Prognostic value of ambulatory blood pressure values in elderly patients with heart failure. Results of the DICUMAP study

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Resultados del estudio DICUMAP" "tienePdf" => "es" "tieneTextoCompleto" => "es" "tieneResumen" => array:2 [ 0 => "es" 1 => "en" ] "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "433" "paginaFinal" => "440" ] ] "titulosAlternativos" => array:1 [ "en" => array:1 [ "titulo" => "Prognostic value of ambulatory blood pressure values in elderly patients with heart failure. Results of the DICUMAP study" ] ] "contieneResumen" => array:2 [ "es" => true "en" => true ] "contieneTextoCompleto" => array:1 [ "es" => true ] "contienePdf" => array:1 [ "es" => true ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figura 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1429 "Ancho" => 2167 "Tamanyo" => 86793 ] ] "descripcion" => array:1 [ "es" => "Curva de supervivencia (días sin muerte ni reingreso) según el patrón dipper de presión arterial nocturna. La prueba del rango logarítmico reveló que la diferencia observada en la curva de Kaplan-Meier fue estadísticamente significativa (ji al cuadrado, 5,131; p=0,024)." ] ] ] "autores" => array:2 [ 0 => array:2 [ "autoresLista" => "M. Camafort, P.S. Jhund, F. Formiga, A. Castro-Salomó, J.C. Arévalo-Lorido, J. Sobrino-Martínez, L. Manzano, J. 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Abbreviations: Rec D (recreational drugs, except alcohol); Pharm (pharmaceuticals); Gas (poisonous gases); OH (alcohol); Nat Pro (natural products: mushrooms, plants, venomous animals); Chem Pro (chemical, domestic, industrial products). X axis: age groups. Y axis: percentage observed according to each group." ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "J. Puiguriguer Ferrando, S. Miralles Corrales, G. Frontera Juan, C. Campillo-Artero, B. Barceló Martín" "autores" => array:5 [ 0 => array:2 [ "nombre" => "J." "apellidos" => "Puiguriguer Ferrando" ] 1 => array:2 [ "nombre" => "S." "apellidos" => "Miralles Corrales" ] 2 => array:2 [ "nombre" => "G." "apellidos" => "Frontera Juan" ] 3 => array:2 [ "nombre" => "C." "apellidos" => "Campillo-Artero" ] 4 => array:2 [ "nombre" => "B." 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Resultados del estudio DICUMAP" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:8 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1429 "Ancho" => 2167 "Tamanyo" => 86793 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0025" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "Survival curve (days free of death or readmission) according to dipper pattern of nighttime blood pressure. The log rank test showed that the difference observed in the Kaplan–Meier curve was statistically significant (chi-square 5.131, p=.024)." ] ] ] "textoCompleto" => "IntroductionHeart failure (HF) is one of the main health problems in our setting<a class="elsevierStyleCrossRefs" href="#bib0005">1,2</a> and one of the main reasons for hospital admission in the developed world.<a class="elsevierStyleCrossRef" href="#bib0015">3</a>The role of hypertension in the development and prognosis of HF is well-known.<a class="elsevierStyleCrossRef" href="#bib0020">4</a> Epidemiological studies show that 75% of patients with HF have a history of hypertension and, in subjects with blood pressure (BP)>160/90mmHg, the probability of HF is double that of those with BP<140/90mmHg.<a class="elsevierStyleCrossRef" href="#bib0005">1</a> Hypertension modulates the natural history of HF and is a relevant prognostic factor.<a class="elsevierStyleCrossRefs" href="#bib0025">5,6</a>There are known to be compensatory neurohormonal changes in HF that alter BP levels and patterns as well as heart rate patterns.<a class="elsevierStyleCrossRef" href="#bib0035">7</a> These changes can cause poor hypertension control, which can precipitate the decompensation of HF.<a class="elsevierStyleCrossRef" href="#bib0040">8</a> Lower clinical BP levels have been associated with a worse prognosis of HF,<a class="elsevierStyleCrossRefs" href="#bib0045">9,10</a> although most available data are based on BP levels measured in doctor’s offices. However, home BP measurement using ambulatory blood pressure monitoring (ABPM) or self-measured BP (SMBP) improves the accuracy and reproducibility of these measures,<a class="elsevierStyleCrossRef" href="#bib0055">11</a> meaning that ABPM may assess cardiovascular prognosis better than office BP measurement in hypertensive patients without cardiovascular disease.<a class="elsevierStyleCrossRef" href="#bib0060">12</a>However, there are few studies on the prognostic value of ABPM in HF to date, and those that do exist include a small number of patients and often focus on this issue in a peripheral manner. Therefore, the available studies provide partial and incomplete answers.<a class="elsevierStyleCrossRefs" href="#bib0065">13–15</a>The objective of this study was to evaluate whether BP values measured by ABPM can identify individuals with stable HF who will have worse clinical progress.MethodsConsecutive patients with HF and a previous admission due to HF were included in the Heart Failure: Usefulness of ABPM (DICUMAP) Registry. This registry is sponsored by the Heart Failure Working Group of the Spanish Society of Internal Medicine.The inclusion criteria were subjects >40 years of age with HF and a previous hospital admission due to HF in the previous year, who were clinically stable (≥15 days after hospital discharge with no clinical deterioration, reappearance of symptoms, or worsening of existing symptoms), and who were able to attend appointments in the outpatient clinics.The exclusion criteria were significant valvular disease as the primary cause of HF and a contraindication for ABPM (arm circumference>42 centimeters, working at night, atrial fibrillation with rapid ventricular response, frequent ventricular extrasystoles, and other tachyarrhythmias).The data collected from all patients included demographic, clinical, physical examination, and analytical variables; a chest X-ray; an electrocardiogram (ECG); ABPM; an echocardiogram (an echocardiogram performed in the previous six months in the case of known HF or up to three months after inclusion were considered valid); and treatment variables. A baseline visit was conducted, with follow-up visits at 90 days and one year. Data were collected on deaths, hospitalizations, and their causes.Office BP was calculated as the mean of two BP measurements taken with the patient sitting and after 5min of rest. The two measurements were taken with an interval of 2min between them. If there was a large difference between the two measurements, a third measurement was taken and the discordant measurement was discarded, as per the European Society of Hypertension recommendations.<a class="elsevierStyleCrossRef" href="#bib0080">16</a>ABPM was carried out on a day considered to be representative of the subject's life. Patients were instructed to avoid vigorous physical exercise and unusual stress and take their usual medication at the usual time. Oscillometric blood pressure monitoring devices (SPACELABS 90207 or 90217) were used with the sleeve placed on the non-dominant arm. ABPM lasted for a minimum of 24h with an interval between readings of 20min. ABPM results with ≥70% valid readings and no more than one hour of inactivity were considered valid.Periods of activity (diurnal) and rest (nocturnal) were defined a posteriori based on the patient’s diary. A reduction of 10%–20% in mean systolic BP (SBP) and/or diastolic BP (DBP) was defined as a normal reduction in nocturnal BP compared to diurnal BP (dipper pattern). A non-dipper pattern was defined as a <10% decrease in nocturnal BP with respect to the mean diurnal SBP and/or DBP. A riser pattern was defined as any increase in nocturnal BP with respect to the mean SBP and/or DBP values. An extreme dipper pattern was defined as reduction>20% in nocturnal BP with respect to the mean diurnal SBP and/or DBP.<a class="elsevierStyleCrossRef" href="#bib0085">17</a>This study was approved by the Ethics and Clinical Research Committee of the Sant Joan University Hospital of Reus. Written informed consent was obtained from all patients prior to their inclusion in the registry.Statistical analysisQuantitative variables were expressed as means±standard deviation (SD) and qualitative variables as frequencies and percentages. Comparisons were made using the Student’s t-test for quantitative variables. The chi-square test or, when dichotomous variables did not allow for its use, Fisher’s exact test were used for qualitative variables. Descriptive statistics, including mean, median, mode, standard deviation, range, confidence intervals, and the minimum and maximum values of the variables, were determined.Kaplan–Meier survival curves were calculated for ABPM values according to the circadian pattern (grouped as dipper or non-dipper) by SBP and DBP quartile for office BP, 24-h ABPM values, and BP during activity and rest in order to assess differences in terms of the main objective and their statistical significance using the log rank test. A p value<.05 was considered significant.To assess whether ABPM values which showed a survival curve with greater morbidity and mortality had prognostic significance, a bivariate analysis of individual categorical variables was performing using the chi-square test. In addition, the strength of the relationship of each variable to the main objective was calculated by means of the odds ratio and 95% confidence intervals (CI). Variables with a p value<.05 were selected. The relationship of continuous variables to the main objective was analyzed using ANOVA, comparing the means and 95% CI. Variables with a p value<.05 were selected.The selected variables were included in a Cox proportional hazards regression model to identify variables with prognostic significance for time to readmission or death. The analyses were performing using SPSS 17.0 for Windows. Bilateral and statistical significance for all variables was established as p<.05.ResultsA total of 154 patients from 17 centers were included. Baseline patient data are shown in <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>. The mean age was 76.8 years (±8.3), 55.2% were female, 58.8% were autonomous, and 80.4% had no cognitive impairment.<elsevierMultimedia ident="tbl0005"></elsevierMultimedia>Previous hypertension was recorded in 148 patients (94%), dyslipidemia in 81 (52.6%), type 2 diabetes mellitus in 65 (42.2%), previous ischemic heart disease in 25 (16.2%), a history of atrial fibrillation in 79 (51.3%), and chronic kidney disease in 68 (44.2%). A total of 117 (76.3%) patients had HF with preserved ejection fraction (HFpEF). In terms of New York Heart Association (NYHA) functional class, 68.2% of patients were class II, 19.5% were class III, and 12.3% were class I.The BP and heart rate values obtained during ABPM are shown in <a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>. With respect to circadian BP patterns, 74.0% had a nocturnal non-dipper BP pattern (34.2% had a rising pattern and 39.6% a non-dipper pattern), while the remaining patients had a dipper pattern (4.5% had an extreme dipper pattern).<elsevierMultimedia ident="tbl0010"></elsevierMultimedia>At one year of follow-up, there were 13 deaths, of which 10 were attributed to HF: 29 patients were readmitted, 19 of which were due to HF. With respect to the main objective, the first admission due to HF or death during the follow-up accounted for 26 events, representing 16.9% of patients.On the survival analysis, of all the hemodynamic markers of ABPM analyzed (nocturnal dipper pattern, concordance between office BP and ambulatory BP monitoring, and nocturnal hypertension), only the nocturnal dipper pattern showed significant differences.For this analysis, only the dipper pattern and the non-dipper pattern were included; given the small number of patients with extreme dipper and riser patterns, they were incorporated into the dipper pattern and non-dipper pattern, respectively, rather than analyzed separately. In patients with a dipper pattern (n=40, 26.0%), only two patients (5%) had an event whereas in patients with a non-dipper pattern (n=114, 74.0%), 24 (21%) had an event during the follow-up period (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>).<elsevierMultimedia ident="fig0005"></elsevierMultimedia>Of all parameters, we selected those which were relevant for inclusion in a logistic regression model. Presence of peripheral arterial disease, NYHA functional class III, a non-dipper BP pattern, and some degree of cognitive impairment were found to be significant and were selected for the logistic regression model. Likewise, with respect to non-categorical variables, glucose, hemoglobin, and creatinine levels; estimated glomerular filtration rate; left atrial diameter; and the percent nocturnal decrease in DBP reached statistical significance.Variables that, upon adjustment, were found to be significant in terms of death or readmission were selected for inclusion in the logistic regression model (<a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a>). Only NYHA functional class III was determined to be predictor of death and readmission, with a hazard ration of 3.5 (95% CI 1.7–7.3, p=.001). The percent reduction in nocturnal DBP compared to diurnal was weakly protective against death and readmission, with a hazard ratio of 0.961 (95% CI 0.926−0.997, p=.032).<elsevierMultimedia ident="tbl0015"></elsevierMultimedia>DiscussionThe main finding of this study is that any non-physiological circadian pattern (non-dipper, extreme dipper, and riser) was associated with a worse prognosis compared to a physiological BP-lowering pattern. Along these lines, a greater nocturnal DBP reduction was associated with fewer hospitalizations and deaths.Our findings show that this pattern was not a clear risk factor for poor prognosis, but was a risk marker. In addition, a greater decrease in nocturnal DBP compared to diurnal DBP, which could contribute to a dipper pattern, was associated with a slight decrease in hospitalizations and deaths due to HF. This aspect has only been partially studied in previous works.The included patients had similar characteristics to those normally admitted for HF<a class="elsevierStyleCrossRefs" href="#bib0090">18,19</a> and particularly to those admitted to Spanish internal medicine departments.<a class="elsevierStyleCrossRefs" href="#bib0100">20–26</a> Unlike most study populations in clinical trials on HF, this study population is older, has a similar percentage of women and men, a higher prevalence of hypertension as a cause of HF, and a greater number of comorbidities.Seventy-four percent of our patients had hypertensive heart disease. A low percentage (17%) had ischemic heart disease and a high percentage (51,3%) had atrial fibrillation. The low percentage of patients with ischemic heart disease may be explained by a possible selection bias towards patients with hypertension.As in other studies, patients admitted for HF had significant comorbidity. The percentages of patients with type 2 diabetes, dyslipidemia, peripheral arterial disease, cerebral vascular disease, and chronic kidney disease were similar to those found in patients included in the RICA registry<a class="elsevierStyleCrossRef" href="#bib0135">27</a> and the UMIPIC study.<a class="elsevierStyleCrossRef" href="#bib0140">28</a>We found a combined rate of readmission and death of 16.8%, which is higher than what has been observed in some clinical trials, such as the I-Preserve study,<a class="elsevierStyleCrossRef" href="#bib0090">18</a> but lower than in the sub-study of the Americas of the TOPCAT trial<a class="elsevierStyleCrossRef" href="#bib0145">29</a> and in the Paragon HF trial.<a class="elsevierStyleCrossRef" href="#bib0150">30</a> However, the characteristics of patients in these trials were clearly different than those included in this registry. Indeed, our results are similar to those found in other studies whose populations had similar characteristics to our patients.<a class="elsevierStyleCrossRefs" href="#bib0090">18–24</a>Certain BP patterns measured by ABPM, such as a lower nocturnal decrease in BP figures and even high nocturnal BP figures (known as nocturnal hypertension), have been associated with increased cardiovascular morbidity and mortality.<a class="elsevierStyleCrossRefs" href="#bib0125">25,26</a> However, this relationship has also been described in hypertensive subjects and those with hypertension along with pre-diabetes<a class="elsevierStyleCrossRef" href="#bib0155">31</a> or dyslipidemia,<a class="elsevierStyleCrossRef" href="#bib0160">32</a> but there is little data on the prevalence of abnormal circadian patterns and their relationship to morbidity and mortality in patients with HF.Our results show that 74% of patients had a non-dipper BP pattern, similar to the 78% found by Mallion et al.<a class="elsevierStyleCrossRef" href="#bib0165">33</a> Studies describe the non-dipper BP pattern and nocturnal hypertension as a marker and, possibly, a prognostic predictor of CVD. However, careful analysis of these studies shows that this situation occurs in registries and series in which CVD was systematically excluded or did not affect more than 15% of patients.<a class="elsevierStyleCrossRefs" href="#bib0170">34–38</a>The importance of our study lies in the fact that there is little data on the prognostic role of the parameters obtained by ABPM in patients with established CVD, even fewer data on patients with HF, and practically no studies in elderly patients with HF and comorbidities. Indeed, only two studies have assessed the influence of ABPM data on the prognosis of HF. Our study included the largest number of real-world patients and indicate that a nocturnal non-dipper pattern is a marker of poor prognosis in patients with HF.Of the available data, the study by Canesin et al.<a class="elsevierStyleCrossRef" href="#bib0195">39</a> shows a higher mortality rate in patients with SBP<105mmHg measured by ABPM than those with SBP≥105mmHg. However, this study was carried out in only 38 patients with NYHA functional class IV, which limits the utility of the results.Shin et al.<a class="elsevierStyleCrossRef" href="#bib0200">40</a> analyzed ABPM values in 118 male patients with HFrEF and found that the non-dipper pattern was associated with an increased risk of death and readmissions due to HF after a 4-year follow-up. The dipper pattern was a risk factor, as was heart rate, probably because the follow-up was longer than in our study. However, in our study, the patient profile was more similar to what is usually seen in real-world situations, in which patients are older than those included in Shin et al.’s work and thus, the results of their study may be more applicable to younger patients with HFrEF.Finally, Komori et al.<a class="elsevierStyleCrossRef" href="#bib0205">41</a> conducted a prospective, observational cohort study of 516 hospitalized patients with HF who underwent ABPM. Their work found that the riser BP pattern subgroup had a significantly higher incidence of the composite outcome (all-cause mortality and cardiovascular events such as coronary events, readmission due to HF, and stroke) than the other subgroups of HFpEF patients (HR: 3.01; 95% CI: 1.54–6.08, p<.01), but not the HFrEF patients. The results are similar to those of our study, but in their cohort, ABPM was conducted during hospitalization, where changes in treatment are usually carried out. In our study, ABPM was performed when the patients were on stable treatment. Furthermore, Komori et al.’s study was on a Japanese population whereas ours concerned a Spanish population.The strengths of the study include its multicenter design, which included 17 Spanish centers throughout the country, and the fact that patients had a highly prevalent disease such as HF and characteristics similar to patients usually admitted to our centers.The study had some limitations. First, a limited number of patients were included. However, based on the calculation of the sample needed, the number of patients recruited was sufficient for an initial assessment of this issue. Second, follow-up was limited to one year. Third, the majority of patients were in non-advanced stages of HF, which could be attributable to the study’s inclusion characteristics, which selected stable patients who were able to attend appointments in outpatient clinics and carry out ABPM. Fourth, data on natriuretic peptides or troponins were not included in the protocol and are therefore not available.In conclusion, a non-dipper circadian BP pattern measured by 24-h ABPM (with a reduction of <10% during the resting period) was associated with a greater number of hospitalizations and higher mortality in patients with HF. Neither nocturnal hypertension nor the SBP or DBP quartiles in each of the three periods measured were significantly associated with a worse prognosis in patients with HF.The non-dipper pattern was not a risk factor for poor prognosis, but was a risk marker. If this is so, this situation would not be susceptible to therapeutic intervention. The explanation of why a non-dipper pattern is not a risk factor, but rather a risk marker is probably due to characteristics that are not entirely clear and which merit further study.FundingThe DICUMAP Registry received an unconditional grant from Laboratorios Almirall to start the registry.Conflicts of interestThe authors declare no conflicts of interest." "textoCompletoSecciones" => array:1 [ "secciones" => array:11 [ 0 => array:3 [ "identificador" => "xres1580898" "titulo" => "Abstract" "secciones" => array:3 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Introduction" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Methods and results" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Conclusion" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec1423190" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres1580897" "titulo" => "Resumen" "secciones" => array:3 [ 0 => array:2 [ "identificador" => "abst0020" "titulo" => "Introducción" ] 1 => array:2 [ "identificador" => "abst0025" "titulo" => "Métodos y resultados" ] 2 => array:2 [ "identificador" => "abst0030" "titulo" => "Conclusiones" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec1423191" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:3 [ "identificador" => "sec0010" "titulo" => "Methods" "secciones" => array:1 [ 0 => array:2 [ "identificador" => "sec0015" "titulo" => "Statistical analysis" ] ] ] 6 => array:2 [ "identificador" => "sec0020" "titulo" => "Results" ] 7 => array:2 [ "identificador" => "sec0025" "titulo" => "Discussion" ] 8 => array:2 [ "identificador" => "sec0030" "titulo" => "Funding" ] 9 => array:2 [ "identificador" => "sec0035" "titulo" => "Conflicts of interest" ] 10 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2020-06-23" "fechaAceptado" => "2020-11-10" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec1423190" "palabras" => array:4 [ 0 => "Heart failure" 1 => "Hypertension" 2 => "ABPM" 3 => "Prognosis" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec1423191" "palabras" => array:4 [ 0 => "Insuficiencia cardíaca" 1 => "Hipertensión arterial" 2 => "MAPA" 3 => "Pronóstico" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:3 [ "titulo" => "Abstract" "resumen" => "IntroductionAmbulatory blood pressure monitoring (ABPM) has demonstrated value in the prognostic assessment of hypertensive patients with heart failure (HF) with or without other cardiovascular diseases. The objective of this study was to evaluate whether ABPM can identify subjects with HF with a worse prognosis. Methods and resultsProspective multicenter study that included clinically stable outpatients with HF. All patients underwent ABPM. A total of 154 patients from 17 centers were included. Their mean age was 76.8 years (± 8.3) and 55.2% were female. In total, 23.7% had HF with a reduced ejection fraction (HFrEF), 68.2% were in NYHA functional class II, and 19.5% were in NYHA functional class III. At one year of follow up, there were 13 (8.4%) deaths, of which 10 were attributed to HF. Twenty-nine patients required hospitalization, of which 19 were due to HF. The presence of a non-dipper BP pattern was associated with an increased risk for readmission or death at one year of follow-up (25% vs. 5%; p=.024). According to a Cox regression analysis, more advanced NYHA functional class (hazard ratio 3.51; 95% CI 1.70–7.26; p=.001; for NYHA class III vs. II) and a higher proportional nocturnal reduction in diastolic BP (hazard ratio 0.961; 95%CI 0.926−0.997; p=.032 per 1% diastolic BP reduction) were independently associated with death or readmission at one year. ConclusionIn older patients with chronic HF, a non-dipper BP pattern measured by ABPM was associated with a higher risk of hospitalization and death due to HF." "secciones" => array:3 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Introduction" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Methods and results" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Conclusion" ] ] ] "es" => array:3 [ "titulo" => "Resumen" "resumen" => "IntroducciónLa monitorización ambulatoria de la presión arterial (MAPA) ha demostrado la utilidad en la evaluación pronóstica de los pacientes hipertensos con insuficiencia cardíaca (IC) con o sin otras enfermedades cardiovasculares. El objetivo de este estudio consistió en determinar si la MAPA puede identificar a pacientes con IC con un peor pronóstico. Métodos y resultadosEstudio multicéntrico prospectivo en el que se incluyeron pacientes ambulatorios y clínicamente estables con IC. Todos los pacientes se sometieron a una MAPA. Se incluyó un total de 154 pacientes de 17 centros. La edad media fue de 76,8 años (± 8,3) y el 55,2% eran mujeres. En total, el 23,7% presentaba IC con fracción de eyección reducida (IC-FEr), el 68,2% se encontraba en la clase funcional II de la NYHA y el 19,5%, en la clase funcional III de la NYHA. Al cabo de un año de seguimiento se produjeron 13 (8,4%) muertes, 10 de ellas atribuidas a la IC. En 19 de los 29 pacientes que precisaron hospitalización, esta se debió a la IC. La presencia de un patrón no dipper de PA se asoció a un mayor riesgo de reingreso o muerte al año de seguimiento (25% frente al 5%; p = 0,024). Según un análisis de regresión de Cox, una clase funcional más avanzada de la NYHA (razón de riesgos instantáneos, 3,51; IC del 95%, 1,70-7,26; p = 0,001; comparación entre las clases III y II de la NYHA) y una mayor reducción nocturna proporcional de la PA diastólica (razón de riesgos instantáneos, 0,961; IC del 95%, 0,926-0,997; p = 0,032 por cada reducción del 1% de la PA diastólica) se asociaron a muerte o reingreso al cabo de un año de manera independiente. ConclusionesEn los pacientes de edad avanzada con IC crónica, un patrón no dipper de PA determinado mediante MAPA se asoció a un mayor riesgo de hospitalización y muerte por IC." "secciones" => array:3 [ 0 => array:2 [ "identificador" => "abst0020" "titulo" => "Introducción" ] 1 => array:2 [ "identificador" => "abst0025" "titulo" => "Métodos y resultados" ] 2 => array:2 [ "identificador" => "abst0030" "titulo" => "Conclusiones" ] ] ] ] "NotaPie" => array:2 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "Please cite this article as: Camafort M, Jhund PS, Formiga F, Castro-Salomó A, Arévalo-Lorido JC, Sobrino-Martínez J, et al. Utilidad pronóstica de las cifras ambulatorias de presión arterial en pacientes de edad avanzada con insuficiencia cardíaca. Resultados del estudio DICUMAP. Rev Clin Esp. 2021;221:433–440." ] 1 => array:3 [ "etiqueta" => "1" "nota" => "The complete list of the DICUMAP Investigators who have participated in this study appears in the Appendix A." "identificador" => "fn0005" ] ] "apendice" => array:1 [ 0 => array:1 [ "seccion" => array:1 [ 0 => array:4 [ "apendice" => "Miguel Camafort Babkowski (Hospital Clínic. Barcelona). José Carlos Arévalo-Lorido (Hospital de Zafra. Badajoz). Javier Sobrino Martínez (Fundació Hospital de l’Esperit Sant. Barcelona). Luis Manzano Espinosa (Hospital Universitario Ramón y Cajal. Madrid). José Luis Arias Jiménez (Hospital Universitario Virgen Macarena. Sevilla). Jorge Gómez Cerezo y Jorge Francisco (Hospital Infanta Sofía. Madrid). Jesús Díez Manglano (Hospital Royo Villanova. Zaragoza). Oscar Aramburu Bodas (Hospital Universitario Virgen Macarena. Sevilla). Jordi Grau Amorós (Hospital Municipal de Badalona. Barcelona). Manuel Montero Peréz-Barquero (Hospital Universitario Reina Sofía. Córdoba). Gerard Torres Cortada (Hospital Santa María. Lleida). Joan Carles Trullàs Vila (Hospital Sant Jaume. Olot. Girona). José Manuel Varela Aguilar (Hospital Virgen del Rocío. Sevilla). Gonzalo Martínez de las Cuevas (Hospital Universitario Marqués de Valdecilla. Cantabria). Fernando Salgado Ordóñez (Hospital Carlos Haya. Málaga). Manuel Méndez Bailón (Hospital Infanta Leonor. Madrid). Nuria Ribas Pizá (Hospital de la Santa Creu i Sant Pau. Barcelona)." "etiqueta" => "Appendix A" "titulo" => "DICUMAP Registry Investigators" "identificador" => "sec0040" ] ] ] ] "multimedia" => array:4 [ 0 => array:8 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1429 "Ancho" => 2167 "Tamanyo" => 86793 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0025" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "Survival curve (days free of death or readmission) according to dipper pattern of nighttime blood pressure. The log rank test showed that the difference observed in the Kaplan–Meier curve was statistically significant (chi-square 5.131, p=.024)." ] ] 1 => array:8 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0030" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:2 [ "leyenda" => "Dependency was defined as a Barthel index below 60 points. Cognitive impairment was defined as 5 or more points on Pfeiffer’s short portable mental state questionnaire.BPM: Beats per minute. CKD: Chronic kidney disease. DBP: Diastolic Blood Pressure. GFR: Glomerular filtration rate. HFrEF: Heart Failure with reduced ejection fraction. HFpEF Heart failure with preserved ejection fraction. LVEF: Left Ventricular Ejection Fraction. SD: standard deviation. SBP: Systolic Blood Pressure." "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Variable \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Mean (±SD)/% \t\t\t\t\t\t\n \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Age at first visit (years) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">76.8 (±8.3) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Women \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">55.2% \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Hypertension \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">94% \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Ischemic cardiomyopahty \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">17% \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Mean Office SBP (mmHg) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">137.4 (±19.4) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Mean Office DBP (mmHg) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">74.8 (±11.4) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Office heart alert (BPM) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">73.1 (±11.5) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Body mass index (kg/m2) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">29.9 (±4.8) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Abdominal circumference (cm) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">100 (±11) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Glucose (mg/dL) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">121.5 (±35.7) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Diabetes (%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">42.2% \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">GFR (mL/min/1.73m2) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">58.3 (±23.2) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">CKD (GFR<60mL/min/1,73m2) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">45.85% \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">LVEF \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">56.9 (±13) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">HFrEF \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">23.7% \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">HFpEF \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">76.3% \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Dependency \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">41.2% \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Cognitive impairment \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">19.6% \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab2708172.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Baseline subject characteristics." ] ] 2 => array:8 [ "identificador" => "tbl0010" "etiqueta" => "Table 2" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0035" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:2 [ "leyenda" => "BPM: Beats per minute. DBP: Diastolic Blood Pressure. HR: Heart Rate. SD: standard deviation. SBP: Systolic Blood Pressure." "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Variable \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Mean±SD/% \t\t\t\t\t\t\n \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">24h SBP (mean), mmHg \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">124.2±16.4 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">24h DBP (mean), mmHg \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">66.1±9.7 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">24h HR (mean) BPM \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">70.8±12,1 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Active SBP (mean), mmHg \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">126.4±16.7 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Active DBP (mean), mmHg \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">68.7±10.7 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Activity HF (mean) BPM \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">73.0±13.2 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Resting SBP (mean), mmHg \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">121.3±18.9 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Resting DBP (mean), mmHg \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">62.9±10.4 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Resting heart rate (mean) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">68.6±13.5 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Reduction in SBP, % \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">4.1±16.7 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Reduction in DBP, % \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">9.0±15.8 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Dipper Pattern \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">21.43% \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Super Dipper Pattern \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">4.55% \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Non Dipper Pattern \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">39.61% \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Riser Pattern \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">34.42% \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab2708170.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Baseline Blood Pressure and Heart Rate parameters." ] ] 3 => array:8 [ "identificador" => "tbl0015" "etiqueta" => "Table 3" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0040" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:2 [ "leyenda" => "CI: confidence interval; NYHA: New York Heart Association; DBP: diastolic blood pressure." "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Variables \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Hazard Ratio \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Significance \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Lower 95% CI \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Upper 95% CI \t\t\t\t\t\t\n \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">NYHA Stage \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">3.511 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.001 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1.699 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">7.256 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Left Atrial Diameter \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1.032 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.058 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.999 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1.066 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">% DBP reduction \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.961 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.032 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.926 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.997 \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab2708171.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Stepwise Cox regression for death/readmission of significant variables in bivariate analysis." ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:41 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "American Heart Association Council on Epidemiology and Prevention Statistics Committee and Stroke Statistics Subcommittee. 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Original article

Prognostic value of ambulatory blood pressure values in elderly patients with heart failure. Results of the DICUMAP study

Utilidad pronóstica de las cifras ambulatorias de presión arterial en pacientes de edad avanzada con insuficiencia cardíaca. Resultados del estudio DICUMAP

M. Camaforta,

Corresponding author

camafort@clinic.cat

Corresponding author.

, P.S. Jhundb, F. Formigac, A. Castro-Salomód, J.C. Arévalo-Loridoe, J. Sobrino-Martínezf, L. Manzanog, J. Díez-Manglanoh, Ó. Aramburui, M. Montero Pérez-Barqueroj, DICUMAP Investigators 1

a Unidad de Insuficiencia Cardíaca, Servicio de Medicina Interna-ICMiD, Hospital Clínic, Universidad de Barcelona, Barcelona, Spain

b BHF Cardiovascular Research Centre, University of Glasgow, Glasgow, United Kingdom

c Servicio de Medicina Interna, Hospital Universitario de Bellvitge-IDIBELL, Universidad de Barcelona, Barcelona, Spain

d Servicio de Medicina Interna, Hospital Sant Joan, Universidad Rovira i Virgili, Reus, Spain

e Servicio de Medicina Interna, Hospital Regional de Zafra, Badajoz, Spain

f Servicio de Medicina Interna, Hospital l’Esperit Sant, Santa Coloma de Gramanet, Spain

g Servicio de Medicina Interna, Hospital Universitario Ramón y Cajal, Universidad de Alcalá, IRYCIS, Madrid, Spain

h Servicio de Medicina Interna, Hospital Royo Villanova, Zaragoza, Spain

i Servicio de Medicina Interna, Hospital Universitario Virgen de la Macarena, Sevilla, Spain

j Servicio de Medicina Interna, Hospital Universitario IMIBIC/Reina Sofía, Córdoba, Spain

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            "entidad" => "Unidad de Insuficiencia Card&#237;aca&#44; Servicio de Medicina Interna-ICMiD&#44; Hospital Cl&#237;nic&#44; Universidad de Barcelona&#44; Barcelona&#44; Spain"
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            "identificador" => "aff0100"
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            "entidad" => "Servicio de Medicina Interna&#44; Hospital Sant Joan&#44; Universidad Rovira i Virgili&#44; Reus&#44; Spain"
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            "identificador" => "aff0105"
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            "entidad" => "Servicio de Medicina Interna&#44; Hospital Regional de Zafra&#44; Badajoz&#44; Spain"
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            "entidad" => "Servicio de Medicina Interna&#44; Hospital l&#8217;Esperit Sant&#44; Santa Coloma de Gramanet&#44; Spain"
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            "entidad" => "Servicio de Medicina Interna&#44; Hospital Universitario Ram&#243;n y Cajal&#44; Universidad de Alcal&#225;&#44; IRYCIS&#44; Madrid&#44; Spain"
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            "entidad" => "Servicio de Medicina Interna&#44; Hospital Universitario Virgen de la Macarena&#44; Sevilla&#44; Spain"
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            "entidad" => "Servicio de Medicina Interna&#44; Hospital Universitario IMIBIC&#47;Reina Sof&#237;a&#44; C&#243;rdoba&#44; Spain"
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            "identificador" => "aff0135"
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        "titulo" => "Utilidad pron&#243;stica de las cifras ambulatorias de presi&#243;n arterial en pacientes de edad avanzada con insuficiencia card&#237;aca&#46; Resultados del estudio DICUMAP"
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          "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Survival curve &#40;days free of death or readmission&#41; according to dipper pattern of nighttime blood pressure&#46;</p> <p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">The log rank test showed that the difference observed in the Kaplan&#8211;Meier curve was statistically significant &#40;chi-square 5&#46;131&#44; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">&#61;</span><span class="elsevierStyleHsp" style=""></span>&#46;024&#41;&#46;</p>"
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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Heart failure &#40;HF&#41; is one of the main health problems in our setting<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#44;2</span></a> and one of the main reasons for hospital admission in the developed world&#46;<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">The role of hypertension in the development and prognosis of HF is well-known&#46;<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> Epidemiological studies show that 75&#37; of patients with HF have a history of hypertension and&#44; in subjects with blood pressure &#40;BP&#41;<span class="elsevierStyleHsp" style=""></span>&#62;<span class="elsevierStyleHsp" style=""></span>160&#47;90<span class="elsevierStyleHsp" style=""></span>mm<span class="elsevierStyleHsp" style=""></span>Hg&#44; the probability of HF is double that of those with BP<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>140&#47;90<span class="elsevierStyleHsp" style=""></span>mm<span class="elsevierStyleHsp" style=""></span>Hg&#46;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> Hypertension modulates the natural history of HF and is a relevant prognostic factor&#46;<a class="elsevierStyleCrossRefs" href="#bib0025"><span class="elsevierStyleSup">5&#44;6</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">There are known to be compensatory neurohormonal changes in HF that alter BP levels and patterns as well as heart rate patterns&#46;<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a> These changes can cause poor hypertension control&#44; which can precipitate the decompensation of HF&#46;<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a> Lower clinical BP levels have been associated with a worse prognosis of HF&#44;<a class="elsevierStyleCrossRefs" href="#bib0045"><span class="elsevierStyleSup">9&#44;10</span></a> although most available data are based on BP levels measured in doctor&#8217;s offices&#46; However&#44; home BP measurement using ambulatory blood pressure monitoring &#40;ABPM&#41; or self-measured BP &#40;SMBP&#41; improves the accuracy and reproducibility of these measures&#44;<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">11</span></a> meaning that ABPM may assess cardiovascular prognosis better than office BP measurement in hypertensive patients without cardiovascular disease&#46;<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">12</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">However&#44; there are few studies on the prognostic value of ABPM in HF to date&#44; and those that do exist include a small number of patients and often focus on this issue in a peripheral manner&#46; Therefore&#44; the available studies provide partial and incomplete answers&#46;<a class="elsevierStyleCrossRefs" href="#bib0065"><span class="elsevierStyleSup">13&#8211;15</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">The objective of this study was to evaluate whether BP values measured by ABPM can identify individuals with stable HF who will have worse clinical progress&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0060">Methods</span><p id="par0030" class="elsevierStylePara elsevierViewall">Consecutive patients with HF and a previous admission due to HF were included in the Heart Failure&#58; Usefulness of ABPM &#40;DICUMAP&#41; Registry&#46; This registry is sponsored by the Heart Failure Working Group of the Spanish Society of Internal Medicine&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">The inclusion criteria were subjects &#62;<span class="elsevierStyleHsp" style=""></span>40 years of age with HF and a previous hospital admission due to HF in the previous year&#44; who were clinically stable &#40;&#8805;<span class="elsevierStyleHsp" style=""></span>15 days after hospital discharge with no clinical deterioration&#44; reappearance of symptoms&#44; or worsening of existing symptoms&#41;&#44; and who were able to attend appointments in the outpatient clinics&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">The exclusion criteria were significant valvular disease as the primary cause of HF and a contraindication for ABPM &#40;arm circumference<span class="elsevierStyleHsp" style=""></span>&#62;<span class="elsevierStyleHsp" style=""></span>42 centimeters&#44; working at night&#44; atrial fibrillation with rapid ventricular response&#44; frequent ventricular extrasystoles&#44; and other tachyarrhythmias&#41;&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">The data collected from all patients included demographic&#44; clinical&#44; physical examination&#44; and analytical variables&#59; a chest X-ray&#59; an electrocardiogram &#40;ECG&#41;&#59; ABPM&#59; an echocardiogram &#40;an echocardiogram performed in the previous six months in the case of known HF or up to three months after inclusion were considered valid&#41;&#59; and treatment variables&#46; A baseline visit was conducted&#44; with follow-up visits at 90 days and one year&#46; Data were collected on deaths&#44; hospitalizations&#44; and their causes&#46;</p><p id="par0050" class="elsevierStylePara elsevierViewall">Office BP was calculated as the mean of two BP measurements taken with the patient sitting and after 5<span class="elsevierStyleHsp" style=""></span>min of rest&#46; The two measurements were taken with an interval of 2<span class="elsevierStyleHsp" style=""></span>min between them&#46; If there was a large difference between the two measurements&#44; a third measurement was taken and the discordant measurement was discarded&#44; as per the European Society of Hypertension recommendations&#46;<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">16</span></a></p><p id="par0055" class="elsevierStylePara elsevierViewall">ABPM was carried out on a day considered to be representative of the subject&#39;s life&#46; Patients were instructed to avoid vigorous physical exercise and unusual stress and take their usual medication at the usual time&#46; Oscillometric blood pressure monitoring devices &#40;SPACELABS 90207 or 90217&#41; were used with the sleeve placed on the non-dominant arm&#46; ABPM lasted for a minimum of 24<span class="elsevierStyleHsp" style=""></span>h with an interval between readings of 20<span class="elsevierStyleHsp" style=""></span>min&#46; ABPM results with &#8805;<span class="elsevierStyleHsp" style=""></span>70&#37; valid readings and no more than one hour of inactivity were considered valid&#46;</p><p id="par0060" class="elsevierStylePara elsevierViewall">Periods of activity &#40;diurnal&#41; and rest &#40;nocturnal&#41; were defined <span class="elsevierStyleItalic">a posteriori</span> based on the patient&#8217;s diary&#46; A reduction of 10&#37;&#8211;20&#37; in mean systolic BP &#40;SBP&#41; and&#47;or diastolic BP &#40;DBP&#41; was defined as a normal reduction in nocturnal BP compared to diurnal BP &#40;dipper pattern&#41;&#46; A non-dipper pattern was defined as a &#60;<span class="elsevierStyleHsp" style=""></span>10&#37; decrease in nocturnal BP with respect to the mean diurnal SBP and&#47;or DBP&#46; A riser pattern was defined as any increase in nocturnal BP with respect to the mean SBP and&#47;or DBP values&#46; An extreme dipper pattern was defined as reduction<span class="elsevierStyleHsp" style=""></span>&#62;<span class="elsevierStyleHsp" style=""></span>20&#37; in nocturnal BP with respect to the mean diurnal SBP and&#47;or DBP&#46;<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">17</span></a></p><p id="par0065" class="elsevierStylePara elsevierViewall">This study was approved by the Ethics and Clinical Research Committee of the Sant Joan University Hospital of Reus&#46; Written informed consent was obtained from all patients prior to their inclusion in the registry&#46;</p><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Statistical analysis</span><p id="par0070" class="elsevierStylePara elsevierViewall">Quantitative variables were expressed as means<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>standard deviation &#40;SD&#41; and qualitative variables as frequencies and percentages&#46; Comparisons were made using the Student&#8217;s t-test for quantitative variables&#46; The chi-square test or&#44; when dichotomous variables did not allow for its use&#44; Fisher&#8217;s exact test were used for qualitative variables&#46; Descriptive statistics&#44; including mean&#44; median&#44; mode&#44; standard deviation&#44; range&#44; confidence intervals&#44; and the minimum and maximum values of the variables&#44; were determined&#46;</p><p id="par0075" class="elsevierStylePara elsevierViewall">Kaplan&#8211;Meier survival curves were calculated for ABPM values according to the circadian pattern &#40;grouped as dipper or non-dipper&#41; by SBP and DBP quartile for office BP&#44; 24-h ABPM values&#44; and BP during activity and rest in order to assess differences in terms of the main objective and their statistical significance using the log rank test&#46; A <span class="elsevierStyleItalic">p</span> value<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>&#46;05 was considered significant&#46;</p><p id="par0080" class="elsevierStylePara elsevierViewall">To assess whether ABPM values which showed a survival curve with greater morbidity and mortality had prognostic significance&#44; a bivariate analysis of individual categorical variables was performing using the chi-square test&#46; In addition&#44; the strength of the relationship of each variable to the main objective was calculated by means of the odds ratio and 95&#37; confidence intervals &#40;CI&#41;&#46; Variables with a <span class="elsevierStyleItalic">p</span> value<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>&#46;05 were selected&#46; The relationship of continuous variables to the main objective was analyzed using ANOVA&#44; comparing the means and 95&#37; CI&#46; Variables with a <span class="elsevierStyleItalic">p</span> value<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>&#46;05 were selected&#46;</p><p id="par0085" class="elsevierStylePara elsevierViewall">The selected variables were included in a Cox proportional hazards regression model to identify variables with prognostic significance for time to readmission or death&#46; The analyses were performing using SPSS 17&#46;0 for Windows&#46; Bilateral and statistical significance for all variables was established as <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>&#46;05&#46;</p></span></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Results</span><p id="par0090" class="elsevierStylePara elsevierViewall">A total of 154 patients from 17 centers were included&#46; Baseline patient data are shown in <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#46; The mean age was 76&#46;8 years &#40;&#177;<span class="elsevierStyleHsp" style=""></span>8&#46;3&#41;&#44; 55&#46;2&#37; were female&#44; 58&#46;8&#37; were autonomous&#44; and 80&#46;4&#37; had no cognitive impairment&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0095" class="elsevierStylePara elsevierViewall">Previous hypertension was recorded in 148 patients &#40;94&#37;&#41;&#44; dyslipidemia in 81 &#40;52&#46;6&#37;&#41;&#44; type 2 diabetes mellitus in 65 &#40;42&#46;2&#37;&#41;&#44; previous ischemic heart disease in 25 &#40;16&#46;2&#37;&#41;&#44; a history of atrial fibrillation in 79 &#40;51&#46;3&#37;&#41;&#44; and chronic kidney disease in 68 &#40;44&#46;2&#37;&#41;&#46; A total of 117 &#40;76&#46;3&#37;&#41; patients had HF with preserved ejection fraction &#40;HFpEF&#41;&#46; In terms of New York Heart Association &#40;NYHA&#41; functional class&#44; 68&#46;2&#37; of patients were class II&#44; 19&#46;5&#37; were class III&#44; and 12&#46;3&#37; were class I&#46;</p><p id="par0100" class="elsevierStylePara elsevierViewall">The BP and heart rate values obtained during ABPM are shown in <a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>&#46; With respect to circadian BP patterns&#44; 74&#46;0&#37; had a nocturnal non-dipper BP pattern &#40;34&#46;2&#37; had a rising pattern and 39&#46;6&#37; a non-dipper pattern&#41;&#44; while the remaining patients had a dipper pattern &#40;4&#46;5&#37; had an extreme dipper pattern&#41;&#46;</p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><p id="par0105" class="elsevierStylePara elsevierViewall">At one year of follow-up&#44; there were 13 deaths&#44; of which 10 were attributed to HF&#58; 29 patients were readmitted&#44; 19 of which were due to HF&#46; With respect to the main objective&#44; the first admission due to HF or death during the follow-up accounted for 26 events&#44; representing 16&#46;9&#37; of patients&#46;</p><p id="par0110" class="elsevierStylePara elsevierViewall">On the survival analysis&#44; of all the hemodynamic markers of ABPM analyzed &#40;nocturnal dipper pattern&#44; concordance between office BP and ambulatory BP monitoring&#44; and nocturnal hypertension&#41;&#44; only the nocturnal dipper pattern showed significant differences&#46;</p><p id="par0115" class="elsevierStylePara elsevierViewall">For this analysis&#44; only the dipper pattern and the non-dipper pattern were included&#59; given the small number of patients with extreme dipper and riser patterns&#44; they were incorporated into the dipper pattern and non-dipper pattern&#44; respectively&#44; rather than analyzed separately&#46; In patients with a dipper pattern &#40;n<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>40&#44; 26&#46;0&#37;&#41;&#44; only two patients &#40;5&#37;&#41; had an event whereas in patients with a non-dipper pattern &#40;n<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>114&#44; 74&#46;0&#37;&#41;&#44; 24 &#40;21&#37;&#41; had an event during the follow-up period &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0120" class="elsevierStylePara elsevierViewall">Of all parameters&#44; we selected those which were relevant for inclusion in a logistic regression model&#46; Presence of peripheral arterial disease&#44; NYHA functional class III&#44; a non-dipper BP pattern&#44; and some degree of cognitive impairment were found to be significant and were selected for the logistic regression model&#46; Likewise&#44; with respect to non-categorical variables&#44; glucose&#44; hemoglobin&#44; and creatinine levels&#59; estimated glomerular filtration rate&#59; left atrial diameter&#59; and the percent nocturnal decrease in DBP reached statistical significance&#46;</p><p id="par0125" class="elsevierStylePara elsevierViewall">Variables that&#44; upon adjustment&#44; were found to be significant in terms of death or readmission were selected for inclusion in the logistic regression model &#40;<a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a>&#41;&#46; Only NYHA functional class III was determined to be predictor of death and readmission&#44; with a hazard ration of 3&#46;5 &#40;95&#37; CI 1&#46;7&#8211;7&#46;3&#44; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">&#61;</span><span class="elsevierStyleHsp" style=""></span>&#46;001&#41;&#46; The percent reduction in nocturnal DBP compared to diurnal was weakly protective against death and readmission&#44; with a hazard ratio of 0&#46;961 &#40;95&#37; CI 0&#46;926&#8722;0&#46;997&#44; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">&#61;</span><span class="elsevierStyleHsp" style=""></span>&#46;032&#41;&#46;</p><elsevierMultimedia ident="tbl0015"></elsevierMultimedia></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Discussion</span><p id="par0130" class="elsevierStylePara elsevierViewall">The main finding of this study is that any non-physiological circadian pattern &#40;non-dipper&#44; extreme dipper&#44; and riser&#41; was associated with a worse prognosis compared to a physiological BP-lowering pattern&#46; Along these lines&#44; a greater nocturnal DBP reduction was associated with fewer hospitalizations and deaths&#46;</p><p id="par0135" class="elsevierStylePara elsevierViewall">Our findings show that this pattern was not a clear risk factor for poor prognosis&#44; but was a risk marker&#46; In addition&#44; a greater decrease in nocturnal DBP compared to diurnal DBP&#44; which could contribute to a dipper pattern&#44; was associated with a slight decrease in hospitalizations and deaths due to HF&#46; This aspect has only been partially studied in previous works&#46;</p><p id="par0140" class="elsevierStylePara elsevierViewall">The included patients had similar characteristics to those normally admitted for HF<a class="elsevierStyleCrossRefs" href="#bib0090"><span class="elsevierStyleSup">18&#44;19</span></a> and particularly to those admitted to Spanish internal medicine departments&#46;<a class="elsevierStyleCrossRefs" href="#bib0100"><span class="elsevierStyleSup">20&#8211;26</span></a> Unlike most study populations in clinical trials on HF&#44; this study population is older&#44; has a similar percentage of women and men&#44; a higher prevalence of hypertension as a cause of HF&#44; and a greater number of comorbidities&#46;</p><p id="par0145" class="elsevierStylePara elsevierViewall">Seventy-four percent of our patients had hypertensive heart disease&#46; A low percentage &#40;17&#37;&#41; had ischemic heart disease and a high percentage &#40;51&#44;3&#37;&#41; had atrial fibrillation&#46; The low percentage of patients with ischemic heart disease may be explained by a possible selection bias towards patients with hypertension&#46;</p><p id="par0150" class="elsevierStylePara elsevierViewall">As in other studies&#44; patients admitted for HF had significant comorbidity&#46; The percentages of patients with type 2 diabetes&#44; dyslipidemia&#44; peripheral arterial disease&#44; cerebral vascular disease&#44; and chronic kidney disease were similar to those found in patients included in the RICA registry<a class="elsevierStyleCrossRef" href="#bib0135"><span class="elsevierStyleSup">27</span></a> and the UMIPIC study&#46;<a class="elsevierStyleCrossRef" href="#bib0140"><span class="elsevierStyleSup">28</span></a></p><p id="par0155" class="elsevierStylePara elsevierViewall">We found a combined rate of readmission and death of 16&#46;8&#37;&#44; which is higher than what has been observed in some clinical trials&#44; such as the I-Preserve study&#44;<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">18</span></a> but lower than in the sub-study of the Americas of the TOPCAT trial<a class="elsevierStyleCrossRef" href="#bib0145"><span class="elsevierStyleSup">29</span></a> and in the Paragon HF trial&#46;<a class="elsevierStyleCrossRef" href="#bib0150"><span class="elsevierStyleSup">30</span></a> However&#44; the characteristics of patients in these trials were clearly different than those included in this registry&#46; Indeed&#44; our results are similar to those found in other studies whose populations had similar characteristics to our patients&#46;<a class="elsevierStyleCrossRefs" href="#bib0090"><span class="elsevierStyleSup">18&#8211;24</span></a></p><p id="par0160" class="elsevierStylePara elsevierViewall">Certain BP patterns measured by ABPM&#44; such as a lower nocturnal decrease in BP figures and even high nocturnal BP figures &#40;known as nocturnal hypertension&#41;&#44; have been associated with increased cardiovascular morbidity and mortality&#46;<a class="elsevierStyleCrossRefs" href="#bib0125"><span class="elsevierStyleSup">25&#44;26</span></a> However&#44; this relationship has also been described in hypertensive subjects and those with hypertension along with pre-diabetes<a class="elsevierStyleCrossRef" href="#bib0155"><span class="elsevierStyleSup">31</span></a> or dyslipidemia&#44;<a class="elsevierStyleCrossRef" href="#bib0160"><span class="elsevierStyleSup">32</span></a> but there is little data on the prevalence of abnormal circadian patterns and their relationship to morbidity and mortality in patients with HF&#46;</p><p id="par0165" class="elsevierStylePara elsevierViewall">Our results show that 74&#37; of patients had a non-dipper BP pattern&#44; similar to the 78&#37; found by Mallion et al&#46;<a class="elsevierStyleCrossRef" href="#bib0165"><span class="elsevierStyleSup">33</span></a> Studies describe the non-dipper BP pattern and nocturnal hypertension as a marker and&#44; possibly&#44; a prognostic predictor of CVD&#46; However&#44; careful analysis of these studies shows that this situation occurs in registries and series in which CVD was systematically excluded or did not affect more than 15&#37; of patients&#46;<a class="elsevierStyleCrossRefs" href="#bib0170"><span class="elsevierStyleSup">34&#8211;38</span></a></p><p id="par0170" class="elsevierStylePara elsevierViewall">The importance of our study lies in the fact that there is little data on the prognostic role of the parameters obtained by ABPM in patients with established CVD&#44; even fewer data on patients with HF&#44; and practically no studies in elderly patients with HF and comorbidities&#46; Indeed&#44; only two studies have assessed the influence of ABPM data on the prognosis of HF&#46; Our study included the largest number of real-world patients and indicate that a nocturnal non-dipper pattern is a marker of poor prognosis in patients with HF&#46;</p><p id="par0175" class="elsevierStylePara elsevierViewall">Of the available data&#44; the study by Canesin et al&#46;<a class="elsevierStyleCrossRef" href="#bib0195"><span class="elsevierStyleSup">39</span></a> shows a higher mortality rate in patients with SBP<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>105<span class="elsevierStyleHsp" style=""></span>mm<span class="elsevierStyleHsp" style=""></span>Hg measured by ABPM than those with SBP<span class="elsevierStyleHsp" style=""></span>&#8805;<span class="elsevierStyleHsp" style=""></span>105<span class="elsevierStyleHsp" style=""></span>mm<span class="elsevierStyleHsp" style=""></span>Hg&#46; However&#44; this study was carried out in only 38 patients with NYHA functional class IV&#44; which limits the utility of the results&#46;</p><p id="par0180" class="elsevierStylePara elsevierViewall">Shin et al&#46;<a class="elsevierStyleCrossRef" href="#bib0200"><span class="elsevierStyleSup">40</span></a> analyzed ABPM values in 118 male patients with HFrEF and found that the non-dipper pattern was associated with an increased risk of death and readmissions due to HF after a 4-year follow-up&#46; The dipper pattern was a risk factor&#44; as was heart rate&#44; probably because the follow-up was longer than in our study&#46; However&#44; in our study&#44; the patient profile was more similar to what is usually seen in real-world situations&#44; in which patients are older than those included in Shin et al&#46;&#8217;s work and thus&#44; the results of their study may be more applicable to younger patients with HFrEF&#46;</p><p id="par0185" class="elsevierStylePara elsevierViewall">Finally&#44; Komori et al&#46;<a class="elsevierStyleCrossRef" href="#bib0205"><span class="elsevierStyleSup">41</span></a> conducted a prospective&#44; observational cohort study of 516 hospitalized patients with HF who underwent ABPM&#46; Their work found that the riser BP pattern subgroup had a significantly higher incidence of the composite outcome &#40;all-cause mortality and cardiovascular events such as coronary events&#44; readmission due to HF&#44; and stroke&#41; than the other subgroups of HFpEF patients &#40;HR&#58; 3&#46;01&#59; 95&#37; CI&#58; 1&#46;54&#8211;6&#46;08&#44; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>&#46;01&#41;&#44; but not the HFrEF patients&#46; The results are similar to those of our study&#44; but in their cohort&#44; ABPM was conducted during hospitalization&#44; where changes in treatment are usually carried out&#46; In our study&#44; ABPM was performed when the patients were on stable treatment&#46; Furthermore&#44; Komori et al&#46;&#8217;s study was on a Japanese population whereas ours concerned a Spanish population&#46;</p><p id="par0190" class="elsevierStylePara elsevierViewall">The strengths of the study include its multicenter design&#44; which included 17 Spanish centers throughout the country&#44; and the fact that patients had a highly prevalent disease such as HF and characteristics similar to patients usually admitted to our centers&#46;</p><p id="par0195" class="elsevierStylePara elsevierViewall">The study had some limitations&#46; First&#44; a limited number of patients were included&#46; However&#44; based on the calculation of the sample needed&#44; the number of patients recruited was sufficient for an initial assessment of this issue&#46; Second&#44; follow-up was limited to one year&#46; Third&#44; the majority of patients were in non-advanced stages of HF&#44; which could be attributable to the study&#8217;s inclusion characteristics&#44; which selected stable patients who were able to attend appointments in outpatient clinics and carry out ABPM&#46; Fourth&#44; data on natriuretic peptides or troponins were not included in the protocol and are therefore not available&#46;</p><p id="par0200" class="elsevierStylePara elsevierViewall">In conclusion&#44; a non-dipper circadian BP pattern measured by 24-h ABPM &#40;with a reduction of &#60;<span class="elsevierStyleHsp" style=""></span>10&#37; during the resting period&#41; was associated with a greater number of hospitalizations and higher mortality in patients with HF&#46; Neither nocturnal hypertension nor the SBP or DBP quartiles in each of the three periods measured were significantly associated with a worse prognosis in patients with HF&#46;</p><p id="par0205" class="elsevierStylePara elsevierViewall">The non-dipper pattern was not a risk factor for poor prognosis&#44; but was a risk marker&#46; If this is so&#44; this situation would not be susceptible to therapeutic intervention&#46; The explanation of why a non-dipper pattern is not a risk factor&#44; but rather a risk marker is probably due to characteristics that are not entirely clear and which merit further study&#46;</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Funding</span><p id="par0210" class="elsevierStylePara elsevierViewall">The DICUMAP Registry received an unconditional grant from <span class="elsevierStyleGrantSponsor" id="gs0005">Laboratorios Almirall</span> to start the registry&#46;</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Conflicts of interest</span><p id="par0215" class="elsevierStylePara elsevierViewall">The authors declare no conflicts of interest&#46;</p></span></span>"
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    "fechaRecibido" => "2020-06-23"
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            0 => "Heart failure"
            1 => "Hypertension"
            2 => "ABPM"
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          "palabras" => array:4 [
            0 => "Insuficiencia card&#237;aca"
            1 => "Hipertensi&#243;n arterial"
            2 => "MAPA"
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        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Introduction</span><p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">Ambulatory blood pressure monitoring &#40;ABPM&#41; has demonstrated value in the prognostic assessment of hypertensive patients with heart failure &#40;HF&#41; with or without other cardiovascular diseases&#46; The objective of this study was to evaluate whether ABPM can identify subjects with HF with a worse prognosis&#46;</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Methods and results</span><p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">Prospective multicenter study that included clinically stable outpatients with HF&#46; All patients underwent ABPM&#46; A total of 154 patients from 17 centers were included&#46; Their mean age was 76&#46;8 years &#40;&#177; 8&#46;3&#41; and 55&#46;2&#37; were female&#46; In total&#44; 23&#46;7&#37; had HF with a reduced ejection fraction &#40;HFrEF&#41;&#44; 68&#46;2&#37; were in NYHA functional class II&#44; and 19&#46;5&#37; were in NYHA functional class III&#46; At one year of follow up&#44; there were 13 &#40;8&#46;4&#37;&#41; deaths&#44; of which 10 were attributed to HF&#46; Twenty-nine patients required hospitalization&#44; of which 19 were due to HF&#46; The presence of a non-dipper BP pattern was associated with an increased risk for readmission or death at one year of follow-up &#40;25&#37; vs&#46; 5&#37;&#59; p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>&#46;024&#41;&#46; According to a Cox regression analysis&#44; more advanced NYHA functional class &#40;hazard ratio 3&#46;51&#59; 95&#37; CI 1&#46;70&#8211;7&#46;26&#59; p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>&#46;001&#59; for NYHA class III vs&#46; II&#41; and a higher proportional nocturnal reduction in diastolic BP &#40;hazard ratio 0&#46;961&#59; 95&#37;CI 0&#46;926&#8722;0&#46;997&#59; p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>&#46;032 per 1&#37; diastolic BP reduction&#41; were independently associated with death or readmission at one year&#46;</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Conclusion</span><p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">In older patients with chronic HF&#44; a non-dipper BP pattern measured by ABPM was associated with a higher risk of hospitalization and death due to HF&#46;</p></span>"
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        "resumen" => "<span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Introducci&#243;n</span><p id="spar0065" class="elsevierStyleSimplePara elsevierViewall">La monitorizaci&#243;n ambulatoria de la presi&#243;n arterial &#40;MAPA&#41; ha demostrado la utilidad en la evaluaci&#243;n pron&#243;stica de los pacientes hipertensos con insuficiencia card&#237;aca &#40;IC&#41; con o sin otras enfermedades cardiovasculares&#46; El objetivo de este estudio consisti&#243; en determinar si la MAPA puede identificar a pacientes con IC con un peor pron&#243;stico&#46;</p></span> <span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">M&#233;todos y resultados</span><p id="spar0070" class="elsevierStyleSimplePara elsevierViewall">Estudio multic&#233;ntrico prospectivo en el que se incluyeron pacientes ambulatorios y cl&#237;nicamente estables con IC&#46; Todos los pacientes se sometieron a una MAPA&#46; Se incluy&#243; un total de 154 pacientes de 17 centros&#46; La edad media fue de 76&#44;8 a&#241;os &#40;&#177; 8&#44;3&#41; y el 55&#44;2&#37; eran mujeres&#46; En total&#44; el 23&#44;7&#37; presentaba IC con fracci&#243;n de eyecci&#243;n reducida &#40;IC-FEr&#41;&#44; el 68&#44;2&#37; se encontraba en la clase funcional II de la NYHA y el 19&#44;5&#37;&#44; en la clase funcional III de la NYHA&#46; Al cabo de un a&#241;o de seguimiento se produjeron 13 &#40;8&#44;4&#37;&#41; muertes&#44; 10 de ellas atribuidas a la IC&#46; En 19 de los 29 pacientes que precisaron hospitalizaci&#243;n&#44; esta se debi&#243; a la IC&#46; La presencia de un patr&#243;n no dipper de PA se asoci&#243; a un mayor riesgo de reingreso o muerte al a&#241;o de seguimiento &#40;25&#37; frente al 5&#37;&#59; p &#61; 0&#44;024&#41;&#46; Seg&#250;n un an&#225;lisis de regresi&#243;n de Cox&#44; una clase funcional m&#225;s avanzada de la NYHA &#40;raz&#243;n de riesgos instant&#225;neos&#44; 3&#44;51&#59; IC del 95&#37;&#44; 1&#44;70-7&#44;26&#59; p &#61; 0&#44;001&#59; comparaci&#243;n entre las clases III y II de la NYHA&#41; y una mayor reducci&#243;n nocturna proporcional de la PA diast&#243;lica &#40;raz&#243;n de riesgos instant&#225;neos&#44; 0&#44;961&#59; IC del 95&#37;&#44; 0&#44;926-0&#44;997&#59; p &#61; 0&#44;032 por cada reducci&#243;n del 1&#37; de la PA diast&#243;lica&#41; se asociaron a muerte o reingreso al cabo de un a&#241;o de manera independiente&#46;</p></span> <span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Conclusiones</span><p id="spar0075" class="elsevierStyleSimplePara elsevierViewall">En los pacientes de edad avanzada con IC cr&#243;nica&#44; un patr&#243;n no dipper de PA determinado mediante MAPA se asoci&#243; a un mayor riesgo de hospitalizaci&#243;n y muerte por IC&#46;</p></span>"
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        "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as&#58; Camafort M&#44; Jhund PS&#44; Formiga F&#44; Castro-Salom&#243; A&#44; Ar&#233;valo-Lorido JC&#44; Sobrino-Mart&#237;nez J&#44; et al&#46; Utilidad pron&#243;stica de las cifras ambulatorias de presi&#243;n arterial en pacientes de edad avanzada con insuficiencia card&#237;aca&#46; Resultados del estudio DICUMAP&#46; Rev Clin Esp&#46; 2021&#59;221&#58;433&#8211;440&#46;</p>"
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        "nota" => "<p class="elsevierStyleNotepara" id="npar0010">The complete list of the DICUMAP Investigators who have participated in this study appears in the Appendix A&#46;</p>"
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            "apendice" => "<p id="par0220" class="elsevierStylePara elsevierViewall">Miguel Camafort Babkowski &#40;Hospital Cl&#237;nic&#46; Barcelona&#41;&#46; Jos&#233; Carlos Ar&#233;valo-Lorido &#40;Hospital de Zafra&#46; Badajoz&#41;&#46; Javier Sobrino Mart&#237;nez &#40;Fundaci&#243; Hospital de l&#8217;Esperit Sant&#46; Barcelona&#41;&#46; Luis Manzano Espinosa &#40;Hospital Universitario Ram&#243;n y Cajal&#46; Madrid&#41;&#46; Jos&#233; Luis Arias Jim&#233;nez &#40;Hospital Universitario Virgen Macarena&#46; Sevilla&#41;&#46; Jorge G&#243;mez Cerezo y Jorge Francisco &#40;Hospital Infanta Sof&#237;a&#46; Madrid&#41;&#46; Jes&#250;s D&#237;ez Manglano &#40;Hospital Royo Villanova&#46; Zaragoza&#41;&#46; Oscar Aramburu Bodas &#40;Hospital Universitario Virgen Macarena&#46; Sevilla&#41;&#46; Jordi Grau Amor&#243;s &#40;Hospital Municipal de Badalona&#46; Barcelona&#41;&#46; Manuel Montero Per&#233;z-Barquero &#40;Hospital Universitario Reina Sof&#237;a&#46; C&#243;rdoba&#41;&#46; Gerard Torres Cortada &#40;Hospital Santa Mar&#237;a&#46; Lleida&#41;&#46; Joan Carles Trull&#224;s Vila &#40;Hospital Sant Jaume&#46; Olot&#46; Girona&#41;&#46; Jos&#233; Manuel Varela Aguilar &#40;Hospital Virgen del Roc&#237;o&#46; Sevilla&#41;&#46; Gonzalo Mart&#237;nez de las Cuevas &#40;Hospital Universitario Marqu&#233;s de Valdecilla&#46; Cantabria&#41;&#46; Fernando Salgado Ord&#243;&#241;ez &#40;Hospital Carlos Haya&#46; M&#225;laga&#41;&#46; Manuel M&#233;ndez Bail&#243;n &#40;Hospital Infanta Leonor&#46; Madrid&#41;&#46; Nuria Ribas Piz&#225; &#40;Hospital de la Santa Creu i Sant Pau&#46; Barcelona&#41;&#46;</p>"
            "etiqueta" => "Appendix A"
            "titulo" => "DICUMAP Registry Investigators"
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          "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Survival curve &#40;days free of death or readmission&#41; according to dipper pattern of nighttime blood pressure&#46;</p> <p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">The log rank test showed that the difference observed in the Kaplan&#8211;Meier curve was statistically significant &#40;chi-square 5&#46;131&#44; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">&#61;</span><span class="elsevierStyleHsp" style=""></span>&#46;024&#41;&#46;</p>"
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          "leyenda" => "<p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Dependency was defined as a Barthel index below 60 points&#46; Cognitive impairment was defined as 5 or more points on Pfeiffer&#8217;s short portable mental state questionnaire&#46;</p><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">BPM&#58; Beats per minute&#46; CKD&#58; Chronic kidney disease&#46; DBP&#58; Diastolic Blood Pressure&#46; GFR&#58; Glomerular filtration rate&#46; HFrEF&#58; Heart Failure with reduced ejection fraction&#46; HFpEF Heart failure with preserved ejection fraction&#46; LVEF&#58; Left Ventricular Ejection Fraction&#46; SD&#58; standard deviation&#46; SBP&#58; Systolic Blood Pressure&#46;</p>"
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                  \t\t\t\t">Age at first visit &#40;years&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">76&#46;8 &#40;&#177;8&#46;3&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
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                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t">Women&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">55&#46;2&#37;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">Hypertension&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">Ischemic cardiomyopahty&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">17&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Mean Office SBP &#40;mm<span class="elsevierStyleHsp" style=""></span>Hg&#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="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">137&#46;4 &#40;&#177;19&#46;4&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Mean Office DBP &#40;mm<span class="elsevierStyleHsp" style=""></span>Hg&#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="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">74&#46;8 &#40;&#177;11&#46;4&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Office heart alert &#40;BPM&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">73&#46;1 &#40;&#177;11&#46;5&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Body mass index &#40;kg&#47;m<span class="elsevierStyleSup">2</span>&#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="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">29&#46;9 &#40;&#177;4&#46;8&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Abdominal circumference &#40;cm&#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="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">100 &#40;&#177;11&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Glucose &#40;mg&#47;dL&#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="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">121&#46;5 &#40;&#177;35&#46;7&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Diabetes &#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="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">42&#46;2&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">GFR &#40;mL&#47;min&#47;1&#46;73<span class="elsevierStyleHsp" style=""></span>m<span class="elsevierStyleSup">2</span>&#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="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">58&#46;3 &#40;&#177;23&#46;2&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">CKD &#40;GFR<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>60<span class="elsevierStyleHsp" style=""></span>mL&#47;min&#47;1&#44;73<span class="elsevierStyleHsp" style=""></span>m<span class="elsevierStyleSup">2</span>&#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="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">45&#46;85&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">LVEF&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">56&#46;9 &#40;&#177;13&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">HFrEF&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">23&#46;7&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">HFpEF&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">76&#46;3&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Dependency&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">41&#46;2&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Cognitive impairment&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">19&#46;6&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
              ]
              "imagenFichero" => array:1 [
                0 => "xTab2708172.png"
              ]
            ]
          ]
        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Baseline subject characteristics&#46;</p>"
        ]
      ]
      2 => array:8 [
        "identificador" => "tbl0010"
        "etiqueta" => "Table 2"
        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "detalles" => array:1 [
          0 => array:3 [
            "identificador" => "at0035"
            "detalle" => "Table "
            "rol" => "short"
          ]
        ]
        "tabla" => array:2 [
          "leyenda" => "<p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">BPM&#58; Beats per minute&#46; DBP&#58; Diastolic Blood Pressure&#46; HR&#58; Heart Rate&#46; SD&#58; standard deviation&#46; SBP&#58; Systolic Blood Pressure&#46;</p>"
          "tablatextoimagen" => array:1 [
            0 => array:2 [
              "tabla" => array:1 [
                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Variable&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Mean<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>SD&#47;&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">24<span class="elsevierStyleHsp" style=""></span>h SBP &#40;mean&#41;&#44; mm<span class="elsevierStyleHsp" style=""></span>Hg&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">124&#46;2<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>16&#46;4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">24<span class="elsevierStyleHsp" style=""></span>h DBP &#40;mean&#41;&#44; mm<span class="elsevierStyleHsp" style=""></span>Hg&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">66&#46;1<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>9&#46;7&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">24<span class="elsevierStyleHsp" style=""></span>h HR &#40;mean&#41; BPM&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">70&#46;8<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>12&#44;1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Active SBP &#40;mean&#41;&#44; mm<span class="elsevierStyleHsp" style=""></span>Hg&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">126&#46;4<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>16&#46;7&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Active DBP &#40;mean&#41;&#44; mm<span class="elsevierStyleHsp" style=""></span>Hg&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">68&#46;7<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>10&#46;7&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Activity HF &#40;mean&#41; BPM&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">73&#46;0<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>13&#46;2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Resting SBP &#40;mean&#41;&#44; mm<span class="elsevierStyleHsp" style=""></span>Hg&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">121&#46;3<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>18&#46;9&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Resting DBP &#40;mean&#41;&#44; mm<span class="elsevierStyleHsp" style=""></span>Hg&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">62&#46;9<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>10&#46;4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Resting heart rate &#40;mean&#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="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">68&#46;6<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>13&#46;5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Reduction in SBP&#44; &#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">4&#46;1<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>16&#46;7&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Reduction in DBP&#44; &#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">9&#46;0<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>15&#46;8&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Dipper Pattern&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">21&#46;43&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Super Dipper Pattern&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">4&#46;55&#37;&nbsp;\t\t\t\t\t\t\n
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Article information

ISSN: 22548874
Original language: English

DOI:10.1016/j.rceng.2020.11.010

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