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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Introducci&#243;n</span><p id="par0005" class="elsevierStylePara elsevierViewall">La artritis reumatoide &#40;AR&#41; afecta al 0&#44;5-1&#37; de la poblaci&#243;n&#44; presenta una mortalidad de 1&#44;3 a 3 veces superior a la poblaci&#243;n general y destaca la mortalidad de origen cardiovascular con un 40-50&#37;<a class="elsevierStyleCrossRefs" href="#bib0280"><span class="elsevierStyleSup">1&#8211;4</span></a>&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">Estudios como los de Solomon et al&#46; y Maradit-Kremers et al&#46; pusieron de manifiesto el incremento del riesgo de infarto agudo del miocardio &#40;RR&#58; 2&#44;07-3&#44;17&#41; y accidente cerebrovascular &#40;RR&#58; 1&#44;48&#41; en los pacientes con AR<a class="elsevierStyleCrossRefs" href="#bib0300"><span class="elsevierStyleSup">5&#44;6</span></a>&#44; comparable con el descrito en la diabetes mellitus de tipo 2 &#40;OR&#58; 2&#44;7-3&#44;11&#41;<a class="elsevierStyleCrossRefs" href="#bib0310"><span class="elsevierStyleSup">7&#44;8</span></a>&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">Si bien los factores de riesgo cl&#225;sico son importantes en la patog&#233;nesis de la aterosclerosis&#44; no explican completamente el incremento de los eventos cardiovasculares &#40;ECV&#41; descritos en este grupo de pacientes<a class="elsevierStyleCrossRefs" href="#bib0320"><span class="elsevierStyleSup">9&#8211;11</span></a>&#46; Por lo que la enfermedad cardiovascular se considera actualmente como una manifestaci&#243;n extrarticular de la AR<a class="elsevierStyleCrossRefs" href="#bib0335"><span class="elsevierStyleSup">12&#8211;16</span></a>&#46; Esto hace necesaria la estimaci&#243;n del riesgo cardiovascular &#40;RCV&#41; a mediano-largo plazo<a class="elsevierStyleCrossRef" href="#bib0360"><span class="elsevierStyleSup">17</span></a>&#44; con lo cual podremos priorizar las actividades de prevenci&#243;n y definir la intensidad con la que deben ser tratados dichos factores<a class="elsevierStyleCrossRefs" href="#bib0365"><span class="elsevierStyleSup">18&#44;19</span></a>&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">En el 2010&#44; EULAR propuso por consenso para la valoraci&#243;n del RCV el uso del SCORE modificado &#40;SCOREm&#41;&#44; que consiste en multiplicar por un factor de conversi&#243;n de 1&#44;5 el resultado obtenido con el SCORE de los pacientes que re&#250;nan 2 de los siguientes 3 criterios&#58; duraci&#243;n de la enfermedad mayor o igual a 10 a&#241;os&#44; factor reumatoide &#40;FR&#41; o antip&#233;ptido c&#237;clico citrulinado positivo &#40;anti-CCP&#41; y la presencia de manifestaciones extrarticulares<a class="elsevierStyleCrossRef" href="#bib0375"><span class="elsevierStyleSup">20</span></a>&#46; Sin embargo&#44; se ha observado c&#243;mo esta herramienta y los factores tomados en cuenta subestiman dicho riesgo&#58; se objetiva hasta un 12-30&#37; de aterosclerosis subcl&#237;nica por ecograf&#237;a carot&#237;dea y el desarrollo de ECV a corto-mediano plazo en los pacientes clasificados de riesgo bajo&#47;intermedio<a class="elsevierStyleCrossRefs" href="#bib0380"><span class="elsevierStyleSup">21&#8211;26</span></a>&#44; por lo que en los &#250;ltimos a&#241;os se ha puesto mayor atenci&#243;n en otras caracter&#237;sticas cl&#237;nicas relacionadas con la AR que podr&#237;an estar m&#225;s asociadas a un incremento en el riesgo de aterosclerosis subcl&#237;nica&#44; entre los que destacan el grado de actividad de la enfermedad&#44; los marcadores de inflamaci&#243;n&#44; grado de afectaci&#243;n o erosi&#243;n articular o el uso de corticoides<a class="elsevierStyleCrossRefs" href="#bib0410"><span class="elsevierStyleSup">27&#8211;33</span></a>&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">El objetivo es estimar el papel de la actividad de la enfermedad en el desarrollo de aterosclerosis subcl&#237;nica en los pacientes con AR de riesgo cardiovascular bajo&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Material y m&#233;todos</span><p id="par0030" class="elsevierStylePara elsevierViewall">Se desarroll&#243; un estudio observacional&#44; transversal y anal&#237;tico &#40;ciego al estudio ecogr&#225;fico&#41; en los pacientes con AR &#40;seg&#250;n los criterios ACR 1987 o ACR&#47;EULAR 2010&#41; del Hospital General Universitario de Ciudad Real &#40;HGUCR&#41; durante el periodo junio de 2013-mayo de 2014&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">Se incluy&#243; a los mayores de 18 a&#241;os que aceptaron participar del estudio mediante la firma del consentimiento informado&#46; Se excluyeron las artritis no filiadas o s&#237;ndromes de superposici&#243;n&#44; los antecedentes o diagn&#243;sticos recientes de ECV previo&#44; las diabetes mellitus o la insuficiencia renal &#40;filtrado glomerular&#160;&#60;&#160;60<span class="elsevierStyleHsp" style=""></span>ml&#47;min&#41;&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">Se realiz&#243; una anal&#237;tica completa que inclu&#237;a los marcadores serol&#243;gicos y de actividad &#40;velocidad de sedimentaci&#243;n globular&#44; prote&#237;na C reactiva&#44; factor reumatoide y antip&#233;ptido citrulinado&#41;&#44; as&#237; como un estudio metab&#243;lico para la valoraci&#243;n del RCV &#40;glucemia basal&#44; hemoglobina glucosilada&#44; uricemia&#44; perfil renal&#44; lip&#237;dico y tiroideo&#41;&#46; Se calcul&#243; el grado de actividad mediante el SDAI &#40;n&#46;&#176; de articulaciones tumefactas&#44; n&#46;&#176; de articulaciones dolorosas&#44; valoraci&#243;n global del paciente&#44; valoraci&#243;n global del m&#233;dico y niveles de PCR&#41;&#46; Para ello se recopilaron los registros de actividad mediante el SDAI en el &#250;ltimo a&#241;o&#44; incluido el realizado al inicio del estudio&#44; y se obtuvo un promedio de la actividad&#46;</p><p id="par0180" class="elsevierStylePara elsevierViewall">Se dividi&#243; a los pacientes con AR en RCV bajo y RCV alto &#40;pacientes con riesgo medio&#44; alto o muy alto&#41; seg&#250;n el SCOREm&#46;</p><p id="par0050" class="elsevierStylePara elsevierViewall">Finalmente&#44; se realiz&#243; un estudio de ecograf&#237;a carot&#237;dea a cargo de un m&#233;dico radi&#243;logo que desconoci&#243; en todo momento el grupo de cada paciente&#46; Se empleo un ec&#243;grafo marca Toshiba Aplio XG&#44; modelo Ssa-790A&#44; transductor lineal de 7-10<span class="elsevierStyleHsp" style=""></span>MHz&#44; haciendo hincapi&#233; en la medici&#243;n del grosor &#237;ntima-media &#40;GIM&#41;&#46; Se consider&#243; patol&#243;gico si el GIM<span class="elsevierStyleHsp" style=""></span>&#62;<span class="elsevierStyleHsp" style=""></span>0&#44;9<span class="elsevierStyleHsp" style=""></span>mm y mediante la presencia de placa ateromatosa &#40;PA&#41; &#40;engrosamiento focal<span class="elsevierStyleHsp" style=""></span>&#62;<span class="elsevierStyleHsp" style=""></span>1&#44;5<span class="elsevierStyleHsp" style=""></span>mm&#41;&#44; seg&#250;n protocolo habitual<a class="elsevierStyleCrossRefs" href="#bib0445"><span class="elsevierStyleSup">34&#8211;36</span></a>&#46;</p><p id="par0055" class="elsevierStylePara elsevierViewall">La informaci&#243;n obtenida se introdujo en una base de datos de Microsoft Excel&#59; se describieron las variables evaluadas usando medidas de frecuencia y medidas de tendencia central&#47;dispersi&#243;n y se evalu&#243; la fuerza de asociaci&#243;n de las variables con la raz&#243;n de momios y su intervalo de confianza al 95&#37;&#46; Para los an&#225;lisis se us&#243; STATA 12&#46;0 y el c&#225;lculo de la correcci&#243;n de Yates se realiz&#243; con el programa IBM SPSS 22&#46;0&#46; El protocolo del estudio fue aprobado por el Comit&#233; &#201;tico de Investigaci&#243;n Cl&#237;nica del HGUCR&#46;</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Resultados</span><p id="par0060" class="elsevierStylePara elsevierViewall">Durante el periodo junio del 2013-mayo del 2014 aceptaron participar en el estudio un total de 119 pacientes con AR &#40;63&#44;87&#37; mujeres&#59; 36&#44;13&#37; hombres&#41; &#40;ver <a class="elsevierStyleCrossRef" href="#tbl0005">tabla 1</a>&#41;&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0065" class="elsevierStylePara elsevierViewall">En la poblaci&#243;n estudiada destaca una prevalencia elevada del 84&#44;87&#37; para la presencia de alg&#250;n factor de RCV y del 73&#44;1&#37; para los factores de riesgo cl&#225;sicos&#46; Asimismo&#44; un 6&#44;72&#37; hab&#237;a presentado un ECV al momento del estudio&#46;</p><p id="par0070" class="elsevierStylePara elsevierViewall">En cuanto al perfil cl&#237;nico de la AR&#44; se observa una prevalencia en torno al 79&#44;83&#37; de los marcadores serol&#243;gicos positivos &#40;FR o anti-CCP&#41;&#44; as&#237; como un tiempo de evoluci&#243;n de la enfermedad mayor a 10 a&#241;os en el 47&#37; de nuestra poblaci&#243;n&#46; Asimismo&#44; un 66&#37; se encontraba con un control adecuado de la enfermedad&#44; tanto de forma global mediante el SDAI &#40;remisi&#243;n o baja actividad&#41; como por la presencia de marcadores biol&#243;gicos de actividad inflamatoria&#46; El tratamiento m&#225;s frecuente fue el uso de corticoterapia a dosis 5-10<span class="elsevierStyleHsp" style=""></span>mg&#47;d&#237;a de prednisona o equivalentes y f&#225;rmacos antirreum&#225;ticos modificadores de la enfermedad &#40;principalmente&#44; metotrexato&#41;&#46;</p><p id="par0075" class="elsevierStylePara elsevierViewall">Para fines del estudio se excluyeron inicialmente 11 pacientes &#40;9&#44;24&#37;&#41; por presentar enfermedad vascular conocida &#40;8 eventos previos&#44; 4 diabetes mellitus y 2 nefropat&#237;as&#41;&#44; por lo que qued&#243; un total de 108 pacientes a los que se les realiz&#243; la anal&#237;tica del estudio y el c&#225;lculo del SCOREm &#40;48 de riesgo bajo y 60 de riesgo intermedio&#44; alto y muy alto&#41; &#40;<a class="elsevierStyleCrossRef" href="#fig0005">fig&#46; 1</a>&#41;&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0080" class="elsevierStylePara elsevierViewall">Tras los resultados del estudio anal&#237;tico espec&#237;fico &#40;glucosa basal&#44; perfil lip&#237;dico y tiroideo&#44; creatinina&#44; filtrado glomerular&#44; hemoglobina glicada&#44; &#225;cido &#250;rico&#44; reactantes de fase aguda&#44; FR&#44; anti-CCP&#44; etc&#46;&#41; se excluyeron 27 pacientes&#44; 18 por hemoglobina glicada alterada y 12 por filtrado glomerular<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>60<span class="elsevierStyleHsp" style=""></span>ml&#47;min &#40;3 pacientes con ambos hallazgos&#41;&#44; lo que elev&#243; la prevalencia de factores de RCV en nuestra poblaci&#243;n total &#40;<a class="elsevierStyleCrossRef" href="#fig0010">fig&#46; 2</a>&#41;&#46;</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0085" class="elsevierStylePara elsevierViewall">De los 81 pacientes restantes &#40;46 de riesgo bajo y 35 de riesgo intermedio&#44; alto y muy alto&#41;&#44; 10 pacientes no acudieron a la realizaci&#243;n de la ecograf&#237;a carot&#237;dea&#44; por lo que finalmente se realiz&#243; el an&#225;lisis del estudio a un total de 71 pacientes &#40;41 de riesgo bajo y 30 de riesgo intermedio&#44; alto y muy alto&#41; &#40;<a class="elsevierStyleCrossRef" href="#tbl0010">tabla 2</a>&#41;&#46; A todos los pacientes se les dieron recomendaciones generales de los estilos de vida saludables y a los de riesgo alto&#47;muy alto se les paut&#243; tratamiento seg&#250;n su perfil de RCV&#44; con seguimiento posterior por su m&#233;dico de Atenci&#243;n Primaria&#46;</p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><p id="par0090" class="elsevierStylePara elsevierViewall">Las variables tomadas en cuenta para el c&#225;lculo del SCOREm fueron m&#225;s prevalentes en el grupo de riesgo alto&#46; Las variables que en el grupo de riesgo alto presentaron una diferencia estad&#237;sticamente significativa &#40;p<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#44;05&#41; fueron la edad&#44; sexo&#44; HTA&#44; anti-CCP y actividad por SDAI&#46;</p><p id="par0095" class="elsevierStylePara elsevierViewall">El GIM promedio en la poblaci&#243;n de riesgo bajo por SCOREm fue de 0&#44;65<span class="elsevierStyleHsp" style=""></span>mm y de 0&#44;80<span class="elsevierStyleHsp" style=""></span>mm en los de alto riesgo&#46; El resto de las caracter&#237;sticas ecogr&#225;ficas seg&#250;n los grupos de riesgo se muestra en la <a class="elsevierStyleCrossRef" href="#fig0015">figura 3</a>&#46;</p><elsevierMultimedia ident="fig0015"></elsevierMultimedia><p id="par0100" class="elsevierStylePara elsevierViewall">Al realizar el an&#225;lisis de la fuerza de asociaci&#243;n entre la estratificaci&#243;n del RCV por el SCOREm y los hallazgos mediante ecograf&#237;a carot&#237;dea se puede observar que&#44; seg&#250;n nuestros resultados&#44; el estratificar como riesgo alto &#40;intermedio&#44; alto y muy alto&#41; incrementa 3 veces el riesgo de presentar placa ateromatosa&#44; con una p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;037&#46; Sin embargo&#44; destaca la existencia de un 14&#44;63&#37; de pacientes clasificados de bajo riesgo &#40;6&#47;41&#41; que presentan aterosclerosis subcl&#237;nica por la presencia de placa ateromatosa&#44; lo que representa el 35&#44;39&#37; &#40;6&#47;17&#41; del total de PA objetivadas en nuestra poblaci&#243;n de estudio &#40;<a class="elsevierStyleCrossRef" href="#tbl0015">tabla 3</a>&#41;&#46;</p><elsevierMultimedia ident="tbl0015"></elsevierMultimedia><p id="par0105" class="elsevierStylePara elsevierViewall">Los resultados son similares si se hace el c&#225;lculo de sensibilidad&#44; especificidad&#44; VPP y VPN usando como punto de corte el GIM &#8805; 0&#44;9<span class="elsevierStyleHsp" style=""></span>mm &#40;<a class="elsevierStyleCrossRef" href="#tbl0020">tabla 4</a>&#41;&#46; Sin embargo&#44; los resultados var&#237;an si tomamos como referencia el percentil p75 del GIM en la poblaci&#243;n espa&#241;ola sana&#44; en la que la sensibilidad de esta herramienta desciende al 38&#44;71&#37;&#44; lo que determina que un 46&#44;34&#37; de los pacientes clasificados de bajo riesgo por SCOREm presenten un GIM mayor al GIM p75 seg&#250;n sexo y edad&#46; Por todo ello&#44; la especificidad obtenida &#40;55-64&#44;81&#37;&#41; expresa una limitaci&#243;n en la capacidad que tiene esta prueba para detectar a los que no tienen la condici&#243;n buscada &#40;verdaderos negativos&#41;&#46;</p><elsevierMultimedia ident="tbl0020"></elsevierMultimedia><p id="par0110" class="elsevierStylePara elsevierViewall">En cuanto a la asociaci&#243;n con el grado de actividad y aterosclerosis subcl&#237;nica&#44; es destacable la fuerte asociaci&#243;n&#44; con un OR 4&#44;95 y p&#160;&#61;&#160;0&#44;008&#44; entre la presencia de placa ateromatosa y el grado de actividad de la enfermedad medida de forma global con par&#225;metros cl&#237;nicos y anal&#237;ticos por el SDAI y no solo por la elevaci&#243;n de los reactantes de fase aguda&#46; Asimismo&#44; la presencia de actividad de la enfermedad condicionar&#237;a un incremento del riesgo de presentar un GIM patol&#243;gico&#58; GIM<span class="elsevierStyleHsp" style=""></span>&#62;<span class="elsevierStyleHsp" style=""></span>0&#44;9<span class="elsevierStyleHsp" style=""></span>mm &#40;OR 2&#46;5&#59; IC&#160;95&#58; 0&#44;59-10&#44;55&#59; p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;21&#41; o GIM&#160;&#62;&#160;p75 &#40;OR 2&#44;2&#59; IC&#160;95&#58; 0&#44;75-6&#44;4&#59; p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;14&#41; con un intervalo de confianza bastante aceptable &#40;<a class="elsevierStyleCrossRef" href="#fig0020">fig&#46; 4</a>&#41;&#46;</p><elsevierMultimedia ident="fig0020"></elsevierMultimedia><p id="par0115" class="elsevierStylePara elsevierViewall">Los factores relacionados con la AR tomados en cuenta por EULAR para la modificaci&#243;n propuesta del SCORE presentaron una asociaci&#243;n con el incremento del riesgo de aterosclerosis subcl&#237;nica&#44; aunque esta no fue estad&#237;sticamente significativa&#58; tiempo de evoluci&#243;n &#62; 10 a&#241;os &#40;p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;19&#41;&#44; FR &#40;p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;95&#41;&#44; anti-CCP &#40;p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;73&#41; y manifestaciones extrarticulares &#40;p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;34&#41;&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Discusi&#243;n</span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">SCOREm y la infraestimaci&#243;n del riesgo cardiovascular</span><p id="par0120" class="elsevierStylePara elsevierViewall">A pesar de los intentos por dise&#241;ar algoritmos para una adecuada estratificaci&#243;n del RCV en la poblaci&#243;n con AR &#40;escala de Reynolds y el QRisk II&#41; y las modificaciones propuestas por EULAR al SCORE&#44; estas herramientas siguen presentando una sensibilidad y especificidad m&#225;s baja de la esperada &#40;68-87&#37; y 55-76&#37;&#44; respectivamente&#41;&#44; lo que ocasiona que hasta un 32&#37; de los ECV puedan ocurrir en la poblaci&#243;n clasificada de bajo riesgo seg&#250;n estas herramientas<a class="elsevierStyleCrossRefs" href="#bib0405"><span class="elsevierStyleSup">26&#44;37&#8211;41</span></a>&#46; Incluso factores considerados hasta el momento como determinantes en el incremento del RCV &#40;tiempo de enfermedad &#62; 10 a&#241;os&#44; FR &#91;&#43;&#93;&#44; anti-CCP &#91;&#43;&#93;&#44; etc&#46;&#41; pueden no tener el impacto esperado en la estratificaci&#243;n del RCV<a class="elsevierStyleCrossRefs" href="#bib0380"><span class="elsevierStyleSup">21&#44;42&#44;43</span></a>&#46;</p><p id="par0125" class="elsevierStylePara elsevierViewall">En nuestro estudio observamos la presencia de placas ateromatosas en un 14&#44;63&#37; de la poblaci&#243;n catalogada de bajo riesgo seg&#250;n el SCOREm&#44; con un GIM promedio de 0&#44;6530<span class="elsevierStyleHsp" style=""></span>mm&#44; valores que son mucho m&#225;s elevados que los esperados en la poblaci&#243;n espa&#241;ola sana de bajo riesgo seg&#250;n el SCORE<a class="elsevierStyleCrossRef" href="#bib0495"><span class="elsevierStyleSup">44</span></a> &#40;3&#37; de placas ateromatosas y un GIM promedio de 0&#44;56<span class="elsevierStyleHsp" style=""></span>mm &#91;DE<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>0&#44;1078<span class="elsevierStyleHsp" style=""></span>mm&#93;&#41;&#46; Estos datos proporcionan al SCOREm una sensibilidad del 64&#44;71&#37; &#40;IC&#160;95&#37;&#58; 41&#44;3-82&#44;69&#41; tomando como referencia la presencia de placa ateromatosa y del 38&#44;71&#37; &#40;IC&#160;95&#37;&#58; 23&#44;73-56&#41; si tomamos el GIM<span class="elsevierStyleHsp" style=""></span>&#62;<span class="elsevierStyleHsp" style=""></span>p75&#44; seg&#250;n edad y sexo en la poblaci&#243;n espa&#241;ola&#46; Es decir&#44; si bien el SCOREm podr&#237;a asociarse aceptablemente con la presencia de aterosclerosis subcl&#237;nica &#40;PA y GIM &#62;0&#44;9<span class="elsevierStyleHsp" style=""></span>mm&#41; en los pacientes con AR&#44; existe un porcentaje no despreciable en el grupo de bajo riesgo que no es detectado por esta herramienta&#46; Hasta el momento&#44; los estudios realizados de aterosclerosis subcl&#237;nica centrados en el grupo de bajo riesgo son muy escasos y nuestros resultados son acordes con ellos&#44; fundamentalmente&#44; en el bajo nivel de especificidad que presenta el SCOREm como herramienta&#46; En el estudio de Corrales et al&#46;<a class="elsevierStyleCrossRefs" href="#bib0400"><span class="elsevierStyleSup">25&#44;45&#44;46</span></a> realizado en poblaci&#243;n espa&#241;ola &#40;Santander&#44; norte de Espa&#241;a&#41;&#44; se objetiv&#243; la presencia aterosclerosis subcl&#237;nica &#40;GIM<span class="elsevierStyleHsp" style=""></span>&#8805;<span class="elsevierStyleHsp" style=""></span>0&#44;9<span class="elsevierStyleHsp" style=""></span>mm o presencia de PA&#41; mediante ecograf&#237;a carot&#237;dea hasta en un 13-33&#37; de la poblaci&#243;n clasificada seg&#250;n el SCOREm como de riesgo bajo&#46; Asimismo&#44; un estudio holand&#233;s de Arts et al&#46;<a class="elsevierStyleCrossRef" href="#bib0510"><span class="elsevierStyleSup">47</span></a>&#44; realizado sobre una cohorte de 1&#46;050 pacientes con AR a lo largo de 10 a&#241;os aproximadamente&#44; registr&#243; 149 ECV&#44; de los cuales un 32&#37; se present&#243; en el grupo de bajo riesgo&#46; Estos datos corroboran los resultados de otros estudios que postulan el bajo impacto final del SCOREm en los pacientes con riesgo intermedio y riesgo bajo<a class="elsevierStyleCrossRefs" href="#bib0380"><span class="elsevierStyleSup">21&#8211;26</span></a>&#46; Es necesario el uso de otras herramientas o t&#233;cnicas con mayor sensibilidad que nos permitan una estratificaci&#243;n m&#225;s exacta y real&#46; Por lo que&#44; como en el estudio de Gonzalez-Gay et al&#46;<a class="elsevierStyleCrossRef" href="#bib0515"><span class="elsevierStyleSup">48</span></a>&#44; se recomienda la utilizaci&#243;n de la ecograf&#237;a carot&#237;dea en aquellos pacientes de riesgo bajo&#47;intermedio para su reclasificaci&#243;n&#46;</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Actividad de la enfermedad e incremento del riesgo cardiovascular</span><p id="par0130" class="elsevierStylePara elsevierViewall">En nuestra cohorte se objetiv&#243; que el grado de actividad de la enfermedad de forma global mediante el SDAI es un factor de riesgo para el desarrollo de placa ateromatosa &#40;OR 4&#44;95&#59; p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;008&#41;&#46; Por el contrario&#44; las variables propuestas por EULAR para su incorporaci&#243;n en el SCORE &#40;FR&#44; anti-CCP&#44; manifestaciones extrarticulares y tiempo de duraci&#243;n &#62;&#160;10 a&#241;os&#41; presentaron una tendencia de asociaci&#243;n con el incremento del riesgo de aterosclerosis subcl&#237;nica&#44; pero no fue significativa&#46; Estos hallazgos son similares a los descritos en los estudios de Montes et al&#46;<a class="elsevierStyleCrossRef" href="#bib0520"><span class="elsevierStyleSup">49</span></a> y Arts et al&#46;<a class="elsevierStyleCrossRef" href="#bib0525"><span class="elsevierStyleSup">50</span></a>&#44; en los que ni el FR&#44; ni el anti-CCP&#44; ni el VSG&#44; ni el tiempo de evoluci&#243;n estuvieron relacionados con la aterosclerosis subcl&#237;nica o el EVC&#46; Por el contrario&#44; el grado de actividad mediante el DAS28 s&#237; estuvo significativamente relacionado con el desarrollo de EVC &#40;p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;002&#41;<a class="elsevierStyleCrossRef" href="#bib0525"><span class="elsevierStyleSup">50</span></a> y la presencia de placas ateromatosas &#40;p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;005&#41;<a class="elsevierStyleCrossRef" href="#bib0530"><span class="elsevierStyleSup">51</span></a>&#46; Asimismo&#44; en el estudio de Myasoedova et al&#46;<a class="elsevierStyleCrossRef" href="#bib0535"><span class="elsevierStyleSup">52</span></a>&#44; en el que se valora la implicaci&#243;n del grado de actividad inflamatoria acumulada en el desarrollo de ECV en una serie de 525 pacientes con AR vs&#46; 524 pacientes no&#160;AR ajustado seg&#250;n edad&#44; sexo y factores de RCV tradicionales&#44; se observa una incidencia de EVC similar entre los pacientes en remisi&#243;n frente a los pacientes no&#160;AR &#40;RR 0&#44;90&#59; IC&#160;95&#37;&#58; 0&#44;51-1&#44;59&#41;&#46; Sin embargo&#44; los pacientes con AR en actividad intermedia y brotes acumulados de un a&#241;o presentan un incremento del RCV de 1&#44;37 &#40;IC&#160;95&#37;&#58; 1&#44;01-1&#44;89&#41; y de 2&#44;42 &#40;IC&#160;95&#37;&#58; 1&#44;14-5&#44;14&#41;&#44; respectivamente&#44; con relaci&#243;n a los pacientes no&#160;AR&#46;</p><p id="par0135" class="elsevierStylePara elsevierViewall">Finalmente&#44; en la cohorte norteamericana de 24&#46;989 pacientes con AR seguida a lo largo de 4 a&#241;os&#44; Solomon et al&#46;<a class="elsevierStyleCrossRef" href="#bib0540"><span class="elsevierStyleSup">53</span></a> observaron que un grado de actividad alta medido por CDAI implicaba un incremento del 60&#37; del riesgo de presentar un EVC sobre los que se encontraban en remisi&#243;n &#40;IC&#160;95&#37;&#58; 23-80&#41;&#46; Esta influencia determinante de la actividad en el incremento del RCV se puede observar incluso a nivel molecular y celular &#40;preaterog&#233;nico&#41;&#44; como lo demostr&#243; el estudio de Groot et al&#46;<a class="elsevierStyleCrossRef" href="#bib0545"><span class="elsevierStyleSup">54</span></a>&#44; en el que se objetiv&#243; una relaci&#243;n directa y estad&#237;sticamente significativa entre el DAS28 y los niveles de expresi&#243;n de las mol&#233;culas de adhesi&#243;n celular &#40;VCAM-1 y factor de Von Willebrand&#41; y los productos finales de la glicaci&#243;n avanzada&#46; Tambi&#233;n lo demostr&#243; el estudio de Targ&#243;nska-Stepniak et al&#46;<a class="elsevierStyleCrossRef" href="#bib0550"><span class="elsevierStyleSup">55</span></a>&#44; que objetiv&#243; una relaci&#243;n directa de los niveles de amiloide s&#233;rico A y el grado de actividad mediante DAS28 &#40;p<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#44;0001&#41; y la presencia de placas ateromatosas mediante ecograf&#237;a carot&#237;dea &#40;p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;04&#41;&#46;</p><p id="par0140" class="elsevierStylePara elsevierViewall">La principal limitaci&#243;n de nuestro estudio fue el tama&#241;o muestral &#40;N<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>71&#41;&#46; Esto genera un poder estad&#237;stico de 67&#44;43&#37;&#46; No obstante&#44; hemos obtenido resultados relevantes y con significaci&#243;n estad&#237;stica suficiente&#46;</p></span></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Conclusiones</span><p id="par0145" class="elsevierStylePara elsevierViewall">Si bien existe una aceptable fuerza de asociaci&#243;n entre la presencia de aterosclerosis subcl&#237;nica mediante ecograf&#237;a carot&#237;dea y la tabla de estratificaci&#243;n SCOREm propuesta por EULAR&#44; esta infraestima el riesgo en un 14&#44;63&#37; de la poblaci&#243;n clasificada de riesgo bajo que presenta placas ateromatosas&#44; lo que le proporciona un baja sensibilidad y especificidad como herramienta de <span class="elsevierStyleItalic">screening</span>&#46; Es por ello por lo que recomendamos la realizaci&#243;n de la ecograf&#237;a carot&#237;dea en los pacientes con AR que inicialmente no son clasificados como de alto&#47;muy alto riesgo seg&#250;n las tablas de estratificaci&#243;n disponibles&#46; Esto nos permitir&#237;a reestratificar a los pacientes considerados inicialmente de riesgo bajo&#47;intermedio y&#44; de esta forma&#44; cambiar nuestra actitud cl&#237;nica&#44; terap&#233;utica y de seguimiento&#46; Por todo ello&#44; es imprescindible la creaci&#243;n de una herramienta espec&#237;fica para pacientes con AR que permita calcular su RCV real&#44; tomando en cuenta factores que est&#233;n fuertemente relacionados con el RCV&#46;</p><p id="par0150" class="elsevierStylePara elsevierViewall">Dado que uno de los factores de riesgo m&#225;s asociado a la presencia de ateroesclerosis subcl&#237;nica fue el grado de actividad inflamatoria&#44; el objetivo de nuestro abordaje &#171;treat to target&#187; influir&#225; no solo en el control del dolor y la mejor&#237;a funcional&#44; sino en la disminuci&#243;n del RCV de nuestros pacientes&#46;</p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">Responsabilidades &#233;ticas</span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0105">Protecci&#243;n de personas y animales</span><p id="par0155" class="elsevierStylePara elsevierViewall">Los autores declaran que para esta investigaci&#243;n no se han realizado experimentos en seres humanos ni en animales&#46;</p></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0110">Confidencialidad de los datos</span><p id="par0160" class="elsevierStylePara elsevierViewall">Los autores declaran que han seguido los protocolos de su centro de trabajo sobre la publicaci&#243;n de datos de pacientes&#46;</p></span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0115">Derecho a la privacidad y consentimiento informado</span><p id="par0165" class="elsevierStylePara elsevierViewall">Los autores declaran que en este art&#237;culo no aparecen datos de pacientes&#46;</p></span></span><span id="sec0060" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0120">Conflicto de intereses</span><p id="par0170" class="elsevierStylePara elsevierViewall">Ninguno de los autores declara conflictos de inter&#233;s&#46;</p></span></span>"
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            0 => "Artritis reumatoide"
            1 => "Inflamaci&#243;n cr&#243;nica"
            2 => "Riesgo cardiovascular"
            3 => "Aterosclerosis subcl&#237;nica"
            4 => "SCOREm"
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            0 => "Rheumatoid arthritis"
            1 => "Chronic inflammation"
            2 => "Cardiovascular risk"
            3 => "Subclinical atherosclerosis"
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        "titulo" => "Resumen"
        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">La artritis reumatoide &#40;AR&#41; presenta una mortalidad de 1&#44;3 a 3 veces superior a la poblaci&#243;n general&#59; la principal causa de muerte son las complicaciones cardiovasculares &#40;40-50&#37;&#41;&#46; En el abordaje inicial se debe incluir la valoraci&#243;n del riesgo cardiovascular &#40;RCV&#41; mediante algoritmos adaptados para esta poblaci&#243;n&#46; Si bien el SCOREm constituye un avance importante&#44; hay datos que indican que podr&#237;a infradiagnosticar la ateroesclerosis subcl&#237;nica&#46;</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Objetivo</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Estimar la fuerza de asociaci&#243;n entre la ecografia carot&#237;dea y el SCOREm en esta poblaci&#243;n&#44; as&#237; como la implicancia de la actividad de la enfermedad&#46;</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Metodolog&#237;a</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Estudio observacional&#44; transversal y anal&#237;tico&#44; realizado en el Hospital General de Ciudad Real durante el periodo junio de 2013-mayo de 2014&#46; Se realiz&#243; la valoraci&#243;n del RCV y seg&#250;n el SCOREm se dividi&#243; a la poblaci&#243;n en riesgo bajo y alto &#40;medio&#44; alto y muy alto&#41;&#46; Se estudi&#243; la presencia de ateroesclerosis subcl&#237;nica en los pacientes de riesgo bajo&#46;</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Resultados</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Del total de 119 pacientes con AR&#44; el 73&#44;1&#37; presentaba factores de riesgo tradicionales&#46; Se excluyeron 38 pacientes por evento cardiovascular previo&#44; diabetes mellitus y nefropat&#237;a&#46; Se objetiv&#243; placa ateromatosa en el 14&#44;63&#37; de la poblaci&#243;n de riesgo bajo&#46; El factor con mayor asociaci&#243;n con la presencia de aterosclerosis subcl&#237;nica fue el grado de actividad moderada&#47;alta de la AR medida mediante el SDAI&#44; con un OR de 4&#44;95 &#40;IC&#160;95&#37;&#58; 1&#44;53-16&#44;01&#41;&#46;</p></span> <span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Conclusiones</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Aunque existe una aceptable asociaci&#243;n entre la presencia de aterosclerosis subcl&#237;nica y el SCOREm&#44; hay una proporci&#243;n no despreciable de pacientes clasificados de riesgo bajo con placas ateromatosas&#46; La actividad de la enfermedad fue el factor de riesgo m&#225;s asociado al incremento del RCV&#46;</p></span>"
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        "resumen" => "<span id="abst0030" class="elsevierStyleSection elsevierViewall"><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Rheumatoid arthritis &#40;RA&#41; is associated with a 1&#46;3 to 3-fold increase in mortality&#44; being the major cause of death from cardiovascular complications &#40;40&#37;-50&#37;&#41;&#46; Therefore&#44; the initial approach should include cardiovascular risk &#40;CVR&#41; assessment using algorithms adapted for this population&#46; Although&#44; SCOREM is an important advance&#44; there are data indicating that subclinical atherosclerosis may be underdiagnosed&#46;</p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Objective</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">To estimate the strength of association between carotid ultrasound and SCOREM in this population&#44; as well as the implication of disease activity&#46;</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Methodology</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">Cross-sectional&#44; observational&#44; analytical study performed at the General Hospital of Ciudad Real&#44; Spain&#44; between June 2013 and May 2014&#46; The evaluation of CVR was performed and&#44; according to SCOREM&#44; the population was divided into low and high &#40;medium&#44; high and very high&#41; risk&#46; We studied the presence of subclinical atherosclerosis in low-risk patients&#46;</p></span> <span id="abst0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Results</span><p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Of the total of 119 RA patients&#44; 73&#46;1&#37; had traditional risk factors&#46; Thirty-eight patients were excluded because of a previous cardiovascular event&#44; diabetes mellitus and&#47;or nephropathy&#46; Atheromatous plaque was observed in 14&#46;63&#37; of the low-risk population&#46; The factor with the strongest association to the presence of subclinical atherosclerosis was a moderate or high activity of RA measured by the simplified disease activity index with an odds ratio of 4&#46;95 &#40;95&#37; CI&#58; 1&#46;53-16&#46;01&#41;&#46;</p></span> <span id="abst0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Conclusions</span><p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">Although there was an acceptable correlation between the presence of subclinical atherosclerosis and SCOREM&#44; there was a considerable proportion of atheromatous plaques in low-risk patients&#46; Disease activity was the risk factor most closely associated with increased CVR&#46;</p></span>"
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          "leyenda" => "<p id="spar0080" class="elsevierStyleSimplePara elsevierViewall">anti-CCP&#58; antip&#233;ptido c&#237;clico citrulinado&#59; FAME&#58; f&#225;rmaco antirreum&#225;tico modificador de la enfermedad&#59; FR&#58; factor reumatoide&#59; kg&#58; kilogramos&#59; m&#58; metros&#59; PCR&#58; prote&#237;na C reactiva&#59; SDAI&#58; <span class="elsevierStyleItalic">Simplified disease activity index</span>&#59; VN&#58; valor normal&#59; VSG&#58; velocidad de sedimentaci&#243;n globular&#46;</p>"
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                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Caracter&#237;sticas&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">N&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">&#37; o intervalo&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">Sexo femenino</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">76&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">63&#44;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="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">Edad promedio &#40;a&#241;os&#41;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">57&#44;43&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">29-85&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">&#205;ndice de masa corporal &#40;peso &#91;kg&#93;&#47;talla</span><span class="elsevierStyleSup"><span class="elsevierStyleItalic">2</span></span><span class="elsevierStyleItalic">&#91;m&#93;&#41;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">27&#44;47&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">16&#44;44-49&#44;48&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">Antecedente familiar de evento cardiovascular</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">22&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">18&#44;48&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">Sedentarismo</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">31&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">26&#44;05&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">Fumador activo</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">25&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">21&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">Hipertensi&#243;n arterial</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">48&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">40&#44;33&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">Dislipidemia</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">36&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">30&#44;25&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">Disfunci&#243;n tiroidea</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">17&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">14&#44;28&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">Hiperuricemia</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">10&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">8&#44;4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="3" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="3" align="left" valign="top"><span class="elsevierStyleItalic">Enfermedad vascular conocida</span></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Evento cardiovascular previo&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">8&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">6&#44;72&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Diabetes de tipo 2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">3&#44;36&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Nefropat&#237;a&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">1&#44;68&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="3" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="3" align="left" valign="top"><span class="elsevierStyleItalic">Artritis reumatoide</span></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Tiempo de evoluci&#243;n &#8805; 10 a&#241;os&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">56&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">47&#44;05&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>FR &#40;&#43;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">58&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">48&#44;74&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Anti-CCP &#40;&#43;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">82&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">68&#44;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="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Manifestaciones extraarticulares&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">28&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">23&#44;53&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>PCR promedio &#40;VN<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#44;5<span class="elsevierStyleHsp" style=""></span>mg&#47;dl&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">1&#44;13&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">0-14&#44;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="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>VSG promedio &#40;VN&#58; hombres<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>10<span class="elsevierStyleHsp" style=""></span>mm&#47;h&#44; mujeres<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>20<span class="elsevierStyleHsp" style=""></span>mm&#47;h&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">22&#44;63&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">2-98&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="3" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="3" align="left" valign="top"><span class="elsevierStyleItalic">Tratamiento actual</span></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Corticoides&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">4&#44;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="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Corticoides<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>FAME&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">76&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">63&#44;87&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Corticoides<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>FAME<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>biol&#243;gico&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">14&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">11&#44;77&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>FAME<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>biol&#243;gico&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">6&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">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="table-entry ; entry_with_role_rowhead " align="left" valign="top">Biol&#243;gico<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>corticoides&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">9&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">7&#44;56&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Otras combinaciones&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">9&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">7&#44;56&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">SDAI &#40;remisi&#243;n o baja actividad&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">79&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">66&#44;39&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
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          "es" => "<p id="spar0075" class="elsevierStyleSimplePara elsevierViewall">Caracter&#237;sticas cl&#237;nicas de los 119 pacientes con artritis reumatoide del HGUCR</p>"
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          "leyenda" => "<p id="spar0090" class="elsevierStyleSimplePara elsevierViewall">anti-CCP&#58; antip&#233;ptido c&#237;clico citrulinado&#59; FR&#58; factor reumatoide&#59; IMC&#58; &#237;ndice de masa corporal&#59; PCR&#58; prote&#237;na C reactiva&#59; SDAI&#58; <span class="elsevierStyleItalic">Simplified disease activity index</span>&#59; VSG&#58; velocidad de sedimentaci&#243;n globular&#46;</p>"
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                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Caracter&#237;sticas &#40;N&#46;&#176; de pacientes&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Riesgo alto por SCOREm &#40;30&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">p&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Edad promedio &#40;a&#241;os&#41;<a class="elsevierStyleCrossRef" href="#tblfn0005"><span class="elsevierStyleSup">a</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">61&#46;2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">45&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#60;0&#44;001<a class="elsevierStyleCrossRef" href="#tblfn0010"><span class="elsevierStyleSup">&#42;</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Sexo femenino &#40;50&#41;<a class="elsevierStyleCrossRef" href="#tblfn0005"><span class="elsevierStyleSup">a</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">15&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">35&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">0&#44;002<a class="elsevierStyleCrossRef" href="#tblfn0010"><span class="elsevierStyleSup">&#42;</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Antecedentes familiares &#40;13&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">8&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">0&#44;12&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Fumador activo &#40;20&#41;<a class="elsevierStyleCrossRef" href="#tblfn0005"><span class="elsevierStyleSup">a</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">10&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">10&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">0&#44;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="table-entry ; entry_with_role_rowhead " align="left" valign="top">Sedentarismo &#40;15&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">8&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">7&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">0&#44;33&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Hipertensi&#243;n &#40;19&#41;<a class="elsevierStyleCrossRef" href="#tblfn0005"><span class="elsevierStyleSup">a</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">12&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">7&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">0&#44;03<a class="elsevierStyleCrossRef" href="#tblfn0010"><span class="elsevierStyleSup">&#42;</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Dislipidemia &#40;11&#41;<a class="elsevierStyleCrossRef" href="#tblfn0005"><span class="elsevierStyleSup">a</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">7&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">0&#44;12&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">IMC promedio&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">27&#46;71&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">26&#46;96&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">0&#44;47&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Alteraci&#243;n tiroidea &#40;10&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">8&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">0&#44;14&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Hiperuricemia &#40;5&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">0&#44;91&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Tiempo de evoluci&#243;n<span class="elsevierStyleHsp" style=""></span>&#62;<span class="elsevierStyleHsp" style=""></span>10 a&#241;os &#40;28&#41;<a class="elsevierStyleCrossRef" href="#tblfn0005"><span class="elsevierStyleSup">a</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">12&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">16&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">0&#44;93&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">FR&#40;&#43;&#41; &#40;38&#41;<a class="elsevierStyleCrossRef" href="#tblfn0005"><span class="elsevierStyleSup">a</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">18&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">20&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">0&#44;35&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Anti-CCP &#40;&#43;&#41; &#40;48&#41;<a class="elsevierStyleCrossRef" href="#tblfn0005"><span class="elsevierStyleSup">a</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">23&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">25&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">0&#44;05<a class="elsevierStyleCrossRef" href="#tblfn0010"><span class="elsevierStyleSup">&#42;</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Manifestaci&#243;n extrarticular &#40;15&#41;<a class="elsevierStyleCrossRef" href="#tblfn0005"><span class="elsevierStyleSup">a</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">7&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">8&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">0&#44;69&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">PCR alterada &#40;37&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">18&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">19&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">0&#44;25&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">VSG alterada &#40;47&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">19&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">28&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">0&#44;66&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">SDAI &#40;mod y alta&#41; &#40;19&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">13&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">6&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">0&#44;009<a class="elsevierStyleCrossRef" href="#tblfn0010"><span class="elsevierStyleSup">&#42;</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
              ]
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            1 => array:3 [
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              "etiqueta" => "&#42;"
              "nota" => "<p class="elsevierStyleNotepara" id="npar0010">Diferencia estad&#237;sticamente significativa&#46;</p>"
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        "descripcion" => array:1 [
          "es" => "<p id="spar0085" class="elsevierStyleSimplePara elsevierViewall">Caracter&#237;sticas cl&#237;nicas de la poblaci&#243;n distribuida seg&#250;n su riesgo cardiovascular mediante la aplicaci&#243;n del SCOREm</p>"
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          "leyenda" => "<p id="spar0100" class="elsevierStyleSimplePara elsevierViewall">Especificidad&#58; 64&#44;81&#37; &#40;IC&#160;95&#37;&#58; 51&#44;48-76&#44;18&#41;&#59; Poder&#58; 67&#44;43&#37;&#59; Sensibilidad&#58; 64&#44;71&#37; &#40;IC&#160;95&#37;&#58; 41&#44;3-82&#44;69&#41;&#59; VPN&#58; 85&#44;37&#37; &#40;IC&#160;95&#37;&#58; 71&#44;56-93&#44;12&#41;&#59; VPP&#58; 36&#44;67&#37; &#40;IC&#160;95&#37;&#58; 21&#44;87-54&#44;49&#41;&#46;</p>"
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            0 => array:2 [
              "tabla" => array:1 [
                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " align="" valign="top" scope="col">&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col">p&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr><tr title="table-row"><th class="td" title="table-head  " align="" valign="top" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</th><th class="td" title="table-head  " align="" valign="top" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="" valign="top" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">SCOREm alto riesgo &#40;30&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">11&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">19&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">3&#44;37 &#40;1&#44;07-10&#44;56&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">0&#44;037&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">SCOREm bajo riesgo &#40;41&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">6&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">35&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
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        "descripcion" => array:1 [
          "es" => "<p id="spar0095" class="elsevierStyleSimplePara elsevierViewall">Asociaci&#243;n entre SCOREm y aterosclerosis subcl&#237;nica tipo placa ateromatosa</p>"
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        "etiqueta" => "Tabla 4"
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            "rol" => "short"
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          "leyenda" => "<p id="spar0110" class="elsevierStyleSimplePara elsevierViewall">Especificidad&#58; 62&#44;9&#37; &#40;IC&#160;95&#37;&#58; 50&#44;46-73&#44;84&#41;&#59; Sensibilidad&#58; 77&#44;78&#37; &#40;IC&#160;95&#37;&#58; 45&#44;26-93&#44;68&#41;&#59; VPN&#58; 95&#44;12&#37; &#40;IC&#160;95&#37;&#58; 83&#44;86-98&#44;65&#41;&#59; VPP&#58; 23&#44;33&#37; &#40;IC&#160;95&#37;&#58; 11&#44;79-40&#44;93&#41;&#46;</p>"
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            0 => array:2 [
              "tabla" => array:1 [
                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " align="" valign="top" scope="col">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " colspan="2" align="center" valign="top" scope="col" style="border-bottom: 2px solid black">GIM<span class="elsevierStyleHsp" style=""></span>&#8805;<span class="elsevierStyleHsp" style=""></span>0&#44;9<span class="elsevierStyleHsp" style=""></span>mm</th><th class="td" title="table-head  " align="left" valign="top" scope="col">OR e IC 95&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col">p&#47;correcci&#243;n de Yates&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr><tr title="table-row"><th class="td" title="table-head  " align="" valign="top" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">&#43; &#40;9&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">&#8722; &#40;62&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="" valign="top" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="" valign="top" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">SCOREm alto riesgo &#40;30&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">7&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">23&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">5&#44;93&#37; &#40;1&#44;13-31&#44;01&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">0&#44;035&#47;0&#44;0514&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">SCOREm bajo riesgo &#40;41&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">39&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
              ]
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                0 => "xTab1918496.png"
              ]
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        ]
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          "es" => "<p id="spar0105" class="elsevierStyleSimplePara elsevierViewall">Asociaci&#243;n entre SCOREm y aterosclerosis subcl&#237;nica tipo GIM &#8805; 0&#44;9<span class="elsevierStyleHsp" style=""></span>mm</p>"
        ]
      ]
    ]
    "bibliografia" => array:2 [
      "titulo" => "Bibliograf&#237;a"
      "seccion" => array:1 [
        0 => array:2 [
          "identificador" => "bibs0015"
          "bibliografiaReferencia" => array:55 [
            0 => array:3 [
              "identificador" => "bib0280"
              "etiqueta" => "1"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "The mortality of rheumatoid arthritis"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [
                            0 => "F&#46; Wolfe"
                            1 => "D&#46;M&#46; Mitchell"
                            2 => "J&#46;T&#46; Sibley"
                            3 => "J&#46;F&#46; Fries"
                            4 => "D&#46;A&#46; Bloch"
                            5 => "C&#46;A&#46; Williams"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "Arthritis Rheum&#46;"
                        "fecha" => "1994"
                        "volumen" => "37"
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