Original article
Long-term and clinical profile of heart failure with recovered ejection fraction in a non-tertiary hospital
Características y evolución de la insuficiencia cardiaca con función sistólica recuperada en un hospital no terciario
Virgilio Martínez-Mateo
, Manuel Fernández-Anguita, Laura Cejudo, Eugenia Martín-Barrios, Antonio J. Paule
Corresponding author
Servicio de Cardiología, Hospital Mancha Centro , Alcázar de San Juan (Ciudad Real), Spain
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Paule" "autores" => array:5 [ 0 => array:4 [ "nombre" => "Virgilio" "apellidos" => "Martínez-Mateo" "email" => array:1 [ 0 => "virgiliomed@hotmail.com" ] "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] 1 => array:2 [ "nombre" => "Manuel" "apellidos" => "Fernández-Anguita" ] 2 => array:2 [ "nombre" => "Laura" "apellidos" => "Cejudo" ] 3 => array:2 [ "nombre" => "Eugenia" "apellidos" => "Martín-Barrios" ] 4 => array:2 [ "nombre" => "Antonio J." "apellidos" => "Paule" ] ] "afiliaciones" => array:1 [ 0 => array:2 [ "entidad" => "Servicio de Cardiología, Hospital Mancha Centro , Alcázar de San Juan (Ciudad Real), Spain" "identificador" => "aff0005" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Características y evolución de la insuficiencia cardiaca con función sistólica recuperada en un hospital no terciario" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1198 "Ancho" => 2110 "Tamanyo" => 165544 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Flow diagram of the study participants.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Heart failure (HF) is a clinical syndrome characterized by typical symptoms and signs caused by the presence of a structural or functional heart abnormality that results in reduced cardiac output or elevated intracardiac pressures at rest or during exertion. According to the systolic function of the left ventricle (LV) calculated based on the ejection fraction (EF), HF has traditionally been categorized as HF with a reduced ejection fraction (EF) (HFrEF), or as HF with a preserved ejection fraction (HFpEF), given that both are associated with two different clinical manifestations in terms of their physiopathology, etiology, comorbidities, prognosis, and response to treatments.<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">1</span></a> Nevertheless, this categorization may be too simplistic, as it only offers a partial representation of patients with HF, considering that the systolic function in itself is not the sole variable involved in cardiac hemodynamics, and that the use of the EF as a parameter to measure systolic function has many limitations, including the controversies regarding the cut-off point of the left ventricular ejection fraction (LVEF) at which the systolic function is considered to be reduced, and its poor correlation with functional capacity.<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">2</span></a> Furthermore, according to the etiology of the HF, the LVEF can fluctuate over time in the same patient, and it has even been seen to normalize in a significant number of cases following reverse remodeling.<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">3</span></a> In recent years, there has been increasing evidence supporting that the latter subgroup of patients have a different clinical progress and prognosis than patients with HFrEF or HFpEF.<a class="elsevierStyleCrossRefs" href="#bib0100"><span class="elsevierStyleSup">4–8</span></a> Thus, the recent clinical practice guidelines now describe it as an independent nosologic entity defined as HF with a recovered or normalized LVEF.<a class="elsevierStyleCrossRefs" href="#bib0085"><span class="elsevierStyleSup">1,9</span></a> However, information on the clinical profile and progress of patients with this entity is limited in the standard clinical practice of non-tertiary hospitals.<a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">10</span></a> Therefore, the aim of our research is to describe this entity based on the data obtained from a cohort of patients with HFrEF followed prospectively in a Heart Failure Unit (HFU) of a non-tertiary hospital.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Methods</span><p id="par0010" class="elsevierStylePara elsevierViewall">In this study we analyzed the clinical progress and prognosis of patients with HFrEF followed prospectively at a HFU of a non-tertiary hospital based on the normalization of their LVEF during follow-up. Our hospital is comprised by 2 cardiologists and a nurse who work part-time to serve a population of 234,283 inhabitants.<a class="elsevierStyleCrossRef" href="#bib0135"><span class="elsevierStyleSup">11</span></a> In addition to working part-time, they also offer the possibility of caring for the patients in the event of unexpected incipient symptoms of decompensation. All patients who were followed consecutively and actively in the unit since its implementation, from 1 January 2010 to 30 June 2017, were included in the study. The study's primary inclusion criterion was a diagnosis of symptomatic HF caused by a significant LV systolic dysfunction (defined as a LVEF equal to or lower than 40%, measured by means of a transthoracic ultrasound) after a first decompensated heart failure warranting a visit to the hospital emergency department or admission to the hospital. Patients who were examined during their stay at the unit or upon their discharge from it, but who had not been followed actively for more than 6 months due to reasons other than death, were excluded from the study (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>). The first follow-up visit took place within 30 days of the patients’ discharge from the hospital or the emergency department, and the patients continued to be monitored at the unit until their systolic function had returned to normal, their pharmacological or non-pharmacological treatments for stage-C HF had been optimized, or until they had achieved clinical stabilization without having experienced episodes of decompensation throughout the previous year. Carriers of class III–IV devices according to the classification of the New York Heart Association (NYHA), or with a stage-D HF, were followed indefinitely. A transthoracic echocardiogram was performed in all cases at the beginning of the follow-up period, at one year of follow-up, and when clinically relevant changes were observed in the patients’ progress (clinical improvement, normalization of their levels of natriuretic peptides, QRS narrowing, implantation of a cardiac resynchronization therapy device [CRT-D], etc.). A LVEF greater than 50% was classified as normalization.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0015" class="elsevierStylePara elsevierViewall">The primary outcome variable of the study was total mortality, including deaths related to the HF and sudden cardiac death (SCD). The secondary outcome variable was the rate of hospital admissions due to HF. A death was considered to be related to the HF in those cases in which worsening of a previous HF or decompensation resistant to medical treatment with no other possible cause were observed, whereas the sudden death, whether or not witnessed, of a previously stable patient without evidence of a worsening heart failure or another cause of death was classified as SCD. All events were identified in the digitalized medical records of each patient, which described all the clinical events that the patients had experienced at any healthcare center.</p><p id="par0020" class="elsevierStylePara elsevierViewall">The statistical analysis was carried out in statistical software program SPSS version 18.0. Quantitative variables were expressed as a mean<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>standard deviation (or a median, where applicable), and qualitative variables were reflected as percentages. The chi-squared statistical test was used to compare categorical variables, whereas Student's <span class="elsevierStyleItalic">T</span> test was used to compare continuous variables. Survival curves were calculated using the Kaplan–Meier method, and their differences were assessed with a log-rank test. Where appropriate, both a univariate and multivariate Cox regression analysis were performed to calculate the odds ratio with a 95% confidence interval (IC). A multiple logistic regression analysis was also carried out to evaluate predictors of LVEF normalization and response to the CRT. <span class="elsevierStyleItalic">p</span> values below 0.05 (<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span><<span class="elsevierStyleHsp" style=""></span>0.05) were considered to be statistically significant.</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Results</span><p id="par0025" class="elsevierStylePara elsevierViewall">During the study period described above, a total of 431 patients with a mean age of 70.3<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>12.2 years (median: 73; range: 23–91), 79.3% of whom were men, were followed at our clinic (median follow-up duration: 50 months). LVEF normalization was observed in 26.9% of the patients (116 patients) during the follow-up period: 76.7% of the normalization occurred within the first year of starting the follow-up and the specific treatment for HF with a reduced LVEF. The main HF etiologies identified in this group of patients in comparison with those whose LVEF did not return to normal were HF due to alcohol toxicity, tachycardiomyopathy (primarily atrial fibrillation/persistent atrial flutter), and hypertensive HF (<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>). The remainder of the baseline characteristics of the patients of both groups are shown in <a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>. Interestingly, the LVEF was severely reduced in most patients of both groups, and it affected the same percentage of male patients. In addition, the LVEF did not improve in the oldest patients of both groups, and the prevalence of complete left bundle branch block (LBBB), HF-related ischemic cardiomyopathy, atherosclerotic disease, chronic kidney failure, and chronic obstructive pulmonary disease (COPD) was also greater among the elderly patients.</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><p id="par0030" class="elsevierStylePara elsevierViewall">As for the pharmacological and non-pharmacological treatment of HF (<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>), no differences were observed with respect to the overall use of beta-blockers, although patients who achieved LVEF normalization tended to reach full doses. Ivabradine and digoxin were prescribed more frequently, in such a way that less patients among those who recovered a normal LVEF had received any of the three drugs that control heart rate. In terms of the use of inhibitors of the renin–angiotensin–aldosterone system, the total rate of use of angiotensin converting enzyme inhibitors (ACEIs)-angiotensin receptor antagonists (ARAs) II-sacubitril/valsartan was similar in both groups, although no patient who achieved a normalized LVEF received sacubitril/valsartan. Nevertheless, there was a greater trend to prescribe full doses of ACEIs/ARAs II in this group of patients. No differences were observed either between the use of antialdosterone agents in both groups. Finally, the rate of implantable cardioverter defibrillators-cardiac resynchronization devices (ICD-CRT) and CRT pacemakers was similar in both groups, although no defibrillator without a CRT function was implanted in patients who achieved a normalized LVEF. All patients of the group who achieved a normalized LVEF and who had a CRT device implanted responded to the therapy, whereas only 62.9% of the patients of the group whose LVEF did not return to normal responded to the therapy (37.1% achieved an improvement in their LVEF, although it did not return to normal), which represents a pooled rate of responders to the CRT of 53.2%. The only determinant of the absence of response in the multivariate analysis was an ischemic HF etiology.</p><p id="par0035" class="elsevierStylePara elsevierViewall">During follow-up, the LVEF improved in 167 patients (38.7% of the total sample of patients) and normalized in 116 patients. In the logistic regression analysis, only an age of less than 69 years (odds ratio [OR]: 0.98; 95% CI: 0.96–0.99; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>0.025), a non-ischemic HF etiology (OR: 1.12; 95% CI: 1.01–1.21; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>0.003), and the prescription of antialdosterone agents (OR: 1.89; 95% CI: 1.09–3.26; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>0.023) were associated with a LVEF normalization. The residual functional class after the first decompensation improved in 61.2% of the patients who achieved a normalized LVEF, and in 39.4% of those who did not achieve it (<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>0.000), with the rate of hospital admissions due to a decompensated HF (38.1% vs. 12.2% were admitted to the hospital at least once a year due to decompensation; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>0.000) and other causes (32.7% vs. 18.9%; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>0.000) being greater in this group. Two patients of the second group received a heart transplant.</p><p id="par0040" class="elsevierStylePara elsevierViewall">The cumulative mortality was calculated at 23.7% (102 cases), with an accumulated survival at 85 months of 76% in the group of patients who recovered a normal LVEF, and of 61% in the group of those who did not (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>A). LVEF normalization is an independent predictor of good prognosis (hazard ratio: 0.37; 95% CI: 0.21–0.67; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>0.002). The median survival rate was 85.2%<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>2.1%, and 74.2%<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>1.9% months, respectively (<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>0.001), with a greater mortality being observed in the survival curves of those patients who did not achieve a normalized LVEF since the beginning of the follow-up period. In contrast, none of the patients who achieved a normalized LVEF passed away before 20 months of follow-up (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>B). Regarding the etiology of the condition (<a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a>), among the group of patients who recovered a normal LVEF, the main causes of death were of neoplastic and infectious nature (26.7%, respectively), whereas refractory/terminal HF represented 20% of the cases (3 patients), and SCD 6.6% of them (1 case). In the group of patients with a persistently reduced LVEF, the main causes of death were terminal/refractory HF (36.8% of the cases), stroke (18.2%), and SCD (17.2%).</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><elsevierMultimedia ident="tbl0015"></elsevierMultimedia></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Discussion</span><p id="par0045" class="elsevierStylePara elsevierViewall">Our work describes the clinical profile and progress of patients with HF with a recovered LVEF based on the results obtained in a cohort of patients with HFrEF followed prospectively in a HFU of a non-tertiary hospital. As in the case of previous studies performed in the same setting but in tertiary hospitals,<a class="elsevierStyleCrossRefs" href="#bib0110"><span class="elsevierStyleSup">6,8</span></a> approximately one quarter of the patients of our study population achieved a normalized LVEF and, as reported in the past, this normalization mostly took place within the first few months of starting the follow-up and the specific treatment for HFrEF.<a class="elsevierStyleCrossRef" href="#bib0140"><span class="elsevierStyleSup">12</span></a> The baseline characteristics of these patients were slightly different owing to their younger age and their lower prevalence of ischemic heart disease, systemic atherosclerotic disease, and chronic kidney failure,<a class="elsevierStyleCrossRefs" href="#bib0100"><span class="elsevierStyleSup">4–7</span></a> and to their more favorable prognosis associated with lower mortality (particularly during the first months of follow-up) and hospitalization rates. In addition, the causes of death of these patients were mostly unrelated to the HF in comparison with those with a persistently reduced LVEF, whose deaths were mostly caused by cardiovascular problems or events related to the HF.</p><p id="par0050" class="elsevierStylePara elsevierViewall">To date, the determination of the LVEF allows for classifying patients with HF, although there is increasingly more evidence available confirming that their dichotomic categorization into 2 strict groups is outdated: a broader syndromic spectrum with multiple patient profiles that do not meet the typical criteria of what is traditionally known as HFrEF or HFpEF is now recognized.<a class="elsevierStyleCrossRef" href="#bib0145"><span class="elsevierStyleSup">13</span></a> In fact, the latest clinical practice guidelines mention this new evidence in their classification of HF.<a class="elsevierStyleCrossRefs" href="#bib0085"><span class="elsevierStyleSup">1,9</span></a> One of the subtypes included in this classification is HF with a normalized or recovered LVEF, an entity that was already described by the end of the last century based on data obtained in the first clinical trials demonstrating the clinical benefit of drugs that block the neurohormonal systems involved in HFrEF,<a class="elsevierStyleCrossRef" href="#bib0145"><span class="elsevierStyleSup">13</span></a> and on the improved knowledge about the evolution of many of the etiologies that cause HFrEF, which were not yet known to cause a deleterious effect on the systolic function.<a class="elsevierStyleCrossRefs" href="#bib0150"><span class="elsevierStyleSup">14–16</span></a> Nevertheless, no studies describing the clinical progress of this type of patients in the standard clinical practice had been published until recent years, and all patients involved had been referred from follow-up consultations carried out at a tertiary hospital.<a class="elsevierStyleCrossRefs" href="#bib0100"><span class="elsevierStyleSup">4–8</span></a></p><p id="par0055" class="elsevierStylePara elsevierViewall">Our results continue to support the theory that HF with a recovered LVEF represents a different subtype of HF than HFrEF and HFpEF, both in terms of their etiology and basal characteristics, and of their clinical progress and prognosis.<a class="elsevierStyleCrossRefs" href="#bib0105"><span class="elsevierStyleSup">5,8</span></a> However, from a pathophysiological viewpoint, this entity probably represents a form of HFrEF in a less advanced phase of the disease, or with a less significant type of myocardial damage, which allows either significant inverse ventricular remodeling by eliminating or attenuating the causative agent of the damage, or starting specific inhibitory treatment of the neurohormonal systems activated in HFrEF.<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">3</span></a> In this sense, it is important to consider the differences between the recovered myocardium and the remitted/normalized myocardium or with inverse remodeling, given that in the case of the recovered myocardium, although the LVEF may be normalized, the affected patients continue to show the phenotypic characteristics of persistent HF. In contrast, those patients who achieve complete remission of the cellular damage and normalization of their myocardium, apart from recovering a normal LVEF, also achieve a resolution of their symptoms of HF as a result of the deactivation of the neurohormonal systems.<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">5</span></a> Nevertheless, making a distinction between patients with a recovered myocardium and the few whose myocardial damage is in remission is complicated in the current daily clinical practice due to the lack of reliable clinical predictors to identify changes occurring at a cellular level. This is one of the most important matters to be clarified for the future, as identifying patients whose myocardial damage is in remission and, therefore, with a “healed” HF, would allow for treating them in a different manner both pharmacologically and in terms of the management of CRT devices to prevent SCD. Until then, it seems wise to continue following the current recommendations to continue prescribing specific treatment for HFrEF in all patients who have achieved a normalized LVEF.<a class="elsevierStyleCrossRefs" href="#bib0085"><span class="elsevierStyleSup">1,9</span></a></p><p id="par0060" class="elsevierStylePara elsevierViewall">To conclude, the authors of this manuscript are aware of the limitations of this study. The most significant ones are those related to the fact that this was a single-center, observational study performed in a HFU managed exclusively by cardiologists, which consequently entailed a selection bias during the inclusion of patients in the registry, and that it was descriptive, owing to which we lack the necessary information to draw conclusions in relation to the mechanisms involved in the phenomenon of systolic function recovery. Moreover, given that clinical progress data were recorded since the moment the patients were included in the follow-up, which is when they started to experience symptoms of HF, we are unaware of the full duration and characteristics of the disease during the subclinical period. Thus, the mortality analysis must be interpreted with the caution applied to a relatively small sample size and the lack of a comparative group with the same demographic characteristics as ours. We also wish to highlight the methodological limitations intrinsic to a non-tertiary hospital, as we lack serial information on the myocardial viability of a significant percentage of patients, which is why they were not included in the analysis.</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Conclusion</span><p id="par0065" class="elsevierStylePara elsevierViewall">The incidence of LVEF normalization in patients with HFrEF followed at a non-tertiary clinic was similar to that described in tertiary hospitals, with basal characteristics that differ from those of patients with a persistently reduced LVEF, as well as a more favorable evolution and prognosis. This supports the hypothesis that HF with a normalized LVEF represents a different subtype of HF. Further research should serve to confirm the natural history of this disease, and to define variables associated with a true remission of the disease and the role that continuing treatment for HFrEF would have on this condition.</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Conflicts of Interest</span><p id="par0070" class="elsevierStylePara elsevierViewall">The authors declare no conflicts of interest.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:11 [ 0 => array:3 [ "identificador" => "xres1136657" "titulo" => "Abstract" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Introduction" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Methods" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Results" ] 3 => array:2 [ "identificador" => "abst0020" "titulo" => "Conclusion" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec1068545" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres1136656" "titulo" => "Resumen" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0025" "titulo" => "Introducción" ] 1 => array:2 [ "identificador" => "abst0030" "titulo" => "Métodos" ] 2 => array:2 [ "identificador" => "abst0035" "titulo" => "Resultados" ] 3 => array:2 [ "identificador" => "abst0040" "titulo" => "Conclusión" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec1068546" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:2 [ "identificador" => "sec0010" "titulo" => "Methods" ] 6 => array:2 [ "identificador" => "sec0015" "titulo" => "Results" ] 7 => array:2 [ "identificador" => "sec0020" "titulo" => "Discussion" ] 8 => array:2 [ "identificador" => "sec0025" "titulo" => "Conclusion" ] 9 => array:2 [ "identificador" => "sec0030" "titulo" => "Conflicts of Interest" ] 10 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2018-03-06" "fechaAceptado" => "2018-05-03" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec1068545" "palabras" => array:3 [ 0 => "Heart failure with reduced ejection fraction" 1 => "Heart failure with preserved ejection fraction" 2 => "Heart failure with recovered ejection fraction" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec1068546" "palabras" => array:3 [ 0 => "Insuficiencia cardiaca con fracción de eyección reducida" 1 => "Insuficiencia cardiaca con fracción de eyección preservada" 2 => "Insuficiencia cardiaca con fracción de eyección recuperada" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:3 [ "titulo" => "Abstract" "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Introduction</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Heart failure (HF) with recovered ejection fraction (EF) is emerging as a different HF subtype. There is little information about his clinical profile in hospitals that are not a reference.</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Methods</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">We analyzed characteristics and prognosis in patients with recovered HF followed prospectively in the HF Unit of a non-tertiary hospital.</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Results</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">A total of 431 patients with HF with reduced EF were followed (median 50 months, 79.3% males, mean age 70.3<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>12.2<span class="elsevierStyleHsp" style=""></span>years). Of the patients, 26.9% (<span class="elsevierStyleItalic">N</span> 116) recovered EF, mainly in the first year of follow-up (76.7%). Compared with patients that did not recovered EF in the follow-up, they were younger, rate of ischemic origin of cardiomyopathy was less frequent and presented less comorbidity. Mortality was lower in patients with recovered HF (survival median of 85.2<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>2.1 vs. 74.2<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>1.9 months [log-rank <span class="elsevierStyleItalic">χ</span><span class="elsevierStyleSup">2</span> 11.5, <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>0.001], hazard ratio 0.37, 95% confidence interval [CI]: 0.21–0.67, <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>0.002). Etiology of deaths was not mainly secondary to HF. Younger age of 68 years (odds ratio [OR] 0–98, 95% CI: 0.96–0.99; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>0.025), ischemic origin (OR 1.12, 95% CI: 1.01–1.21; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>0.003) and use of aldosterone antagonists (OR 1.89, 95% CI: 1.09–3.26; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>0.023) were the variables independently associated to normalization of EF.</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Conclusion</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">HF with recovered EF is a frequent phenomenon. It has a more favorable clinical course, prognosis and basal characteristics than HF with persistent reduced EF. Further studies are needed to identify natural history and optimal medications for HF-recovered patients.</p></span>" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Introduction" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Methods" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Results" ] 3 => array:2 [ "identificador" => "abst0020" "titulo" => "Conclusion" ] ] ] "es" => array:3 [ "titulo" => "Resumen" "resumen" => "<span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Introducción</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">La insuficiencia cardiaca (IC) con fracción de eyección (FE) recuperada está emergiendo como un subtipo de IC diferenciada. Existe poca información sobre su perfil clínico en centros que no son referencia.</p></span> <span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Métodos</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Analizamos la evolución y pronóstico de los pacientes afectos de IC con FE recuperada seguidos prospectivamente en una unidad de IC de un hospital no terciario.</p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Resultados</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Se ha seguido a 431 pacientes con FE deprimida (mediana 50 meses; edad media de 70,3<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>12,2 años; el 79,3% eran varones.) El 26,9% normalizaron la FEVI; el 76,7% de ellos en el primer año. Comparados con los pacientes que no normalizaron la FEVI, eran más jóvenes, el origen isquémico de la IC era menos frecuente y presentaban menos comorbilidad. Su pronóstico es mejor (mediana de supervivencia 85,2<span class="elsevierStyleHsp" style=""></span>± 2,1<span class="elsevierStyleHsp" style=""></span>vs. 74,2<span class="elsevierStyleHsp" style=""></span>± 1,9 meses, log-rank χ<span class="elsevierStyleSup">2</span> 11,5; p = 0,001; <span class="elsevierStyleItalic">hazard ratio</span> de 0,37, intervalo de confianza [IC] del 95%: 0,21-0,67; p = 0,002). Las causas de muerte principalmente no estaban relacionadas con IC. Las variables predictoras de normalización de la FEVI fueron la edad (<span class="elsevierStyleItalic">odds ratio</span> [OR] para más de 69 años 0,98; IC 95%: 0,96-0,99; p = 0,025), origen no isquémico (OR 1,12; IC 95%: 1,01-1,21; p = 0,003) y prescripción de antialdosterónicos (OR 1,89; IC 95%: 1,05-3,26; p = 0,023).</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Conclusión</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">La normalización de la FE en pacientes con IC con FE reducida es frecuente y presenta unas características basales, evolución y pronóstico más favorables que la IC con persistencia de FE reducida. Investigaciones futuras deberán confirmar su historia natural y tratamiento óptimo.</p></span>" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0025" "titulo" => "Introducción" ] 1 => array:2 [ "identificador" => "abst0030" "titulo" => "Métodos" ] 2 => array:2 [ "identificador" => "abst0035" "titulo" => "Resultados" ] 3 => array:2 [ "identificador" => "abst0040" "titulo" => "Conclusión" ] ] ] ] "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Martínez-Mateo V, Fernández-Anguita M, Cejudo L, Martín-Barrios E, Paule AJ. Características y evolución de la insuficiencia cardiaca con función sistólica recuperada en un hospital no terciario. Med Clin (Barc). 2019;152:50–54.</p>" ] ] "multimedia" => array:5 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1198 "Ancho" => 2110 "Tamanyo" => 165544 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Flow diagram of the study participants.</p>" ] ] 1 => array:7 [ "identificador" => "fig0010" "etiqueta" => "Fig. 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 1240 "Ancho" => 2964 "Tamanyo" => 155049 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">Cumulative survival of the sample of patients, represented by Kaplan–Meier curves according to the LVEF normalization. Chi-squared log-rank 11.5 (<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>0.001) for the difference between the mortality of both groups (hazard ratio: 0.37; 95% CI: 0.21–0.67; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>0.002). LVEF is an abbreviation of left ventricular ejection fraction.</p>" ] ] 2 => array:8 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at1" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:1 [ "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="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Etiology \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Normalized LVEF (<span class="elsevierStyleItalic">N</span>: 116) expressed as <span class="elsevierStyleItalic">a</span>% \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Reduced LVEF (<span class="elsevierStyleItalic">N</span>: 315) expressed as <span class="elsevierStyleItalic">a</span>% \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black"><span class="elsevierStyleItalic">p</span>-Value \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Ischemic \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">31.3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">51.4 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">0.000 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Idiopathic \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">19.0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">19.7 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">NA \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Hypertensive \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">14.7 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">6.0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">0.023 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Tachycardiomyopathy \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">12.1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1.6 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">0.000 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Alcoholic \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">10.3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2.9 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">0.000 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Valvular \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">6.0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">5.1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">NA \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Anthracyclines \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">4.3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">4.8 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">NA \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1939363.png" ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">Main causes of heart failure.</p>" ] ] 3 => array:8 [ "identificador" => "tbl0010" "etiqueta" => "Table 2" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at2" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:2 [ "leyenda" => "<p id="spar0065" class="elsevierStyleSimplePara elsevierViewall">ARA II: angiotensin receptor antagonists; LBBB: left bundle branch block; ICD: implantable cardioverter defibrillator; LVEF: left ventricular ejection fraction; ACEI: angiotensin converting enzyme inhibitor; CRT: cardiac resynchronization therapy.</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="table-head " align="" valign="top" scope="col" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Normalized LVEF (<span class="elsevierStyleItalic">N</span>: 116) \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Reduced LVEF (<span class="elsevierStyleItalic">N</span>: 315) \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black"><span class="elsevierStyleItalic">p</span>-Value \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Age (years) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">64.3<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>12.3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">68.0<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>12.6 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">0.006 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Male sex \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">79.3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">79.4 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">NA \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Basal LVEF <30% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">69.8 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">70.2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">NA \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Functional class III \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">63.8 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">51.7 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">NA \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">LBBB \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">25 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">35 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">NA \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Atrial fibrillation \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">35.4 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">38.1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">NA \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Smoking habit \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">60.3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">61 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">NA \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">High blood pressure \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">55.2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">61.2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">NA \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Dyslipidemia \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">52.6 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">56.8 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">NA \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Diabetes mellitus \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">37.9 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">33.4 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">NA \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Chronic kidney failure \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">19 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">27.9 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">0.052 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Chronic obstructive pulmonary disease \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">23 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">33.7 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">0.048 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Peripheral arterial disease \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">15.1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">26.1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">0.074 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Beta-blockers \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">77.6 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">78.1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">NA \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Full doses of beta-blockers \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">45 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">35 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">0.065 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">ACEI/ARA II \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">95.7 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">75.2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">0.000 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Full doses of ACEI/ARA II \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">47 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">38 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">0.062 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Sacubitril/valsartan \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">16 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">0.000 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Aldosterone antagonists \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">56.4 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">57.1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">NA \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Ivabradine \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">15.5 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">10.2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">NA \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Digoxin \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">18.1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">14.9 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">NA \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">ICD \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">12.7 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">0.000 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">ICD-CRT \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">7.8 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">9.8 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">NA \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">CRT \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2.6 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1.3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">NA \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1939362.png" ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">Baseline characteristics of the patients, and treatment regimens used.</p>" ] ] 4 => array:8 [ "identificador" => "tbl0015" "etiqueta" => "Table 3" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at3" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:2 [ "leyenda" => "<p id="spar0075" class="elsevierStyleSimplePara elsevierViewall">LVEF: left ventricular ejection fraction; HF: heart failure; SCD: sudden cardiac death.</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="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Etiology \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Normalized LVEF (<span class="elsevierStyleItalic">N</span>: 15) \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Reduced LVEF (<span class="elsevierStyleItalic">N</span>: 85) \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black"><span class="elsevierStyleItalic">p</span>-Value \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Terminal/refractory HF \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">20.0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">36.8 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.041 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">SCD \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">6.6 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">17.2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.000 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Stroke \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">6.6 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">18.5 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.023 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Neoplastic \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">26.6 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">14.9 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.036 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Infectious \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">26.6 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">4.6 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.000 \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1939364.png" ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0070" class="elsevierStyleSimplePara elsevierViewall">Causes of mortality.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0015" "bibliografiaReferencia" => array:16 [ 0 => array:3 [ "identificador" => "bib0085" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "2016 ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure: The Task Force for the diagnosis and treatment of acute and chronic heart failure of the European Society of Cardiology (ESC) developed with the special contribution of the Heart Failure Association (HFA) of the ESC" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "P. 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