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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Introducci&#243;n</span><p id="par0005" class="elsevierStylePara elsevierViewall">Las personas de 80 o m&#225;s a&#241;os constituyen el grupo poblacional que presenta el crecimiento m&#225;s r&#225;pido del mundo<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a>&#46; En esta poblaci&#243;n&#44; las enfermedades cardiovasculares&#44; especialmente el infarto agudo de miocardio &#40;IAM&#41;&#44; constituyen la principal causa de muerte en los pa&#237;ses desarrollados y la segunda causa de deterioro funcional y p&#233;rdida de independencia<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a>&#46; Adem&#225;s&#44; la mortalidad ligada al IAM es casi el doble cuando se presenta en los estados avanzados de la vida<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">3&#8211;7</span></a>&#46; Parad&#243;jicamente los pacientes mayores suelen estar poco representados o incluso excluidos en muchos ensayos cl&#237;nicos<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a>&#46; Asimismo&#44; las recomendaciones terap&#233;uticas bien establecidas&#44; como la administraci&#243;n de aspirina&#44; betabloqueantes&#44; inhibidores de la enzima de conversi&#243;n de la angiotensina &#40;IECA&#41; y estatinas<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a><span class="elsevierStyleSup">&#44;</span><a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a>&#44; se aplican en menor medida en los pacientes de edad avanzada que en el resto de pacientes<a class="elsevierStyleCrossRefs" href="#bib0020"><span class="elsevierStyleSup">4&#8211;7</span></a><span class="elsevierStyleSup">&#44;</span><a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">11</span></a><span class="elsevierStyleSup">&#44;</span><a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">12</span></a>&#44; a pesar de estar recomendados en este grupo de alto riesgo<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">13</span></a><span class="elsevierStyleSup">&#44;</span><a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">14</span></a>&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">Sin embargo&#44; no hay un claro acuerdo de si la menor proporci&#243;n con la que los pacientes mayores reciben estos f&#225;rmacos expresa una discriminaci&#243;n real por la edad o es consecuencia&#44; y por tanto se justificar&#237;a&#44; por las peculiaridades de esta poblaci&#243;n&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">Con estas consideraciones previas&#44; nos propusimos determinar si existe una asociaci&#243;n lineal de la edad y la administraci&#243;n de aspirina&#44; betabloqueantes&#44; IECA y estatinas&#44; en qu&#233; medida los pacientes de edad avanzada con IAM reciben con menor frecuencia cada uno de estos f&#225;rmacos y hasta qu&#233; punto esta menor proporci&#243;n se asocia de forma independiente a la edad o puede atribuirse a otros factores&#44; especialmente la comorbilidad subyacente y la situaci&#243;n cl&#237;nica al ingreso&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Pacientes y m&#233;todos</span><p id="par0020" class="elsevierStylePara elsevierViewall">Entre enero de 1998 y enero de 2008&#44; todos los pacientes de cualquier edad ingresados consecutivamente con diagn&#243;stico de IAM&#44; en las respectivas Unidades Coronarias de 2 hospitales de la Regi&#243;n de Murcia &#40;Espa&#241;a&#41;&#44; fueron incluidos en un estudio observacional&#44; longitudinal y prospectivo&#46; Se excluyeron a los pacientes con un IAM ocurrido periprocedimiento de revascuarizaci&#243;n coronaria &#40;quir&#250;rgico o percut&#225;neo&#41;&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">Debido a que la determinaci&#243;n de la troponina no se generaliz&#243; a todos los pacientes hasta el a&#241;o 2001&#44; el diagn&#243;stico de IAM se realiz&#243; ante la presencia de la elevaci&#243;n de la prote&#237;na CK&#91;MB&#93; s&#233;rica al doble de su rango normal y al menos uno de los siguientes criterios&#58; 1&#41; dolor tor&#225;cico de caracter&#237;sticas isqu&#233;micas de m&#225;s de 20 minutos de duraci&#243;n y 2&#41; cambios en el electrocardiograma de ingreso compatibles con isquemia activa o necrosis mioc&#225;rdica establecida seg&#250;n los criterios establecidos<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">15</span></a>&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">De forma prospectiva se rellen&#243; en cada paciente un formulario que incluy&#243; variables demogr&#225;ficas&#44; antecedentes personales&#44; retraso al ingreso desde el inicio de los s&#237;ntomas&#44; datos relativos a la situaci&#243;n cl&#237;nica al ingreso&#44; caracter&#237;sticas del electrocardiograma inicial y todos los tratamientos administrados tanto inmediatamente al ingreso en la Unidad Coronaria como durante su estancia en la Unidad Coronaria&#46; Tambi&#233;n se determin&#243;&#44; siempre que fue posible&#44; la fracci&#243;n de eyecci&#243;n del ventr&#237;culo izquierdo &#40;FEVI&#41; mediante ecocardiograf&#237;a en las primeras 24 horas&#46; Adem&#225;s&#44; se recogi&#243; la mortalidad a las 24 horas y a los 30 d&#237;as&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">Se consider&#243; <span class="elsevierStyleItalic">insuficiencia renal cr&#243;nica</span> cuando el valor de creatinina plasm&#225;tica obtenida al ingreso en la Unidad Coronaria era igual o mayor de 2<span class="elsevierStyleHsp" style=""></span>mg&#47;dl o bien el paciente ya se encontraba en programa de hemodi&#225;lisis&#46; La presencia de <span class="elsevierStyleItalic">insuficiencia cardiaca al ingreso</span> se estableci&#243; de acuerdo con los criterios de Killip y Kimball&#46; Se defini&#243; IAM de localizaci&#243;n anterior seg&#250;n los criterios publicados previamente<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">16</span></a>&#46;</p><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Estrategia de an&#225;lisis</span><p id="par0040" class="elsevierStylePara elsevierViewall">Comprobamos la linealidad de la asociaci&#243;n de la edad con cada variable de resultado&#46; Para ello&#44; se introdujo en un modelo la edad como variable continua y despu&#233;s&#44; en otro modelo&#44; categorizada en quinquenios&#46; Si al comparar ambos modelos mediante el test de la raz&#243;n de verisimilitud se produce un resultado significativo &#40;p&#60;0&#44;05&#41; se podr&#237;a descartar una asociaci&#243;n lineal entre la edad y cada variable&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">A continuaci&#243;n se realizaron 2 grupos de edad&#58; mayores y menores de 80 a&#241;os&#46; Las caracter&#237;sticas estudiadas fueron comparadas en los 2 grupos de edad mediante diferentes pruebas de contraste para variables cuantitativas &#40;t de Student para datos independientes&#41; y cualitativas &#40;prueba de Ji cuadrado&#41;&#46;</p><p id="par0050" class="elsevierStylePara elsevierViewall">El control de la posible confusi&#243;n en las relaciones encontradas entre la edad y los diferentes indicadores de resultado se realiz&#243; mediante regresi&#243;n log&#237;stica no condicional&#44; estimando la odds ratio &#40;OR&#41; y su intervalo de confianza del 95&#37; &#40;IC95&#37;&#41; como medida de asociaci&#243;n&#46; Las variables candidatas a formar parte de cada uno de los modelos fueron&#58; g&#233;nero&#44; tensi&#243;n arterial media al ingreso&#44; ictus previo&#44; infarto de miocardio previo&#44; retraso al ingreso&#44; frecuencia cardiaca&#44; clase Killip&#44; FEVI&#44; localizaci&#243;n anterior&#44; bradicardia&#44; centro hospitalario&#44; tratamiento de reperfusi&#243;n&#44; arteriopat&#237;a perif&#233;rica&#44; insuficiencia renal cr&#243;nica&#44; diabetes mellitus&#44; EPOC&#44; bloqueo auriculoventricular&#44; hipercolesterolemia previa y mortalidad en las primeras 24 horas&#46;</p><p id="par0055" class="elsevierStylePara elsevierViewall">Por &#250;ltimo&#44; se evaluaron las estimaciones ajustadas para cada indicador teniendo en cuenta el periodo en el que se atendi&#243; al paciente&#58; antes de 2000&#44; de 2001 a 2004 y a partir de 2004&#46; Esta divisi&#243;n se realiz&#243; teniendo en cuenta la fecha de publicaci&#243;n de las principales gu&#237;as de pr&#225;ctica cl&#237;nica sobre el manejo terap&#233;utico del IAM<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">17</span></a><span class="elsevierStyleSup">&#44;</span><a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">18</span></a>&#46;</p><p id="par0060" class="elsevierStylePara elsevierViewall">Todos los c&#225;lculos se realizaron con el programa estad&#237;stico PASW 18&#46;0 &#40;SPSS Inc&#41;&#46;</p></span></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Resultados</span><p id="par0065" class="elsevierStylePara elsevierViewall">Durante el periodo de estudio ingresaron en las 2 Unidades Coronarias 5&#46;521 pacientes con el diagn&#243;stico de IAM&#44; de los cuales 4&#46;846 &#40;87&#44;8&#37;&#41; ten&#237;an menos de 80 a&#241;os y 675 &#40;12&#44;2&#37;&#41; 80 o m&#225;s&#46; La proporci&#243;n de mujeres fue m&#225;s del doble en el grupo de los octogenarios en comparaci&#243;n a los de menor edad&#46; Los octogenarios presentaron con mayor frecuencia hipertensi&#243;n arterial y antecedentes de infarto de miocardio&#44; insuficiencia cardiaca&#44; ictus e insuficiencia renal cr&#243;nica&#46; En cambio&#44; los octogenarios presentaron con menor frecuencia hipercolesterolemia conocida&#44; tabaquismo activo y obesidad &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">tabla 1</a>&#41;&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0070" class="elsevierStylePara elsevierViewall">Al ingreso&#44; los octogenarios presentaron con menor frecuencia una cl&#237;nica t&#237;pica e IAM con elevaci&#243;n persistente del segmento ST&#46; Por el contrario&#44; estos pacientes ingresaron con mayor retraso&#44; m&#225;s frecuentemente con signos de insuficiencia cardiaca grados Killip II-III y con m&#225;s del doble de frecuencia en shock cardiog&#233;nico&#46; En cuanto a algunas complicaciones&#44; los octogenarios presentaron m&#225;s frecuentemente rotura cardiaca&#44; bloqueo auriculoventricular completo y mayor mortalidad en las primeras 24 horas y a los 30 d&#237;as &#40;<a class="elsevierStyleCrossRef" href="#tbl0010">tabla 2</a>&#41;&#46;</p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><p id="par0075" class="elsevierStylePara elsevierViewall">Con respecto al tratamiento m&#233;dico&#44; al grupo de pacientes octogenarios se le administr&#243; con menor frecuencia aspirina&#44; betabloqueantes y estatinas &#40;<a class="elsevierStyleCrossRef" href="#tbl0015">tabla 3</a>&#41;&#46;</p><elsevierMultimedia ident="tbl0015"></elsevierMultimedia><p id="par0080" class="elsevierStylePara elsevierViewall">Cuando se analiz&#243; el efecto lineal de la edad sobre la probabilidad de recibir aspirina&#44; betabloqueantes e IECA y&#47;o ARA-II se observ&#243; que conforme avanzaba la edad iba disminuyendo de forma progresiva y en la misma proporci&#243;n &#40;efecto lineal&#41; la administraci&#243;n de aspirina y betabloqueantes&#44; mientras que aumentaba la administraci&#243;n de IECA y&#47;o ARA-II &#40;<a class="elsevierStyleCrossRef" href="#tbl0020">tabla 4</a>&#41;&#46; En cambio&#44; cuando se analiz&#243; el tratamiento con estatinas pudo observarse que la relaci&#243;n con la edad no era lineal&#44; de modo que a partir de los 80-85 a&#241;os se observa una disminuci&#243;n brusca y significativa en la administraci&#243;n de estatinas &#40;<a class="elsevierStyleCrossRef" href="#fig0005">fig&#46; 1</a>&#41;&#46;</p><elsevierMultimedia ident="tbl0020"></elsevierMultimedia><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0085" class="elsevierStylePara elsevierViewall">En el an&#225;lisis de regresi&#243;n multivariante se observ&#243; una asociaci&#243;n significativa e independiente entre la edad y la administraci&#243;n de betabloqueantes y estatinas &#40;<a class="elsevierStyleCrossRef" href="#fig0010">fig&#46; 2</a>&#41;&#46; El ingreso en una clase Killip&#62;1 &#40;betabloqueantes&#41; o en clase Killip&#62;2 &#40;estatinas&#41; y una elevada mortalidad precoz &#40;primeras 24 horas&#41; tambi&#233;n se asoci&#243; a una menor administraci&#243;n de estos f&#225;rmacos &#40;<a class="elsevierStyleCrossRef" href="#tbl0025">tabla 5</a>&#41;&#46;</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><elsevierMultimedia ident="tbl0025"></elsevierMultimedia><p id="par0090" class="elsevierStylePara elsevierViewall">Cuando se dividieron los 10 a&#241;os de duraci&#243;n de este estudio en 3 periodos y se repitieron los modelos de regresi&#243;n multivariante&#44; se observ&#243; que la utilizaci&#243;n de los f&#225;rmacos ha sido bastante homog&#233;nea a lo largo de los 10 a&#241;os &#40;<a class="elsevierStyleCrossRef" href="#fig0015">fig&#46; 3</a>&#41;&#46;</p><elsevierMultimedia ident="fig0015"></elsevierMultimedia></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Discusi&#243;n</span><p id="par0095" class="elsevierStylePara elsevierViewall">Nuestro estudio evidencia que&#44; respecto a los pacientes de menor edad&#44; los octogenarios reciben una similar proporci&#243;n de tratamiento con IECA o ARA-II y con menor frecuencia aspirina&#44; betabloqueantes y estatinas&#44; aunque solo la menor utilizaci&#243;n de estos 2 &#250;ltimos f&#225;rmacos se asoci&#243; de forma independiente a la edad avanzada&#46; Cuando analizamos el efecto lineal de la edad sobre la probabilidad de recibir alguno de estos f&#225;rmacos observamos que su administraci&#243;n decreci&#243; conforme aument&#243; la edad&#44; aunque fue evidente un cambio relativamente brusco en torno a los 80 a&#241;os&#44; especialmente en el caso de las estatinas&#46;</p><p id="par0100" class="elsevierStylePara elsevierViewall">Aunque las evidencias del beneficio farmacol&#243;gico se incorporan con cierto retraso a la pr&#225;ctica cl&#237;nica<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">19</span></a>&#44; la indicaci&#243;n de los f&#225;rmacos estudiados en el presente estudio en el IAM est&#225; bien establecida a&#241;os antes del inicio de la recogida de los datos&#44; no habi&#233;ndose modificado durante el periodo del mismo<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">17</span></a><span class="elsevierStyleSup">&#44;</span><a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">20</span></a>&#46; Considerando&#44; adem&#225;s&#44; que los tratamientos deben iniciarse durante el ingreso hospitalario<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">21</span></a>&#44; es posible que nuestros hallazgos sean consecuencia de que&#44; al igual que ocurre en el caso de las mujeres<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">22</span></a>&#44; las recomendaciones no se sigan en igual medida en los pacientes de edad avanzada&#46; Dadas las diferencias en la inmediatez de la administraci&#243;n y las contraindicaciones espec&#237;ficas de cada f&#225;rmaco&#44; son oportunas algunas consideraciones en cada uno de ellos&#46;</p><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Aspirina</span><p id="par0105" class="elsevierStylePara elsevierViewall">La administraci&#243;n global de aspirina en nuestra poblaci&#243;n &#40;94&#37;&#41; es ligeramente superior al 86&#44;9&#37; del registro MASCARA<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">23</span></a> y al 92&#44;5&#37; del Euro Heart Survey <a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">24</span></a>&#46; El 90&#44;4&#37; de los octogenarios recibi&#243; aspirina&#44; una cifra superior de la referida por otros estudios <a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">12</span></a><span class="elsevierStyleSup">&#44;</span><a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">25</span></a><span class="elsevierStyleSup">&#44;</span><a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">26</span></a> donde oscila entre el 66&#44;7 y 83&#37;&#46; En nuestro estudio&#44; el ajuste por diferentes variables no evidenci&#243; diferencias en la administraci&#243;n de aspirina entre los mayores y menores de 80 a&#241;os&#46; En cambio&#44; Magid et al&#46;<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">25</span></a> evidenciaron c&#243;mo los octogenarios tienen un 4&#37; menos de probabilidad de recibirla con respecto a los pacientes de 65 a 69 a&#241;os &#40;OR 0&#44;96&#59; IC95&#37; 0&#44;95-0&#44;97&#41; y Rathore et al&#46;<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">12</span></a> una reducci&#243;n del 15&#37; &#40;OR 0&#44;85&#59; IC95&#37; 0&#44;77-0&#44;93&#41; en la probabilidad de recibir aspirina por cada incremento de 10 a&#241;os de la edad&#46; Por otro lado&#44; en nuestro estudio se demostr&#243; un efecto lineal de la edad sobre la probabilidad de recibir aspirina&#44; observando una progresiva menor administraci&#243;n de aspirina conforme avanzaba la edad&#46; Por tanto&#44; conforme el paciente presenta una mayor edad se observa siempre el mismo descenso en la administraci&#243;n de aspirina&#46; En cambio&#44; el estudio de Schoenenberger et al&#46; <a class="elsevierStyleCrossRef" href="#bib0135"><span class="elsevierStyleSup">27</span></a> descart&#243; dicho efecto lineal&#44; aunque no indic&#243; a partir de qu&#233; edad disminu&#237;a bruscamente su administraci&#243;n&#46; Es posible que la alta tasa de tratamiento con aspirina en nuestro caso sea consecuencia de que su administraci&#243;n se produzca con frecuencia en los primeros momentos de evoluci&#243;n&#44; incluso en la atenci&#243;n extrahospitalaria&#46;</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Betabloqueantes</span><p id="par0110" class="elsevierStylePara elsevierViewall">Globalmente el 66&#44;3&#37; de nuestros pacientes recibi&#243; betabloqueantes&#44; cifra similar al 67&#44;8&#37; del registro MASCARA<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">23</span></a> pero inferior al 79&#44;6&#37; del Euro Heart Survey <a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">24</span></a> y al 87&#44;9&#37; del GWTG-CAD &#40;Get With The Guidelines-Coronary Artery Disease&#41;&#44; aunque este &#250;ltimo registro formaba parte de un proyecto de implementaci&#243;n de las recomendaciones de las gu&#237;as de pr&#225;ctica cl&#237;nica<a class="elsevierStyleCrossRef" href="#bib0140"><span class="elsevierStyleSup">28</span></a>&#46; A pesar de las evidencias del beneficio de los betabloqueantes en los pacientes mayores de 80 a&#241;os<a class="elsevierStyleCrossRef" href="#bib0145"><span class="elsevierStyleSup">29</span></a><span class="elsevierStyleSup">&#44;</span><a class="elsevierStyleCrossRef" href="#bib0150"><span class="elsevierStyleSup">30</span></a>&#44; en nuestro estudio este tratamiento lo recibi&#243; solo el 44&#44;4&#37; de los octogenarios&#44; aunque esta cifra es superior a los valores entre el 29 y el 42&#44;3&#37; referidos por otros estudios<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">12</span></a><span class="elsevierStyleSup">&#44;</span><a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">25</span></a><span class="elsevierStyleSup">&#44;</span><a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">26</span></a><span class="elsevierStyleSup">&#44;</span><a class="elsevierStyleCrossRef" href="#bib0155"><span class="elsevierStyleSup">31</span></a>&#46; Respecto a la influencia de la edad en el tratamiento con betabloqueantes&#44; su administraci&#243;n disminuy&#243; conforme aumenta la edad&#44; en coincidencia con los estudios de Ruiz-Bail&#233;n et al&#46;<a class="elsevierStyleCrossRef" href="#bib0155"><span class="elsevierStyleSup">31</span></a> y de Magid et al&#46;<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">25</span></a> que mostr&#243; un 21&#37; de reducci&#243;n de la probabilidad de recibir este tratamiento en cada uno de los 6 grupos de edad considerados&#46; A diferencia del estudio de Schoenenberger et al&#46;<a class="elsevierStyleCrossRef" href="#bib0135"><span class="elsevierStyleSup">27</span></a> en el que se descart&#243; un efecto lineal de la edad sobre la probabilidad de recibir betabloqueantes&#44; en nuestro caso y al igual que con la aspirina se demostr&#243; este efecto lineal&#44; aunque pudimos observar c&#243;mo en torno a los 80 a&#241;os hab&#237;a una mayor tendencia hacia una menor administraci&#243;n&#46; La menor administraci&#243;n de betabloqueantes en los octogenarios se podr&#237;a atribuir a la frecuente comorbilidad asociada&#44; sin embargo&#44; tanto nuestro estudio como otros<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a><span class="elsevierStyleSup">&#44;</span><a class="elsevierStyleCrossRef" href="#bib0135"><span class="elsevierStyleSup">27</span></a> coinciden en que independientemente de la comorbilidad&#44; la edad avanzada se asocia significativamente con una menor administraci&#243;n de estos f&#225;rmacos&#46; Otro motivo para no administrar betabloqueantes a los octogenarios con IAM ser&#237;a la frecuente presentaci&#243;n con cl&#237;nica at&#237;pica y&#47;o con enfermedades concomitantes&#44; como la insuficiencia cardiaca congestiva o la neumon&#237;a<a class="elsevierStyleCrossRef" href="#bib0160"><span class="elsevierStyleSup">32</span></a>&#44; que con frecuencia difiere el diagn&#243;stico de infarto de miocardio lo que puede resultar en la no administraci&#243;n precoz de este f&#225;rmaco&#46; Tambi&#233;n es posible que la presencia de insuficiencia cardiaca al ingreso en los octogenarios favorezca la elecci&#243;n del tratamiento precoz con IECA o ARA-II dado el beneficio de estos f&#225;rmacos en los pacientes de alto riesgo<a class="elsevierStyleCrossRef" href="#bib0165"><span class="elsevierStyleSup">33</span></a>&#46; Por &#250;ltimo&#44; no podemos descartar que los m&#233;dicos que atienden a estos pacientes sobreestimen los efectos adversos de estos f&#225;rmacos<a class="elsevierStyleCrossRef" href="#bib0170"><span class="elsevierStyleSup">34</span></a>&#44; especialmente en pacientes con enfermedad pulmonar obstructiva cr&#243;nica aunque sea este un grupo de especial beneficio <a class="elsevierStyleCrossRef" href="#bib0175"><span class="elsevierStyleSup">35</span></a>&#44; constituyendo solo la bradicardia&#44; bloqueo auriculoventricular avanzado&#44; broncoespasmo&#44; shock cardiog&#233;nico o en caso de insuficiencia cardiaca aguda severa sin respuesta al tratamiento inicial una contraindicaci&#243;n absoluta a la administraci&#243;n de los betabloqueantes <a class="elsevierStyleCrossRef" href="#bib0180"><span class="elsevierStyleSup">36</span></a>&#46;</p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Bloqueadores del eje renina-angiotensina</span><p id="par0115" class="elsevierStylePara elsevierViewall">La administraci&#243;n de IECA y&#47;o ARA-II en nuestra poblaci&#243;n global &#40;69&#44;4&#37;&#41; es superior al 46&#37; registrado por el registro DESCARTES<a class="elsevierStyleCrossRef" href="#bib0185"><span class="elsevierStyleSup">37</span></a> y al 65&#44;4&#37; del Euro Heart Survey<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">24</span></a>&#46; Adem&#225;s&#44; aunque en el an&#225;lisis bivariado no se encuentran diferencias entre los mayores y menores de 80 a&#241;os&#44; cuando analizamos el efecto lineal de la edad sobre la probabilidad de recibir estos f&#225;rmacos observamos una tendencia a una mayor administraci&#243;n conforme aumenta la edad&#46; Esta tendencia puede ser consecuencia de que en presencia de una similar eficacia a la de los betabloqueantes<a class="elsevierStyleCrossRef" href="#bib0190"><span class="elsevierStyleSup">38</span></a>&#44; los IECA o ARA-II son mejor tolerados por los pacientes de edad avanzada&#46;</p></span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Estatinas</span><p id="par0120" class="elsevierStylePara elsevierViewall">A pesar de que en 2 grandes estudios<a class="elsevierStyleCrossRef" href="#bib0195"><span class="elsevierStyleSup">39</span></a><span class="elsevierStyleSup">&#44;</span><a class="elsevierStyleCrossRef" href="#bib0200"><span class="elsevierStyleSup">40</span></a> se haya demostrado el beneficio de la administraci&#243;n de estatinas en todos los grupos de edad&#44; incluso en aquellos pacientes con una corta expectativa de vida<a class="elsevierStyleCrossRef" href="#bib0205"><span class="elsevierStyleSup">41</span></a> y que es un tratamiento coste-efectivo en los pacientes de 75-84 a&#241;os<a class="elsevierStyleCrossRef" href="#bib0210"><span class="elsevierStyleSup">42</span></a>&#44; nuestros octogenarios&#44; en comparaci&#243;n a los menores de 80 a&#241;os&#44; recibieron con menor frecuencia este tratamiento&#44; aunque la proporci&#243;n de pacientes octogenarios que recibieron estatinas aument&#243; del 17&#44;2&#37; en los primeros a&#241;os del estudio al 70&#44;5&#37; en coincidencia con los hallazgos aportados por otros registros<a class="elsevierStyleCrossRef" href="#bib0140"><span class="elsevierStyleSup">28</span></a><span class="elsevierStyleSup">&#44;</span><a class="elsevierStyleCrossRefs" href="#bib0215"><span class="elsevierStyleSup">43&#8211;45</span></a>&#46; A pesar de ello&#44; nuestro porcentaje de administraci&#243;n global de estatinas &#40;62&#44;6&#37;&#41; es superior al 52&#44;3&#37; del registro DESCARTES<a class="elsevierStyleCrossRef" href="#bib0185"><span class="elsevierStyleSup">37</span></a> y al 60&#44;3&#37; del Euro Heart Survey<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">24</span></a>&#46; Adem&#225;s&#44; la mitad de nuestros pacientes octogenarios recibieron estatinas&#44; un porcentaje superior al 38&#37; del registro PRAIS-UK<a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">26</span></a>&#46; Igualmente&#44; en el registro GRACE se observ&#243; c&#243;mo la administraci&#243;n de estatinas descendi&#243; del 59&#37; en los pacientes de 45 a 54 a&#241;os al 24&#44;2&#37; en los pacientes de 85 o m&#225;s a&#241;os<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a>&#46; Al contrario que con los f&#225;rmacos anteriores&#44; con las estatinas pudimos descartar un efecto lineal de la edad sobre la probabilidad de recibir este tratamiento observando&#44; adem&#225;s&#44; como en torno a los 80 a&#241;os hab&#237;a una tendencia brusca hacia una menor administraci&#243;n&#46; Esta menor utilizaci&#243;n de las estatinas en los pacientes de mayor edad es probable que se deba a una percepci&#243;n de un menor beneficio en la prevenci&#243;n secundaria en estos pacientes que ingresan con mayor frecuencia en una peor situaci&#243;n cl&#237;nica&#46; Adem&#225;s&#44; la administraci&#243;n extrahospitalaria o en urgencias de las estatinas es inusual y suele diferirse program&#225;ndola por la noche&#44; lo que en presencia de una mortalidad precoz elevada puede explicar&#44; en parte&#44; los casos en los que dicho f&#225;rmaco no se ha administrado&#46;</p><p id="par0125" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">Limitaciones del estudio&#46;</span> En primer lugar&#44; es posible que exista un sesgo de selecci&#243;n dado que este registro solo recogi&#243; a los pacientes con IAM que ingresaron en las Unidades Coronarias&#46; Es posible que no infrecuentemente los pacientes atendidos fuera de las Unidades Coronarias no hubieran sido consultados para su ingreso por asociar gran comorbilidad y&#44; por lo tanto&#44; ser pacientes de avanzada edad&#46; A pesar de esta limitaci&#243;n&#44; nuestra poblaci&#243;n no ha sido sesgada por otros criterios por lo que debiera ser tomada como representativa de los pacientes con IAM que ingresan en nuestras Unidades Coronarias&#46; En segundo lugar&#44; es posible que algunos factores de dif&#237;cil apreciaci&#243;n &#40;intolerancia a determinadas medicaciones&#44; presencia de demencia senil o la percepci&#243;n subjetiva de un deterioro marcado de la condici&#243;n biol&#243;gica de algunos pacientes&#41; puedan haber inducido una limitaci&#243;n del esfuerzo terap&#233;utico en algunos casos y&#44; por tanto&#44; haber influido en los resultados de este estudio&#46; En tercer lugar&#44; este estudio se circunscribe a una regi&#243;n del sureste de Espa&#241;a aunque nuestros resultados son concordantes a los obtenidos en otros estudios de otras zonas geogr&#225;ficas&#46; Por &#250;ltimo&#44; nuestro registro no contempl&#243; la recogida prospectiva de las posibles contraindicaciones absolutas y relativas de los diferentes tratamientos&#44; pero es poco probable que tales contraindicaciones expliquen completamente las diferencias observadas en el an&#225;lisis multivariable entre los mayores y menores de 80 a&#241;os&#46;</p></span></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Conclusiones</span><p id="par0130" class="elsevierStylePara elsevierViewall">En nuestro caso&#44; los pacientes octogenarios&#44; con respecto a los m&#225;s j&#243;venes&#44; reciben con menor frecuencia tratamiento con aspirina&#44; betabloqueantes y estatinas&#44; mientras que no hemos encontrado diferencias con respecto a la administraci&#243;n de IECA o ARA-II&#46; Sin embargo&#44; la edad avanzada no constituye un factor independiente asociado a la menor administraci&#243;n de aspirina&#46; En cambio&#44; es posible que los octogenarios sean discriminados en el sentido de recibir&#44; sin una aparente justificaci&#243;n m&#225;s all&#225; de la edad&#44; una baja proporci&#243;n de betabloqueantes y estatinas&#44; aunque influye en gran medida el ingresar en una mala situaci&#243;n cl&#237;nica y el tener con mayor frecuencia una elevada mortalidad precoz&#46; El mal pron&#243;stico de los pacientes de edad avanzada debe hacernos reflexionar hasta que punto estos pacientes se identifican e individualizan de forma adecuada en la pr&#225;ctica cl&#237;nica diaria&#46; La denegaci&#243;n de los tratamientos con beneficio probado en los pacientes ancianos debe ser justificada y no atribuirse a la ligera a sus riesgos potenciales&#44; lo cual nos llevar&#237;a a una discriminaci&#243;n de esta poblaci&#243;n&#46;</p></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Conflictos de intereses</span><p id="par0135" class="elsevierStylePara elsevierViewall">Los autores declaran no tener ning&#250;n conflicto de intereses&#46;</p></span></span>"
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            0 => "Resumen"
            1 => "Objetivo"
            2 => "Dise&#241;o"
            3 => "&#193;mbito"
            4 => "Pacientes"
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            6 => "Variables principales"
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            0 => "Abstract"
            1 => "Objectives"
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              "titulo" => "Aspirina"
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            1 => array:2 [
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              "titulo" => "Betabloqueantes"
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            2 => array:2 [
              "identificador" => "sec0040"
              "titulo" => "Bloqueadores del eje renina-angiotensina"
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            3 => array:2 [
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              "titulo" => "Estatinas"
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    "fechaRecibido" => "2012-03-01"
    "fechaAceptado" => "2012-05-06"
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          "clase" => "keyword"
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          "palabras" => array:4 [
            0 => "Octogenarios"
            1 => "Infarto de miocardio"
            2 => "Estudios de cohortes"
            3 => "Tratamiento m&#233;dico"
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            0 => "Aged 80 and over"
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        "titulo" => "Resumen"
        "resumen" => "<span class="elsevierStyleSectionTitle">Objetivo</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Determinar si existe una asociaci&#243;n lineal de la edad y la administraci&#243;n de aspirina&#44; betabloqueantes&#44; inhibidores de la enzima convertidora de la angiotensina y estatinas&#44; en qu&#233; medida los pacientes de edad avanzada reciben estos tratamientos y si la edad se asocia de forma independiente a estos tratamientos&#46;</p> <span class="elsevierStyleSectionTitle">Dise&#241;o</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Estudio de cohortes prospectivo&#46;</p> <span class="elsevierStyleSectionTitle">&#193;mbito</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Unidades Coronarias de 2 hospitales de la Regi&#243;n de Murcia</p> <span class="elsevierStyleSectionTitle">Pacientes</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Pacientes consecutivos ingresados con el diagn&#243;stico de infarto agudo de miocardio entre enero de 1998 y enero de 2008&#46;</p> <span class="elsevierStyleSectionTitle">Intervenciones</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Ninguna&#46;</p> <span class="elsevierStyleSectionTitle">Variables principales</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Las relacionadas con la administraci&#243;n de aspirina&#44; betabloqueantes&#44; inhibidores de la enzima convertidora de la angiotensina y estatinas durante la estancia en la Unidad Coronaria&#46;</p> <span class="elsevierStyleSectionTitle">Resultados</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Respecto al resto de pacientes&#44; los octogenarios recibieron en similar proporci&#243;n inhibidores de la enzima convertidora de la angiotensina &#40;70&#44;8 vs 69&#44;3&#37;&#44; p&#61;0&#44;41&#41; y con menor frecuencia aspirina &#40;90&#44;4 vs 94&#44;6&#37;&#44; p&#60;0&#44;001&#41;&#44; betabloqueantes &#40;44&#44;4 vs 69&#44;4&#37;&#44; p&#60;0&#44;001&#41; y estatinas &#40;47&#44;6 vs 64&#44;7&#37;&#44; p&#60;0&#44;001&#41;&#46; Solo pudo demostrarse una disminuci&#243;n brusca y significativa en la administraci&#243;n de estatinas a partir de los 80 a&#241;os&#46; La edad se asoci&#243; independientemente con la administraci&#243;n de betabloqueantes &#40;OR 0&#44;59&#59; IC95&#37; 0&#44;47 - 0&#44;73&#41; y estatinas &#40;OR 0&#44;78&#59; IC95&#37; 0&#44;65 - 0&#44;95&#41;&#46; La menor administraci&#243;n de estos f&#225;rmacos tambi&#233;n se asoci&#243; a una mayor mortalidad precoz &#40;OR 0&#44;17&#59; IC95&#37; 0&#44;09 - 0&#44;33 y OR 0&#44;14&#59; IC95&#37; 0&#44;08 - 0&#44;23&#44; respectivamente&#41;&#46;</p> <span class="elsevierStyleSectionTitle">Conclusiones</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">Los pacientes octogenarios reciben con menor frecuencia tratamiento con aspirina&#44; betabloqueantes y estatinas&#44; sin embargo&#44; la edad avanzada no constituy&#243; un factor independiente asociado a la menor administraci&#243;n de aspirina&#46;</p>"
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        "titulo" => "Abstract"
        "resumen" => "<span class="elsevierStyleSectionTitle">Objectives</span><p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">To determine whether there is a linear association of age and aspirin&#44; betablockers&#44; angiotensin-converting enzyme inhibitors and statins&#59; the extent to which elderly patients receive these treatments&#59; and whether age is independently associated with these treatments&#46;</p> <span class="elsevierStyleSectionTitle">Design</span><p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">A prospective cohort study&#46;</p> <span class="elsevierStyleSectionTitle">Setting</span><p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">Coronary Unit of two hospitals in the Region of Murcia &#40;Spain&#41;&#46;</p> <span class="elsevierStyleSectionTitle">Patients</span><p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">Consecutive patients admitted with the diagnosis of acute myocardial infarction between January 1998 and January 2008&#46;</p> <span class="elsevierStyleSectionTitle">Interventions</span><p id="spar0065" class="elsevierStyleSimplePara elsevierViewall">None&#46;</p> <span class="elsevierStyleSectionTitle">Main outcomes</span><p id="spar0070" class="elsevierStyleSimplePara elsevierViewall">Those related to the administration of aspirin&#44; betablockers&#44; angiotensin-converting enzyme inhibitors and statins during stay in the Coronary Care Unit&#46;</p> <span class="elsevierStyleSectionTitle">Results</span><p id="spar0075" class="elsevierStyleSimplePara elsevierViewall">Regarding the remaining patients&#44; octogenarians received a similar proportion of angiotensin-converting enzyme inhibitors &#40;70&#46;8&#37; vs&#46; 69&#46;3&#37;&#44; p&#61;0&#46;41&#41; and less often aspirin &#40;90&#46;4&#37; vs&#46; 94&#46;6&#37;&#44; p&#60;0&#46;001&#41;&#44; betablockers &#40;44&#46;4&#37; vs&#46; 69&#46;4&#37;&#44; p&#60;0&#44;001&#41; and statins &#40;47&#46;6&#37; vs&#46; 64&#46;7&#37;&#44; p&#60;0&#46;001&#41;&#46; We were only able to demonstrate an abrupt and significant decrease in the use of statins after 80 years of age&#46; Patient age was independently associated with the use of betablockers &#40;OR 0&#46;59&#59; 95&#37;CI 0&#46;47 - 0&#46;73&#41; and statins &#40;OR 0&#46;78&#59; 95&#37;CI 0&#46;65 - 0&#46;95&#41;&#46; The lesser administration of these drugs was also associated with early mortality &#40;OR 0&#46;17&#44; 95&#37;CI 0&#46;09 to 0&#46;33 and OR 0&#46;14&#59; 95&#37;CI 0&#46;08 to 0&#46;23&#44; respectively&#41;&#46;</p> <span class="elsevierStyleSectionTitle">Conclusions</span><p id="spar0080" class="elsevierStyleSimplePara elsevierViewall">Octogenarians less often receive aspirin&#44; betablockers and statins&#44; though old age was not an independent factor associated with lesser aspirin use&#46;</p>"
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                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">982 &#40;20&#44;3&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">245 &#40;36&#44;3&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#60;0&#44;001&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Clase Killip IV&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t">178 &#40;3&#44;2&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t">136 &#40;2&#44;8&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t">42 &#40;6&#44;2&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#60;0&#44;001&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Glucemia &#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="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">192&#177;101&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">191&#177;102&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">200&#177;98&#44;9&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#44;03&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Frecuencia cardiaca &#40;latidos&#47;min&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">81&#177;25&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">80&#177;25&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">85&#177;26&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#60;0&#44;001&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Bradicardia&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">488 &#40;8&#44;8&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">426 &#40;8&#44;8&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">62 &#40;9&#44;2&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#44;74&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Tensi&#243;n arterial media &#40;mmHg&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">98&#177;22&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t">99&#177;22&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">95&#177;24&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#60;0&#44;001&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Fracci&#243;n de eyecci&#243;n del <span class="elsevierStyleSmallCaps">vi</span> &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">48&#44;4&#177;10&#44;8&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t">48&#44;8&#177;10&#44;7&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t">44&#44;9&#177;10&#44;9&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#60;0&#44;001&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Pico creatinfosfocinasa &#40;UI&#47;L&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">902&#177;1506&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">929&#177;1516&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">814&#177;1325&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#60;0&#44;001&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Pico creatincinasa-MB &#40;ng&#47;mL&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t">93&#177;167&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t">94&#177;168&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t">87&#177;160&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t">0&#44;22&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Pico troponina T &#40;ng&#47;mL&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2&#44;9&#177;7&#44;2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2&#44;9&#177;7&#44;4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">3&#44;1&#177;6&#44;8&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#44;32&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Rotura cardiaca&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">109 &#40;2&#44;0&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">79 &#40;1&#44;6&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">30 &#40;4&#44;4&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#60;0&#44;001&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Bloqueo AV completo&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t">315 &#40;5&#44;7&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t">258 &#40;5&#44;3&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t">57 &#40;8&#44;4&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t">0&#44;001&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Fibrilaci&#243;n ventricular&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t">345 &#40;6&#44;2&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t">314 &#40;6&#44;5&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t">31 &#40;4&#44;6&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t">0&#44;058&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Mortalidad precoz &#40;24 horas&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t">221 &#40;4&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t">159 &#40;3&#44;3&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t">62 &#40;9&#44;2&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t">&#60;0&#44;001&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Mortalidad a los 30 d&#237;as&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t">721 &#40;13&#44;1&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t">514 &#40;10&#44;6&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>No fraccionada&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
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                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t\ttop\n
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                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t\ttop\n
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                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t\ttop\n
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                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>Bajo peso molecular&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t\ttop\n
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                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t\ttop\n
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                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t\ttop\n
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                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t\ttop\n
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                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t\ttop\n
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                  \t\t\t\t\ttop\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
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                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t\ttop\n
                  \t\t\t\t">3&#46;916 &#40;80&#44;8&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">497 &#40;73&#44;6&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttop\n
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                  \t\t\t\t\ttop\n
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                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t\ttop\n
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                  \t\t\t\t\ttop\n
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                  \t\t\t\t\ttop\n
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                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t\ttop\n
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                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">Inhibidores receptor de aldosterona</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t\ttop\n
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                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t\ttop\n
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                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t\ttop\n
                  \t\t\t\t">10 &#40;1&#44;5&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t\ttop\n
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                  \t\t\t\t\ttop\n
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                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t\ttop\n
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                  \t\t\t\t\ttop\n
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                  \t\t\t\t\ttop\n
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                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttop\n
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                  \t\t\t\t\ttable-entry\n
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                  """
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                  \t\t\t\t"><span class="elsevierStyleItalic">Diabetes Mellitus conocida</span>&nbsp;\t\t\t\t\t\t\n
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Original
Ajuste del tratamiento farmacológico a las guías de práctica clínica en pacientes octogenarios con infarto agudo de miocardio
Drug treatment adjustment to the clinical guidelines in octagenarians with acute myocardial infarction
A. Padilla-Serranoa,
Autor para correspondencia
apadilla@jccm.es

Autor para correspondencia.
, J. Galcerá-Tomásb, A. Melgarejo-Morenoc, J.M. Tenías-Burillod, N. Alonso-Fernándezc, E. Andreu-Solerb, P. Rodríguez-Garcíab, M.D. del Rey-Carriónc, Á. Díaz-Pastorc, J.H. de Gea-Garcíab
a Unidad Coronaria, Hospital General La Mancha Centro, Alcázar de San Juan, Ciudad Real, España
b Unidad Coronaria, Hospital Universitario Virgen de la Arrixaca, Murcia, España
c Unidad Coronaria, Hospital Universitario Santa María del Rosell, Cartagena, Murcia
d Unidad de Investigación, Hospital General La Mancha Centro, Alcázar de San Juan, Ciudad Real, España
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Parad&#243;jicamente los pacientes mayores suelen estar poco representados o incluso excluidos en muchos ensayos cl&#237;nicos<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a>&#46; Asimismo&#44; las recomendaciones terap&#233;uticas bien establecidas&#44; como la administraci&#243;n de aspirina&#44; betabloqueantes&#44; inhibidores de la enzima de conversi&#243;n de la angiotensina &#40;IECA&#41; y estatinas<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a><span class="elsevierStyleSup">&#44;</span><a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a>&#44; se aplican en menor medida en los pacientes de edad avanzada que en el resto de pacientes<a class="elsevierStyleCrossRefs" href="#bib0020"><span class="elsevierStyleSup">4&#8211;7</span></a><span class="elsevierStyleSup">&#44;</span><a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">11</span></a><span class="elsevierStyleSup">&#44;</span><a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">12</span></a>&#44; a pesar de estar recomendados en este grupo de alto riesgo<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">13</span></a><span class="elsevierStyleSup">&#44;</span><a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">14</span></a>&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">Sin embargo&#44; no hay un claro acuerdo de si la menor proporci&#243;n con la que los pacientes mayores reciben estos f&#225;rmacos expresa una discriminaci&#243;n real por la edad o es consecuencia&#44; y por tanto se justificar&#237;a&#44; por las peculiaridades de esta poblaci&#243;n&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">Con estas consideraciones previas&#44; nos propusimos determinar si existe una asociaci&#243;n lineal de la edad y la administraci&#243;n de aspirina&#44; betabloqueantes&#44; IECA y estatinas&#44; en qu&#233; medida los pacientes de edad avanzada con IAM reciben con menor frecuencia cada uno de estos f&#225;rmacos y hasta qu&#233; punto esta menor proporci&#243;n se asocia de forma independiente a la edad o puede atribuirse a otros factores&#44; especialmente la comorbilidad subyacente y la situaci&#243;n cl&#237;nica al ingreso&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Pacientes y m&#233;todos</span><p id="par0020" class="elsevierStylePara elsevierViewall">Entre enero de 1998 y enero de 2008&#44; todos los pacientes de cualquier edad ingresados consecutivamente con diagn&#243;stico de IAM&#44; en las respectivas Unidades Coronarias de 2 hospitales de la Regi&#243;n de Murcia &#40;Espa&#241;a&#41;&#44; fueron incluidos en un estudio observacional&#44; longitudinal y prospectivo&#46; Se excluyeron a los pacientes con un IAM ocurrido periprocedimiento de revascuarizaci&#243;n coronaria &#40;quir&#250;rgico o percut&#225;neo&#41;&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">Debido a que la determinaci&#243;n de la troponina no se generaliz&#243; a todos los pacientes hasta el a&#241;o 2001&#44; el diagn&#243;stico de IAM se realiz&#243; ante la presencia de la elevaci&#243;n de la prote&#237;na CK&#91;MB&#93; s&#233;rica al doble de su rango normal y al menos uno de los siguientes criterios&#58; 1&#41; dolor tor&#225;cico de caracter&#237;sticas isqu&#233;micas de m&#225;s de 20 minutos de duraci&#243;n y 2&#41; cambios en el electrocardiograma de ingreso compatibles con isquemia activa o necrosis mioc&#225;rdica establecida seg&#250;n los criterios establecidos<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">15</span></a>&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">De forma prospectiva se rellen&#243; en cada paciente un formulario que incluy&#243; variables demogr&#225;ficas&#44; antecedentes personales&#44; retraso al ingreso desde el inicio de los s&#237;ntomas&#44; datos relativos a la situaci&#243;n cl&#237;nica al ingreso&#44; caracter&#237;sticas del electrocardiograma inicial y todos los tratamientos administrados tanto inmediatamente al ingreso en la Unidad Coronaria como durante su estancia en la Unidad Coronaria&#46; Tambi&#233;n se determin&#243;&#44; siempre que fue posible&#44; la fracci&#243;n de eyecci&#243;n del ventr&#237;culo izquierdo &#40;FEVI&#41; mediante ecocardiograf&#237;a en las primeras 24 horas&#46; Adem&#225;s&#44; se recogi&#243; la mortalidad a las 24 horas y a los 30 d&#237;as&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">Se consider&#243; <span class="elsevierStyleItalic">insuficiencia renal cr&#243;nica</span> cuando el valor de creatinina plasm&#225;tica obtenida al ingreso en la Unidad Coronaria era igual o mayor de 2<span class="elsevierStyleHsp" style=""></span>mg&#47;dl o bien el paciente ya se encontraba en programa de hemodi&#225;lisis&#46; La presencia de <span class="elsevierStyleItalic">insuficiencia cardiaca al ingreso</span> se estableci&#243; de acuerdo con los criterios de Killip y Kimball&#46; Se defini&#243; IAM de localizaci&#243;n anterior seg&#250;n los criterios publicados previamente<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">16</span></a>&#46;</p><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Estrategia de an&#225;lisis</span><p id="par0040" class="elsevierStylePara elsevierViewall">Comprobamos la linealidad de la asociaci&#243;n de la edad con cada variable de resultado&#46; Para ello&#44; se introdujo en un modelo la edad como variable continua y despu&#233;s&#44; en otro modelo&#44; categorizada en quinquenios&#46; Si al comparar ambos modelos mediante el test de la raz&#243;n de verisimilitud se produce un resultado significativo &#40;p&#60;0&#44;05&#41; se podr&#237;a descartar una asociaci&#243;n lineal entre la edad y cada variable&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">A continuaci&#243;n se realizaron 2 grupos de edad&#58; mayores y menores de 80 a&#241;os&#46; Las caracter&#237;sticas estudiadas fueron comparadas en los 2 grupos de edad mediante diferentes pruebas de contraste para variables cuantitativas &#40;t de Student para datos independientes&#41; y cualitativas &#40;prueba de Ji cuadrado&#41;&#46;</p><p id="par0050" class="elsevierStylePara elsevierViewall">El control de la posible confusi&#243;n en las relaciones encontradas entre la edad y los diferentes indicadores de resultado se realiz&#243; mediante regresi&#243;n log&#237;stica no condicional&#44; estimando la odds ratio &#40;OR&#41; y su intervalo de confianza del 95&#37; &#40;IC95&#37;&#41; como medida de asociaci&#243;n&#46; Las variables candidatas a formar parte de cada uno de los modelos fueron&#58; g&#233;nero&#44; tensi&#243;n arterial media al ingreso&#44; ictus previo&#44; infarto de miocardio previo&#44; retraso al ingreso&#44; frecuencia cardiaca&#44; clase Killip&#44; FEVI&#44; localizaci&#243;n anterior&#44; bradicardia&#44; centro hospitalario&#44; tratamiento de reperfusi&#243;n&#44; arteriopat&#237;a perif&#233;rica&#44; insuficiencia renal cr&#243;nica&#44; diabetes mellitus&#44; EPOC&#44; bloqueo auriculoventricular&#44; hipercolesterolemia previa y mortalidad en las primeras 24 horas&#46;</p><p id="par0055" class="elsevierStylePara elsevierViewall">Por &#250;ltimo&#44; se evaluaron las estimaciones ajustadas para cada indicador teniendo en cuenta el periodo en el que se atendi&#243; al paciente&#58; antes de 2000&#44; de 2001 a 2004 y a partir de 2004&#46; Esta divisi&#243;n se realiz&#243; teniendo en cuenta la fecha de publicaci&#243;n de las principales gu&#237;as de pr&#225;ctica cl&#237;nica sobre el manejo terap&#233;utico del IAM<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">17</span></a><span class="elsevierStyleSup">&#44;</span><a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">18</span></a>&#46;</p><p id="par0060" class="elsevierStylePara elsevierViewall">Todos los c&#225;lculos se realizaron con el programa estad&#237;stico PASW 18&#46;0 &#40;SPSS Inc&#41;&#46;</p></span></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Resultados</span><p id="par0065" class="elsevierStylePara elsevierViewall">Durante el periodo de estudio ingresaron en las 2 Unidades Coronarias 5&#46;521 pacientes con el diagn&#243;stico de IAM&#44; de los cuales 4&#46;846 &#40;87&#44;8&#37;&#41; ten&#237;an menos de 80 a&#241;os y 675 &#40;12&#44;2&#37;&#41; 80 o m&#225;s&#46; La proporci&#243;n de mujeres fue m&#225;s del doble en el grupo de los octogenarios en comparaci&#243;n a los de menor edad&#46; Los octogenarios presentaron con mayor frecuencia hipertensi&#243;n arterial y antecedentes de infarto de miocardio&#44; insuficiencia cardiaca&#44; ictus e insuficiencia renal cr&#243;nica&#46; En cambio&#44; los octogenarios presentaron con menor frecuencia hipercolesterolemia conocida&#44; tabaquismo activo y obesidad &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">tabla 1</a>&#41;&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0070" class="elsevierStylePara elsevierViewall">Al ingreso&#44; los octogenarios presentaron con menor frecuencia una cl&#237;nica t&#237;pica e IAM con elevaci&#243;n persistente del segmento ST&#46; Por el contrario&#44; estos pacientes ingresaron con mayor retraso&#44; m&#225;s frecuentemente con signos de insuficiencia cardiaca grados Killip II-III y con m&#225;s del doble de frecuencia en shock cardiog&#233;nico&#46; En cuanto a algunas complicaciones&#44; los octogenarios presentaron m&#225;s frecuentemente rotura cardiaca&#44; bloqueo auriculoventricular completo y mayor mortalidad en las primeras 24 horas y a los 30 d&#237;as &#40;<a class="elsevierStyleCrossRef" href="#tbl0010">tabla 2</a>&#41;&#46;</p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><p id="par0075" class="elsevierStylePara elsevierViewall">Con respecto al tratamiento m&#233;dico&#44; al grupo de pacientes octogenarios se le administr&#243; con menor frecuencia aspirina&#44; betabloqueantes y estatinas &#40;<a class="elsevierStyleCrossRef" href="#tbl0015">tabla 3</a>&#41;&#46;</p><elsevierMultimedia ident="tbl0015"></elsevierMultimedia><p id="par0080" class="elsevierStylePara elsevierViewall">Cuando se analiz&#243; el efecto lineal de la edad sobre la probabilidad de recibir aspirina&#44; betabloqueantes e IECA y&#47;o ARA-II se observ&#243; que conforme avanzaba la edad iba disminuyendo de forma progresiva y en la misma proporci&#243;n &#40;efecto lineal&#41; la administraci&#243;n de aspirina y betabloqueantes&#44; mientras que aumentaba la administraci&#243;n de IECA y&#47;o ARA-II &#40;<a class="elsevierStyleCrossRef" href="#tbl0020">tabla 4</a>&#41;&#46; En cambio&#44; cuando se analiz&#243; el tratamiento con estatinas pudo observarse que la relaci&#243;n con la edad no era lineal&#44; de modo que a partir de los 80-85 a&#241;os se observa una disminuci&#243;n brusca y significativa en la administraci&#243;n de estatinas &#40;<a class="elsevierStyleCrossRef" href="#fig0005">fig&#46; 1</a>&#41;&#46;</p><elsevierMultimedia ident="tbl0020"></elsevierMultimedia><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0085" class="elsevierStylePara elsevierViewall">En el an&#225;lisis de regresi&#243;n multivariante se observ&#243; una asociaci&#243;n significativa e independiente entre la edad y la administraci&#243;n de betabloqueantes y estatinas &#40;<a class="elsevierStyleCrossRef" href="#fig0010">fig&#46; 2</a>&#41;&#46; El ingreso en una clase Killip&#62;1 &#40;betabloqueantes&#41; o en clase Killip&#62;2 &#40;estatinas&#41; y una elevada mortalidad precoz &#40;primeras 24 horas&#41; tambi&#233;n se asoci&#243; a una menor administraci&#243;n de estos f&#225;rmacos &#40;<a class="elsevierStyleCrossRef" href="#tbl0025">tabla 5</a>&#41;&#46;</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><elsevierMultimedia ident="tbl0025"></elsevierMultimedia><p id="par0090" class="elsevierStylePara elsevierViewall">Cuando se dividieron los 10 a&#241;os de duraci&#243;n de este estudio en 3 periodos y se repitieron los modelos de regresi&#243;n multivariante&#44; se observ&#243; que la utilizaci&#243;n de los f&#225;rmacos ha sido bastante homog&#233;nea a lo largo de los 10 a&#241;os &#40;<a class="elsevierStyleCrossRef" href="#fig0015">fig&#46; 3</a>&#41;&#46;</p><elsevierMultimedia ident="fig0015"></elsevierMultimedia></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Discusi&#243;n</span><p id="par0095" class="elsevierStylePara elsevierViewall">Nuestro estudio evidencia que&#44; respecto a los pacientes de menor edad&#44; los octogenarios reciben una similar proporci&#243;n de tratamiento con IECA o ARA-II y con menor frecuencia aspirina&#44; betabloqueantes y estatinas&#44; aunque solo la menor utilizaci&#243;n de estos 2 &#250;ltimos f&#225;rmacos se asoci&#243; de forma independiente a la edad avanzada&#46; Cuando analizamos el efecto lineal de la edad sobre la probabilidad de recibir alguno de estos f&#225;rmacos observamos que su administraci&#243;n decreci&#243; conforme aument&#243; la edad&#44; aunque fue evidente un cambio relativamente brusco en torno a los 80 a&#241;os&#44; especialmente en el caso de las estatinas&#46;</p><p id="par0100" class="elsevierStylePara elsevierViewall">Aunque las evidencias del beneficio farmacol&#243;gico se incorporan con cierto retraso a la pr&#225;ctica cl&#237;nica<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">19</span></a>&#44; la indicaci&#243;n de los f&#225;rmacos estudiados en el presente estudio en el IAM est&#225; bien establecida a&#241;os antes del inicio de la recogida de los datos&#44; no habi&#233;ndose modificado durante el periodo del mismo<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">17</span></a><span class="elsevierStyleSup">&#44;</span><a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">20</span></a>&#46; Considerando&#44; adem&#225;s&#44; que los tratamientos deben iniciarse durante el ingreso hospitalario<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">21</span></a>&#44; es posible que nuestros hallazgos sean consecuencia de que&#44; al igual que ocurre en el caso de las mujeres<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">22</span></a>&#44; las recomendaciones no se sigan en igual medida en los pacientes de edad avanzada&#46; Dadas las diferencias en la inmediatez de la administraci&#243;n y las contraindicaciones espec&#237;ficas de cada f&#225;rmaco&#44; son oportunas algunas consideraciones en cada uno de ellos&#46;</p><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Aspirina</span><p id="par0105" class="elsevierStylePara elsevierViewall">La administraci&#243;n global de aspirina en nuestra poblaci&#243;n &#40;94&#37;&#41; es ligeramente superior al 86&#44;9&#37; del registro MASCARA<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">23</span></a> y al 92&#44;5&#37; del Euro Heart Survey <a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">24</span></a>&#46; El 90&#44;4&#37; de los octogenarios recibi&#243; aspirina&#44; una cifra superior de la referida por otros estudios <a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">12</span></a><span class="elsevierStyleSup">&#44;</span><a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">25</span></a><span class="elsevierStyleSup">&#44;</span><a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">26</span></a> donde oscila entre el 66&#44;7 y 83&#37;&#46; En nuestro estudio&#44; el ajuste por diferentes variables no evidenci&#243; diferencias en la administraci&#243;n de aspirina entre los mayores y menores de 80 a&#241;os&#46; En cambio&#44; Magid et al&#46;<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">25</span></a> evidenciaron c&#243;mo los octogenarios tienen un 4&#37; menos de probabilidad de recibirla con respecto a los pacientes de 65 a 69 a&#241;os &#40;OR 0&#44;96&#59; IC95&#37; 0&#44;95-0&#44;97&#41; y Rathore et al&#46;<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">12</span></a> una reducci&#243;n del 15&#37; &#40;OR 0&#44;85&#59; IC95&#37; 0&#44;77-0&#44;93&#41; en la probabilidad de recibir aspirina por cada incremento de 10 a&#241;os de la edad&#46; Por otro lado&#44; en nuestro estudio se demostr&#243; un efecto lineal de la edad sobre la probabilidad de recibir aspirina&#44; observando una progresiva menor administraci&#243;n de aspirina conforme avanzaba la edad&#46; Por tanto&#44; conforme el paciente presenta una mayor edad se observa siempre el mismo descenso en la administraci&#243;n de aspirina&#46; En cambio&#44; el estudio de Schoenenberger et al&#46; <a class="elsevierStyleCrossRef" href="#bib0135"><span class="elsevierStyleSup">27</span></a> descart&#243; dicho efecto lineal&#44; aunque no indic&#243; a partir de qu&#233; edad disminu&#237;a bruscamente su administraci&#243;n&#46; Es posible que la alta tasa de tratamiento con aspirina en nuestro caso sea consecuencia de que su administraci&#243;n se produzca con frecuencia en los primeros momentos de evoluci&#243;n&#44; incluso en la atenci&#243;n extrahospitalaria&#46;</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Betabloqueantes</span><p id="par0110" class="elsevierStylePara elsevierViewall">Globalmente el 66&#44;3&#37; de nuestros pacientes recibi&#243; betabloqueantes&#44; cifra similar al 67&#44;8&#37; del registro MASCARA<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">23</span></a> pero inferior al 79&#44;6&#37; del Euro Heart Survey <a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">24</span></a> y al 87&#44;9&#37; del GWTG-CAD &#40;Get With The Guidelines-Coronary Artery Disease&#41;&#44; aunque este &#250;ltimo registro formaba parte de un proyecto de implementaci&#243;n de las recomendaciones de las gu&#237;as de pr&#225;ctica cl&#237;nica<a class="elsevierStyleCrossRef" href="#bib0140"><span class="elsevierStyleSup">28</span></a>&#46; A pesar de las evidencias del beneficio de los betabloqueantes en los pacientes mayores de 80 a&#241;os<a class="elsevierStyleCrossRef" href="#bib0145"><span class="elsevierStyleSup">29</span></a><span class="elsevierStyleSup">&#44;</span><a class="elsevierStyleCrossRef" href="#bib0150"><span class="elsevierStyleSup">30</span></a>&#44; en nuestro estudio este tratamiento lo recibi&#243; solo el 44&#44;4&#37; de los octogenarios&#44; aunque esta cifra es superior a los valores entre el 29 y el 42&#44;3&#37; referidos por otros estudios<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">12</span></a><span class="elsevierStyleSup">&#44;</span><a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">25</span></a><span class="elsevierStyleSup">&#44;</span><a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">26</span></a><span class="elsevierStyleSup">&#44;</span><a class="elsevierStyleCrossRef" href="#bib0155"><span class="elsevierStyleSup">31</span></a>&#46; Respecto a la influencia de la edad en el tratamiento con betabloqueantes&#44; su administraci&#243;n disminuy&#243; conforme aumenta la edad&#44; en coincidencia con los estudios de Ruiz-Bail&#233;n et al&#46;<a class="elsevierStyleCrossRef" href="#bib0155"><span class="elsevierStyleSup">31</span></a> y de Magid et al&#46;<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">25</span></a> que mostr&#243; un 21&#37; de reducci&#243;n de la probabilidad de recibir este tratamiento en cada uno de los 6 grupos de edad considerados&#46; A diferencia del estudio de Schoenenberger et al&#46;<a class="elsevierStyleCrossRef" href="#bib0135"><span class="elsevierStyleSup">27</span></a> en el que se descart&#243; un efecto lineal de la edad sobre la probabilidad de recibir betabloqueantes&#44; en nuestro caso y al igual que con la aspirina se demostr&#243; este efecto lineal&#44; aunque pudimos observar c&#243;mo en torno a los 80 a&#241;os hab&#237;a una mayor tendencia hacia una menor administraci&#243;n&#46; La menor administraci&#243;n de betabloqueantes en los octogenarios se podr&#237;a atribuir a la frecuente comorbilidad asociada&#44; sin embargo&#44; tanto nuestro estudio como otros<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a><span class="elsevierStyleSup">&#44;</span><a class="elsevierStyleCrossRef" href="#bib0135"><span class="elsevierStyleSup">27</span></a> coinciden en que independientemente de la comorbilidad&#44; la edad avanzada se asocia significativamente con una menor administraci&#243;n de estos f&#225;rmacos&#46; Otro motivo para no administrar betabloqueantes a los octogenarios con IAM ser&#237;a la frecuente presentaci&#243;n con cl&#237;nica at&#237;pica y&#47;o con enfermedades concomitantes&#44; como la insuficiencia cardiaca congestiva o la neumon&#237;a<a class="elsevierStyleCrossRef" href="#bib0160"><span class="elsevierStyleSup">32</span></a>&#44; que con frecuencia difiere el diagn&#243;stico de infarto de miocardio lo que puede resultar en la no administraci&#243;n precoz de este f&#225;rmaco&#46; Tambi&#233;n es posible que la presencia de insuficiencia cardiaca al ingreso en los octogenarios favorezca la elecci&#243;n del tratamiento precoz con IECA o ARA-II dado el beneficio de estos f&#225;rmacos en los pacientes de alto riesgo<a class="elsevierStyleCrossRef" href="#bib0165"><span class="elsevierStyleSup">33</span></a>&#46; Por &#250;ltimo&#44; no podemos descartar que los m&#233;dicos que atienden a estos pacientes sobreestimen los efectos adversos de estos f&#225;rmacos<a class="elsevierStyleCrossRef" href="#bib0170"><span class="elsevierStyleSup">34</span></a>&#44; especialmente en pacientes con enfermedad pulmonar obstructiva cr&#243;nica aunque sea este un grupo de especial beneficio <a class="elsevierStyleCrossRef" href="#bib0175"><span class="elsevierStyleSup">35</span></a>&#44; constituyendo solo la bradicardia&#44; bloqueo auriculoventricular avanzado&#44; broncoespasmo&#44; shock cardiog&#233;nico o en caso de insuficiencia cardiaca aguda severa sin respuesta al tratamiento inicial una contraindicaci&#243;n absoluta a la administraci&#243;n de los betabloqueantes <a class="elsevierStyleCrossRef" href="#bib0180"><span class="elsevierStyleSup">36</span></a>&#46;</p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Bloqueadores del eje renina-angiotensina</span><p id="par0115" class="elsevierStylePara elsevierViewall">La administraci&#243;n de IECA y&#47;o ARA-II en nuestra poblaci&#243;n global &#40;69&#44;4&#37;&#41; es superior al 46&#37; registrado por el registro DESCARTES<a class="elsevierStyleCrossRef" href="#bib0185"><span class="elsevierStyleSup">37</span></a> y al 65&#44;4&#37; del Euro Heart Survey<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">24</span></a>&#46; Adem&#225;s&#44; aunque en el an&#225;lisis bivariado no se encuentran diferencias entre los mayores y menores de 80 a&#241;os&#44; cuando analizamos el efecto lineal de la edad sobre la probabilidad de recibir estos f&#225;rmacos observamos una tendencia a una mayor administraci&#243;n conforme aumenta la edad&#46; Esta tendencia puede ser consecuencia de que en presencia de una similar eficacia a la de los betabloqueantes<a class="elsevierStyleCrossRef" href="#bib0190"><span class="elsevierStyleSup">38</span></a>&#44; los IECA o ARA-II son mejor tolerados por los pacientes de edad avanzada&#46;</p></span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Estatinas</span><p id="par0120" class="elsevierStylePara elsevierViewall">A pesar de que en 2 grandes estudios<a class="elsevierStyleCrossRef" href="#bib0195"><span class="elsevierStyleSup">39</span></a><span class="elsevierStyleSup">&#44;</span><a class="elsevierStyleCrossRef" href="#bib0200"><span class="elsevierStyleSup">40</span></a> se haya demostrado el beneficio de la administraci&#243;n de estatinas en todos los grupos de edad&#44; incluso en aquellos pacientes con una corta expectativa de vida<a class="elsevierStyleCrossRef" href="#bib0205"><span class="elsevierStyleSup">41</span></a> y que es un tratamiento coste-efectivo en los pacientes de 75-84 a&#241;os<a class="elsevierStyleCrossRef" href="#bib0210"><span class="elsevierStyleSup">42</span></a>&#44; nuestros octogenarios&#44; en comparaci&#243;n a los menores de 80 a&#241;os&#44; recibieron con menor frecuencia este tratamiento&#44; aunque la proporci&#243;n de pacientes octogenarios que recibieron estatinas aument&#243; del 17&#44;2&#37; en los primeros a&#241;os del estudio al 70&#44;5&#37; en coincidencia con los hallazgos aportados por otros registros<a class="elsevierStyleCrossRef" href="#bib0140"><span class="elsevierStyleSup">28</span></a><span class="elsevierStyleSup">&#44;</span><a class="elsevierStyleCrossRefs" href="#bib0215"><span class="elsevierStyleSup">43&#8211;45</span></a>&#46; A pesar de ello&#44; nuestro porcentaje de administraci&#243;n global de estatinas &#40;62&#44;6&#37;&#41; es superior al 52&#44;3&#37; del registro DESCARTES<a class="elsevierStyleCrossRef" href="#bib0185"><span class="elsevierStyleSup">37</span></a> y al 60&#44;3&#37; del Euro Heart Survey<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">24</span></a>&#46; Adem&#225;s&#44; la mitad de nuestros pacientes octogenarios recibieron estatinas&#44; un porcentaje superior al 38&#37; del registro PRAIS-UK<a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">26</span></a>&#46; Igualmente&#44; en el registro GRACE se observ&#243; c&#243;mo la administraci&#243;n de estatinas descendi&#243; del 59&#37; en los pacientes de 45 a 54 a&#241;os al 24&#44;2&#37; en los pacientes de 85 o m&#225;s a&#241;os<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a>&#46; Al contrario que con los f&#225;rmacos anteriores&#44; con las estatinas pudimos descartar un efecto lineal de la edad sobre la probabilidad de recibir este tratamiento observando&#44; adem&#225;s&#44; como en torno a los 80 a&#241;os hab&#237;a una tendencia brusca hacia una menor administraci&#243;n&#46; Esta menor utilizaci&#243;n de las estatinas en los pacientes de mayor edad es probable que se deba a una percepci&#243;n de un menor beneficio en la prevenci&#243;n secundaria en estos pacientes que ingresan con mayor frecuencia en una peor situaci&#243;n cl&#237;nica&#46; Adem&#225;s&#44; la administraci&#243;n extrahospitalaria o en urgencias de las estatinas es inusual y suele diferirse program&#225;ndola por la noche&#44; lo que en presencia de una mortalidad precoz elevada puede explicar&#44; en parte&#44; los casos en los que dicho f&#225;rmaco no se ha administrado&#46;</p><p id="par0125" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">Limitaciones del estudio&#46;</span> En primer lugar&#44; es posible que exista un sesgo de selecci&#243;n dado que este registro solo recogi&#243; a los pacientes con IAM que ingresaron en las Unidades Coronarias&#46; Es posible que no infrecuentemente los pacientes atendidos fuera de las Unidades Coronarias no hubieran sido consultados para su ingreso por asociar gran comorbilidad y&#44; por lo tanto&#44; ser pacientes de avanzada edad&#46; A pesar de esta limitaci&#243;n&#44; nuestra poblaci&#243;n no ha sido sesgada por otros criterios por lo que debiera ser tomada como representativa de los pacientes con IAM que ingresan en nuestras Unidades Coronarias&#46; En segundo lugar&#44; es posible que algunos factores de dif&#237;cil apreciaci&#243;n &#40;intolerancia a determinadas medicaciones&#44; presencia de demencia senil o la percepci&#243;n subjetiva de un deterioro marcado de la condici&#243;n biol&#243;gica de algunos pacientes&#41; puedan haber inducido una limitaci&#243;n del esfuerzo terap&#233;utico en algunos casos y&#44; por tanto&#44; haber influido en los resultados de este estudio&#46; En tercer lugar&#44; este estudio se circunscribe a una regi&#243;n del sureste de Espa&#241;a aunque nuestros resultados son concordantes a los obtenidos en otros estudios de otras zonas geogr&#225;ficas&#46; Por &#250;ltimo&#44; nuestro registro no contempl&#243; la recogida prospectiva de las posibles contraindicaciones absolutas y relativas de los diferentes tratamientos&#44; pero es poco probable que tales contraindicaciones expliquen completamente las diferencias observadas en el an&#225;lisis multivariable entre los mayores y menores de 80 a&#241;os&#46;</p></span></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Conclusiones</span><p id="par0130" class="elsevierStylePara elsevierViewall">En nuestro caso&#44; los pacientes octogenarios&#44; con respecto a los m&#225;s j&#243;venes&#44; reciben con menor frecuencia tratamiento con aspirina&#44; betabloqueantes y estatinas&#44; mientras que no hemos encontrado diferencias con respecto a la administraci&#243;n de IECA o ARA-II&#46; Sin embargo&#44; la edad avanzada no constituye un factor independiente asociado a la menor administraci&#243;n de aspirina&#46; En cambio&#44; es posible que los octogenarios sean discriminados en el sentido de recibir&#44; sin una aparente justificaci&#243;n m&#225;s all&#225; de la edad&#44; una baja proporci&#243;n de betabloqueantes y estatinas&#44; aunque influye en gran medida el ingresar en una mala situaci&#243;n cl&#237;nica y el tener con mayor frecuencia una elevada mortalidad precoz&#46; El mal pron&#243;stico de los pacientes de edad avanzada debe hacernos reflexionar hasta que punto estos pacientes se identifican e individualizan de forma adecuada en la pr&#225;ctica cl&#237;nica diaria&#46; La denegaci&#243;n de los tratamientos con beneficio probado en los pacientes ancianos debe ser justificada y no atribuirse a la ligera a sus riesgos potenciales&#44; lo cual nos llevar&#237;a a una discriminaci&#243;n de esta poblaci&#243;n&#46;</p></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Conflictos de intereses</span><p id="par0135" class="elsevierStylePara elsevierViewall">Los autores declaran no tener ning&#250;n conflicto de intereses&#46;</p></span></span>"
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            1 => "Objetivo"
            2 => "Dise&#241;o"
            3 => "&#193;mbito"
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            0 => "Abstract"
            1 => "Objectives"
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              "titulo" => "Betabloqueantes"
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            2 => array:2 [
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              "titulo" => "Bloqueadores del eje renina-angiotensina"
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              "titulo" => "Estatinas"
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    "fechaRecibido" => "2012-03-01"
    "fechaAceptado" => "2012-05-06"
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        "titulo" => "Resumen"
        "resumen" => "<span class="elsevierStyleSectionTitle">Objetivo</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Determinar si existe una asociaci&#243;n lineal de la edad y la administraci&#243;n de aspirina&#44; betabloqueantes&#44; inhibidores de la enzima convertidora de la angiotensina y estatinas&#44; en qu&#233; medida los pacientes de edad avanzada reciben estos tratamientos y si la edad se asocia de forma independiente a estos tratamientos&#46;</p> <span class="elsevierStyleSectionTitle">Dise&#241;o</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Estudio de cohortes prospectivo&#46;</p> <span class="elsevierStyleSectionTitle">&#193;mbito</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Unidades Coronarias de 2 hospitales de la Regi&#243;n de Murcia</p> <span class="elsevierStyleSectionTitle">Pacientes</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Pacientes consecutivos ingresados con el diagn&#243;stico de infarto agudo de miocardio entre enero de 1998 y enero de 2008&#46;</p> <span class="elsevierStyleSectionTitle">Intervenciones</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Ninguna&#46;</p> <span class="elsevierStyleSectionTitle">Variables principales</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Las relacionadas con la administraci&#243;n de aspirina&#44; betabloqueantes&#44; inhibidores de la enzima convertidora de la angiotensina y estatinas durante la estancia en la Unidad Coronaria&#46;</p> <span class="elsevierStyleSectionTitle">Resultados</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Respecto al resto de pacientes&#44; los octogenarios recibieron en similar proporci&#243;n inhibidores de la enzima convertidora de la angiotensina &#40;70&#44;8 vs 69&#44;3&#37;&#44; p&#61;0&#44;41&#41; y con menor frecuencia aspirina &#40;90&#44;4 vs 94&#44;6&#37;&#44; p&#60;0&#44;001&#41;&#44; betabloqueantes &#40;44&#44;4 vs 69&#44;4&#37;&#44; p&#60;0&#44;001&#41; y estatinas &#40;47&#44;6 vs 64&#44;7&#37;&#44; p&#60;0&#44;001&#41;&#46; Solo pudo demostrarse una disminuci&#243;n brusca y significativa en la administraci&#243;n de estatinas a partir de los 80 a&#241;os&#46; La edad se asoci&#243; independientemente con la administraci&#243;n de betabloqueantes &#40;OR 0&#44;59&#59; IC95&#37; 0&#44;47 - 0&#44;73&#41; y estatinas &#40;OR 0&#44;78&#59; IC95&#37; 0&#44;65 - 0&#44;95&#41;&#46; La menor administraci&#243;n de estos f&#225;rmacos tambi&#233;n se asoci&#243; a una mayor mortalidad precoz &#40;OR 0&#44;17&#59; IC95&#37; 0&#44;09 - 0&#44;33 y OR 0&#44;14&#59; IC95&#37; 0&#44;08 - 0&#44;23&#44; respectivamente&#41;&#46;</p> <span class="elsevierStyleSectionTitle">Conclusiones</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">Los pacientes octogenarios reciben con menor frecuencia tratamiento con aspirina&#44; betabloqueantes y estatinas&#44; sin embargo&#44; la edad avanzada no constituy&#243; un factor independiente asociado a la menor administraci&#243;n de aspirina&#46;</p>"
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        "titulo" => "Abstract"
        "resumen" => "<span class="elsevierStyleSectionTitle">Objectives</span><p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">To determine whether there is a linear association of age and aspirin&#44; betablockers&#44; angiotensin-converting enzyme inhibitors and statins&#59; the extent to which elderly patients receive these treatments&#59; and whether age is independently associated with these treatments&#46;</p> <span class="elsevierStyleSectionTitle">Design</span><p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">A prospective cohort study&#46;</p> <span class="elsevierStyleSectionTitle">Setting</span><p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">Coronary Unit of two hospitals in the Region of Murcia &#40;Spain&#41;&#46;</p> <span class="elsevierStyleSectionTitle">Patients</span><p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">Consecutive patients admitted with the diagnosis of acute myocardial infarction between January 1998 and January 2008&#46;</p> <span class="elsevierStyleSectionTitle">Interventions</span><p id="spar0065" class="elsevierStyleSimplePara elsevierViewall">None&#46;</p> <span class="elsevierStyleSectionTitle">Main outcomes</span><p id="spar0070" class="elsevierStyleSimplePara elsevierViewall">Those related to the administration of aspirin&#44; betablockers&#44; angiotensin-converting enzyme inhibitors and statins during stay in the Coronary Care Unit&#46;</p> <span class="elsevierStyleSectionTitle">Results</span><p id="spar0075" class="elsevierStyleSimplePara elsevierViewall">Regarding the remaining patients&#44; octogenarians received a similar proportion of angiotensin-converting enzyme inhibitors &#40;70&#46;8&#37; vs&#46; 69&#46;3&#37;&#44; p&#61;0&#46;41&#41; and less often aspirin &#40;90&#46;4&#37; vs&#46; 94&#46;6&#37;&#44; p&#60;0&#46;001&#41;&#44; betablockers &#40;44&#46;4&#37; vs&#46; 69&#46;4&#37;&#44; p&#60;0&#44;001&#41; and statins &#40;47&#46;6&#37; vs&#46; 64&#46;7&#37;&#44; p&#60;0&#46;001&#41;&#46; We were only able to demonstrate an abrupt and significant decrease in the use of statins after 80 years of age&#46; Patient age was independently associated with the use of betablockers &#40;OR 0&#46;59&#59; 95&#37;CI 0&#46;47 - 0&#46;73&#41; and statins &#40;OR 0&#46;78&#59; 95&#37;CI 0&#46;65 - 0&#46;95&#41;&#46; The lesser administration of these drugs was also associated with early mortality &#40;OR 0&#46;17&#44; 95&#37;CI 0&#46;09 to 0&#46;33 and OR 0&#46;14&#59; 95&#37;CI 0&#46;08 to 0&#46;23&#44; respectively&#41;&#46;</p> <span class="elsevierStyleSectionTitle">Conclusions</span><p id="spar0080" class="elsevierStyleSimplePara elsevierViewall">Octogenarians less often receive aspirin&#44; betablockers and statins&#44; though old age was not an independent factor associated with lesser aspirin use&#46;</p>"
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                  \t\t\t\t">1&#46;683 &#40;34&#44;7&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t">223 &#40;33&#44;0&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">120&#177;180&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">120&#177;170&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">140&#177;190&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#60;0&#44;001&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Clase Killip II-III&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&#46;227 &#40;22&#44;2&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">982 &#40;20&#44;3&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">245 &#40;36&#44;3&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t">&#60;0&#44;001&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Clase Killip IV&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">178 &#40;3&#44;2&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">136 &#40;2&#44;8&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">42 &#40;6&#44;2&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#60;0&#44;001&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Glucemia &#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="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">192&#177;101&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">191&#177;102&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">200&#177;98&#44;9&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#44;03&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Frecuencia cardiaca &#40;latidos&#47;min&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">81&#177;25&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">80&#177;25&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">85&#177;26&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#60;0&#44;001&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Bradicardia&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">488 &#40;8&#44;8&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">426 &#40;8&#44;8&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">62 &#40;9&#44;2&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#44;74&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Tensi&#243;n arterial media &#40;mmHg&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">98&#177;22&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">99&#177;22&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">95&#177;24&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#60;0&#44;001&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Fracci&#243;n de eyecci&#243;n del <span class="elsevierStyleSmallCaps">vi</span> &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">48&#44;4&#177;10&#44;8&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">48&#44;8&#177;10&#44;7&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">44&#44;9&#177;10&#44;9&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#60;0&#44;001&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Pico creatinfosfocinasa &#40;UI&#47;L&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">902&#177;1506&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">929&#177;1516&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">814&#177;1325&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#60;0&#44;001&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Pico creatincinasa-MB &#40;ng&#47;mL&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">93&#177;167&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">94&#177;168&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">87&#177;160&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#44;22&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Pico troponina T &#40;ng&#47;mL&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2&#44;9&#177;7&#44;2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2&#44;9&#177;7&#44;4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">3&#44;1&#177;6&#44;8&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#44;32&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Rotura cardiaca&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">109 &#40;2&#44;0&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">79 &#40;1&#44;6&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">30 &#40;4&#44;4&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#60;0&#44;001&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Bloqueo AV completo&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">315 &#40;5&#44;7&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">258 &#40;5&#44;3&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">57 &#40;8&#44;4&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#44;001&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Fibrilaci&#243;n ventricular&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">345 &#40;6&#44;2&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">314 &#40;6&#44;5&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">31 &#40;4&#44;6&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#44;058&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Mortalidad precoz &#40;24 horas&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">221 &#40;4&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">159 &#40;3&#44;3&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">62 &#40;9&#44;2&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#60;0&#44;001&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Mortalidad a los 30 d&#237;as&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">721 &#40;13&#44;1&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">514 &#40;10&#44;6&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">207 &#40;30&#44;7&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#60;0&#44;001&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
              ]
              "imagenFichero" => array:1 [
                0 => "xTab251920.png"
              ]
            ]
          ]
          "notaPie" => array:1 [
            0 => array:3 [
              "identificador" => "tblfn0010"
              "etiqueta" => "a"
              "nota" => "<p class="elsevierStyleNotepara">Incluye el bloqueo de rama izquierda&#46;</p>"
            ]
          ]
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                  \t\t\t\t\ttop\n
                  \t\t\t\t">8&#44;44&#59; 9&#59; 0&#44;49&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">Betabloqueantes&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t">0&#44;973 &#40;0&#44;967 &#8211; 0&#44;980&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">1&#44;011 &#40;1&#44;005 &#8211; 1&#44;016&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">10&#44;57&#59; 9&#59; 0&#44;31&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t">0&#44;982 &#40;0&#44;977 &#8211; 0&#44;988&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t">19&#44;30&#59; 9&#59; 0&#44;02&nbsp;\t\t\t\t\t\t\n
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Información del artículo
ISSN: 02105691
Idioma original: Español
DOI:10.1016/j.medin.2012.05.002
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Monitorización de la ventilación con tomografía de impedancia
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Maniobra de prono en paciente con ECMO
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