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Case Report
Is it necessary to perform cardiovascular screening in migrant patients?
¿Es necesario realizar un screening cardiovascular en los pacientes migrantes?
Ricardo Roa-Chamorroa,
Corresponding author
ricardoroa@gmail.com

Corresponding author.
, Pablo González-Bustosa, Lucía Torres-Quinterob
a Unidad de Riesgo Vascular, Medicina Interna, Hospital Universitario Virgen de las Nieves, Granada, Spain
b Cardiología, Hospital Universitario Virgen de las Nieves, Granada, Spain
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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">There are several signs that should raise suspicion of secondary hypertension&#46; These include hypertension in young patients &#40;usually younger than 30 years old&#41;&#44; severe hypertension or hypertension with early target organ damage&#46;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> Although the criteria for screening for secondary hypertension are well established in developed countries&#44; this situation is not the same in some developing countries&#46; This situation is evident in our setting with patients migrating to Spain&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">Renovascular disease is an important and potentially correctable cause of secondary hypertension&#46; The frequency with which it occurs varies&#44; but appears to account for less than 1&#37; of cases of moderate and severe hypertension&#46;<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> Renal artery involvement may be secondary to atherosclerotic disease&#44; vasculitis or vascular malformations&#44; among other causes&#46; Its importance lies in the fact that it is a potentially reversible cause of arterial hypertension&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Clinical case study</span><p id="par0015" class="elsevierStylePara elsevierViewall">We present the case of a 36-year-old Senegalese man&#44; with no known pathological history&#46; He emigrated to Spain at the age of 35 and currently lives in Baza&#44; a small village in the province of Granada&#44; and words in agriculture&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">In January 2020 he went to the emergency department for hypertensive crisis &#40;blood pressure 238&#47;130<span class="elsevierStyleHsp" style=""></span>mmHg&#41;&#46; Physical examination revealed no differences in pulses or blood pressure between the two arms&#46; Cardiac auscultation revealed a systolic murmur in mitral and aortic focus grade V&#47;VI&#44; which did not erase the second sound&#46; There were no signs of heart failure or abdominal murmurs&#46; The electrocardiogram &#40;ECG&#41; showed signs of ventricular hypertrophy &#40;positive Sokolow-Lyon criteria and negative inferolateral T wave&#41; &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;&#46; The echocardiogram confirmed the ECG suspicion and diagnosed severe concentric left ventricular hypertrophy &#40;septal thickness of 28<span class="elsevierStyleHsp" style=""></span>mm at mid-septal level&#59; inferior&#44; lateral and anterior 24<span class="elsevierStyleHsp" style=""></span>mm&#41;&#46; In view of all these findings&#44; an aetiological study of secondary arterial hypertension was performed&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0025" class="elsevierStylePara elsevierViewall">This included thyroid hormones&#44; plasma ACTH and cortisol and urine metanephrines&#44; which were normal&#46; Renin and aldosterone levels in blood were requested&#44; with elevated values of both&#44; suggestive of hyperaldosteronism &#40;aldosterone 331<span class="elsevierStyleHsp" style=""></span>pg&#47;mL&#44; normal between 38 and 150<span class="elsevierStyleHsp" style=""></span>pg&#47;mL&#44; and renin 1989<span class="elsevierStyleHsp" style=""></span>pg&#47;mL&#44; normal values between 1&#46;7&#8211;23&#46;9<span class="elsevierStyleHsp" style=""></span>pg&#47;mL&#41;&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">Angio-CT showed a critical stenosis in the middle third of the left renal artery&#44; with a vascular malformation in the form of a ball in the renal hilum extending caudally with numerous collaterals joining the vertebral and mesenteric arteries &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>&#41; with delayed perfusion in the arterial and venous phase of the left kidney with respect to the contralateral kidney&#46;</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0035" class="elsevierStylePara elsevierViewall">No atherosclerotic lesions were found on CT angiography&#46; He also did not meet the criteria for Takayasu&#39;s arteritis or other types of vasculitis&#44; nor had he presented any local trauma&#46; For these reasons&#44; it was suggested that the origin of the renal artery stenosis and vascular tangle was malformational in origin&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">Renal angiography and renin&#47;aldosterone selective venous sampling &#40;SVS&#41; was performed&#46; This supported the angio-CT findings and demonstrated hypertensive behaviour of the left kidney&#46; The left renal vein had a 3-fold higher renin concentration with respect to the common iliac and right renal veins &#40;left vein&#58; 265<span class="elsevierStyleHsp" style=""></span>pg&#47;mL&#59; right vein 78<span class="elsevierStyleHsp" style=""></span>pg&#47;mL&#44; reference values 3&#46;58&#8211;36&#46;62<span class="elsevierStyleHsp" style=""></span>pg&#47;mL&#41;&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">The presence of grade 3 hypertensive retinopathy and the findings on cardiovascular magnetic resonance imaging &#40;severe circumferential hypertrophy of the left ventricle&#44; predominantly in the middle and apical segments&#44; as well as in the papillary muscles&#44; with absence of late gadolinium enhancement&#41; were confirmed&#46; Ambulatory blood pressure monitoring &#40;ABPM&#41; was performed to characterise the degree of arterial hypertension&#44; showing mean 24<span class="elsevierStyleHsp" style=""></span>h values of 168&#47;113<span class="elsevierStyleHsp" style=""></span>mmHg&#44; daytime mean of 174&#47;119<span class="elsevierStyleHsp" style=""></span>mmHg and nighttime mean of 152&#47;101<span class="elsevierStyleHsp" style=""></span>mmHg &#40;<a class="elsevierStyleCrossRef" href="#fig0015">Fig&#46; 3</a>&#41;&#44; with dipper pattern of blood pressure and with a percentage of systolic and diastolic readings above baseline values greater than 95&#37;&#44; despite daily treatment with labetalol 100<span class="elsevierStyleHsp" style=""></span>mg 1 at breakfast&#44; enalapril 5<span class="elsevierStyleHsp" style=""></span>mg 1 tablet at breakfast and 1 tablet at dinner&#44; manidipine 10<span class="elsevierStyleHsp" style=""></span>mg 1 tablet at breakfast and 1 tablet at dinner and furosemide 40<span class="elsevierStyleHsp" style=""></span>mg 1 tablet at breakfast&#46; Higher doses of ACE inhibitors were not tolerated due to impaired renal function&#46;</p><elsevierMultimedia ident="fig0015"></elsevierMultimedia><p id="par0050" class="elsevierStylePara elsevierViewall">After left renal artery angioplasty&#44; blood pressure values decreased and treatment was reduced to manidipine 10<span class="elsevierStyleHsp" style=""></span>mg 1 tablet at breakfast and atenolol 50<span class="elsevierStyleHsp" style=""></span>mg 1 tablet at dinner&#46; On subsequent ABPM &#40;<a class="elsevierStyleCrossRef" href="#fig0020">Fig&#46; 4</a>&#41; mean 24<span class="elsevierStyleHsp" style=""></span>h blood pressure values were 121&#47;84<span class="elsevierStyleHsp" style=""></span>mmHg&#44; daytime mean of 123&#47;87<span class="elsevierStyleHsp" style=""></span>mmHg and nighttime mean of 117&#47;74<span class="elsevierStyleHsp" style=""></span>mmHg&#46; The blood pressure pattern was dipper and the percentage of systolic readings above baseline values less than 20&#37;&#44; with 65&#37; of diastolic readings elevated&#46; Eighteen months later&#44; a transthoracic echocardiogram was performed and showed reduced ventricular hypertrophy&#44; currently compatible with mild-moderate LVH &#40;septal thickness 14<span class="elsevierStyleHsp" style=""></span>mm&#59; left ventricular posterior thickness 10<span class="elsevierStyleHsp" style=""></span>mm&#41;&#46;</p><elsevierMultimedia ident="fig0020"></elsevierMultimedia></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Discussion</span><p id="par0055" class="elsevierStylePara elsevierViewall">Cardiovascular diseases are the leading cause of death in Spain&#46; Among the main causes are cardiovascular risk factors&#44; which is why there are screening systems in place in primary care&#46;<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">3&#44;4</span></a> Among them&#44; arterial hypertension stands out&#44; with an approximate frequency of 40&#37; in Spain in people over 18 years of age&#46; There are criteria under which the search for a secondary aetiology of hypertension is indicated&#46; These include early onset &#40;generally before the age of 30&#41;&#44; severe or refractory hypertension&#44; and analytical alterations &#40;e&#46;g&#46;&#44; hypokalaemia&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a></p><p id="par0060" class="elsevierStylePara elsevierViewall">However&#44; these circumstances are different in some developing African countries&#46; According to a 1927 article in The Lancet&#44; hypertension was an anecdotal condition in some African communities&#44; with a prevalence of less than 5&#37;&#46;<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> Today&#44; however&#44; cardiovascular diseases &#40;including hypertension&#41; represent a real public health problem&#44; with increasing morbidity and mortality&#46;<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> There are also significant differences in the prevalence of hypertension between rural and urban populations&#44; mainly due to changes in lifestyle and especially diet&#46;<a class="elsevierStyleCrossRefs" href="#bib0035"><span class="elsevierStyleSup">7&#44;8</span></a></p><p id="par0065" class="elsevierStylePara elsevierViewall">In Senegal&#44; an African country on the west coast of Africa with more than 13 million inhabitants&#44; despite the existence of social security&#44; there is no universal health coverage and no established basis for primary health care or screening programmes for chronic diseases such as hypertension&#46; The estimated prevalence of hypertension in the area is less than 20&#37;&#46; This percentage&#44; lower than that described in Spain&#44;<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a> has been related mainly to dietary factors &#40;such as lower salt consumption&#41;&#44; although under-diagnosis bias must be considered due to lower access to the health system&#46; Only 10&#37;&#8211;20&#37; of patients were found to have adequate blood pressure control&#46;<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a></p><p id="par0070" class="elsevierStylePara elsevierViewall">Hypertension has been reported to be more frequent and severe in blacks&#44; although these data refer mainly to African-American patients&#44; for multiple causes&#46;<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">11</span></a> Although there is less scientific evidence&#44; it appears that sub-Saharan African populations also have more severe hypertension than white subjects&#44; matched by age and sex&#46; In a study published by the French National Academy of Medicine&#44;<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a> patients from sub-Saharan Africa were found to have higher grade hypertension compared to age- and sex-matched controls&#46; This could be due to increased obesity&#44; although alterations in epithelial sodium channel functions and abnormalities in angiotensinogen and aldosterone synthase genes have also been suggested&#44; although there is currently little evidence&#46;<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">11</span></a></p><p id="par0075" class="elsevierStylePara elsevierViewall">No significant differences in the prevalence of secondary hypertension have been observed with respect to European populations&#44; although there appears to be a higher frequency of primary hyperaldosteronism and lower renovascular hypertension&#46;<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a> Renovascular hypertension has a frequency of less than 1&#37; in people with mild or moderate hypertension&#44; although this prevalence appears much higher in those with severe or refractory hypertension&#46;<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> The most common cause is atherosclerotic in origin&#44; with vascular malformations or stenosis secondary to vasculitis being rare&#46;</p><p id="par0080" class="elsevierStylePara elsevierViewall">We know that migration is one of the greatest challenges facing society in the 21st century&#46; Until now&#44; the biggest health problems have been due to imported infectious pathology &#40;e&#46;g&#46;&#44; malaria&#41;&#46; However&#44; the burden of cardiovascular diseases is increasing&#46; Changes in diet and lifestyle in this population have led to an increase in the incidence of hypertension and diabetes&#46; In addition&#44; the lack of health checks in their countries of origin can lead to under-diagnosis of pathologies such as hypertension&#46; In host countries&#44; the prevalence of cardiovascular risk factors is&#44; in many cases&#44; unknown in the migrant population due to less access to health resources&#46;<a class="elsevierStyleCrossRefs" href="#bib0060"><span class="elsevierStyleSup">12&#44;13</span></a> Therefore&#44; in cases of prolonged evolution and poor control&#44; these patients may develop hypertension-mediated target organ damage&#46;</p><p id="par0085" class="elsevierStylePara elsevierViewall">In the case in question&#44; our patient had had high blood pressure for several years&#44; as he had developed heart disease and hypertensive retinopathy&#44; a condition of which he was unaware&#46; For this reason&#44; it had not been possible to diagnose the stenosis and malformation of the left renal artery that was causing the disease&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Conclusions</span><p id="par0090" class="elsevierStylePara elsevierViewall">Migration is one of the major health challenges of the 21st century&#46; So far&#44; the focus has been mainly on imported infectious pathology&#44; but we know that changing diets and lifestyles in developing countries are causing the prevalence of cardiovascular diseases to increase&#46; In many of these countries&#44; there is no universal access to healthcare&#44; so they may go undiagnosed&#46; For this reason&#44; migrant patients arriving in their host countries should be included in health screening to avoid future health complications&#46;</p><p id="par0095" class="elsevierStylePara elsevierViewall">It is important to identify secondary and possibly reversible causes of hypertension&#46; Renovascular pathology has a low frequency&#44; with arterial malformations being a rare cause&#46; In our case&#44; after an in-depth study&#44; the left kidney was found to have a pressor mechanism&#44; characterised by increased renin and aldosterone&#46; After correction of the renal artery stenosis&#44; blood pressure values normalised&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Funding</span><p id="par0100" class="elsevierStylePara elsevierViewall">None&#46;</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Authorship</span><p id="par0105" class="elsevierStylePara elsevierViewall">All the authors contributed equally&#46;</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Conflict of interests</span><p id="par0110" class="elsevierStylePara elsevierViewall">None&#46;</p></span></span>"
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            0 => "Vascular malformation"
            1 => "Hypertensive emergency"
            2 => "Secondary hypertension"
            3 => "Target organ damage"
            4 => "Migration"
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            0 => "Malformaci&#243;n vascular"
            1 => "Emergencia hipertensiva"
            2 => "Hipertensi&#243;n arterial secundaria"
            3 => "Da&#241;o de &#243;rgano diana"
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        "titulo" => "Abstract"
        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Migrant patients arriving in Spain often come from countries where there is no universal access to healthcare&#46; Although the prevalence of arterial hypertension &#40;HTN&#41; is lower in West Africa than in Spain&#44; there is a higher prevalence of masked HT due to the absence of health screening&#46; Furthermore&#44; patients with secondary hypertension may not be diagnosed&#46; We present the case of a 36-year-old Senegalese man&#44; with no known pathological history&#44; resident for a year in Spain&#44; who debuted with a hypertensive emergency&#46; At the time of diagnosis&#44; the patient had severe end-organ damage &#40;hypertensive heart disease&#44; hypertensive retinopathy&#41;&#46; After the study&#44; he was diagnosed with arterial hypertension secondary to malformation of the renal artery&#46; After performing angioplasty&#44; blood pressure normalized and&#44; at 18 months&#44; target organ damage had reduced&#46; Migrants who arrive in our country must be incorporated into health screening systems to diagnose and treat possible unknown pathologies&#46; In our case&#44; the clue to secondary hypertension was the development of resistant hypertension with target organ damage in a young subject&#46;</p></span>"
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        "resumen" => "<span id="abst0010" class="elsevierStyleSection elsevierViewall"><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Los pacientes migrantes que llegan a Espa&#241;a a menudo proceden de pa&#237;ses donde no existe acceso universal a la sanidad&#46; Aunque la prevalencia de hipertensi&#243;n arterial &#40;HTA&#41; es menor en &#193;frica occidental que en Espa&#241;a&#44; existe una mayor prevalencia de HTA enmascarada debido a la ausencia de cribados de salud&#46; Esto tambi&#233;n puede producir que no se diagnostiquen a los pacientes con HTA secundaria&#46; Presentamos el caso de un var&#243;n senegal&#233;s de 36 a&#241;os&#44; sin antecedentes patol&#243;gicos conocidos&#44; residente desde hac&#237;a un a&#241;o en Espa&#241;a&#44; que debut&#243; con una emergencia hipertensiva&#46; En el momento del diagn&#243;stico&#44; el paciente presentaba da&#241;o grave de &#243;rgano diana &#40;cardiopat&#237;a hipertensiva&#44; retinopat&#237;a hipertensiva&#41;&#46; Tras el estudio&#44; se le diagnostic&#243; hipertensi&#243;n arterial secundaria a malformaci&#243;n de la arteria renal&#46; Despu&#233;s de realizar la angioplastia&#44; la presi&#243;n arterial se normaliz&#243; y&#44; a los 18 meses&#44; el da&#241;o a los &#243;rganos diana se hab&#237;a reducido&#46;</p></span>"
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          "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">CT angiography showed a critical stenosis in the middle third of the left renal artery&#44; with an enlarged&#44; kinked and tangled vascular malformation in the renal hilum extending caudally with numerous collaterals linking the vertebral and mesenteric arteries&#46;</p>"
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          "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Ambulatory blood pressure monitoring prior to angioplasty&#46; Mean 24<span class="elsevierStyleHsp" style=""></span>h values of 168&#47;113<span class="elsevierStyleHsp" style=""></span>mmHg&#44; daytime mean of 174&#47;119<span class="elsevierStyleHsp" style=""></span>mmHg and nighttime mean of 152&#47;101<span class="elsevierStyleHsp" style=""></span>mmHg were detected&#46;</p>"
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          "en" => "<p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Ambulatory blood pressure monitoring after angioplasty&#46; Mean 24<span class="elsevierStyleHsp" style=""></span>h blood pressure values were 121&#47;84<span class="elsevierStyleHsp" style=""></span>mmHg&#44; daytime mean of 123&#47;87<span class="elsevierStyleHsp" style=""></span>mmHg and nighttime mean of 117&#47;74<span class="elsevierStyleHsp" style=""></span>mmHg&#46;</p>"
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                      "titulo" => "American Heart Association Professional&#47;Public Education and Publications Committee of the Council on Hypertension&#59; Council on Cardiovascular and Stroke Nursing&#59; Council on Clinical Cardiology&#59; Council on Genomic and Precision Medicine&#59; Council on Peripheral Vascular Disease&#59; Council on Quality of Care and Outcomes Research&#59; and Stroke Council&#46; Resistant hypertension&#58; detection&#44; evaluation&#44; and management&#58; a scientific statement from the American Heart Association"
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                            0 => "R&#46;M&#46; Carey"
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                            2 => "G&#46;L&#46; Bakris"
                            3 => "R&#46;D&#46; Brook"
                            4 => "S&#46;L&#46; Daugherty"
                            5 => "C&#46;R&#46; Dennison-Himmelfarb"
                          ]
                        ]
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                    0 => array:2 [
                      "doi" => "10.1161/HYP.0000000000000084"
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                        "tituloSerie" => "Hypertension&#46;"
                        "fecha" => "2018"
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                            3 => "P&#46;K&#46; Whelton"
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                    ]
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                      "titulo" => "en nombre del Grupo de Trabajo de Hipertensi&#243;n Arterial y Enfermedad Cardiovascular de SEMERGEN&#46; Posicionamiento para el manejo de la hipertensi&#243;n arterial en atenci&#243;n primaria a partir del an&#225;lisis cr&#237;tico de las gu&#237;as americana &#40;2017&#41; y europea &#40;2018&#41;&#46; Sociedad Espa&#241;ola de M&#233;dicos de Atenci&#243;n Primaria &#40;SEMERGEN&#41;"
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                            2 => "M&#46;A&#46; Prieto D&#237;az"
                            3 => "L&#46; Garc&#237;a Matar&#237;n"
                            4 => "M&#46;C&#46; Seoane Vicente"
                            5 => "F&#46; Molina Escribano"
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                      "doi" => "10.1016/j.semerg.2019.02.003"
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                            2 => "J&#46;J&#46; Alem&#225;n S&#225;nchez"
                            3 => "J&#46;R&#46; Banegas Banegas"
                            4 => "A&#46;M&#46; Cebri&#225;n-Cuenca"
                            5 => "V&#46;F&#46; Gil Guillen"
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                      "titulo" => "Blood pressure in the African natives&#58; its bearing upon aetiology of hyperpiesa and arteriosclerosis"
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                    0 => array:2 [
                      "titulo" => "Prevalence&#44; detection&#44; management&#44; and control of hypertension in Ashanti&#44; West Africa"
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                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [
                            0 => "F&#46;P&#46; Cappuccio"
                            1 => "F&#46;B&#46; Micah"
                            2 => "L&#46; Emmett"
                            3 => "S&#46;M&#46; Kerry"
                            4 => "S&#46; Antwi"
                            5 => "R&#46; Martin-Peprah"
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                    0 => array:2 [
                      "doi" => "10.1161/01.HYP.0000126176.03319.d8"
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