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Letter to the Editor
Hydrotherapy in Heart Failure: A Case Report
Vitor Oliveira CarvalhoI,II, Edimar Alcides BocchiI,II, Guilherme Veiga GuimarãesI,II
I Unidade Clínica de Insuficiência Cardíaca e Transplante do Instituto do Coração do Hospital das Clínicas da Faculdade de Medicina da USP (InCor HC-FMUSP) - São Paulo/SP, Brazil
II Laboratório de Atividade Física e Saúde do Centro de Práticas Esportivas da Universidade de São Paulo (LATIS-CEPEUSP) - São Paulo/SP, Brazil.
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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="cesec10" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="cestitle10">BACKGROUND</span><p id="para10" class="elsevierStylePara elsevierViewall">Heart failure is considered to be the last stage of heart disease and a significant cause of morbidity and mortality worldwide&#46;<a class="elsevierStyleCrossRefs" href="#bib1">1&#44;2&#44;3</a> It is characterized by the persistent activation of the neurohormonal system&#44;<a class="elsevierStyleCrossRef" href="#bib4">4</a> endothelial dysfunction&#44;<a class="elsevierStyleCrossRef" href="#bib5">5</a> exercise intolerance&#44;<a class="elsevierStyleCrossRefs" href="#bib6">6&#44;7&#44;8&#44;9</a> high mortality<a class="elsevierStyleCrossRef" href="#bib10">10</a> and a poor quality of life&#46;<a class="elsevierStyleCrossRef" href="#bib11">11</a></p><p id="para20" class="elsevierStylePara elsevierViewall">Exercise training has been strongly recommended as a safe and important tool for the non-pharmacological treatment of heart failure&#46; Exercise training improves exercise capacity&#44;<a class="elsevierStyleCrossRefs" href="#bib12">12&#44;13</a> quality of life&#44;<a class="elsevierStyleCrossRef" href="#bib14">14</a> endothelial dysfunction&#44;<a class="elsevierStyleCrossRef" href="#bib15">15</a> skeletal muscle oxidative capacity&#44;<a class="elsevierStyleCrossRef" href="#bib16">16</a> the cathecolamine plasma level<a class="elsevierStyleCrossRef" href="#bib17">17</a> and the autonomic and ventilatory responses&#46;<a class="elsevierStyleCrossRef" href="#bib18">18</a> In heart failure patients&#44; designing an appropriate aerobic exercise routine is crucial for obtaining both an increase in exercise capacity and the reasonable control of exercise-related risks&#46;<a class="elsevierStyleCrossRefs" href="#bib1">1&#44;6</a></p><p id="para30" class="elsevierStylePara elsevierViewall">Hydrotherapy &#40;i&#46;e&#46;&#44; exercise in warm water&#41; had been considered potentially dangerous in heart failure patients due to the increased venous return caused by the hydrostatic pressure&#46; However&#44; it is now known that cardiac function actually improves during water immersion due to the increase in early diastolic filling and decrease in heart rate&#44; resulting in improvements in stroke volume and ejection fraction&#46;<a class="elsevierStyleCrossRef" href="#bib19">19</a> Studies with sauna therapy &#40;i&#46;e&#46;&#44; warming&#41; have demonstrated important improvements in neurohormonal attenuation and exercise status in heart failure patients&#46; These data suggest that hydrotherapy is a good potential treatment for heart failure patients&#46; However&#44; few studies are available&#44; and none have compared conventional rehabilitation to hydrotherapy&#46;<a class="elsevierStyleCrossRef" href="#bib20">20</a></p><p id="para40" class="elsevierStylePara elsevierViewall">This study was partially supported by &#8220;Coordena&#231;&#227;o de Aperfei&#231;oamento de Pessoal de N&#237;vel Superior&#8221;&#46;</p></span><span id="cesec20" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="cestitle20">CASE REPORT</span><p id="para50" class="elsevierStylePara elsevierViewall">A 51-year-old male heart failure patient &#40;ischemic etiology with 40&#37; left ventricular ejection fraction&#41; was recruited from a cardiology hospital to this rehabilitation program &#40;<a class="elsevierStyleCrossRef" href="#t1-cln64_8p824">Table 1</a>&#41;&#46; This patient underwent 24 exercise sessions in a 22&#8211;24&#176;C temperature-controlled gym &#40;conventional exercises&#41; between May and July 2007&#46; After the exercise training program&#44; this patient was invited to continue in our rehabilitation program but opted out&#46; After 6 months&#44; the patient returned to our program to continue the exercise program&#44; and we assigned him to hydrotherapy&#46; Between January and March 2008&#44; he had 24 more exercise sessions in a 30&#8211;31&#176;C temperature-controlled swimming pool &#40;hydrotherapy&#41;&#46; The exercise training protocol was almost the same for both methods&#58; 5 minutes of warm up exercises &#40;stretching&#41;&#44; 30 minutes of aerobic exercise training &#40;90&#37; of ventilatory threshold&#41;&#44; 25 minutes of strength exercises &#40;lower and upper limbs&#41; and 5 minutes of cool down exercises &#40;stretching&#41;&#46; A treadmill &#40;Max 1&#59; Marquette Electronics&#59; Milwaukee&#44; WI&#44; USA&#41; cardiopulmonary exercise test &#40;Vmax 229 model&#44; SensorMedics&#44; Yorba Linda&#44; CA&#44; USA&#41;&#44; 24-hour ambulatory blood pressure measurement &#40;Space Labs Redmond&#44; Wash&#44; USA&#41;&#44; New York Heart Association functional classification and a Minnesota Living With Heart Failure Questionnaire were performed before and after the exercise training protocols &#40;the cardiopulmonary exercise test was performed 2 days prior to the other evaluations&#41;&#46; The medications were not changed during the protocols &#40;150 mg&#47;day Carvedilol&#44; 100 mg&#47;day Losartan&#44; 40 mg&#47;day Furosemide&#44; 25 mg&#47;day Spironolactone and 0&#46;25 mg&#47;day Digoxin&#41;&#46; This protocol was approved by the ethical committee of our institution &#40;number 1107&#47;05&#41;&#46;</p><elsevierMultimedia ident="t1-cln64_8p824"></elsevierMultimedia></span><span id="cesec30" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="cestitle30">DISCUSSION</span><p id="para60" class="elsevierStylePara elsevierViewall">Exercise training is a well-established non-pharmacological treatment for patients with heart failure&#46; Hydrotherapy is a new and well-tolerated method of exercise rehabilitation for heart failure patients&#46; It is an alternative for elderly patients and patients with impaired mobility&#46;<a class="elsevierStyleCrossRef" href="#bib21">21</a> The patient in this case study did not have any orthopedic problems despite his high body mass index&#46;</p><p id="para70" class="elsevierStylePara elsevierViewall">Studies with sauna baths have shown that they can lead to great improvements in heart failure by attenuating the neurohormonal system&#46;<a class="elsevierStyleCrossRefs" href="#bib21">21&#44;22</a> It is possible that hydrotherapy &#40;i&#46;e&#46;&#44; exercise in a warm swimming pool&#41; could provide the same beneficial effects of conventional exercise training and warming while also attenuating the neurohormonal system more significantly&#46; Therefore&#44; we expected the patient to improve more with hydrotherapy than with conventional exercise&#46;</p><p id="para80" class="elsevierStylePara elsevierViewall">In this case&#44; hydrotherapy was an effective method of cardiovascular rehabilitation and a safe alternative to conventional exercise&#46; This is the first report in which a patient has performed both forms of exercise&#46; The patient&#8217;s peak and anaerobic threshold oxygen consumption&#44; VE&#47;VCO<span class="elsevierStyleInf">2</span> slope&#44; Minnesota living with heart failure quality of life score&#44; body mass index&#44; 24-hour ambulatory blood pressure and waist and hip circumference improved with both methods of exercise rehabilitation&#44; but the improvements were more pronounced with hydrotherapy&#46; The patient&#8217;s peak and anaerobic threshold oxygen consumption showed an increase of 7&#46;2 mLO<span class="elsevierStyleInf">2</span>&#183;kg<span class="elsevierStyleSup">&#8722;1</span>&#183;min<span class="elsevierStyleSup">&#8722;1</span> during regular exercise training versus 10&#46;4 mLO<span class="elsevierStyleInf">2</span>&#183;kg<span class="elsevierStyleSup">&#8722;1</span>&#183;min<span class="elsevierStyleSup">&#8722;1</span> with hydrotherapy and an increase of 0&#46;5 mLO<span class="elsevierStyleInf">2</span>&#183;kg<span class="elsevierStyleSup">&#8722;1</span>&#183;min<span class="elsevierStyleSup">&#8722;1</span> with regular training versus 3&#46;5 mLO<span class="elsevierStyleInf">2</span>&#183;kg<span class="elsevierStyleSup">&#8722;1</span>&#183;min<span class="elsevierStyleSup">&#8722;1</span> with hydrotherapy&#44; respectively&#46; His VE&#47;VCO<span class="elsevierStyleInf">2</span> slope decreased by 1&#46;2 with regular training&#44; while it decreased to 8&#46;8 with hydrotherapy&#46; The Minnesota living with heart failure quality of life score decreased by 2 with regular training and by 42 with hydrotherapy&#46; The patient&#8217;s body mass index increased by 0&#46;4 kg&#47;m<span class="elsevierStyleSup">2</span> with regular training&#44; while it decreased by 1&#46;3 kg&#47;m<span class="elsevierStyleSup">2</span> with hydrotherapy&#46; His mean 24-hour systolic blood pressure showed a 1 cm H<span class="elsevierStyleInf">2</span>O decrease with regular training&#44; while it decreased by 5 cm H<span class="elsevierStyleInf">2</span>O with hydrotherapy&#46; On the other hand&#44; his mean diastolic blood pressure was unchanged by regular training while it decreased by 5 cm H<span class="elsevierStyleInf">2</span>O with hydrotherapy&#46; The patient&#8217;s waist circumference showed a decrease of 1 cm with regular training and a decrease of 2 cm with hydrotherapy&#44; while his hip circumference was unchanged by regular training but showed a 4 cm decrease with hydrotherapy&#46;</p><p id="para90" class="elsevierStylePara elsevierViewall">Exercise intolerance &#40;low peak oxygen consumption&#41; and poor quality of life have been negatively correlated to neurohormonal activity in heart failure patients&#46;<a class="elsevierStyleCrossRef" href="#bib23">23</a> Some clinical exams&#44; such as the 24-hour ambulatory blood pressure&#44; can detect the exacerbated neurohormonal activity seen in heart failure&#46;<a class="elsevierStyleCrossRef" href="#bib24">24</a> These clinical data reflect the stronger neurohormonal attenuation provided by hydrotherapy&#46; Importantly&#44; signs and symptoms of exercise intolerance were not observed during either exercise regimen&#46;</p></span><span id="cesec40" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="cestitle40">CONCLUSION</span><p id="para100" class="elsevierStylePara elsevierViewall">In this case report&#44; we demonstrate that hydrotherapy is an effective method of cardiovascular rehabilitation and can be a safe alternative to conventional exercise&#46;</p></span></span>"
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                  \t\t\t\t">121&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Peak VO<span class="elsevierStyleInf">2</span> &#40;mLO<span class="elsevierStyleInf">2</span>&#183;kg<span class="elsevierStyleSup">&#8722;1</span>&#183;min<span class="elsevierStyleSup">&#8722;1</span>&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">21&#46;5&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">VO<span class="elsevierStyleInf">2</span> AT &#40;mLO<span class="elsevierStyleInf">2</span>&#183;kg<span class="elsevierStyleSup">&#8722;1</span>&#183;min<span class="elsevierStyleSup">&#8722;1</span>&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">VO<span class="elsevierStyleInf">2</span> VT &#40;mLO<span class="elsevierStyleInf">2</span>&#183;kg<span class="elsevierStyleSup">&#8722;1</span>&#183;min<span class="elsevierStyleSup">&#8722;1</span>&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">VE&#47;VCO<span class="elsevierStyleInf">2</span> slope&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">Time &#40;exercise test&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">NYHA&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">MLHFQ&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">51&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">49&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">68&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">26&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
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                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">SBP 24 hours &#40;mmHg&#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="center" valign="\n
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                  \t\t\t\t">118&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="\n
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                  \t\t\t\t">117&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="\n
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                  \t\t\t\t">130&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">125&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">DBP 24 hours &#40;mmHg&#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="center" valign="\n
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                  \t\t\t\t">63&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">67&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="center" valign="\n
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                  \t\t\t\t">70&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="center" valign="\n
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                  \t\t\t\t">66&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
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                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">HR 24 hours &#40;bpm&#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="center" valign="\n
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                  \t\t\t\t">69&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="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">76&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">91&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">69&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">SBP daytime &#40;mmHg&#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="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">124&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="\n
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                  \t\t\t\t">117&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">137&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">127&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">DBP daytime &#40;mmHg&#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="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">67&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="\n
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                  \t\t\t\t">67&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">74&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">69&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">HR daytime &#40;bpm&#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="center" valign="\n
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                  \t\t\t\t">69&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="center" valign="\n
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                  \t\t\t\t">78&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">94&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="\n
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                  \t\t\t\t">67&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">SBP nighttime &#40;mmHg&#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="center" valign="\n
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                  \t\t\t\t">108&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="\n
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                  \t\t\t\t">118&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">116&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">122&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">DBP nighttime &#40;mmHg&#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="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">55&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">68&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">62&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="\n
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                  \t\t\t\t">61&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">HR nighttime &#40;bpm&#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="center" valign="\n
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                  \t\t\t\t" style="border-bottom: 2px solid black">69&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="\n
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                  \t\t\t\t" style="border-bottom: 2px solid black">72&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">85&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">73&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
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          "en" => "<p id="spara10" class="elsevierStyleSimplePara elsevierViewall">Patient data before and after exercise training</p>"
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es en pt

¿Es usted profesional sanitario apto para prescribir o dispensar medicamentos?

Are you a health professional able to prescribe or dispense drugs?

Você é um profissional de saúde habilitado a prescrever ou dispensar medicamentos