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Original article
Implementation of clinical practice guidelines for acute ischaemic stroke in specialist care centres
Implementación de las guías de práctica clínica sobre ictus isquémico agudo en atención especializada
A.J. Pardo Cabelloa,
Corresponding author
apardoc05@yahoo.es

Corresponding author.
, S. Bermudo Condea, V. Manzano Gamerob, F.J. Gómez Jiménezc, J. de la Higuera Torres-Pucholc
a Servicio de Medicina Interna, Hospital Universitario San Rafael, Granada, Spain
b Servicio de Medicina Interna, Hospital Universitario Virgen de las Nieves, Granada, Spain
c Departamento de Medicina, Universidad de Granada, Granada, Spain
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such as ischaemic heart disease&#44; have received more attention&#46; Regarding secondary prevention for cardiovascular disease&#44; the literature<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> reports that only 43&#37; of patients have well-controlled blood pressure&#44; while 51&#46;8&#37; have cholesterol levels within the recommended range and 70&#37; have good blood sugar levels&#46; Studies of treatment prescribed to patients with acute ischaemic stroke<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2&#44;3</span></a> reveal that 77&#37; to 83&#37; of these patients are treated with antiplatelet drugs while 17&#37; to 18&#37; are on anticoagulants&#59; statin drugs are prescribed to 11&#37; to 52&#37;&#46;<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2&#44;4</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">In 2008&#44; the Ministry of Health published clinical practice guidelines &#40;CPG&#41; for primary and secondary stroke prevention&#46;<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> For patients who are stable after having suffered ischaemic stroke or transient ischaemic attack &#40;TIA&#41;&#44; the guidelines recommend gradually decreasing blood pressure to reach a target of 130&#47;80<span class="elsevierStyleHsp" style=""></span>mm Hg &#40;grade B recommendation&#41;&#46; Ideally&#44; this is achieved through treatment with an angiotensin converting enzyme &#40;ACE&#41; inhibitor associated with a diuretic drug &#40;grade A recommendation&#41;&#46; Depending on the patient&#39;s tolerance and concomitant illnesses&#44; another approach may be monotherapy &#40;grade B recommendation&#41; with diuretics&#44; ace inhibitors&#44; or angiotensin II receptor blockers &#40;ARBs&#41;&#46; The guidelines also recommend prescribing atorvastatin at a dose of 80<span class="elsevierStyleHsp" style=""></span>mg&#47;day &#40;grade A recommendation&#41; or simvastatin at a dose of 40<span class="elsevierStyleHsp" style=""></span>mg&#47;day &#40;grade B recommendation&#41; in patients with ischaemic stroke or TIA due to an atherothrombotic cause&#44; regardless of baseline LDL cholesterol readings&#46; In patients with atrial fibrillation who have a prior history of stroke and no formal contraindications for treatment&#44; the CPG<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> recommends indefinite treatment with oral anticoagulation drugs with an INR of between 2 and 3 &#40;grade A recommendation&#41;&#46; For patients with ischaemic stroke or non-cardioembolic TIA&#44; the guidelines indicate antiplatelet treatment with aspirin&#44; triflusal&#44; clopidogrel&#44; or a combination of aspirin and slow-release dipyridamole &#40;grade A recommendation&#41;&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">The Spanish Society of Neurology&#39;s study group for cerebrovascular diseases recently published guidelines for preventative treatment of ischaemic stroke and TIA&#46;<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> This document coincides with the 2008 CPG<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> in recommending the following secondary stroke prevention measures&#58; blood pressure levels below 130&#47;80<span class="elsevierStyleHsp" style=""></span>mm Hg&#44; good blood sugar control in diabetics to achieve an HbA<span class="elsevierStyleInf">1c</span> below 7&#37;&#44; and LDL cholesterol levels below 100<span class="elsevierStyleHsp" style=""></span>mg&#47;dL &#40;below 70<span class="elsevierStyleHsp" style=""></span>mg&#47;dL in patients with known atherosclerosis&#41;&#46; These guidelines<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> also recommend that all patients who have suffered TIA or cerebral infarct due to atherothrombosis or small vessel disease receive treatment with 80<span class="elsevierStyleHsp" style=""></span>mg atorvastatin daily&#46; The second section of the guidelines published by the Spanish Society of Neurology<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a> recommends the use of antiplatelet drugs in the secondary prevention of ischaemic stroke associated with large vessel arteriosclerosis and small vessel disease&#46; Oral anticoagulants are also recommended for strokes of cardioembolic origin&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">Given that the most important Spanish studies on the implementation of secondary prevention measures for cerebrovascular disease<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2&#8211;4</span></a> pre-date the new CPG on stroke&#44;<a class="elsevierStyleCrossRefs" href="#bib0025"><span class="elsevierStyleSup">5&#8211;7</span></a> we decided to undertake a study of current compliance with the recommendations cited by the guidelines&#46; To this end&#44; we listed the following objectives&#58;</p><p id="par0030" class="elsevierStylePara elsevierViewall">-Describe the prevalence of vascular risk factors among hospitalised patients completing medium to long neurorehabilitation programmes following an acute ischaemic stroke&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">-Examine adherence to CPG recommendations for stroke prevention by analysing the degree of control over vascular risk factors&#44; anti-thrombotic treatment according to stroke aetiology &#40;atherothrombosis&#44; cardioembolism&#44; etc&#46;&#41;&#44; and antihypertensive&#47;statin treatment among the patients described above&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Patients and methods</span><p id="par0040" class="elsevierStylePara elsevierViewall">Hospital Universitario San Rafael &#40;Hospitaller Order of Saint John of God&#41; is a medium-to-long stay hospital&#46; Its patients include stroke patients in acute and subacute phases who are undergoing neurorehabilitation and&#47;or receiving care for clinical and functional sequelae&#46; These patients were referred from hospitals in the province of Granada&#46; We completed a descriptive transversal study with a view to the objectives described above and using the 2008 CPG for stroke<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> as our reference&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">Inclusion criteria&#58; patients of any age and either sex admitted by the Internal Medicine division of Hospital Universitario San Rafael in 2009 or 2010 with a primary diagnosis of acute ischaemic stroke&#46; Patients were selected by means of a search using Acticx software that filtered records to locate cases with the following diagnoses &#40;ICD-9&#41; upon admission&#58; hemiplegia and hemiparesis &#40;342&#41;&#44; stenosis of precerebral arteries &#40;433&#41;&#44; occlusion of cerebral arteries &#40;434&#41;&#44; ill-defined cerebrovascular disease &#40;436&#41;&#44; and other and ill-defined cerebrovascular disease &#40;437&#41;&#46;</p><p id="par0050" class="elsevierStylePara elsevierViewall">Exclusion criteria&#58; patients without a discharge report from the referring hospital and patients diagnosed with haemorrhagic stroke&#46;</p><p id="par0055" class="elsevierStylePara elsevierViewall">Study variables were age&#44; sex&#44; referring department &#40;neurology&#44; internal medicine&#44; rehabilitation&#44; or the emergency department&#41;&#44; and referring hospital&#46; We also recorded history of HTN&#44; type 2 diabetes mellitus &#40;DM-2&#41;&#44; dyslipidaemia &#40;when type was not specified in the discharge report&#41;&#44; high cholesterol&#44; high triglycerides&#44; prior stroke&#47;transient ischaemic attack &#40;TIA&#41;&#44; atrial fibrillation and smoking &#40;includes active smokers and former smokers&#41;&#46; Data included the admitting diagnosis from the referring hospital&#44; including aetiology of ischaemic stroke&#44; and the treatment prescribed&#46; Treatment information included whether or not intravenous fibrinolysis was performed&#44; any anti-platelet drugs prescribed&#44; any anticoagulants prescribed&#44; motive or explanation for not prescribing anticoagulants in cases of embolic stroke&#44; statin drugs and dose&#44; and antihypertensive drugs and type&#46; We also recorded any supplementary antihypertensive drugs &#40;those taken depending on blood pressure readings&#41; as indicated by the discharge report&#46; Data also include blood pressure readings &#40;measured with an OMRON M6 digital sphygmomanometer&#41; at time of admission to Hospital San Rafael&#44; plus fasting plasma glucose&#44; total cholesterol and triglyceride levels &#40;Hitachi 917&#41; from the first analysis performed at our centre&#46; HbA<span class="elsevierStyleInf">1c</span> levels to determine diabetes control are not included&#44; since this measurement is not routinely taken in all patients admitted to our hospital&#46; Likewise&#44; LDL cholesterol levels were not included due to data not being available for many of our patients&#44; while we did have total cholesterol data for all patients&#46;</p><p id="par0060" class="elsevierStylePara elsevierViewall">The following measurements were considered to indicate good control over cardiovascular risk factors&#44; according to CPGs for stroke<a class="elsevierStyleCrossRefs" href="#bib0025"><span class="elsevierStyleSup">5&#44;6</span></a> and vascular disease prevention<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a>&#58; blood pressure below 130&#47;80<span class="elsevierStyleHsp" style=""></span>mm Hg&#44; plasma glucose below 126<span class="elsevierStyleHsp" style=""></span>mg&#47;dL&#44; total cholesterol below 175<span class="elsevierStyleHsp" style=""></span>mg&#47;dL&#44; and triglycerides below 150<span class="elsevierStyleHsp" style=""></span>mg&#47;dL&#46;</p><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Statistical analysis</span><p id="par0065" class="elsevierStylePara elsevierViewall">Results for numerical variables were expressed as arithmetic means<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>standard deviation &#40;<span class="elsevierStyleItalic">X</span><span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>SD&#41; and categorical variables were given as frequencies &#40;&#37;&#41;&#46; The <span class="elsevierStyleItalic">t</span>-test was used to compare means of different numerical variables when population variances were equal&#46; The Welch <span class="elsevierStyleItalic">t</span>-test was used for samples with unequal variances&#46; Pearson&#39;s <span class="elsevierStyleItalic">&#967;</span><span class="elsevierStyleSup">2</span> test was employed to compare categorical variables&#59; Fisher&#39;s exact test was also used when necessary&#46; Values of <span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>&#46;05 were considered statistically significant&#46; Statistical analysis was performed using SPSS software version 15&#46;0&#46;</p></span></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Results</span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Demographical data&#44; services&#44; and referring hospitals</span><p id="par0070" class="elsevierStylePara elsevierViewall">The study includes data from 203 patients with a mean age of 75&#46;7<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>10&#46;3 years&#59; 56&#37; were women&#46; Mean age was significantly lower for male patients than for female patients &#40;71&#46;8<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>12&#46;2 years and 78&#46;8<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>7&#46;5 years&#44; respectively&#59; <span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>&#46;0001&#41;&#46; Patients were referred by the following units&#58; neurology &#40;75&#46;4&#37;&#41;&#44; internal medicine &#40;16&#46;7&#37;&#41;&#44; rehabilitation &#40;6&#46;9&#37;&#41;&#44; and emergency department&#47;other &#40;1&#37;&#41;&#46; Patients&#8217; referring hospitals were Hospital Cl&#237;nico San Cecilio &#40;72&#46;9&#37;&#41;&#44; which has a neurology department but no stroke unit&#59; Virgen de las Nieves Rehabilitation and Traumatology Centre &#40;20&#46;7&#37;&#41;&#44; which has a neurology department and a stroke unit&#59; Hospital Santa Ana in Motril&#59; &#40;3&#46;9&#37;&#41; and the Virgen de las Nieves General Hospital &#40;1&#46;5&#37;&#41;&#44; both of which lack neurology departments&#46;</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Ischaemic stroke aetiology and vascular risk factors</span><p id="par0075" class="elsevierStylePara elsevierViewall">Regarding ischaemic stroke aetiologies&#44; 31&#46;5&#37; were cardioembolic in origin&#59; 29&#46;6&#37; were atherothrombotic&#59; 8&#46;4&#37; were lacunar&#59; and in 30&#46;5&#37;&#44; the cause was either undetermined or unspecified &#40;either several causes were present or the study was incomplete&#41;&#46;</p><p id="par0080" class="elsevierStylePara elsevierViewall"><a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a> shows the prevalence of each of the vascular risk factors in the total study population and its subgroups broken down by stroke aetiology&#46; Patients with cardioembolic stroke were significantly older than patients with atherothrombotic stroke &#40;<span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>&#46;0001&#41;&#46; We also observed that patients with atherothrombotic stroke had a higher prevalence of type 2 DM than did patients with cardioembolic stroke &#40;<span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>&#46;001&#41;&#46; The latter group showed a higher prevalence of atrial fibrillation &#40;<span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>&#46;0001&#41;&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Antithrombotic treatment in secondary prevention of ischaemic stroke</span><p id="par0085" class="elsevierStylePara elsevierViewall"><a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a> displays the antithrombotic treatments prescribed &#40;fibrinolysis&#44; antiplatelet drugs&#44; and anticoagulants&#41; for the study total and the study population broken down by stroke aetiology&#46; Antiplatelet drugs were administered to 91&#46;7&#37; of the patients with atherothrombotic stroke&#44; while 59&#46;4&#37; of the patients with cardioembolic stroke were prescribed anticoagulants at therapeutic doses&#46; Patients with atherothrombotic stroke were significantly more likely to have a prescription for antiplatelet drugs than patients with cardioembolic stroke &#40;91&#46;7&#37; vs 35&#46;9&#37;&#44; <span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>&#46;0001&#41;&#46; Patients with cardioembolic stroke were more likely than those in the atherothrombotic group to receive anticoagulant drugs &#40;59&#46;4&#37; vs 5&#37;&#44; <span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>&#46;0001&#41;&#46; A comparison between cases of atherothrombotic stroke and those of undetermined aetiology revealed statistically significant differences in the use of antiplatelet drugs&#46; These drugs were more frequently prescribed to patients with atherothrombotic stroke &#40;<span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>&#46;006&#41;&#44; while anticoagulant treatment was more common in patients with an undetermined cause of stroke &#40;<span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>&#46;009&#41;&#46;</p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><p id="par0090" class="elsevierStylePara elsevierViewall">Our comparison of percentages of patients receiving antiplatelet drugs for atherothrombotic stroke according to whether they were referred by neurology or by internal medicine revealed no statistically significant differences &#40;90&#37; for neurology and 100&#37; for internal medicine&#59; <span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>&#46;738&#41;&#46; Likewise&#44; no significant differences could be detected between the percentages of patients on anticoagulants for cardioembolic stroke based on the referring department &#40;58&#46;5&#37; for neurology&#44; 55&#46;6&#37; for internal medicine&#59; <span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>&#46;573&#41;&#46;</p><p id="par0095" class="elsevierStylePara elsevierViewall">A total of 26 patients had cardioembolic stroke and no anticoagulant treatment &#40;40&#46;6&#37; of the total patients with that aetiology&#41;&#46; The reasons for not providing anticoagulants were listed in the reports for 14 of those patients &#40;53&#46;8&#37;&#41;&#58; high risk of haemorrhage or haemorrhagic transformation &#40;28&#46;5&#37;&#41;&#59; significant residual deficit &#40;28&#46;5&#37;&#41;&#59; and disease or poor baseline condition &#40;21&#46;4&#37;&#41;&#46;</p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Statin drugs in secondary prevention of ischaemic stroke</span><p id="par0100" class="elsevierStylePara elsevierViewall"><a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a> lists the percentages of patients treated with statins in keeping with CPG recommendations for stroke&#46;<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> Prescription of statins was significantly higher among patients with atherothrombotic stroke than among those with embolic stroke &#40;<span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>&#46;0001&#41;&#44; lacunar stroke &#40;<span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>&#46;028&#41; and stroke of undetermined cause &#40;<span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>&#46;0001&#41;&#46;</p><p id="par0105" class="elsevierStylePara elsevierViewall">An analysis of referring departments&#8217; prescription of statin drugs for patients with atherothrombotic stroke revealed no statistically significant differences &#40;62&#46;0&#37; for neurology&#59; 66&#46;7&#37; for internal medicine&#59; <span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>&#46;684&#41;&#46; Similarly&#44; there were no significant differences between referring departments regarding the percentage of patients treated with the recommended doses of atorvastatin or simvastatin &#40;74&#46;2&#37; for neurology vs 50&#37; for internal medicine&#44; <span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>&#46;477&#41;&#46;</p></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Diagnosis and treatment of hypertension as secondary stroke prevention</span><p id="par0110" class="elsevierStylePara elsevierViewall">A history of HTN was present in 68&#46;5&#37; of the patients in the total study population&#44; although 21&#46;1&#37; of the patients diagnosed with HTN did not receive antihypertensive drugs&#46; <a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a> lists the antihypertensive drug groups prescribed to all patients in the sample&#44; who are broken down by stroke aetiology&#46; Supplementary antihypertensive treatment was prescribed to 20&#37; of the patients &#40;captopril in 73&#46;8&#37; and labetalol in 16&#46;6&#37;&#41;&#46;</p><p id="par0115" class="elsevierStylePara elsevierViewall">Comparison of the antihypertensive drugs prescribed &#40;<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>&#41; reveals a stronger tendency towards prescribing beta blockers to patients with embolic stroke than to those with atherothrombotic stroke &#40;<span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>&#46;001&#41;&#59; ACE inhibitors were more common for patients with lacunar stroke than for those with thrombotic stroke &#40;<span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>&#46;026&#41;&#46; ARBs were more commonly prescribed to patients with thrombotic stroke than to those with a stroke of undetermined origin &#40;<span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>&#46;034&#41;&#46;</p></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Control over vascular risk factors in secondary prevention of ischaemic stroke</span><p id="par0120" class="elsevierStylePara elsevierViewall"><a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a> displays the descriptive and comparative studies of quantitative variables &#40;blood pressure&#44; fasting blood glucose&#44; and total cholesterol and triglycerides&#41; in the total study population&#44; broken down by stroke aetiology&#46; This table also shows the percentage of patients presenting a good degree of control over vascular risk factors upon admission&#46; Patients with cardioembolic stroke had significantly higher triglyceride levels than those with atherothrombotic stroke &#40;<span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>&#46;046&#41;&#46; We also found higher glucose levels in atherothrombotic stroke patients than in those with stroke of undetermined origin&#44; and the difference was statistically significant &#40;<span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>&#46;019&#41;&#46;</p><elsevierMultimedia ident="tbl0015"></elsevierMultimedia><p id="par0125" class="elsevierStylePara elsevierViewall">Comparison of the degree of control over vascular risk factors between patients referred by a neurology department and those referred by internal medicine did not reveal any statistically significant differences in the percentage of patients with good control over the following&#58; blood pressure &#40;51&#37; from the neurology department&#59; 55&#46;9&#37; from internal medicine&#44; <span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>&#46;605&#41;&#59; fasting plasma glucose &#40;72&#37; from neurology and 75&#46;8&#37; from internal medicine&#44; <span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>&#46;661&#41;&#59; cholesterol levels &#40;78&#46;2&#37; from neurology and 72&#46;7&#37; from internal medicine&#44; <span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>&#46;496&#41;&#59; and triglycerides &#40;73&#46;5&#37; from neurology and 72&#46;7&#37; from internal medicine&#44; <span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>&#46;931&#41;&#46;</p></span></span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Discussion</span><p id="par0130" class="elsevierStylePara elsevierViewall">From our point of view&#44; one of the study&#39;s limitations is that it was carried out in a single hospital&#46; However&#44; the fact that it included patients who had been referred by several different hospitals may increase its external validity and permit extrapolation of results&#46; Another of our study&#39;s limitations is the possible existence of a selection bias&#46; The study only included patients with ischaemic stroke requiring hospital rehabilitation due to sequelae&#44; and secondary prevention measures were probably applied less strictly to patients who had suffered greater clinical and functional impairment&#46; This may explain the percentage of patients with cardioembolic stroke and but no anticoagulant treatment&#44; and the fact that residual clinical and&#47;or functional impairment was one of the main reasons cited for not using anticoagulants&#46;</p><p id="par0135" class="elsevierStylePara elsevierViewall">In Spain&#44; as stated in the introduction&#44; several studies have addressed follow-up on secondary prevention measures for cerebrovascular disease&#46; The most relevant are DIAPRESIC<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> &#40;a multi-centre retrospective study promoted by the Spanish Society of Neurology&#39;s study group for cerebrovascular diseases and completed with data taken from the discharge reports of patients hospitalised for acute cerebral infarction&#41; and REACH<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> &#40;a record of vascular risk factor management among patients at risk for vascular events and with confirmed vascular&#47;cerebrovascular disease&#41;&#46;</p><p id="par0140" class="elsevierStylePara elsevierViewall">Regarding risk factors associated with acute ischaemic stroke&#44; our findings were similar to those described in the DIAPRESIC<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> study&#44; which calculated a prevalence of 62&#46;6&#37; for HTN&#44; 30&#46;6&#37; for type-2 DM&#44; and 29&#46;9&#37; for dyslipidaemia&#46; On the other hand&#44; our data did not support those from the REACH study&#46;<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> The cerebrovascular disease subgroup in REACH showed higher prevalence of HTN &#40;74&#46;8&#37;&#41;&#44; smoking &#40;54&#46;8&#37;&#41;&#44; and high cholesterol &#40;50&#46;3&#37;&#41;&#44; although the prevalence of type-2 DM was somewhat lower &#40;37&#46;2&#37;&#41;&#46;</p><p id="par0145" class="elsevierStylePara elsevierViewall">An interesting finding is that more than a third &#40;34&#37;&#41; of the total patients included in our study &#40;and 47&#37; of those with lacunar stroke&#41; had a prior history of stroke or TIA&#46; We therefore need to stress the importance and transcendence of secondary prevention in cerebrovascular disease&#46;</p><p id="par0150" class="elsevierStylePara elsevierViewall">When we compare antithrombotic drug prescriptions in our total population with those from the other 2 studies&#44; we see that a smaller percentage of our patients were prescribed antiplatelet drugs than in DIAPRESIC<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> &#40;77&#46;5&#37;&#41; or in REACH<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> &#40;83&#46;2&#37;&#41;&#46; Meanwhile&#44; a larger percentage of patients were treated with anticoagulants in our sample than in the DIAPRESIC<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> &#40;18&#46;4&#37;&#41; or the REACH studies<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> &#40;17&#46;9&#37;&#41;&#46;</p><p id="par0155" class="elsevierStylePara elsevierViewall">In contrast to the other 2 studies&#44;<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2&#44;4</span></a> our study provides a breakdown of population by stroke aetiology&#46; However&#44; we have found no studies published in Spain that evaluate use of anti-thrombotic drugs for secondary stroke prevention according to stroke aetiology&#46; Anti-platelet drugs were prescribed to more than 90&#37; of the patients with atherothrombotic stroke&#44; while anticoagulant drugs were only prescribed to 60&#37; of the patients with cardioembolic stroke&#46; We believe that the discrepancy between observations in our study and the CPG recommendations<a class="elsevierStyleCrossRefs" href="#bib0025"><span class="elsevierStyleSup">5&#44;7</span></a> on how anti-thrombotic drugs should be used depending on stroke aetiology arises because of multiple reasons&#46; These include the idea that anti-platelet drugs are more safe and incur less risk of haemorrhage than anticoagulants&#44; as well as being easier to dose and requiring fewer dose adjustments&#46; Although residual clinical and functional sequelae were not analysed in detail in this study &#40;leaving room for later studies to do so&#41;&#44; this may be yet another factor with a clear influence on the decision of whether or not to opt for anticoagulant treatment in certain patients with cardioembolic stroke added to a low risk of haemorrhage or haemorrhagic transformation&#46; We would like to stress that reasons for not providing anticoagulants to patients with cardioembolic stroke were only listed in half of such cases&#46; This information is crucial to understanding the treatment approaches of professionals who will be monitoring patients later on&#46;</p><p id="par0160" class="elsevierStylePara elsevierViewall">Our study also analysed the percentage of patients receiving statins dosed according to the CPG recommendations&#46;<a class="elsevierStyleCrossRefs" href="#bib0025"><span class="elsevierStyleSup">5&#44;7</span></a> Only 43&#46;4&#37; of patients with atherothrombotic stroke received atorvastatin and simvastatin at correct doses&#46; We therefore believe that the percentage of patients with atherothrombotic stroke who benefit from the prescription of these drugs remains low in our area&#46; It is interesting to note that although 65&#37; of patients with atherothrombotic stroke are treated with statins&#44; only 43&#46;4&#37; of them receive atorvastatin and simvastatin at their recommended doses&#46; We cannot offer an explanation for this observation&#46; Returning to earlier studies&#44; REACH<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> reported that statins were administered to 51&#46;9&#37; of the patients with cerebrovascular disease &#40;aetiology was not specified&#41;&#46; The same figure in the DIAPRESIC<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> study was 53&#46;8&#37; among patients with a prior history of dyslipidaemia&#46;</p><p id="par0165" class="elsevierStylePara elsevierViewall">Our study also reported a higher percentage of patients with HTN and anti-hypertensive treatment than was indicated by the DIAPRESIC study<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> &#40;73&#46;2&#37;&#41;&#46; The most commonly prescribed antihypertensive drugs in our sample were ACE inhibitors&#44; followed by diuretics and beta-blockers&#46; This was in line with CPG recommendations&#44;<a class="elsevierStyleCrossRefs" href="#bib0025"><span class="elsevierStyleSup">5&#44;6</span></a> which report a lower risk of stroke recurrence with a combination of perindopril and indapamide<a class="elsevierStyleCrossRefs" href="#bib0025"><span class="elsevierStyleSup">5&#44;6</span></a> or with ramipril<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> or a diuretic<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> in monotherapy&#46; Our results resemble those from the DIAPRESIC study<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> in which use of ACE inhibitors &#40;56&#46;5&#37;&#41; and diuretics &#40;27&#46;8&#37;&#41; predominated&#46; The current study also recorded supplementary antihypertensive treatment&#44; prescribed to 20&#46;1&#37; of the patients&#59; this type of treatment was not included in earlier studies&#46;</p><p id="par0170" class="elsevierStylePara elsevierViewall">Regarding control over vascular risk factors&#44; we found a higher percentage of patients with good blood pressure levels in our sample &#40;52&#46;2&#37;&#41; than in the REACH study<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> &#40;only 42&#46;9&#37; of these subjects had blood pressure levels below 140&#47;90<span class="elsevierStyleHsp" style=""></span>mm Hg&#46; However&#44; we believe that still more can be done to bring blood pressure under control and meet the objectives stated in the CPG&#46;<a class="elsevierStyleCrossRefs" href="#bib0025"><span class="elsevierStyleSup">5&#44;6</span></a> Results for glucose and lipid control were also better than those in the REACH study&#44; which reported glucose below 126<span class="elsevierStyleHsp" style=""></span>mg&#47;dL in 69&#46;9&#37; of the patients&#44; cholesterol levels above 200<span class="elsevierStyleHsp" style=""></span>mg&#47;dL in 48&#46;2&#37;&#44; and triglycerides above 150<span class="elsevierStyleHsp" style=""></span>mg&#47;dL in 31&#46;5&#37;&#46; When examining lipid control&#44; we should stress that the percentage of patients with good control over cholesterol levels could be underestimated&#46; Cholesterol was measured upon the patient&#39;s admission to our hospital&#59; in some cases&#44; patients&#8217; lipid-lowering treatment would not have had enough time to produce an effect&#46;</p><p id="par0175" class="elsevierStylePara elsevierViewall">We found no significant differences in prescription tendencies for antithrombotic&#44; antihypertensive&#44; or statin drugs&#46; Likewise&#44; there were no differences in the degree of control over vascular risk factors regarding the referring department &#40;neurology or internal medicine&#41;&#46; Lack of such differences may lie in the fact that a large percentage of the patients referred by neurology departments came from a hospital with no stroke unit &#40;Hospital Cl&#237;nico San Cecilio&#41;&#46; In contrast&#44; the Virgen de las Nieves Rehabilitation and Traumatology Centre&#44; which has a stroke unit&#44; referred fewer patients&#46;</p><p id="par0180" class="elsevierStylePara elsevierViewall">In summary&#44; from the viewpoint of clinical practice&#44; our study points to better control over vascular risk factors and improvements in the treatments prescribed for secondary prevention among patients with acute ischaemic stroke&#46; However&#44; we believe that further progress may still be made&#44; especially by increasing the percentage of patients with cardioembolic stroke treated with anticoagulants&#44; prescribing statins at the recommended doses for the subgroup of patients with atherothrombotic stroke&#44; and increasing the percentage of patients with well-controlled blood pressure&#46; Given that more than a third of the stroke patients included in our study had experienced a prior episode of cerebral ischaemia&#44; we believe it important to stress the importance and transcendence of secondary prevention&#46; This will aid in avoiding an illness with high morbidity and mortality rates and a huge social and healthcare burden owing to the dependency that it may provoke&#46;</p></span><span id="sec0060" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Conflicts of interest</span><p id="par0185" class="elsevierStylePara elsevierViewall">The authors have no conflicts of interest to declare&#46;</p></span></span>"
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          "titulo" => "Patients and methods"
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              "titulo" => "Statistical analysis"
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          "titulo" => "Results"
          "secciones" => array:6 [
            0 => array:2 [
              "identificador" => "sec0025"
              "titulo" => "Demographical data&#44; services&#44; and referring hospitals"
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              "identificador" => "sec0030"
              "titulo" => "Ischaemic stroke aetiology and vascular risk factors"
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            2 => array:2 [
              "identificador" => "sec0035"
              "titulo" => "Antithrombotic treatment in secondary prevention of ischaemic stroke"
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              "identificador" => "sec0040"
              "titulo" => "Statin drugs in secondary prevention of ischaemic stroke"
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              "identificador" => "sec0045"
              "titulo" => "Diagnosis and treatment of hypertension as secondary stroke prevention"
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            5 => array:2 [
              "identificador" => "sec0050"
              "titulo" => "Control over vascular risk factors in secondary prevention of ischaemic stroke"
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          "titulo" => "Discussion"
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          "titulo" => "Conflicts of interest"
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          "titulo" => "Acknowledgements"
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          "titulo" => "References"
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    "fechaRecibido" => "2011-11-11"
    "fechaAceptado" => "2012-04-03"
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          "clase" => "keyword"
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          "palabras" => array:6 [
            0 => "Stroke"
            1 => "Diabetes mellitus"
            2 => "Risk factors"
            3 => "Hypercholesterolaemia"
            4 => "Hypertension"
            5 => "Cerebral infarction"
          ]
        ]
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          "palabras" => array:6 [
            0 => "Accidente cerebrovascular"
            1 => "Diabetes mellitus"
            2 => "Factores de riesgo"
            3 => "Hipercolesterolemia"
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        "titulo" => "Abstract"
        "resumen" => "<span class="elsevierStyleSectionTitle">Introduction</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Cerebrovascular disease is associated with high morbidity and mortality&#46; In 2008&#44; the Spanish Ministry of Health published its Clinical Practice Guidelines for stroke prevention&#44; but implementation of that document has not yet been assessed&#46; Our study aims to investigate compliance with the Guidelines by analysing control over vascular risk factors&#44; antithrombotic treatment and lipid lowering treatment in patients who had suffered an acute ischaemic stroke and who were under the care of neurologists or internists&#46;</p> <span class="elsevierStyleSectionTitle">Methods</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Cross-sectional study based on data from clinical reports &#40;vascular risk factors&#44; diagnosis and treatment&#41;&#44; blood pressure readings and laboratory tests pertaining to 203 patients diagnosed with acute ischaemic stroke and admitted to a medium-to-long stay hospital for rehabilitation and care&#46;</p> <span class="elsevierStyleSectionTitle">Results</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">The mean patient age was 75<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>10 years&#59; 56&#37; were women&#46; The most common risk factors were hypertension &#40;68&#37;&#41; and diabetes mellitus &#40;40&#37;&#41;&#46; Intravenous fibrinolytic therapy had been administered to 8&#46;9&#37; of the patients&#46; Of the patients with thrombotic cerebral infarction&#44; 91&#46;7&#37; received antiplatelet agents&#59; 59&#46;4&#37; of patients with embolic infarction received anticoagulants&#46; Statins were prescribed to 65&#37; of patients with thrombotic infarction&#46; Laboratory tests upon admission showed that 23&#37; of patients had total cholesterol levels above 175<span class="elsevierStyleHsp" style=""></span>mg&#47;dl and 26&#46;6&#37; had plasma glucose levels above 126<span class="elsevierStyleHsp" style=""></span>mg&#47;dl&#46; Of the patient total&#44; 70&#37; received antihypertensive therapy&#44; but 47&#46;5&#37; had blood pressure levels above 130&#47;80<span class="elsevierStyleHsp" style=""></span>mm Hg&#46;</p> <span class="elsevierStyleSectionTitle">Conclusions</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">In our opinion&#44; secondary prevention of acute cerebrovascular disease could be improved&#44; mainly by increasing the percentage of patients treated with antiplatelet or anticoagulant drugs &#40;depending on aetiology&#41;&#44; increasing prescription of statins&#44; and improving blood pressure control&#46;</p>"
      ]
      "es" => array:2 [
        "titulo" => "Resumen"
        "resumen" => "<span class="elsevierStyleSectionTitle">Introducci&#243;n</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">La enfermedad cerebrovascular se asocia a una elevada morbimortalidad&#46; En el a&#241;o 2008&#44; el Ministerio de Sanidad public&#243; la &#171;Gu&#237;a de pr&#225;ctica cl&#237;nica&#187; sobre prevenci&#243;n del ictus sin que se haya evaluado su implementaci&#243;n&#46; Nos planteamos investigar el seguimiento de dicha gu&#237;a a trav&#233;s del an&#225;lisis del control de factores de riesgo vascular y el tratamiento antitromb&#243;tico e hipolipemiante en pacientes con ictus isqu&#233;mico agudo atendidos por neur&#243;logos o internistas&#46;</p> <span class="elsevierStyleSectionTitle">M&#233;todos</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Estudio transversal descriptivo basado en los datos obtenidos de informes cl&#237;nicos &#40;factores de riesgo vascular&#44; diagn&#243;stico y tratamientos&#41;&#44; cifras tensionales y anal&#237;ticas de 203 pacientes con diagn&#243;stico principal de ictus isqu&#233;mico agudo que ingresaron para rehabilitaci&#243;n y cuidados en un hospital de media-larga estancia&#46;</p> <span class="elsevierStyleSectionTitle">Resultados</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">La edad media<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>DE de los pacientes incluidos fue de 75<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>10 a&#241;os con un 56&#37; de mujeres&#46; Los factores de riesgo m&#225;s frecuentes fueron hipertensi&#243;n arterial &#40;68&#37;&#41; y diabetes mellitus &#40;40&#37;&#41;&#46; El 8&#44;9&#37; de los pacientes hab&#237;a recibido fibrin&#243;lisis por v&#237;a intravenosa&#46; El 91&#44;7&#37; de los pacientes con ictus aterotromb&#243;tico recib&#237;a antiagregantes&#59; el 59&#44;4&#37; de los pacientes con ictus cardioemb&#243;lico estaba anticoagulado&#46; Se prescribieron estatinas al 65&#37; de los pacientes con ictus aterotromb&#243;tico&#46; En la anal&#237;tica de ingreso&#44; el 23&#37; de los pacientes presentaba una colesterolemia total mayor de 175<span class="elsevierStyleHsp" style=""></span>mg&#47;dl y el 26&#44;6&#37; una glucemia plasm&#225;tica mayor de 126<span class="elsevierStyleHsp" style=""></span>mg&#47;dl&#46; El 70&#37; de los pacientes ten&#237;a tratamiento antihipertensivo&#44; aunque el 47&#44;5&#37; presentaba cifras tensionales mayores de 130&#47;80<span class="elsevierStyleHsp" style=""></span>mmHg&#46;</p> <span class="elsevierStyleSectionTitle">Conclusiones</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">Creemos que a&#250;n es posible mejorar la prevenci&#243;n secundaria en enfermedad cerebrovascular&#44; principalmente aumentando el porcentaje de pacientes tratados con antiagregantes o anticoagulantes seg&#250;n la etiolog&#237;a&#44; la prescripci&#243;n de estatinas y mejorando el control tensional&#46;</p>"
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        "nota" => "<p class="elsevierStyleNotepara">Please cite this article as&#58; Pardo Cabello AJ&#44; et al&#46; Implementaci&#243;n de las gu&#237;as de pr&#225;ctica cl&#237;nica sobre ictus isqu&#233;mico agudo en atenci&#243;n especializada&#46; Neurolog&#237;a&#46; 2013&#59;28&#58;137&#8211;44&#46;</p>"
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          "leyenda" => "<p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">TIA&#58; transient ischaemic attack&#59; <span class="elsevierStyleItalic">X</span><span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>SD&#58; mean<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>standard deviation&#46;</p>"
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                  \t\t\t\t" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t" style="border-bottom: 2px solid black">Total population&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t" style="border-bottom: 2px solid black">Atherothrombotic stroke&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t" style="border-bottom: 2px solid black">Cardioembolic stroke&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t" style="border-bottom: 2px solid black">Stroke&#44; undetermined&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">203&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">60&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">64&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">79&#46;7<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>7&#46;6<a class="elsevierStyleCrossRef" href="#tblfn0005"><span class="elsevierStyleSup">&#42;</span></a>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">6 &#40;10&#46;0&#41;&nbsp;\t\t\t\t\t\t\n
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          "leyenda" => "<p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">ASA&#58; acetylsalicylic acid&#59; OAC&#58; oral anticoagulants&#59; ARB&#58; angiotensin II receptor blockers&#59; LMWH&#58; low molecular-weight heparin&#59; ACE inhibitors&#58; angiotensin converter enzyme inhibitors&#46;</p><p id="spar0065" class="elsevierStyleSimplePara elsevierViewall">Dual antiplatelet therapy refers to use of ASA in conjunction with clopidogrel&#46; The dose of LMWH indicated for anticoagulation corresponds to enoxaparin at 1<span class="elsevierStyleHsp" style=""></span>mg&#47;kg&#47;12<span class="elsevierStyleHsp" style=""></span>hours or bemiparin at 115<span class="elsevierStyleHsp" style=""></span>U&#47;kg&#47;day&#46; Thromboprophylaxis refers to treatment with enoxaparin at 20 or 40<span class="elsevierStyleHsp" style=""></span>mg&#47;day or bemiparin at 2500 or 3500<span class="elsevierStyleHsp" style=""></span>U&#47;day&#46;</p>"
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                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">Lacunar stroke&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
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                  \t\t\t\t">203&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">60&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t">64&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
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                  \t\t\t\t">17&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
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                  \t\t\t\t">62&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Fibrinolysis&#44; <span class="elsevierStyleItalic">n</span> &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t">18 &#40;8&#46;9&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttop\n
                  \t\t\t\t">8 &#40;13&#46;3&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">8 &#40;12&#46;5&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0 &#40;0&#46;0&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2 &#40;3&#46;2&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Antiplatelet drugs&#44; <span class="elsevierStyleItalic">n</span> &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
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                  \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">139 &#40;68&#46;5&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t">55 &#40;91&#46;7&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">23 &#40;35&#46;9&#41;<a class="elsevierStyleCrossRef" href="#tblfn0015"><span class="elsevierStyleSup">&#42;</span></a>&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 &#40;100&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">44 &#40;70&#46;9&#41;<a class="elsevierStyleCrossRef" href="#tblfn0025"><span class="elsevierStyleSup">&#42;&#42;&#42;</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">ASA&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">120 &#40;59&#46;1&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">44 &#40;73&#46;3&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">22 &#40;34&#46;4&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">13 &#40;76&#46;5&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">41 &#40;66&#46;1&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Clopidogrel&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">26 &#40;12&#46;8&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">13 &#40;21&#46;7&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2 &#40;3&#46;1&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">4 &#40;23&#46;5&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">7 &#40;11&#46;3&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Dual antiplatelet therapy&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">7 &#40;3&#46;4&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2 &#40;3&#46;3&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1 &#40;1&#46;6&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0 &#40;0&#46;0&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">4 &#40;6&#46;5&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Thromboprophylaxis&#44; <span class="elsevierStyleItalic">n</span> &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">130 &#40;64&#46;0&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">46 &#40;76&#46;7&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">25 &#40;39&#46;1&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">12 &#40;70&#46;6&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">47 &#40;75&#46;8&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Anticoagulant therapy&#44; <span class="elsevierStyleItalic">n</span> &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">54 &#40;26&#46;6&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">3 &#40;5&#46;0&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">38 &#40;59&#46;4&#41;<a class="elsevierStyleCrossRef" href="#tblfn0015"><span class="elsevierStyleSup">&#42;</span></a>&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 &#40;0&#46;0&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">13 &#40;21&#46;0&#41;<a class="elsevierStyleCrossRef" href="#tblfn0025"><span class="elsevierStyleSup">&#42;&#42;&#42;</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">OAC&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 &#40;18&#46;2&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0 &#40;0&#46;0&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">28 &#40;43&#46;8&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">LMWH&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">5 &#40;8&#46;1&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
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                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Statins&#44; <span class="elsevierStyleItalic">n</span> &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">77 &#40;37&#46;9&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">16 &#40;25&#41;<a class="elsevierStyleCrossRef" href="#tblfn0015"><span class="elsevierStyleSup">&#42;</span></a>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">6 &#40;35&#46;3&#41;<a class="elsevierStyleCrossRef" href="#tblfn0020"><span class="elsevierStyleSup">&#42;&#42;</span></a>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">16 &#40;25&#46;8&#41;<a class="elsevierStyleCrossRef" href="#tblfn0025"><span class="elsevierStyleSup">&#42;&#42;&#42;</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
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                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Atorvastatin 80<span class="elsevierStyleHsp" style=""></span>mg&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">9 &#40;14&#46;5&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">Simvastatin 40<span class="elsevierStyleHsp" style=""></span>mg&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">1 &#40;1&#46;7&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">Other&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t">36 &#40;17&#46;7&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">13 &#40;21&#46;7&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">6 &#40;9&#46;7&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">Antihypertensive drugs&#44; <span class="elsevierStyleItalic">n</span> &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">35 &#40;56&#46;5&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Monotherapy&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t">22 &#40;36&#46;7&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">Polytherapy&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t">64 &#40;31&#46;5&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">19 &#40;31&#46;7&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">24 &#40;37&#46;5&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">6 &#40;35&#46;3&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">15 &#40;24&#46;2&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">ACE inhibitors&#44; <span class="elsevierStyleItalic">n</span> &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">89 &#40;43&#46;8&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">24 &#40;40&#46;0&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">27 &#40;42&#46;2&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">12 &#40;70&#46;6&#41;<a class="elsevierStyleCrossRef" href="#tblfn0020"><span class="elsevierStyleSup">&#42;&#42;</span></a>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">26 &#40;41&#46;9&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">ARBs&#44; <span class="elsevierStyleItalic">n</span> &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">23 &#40;11&#46;3&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">10 &#40;16&#46;7&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">7 &#40;10&#46;9&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">3 &#40;17&#46;6&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t">3 &#40;4&#46;8&#41;<a class="elsevierStyleCrossRef" href="#tblfn0025"><span class="elsevierStyleSup">&#42;&#42;&#42;</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">Calcium channel blockers&#44; <span class="elsevierStyleItalic">n</span> &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">25 &#40;12&#46;3&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">7 &#40;11&#46;7&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">7 &#40;10&#46;9&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">4 &#40;23&#46;5&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
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                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t">Beta-blocker&#44; <span class="elsevierStyleItalic">n</span> &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">33 &#40;16&#46;3&#41;&nbsp;\t\t\t\t\t\t\n
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                      "titulo" => "Control de factores de riesgo y tratamiento de la aterotrombosis&#46; Registro REACH Espa&#241;a"
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                            0 => "C&#46; Su&#225;rez"
                            1 => "M&#46; Cairols"
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                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Factores de riesgo vascular en pacientes con ictus isqu&#233;mico&#46; Distribuci&#243;n seg&#250;n edad&#44; sexo y subtipo de ictus"
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                          "etal" => true
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                            1 => "A&#46; Garc&#237;a-Raso"
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                            4 => "E&#46; Meseguer"
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                  ]
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                      "titulo" => "Diagn&#243;stico y prevenci&#243;n secundaria del infarto cerebral en Espa&#241;a&#46; Estudio DIAPRESIC"
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                        ]
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                    ]
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                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Gu&#237;a para el tratamiento preventivo del ictus isqu&#233;mico y AIT &#40;I&#41;&#46; Actuaci&#243;n sobre los factores de riesgo y estilo de vida"
                      "autores" => array:1 [
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                          "etal" => true
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                            0 => "B&#46; Fuentes"
                            1 => "J&#46; Gallego"
                            2 => "A&#46; Gil-Nu&#241;ez"
                            3 => "A&#46; Morales"
                            4 => "F&#46; Purroy"
                            5 => "J&#46; Roquer"
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                      "doi" => "10.1016/j.nrl.2011.06.002"
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                        "fecha" => "2011"
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                      "titulo" => "Gu&#237;as de pr&#225;ctica cl&#237;nica sobre prevenci&#243;n de la enfermedad cardiovascular&#58; versi&#243;n resumida"
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                            2 => "K&#46; Borch-Johnsen"
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                            4 => "G&#46; Burell"
                            5 => "R&#46; Cifkova"
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                      "Revista" => array:5 [
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        "texto" => "<p id="par0190" class="elsevierStylePara elsevierViewall">We would like to thank Dr Vanessa P&#233;rez Arco from the Medical Reporting Service at Hospital San Rafael for helping us manage the medical histories used in the preparation of this study&#46;</p>"
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Article information
ISSN: 21735808
Original language: English
DOI:10.1016/j.nrleng.2012.04.011
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2022 September 19 19 38
2022 August 32 9 41
2022 July 17 7 24
2022 June 17 7 24
2022 May 23 7 30
2022 April 29 13 42
2022 March 36 13 49
2022 February 22 5 27
2022 January 30 6 36
2021 December 6 9 15
2021 November 19 9 28
2021 October 18 10 28
2021 September 17 12 29
2021 August 24 12 36
2021 July 16 11 27
2021 June 9 5 14
2021 May 29 4 33
2021 April 35 12 47
2021 March 24 8 32
2021 February 16 7 23
2021 January 20 17 37
2020 December 16 9 25
2020 November 8 5 13
2020 October 12 7 19
2020 September 8 11 19
2020 August 17 9 26
2020 July 9 8 17
2020 June 9 10 19
2020 May 7 7 14
2020 April 11 6 17
2020 March 6 3 9
2020 February 10 1 11
2020 January 12 6 18
2019 December 10 6 16
2019 November 6 7 13
2019 October 12 2 14
2019 September 13 4 17
2019 August 7 2 9
2019 July 16 7 23
2019 June 32 4 36
2019 May 116 20 136
2019 April 33 6 39
2019 March 11 2 13
2019 February 11 7 18
2019 January 19 6 25
2018 December 11 10 21
2018 November 18 5 23
2018 October 14 14 28
2018 September 13 5 18
2018 August 14 0 14
2018 July 2 0 2
2018 June 2 2 4
2018 May 9 2 11
2018 April 4 2 6
2018 March 6 0 6
2018 February 3 0 3
2018 January 1 18 19
2017 December 1 2 3
2017 November 4 3 7
2017 October 9 1 10
2017 September 20 1 21
2017 August 11 4 15
2017 July 12 2 14
2017 June 15 2 17
2017 May 18 6 24
2017 April 16 9 25
2017 March 7 14 21
2017 February 10 1 11
2017 January 19 1 20
2016 December 7 5 12
2016 November 4 4 8
2016 October 18 6 24
2016 September 5 11 16
2016 August 13 3 16
2016 July 12 2 14
2016 June 11 6 17
2016 May 17 15 32
2016 April 12 13 25
2016 March 19 21 40
2016 February 16 12 28
2016 January 8 9 17
2015 December 12 5 17
2015 November 12 3 15
2015 October 16 4 20
2015 September 18 7 25
2015 August 6 6 12
2015 July 14 4 18
2015 June 8 1 9
2015 May 11 7 18
2015 April 11 8 19
2015 March 25 5 30
2015 February 20 1 21
2015 January 27 8 35
2014 December 35 9 44
2014 November 16 3 19
2014 October 21 7 28
2014 September 16 2 18
2014 August 30 6 36
2014 July 20 2 22
2014 June 25 1 26
2014 May 18 6 24
2014 April 11 3 14
2014 March 21 4 25
2014 February 9 3 12
2014 January 14 9 23
2013 December 19 4 23
2013 November 17 2 19
2013 October 29 7 36
2013 September 20 5 25
2013 August 41 7 48
2013 July 32 6 38
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Neurología

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

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

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