External validation of the FAscore scale to evaluate the risk of atrial fibrillation in patients with arterial hypertension

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          "en" => "<p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">Predictive capacity of FAscore for detecting atrial fibrillation in a community-based hypertensive population in the Basque Country &#40;Spain&#41;&#46;</p>"
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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Atrial fibrillation &#40;AF&#41; is the most common chronic arrhythmia in adults&#46; Currently&#44; the estimated prevalence worldwide is around 2&#8211;4&#37;&#44; but this figure is expected to double or even triple by 2060 due longer life expectancies and improved detection of the condition&#46;<a class="elsevierStyleCrossRef" href="#bib0150"><span class="elsevierStyleSup">1</span></a> In Spain&#44; the reported prevalence of AF varies by study&#44; but it is estimated at 4&#46;4&#37; in people over 40 years of age&#44;<a class="elsevierStyleCrossRef" href="#bib0155"><span class="elsevierStyleSup">2</span></a> 9&#37; in those over 50&#44;<a class="elsevierStyleCrossRef" href="#bib0160"><span class="elsevierStyleSup">3</span></a> and 5&#8211;15&#37; in those over 80&#46;<a class="elsevierStyleCrossRef" href="#bib0165"><span class="elsevierStyleSup">4</span></a> AF is thus an important health problem and one of the leading reasons to seek health care in Western countries&#46;<a class="elsevierStyleCrossRef" href="#bib0170"><span class="elsevierStyleSup">5</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">The risk of AF increases with age and is associated with different risk factors&#44; such as smoking&#44; alcohol&#44; obesity&#44; hypertension&#44; diabetes&#44; and previous heart disease&#46;<a class="elsevierStyleCrossRef" href="#bib0175"><span class="elsevierStyleSup">6</span></a> The European Heart Rhythm Association &#40;EHRA&#41;&#47;European Association of Cardiovascular Prevention and Rehabilitation &#40;EACPR&#41; considers that AF leads to increased morbidity as well as a 40&#8211;90&#37; rise in mortality from stroke&#44; dementia&#44; heart failure&#44; and acute myocardial infarction &#40;AMI&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0180"><span class="elsevierStyleSup">7</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">Even if AF is not specifically associated with any concomitant condition or underlying morbidity&#44; in most cases there is some relevant history of disease&#46; Several pathological processes affect the atrium&#44; including collagen&#44; lipid&#44; and amyloid deposits that contribute to the genesis and perpetuation of AF&#44;<a class="elsevierStyleCrossRef" href="#bib0185"><span class="elsevierStyleSup">8</span></a> a phenomenon known as atrial cardiomyopathy&#46;<a class="elsevierStyleCrossRef" href="#bib0190"><span class="elsevierStyleSup">9</span></a> Several studies point to the fundamental role of arterial hypertension as a risk factor for AF&#44; which may be behind up to 14&#37; of all cases&#46; Hypertension is present in around 70&#37; of patients with AF&#44; and anywhere from 49&#37; to 90&#37; of participants in randomized trials&#46;<a class="elsevierStyleCrossRefs" href="#bib0195"><span class="elsevierStyleSup">10&#44;11</span></a> On the other hand&#44; comorbidities such as diabetes can complicate the effects of anticoagulation therapy or control strategies&#44; increasing the risk of adverse cardiovascular events and death&#46;<a class="elsevierStyleCrossRef" href="#bib0205"><span class="elsevierStyleSup">12</span></a> Similarly&#44; hypertension may increase the risk of stroke or systemic embolism&#46;<a class="elsevierStyleCrossRef" href="#bib0210"><span class="elsevierStyleSup">13</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">In recent years&#44; several community-based predictive models for AF have been developed&#44; such as the Cohorts for Heart and Aging Research in Genomic Epidemiology &#40;CHARGE-AF&#41;<a class="elsevierStyleCrossRef" href="#bib0215"><span class="elsevierStyleSup">14</span></a>&#59; the Framingham Heart Study risk for Atrial Fibrillation &#40;FHS-AF&#41;<a class="elsevierStyleCrossRef" href="#bib0220"><span class="elsevierStyleSup">15</span></a>&#59; and Congestive Heart Failure&#44; Hypertension&#44; Age&#44; Diabetes&#44; Previous Stroke &#40;CHA2DS2-VASc&#41;&#44;<a class="elsevierStyleCrossRef" href="#bib0225"><span class="elsevierStyleSup">16</span></a> with predictive C-index values of around 0&#46;70&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">In a recent study&#44;<a class="elsevierStyleCrossRef" href="#bib0230"><span class="elsevierStyleSup">17</span></a> our research group fitted a predictive model for the appearance of AF at four years in patients over 40 years of age with hypertension&#44; based on four predictors&#58; body mass index &#40;BMI&#41;&#44; age&#44; sex&#44; and a diagnosis of heart failure&#46; The study included patients who attended primary care in the Valencian Region from 2008 to 2012&#46; The resulting predictive model was a multivariable Cox model&#44; adjusted for a population of 12&#44;206 patients&#44; with an incidence of AF of 3&#46;2&#37; at a mean follow-up of three years and four years at most&#59; it yielded an acceptable predictive capacity &#40;C-index 0&#46;69 estimated by cross-validation&#41;&#46; Using this model as a basis&#44; a point-based risk scale was constructed based on the Sullivan et al&#46;&#8217;s approach&#44;<a class="elsevierStyleCrossRef" href="#bib0235"><span class="elsevierStyleSup">18</span></a> and an application for Android mobile devices called FAscore was developed&#46; The app calculates four-year AF risk using four predictor questions&#44; does not store any patient information&#44; is free&#44; and can be downloaded from the Google Play Store&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">To use a risk scale or predictive model outside the population of origin&#44; it is necessary to evaluate the predictive indicators through external validation&#46; The differential characteristics of patients in each region of Spain can affect the prevalence of AF and the behavior of predictive models&#46; Thus&#44; the aim of this study was to validate the FAscore&#44; originally constructed in hypertensive patients in primary care in the Valencian Region&#44; in an external cohort of patients with hypertension in primary care in the Basque Country&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Material and methods</span><p id="par0035" class="elsevierStylePara elsevierViewall">This retrospective cohort study was designed to perform an external validation of the FAscore app in patients affiliated with 26 health centers in the municipality of Bilbao &#40;Basque Country&#44; Spain&#41;&#44; covering a total population of 342&#44;484 inhabitants as of 1 January 2023&#44; according to census data&#46; The study took place between September and December 2023&#44; complies with the principles of the Declaration of Helsinki&#44; and was approved by the Office for Responsible Research of Miguel Hern&#225;ndez University &#40;Alicante&#44; Spain&#59; authorization code AUT&#46;DMC&#46;JAQR&#46;230912&#41;&#46; Since this was a clinical history review study&#44; the need for informed consent was waived&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">The study included people aged 40 years or older&#44; with a diagnosis of hypertension &#40;International Classification of Diseases&#44; 10th revision &#91;ICD-10&#93; I10-I15&#41; recorded in their medical records before 31 December 2019&#44; and registered with the public primary care health centers of Bilbao&#46; Patients with a diagnosis of AF or cardiovascular event &#40;ICD-10&#58; I20&#8211;I25&#44; I60&#8211;I69&#41; before the diagnosis of hypertension and the start of follow-up were excluded&#44; as were patients aged 95 years or older &#40;the maximum age envisaged in the risk scale&#41;&#46; The outcome variable was the occurrence of AF &#40;ICD-10 diagnosis&#58; I48&#41; over follow-up&#44; from 1 January 2016 &#40;or date of hypertension diagnosis if this was after 1 January 2016&#41; to 31 December 2019 &#40;four years&#8217; maximum follow-up&#41;&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">Patients electronic medical records were reviewed to collect the variables necessary to calculate AF risk using the FAscore risk scale &#40;at the date nearest the beginning of follow-up&#41;&#58; sex &#40;male&#47;female&#41;&#44; age &#40;years&#41;&#44; BMI &#40;kg&#47;m<span class="elsevierStyleSup">2</span>&#41;&#44; and diagnosis of heart failure &#40;ICD-10 I50&#44; yes&#47;no&#41;&#46; In addition&#44; information was collected on other variables&#58; diagnosis of dyslipidemia &#40;ICD-10 E78&#44; yes&#47;no&#41;&#44; treatment for hypertension with angiotensin-converting enzyme &#40;ACE&#41; inhibitors or angiotensin II receptor antagonists &#40;ARA-II&#41; &#40;yes&#47;no&#41;&#44; systolic and diastolic blood pressure &#40;mmHg&#41;&#44; albumin &#40;g&#47;dL&#41;&#44; creatinine &#40;mg&#47;dL&#41;&#44; total cholesterol &#40;mg&#47;dL&#41;&#44; basal glucose &#40;mg&#47;dL&#41;&#44; high-density lipoprotein &#40;HDL&#41; cholesterol &#40;mg&#47;dL&#41;&#44; and triglycerides &#40;mg&#47;dL&#41;&#46;</p><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Statistical analysis</span><p id="par0050" class="elsevierStylePara elsevierViewall">A descriptive analysis of the variables was performed by calculating absolute and relative frequencies of categorical variables&#44; and the mean&#44; standard deviation &#40;SD&#41;&#44; and range of quantitative variables&#46;</p><p id="par0055" class="elsevierStylePara elsevierViewall">The risk of AF occurrence at four years was calculated using the FAscore risk point scale&#44; entering in the baseline values of the study variables to obtain the risk&#44; expressed as a percentage and illustrated with a histogram&#46; External validation of the FAscore consisted of comparing the risk estimated using the FAscore with the AF diagnoses observed in the study population&#46; The area under the receiver-operating characteristics &#40;ROC&#41; curve &#40;AUC&#41; was calculated&#44; together with its 95&#37; confidence interval &#40;CI&#41;&#44; as a predictive indicator of the FAscore&#46; Calibration graph was calculated&#46;</p><p id="par0060" class="elsevierStylePara elsevierViewall">To evaluate the optimal cutoff to best predict a case of AF&#44; we calculated the sensitivity&#44; specificity&#44; positive and negative predictive values &#40;PPV and NPV&#41;&#44; and likelihood ratios at each cutoff point&#44; along with their 95&#37; Cis&#44; and Youden index&#46; Analyses were performed with the R program v&#46;4&#46;2&#46;2&#46;2&#46;<a class="elsevierStyleCrossRef" href="#bib0240"><span class="elsevierStyleSup">19</span></a></p></span></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Results</span><p id="par0065" class="elsevierStylePara elsevierViewall">A total of 58&#44;116 patients met the inclusion criteria&#46; After excluding 19&#44;948 &#40;34&#46;3&#37;&#41; patients who did not present valid values for all the FAscore variables and 1359 &#40;2&#46;3&#37;&#41; who were over 94 years of age&#44; the final sample included in the analysis comprised 36&#44;809 patients&#58; 53&#46;6&#37; &#40;<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>19&#44;719&#41; were women&#44; the mean age was 75&#46;1 years&#44; 41&#46;8&#37; &#40;<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>15&#44;381&#41; were overweight&#44; and 39&#46;2&#37; &#40;<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>14&#44;451&#41; were obese&#46; In addition&#44; 3&#46;8&#37; &#40;<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>1403&#41; had heart failure&#44; 20&#46;3&#37; &#40;<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>7464&#41; dyslipidemia&#44; and 47&#46;4&#37; &#40;<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>17&#44;430&#41; were being treated with ACE inhibitors&#47;ARA-II for hypertension&#46; Blood tests showed mean values of 200&#46;1<span class="elsevierStyleHsp" style=""></span>mg&#47;dL for total cholesterol&#44; 58&#46;8<span class="elsevierStyleHsp" style=""></span>mg&#47;dL for high-density lipoprotein &#40;HDL&#41; cholesterol&#44; 107&#46;1<span class="elsevierStyleHsp" style=""></span>mg&#47;dL for basal glucose&#44; and 130&#46;4<span class="elsevierStyleHsp" style=""></span>mg&#47;dL for triglycerides&#46; Mean systolic&#47;diastolic blood pressure was 80&#47;138<span class="elsevierStyleHsp" style=""></span>mmHg &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#41;&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0070" class="elsevierStylePara elsevierViewall">Over the four-year follow-up period&#44; 1420 patients were diagnosed with AF &#40;cumulative incidence 3&#46;9&#37;&#41;&#46; The median risk estimated by FAscore was 4&#46;5&#37; &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0075" class="elsevierStylePara elsevierViewall"><a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a> shows the ROC curve for the risk estimated by FAscore and the cases of AF observed &#40;AUC 0&#46;715&#44; 95&#37; CI 0&#46;703&#8211;0&#46;727&#41;&#46; <a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a> shows the possible risk cutoff points&#46; The 5&#37; cutoff provides a sensitivity of 70&#46;8&#37;&#44; specificity of 61&#46;0&#37;&#44; PPV of 6&#46;8&#37;&#44; NPV of 98&#46;1&#37;&#44; and positive and negative likelihood ratios of 1&#46;82 and 0&#46;48&#44; respectively&#44; with a maximum Youden index&#46; A total of 14&#44;803 &#40;40&#46;2&#37;&#41; patients were observed with a risk greater than or equal to 5&#37; measured by FAscore&#44; of which 70&#46;8&#37; were diagnosed with AF during follow-up&#46;</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><p id="par0080" class="elsevierStylePara elsevierViewall"><a class="elsevierStyleCrossRef" href="#fig0015">Fig&#46; 3</a> shows the calibration graph&#44; using eight intervals according to the Hosmer&#8211;Lemeshow approach&#44; indicating moderate calibration&#46;</p><elsevierMultimedia ident="fig0015"></elsevierMultimedia></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Discussion</span><p id="par0085" class="elsevierStylePara elsevierViewall">This study reports on the external validation of the AF risk scale in hypertensive patients &#40;FAscore&#41;&#44; which shows an acceptable predictive capacity &#40;AUC 0&#46;715&#41;&#46; The best-performing risk cutoff&#44; providing good predictive indicators&#44; can be set at 5&#37;&#46;</p><p id="par0090" class="elsevierStylePara elsevierViewall">Some differences were observed in the characteristics of the populations used in the original study and the external validation study &#40;Valencian Region vs&#46; Basque Country&#41;&#44; both set in primary care&#58; the Baque population was older &#40;mean age 75 years vs&#46; 65 years&#41;&#44; had a higher proportion of women &#40;53&#37; vs&#46; 47&#37;&#41;&#44; a lower prevalence of obesity &#40;39&#37; vs&#46; 48&#37;&#41; and dyslipidemia &#40;20&#46;3&#37; vs&#46; 42&#46;7&#37;&#41;&#44; a higher prevalence of heart failure &#40;3&#46;8&#37; vs&#46; 1&#46;1&#37;&#41;&#44; and a larger proportion under pharmacological treatment for hypertension &#40;47&#37; vs&#46; 38&#37;&#41;&#46; The cumulative incidence of AF at four years was similar in both populations &#40;3&#46;9&#37; vs&#46; 3&#46;2&#37;&#41;&#46; These discordancies may be attributed to differences in behavioral patterns and management of hypertension in the two settings&#44; plus the 10-year gap between the performance of each study&#46; Despite these differences&#44; the predictive capacity of FAscore in the external population &#40;AUC 0&#46;72&#41; can be considered good and is similar to that obtained in the original population &#40;C-index 0&#46;69&#41;&#44; demonstrating that FAscore can be applied to patients with hypertension in different regions of Spain&#46;</p><p id="par0095" class="elsevierStylePara elsevierViewall">In the original study&#44; Orozco-Beltran et al&#46;<a class="elsevierStyleCrossRef" href="#bib0230"><span class="elsevierStyleSup">17</span></a> did not propose an optimal cutoff point for estimating AF risk with the FAscore&#46; The present study shows that the 5&#37; cutoff yields acceptable sensitivity &#40;70&#37;&#41; and specificity &#40;61&#37;&#41;&#44; very high NPV &#40;98&#37;&#41;&#44; but low PPV &#40;6&#46;8&#37;&#41;&#44; with a maximum Youden index&#46; The PPV is the probability of AF occurring in the following four years when the scale estimates a risk greater than 5&#37;&#46; The low value in our study can be explained by the low cumulative incidence of AF &#40;3&#46;9&#37;&#41;&#46;</p><p id="par0100" class="elsevierStylePara elsevierViewall">Similarly&#44; the probability that a patient will not develop AF in the next four years when the FAscore risk is less than 5&#37; is very high&#58; 98&#37;&#46; With these data&#44; and given the low frequency of AF&#44; the FAscore could be used as a screening tool&#44; due to its high NPV and moderate sensitivity&#44; and confirm the diagnosis with opportunistic electrocardiograms or monitoring with ambulatory electrocardiographic recording systems such as a Holter device&#44; watches&#44; textiles&#44; patches&#44; or other portable systems&#46;<a class="elsevierStyleCrossRef" href="#bib0245"><span class="elsevierStyleSup">20</span></a></p><p id="par0105" class="elsevierStylePara elsevierViewall">Scientific societies recommend preventive measures and early detection strategies&#44;<a class="elsevierStyleCrossRef" href="#bib0180"><span class="elsevierStyleSup">7</span></a> but there are multiple diagnostic pathways&#44; and population-based screening is unfeasible&#44; so careful selection of patients who can benefit most from scales such as the one presented in this study can be of great utility&#46;</p><p id="par0110" class="elsevierStylePara elsevierViewall">Several predictive models for AF have been applied in cohort studies in the general population<a class="elsevierStyleCrossRefs" href="#bib0250"><span class="elsevierStyleSup">21&#8211;24</span></a> as well as specifically in men&#44;<a class="elsevierStyleCrossRef" href="#bib0270"><span class="elsevierStyleSup">25</span></a> the biracial population&#44;<a class="elsevierStyleCrossRef" href="#bib0275"><span class="elsevierStyleSup">26</span></a> and the Asian population&#46;<a class="elsevierStyleCrossRef" href="#bib0280"><span class="elsevierStyleSup">27</span></a> In a recent meta-analysis&#44;<a class="elsevierStyleCrossRef" href="#bib0285"><span class="elsevierStyleSup">28</span></a> review authors identified 10 predictive models for AF&#58; the length of follow-up ranged from 5 to 11 years&#44; and the number of predictors&#44; from 5 to 18 variables&#44; with a maximum of 27 unique variables&#46; Age was the only parameter used in all models&#59; other predictors were sex&#59; BMI&#59; blood pressure&#59; the presence of comorbidities such as diabetes&#44; heart failure&#44; stroke&#44; myocardial infarction&#44; and COPD&#59; and behavioral risk factors like smoking and alcohol intake&#46; The FAscore uses only four variables&#44; which coincide with some of these other models&#58; age&#44; sex&#44; BMI&#44; and the presence of heart failure&#46; The difference between the number and type of predictors may be due to the fact that these studies are applied to the general population&#44; while the FAscore is indicated only in people with hypertension&#46; Regarding predictive capacity&#44; the meta-analysis estimates a C-index of 0&#46;70 &#40;95&#37; CI 0&#46;66&#8211;0&#46;76&#41;&#46; This discriminative capacity is similar to that obtained in the present study with an external population&#46; Only one study has been undertaken in a population with diabetes and hypertension&#44; with a total of 14 variables&#44; with a C-index of 0&#46;69 in external validation&#46;<a class="elsevierStyleCrossRef" href="#bib0290"><span class="elsevierStyleSup">29</span></a> On the other hand&#44; most scales make 10-year predictions&#59; however&#44; the possibility of shorter-term predictions &#40;four years in our study&#41; enables better tailoring of preventive measures and a more immediate perception of risk&#44; both for health professionals and patients&#46;</p><p id="par0115" class="elsevierStylePara elsevierViewall">The limitations of the study include the possible existence of unknown predictors not included in the model&#44; although with only four predictors &#40;age&#44; sex&#44; BMI&#44; and presence of heart failure&#41;&#44; the FAscore achieves an acceptable predictive capacity&#46; While medical record review studies may also have data quality limitations&#44; these are common in studies of this type&#44; and external validation is acceptable&#46;</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Conclusion</span><p id="par0120" class="elsevierStylePara elsevierViewall">This investigation presents the external validation in the Basque country of the AF risk scale in hypertensive patients &#40;FAscore&#41;&#44; demonstrating a satisfactory predictive capacity with an AUC of 0&#46;715 in an external cohort&#44; and could be a useful tool for clinical practice in patients with arterial hypertension&#46; Optimal predictive performance is achieved with a risk cutoff set at 5&#37;&#46;<elsevierMultimedia ident="tb0005"></elsevierMultimedia></p></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0110">Ethical considerations</span><p id="par0145" class="elsevierStylePara elsevierViewall">Since this was a clinical history review study&#44; the need for informed consent was waived&#46;</p></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0115">Funding</span><p id="par0150" class="elsevierStylePara elsevierViewall">This study was funded by the <span class="elsevierStyleGrantSponsor" id="gs1">Spanish Ministry of Science and Innovation &#40;MICINN&#41;</span> and <span class="elsevierStyleGrantSponsor" id="gs2">Carlos III Health Institute &#40;ISCIII&#41;&#47;European Regional Development Fund &#40;ERDF&#41;</span> &#40;RICAPPS&#58; <span class="elsevierStyleGrantNumber" refid="gs2">RD21&#47;0016&#47;0024</span>&#41;&#46; The funder played no role in the design&#44; conduct&#44; or reporting of this study&#46;</p></span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0120">Conflicts of interest</span><p id="par0155" class="elsevierStylePara elsevierViewall">The authors declare no conflict of interest&#46; The funders had no role in the design of the study&#59; in the collection&#44; analyses&#44; or interpretation of data&#59; in the writing of the manuscript&#59; or in the decision to publish the results&#46;</p></span><span id="sec0060" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0125">Data availability</span><p id="par0160" class="elsevierStylePara elsevierViewall">The data underlying this article will be shared on reasonable request with the corresponding author&#46;</p></span></span>"
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        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Background and aim</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">To use a risk scale or predictive model outside the population of origin&#44; it is necessary to evaluate the predictive indicators through external validation&#46; The aim was to validate the FAscore&#44; originally constructed in hypertensive patients in primary care in the Valencian Region&#44; in an external cohort with hypertension in primary care in the Basque Country&#46;</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Methods</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">A retrospective cohort study was designed to perform an external validation of the FAscore app in patients affiliated with 26 health centers in the municipality of Bilbao&#46; The area under the ROC curve and predictive indicators were calculated with their 95&#37; confidence intervals&#46;</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Results</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Thirty-six thousand eight hundred nine patients were included&#58; 53&#46;6&#37; &#40;<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>19&#44;719&#41; were women&#44; the mean age was 75&#46;1 years&#44; 41&#46;8&#37; &#40;<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>15&#44;381&#41;&#46; Over the four-year follow-up period&#44; 1420 patients were diagnosed with AF &#40;cumulative incidence 3&#46;9&#37;&#41;&#46; The median risk estimated by FAscore was 4&#46;5&#37;&#44; and the 5th&#44; 25th&#44; 75th&#44; and 95th percentiles were 1&#46;0&#37;&#44; 2&#46;5&#37;&#44; 6&#46;1&#37;&#44; and 14&#46;8&#37;&#44; respectively&#46; The ROC curve for the risk estimated by FAscore and the cases of atrial fibrillation observed was AUC 0&#46;715 &#40;95&#37; CI 0&#46;703&#8211;0&#46;727&#41;&#46; The 5&#37; risk cutoff provides a sensitivity of 70&#46;8&#37;&#44; specificity of 61&#46;0&#37;&#44; positive predictive value of 6&#46;8&#37;&#44; negative predictive value of 98&#46;1&#37;&#44; and positive and negative likelihood ratios of 1&#46;82 and 0&#46;48&#44; respectively&#46;</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Conclusion</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">This study reports on the external validation of the atrial fibrillation risk scale in hypertensive patients&#44; which shows an acceptable predictive capacity&#46; The best-performing risk cutoff&#44; providing good predictive indicators&#44; can be set at 5&#37;&#46;</p></span>"
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        "resumen" => "<span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Introducci&#243;n y objetivo</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Para utilizar una escala de riesgo fuera de la poblaci&#243;n de origen es necesario evaluar los indicadores predictivos mediante una validaci&#243;n externa&#46; El objetivo fue validar el FAscore en una cohorte externa con hipertensi&#243;n en atenci&#243;n primaria en el Pa&#237;s Vasco&#46;</p></span> <span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">M&#233;todos</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Estudio de cohorte retrospectivo para validaci&#243;n externa de la aplicaci&#243;n FAscore en pacientes de 26 centros de salud en el municipio de Bilbao&#46; Se calcul&#243; &#225;rea bajo la curva ROC e indicadores predictivos con sus intervalos de confianza al 95&#37; &#40;IC 95&#37;&#41;&#46;</p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Resultados</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Se incluyeron 36&#46;809 pacientes&#58; el 53&#44;6&#37; &#40;n<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>19&#46;719&#41; eran mujeres y la edad promedio fue de 75&#44;1 a&#241;os &#40;41&#44;8&#37;&#59; n<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>15&#46;381&#41;&#46; Durante el periodo de seguimiento de 4 a&#241;os se diagnostic&#243; fibrilaci&#243;n auricular en 1&#46;420 pacientes &#40;incidencia acumulativa 3&#44;9&#37;&#41;&#46; La mediana del riesgo estimado por el FAscore fue del 4&#44;5&#37; y los percentiles 5&#44; 25&#44; 75 y 95 fueron 1&#44;0&#37;&#44; 2&#44;5&#37;&#44; 6&#44;1&#37; y 14&#44;8&#37;&#44; respectivamente&#46; La curva ROC para el riesgo estimado por el FAscore y los casos de fibrilaci&#243;n auricular observados fue de AUC 0&#44;715 &#40;IC 95&#37;&#58; 0&#44;703-0&#44;727&#41;&#46; El punto de corte del 5&#37; de riesgo proporciona una sensibilidad del 70&#44;8&#37;&#44; una especificidad del 61&#44;0&#37;&#44; un valor predictivo positivo del 6&#44;8&#37;&#44; un valor predictivo negativo del 98&#44;1&#37; y razones de probabilidad positiva y negativa de 1&#44;82 y 0&#44;48&#44; respectivamente&#46;</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Conclusi&#243;n</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">La validaci&#243;n externa de la escala de riesgo muestra una capacidad predictiva aceptable&#46; El punto de corte de riesgo que mejor funciona se puede establecer en el 5&#37;&#46;</p></span>"
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Overweight &#40;25&#8211;29&#46;9<span class="elsevierStyleHsp" style=""></span>kg&#47;m<span class="elsevierStyleSup">2</span>&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Obesity&#44; class II &#40;&#8805;35<span class="elsevierStyleHsp" style=""></span>kg&#47;m<span class="elsevierStyleSup">2</span>&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">4875&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">79&#46;7&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">7464&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="3" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Atrial fibrillation</span></td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>No&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">35&#44;389&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">96&#46;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="elsevierStyleHsp" style=""></span>Yes&nbsp;\t\t\t\t\t\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">1420&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">3&#46;9&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
              ]
              "imagenFichero" => array:1 [
                0 => "xTab3699815.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  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Quantitative variables&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"><span class="elsevierStyleItalic">n</span>&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">Mean&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">SD&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">Range&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">Age&#44; 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="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">36&#44;809&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">75&#46;12&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">11&#46;43&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">41&#46;00&#8211;94&#46;00&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">Albumin&#44; g&#47;dL&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">25&#44;993&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">4&#46;45&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;89&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2&#46;11&#8211;49&#46;10&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">Creatinine&#44; mg&#47;dL&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">34&#44;652&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;92&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;38&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;32&#8211;8&#46;57&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">Total cholesterol&#44; mg&#47;dL&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">34&#44;802&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">200&#46;12&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">39&#46;66&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">81&#46;00&#8211;372&#46;00&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">Basal glucose&#44; mg&#47;dL&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">35&#44;012&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">107&#46;14&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">32&#46;86&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">41&#46;00&#8211;496&#46;00&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">HDL cholesterol&#44; mg&#47;dL&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">34&#44;208&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">58&#46;81&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">17&#46;27&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">10&#46;00&#8211;159&#46;00&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">Triglycerides&#44; mg&#47;dL&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">34&#44;239&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">130&#46;39&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">71&#46;77&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">25&#46;00&#8211;787&#46;00&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">Diastolic blood pressure&#44; 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="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">36&#44;683&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">80&#46;35&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">10&#46;80&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">37&#46;00&#8211;145&#46;00&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">Systolic blood pressure&#44; 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="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">36&#44;711&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">138&#46;23&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">16&#46;83&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">60&#46;00&#8211;248&#46;00&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
              ]
              "imagenFichero" => array:1 [
                0 => "xTab3699814.png"
              ]
            ]
          ]
        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">Sample characteristics &#40;<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>36&#44;809&#41;&#46;</p>"
        ]
      ]
      4 => 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"
          ]
        ]
        "tabla" => array:2 [
          "leyenda" => "<p id="spar0075" class="elsevierStyleSimplePara elsevierViewall">Y&#58; Youden index&#46;</p><p id="spar0080" class="elsevierStyleSimplePara elsevierViewall">Bold values&#58; maximum value of Youden index&#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">Cutoff &#40;&#37;&#41;&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">Sensitivity &#40;95&#37; CI&#41;</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">Specificity &#40;95&#37; CI&#41;</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"><span class="elsevierStyleItalic">Y</span>&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">Positive predictive value &#40;95&#37; CI&#41;</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">Negative predictive value &#40;95&#37; CI&#41;</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">Positive likelihood ratio &#40;95&#37; CI&#41;</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">Negative likelihood ratio &#40;95&#37; CI&#41;</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  " align="char" valign="\n
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                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t">0&#46;992&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">&#40;0&#46;987&#8211;0&#46;997&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">&#40;0&#46;041&#8211;0&#46;045&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">&#40;0&#46;992&#8211;0&#46;996&#41;&nbsp;\t\t\t\t\t\t\n
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        "descripcion" => array:1 [
          "en" => "<p id="spar0070" class="elsevierStyleSimplePara elsevierViewall">Predictive indicators&#44; according to risk cutoffs as estimated by FAscore&#46;</p>"
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      5 => array:5 [
        "identificador" => "tb0005"
        "tipo" => "MULTIMEDIATEXTO"
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          "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">What is known about the topic</span><p id="par0125" class="elsevierStylePara elsevierViewall">The FAscore was originally constructed in hypertensive patients in primary care in the Valencian Region&#46;</p><p id="par0130" class="elsevierStylePara elsevierViewall">In the original study did not propose an optimal cutoff point for estimating AF risk with the FAscore&#46;</p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0105">What this study contributes</span><p id="par0135" class="elsevierStylePara elsevierViewall">The external validation in the Basque Country of the atrial fibrillation risk scale in hypertensive patients shows an acceptable predictive capacity&#46;</p><p id="par0140" class="elsevierStylePara elsevierViewall">The best-performing risk cutoff&#44; providing good predictive indicators&#44; can be set at 5&#37;&#46;</p></span></span>"
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                        "volumen" => "42"
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                            3 => "V&#46;F&#46; Gil-Guill&#233;n"
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                            5 => "C&#46; Carratal&#225;-Munuera"
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