsevierStyleList" id="lis0510"><li class="elsevierStyleListItem" id="lsti1380"><span class="elsevierStyleLabel">&#8728;</span><p id="par1690" class="elsevierStylePara elsevierViewall">Evaluation of comorbidities</p></li></ul><ul class="elsevierStyleList" id="lis0515"><li class="elsevierStyleListItem" id="lsti1385"><span class="elsevierStyleLabel">a&#46;</span><p id="par1695" class="elsevierStylePara elsevierViewall">None or HT or HFpEF&#58; BB or non-dihydropiridine CCB &#40;verapamil&#44; diltiazem&#41;&#59;</p></li><li class="elsevierStyleListItem" id="lsti1390"><span class="elsevierStyleLabel">b&#46;</span><p id="par1700" class="elsevierStylePara elsevierViewall">HFrEF&#58; BB&#59;</p></li><li class="elsevierStyleListItem" id="lsti1395"><span class="elsevierStyleLabel">c&#46;</span><p id="par1705" class="elsevierStylePara elsevierViewall">Severe COPD or asthma&#58; non-dihydropiridine CCB &#40;verapamil&#44; diltiazem&#41;&#59;</p></li><li class="elsevierStyleListItem" id="lsti1400"><span class="elsevierStyleLabel">d&#46;</span><p id="par1710" class="elsevierStylePara elsevierViewall">Pre-excited AF&#47;Atrial flutter&#58; ablation&#46;</p></li></ul><ul class="elsevierStyleList" id="lis0740"><li class="elsevierStyleListItem" id="lsti1405"><span class="elsevierStyleLabel">&#8728;</span><p id="par1715" class="elsevierStylePara elsevierViewall">Combination of various drugs&#44; including digoxin and amiodarone&#59;</p></li></ul><ul class="elsevierStyleList" id="lis0745"><li class="elsevierStyleListItem" id="lsti1410"><span class="elsevierStyleLabel">ii&#46;</span><p id="par1720" class="elsevierStylePara elsevierViewall">Heart rhythm control&#58;</p></li></ul><ul class="elsevierStyleList" id="lis0520"><li class="elsevierStyleListItem" id="lsti1415"><span class="elsevierStyleLabel">&#8728;</span><p id="par1725" class="elsevierStylePara elsevierViewall">Propafenone &#40;patients without structural cardiopathy&#41;&#59; Flecainide may be an alternative after cardiology assessment&#59;</p></li><li class="elsevierStyleListItem" id="lsti1420"><span class="elsevierStyleLabel">&#8728;</span><p id="par1730" class="elsevierStylePara elsevierViewall">Amiodarone &#40;patients with structural cardiopathy&#41;&#59;</p></li><li class="elsevierStyleListItem" id="lsti1425"><span class="elsevierStyleLabel">&#8728;</span><p id="par1735" class="elsevierStylePara elsevierViewall">Electrical cardioversion&#46;</p></li></ul><ul class="elsevierStyleList" id="lis0750"><li class="elsevierStyleListItem" id="lsti1430"><span class="elsevierStyleLabel">&#8226;</span><p id="par1740" class="elsevierStylePara elsevierViewall">C - Control comorbidities and RF<a class="elsevierStyleCrossRef" href="#bib0595"><span class="elsevierStyleSup">54</span></a>&#58;</p></li></ul><ul class="elsevierStyleList" id="lis0525"><li class="elsevierStyleListItem" id="lsti1435"><span class="elsevierStyleLabel">&#8728;</span><p id="par1745" class="elsevierStylePara elsevierViewall">HT&#44; type 2 diabetes&#44; obesity&#44; sleep apnea syndrome&#44; dyslipidemia&#44; HF&#44; CAD&#44; COPD&#44; severe asthma&#44; advanced age&#44; genetic alterations&#44; physical inactivity&#44; alcohol and tobacco consumption&#59;</p></li><li class="elsevierStyleListItem" id="lsti1440"><span class="elsevierStyleLabel">&#8728;</span><p id="par1750" class="elsevierStylePara elsevierViewall">Aggressive control of risk factors&#44; lifestyle modification&#59;</p></li><li class="elsevierStyleListItem" id="lsti1445"><span class="elsevierStyleLabel">&#8728;</span><p id="par1755" class="elsevierStylePara elsevierViewall">Clinical stabilization of comorbidities&#46;</p></li></ul></p></span></span><span id="sec0420" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0440">When and how to refer to cardiology</span><span id="sec0425" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0445">Referral criteria<a class="elsevierStyleCrossRefs" href="#bib0595"><span class="elsevierStyleSup">54&#44;55</span></a></span><p id="par1760" class="elsevierStylePara elsevierViewall"><ul class="elsevierStyleList" id="lis0530"><li class="elsevierStyleListItem" id="lsti1450"><span class="elsevierStyleLabel">&#8226;</span><p id="par1765" class="elsevierStylePara elsevierViewall">Patients with indication for rhythm control strategy&#44; unresponsive to pharmacological therapy &#40;for possible electrical cardioversion&#41;&#59;</p></li><li class="elsevierStyleListItem" id="lsti1455"><span class="elsevierStyleLabel">&#8226;</span><p id="par1770" class="elsevierStylePara elsevierViewall">Patients who remain symptomatic under appropriate therapy and with controlled ventricular response&#59;</p></li><li class="elsevierStyleListItem" id="lsti1460"><span class="elsevierStyleLabel">&#8226;</span><p id="par1775" class="elsevierStylePara elsevierViewall">Patients with hard to control ventricular response &#40;mean heart rate in Holter 24 hours &#62;110 bpm after therapy optimization or bradycardia-tachycardia syndrome&#41;&#59;</p></li><li class="elsevierStyleListItem" id="lsti1465"><span class="elsevierStyleLabel">&#8226;</span><p id="par1780" class="elsevierStylePara elsevierViewall">Patient with mean HR&#60;45&#47;min&#44; documentation of pauses &#62;3&#46;0 seconds during the day&#44; or &#62;4&#46;0 seconds at night&#59;</p></li><li class="elsevierStyleListItem" id="lsti1470"><span class="elsevierStyleLabel">&#8226;</span><p id="par1785" class="elsevierStylePara elsevierViewall">Symptoms associated with AF&#58; angina&#44; HF&#44; syncope&#44; hypotension&#59;</p></li><li class="elsevierStyleListItem" id="lsti1475"><span class="elsevierStyleLabel">&#8226;</span><p id="par1790" class="elsevierStylePara elsevierViewall">Structural cardiopathy associated with AF&#44; unable to control in PHC&#59;</p></li><li class="elsevierStyleListItem" id="lsti1480"><span class="elsevierStyleLabel">&#8226;</span><p id="par1795" class="elsevierStylePara elsevierViewall">Complications associated with treatment&#58;</p></li></ul><ul class="elsevierStyleList" id="lis0535"><li class="elsevierStyleListItem" id="lsti1485"><span class="elsevierStyleLabel">&#8728;</span><p id="par1800" class="elsevierStylePara elsevierViewall">Thromboembolic&#58; major hemorrhage&#44; thromboembolism&#44; international normalized ratio outside therapeutic target&#46;</p></li><li class="elsevierStyleListItem" id="lsti1490"><span class="elsevierStyleLabel">&#8728;</span><p id="par1805" class="elsevierStylePara elsevierViewall">Cardiac arrhythmia&#58; AF with rapid ventricular response&#44; tachycardia&#44; or ventricular fibrillation&#46;</p></li></ul></p></span><span id="sec0430" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0450">Follow-up plan in primary health care</span><p id="par1810" class="elsevierStylePara elsevierViewall">The management of patients with AF should be multidisciplinary with an effective communication between primary and secondary health care&#46; The goals of follow-up for patients with AF in PHC are<a class="elsevierStyleCrossRefs" href="#bib0595"><span class="elsevierStyleSup">54&#44;55</span></a>&#58;<ul class="elsevierStyleList" id="lis0540"><li class="elsevierStyleListItem" id="lsti1495"><span class="elsevierStyleLabel">&#8226;</span><p id="par1815" class="elsevierStylePara elsevierViewall">Prevent stoke&#59;</p></li><li class="elsevierStyleListItem" id="lsti1500"><span class="elsevierStyleLabel">&#8226;</span><p id="par1820" class="elsevierStylePara elsevierViewall">Educate the patient about their condition&#58;</p></li></ul><ul class="elsevierStyleList" id="lis0545"><li class="elsevierStyleListItem" id="lsti1505"><span class="elsevierStyleLabel">&#8728;</span><p id="par1825" class="elsevierStylePara elsevierViewall">Establish goals and&#47;or action plan&#44; management of exacerbations&#59;</p></li></ul><ul class="elsevierStyleList" id="lis0755"><li class="elsevierStyleListItem" id="lsti1510"><span class="elsevierStyleLabel">&#8226;</span><p id="par1830" class="elsevierStylePara elsevierViewall">Optimize the treatment of symptoms such as heart rate and heart rhythm control&#59;</p></li><li class="elsevierStyleListItem" id="lsti1515"><span class="elsevierStyleLabel">&#8226;</span><p id="par1835" class="elsevierStylePara elsevierViewall">Control all cardiovascular risk factors and comorbidities&#59;</p></li><li class="elsevierStyleListItem" id="lsti1520"><span class="elsevierStyleLabel">&#8226;</span><p id="par1840" class="elsevierStylePara elsevierViewall">Encourage lifestyle changes&#58;</p></li></ul><ul class="elsevierStyleList" id="lis0550"><li class="elsevierStyleListItem" id="lsti1525"><span class="elsevierStyleLabel">&#8728;</span><p id="par1845" class="elsevierStylePara elsevierViewall">Smoking cessation&#44; weight loss&#44; physical activity&#59;</p></li></ul><ul class="elsevierStyleList" id="lis0760"><li class="elsevierStyleListItem" id="lsti1530"><span class="elsevierStyleLabel">&#8226;</span><p id="par1850" class="elsevierStylePara elsevierViewall">Promote therapeutic adherence&#59;</p></li><li class="elsevierStyleListItem" id="lsti1535"><span class="elsevierStyleLabel">&#8226;</span><p id="par1855" class="elsevierStylePara elsevierViewall">Monitor diagnostic exams &#40;according to <a class="elsevierStyleCrossRef" href="#tbl0050">Table 10</a>&#41;&#46;</p><elsevierMultimedia ident="tbl0050"></elsevierMultimedia></li></ul></p></span></span></span><span id="sec0435" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0455">Conclusion</span><p id="par1860" class="elsevierStylePara elsevierViewall">This document does not contain official guidelines but should be viewed rather as an additional tool for the correct referral of patients&#46; Thus&#44; local validation of these recommendations with the referral hospital and the primary health care network is recommended&#46; Although the references cited are based mainly on guidelines from international scientific societies&#44; this document does not intend to be a summary of those guidelines nor does it aim to replace them&#46; On the contrary&#44; it aims to put these recommendations into perspective&#44; taking into account daily clinical practice&#44; especially considering the limitations of access to diagnostic exams and the particularities of the Portuguese national referral network&#46;</p></span><span id="sec0440" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0460">Conflicts of interest</span><p id="par1865" class="elsevierStylePara elsevierViewall">Rui Baptista has received fees for consultancy services and congress attendance from AstraZeneca&#44; Janssen&#44; Ferrer&#44; Bial&#44; Bayer&#44; Novartis&#44; Servier&#44; Medinfar&#44; Jaba-Recordati&#44; Boehringer-Ingelheim&#44; Pfizer&#44; Bristol Myers-Squibb e Vifor Pharma&#46; Silvia Monteiro has received advisory board participation fees from Astrazeneca&#44; Amgen and Bayer in the areas of chronic coronary syndromes and atrial fibrillation and is a subinvestigator in the clinical trials RE-LY&#44; ENGAGE AF-TIMI 48&#44; EMPA-REG OUTCOME&#44; IMPROVE-IT&#44; FOURIER&#44; ODYSSEY OUTCOMES&#44; VESALIUS&#44; CAROLINA and CARMELINA&#46; Sara Gon&#231;alves has received consultant fees from AstraZeneca and Servier and speaker fees from Bial and Novartis&#46; Tiago Maricoto&#44; Jordana Dias&#44; Helena Febra and Victor Gil have no conflicts of interest to declare&#46;</p></span><span id="sec0445" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0465">Funding</span><p id="par1870" class="elsevierStylePara elsevierViewall">Financial support for the preparation of this article was provided by <span class="elsevierStyleGrantSponsor" id="gs1">AstraZeneca</span>&#46; AstraZeneca had no role in the writing of the report and in the decision to submit the article for publication&#46;</p></span></span>"
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    "fechaRecibido" => "2021-09-16"
    "fechaAceptado" => "2022-01-10"
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          "clase" => "keyword"
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            0 => "Hospital referral"
            1 => "Cardiology consultation"
            2 => "Primary health care"
            3 => "Chronic coronary syndrome"
            4 => "Heart Failure"
            5 => "Syncope"
            6 => "Arrhythmias"
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          "palabras" => array:10 [
            0 => "Referencia&#231;&#227;o hospitalar"
            1 => "Consulta de Cardiologia"
            2 => "Cuidados de Sa&#250;de Prim&#225;rios"
            3 => "S&#237;ndrome coron&#225;ria cr&#243;nica"
            4 => "Insufici&#234;ncia card&#237;aca"
            5 => "S&#237;ncope"
            6 => "Arritmias"
            7 => "Doen&#231;a valvular"
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      "en" => array:2 [
        "titulo" => "Abstract"
        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">In Portugal&#44; up to 38&#37; of the population has cardiovascular disease&#44; which highlights the importance of primary health care &#40;PHC&#41; in its management&#46;</p><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Adequate management of people with cardiovascular disease often requires hospital referral for a cardiology consultation&#46; However&#44; it is not always easy to ascertain which situations should be referred&#44; especially given that PHC does not have access to all diagnostic exams recommended by international guidelines&#44; such as natriuretic peptides in heart failure or computed tomography coronary angiogram in chronic coronary syndromes&#44; among others&#46;</p><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">The aim of this document is to describe a practical approach to the most frequent heart diseases that may require a referral for a hospital cardiology consultation&#46; Thus&#44; in the different chapters&#44; the recommendations for referral are highlighted generically according to group of disease&#44; as well as&#44; albeit briefly&#44; the initial clinical approach within the scope of PHC for a differential diagnosis and more efficient follow-up&#46;</p><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">A modified Metaplan methodology was used&#46; A panel of 4 cardiology specialists and 3 specialists in General and Family Medicine developed this document&#44; which should not be taken as an official guideline&#44; but as additional guidance for the correct referral of patients&#46; It is therefore advisable to validate these recommendations locally with the referral hospital&#44; as well as to be aware of the respective international and national guidelines&#46;</p></span>"
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      "pt" => array:2 [
        "titulo" => "Resumo"
        "resumen" => "<span id="abst0010" class="elsevierStyleSection elsevierViewall"><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Em Portugal&#44; at&#233; 38&#37; da popula&#231;&#227;o sofre de doen&#231;a cardiovascular&#44; o que salienta a import&#226;ncia dos cuidados de sa&#250;de prim&#225;rios &#40;CSP&#41; na sua gest&#227;o&#46;</p><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">A gest&#227;o adequada da pessoa com doen&#231;a cardiovascular obriga frequentemente &#224; referencia&#231;&#227;o hospitalar para consulta de cardiologia&#46; Contudo&#44; nem sempre &#233; f&#225;cil distinguir quais as situa&#231;&#245;es mais prementes&#44; principalmente tendo em conta que os CSP n&#227;o t&#234;m acesso a todos os exames complementares de diagn&#243;stico recomendados pelas <span class="elsevierStyleItalic">guidelines</span> internacionais&#44; como por exemplo p&#233;ptidos natriur&#233;ticos na insufici&#234;ncia card&#237;aca ou angiografia por tomografia computorizada card&#237;aca nas s&#237;ndromes coron&#225;rias cr&#243;nicas&#44; entre outros&#46;</p><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">O objetivo deste documento &#233; descrever uma abordagem pr&#225;tica &#224;s patologias do foro cardiol&#243;gico mais frequentes que podem requerer uma referencia&#231;&#227;o para consulta hospitalar de cardiologia&#46; Assim&#44; nos diferentes cap&#237;tulos s&#227;o destacadas as recomenda&#231;&#245;es de referencia&#231;&#227;o de forma gen&#233;rica&#44; por grupo de patologias&#44; bem como&#44; ainda que de forma sucinta&#44; a abordagem cl&#237;nica inicial no &#226;mbito dos CSP para um diagn&#243;stico diferencial e acompanhamento cr&#243;nico mais eficiente&#46;</p><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">Foi utilizada uma metodologia Metaplan modificada reunindo um painel de quatro especialistas em cardiologia e tr&#234;s especialistas em medicina geral e familiar que desenvolveram este documento&#44; o qual deve ser entendido n&#227;o como uma norma oficial&#44; mas sim como um instrumento de orienta&#231;&#227;o adicional para o correto encaminhamento dos doentes&#46; &#201; por isso aconselhada a valida&#231;&#227;o local destas recomenda&#231;&#245;es com o hospital de refer&#234;ncia&#44; bem como a leitura das respetivas <span class="elsevierStyleItalic">guidelines</span> internacionais e nacionais&#46;</p></span>"
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          "en" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Diagnostic algorithm and classification of the type of heart failure&#46;<a class="elsevierStyleCrossRef" href="#bib0375"><span class="elsevierStyleSup">10</span></a><span class="elsevierStyleSup">a</span>The key structural changes &#40;left atrium dilation and&#47;or left ventricular hypertrophy&#41; are characterized by LAVI&#62;34 mL&#47;m<span class="elsevierStyleSup">2</span> or an LVMI&#8805;115 g&#47;m<span class="elsevierStyleSup">2</span> in men and &#8805;95 g&#47;m<span class="elsevierStyleSup">2</span> in women or relative wall thickness &#62;0&#46;42&#46; The key functional changes are an E&#47;e&#8217; at rest &#8805;9&#44; PA systolic pressure &#62;35 mmHg and a TR velocity at rest &#62;2&#46;8 m&#47;s&#46; AF&#58; atrial fibrillation&#59; BNP&#58; B-type natriuretic peptide&#59; CAD&#58; coronary artery disease&#59; COPD&#58; chronic obstructive pulmonary disease&#59; ECG&#58; electrocardiogram&#59; HF&#58; heart failure&#59; LAVI&#58; left atrial volume index&#59; LVMI&#58; left ventricular mass index&#59; MI&#58; myocardial infarction&#59; NT-proBNP&#58; N-terminal fragment of type B natriuretic peptide&#59; OSAS&#58; obstructive sleep apnea syndrome&#59; PA&#58; pulmonary arterial&#59; T2DM&#58; type 2 diabetes&#59; TR&#58; tricuspid regurgitation&#46;</p>"
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          "en" => "<p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">Suggested therapeutic regimen for the management of hypertension&#46;<a class="elsevierStyleCrossRef" href="#bib0480"><span class="elsevierStyleSup">31</span></a><span class="elsevierStyleSup">a</span>CKD is defined as eGFR&#60;60 ml&#47;min&#47;1&#46;72 m<span class="elsevierStyleSup">2</span> with or without proteinuria&#59; <span class="elsevierStyleSup">b</span>preferential use of loop diuretics if eGFR&#60;30 ml&#47;min&#47;1&#46;72 m<span class="elsevierStyleSup">2</span>&#44; due to thiazide diuretics or similar being much less effective when eGFR is reduced to these levels&#59; <span class="elsevierStyleSup">c</span>caution&#58; risk of hyperkalemia with spironolactone&#44; especially when eGFR is less than 45 ml&#47;min&#47;1&#46;72 m<span class="elsevierStyleSup">2</span> or when basal kalemia &#8805;4&#46;5 mmol&#47;L&#46; ACEi&#58; angiotensin converting enzyme inhibitor&#59; AMI&#58; acute myocardial infarction&#59; ARB&#58; angiotensin receptor blocker&#59; BP&#58; blood pressure&#59; CCB&#58; calcium channel blocker&#59; CKD&#58; chronic kidney disease&#59; eGFR&#58; estimated glomerular filtration rate&#59; HF&#58; heart failure&#46;</p>"
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          "leyenda" => "<p id="spar0175" class="elsevierStyleSimplePara elsevierViewall">ACC&#47;AHA&#58; American Colleage of Cardiology&#47;American Heart Association&#59; HF&#58; Heart Failure&#59; NYHA&#58; New York Heart Association</p>"
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                  \t\t\t\t">ACC&#47;AHA stages</td><td class="td" title="\n
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                  \t\t\t\t">NYHA functional classification</td></tr><tr title="table-row"><td class="td-with-role" title="\n
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                  \t\t\t\t"><span class="elsevierStyleBold">Stage A</span>&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">Risk of developing HF&#44; with no structural cardiac changes or symptoms&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"><span class="elsevierStyleBold">Stage B</span>&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">Structural heart disease with no signs or symptoms&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t">Symptomatic with minimal physical activity&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t\ttop\n
                  \t\t\t\t">Refractory heart failure requiring specialized intervention&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"><span class="elsevierStyleBold">Class IV</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">Symptomatic at rest&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
              ]
              "imagenFichero" => array:1 [
                0 => "xTab3184000.png"
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            ]
          ]
        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0170" class="elsevierStyleSimplePara elsevierViewall">Classification of Heart Failure regarding cardiac structural changes &#40;ACC&#47;AHA&#41; and function &#40;NYHA&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0465"><span class="elsevierStyleSup">28</span></a></p>"
        ]
      ]
      3 => array:8 [
        "identificador" => "tbl0010"
        "etiqueta" => "Table 2"
        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "detalles" => array:1 [
          0 => array:3 [
            "identificador" => "at2"
            "detalle" => "Table "
            "rol" => "short"
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        ]
        "tabla" => array:2 [
          "leyenda" => "<p id="spar0070" class="elsevierStyleSimplePara elsevierViewall">CV&#58; cardiovascular&#59; CVD&#58; cardiovascular disease&#59; CKD&#58; chronic kidney disease&#59; DBP&#58; diastolic blood pressure&#59; HT&#58; hypertension&#59; RF&#58; risk factors&#59; SBP&#58; systolic blood pressure&#59; TOD&#58; target organ damage&#46;</p>"
          "tablatextoimagen" => array:1 [
            0 => array:1 [
              "tablaImagen" => array:1 [
                0 => array:4 [
                  "imagenFichero" => "fx1.jpeg"
                  "imagenAlto" => 1634
                  "imagenAncho" => 2667
                  "imagenTamanyo" => 392426
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          ]
        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0065" class="elsevierStyleSimplePara elsevierViewall">Stratification of total CV risk in low &#40;yellow&#41;&#44; moderate &#40;orange&#41;&#44; high &#40;red&#41; and very high &#40;dark red&#41; risk categories according to SBP and DBP&#46;<a class="elsevierStyleCrossRef" href="#bib0480"><span class="elsevierStyleSup">31</span></a></p>"
        ]
      ]
      4 => array:8 [
        "identificador" => "tbl0015"
        "etiqueta" => "Table 3"
        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "detalles" => array:1 [
          0 => array:3 [
            "identificador" => "at3"
            "detalle" => "Table "
            "rol" => "short"
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        ]
        "tabla" => array:2 [
          "leyenda" => "<p id="spar0080" class="elsevierStyleSimplePara elsevierViewall">ECG&#58; electrocardiogram&#59; HF&#58; heart failure&#59; IMT&#58; Intima-media thickness&#59; LVH&#58; left ventricular hypertrophy&#59; RF&#58; risk factors&#59; TOD&#58; target organ damage&#59; TTE&#58; transthoracic echocardiogram&#46;</p>"
          "tablatextoimagen" => array:2 [
            0 => array:2 [
              "tabla" => array:1 [
                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td-with-role" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t ; entry_with_role_rowhead " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Recommended exams for all hypertensive patients&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><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">&#8226; Basic laboratory evaluation&#59;&#8226; Serum potassium and sodium&#59;&#8226; Serum uric acid&#59;&#8226; Urine analysis&#58; microscopic examination&#44; proteinuria by dipstick test<span class="elsevierStyleItalic">&#44;</span> microalbuminuria test&#59;&#8226; 12-lead ECG&#59;&#8226; Ambulatory blood pressure monitoring&#44; if available&#44; for diagnosis and treatment surveillance&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
              ]
              "imagenFichero" => array:1 [
                0 => "xTab3183999.png"
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            ]
            1 => array:2 [
              "tabla" => array:1 [
                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " colspan="2" align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Recommended exams in specific populations for TOD research</th></tr></thead><tbody title="tbody"><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">Chest X-ray&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">Clinical suspicion of cardiac and&#47;or pulmonary involvementDilation or aortic aneurysm &#40;if TTE not available&#41;Suspected coarctation of the aorta&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">Transthoracic echocardiogram &#40;TTE&#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">Signs of LVH on ECG or in patients with clinical suspicion of HF&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">Albuminuria&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">Hypertensive patients with diabetes&#44; metabolic syndrome&#44; or with two or more RFNormal values &#60;30 mg&#47;24 h&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">Carotid echo&#47;doppler&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">Carotid murmur&#44; signs of cerebrovascular disease&#44; atherosclerotic disease in other areas&#46;IMT values &#62;0&#46;9 mm and&#47;or atherosclerotic plaques&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">Renal echo&#47;doppler&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">Patients with abdominal masses or abdominal murmur&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
              ]
              "imagenFichero" => array:1 [
                0 => "xTab3184006.png"
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        "descripcion" => array:1 [
          "en" => "<p id="spar0075" class="elsevierStyleSimplePara elsevierViewall">Recommended exams<a class="elsevierStyleCrossRefs" href="#bib0470"><span class="elsevierStyleSup">29&#44;31</span></a></p>"
        ]
      ]
      5 => array:8 [
        "identificador" => "tbl0020"
        "etiqueta" => "Table 4"
        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "detalles" => array:1 [
          0 => array:3 [
            "identificador" => "at4"
            "detalle" => "Table "
            "rol" => "short"
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        ]
        "tabla" => array:2 [
          "leyenda" => "<p id="spar0090" class="elsevierStyleSimplePara elsevierViewall">AF&#58; atrial fibrillation&#59; AV&#58; atrio-ventricular&#59; BBB&#58; bundle branch block&#59; ECG&#58; electrocardiogram&#59; VT&#58; ventricular tachycardia&#46;</p>"
          "tablatextoimagen" => array:1 [
            0 => array:2 [
              "tabla" => array:1 [
                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td-with-role" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col">Reflex syncope&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col">Syncope due to orthostatic hypotension&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col">Cardiac syncope&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><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">&#8226; Long history of recurrent syncope&#44; particularly occurring before 40 years of age&#59;&#8226; After unpleasant vision&#44; sound&#44; smell or pain&#59;&#8226; Prolonged orthostatism&#59;&#8226; During the meal&#59;&#8226; To be in crowded and&#47;or hot places&#59;&#8226; Autonomic activation before syncope&#58; paleness&#44; perspiration and&#47;or nausea&#47;vomiting&#59;&#8226; With rotation of the head or pressure in the carotid sinus &#40;such as in tumors&#44; shaving&#44; tight collars&#41;&#59;&#8226; Absence of heart disease&#46;&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">&#8226; While or after standing&#59;&#8226; Prolonged orthostatism&#59;&#8226; Standing after exertion&#59;&#8226; Postprandial hypotension&#59;&#8226; Temporal relationship with onset or alteration of the dosage of vasodepressor or diuretic drugs leading to hypotension&#59;&#8226; Presence of autonomic neuropathy or Parkinson&#39;s disease&#46;&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">&#8226; During exertion or in supine position&#59;&#8226; Palpitations of sudden onset immediately followed by syncope&#59;&#8226; Family history of unexplained sudden death at an early age&#59;&#8226; Presence of structural heart disease &#40;left ventricular dysfunction&#59; moderate or severe valvular disease&#59; cardiomyopathies&#59; pulmonary hypertension&#41;&#59;&#8226; Presence of coronary artery disease&#46;<span class="elsevierStyleBold">ECG findings suggestive of arrhythmic syncope&#58;</span>&#8226; Bifascicular block &#40;defined as left or right BBB combined with left anterior or posterior fascicular block&#41;&#59;&#8226; Other intraventricular conduction anomalies &#40;QRS duration &#8805;0&#46;12 s&#41;&#59;&#8226; Mobitz I second degree atrio-ventricular &#40;AV&#41; block and 1st degree AV block with markedly prolonged PR interval&#59;&#8226; Mild asymptomatic inadequate sinus bradycardia &#40;40-50 bpm&#41; or slow AF &#40;40-50 bpm&#41; in the absence of negative chronotropic drugs&#59;&#8226; Non-sustained VT&#59;&#8226; Pre-excited QRS complexes &#40;Wolff-Parkinson-White&#41;&#59;&#8226; Long or short QT intervals&#59;&#8226; Early repolarization&#59;&#8226; Elevation of the ST segment with type 1 morphology on the V1-V3 leads &#40;Brugada pattern&#41;&#59;&#8226; Negative T waves on the right precordial leads&#44; epsilon waves suggestive of arrhythmogenic right ventricle dysplasia&#59;&#8226; Left ventricular hypertrophy suggesting hypertrophic cardiomyopathy&#46;<span class="elsevierStyleBold">TTE findings suggestive of cardiac syncope &#40;non-exhaustive list&#41;&#58;</span>&#8226; Obstructive valvular disease&#59;&#8226; Cardiomyopathy pattern&#59;&#8226; Left or right ventricular dysfunction&#59;&#8226; Pulmonary hypertension&#59;&#8226; Changes in segmental kinetics suggestive of ischemia&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
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              "imagenFichero" => array:1 [
                0 => "xTab3184003.png"
              ]
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          ]
        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0085" class="elsevierStyleSimplePara elsevierViewall">Signs and symptoms suggestive of reflex etiology&#44; orthostatic hypotension or cardiac&#46;<a class="elsevierStyleCrossRef" href="#bib0490"><span class="elsevierStyleSup">33</span></a></p>"
        ]
      ]
      6 => array:8 [
        "identificador" => "tbl0025"
        "etiqueta" => "Table 5"
        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "detalles" => array:1 [
          0 => array:3 [
            "identificador" => "at5"
            "detalle" => "Table "
            "rol" => "short"
          ]
        ]
        "tabla" => array:2 [
          "leyenda" => "<p id="spar0100" class="elsevierStyleSimplePara elsevierViewall">ACEi&#58; angiotensin converting enzyme inhibitor&#59; ARB&#58; angiotensin receptor blocker&#59; CCB&#58; calcium channel blocker&#59; Od&#58; daily&#59; Tid&#58; three times a day&#46;</p>"
          "tablatextoimagen" => array:1 [
            0 => array:2 [
              "tabla" => array:1 [
                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " colspan="3" align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Reflex syncope</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="3" align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Education&#44; lifestyle changes and reassurance as to the benign nature of this condition</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="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleBold">Severe&#47;recurrent type</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="elsevierStyleBold">Low BP phenotype</span><span class="elsevierStyleBold">Younger patients</span>&#8226; Fludrocortisone&#8226; Midodrine&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"><span class="elsevierStyleBold">Prodromes</span><span class="elsevierStyleBold">Younger patients</span>&#58; Counter-pressure maneuvers&#59; Orthostatic training&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"><span class="elsevierStyleBold">Hypotensive drugs</span>Younger and younger or older patientsSuspend&#47;reduce hypotensive drugs&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="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleBold">Syncope due to orthostatic hypotension</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="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Education&#44; lifestyle changes&#44; hydration&#44; and adequate saline intake</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="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleBold">Suspend&#47;reduce vasoactive drugs</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="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleBold">If symptoms persist&#58;</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">a&#46; Counter-pressure maneuvers &#40;cross legs or hands or press with arms&#41;&#59;b&#46; Elastic compression stockings&#59;c&#46; Sleeping with raised headboard&#59;d&#46; Anti-hypertensives &#40;ACEi&#44; ARB&#44; CCB&#41; should be carefully used&#44; especially in patients at high risk of falls&#59;e&#46; Midodrine &#40;2&#46;5&#8211;10 mg&#44; tid&#41;&#59;f&#46; Fludrocortisone &#40;0&#46;1&#8211;0&#46;3 mg od&#41;&#46;</td></tr></tbody></table>
                  """
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        "descripcion" => array:1 [
          "en" => "<p id="spar0095" class="elsevierStyleSimplePara elsevierViewall">Pharmacological and non-pharmacological treatment of syncope&#46;<a class="elsevierStyleCrossRef" href="#bib0490"><span class="elsevierStyleSup">33</span></a></p>"
        ]
      ]
      7 => array:8 [
        "identificador" => "tbl0030"
        "etiqueta" => "Table 6"
        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "detalles" => array:1 [
          0 => array:3 [
            "identificador" => "at6"
            "detalle" => "Table "
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        "tabla" => array:2 [
          "leyenda" => "<p id="spar0110" class="elsevierStyleSimplePara elsevierViewall">AS&#58; aortic stenosis&#59; AR&#58; aortic regurgitation&#59; AVR&#58; Aortic valve replacement&#59; EROA&#58; Effective regurgitant orifice area&#59; HFrEF&#47;p&#58; Heart failure with reduced ejection fraction&#47;preserved&#59; INR&#58; International normalized ratio&#59; LV&#58; left ventricular&#59; LVEF&#58; Left ventricular ejection fraction&#59; LVOT VTI&#58; left ventricular outflow tract velocity-time integral&#59; MR&#58; mitral regurgitation&#59; MS&#58; mitral stenosis&#59; MVA&#58; Mitral valve area&#59; PAP&#58; Pulmonary arterial pressure&#59; PHT&#58; Pressure halftime&#59; PISA&#58; proximal isovelocity surface area&#59; PT&#58; Pulmonary thromboembolism&#59; RF&#58; Risk factors &#40;previous PT and VT&#59; recent surgery or immobilization&#59; neoplasm&#59; heart rate&#62;100 bpm&#41;&#59; TR&#58; tricuspid regurgitation&#59; TTE&#58; Transthoracic echocardiogram&#59; VCW&#58; Vena contracta width&#59; VKA&#58; Vitamin K antagonist&#59; VT&#58; Venous thromboembolism&#59; VTI&#58; velocity-time integral&#46;</p>"
          "tablatextoimagen" => array:1 [
            0 => array:2 [
              "tabla" => array:1 [
                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Valve diseases&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Definition &#38; diagnosis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Referral criteria&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " colspan="3" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Follow-up plan in PHC</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="6" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleBold">Aortic valve disease</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">Aortic Stenosis &#40;AS&#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">Systolic opening restriction due to degenerative disease &#40;majority&#41;&#46; In younger patients resulting from bicuspid aortic valve&#46;Diagnosis&#58;Natriuretic Peptides &#40;if possible&#41;&#59;<span class="elsevierStyleItalic">Mode M and 2D and Doppler TTE</span>&#58;&#8226; Mild&#58; Vmax&#62;2&#46;5 m&#47;s or mean &#916;P&#60;20 mmHg&#59; valvular area&#62;1&#46;5cm<span class="elsevierStyleSup">2</span>&#59; aortic VTI LVOT&#47;VTI ratio &#62;0&#46;5&#8226; Moderate&#58; Vmax 3&#46;0&#8211;3&#46;9 m&#47;s or &#916;P 20&#8211;39 mmHg&#59; valvular area &#62;1&#46;0&#8211;1&#46;5 cm<span class="elsevierStyleSup">2</span>&#59; aortic VTI LVOT&#47;VTI ratio&#61;0&#46;25-0&#46;5&#8226; Severe&#58; Vmax&#8805;4m&#47;s or &#916;P&#8805;40mmHg&#59; valvular area&#58; &#8804;0&#46;1 cm<span class="elsevierStyleSup">2</span>&#59; aortic VTI LVOT&#47;VTI ratio &#60;0&#46;25&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">i&#41; Patients with severe ASii&#41; Patients with moderate AS&#44; symptomatic or with systolic dysfunction&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  " colspan="3" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Echocardiographic control&#58;<span class="elsevierStyleItalic">Progressive lesion</span>&#8226; Mild AS&#58; 3&#8211;5 years&#59;&#8226; Moderate AS&#58; 1&#8211;2 years&#46;Patients with severe AS will be followed-up at the hospital&#46;</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">Aortic Regurgitation &#40;AR&#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">Primary disease of the aortic valve cusps and&#47;or anomalies of the aortic root and ascending aortic geometry&#46; The primary causes of AR in adults are&#58; degeneration of the aortic valve or root &#40;with or without a bicuspid valve&#41;&#59; rheumatic fever&#59; infectious endocarditis&#59; myxomatous degeneration&#59; thoracic aortic aneurysm&#46; In children&#44; the most common cause is ventricular septal defect with aortic valve prolapse&#46;Diagnosis&#58;TTE&#58;<span class="elsevierStyleHsp" style=""></span>&#8226; Mild AR&#58;<span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>&#8728; Semi-quantitative methods&#58; Vena contracta width &#40;VCW&#41; &#60;3 mm&#44; PHT &#62;500 ms&#59;<span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>&#8728; Quantitative methods&#58; EROA &#60;10 mm<span class="elsevierStyleSup">2</span>&#44; regurgitant volume &#60;30 ml&#59;<span class="elsevierStyleHsp" style=""></span>&#8226; Moderate AR&#58;<span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>&#8728; Semi-quantitative methods&#58; VCW &#8805;3-&#60;6 mm&#44; PHT &#8805;200-&#8804;500 ms&#59;<span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>&#8728; Quantitative methods&#58;<span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>&#183;Mild to moderate AR&#58; EROA 10-19 mm<span class="elsevierStyleSup">2</span>&#44; regurgitant volume 30-44 ml&#59;<span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>&#183;Moderate to severe AR&#58; EROA 20-29 mm<span class="elsevierStyleSup">2</span>&#44; regurgitant volume 45-59 ml&#59;<span class="elsevierStyleHsp" style=""></span>&#8226; Severe AR&#58;<span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>&#8728; Semi-quantitative methods&#58; VCW &#8805;6 mm&#44; PHT &#60;200 ms&#59;<span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>&#8728; Quantitative methods&#58; EROA &#8805;30 mm<span class="elsevierStyleSup">2</span>&#44; regurgitant volume &#8805;60 ml&#59;&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">i&#41; Documented severe AR in symptomatic and non-symptomatic patients&#59;ii&#41; Patients with moderate AR and LV dilation&#59;iii&#41; Patients with severe dilation of the aortic root&#59;iv&#41; Patients with Marfan syndrome with aortics root disease&#59;v&#41; Patients with aortic bicuspid&#59;vi&#41; Collagen diseases&#46;&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  " colspan="3" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Echocardiographic control&#58;<span class="elsevierStyleItalic">Progressive lesion</span>&#8226; Mild AR&#58; 3&#8211;5 years&#59;&#8226; Moderate AR&#58; 1&#8211;2 years&#46;Patients with severe AR will be followed-up at the hospital&#46;</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="6" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleBold">Mitral valve disease</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">Mitral Stenosis &#40;MS&#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">Thickening and calcification of the mitral valve&#44; resulting in blood flow restriction from the left atrium to the left ventricle due to a narrowed mitral passage&#46;Mitral stenosis usually results from rheumatic fever&#46; Rheumatic fever occurs mainly in children following streptococcal pharyngitis or scarlet fever&#46; In the elderly&#44; it occurs mainly if they had rheumatic fever and did not undergo antibiotic therapy during their youth&#46;Diagnosis&#58;TTE&#58;<span class="elsevierStyleHsp" style=""></span>&#8226; Mild MS&#58; mitral valve area &#40;MVA&#41; &#62;1&#46;5 cm<span class="elsevierStyleSup">2</span>&#44; mean gradient &#60;5 mmHg&#44; pulmonary arterial pressure &#40;PAP&#41; &#60;30 mmHg&#59;<span class="elsevierStyleHsp" style=""></span>&#8226; Moderate MS&#58; MVA 1&#46;0-1&#46;5 cm<span class="elsevierStyleSup">2</span>&#44; mean gradient 5-10 mmHg&#44; PAP 30-50 mmHg&#59;<span class="elsevierStyleHsp" style=""></span>&#8226; Severe MS&#58; MVA &#60;1&#46;0 cm<span class="elsevierStyleSup">2</span>&#44; mean gradient &#62;10 mmHg&#44; PAP &#62;50 mmHg&#59;&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">i&#41; Symptomatic and non-symptomatic patients with moderate&#47;severe MS&#59;&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  " colspan="3" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Echocardiographic control&#58;Progressive lesion3&#8211;5 years &#40;MVA &#62; 1&#46;5 cm<span class="elsevierStyleSup">2</span>&#41;&#46;Patients with significant MS &#40;MVA&#60;1&#46;5 cm<span class="elsevierStyleSup">2</span>&#41; will be followed-up at the hospital&#46;</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">Mitral Regurgitation &#40;MR&#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">It is essential to distinguish primary from secondary MR&#46; In primary MR&#44; one or several components of the mitral valve apparatus are directly affected&#46;Secondary MR may be of the atrial &#40;secondary to atrial dilation &#8211; frequent in HFpEF&#41; or ventricular &#40;frequent in HFrEF&#41; type&#46;Diagnosis&#58;TTE<span class="elsevierStyleHsp" style=""></span>&#8226; Mild MR&#58;<span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>&#8728; Semi-quantitative methods&#58; VCW &#60;3 mm&#59;<span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>&#8728; Quantitative methods&#58; EROA &#60;20 mm<span class="elsevierStyleSup">2</span>&#44; regurgitant volume &#60;30 ml&#59;<span class="elsevierStyleHsp" style=""></span>&#8226; Moderate MR&#58;<span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>&#8728; Semi-quantitative methods&#58; VCW &#8805;3-&#60;7 mm&#59;<span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>&#8728; Quantitative methods&#58;<span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>&#183; Mild to moderate MR&#58; EROA 20-29 mm<span class="elsevierStyleSup">2</span>&#44; regurgitant volume 30-44 ml&#59;<span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>&#183; Moderate to severe MR&#58; EROA 30-39 mm<span class="elsevierStyleSup">2</span>&#44; regurgitant volume 45-59 ml&#59;<span class="elsevierStyleHsp" style=""></span>&#8226; Severe MR&#58;<span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>&#8728; Semi-quantitative methods&#58; VCW &#8805;7 mm&#59;<span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>&#8728; Quantitative methods&#58; EROA &#8805;40 mm<span class="elsevierStyleSup">2</span>&#44; regurgitant volume &#8805;60 ml&#46;&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">i&#41; Patients with severe MR&#59;ii&#41; Patients with moderate MR with LV dilatation or systolic dysfunction&#44;&#44; pulmonary hypertension or heart failure&#46;&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  " colspan="3" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Echocardiographic control&#58;<span class="elsevierStyleItalic">Progressive lesion</span><span class="elsevierStyleHsp" style=""></span>&#8226; Mild&#58; 3&#8211;5 years&#59;<span class="elsevierStyleHsp" style=""></span>&#8226; Moderate&#58; 1&#8211;2 years&#46;Patients with severe MR will be followed-up at the hospital&#46;</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="6" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleBold">Tricuspid valve disease</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">Tricuspid regurgitation &#40;TR&#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">Pathological TR is most commonly secondary and due to right ventricle dysfunction following pressure and&#47;or volume overload in the presence of structurally normal leaflets&#46; The most frequent causes are&#58; infectious endocarditis&#44; rheumatic heart disease&#44; carcinoid syndrome&#44; myxomatous disease&#44; endomyocardial fibrosis&#44; Ebstein&#39;s disease and congenitally dysplastic valves&#44; drug-induced valve diseases&#44; chest trauma&#44; and iatrogenic valve injury&#46;Diagnosis&#58;TTE<span class="elsevierStyleHsp" style=""></span>&#8226; Mild TR&#58;<span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>&#8728; Semi-quantitative methods&#58; VCW not defined&#59; PISA&#8804;5 mm&#59;<span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>&#8728; Quantitative methods&#58;<span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>&#183; Not defined&#59;<span class="elsevierStyleHsp" style=""></span>&#8226; Moderate TR&#58;<span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>&#8728; Semi-quantitative methods&#58; VCW &#60;7 mm&#44; PISA 6-9 mm&#59;<span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>&#8728; Quantitative methods&#58;<span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>&#183; Not defined&#59;<span class="elsevierStyleHsp" style=""></span>&#8226; Severe TR&#58;<span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>&#8728; Semi-quantitative methods&#58; VCW &#62; 7 mm&#44; PISA &#62;9 mm&#59;<span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>&#8728; Quantitative methods&#58; EROA &#8805;40 mm<span class="elsevierStyleSup">2</span>&#44; regurgitant volume&#8805;45 ml&#46;&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">Patients with severe TR&#59;Patients with moderate isolated TR with right ventricular dilation with symptoms of heart failure and pulmonary hypertension&#46;&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  " colspan="3" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Echocardiographic control&#58;<span class="elsevierStyleItalic">Progressive lesion</span><span class="elsevierStyleHsp" style=""></span>&#8226; Mild&#58; 3&#8211;5 years&#59;<span class="elsevierStyleHsp" style=""></span>&#8226; Moderate&#58; 1&#8211;2 years&#46;Patients with severe TR will be followed-up at the hospital&#46;</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="6" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleBold">Valve prostheses</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">Mechanical and biological valve prostheses&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">In adults&#44; the choice between a mechanical and biological valve is mainly determined by the risk of bleeding related to anticoagulation and the risk of thromboembolism when using a mechanical valve versus the risk of structural deterioration of the bioprosthesis&#44; with lifestyle and patient&#39;s preferences being also considered&#46;&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">i&#41; Patients with prosthesis with <span class="elsevierStyleItalic">de novo</span> onset of cardiac symptoms &#40;heart failure&#44; angor&#44; syncope&#41;&#59;ii&#41; Evidence of prosthesis dysfunction in TTE&#46;&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  " colspan="3" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Echocardiographic control&#58;<span class="elsevierStyleHsp" style=""></span>1&#46; Mechanical valve &#40;surgical&#41; &#8211; baseline&#59;<span class="elsevierStyleHsp" style=""></span>2&#46; Bioprosthesis &#40;surgical&#41; &#8211; baseline&#59; 5&#8211;10 after surgery&#59; and then annually&#59;<span class="elsevierStyleHsp" style=""></span>3&#46; Bioprosthesis &#40;transcatheter&#41; &#8211; baseline and annually thereafter&#59;<span class="elsevierStyleHsp" style=""></span>4&#46; Mitral valve repair &#40;surgical&#41; &#8211; baseline&#59; 1 year&#59; and 2&#8211;3 years thereafter&#59;<span class="elsevierStyleHsp" style=""></span>5&#46; Mitral valve repair &#40;transcatheter&#41; &#8211; baseline and then annually&#59;<span class="elsevierStyleHsp" style=""></span>6&#46; Bicuspid aortic valve disease &#8211; Post-AVR monitoring of aortic diameter if aortic diameter &#8805;4&#46;0 cm at the time of AVR&#46;</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">Mechanical and biological valve prostheses&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><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">Antithrombotic theraphy</span>&#58;It is recommended to follow the regimen suggested by the surgical team&#59;<span class="elsevierStyleItalic">INR control&#58;</span></td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleBold">Thrombogenicity of the prosthesis</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" style="border-bottom: 2px solid black">Risk factors &#40;RF&#41;<span class="elsevierStyleItalic">&#40;tricuspid or mitral valve replacement&#44; previous venous thromboembolism&#44; AF&#44; mitral stenosis of any degree&#44; LVEF &#60;35&#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="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black"><span class="elsevierStyleBold">None</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" style="border-bottom: 2px solid black"><span class="elsevierStyleBold">&#8805;1 RF</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleBold">Low</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">2&#46;5&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&#46;0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleBold">Average</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">3&#46;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">3&#46;5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><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" style="border-bottom: 2px solid black"><span class="elsevierStyleBold">High</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" style="border-bottom: 2px solid black">3&#46;5&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" style="border-bottom: 2px solid black">4&#46;0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Prophylaxis of endocarditis</span>&#58;Antibiotic prophylaxis is recommended in high risk procedures in patients with valve prostheses&#44; including percutaneous valves or valves repaired with prosthetic material&#44; and in patients with previous episodes of infectious endocarditis&#46;High risk procedures &#40;for which antibiotic prophylaxis of endocarditis is recommended&#41; are&#58;<span class="elsevierStyleHsp" style=""></span>&#8226; Dental procedures that require perforation of the oral mucosa or gingival or periapical manipulation&#59;<span class="elsevierStyleHsp" style=""></span>&#8226; Invasive procedures in an infectious context of respiratory&#44; gastrointestinal&#44; genitourinary&#44; musculoskeletal&#44; or dermatological tracts&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
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          "en" => "<p id="spar0105" class="elsevierStyleSimplePara elsevierViewall">Definition&#44; diagnosis&#44; referral criteria and follow-up plan in primary health care&#46;<a class="elsevierStyleCrossRefs" href="#bib0620"><span class="elsevierStyleSup">59-63</span></a></p>"
        ]
      ]
      8 => array:8 [
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          "leyenda" => "<p id="spar0120" class="elsevierStyleSimplePara elsevierViewall">Higher probability is indicated by darker shades of blue&#46;</p>"
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          "en" => "<p id="spar0115" class="elsevierStyleSimplePara elsevierViewall">Pre-test probability of coronary artery disease&#46;<a class="elsevierStyleCrossRef" href="#bib0535"><span class="elsevierStyleSup">42</span></a></p>"
        ]
      ]
      9 => array:8 [
        "identificador" => "tbl0040"
        "etiqueta" => "Table 8"
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          "leyenda" => "<p id="spar0130" class="elsevierStyleSimplePara elsevierViewall">AF&#58; Atrial Fibrillation&#59; EHRA&#58; European Heart Rhythm Association&#46;</p>"
          "tablatextoimagen" => array:1 [
            0 => array:2 [
              "tabla" => array:1 [
                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " colspan="3" align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Modified European Heart Rhythm Association &#40;EHRA&#41; scale of symptoms</th></tr><tr title="table-row"><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Modified EHRA score&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Symptoms&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Description&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><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="elsevierStyleBold">1</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">None&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">AF does not cause any symptoms&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="elsevierStyleBold">2a</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">Mild&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">Normal daily activity is unaffected by AF-related symptoms&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="elsevierStyleBold">2b</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">Moderate&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">Normal daily activity is unaffected by AF-related symptoms&#44; but the patient suffers from the symptoms&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="elsevierStyleBold">3</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">Severe&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">Normal daily activity affected by AF-related symptoms&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="elsevierStyleBold">4</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">Incapacitating&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">Normal daily activity discontinued&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
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          "en" => "<p id="spar0125" class="elsevierStyleSimplePara elsevierViewall">Modified European Heart Rhythm Association &#40;EHRA&#41; scale of symptoms&#46;<a class="elsevierStyleCrossRef" href="#bib0605"><span class="elsevierStyleSup">56</span></a></p>"
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      10 => array:8 [
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          "leyenda" => "<p id="spar0140" class="elsevierStyleSimplePara elsevierViewall">&#40;a&#41; in the presence of previous hemorrhagic stroke&#44; the next criterion related to previous hemorrhage should also be scored&#59;</p><p id="spar0145" class="elsevierStyleSimplePara elsevierViewall">&#40;b&#41; only relevant if the patient is under VKA&#59;</p><p id="spar0150" class="elsevierStyleSimplePara elsevierViewall">&#40;c&#41; excessive alcohol consumption refers to an excessive intake &#40;i&#46;e&#46; &#62;14 units per week&#41;&#44; in a situation where the clinician considers that there may be an impact on health or bleeding risk&#46;</p><p id="spar0155" class="elsevierStyleSimplePara elsevierViewall">ALP&#58; alkaline phosphatase&#59; ALT&#58; alanine aminotransferase&#59; AST&#58; aspartate aminotransferase&#59; BP&#58; blood pressure&#59; INR&#58; international normalized ratio&#59; NSAID&#58; non-steroidal anti-inflammatory drugs&#59; TTR&#58; time in therapeutic range&#59; VKA&#58; vitamin K antagonists&#46;</p>"
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                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " colspan="2" align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">CHA<span class="elsevierStyleInf">2</span>DS<span class="elsevierStyleInf">2</span>-VASc score</th></tr><tr title="table-row"><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">CHA<span class="elsevierStyleInf">2</span>DS<span class="elsevierStyleInf">2</span>-VASc risk factors&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Score&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><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="elsevierStyleBold">Congestive heart failure</span>Signs&#47;symptoms of heart failure or objective evidence of reduced left ventricular ejection fraction&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">&#43;1&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="elsevierStyleBold">Hypertension</span>BP at rest &#62;140&#47;90 mmHg on at least two occasions or ongoing antihypertensive treatment&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">&#43;1&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="elsevierStyleBold">Age&#58;</span> 75 years or older&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">&#43;2&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="elsevierStyleBold">Diabetes</span><span class="elsevierStyleItalic"><span class="elsevierStyleBold">mellitus</span></span>Fasting glucose &#62; 125 mg&#47;dL or treatment with oral hypoglycemic agent and&#47;or insulin&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">&#43;1&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="elsevierStyleBold">Previous stroke&#44; transient ischemic accident&#44; or thromboembolism</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">&#43;2&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="elsevierStyleBold">Vascular disease</span>Previous myocardial infarction&#44; peripheral artery disease&#44; or aortic plaque&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">&#43;1&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="elsevierStyleBold">Age&#58;</span> 65&#8211;74 years&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">&#43;1&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="elsevierStyleBold">Gender&#58;</span> women&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">&#43;1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
              ]
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                0 => "xTab3184005.png"
              ]
            ]
            1 => array:2 [
              "tabla" => array:1 [
                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " colspan="2" align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">HAS-BLED score</th></tr><tr title="table-row"><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">HAS-BLED risk factors&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Score&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><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="elsevierStyleBold">Uncontrolled hypertension</span>SBP&#62;160 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">&#43;1&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="elsevierStyleBold">Altered renal and&#47;or hepatic function</span>Dialysis&#44; transplant&#44; serum creatinine&#62;2&#46;26 mg&#47;dL&#44; cirrhosis&#44; bilirubin&#62;2x reference limit value&#44; AST&#47;ALT&#47;ALP&#62;3x reference limit value&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 point per each&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="elsevierStyleBold">Stroke</span>Previous ischemic or hemorrhagic stroke<span class="elsevierStyleSup">a</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">&#43;1&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="elsevierStyleBold">Previous history of bleeding or predisposition to bleeding</span>Major previous hemorrhage or anemia or severe thrombocytopenia&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">&#43;1&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="elsevierStyleBold">Labile INR</span><span class="elsevierStyleSup">b</span>TTR &#40;Time in therapeutic range&#41;&#60;60&#37; in patients under VKA&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">&#43;1&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="elsevierStyleBold">Elderly</span>Age&#62;65 years or extreme frailty&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">&#43;1&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="elsevierStyleBold">Concomitant consumption of drugs&#47;alcohol</span>Concomitant consumption of antiplatelet agents or NSAID&#59; and&#47;or excessive alcohol consumption<span class="elsevierStyleSup">c</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 point per each&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
              ]
              "imagenFichero" => array:1 [
                0 => "xTab3184004.png"
              ]
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        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0135" class="elsevierStyleSimplePara elsevierViewall">Risk factors and respective CHA<span class="elsevierStyleInf">2</span>DS<span class="elsevierStyleInf">2</span>-VASc and HAS-BLED scores&#46;<a class="elsevierStyleCrossRefs" href="#bib0645"><span class="elsevierStyleSup">64&#44;65</span></a></p>"
        ]
      ]
      11 => array:8 [
        "identificador" => "tbl0050"
        "etiqueta" => "Table 10"
        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "detalles" => array:1 [
          0 => array:3 [
            "identificador" => "at10"
            "detalle" => "Table 1"
            "rol" => "short"
          ]
        ]
        "tabla" => array:2 [
          "leyenda" => "<p id="spar0165" class="elsevierStyleSimplePara elsevierViewall">BB&#58; beta blockers&#59; CBC&#58; complete blood count&#59; CCB&#58; calcium channel blocker&#59; DOAC&#58; direct oral anticoagulant&#59; ECG&#58; electrocardiogram&#59; HR&#58; heart rate&#59; INR&#58; international normalized ratio&#59; VKA&#58; vitamin K antagonist&#46; &#40;a&#41; In the case of mechanical valve prosthesis and in moderate-severe mitral stenosis DOACs are contra-indicated and vitamin K antagonists are mandatory&#59; &#40;b&#41; the prescriber should consider its utilization taking in account its potential pro-arrhythmia effect&#46;</p>"
          "tablatextoimagen" => array:1 [
            0 => array:2 [
              "tabla" => array:1 [
                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td-with-role" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col">Type of treatment&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " colspan="2" align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Cardiology&#47;General practitioner</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " colspan="2" align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Primary health care</th></tr><tr title="table-row"><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Initial follow-up&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Evaluation&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Chronic follow-up&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Evaluation&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><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">Basic&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">-&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">-&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">Annual&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">Symptoms&#43;ECG &#40;heart rate&#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="5" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Thromboembolic risk control</span><span class="elsevierStyleSup">a</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">VKA&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">According to INR&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">According to INR&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">According to INR&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">INR&#43;CBC every 6 months&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">DOAC&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 month&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">CBC&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">Annual&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">Renal and hepatic function&#43;CBC&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="5" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Heart rate &#40;HR&#41; control</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">CCB or BB&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 month&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">ECG &#40;HR&#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">Every 6 months&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">ECG &#40;HR&#41;&#43;Renal and hepatic function &#40;annual&#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="5" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Rhythm control</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">Flecainide<span class="elsevierStyleSup">b</span>Propafenone&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">1 week&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">ECG &#40;HR and QRS&#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">Every 6 months&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">ECG &#40;HR&#41;&#43;Renal &#40;ion&#41; and hepatic function &#40;annual&#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">Sotalol<span class="elsevierStyleSup">s</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 week&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">ECG &#40;HR and QT&#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">Every 6 months&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">ECG &#40;HR and QT&#41;&#43;Annual renal function &#40;ions&#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">Amiodarone&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">Bimonthly &#40;x3&#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">Respiratory function test&#43;Liver function&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">Every 6 months&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">ECG &#40;HR&#41;&#43;Annual chest X-ray&#43;Renal&#44; hepatic and thyroid function&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
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            1 => array:3 [
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            5 => array:3 [
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                            0 => "M&#46;M&#46; Ortiz"
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                        0 => array:2 [
                          "etal" => true
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              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Sodium-glucose co-transporter 2 inhibitors in heart failure&#58; recent data and implications for practice"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:3 [
                            0 => "G&#46; Rosano"
                            1 => "D&#46; Quek"
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                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.15420/cfr.2020.23"
                      "Revista" => array:5 [
                        "tituloSerie" => "Card Fail Rev"
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            8 => array:3 [
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              "etiqueta" => "9"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
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                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
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                            1 => "A&#46;A&#46; Voors"
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                  ]
                  "host" => array:1 [
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                      "Revista" => array:6 [
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            ]
            9 => array:3 [
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                0 => array:2 [
                  "contribucion" => array:1 [
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                      "titulo" => "ESC guidelines for the diagnosis and treatment of acute and chronic heart failure"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
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                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:2 [
                        "tituloSerie" => "Eur Heart J"
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            10 => array:3 [
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              "etiqueta" => "11"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "National Institute for Health and Care Excellence&#58; clinical guidelines"
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                        0 => array:2 [
                          "etal" => false
                          "autores" => array:1 [
                            0 => "National Guideline Centre"
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                  "host" => array:1 [
                    0 => array:1 [
                      "Libro" => array:4 [
                        "titulo" => "Chronic heart failure in adults&#58; diagnosis and management"
                        "fecha" => "2018"
                        "editorial" => "National Institute for Health and Care Excellence &#40;UK&#41;&#44; Copyright &#169; NICE 2018"
                        "editorialLocalizacion" => "London"
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                0 => array:2 [
                  "contribucion" => array:1 [
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                      "titulo" => "Self-care management of heart failure&#58; practical recommendations from the Patient Care Committee of the Heart Failure Association of the European Society of Cardiology"
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                        0 => array:2 [
                          "etal" => true
                          "autores" => array:3 [
                            0 => "M&#46; Lainscak"
                            1 => "L&#46; Blue"
                            2 => "A&#46;L&#46; Clark"
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                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1093/eurjhf/hfq219"
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                        "tituloSerie" => "Eur J Heart Fail"
                        "fecha" => "2011"
                        "volumen" => "13"
                        "paginaInicial" => "115"
                        "paginaFinal" => "126"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/21148593"
                            "web" => "Medline"
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                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "2021 ESC guidelines for the diagnosis and treatment of acute and chronic heart failure&#58; supplementary data"
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                        0 => array:2 [
                          "etal" => true
                          "autores" => array:3 [
                            0 => "T&#46;A&#46; McDonagh"
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                0 => array:1 [
                  "referenciaCompleta" => "Dapagliflozin&#46; Summary of product characteristics&#46; European Medicines Agency &#91;last updated 28&#47;08&#47;2017&#93;"
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              ]
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            14 => array:3 [
              "identificador" => "bib0400"
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