array:23 [
  "pii" => "S1579212909710171"
  "issn" => "15792129"
  "doi" => "10.1016/S1579-2129(09)71017-1"
  "estado" => "S300"
  "fechaPublicacion" => "2009-04-01"
  "aid" => "71017"
  "copyright" => "Sociedad Española de Neumología y Cirugía Torácica"
  "copyrightAnyo" => "2009"
  "documento" => "article"
  "crossmark" => 0
  "subdocumento" => "fla"
  "cita" => "Arch Bronconeumol. 2009;45:173-80"
  "abierto" => array:3 [
    "ES" => false
    "ES2" => false
    "LATM" => false
  ]
  "gratuito" => false
  "lecturas" => array:2 [
    "total" => 2289
    "formatos" => array:3 [
      "EPUB" => 105
      "HTML" => 1600
      "PDF" => 584
    ]
  ]
  "itemSiguiente" => array:18 [
    "pii" => "S1579212909710183"
    "issn" => "15792129"
    "doi" => "10.1016/S1579-2129(09)71018-3"
    "estado" => "S300"
    "fechaPublicacion" => "2009-04-01"
    "aid" => "71018"
    "copyright" => "Sociedad Española de Neumología y Cirugía Torácica"
    "documento" => "article"
    "crossmark" => 0
    "subdocumento" => "fla"
    "cita" => "Arch Bronconeumol. 2009;45:181-5"
    "abierto" => array:3 [
      "ES" => false
      "ES2" => false
      "LATM" => false
    ]
    "gratuito" => false
    "lecturas" => array:2 [
      "total" => 3265
      "formatos" => array:3 [
        "EPUB" => 102
        "HTML" => 2441
        "PDF" => 722
      ]
    ]
    "en" => array:11 [
      "idiomaDefecto" => true
      "cabecera" => "<span class="elsevierStyleTextfn">Original article</span>"
      "titulo" => "Causes of Death and Risk Factors for Mortality in Patients With Severe Chronic Obstructive Pulmonary Disease"
      "tienePdf" => "en"
      "tieneTextoCompleto" => 0
      "tieneResumen" => array:2 [
        0 => "en"
        1 => "es"
      ]
      "paginas" => array:1 [
        0 => array:2 [
          "paginaInicial" => "181"
          "paginaFinal" => "185"
        ]
      ]
      "titulosAlternativos" => array:1 [
        "es" => array:1 [
          "titulo" => "Causas de muerte en pacientes con EPOC grave&#46; Factores pron&#243;sticos"
        ]
      ]
      "contieneResumen" => array:2 [
        "en" => true
        "es" => true
      ]
      "contienePdf" => array:1 [
        "en" => true
      ]
      "autores" => array:1 [
        0 => array:2 [
          "autoresLista" => "Amalia Moreno, Concepci&#243;n Mont&#243;n, Yolanda Belmonte, Miguel Gallego, Xavier Pomares, Jordi Real"
          "autores" => array:6 [
            0 => array:2 [
              "nombre" => "Amalia"
              "apellidos" => "Moreno"
            ]
            1 => array:2 [
              "nombre" => "Concepci&#243;n"
              "apellidos" => "Mont&#243;n"
            ]
            2 => array:2 [
              "nombre" => "Yolanda"
              "apellidos" => "Belmonte"
            ]
            3 => array:2 [
              "nombre" => "Miguel"
              "apellidos" => "Gallego"
            ]
            4 => array:2 [
              "nombre" => "Xavier"
              "apellidos" => "Pomares"
            ]
            5 => array:2 [
              "nombre" => "Jordi"
              "apellidos" => "Real"
            ]
          ]
        ]
      ]
    ]
    "idiomaDefecto" => "en"
    "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S1579212909710183?idApp=UINPBA00003Z"
    "url" => "/15792129/0000004500000004/v1_201305150418/S1579212909710183/v1_201305150418/en/main.assets"
  ]
  "itemAnterior" => array:18 [
    "pii" => "S157921290971016X"
    "issn" => "15792129"
    "doi" => "10.1016/S1579-2129(09)71016-X"
    "estado" => "S300"
    "fechaPublicacion" => "2009-04-01"
    "aid" => "71016"
    "copyright" => "Sociedad Espa&#241;ola de Neumolog&#237;a y Cirug&#237;a Tor&#225;cica"
    "documento" => "article"
    "crossmark" => 0
    "subdocumento" => "fla"
    "cita" => "Arch Bronconeumol. 2009;45:168-72"
    "abierto" => array:3 [
      "ES" => false
      "ES2" => false
      "LATM" => false
    ]
    "gratuito" => false
    "lecturas" => array:2 [
      "total" => 2620
      "formatos" => array:3 [
        "EPUB" => 98
        "HTML" => 1888
        "PDF" => 634
      ]
    ]
    "en" => array:11 [
      "idiomaDefecto" => true
      "cabecera" => "<span class="elsevierStyleTextfn">Original article</span>"
      "titulo" => "Activity of an Intermediate Respiratory Care Unit Attached to a Respiratory Medicine Department"
      "tienePdf" => "en"
      "tieneTextoCompleto" => 0
      "tieneResumen" => array:2 [
        0 => "en"
        1 => "es"
      ]
      "paginas" => array:1 [
        0 => array:2 [
          "paginaInicial" => "168"
          "paginaFinal" => "172"
        ]
      ]
      "titulosAlternativos" => array:1 [
        "es" => array:1 [
          "titulo" => "Actividad de una unidad de cuidados respiratorios intermedios dependiente de un servicio de neumolog&#237;a"
        ]
      ]
      "contieneResumen" => array:2 [
        "en" => true
        "es" => true
      ]
      "contienePdf" => array:1 [
        "en" => true
      ]
      "autores" => array:1 [
        0 => array:2 [
          "autoresLista" => "Ernest Sala, Catalina Balaguer, Miguel Carrera, Alexandre Palou, Juana Bover, &#192;lvar Agust&#237;"
          "autores" => array:6 [
            0 => array:2 [
              "nombre" => "Ernest"
              "apellidos" => "Sala"
            ]
            1 => array:2 [
              "nombre" => "Catalina"
              "apellidos" => "Balaguer"
            ]
            2 => array:2 [
              "nombre" => "Miguel"
              "apellidos" => "Carrera"
            ]
            3 => array:2 [
              "nombre" => "Alexandre"
              "apellidos" => "Palou"
            ]
            4 => array:2 [
              "nombre" => "Juana"
              "apellidos" => "Bover"
            ]
            5 => array:2 [
              "nombre" => "&#192;lvar"
              "apellidos" => "Agust&#237;"
            ]
          ]
        ]
      ]
    ]
    "idiomaDefecto" => "en"
    "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S157921290971016X?idApp=UINPBA00003Z"
    "url" => "/15792129/0000004500000004/v1_201305150418/S157921290971016X/v1_201305150418/en/main.assets"
  ]
  "en" => array:15 [
    "idiomaDefecto" => true
    "cabecera" => "<span class="elsevierStyleTextfn">Original article</span>"
    "titulo" => "Usefulness of the N-Terminal Fraction of Brain Natriuretic Peptide for Deciding When to Refer Patients With Sleep Apnea-Hypopnea Syndrome to the Cardiologist"
    "tieneTextoCompleto" => 0
    "paginas" => array:1 [
      0 => array:2 [
        "paginaInicial" => "173"
        "paginaFinal" => "180"
      ]
    ]
    "autores" => array:1 [
      0 => array:4 [
        "autoresLista" => "Estrella Fern&#225;ndez Fabrellas, Luis Almenar Bonet, Silvia Ponce P&#233;rez, Jos&#233; Antonio Moro L&#243;pez, Rafael Blanquer Olivas, Antonio Salvador Sanz"
        "autores" => array:6 [
          0 => array:4 [
            "nombre" => "Estrella"
            "apellidos" => "Fern&#225;ndez Fabrellas"
            "email" => array:1 [
              0 => "fernandez&#95;est&#64;gva&#46;es"
            ]
            "referencia" => array:2 [
              0 => array:2 [
                "etiqueta" => "<span class="elsevierStyleSup">a</span>"
                "identificador" => "aff1"
              ]
              1 => array:2 [
                "etiqueta" => "<span class="elsevierStyleSup">¿</span>"
                "identificador" => "cor1"
              ]
            ]
          ]
          1 => array:3 [
            "nombre" => "Luis"
            "apellidos" => "Almenar Bonet"
            "referencia" => array:1 [
              0 => array:2 [
                "etiqueta" => "<span class="elsevierStyleSup">b</span>"
                "identificador" => "aff2"
              ]
            ]
          ]
          2 => array:3 [
            "nombre" => "Silvia"
            "apellidos" => "Ponce P&#233;rez"
            "referencia" => array:1 [
              0 => array:2 [
                "etiqueta" => "<span class="elsevierStyleSup">a</span>"
                "identificador" => "aff1"
              ]
            ]
          ]
          3 => array:3 [
            "nombre" => "Jos&#233; Antonio"
            "apellidos" => "Moro L&#243;pez"
            "referencia" => array:1 [
              0 => array:2 [
                "etiqueta" => "<span class="elsevierStyleSup">b</span>"
                "identificador" => "aff2"
              ]
            ]
          ]
          4 => array:3 [
            "nombre" => "Rafael"
            "apellidos" => "Blanquer Olivas"
            "referencia" => array:1 [
              0 => array:2 [
                "etiqueta" => "<span class="elsevierStyleSup">a</span>"
                "identificador" => "aff1"
              ]
            ]
          ]
          5 => array:3 [
            "nombre" => "Antonio"
            "apellidos" => "Salvador Sanz"
            "referencia" => array:1 [
              0 => array:2 [
                "etiqueta" => "<span class="elsevierStyleSup">c</span>"
                "identificador" => "aff3"
              ]
            ]
          ]
        ]
        "afiliaciones" => array:3 [
          0 => array:3 [
            "entidad" => "Servicio de Neumolog&#237;a&#44; Hospital Universitario Dr&#46; Peset&#44; Valencia&#44; Spain"
            "etiqueta" => "<span class="elsevierStyleSup">a</span>"
            "identificador" => "aff1"
          ]
          1 => array:3 [
            "entidad" => "Servicio de Cardiolog&#237;a&#44; Hospital Universitario La Fe&#44; Valencia&#44; Spain"
            "etiqueta" => "<span class="elsevierStyleSup">b</span>"
            "identificador" => "aff2"
          ]
          2 => array:3 [
            "entidad" => "Servicio de Cardiolog&#237;a&#44; Hospital Universitario Dr&#46; Peset&#44; Valencia&#44; Spain"
            "etiqueta" => "<span class="elsevierStyleSup">c</span>"
            "identificador" => "aff3"
          ]
        ]
        "correspondencia" => array:1 [
          0 => array:3 [
            "identificador" => "cor1"
            "etiqueta" => "&#8270;"
            "correspondencia" => "Corresponding author&#46;"
          ]
        ]
      ]
    ]
    "titulosAlternativos" => array:1 [
      "es" => array:1 [
        "titulo" => "&#191;Cu&#225;ndo remitir al cardi&#243;logo al paciente con s&#237;ndrome de apneas-hipopneas durante el sue&#241;o&#63; Utilidad del NT-proBNP"
      ]
    ]
    "pdfFichero" => "main.pdf"
    "tienePdf" => true
    "fechaRecibido" => "2008-01-13"
    "fechaAceptado" => "2008-09-23"
    "PalabrasClave" => array:2 [
      "en" => array:1 [
        0 => array:4 [
          "clase" => "keyword"
          "titulo" => "Keywords"
          "identificador" => "xpalclavsec155663"
          "palabras" => array:3 [
            0 => "Sleep apnea-hypopnea syndrome"
            1 => "Doppler echocardiography"
            2 => "Natriuretic peptides"
          ]
        ]
      ]
      "es" => array:1 [
        0 => array:4 [
          "clase" => "keyword"
          "titulo" => "Palabras clave"
          "identificador" => "xpalclavsec155662"
          "palabras" => array:3 [
            0 => "S&#237;ndrome de apneas-hipopneas durante el sue&#241;o"
            1 => "Ecocardiograf&#237;a Doppler"
            2 => "P&#233;ptidos natriur&#233;ticos"
          ]
        ]
      ]
    ]
    "tieneResumen" => true
    "resumen" => array:2 [
      "en" => array:2 [
        "titulo" => "Abstract"
        "resumen" => "<span class="elsevierStyleSectionTitle">Introduction and objective</span><p class="elsevierStyleSimplePara elsevierViewall">When sleep apnea-hypopnea syndrome &#40;SAHS&#41; and cardiovascular disease occur concurrently&#44; prognosis is affected&#46; Echocardiography can detect structural cardiac abnormalities but using this technique in all patients would place a heavy burden on resources&#46; The objective of this study was to investigate whether the N-terminal fraction of brain natriuretic peptide &#40;NT-proBNP&#41; can be used as a marker for silent heart disease&#46;</p> <span class="elsevierStyleSectionTitle">Patients and methods</span><p class="elsevierStyleSimplePara elsevierViewall">NT-proBNP concentration was measured in the 114 consecutive patients with SAHS who underwent echocardiography before starting treatment&#46; Left and right ventricular systolic and diastolic function&#44; as well as structural abnormalities&#44; were studied&#46; Correlations between NT-proBNP concentration and the abnormalities detected were investigated&#46; A receiver operating characteristics &#40;ROC&#41; curve was plotted for NT-proBNP concentration and cardiac abnormalities&#46;</p> <span class="elsevierStyleSectionTitle">Results</span><p class="elsevierStyleSimplePara elsevierViewall">Data for 98 patients were finally analyzed&#46; NT-proBNP concentration was significantly correlated with ventricular septal thickness &#40;<span class="elsevierStyleItalic">r</span>&#61;0&#46;63&#41;&#44; posterior wall thickness &#40;<span class="elsevierStyleItalic">r</span>&#61;0&#46;45&#41;&#44; and left ventricular enddiastolic diameter &#40;<span class="elsevierStyleItalic">r</span>&#61;0&#46;51&#41; &#40;<span class="elsevierStyleItalic">P</span>&#60;&#46;0001 for all correlations&#41;&#46; The area under the ROC curve was significant &#40;0&#46;870&#59; 95&#37; confidence interval&#44; 0&#46;801-0&#46;939&#59; <span class="elsevierStyleItalic">P</span>&#60;&#46;0001&#41;&#46; Assuming that specificity would be more useful for clinical practice&#44; we calculated that NT-proBNP concentrations below 100 and 200 pg&#47;mL could rule out structural abnormalities with a reliability of 90&#37; and 100&#37;&#44; respectively&#46;</p> <span class="elsevierStyleSectionTitle">Conclusions</span><p class="elsevierStyleSimplePara elsevierViewall">NT-proBNP concentration was strongly correlated with echocardiographic abnormalities and so could be a useful tool for identifying patients who should be referred to the cardiologist&#46;</p>"
      ]
      "es" => array:2 [
        "titulo" => "Resumen"
        "resumen" => "<span class="elsevierStyleSectionTitle">Introducci&#243;n y objetivo</span><p class="elsevierStyleSimplePara elsevierViewall">La comorbilidad cardiovascular del s&#237;ndrome de apneas-hipopneas durante el sue&#241;o &#40;SAHS&#41; condiciona su pron&#243;stico&#46; La ecocardiograf&#237;a detecta alteraciones estructurales&#44; pero realizarla a todos los pacientes ocasionar&#237;a un gran consumo de recursos&#46; El objetivo de este trabajo ha sido estudiar el papel de la fracci&#243;n N-terminal del p&#233;ptido natriur&#233;tico cerebral &#40;NT-proBNP&#41; para detectar cardiopat&#237;a silente&#46;</p> <span class="elsevierStyleSectionTitle">Pacientes y m&#233;todos</span><p class="elsevierStyleSimplePara elsevierViewall">Se seleccion&#243; a 114 pacientes consecutivos con SAHS&#44; a quienes se les determin&#243; la concentraci&#243;n de NT-proBNP y se les realiz&#243; una ecocardiograf&#237;a antes de que recibieran tratamiento&#46; Se estudiaron las funciones sist&#243;lica y diast&#243;lica de ambos ventr&#237;culos&#44; as&#237; como las alteraciones morfol&#243;gicas&#46; Se analizaron las correlaciones existentes entre el NT-proBNP y las alteraciones halladas&#46; Se realiz&#243; una curva de eficacia diagn&#243;stica entre el NT-proBNP y la presencia de alteraci&#243;n card&#237;aca&#46;</p> <span class="elsevierStyleSectionTitle">Resultados</span><p class="elsevierStyleSimplePara elsevierViewall">Finalmente se estudi&#243; a 98 pacientes&#46; El NT-proBNP se correlacion&#243; de forma significativa &#40;p<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#44;0001&#41; con el grosor del tabique interventricular &#40;r<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;63&#41;&#44; con el de la pared posterior &#40;r<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;45&#41; y con el di&#225;metro telediast&#243;lico del ventr&#237;culo izquierdo &#40;r<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;51&#41;&#46; La curva de eficacia diagn&#243;stica calcul&#243; un &#225;rea bajo la curva significativa &#40;0&#44;870&#59; intervalo de confianza del 95&#37;&#44; 0&#44;801-0&#44;939&#59; p<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#44;0001&#41;&#46; Se consider&#243; m&#225;s &#250;til para la pr&#225;ctica cl&#237;nica el valor de especificidad&#46; As&#237;&#44; unos valores de NT-proBNP inferiores a 100 y 200 pg&#47;ml descartan que haya alteraciones morfol&#243;gicas card&#237;acas con una fiabilidad del 90 y el 100&#37;&#44; respectivamente&#46;</p> <span class="elsevierStyleSectionTitle">Conclusiones</span><p class="elsevierStyleSimplePara elsevierViewall">El NT-proBNP tiene correlaciones relevantes con la presencia de alteraciones ecocardiogr&#225;ficas y podr&#237;a ser una herramienta &#250;til para identificar a los pacientes que deber&#237;an ser remitidos para estudio cardiol&#243;gico&#46;</p>"
      ]
    ]
    "bibliografia" => array:2 [
      "titulo" => "References"
      "seccion" => array:1 [
        0 => array:1 [
          "bibliografiaReferencia" => array:28 [
            0 => array:3 [
              "identificador" => "bib1"
              "etiqueta" => "1&#46;"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Epidemiology of sleep-disordered breathing"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:1 [
                            0 => "S&#46; Redline"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:5 [
                        "tituloSerie" => "Semin Respir Crit Care Med"
                        "fecha" => "1998"
                        "volumen" => "19"
                        "paginaInicial" => "113"
                        "paginaFinal" => "122"
                      ]
                    ]
                  ]
                ]
              ]
            ]
            1 => array:3 [
              "identificador" => "bib2"
              "etiqueta" => "2&#46;"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "The occurrence of sleepdisordered breathing among middle-aged adults"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:6 [
                            0 => "T&#46; Young"
                            1 => "M&#46; Palta"
                            2 => "J&#46; Dempsey"
                            3 => "J&#46; Skatrud"
                            4 => "S&#46; Weber"
                            5 => "S&#46; Badr"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1056/NEJM199304293281704"
                      "Revista" => array:6 [
                        "tituloSerie" => "N Engl J Med"
                        "fecha" => "1993"
                        "volumen" => "328"
                        "paginaInicial" => "1230"
                        "paginaFinal" => "1235"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/8464434"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            2 => array:3 [
              "identificador" => "bib3"
              "etiqueta" => "3&#46;"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:1 [
                      "autores" => array:1 [
                        0 => array:3 [
                          "colaboracion" => "The Management Committee of EU COST ACTION B26"
                          "etal" => false
                          "autores" => array:2 [
                            0 => "W&#46;T&#46; McNicholas"
                            1 => "M&#46;R&#46; Bonsignore"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1183/09031936.00027406"
                      "Revista" => array:6 [
                        "tituloSerie" => "Eur Respir J"
                        "fecha" => "2007"
                        "volumen" => "29"
                        "paginaInicial" => "156"
                        "paginaFinal" => "178"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/17197482"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            3 => array:3 [
              "identificador" => "bib4"
              "etiqueta" => "4&#46;"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Sleepdisordered breathing and cardiovascular disease&#58; cross-sectional results of the Sleep Heart Health Study"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [
                            0 => "E&#46; Shahar"
                            1 => "C&#46;W&#46; Whitney"
                            2 => "S&#46; Redline"
                            3 => "E&#46;T&#46; Lee"
                            4 => "A&#46;B&#46; Newman"
                            5 => "F&#46;J&#46; Nieto"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1164/ajrccm.163.1.2001008"
                      "Revista" => array:7 [
                        "tituloSerie" => "Am J Respir Crit Care Med"
                        "fecha" => "2001"
                        "volumen" => "163"
                        "paginaInicial" => "19"
                        "paginaFinal" => "25"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/11208620"
                            "web" => "Medline"
                          ]
                        ]
                        "itemHostRev" => array:3 [
                          "pii" => "S0034935612000059"
                          "estado" => "S300"
                          "issn" => "00349356"
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            4 => array:3 [
              "identificador" => "bib5"
              "etiqueta" => "5&#46;"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Deleterious effects of sleep-disordered breathing on the heart and vascular system"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:2 [
                            0 => "H&#46;E&#46; Dincer"
                            1 => "W&#46; O&#8217;Neill"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1159/000089814"
                      "Revista" => array:6 [
                        "tituloSerie" => "Respiration"
                        "fecha" => "2006"
                        "volumen" => "73"
                        "paginaInicial" => "124"
                        "paginaFinal" => "130"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/16293956"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            5 => array:3 [
              "identificador" => "bib6"
              "etiqueta" => "6&#46;"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "P&#233;ptidos natriur&#233;ticos en insuficiencia card&#237;aca"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:2 [
                            0 => "L&#46; Almenar Bonet"
                            1 => "L&#46; Mart&#237;nez-Dolz"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:5 [
                        "tituloSerie" => "Rev Esp Cardiol"
                        "fecha" => "2006"
                        "numero" => "6 Supl"
                        "paginaInicial" => "15F"
                        "paginaFinal" => "26F"
                      ]
                    ]
                  ]
                ]
              ]
            ]
            6 => array:3 [
              "identificador" => "bib7"
              "etiqueta" => "7&#46;"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Evaluation of a portable device for diagnosing the sleep apnoea&#47;hypopnoea syndrome"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [
                            0 => "K&#46; Dingli"
                            1 => "E&#46;L&#46; Coleman"
                            2 => "M&#46; Vennelle"
                            3 => "S&#46;P&#46; Finch"
                            4 => "P&#46;K&#46; Wraith"
                            5 => "T&#46;W&#46; McKay"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "Eur Respir J"
                        "fecha" => "2003"
                        "volumen" => "21"
                        "paginaInicial" => "253"
                        "paginaFinal" => "259"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/12608438"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            7 => array:3 [
              "identificador" => "bib8"
              "etiqueta" => "8&#46;"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:1 [
                      "autores" => array:1 [
                        0 => array:2 [
                          "colaboracion" => "Consenso Espa&#241;ol sobre el s&#237;ndrome de apneas-hipopneas del sue&#241;o &#40;SAHS&#41;&#46; Grupo Espa&#241;ol de Sue&#241;o"
                          "etal" => false
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:5 [
                        "tituloSerie" => "Arch Bronconeumol"
                        "fecha" => "2005"
                        "volumen" => "41"
                        "paginaInicial" => "51"
                        "paginaFinal" => "67"
                      ]
                    ]
                  ]
                ]
              ]
            ]
            8 => array:3 [
              "identificador" => "bib9"
              "etiqueta" => "9&#46;"
              "referencia" => array:1 [
                0 => array:1 [
                  "referenciaCompleta" => "Chobanian AV&#44; Bakris GL&#44; Black HR&#44; Cushman WC&#44; Green LA&#44; Izzo JL&#44; et al&#46; Seventh report of the Joint National Committee in Prevention&#44; Detection&#44; Evaluation and Treatment of High Blood Pressure&#46; Hypertension&#46; 2003&#59;42&#58;1206-52&#46;"
                ]
              ]
            ]
            9 => array:3 [
              "identificador" => "bib10"
              "etiqueta" => "10&#46;"
              "referencia" => array:1 [
                0 => array:1 [
                  "referenciaCompleta" => "Global Initiative for Chronic Obstructive Lung Disease&#46; Update 2007&#46; Available from&#58; <a class="elsevierStyleInterRef" href="http://www.goldcopd.com/">http&#58;&#47;&#47;www&#46;goldcopd&#46;com</a>"
                ]
              ]
            ]
            10 => array:3 [
              "identificador" => "bib11"
              "etiqueta" => "11&#46;"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Mortality risk factors in sleep apnoea&#58; a matched casecontrol study"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:3 [
                            0 => "P&#46; Lavie"
                            1 => "P&#46; Herer"
                            2 => "L&#46; Lavie"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1111/j.1365-2869.2007.00578.x"
                      "Revista" => array:6 [
                        "tituloSerie" => "J Sleep Res"
                        "fecha" => "2007"
                        "volumen" => "16"
                        "paginaInicial" => "128"
                        "paginaFinal" => "134"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/17309772"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            11 => array:3 [
              "identificador" => "bib12"
              "etiqueta" => "12&#46;"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Left ventricular hypertrophy independent of hypertension in patients with obstructive sleep apnoea"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:3 [
                            0 => "J&#46; Hedner"
                            1 => "H&#46; Ejnell"
                            2 => "K&#46; Caidahl"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "J Hypertens"
                        "fecha" => "1990"
                        "volumen" => "8"
                        "paginaInicial" => "941"
                        "paginaFinal" => "946"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/2174947"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            12 => array:3 [
              "identificador" => "bib13"
              "etiqueta" => "13&#46;"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Left ventricular systolic dysfunction in patients with obstructive sleep apnea syndrome"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:6 [
                            0 => "J&#46;P&#46; Laaban"
                            1 => "S&#46; Pascal-Sebaouns"
                            2 => "E&#46; Bloch"
                            3 => "E&#46; Orvoen-Frija"
                            4 => "J&#46;M&#46; Oppert"
                            5 => "G&#46; Huchon"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "Chest"
                        "fecha" => "2002"
                        "volumen" => "122"
                        "paginaInicial" => "1133"
                        "paginaFinal" => "1138"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/12377833"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            13 => array:3 [
              "identificador" => "bib14"
              "etiqueta" => "14&#46;"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Severe obstructive sleep apnea is associated with left ventricular diastolic dysfunction"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [
                            0 => "J&#46;W&#46; Fung"
                            1 => "T&#46;S&#46; Li"
                            2 => "D&#46;K&#46; Choy"
                            3 => "W&#46; Yip"
                            4 => "F&#46;W&#46; Ko"
                            5 => "J&#46;E&#46; Sandersen"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "Chest"
                        "fecha" => "2002"
                        "volumen" => "121"
                        "paginaInicial" => "422"
                        "paginaFinal" => "429"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/11834652"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            14 => array:3 [
              "identificador" => "bib15"
              "etiqueta" => "15&#46;"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "The prognostic value of B-type natriuretic peptide in patients with acute coronary syndromes"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [
                            0 => "J&#46;A&#46; de Lemos"
                            1 => "D&#46;A&#46; Morrow"
                            2 => "J&#46;H&#46; Bentley"
                            3 => "T&#46; Omland"
                            4 => "M&#46;S&#46; Sabatine"
                            5 => "C&#46;H&#46; McCabe"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1056/NEJMoa011053"
                      "Revista" => array:6 [
                        "tituloSerie" => "N Engl J Med"
                        "fecha" => "2001"
                        "volumen" => "345"
                        "paginaInicial" => "1014"
                        "paginaFinal" => "1021"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/11586953"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            15 => array:3 [
              "identificador" => "bib16"
              "etiqueta" => "16&#46;"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "N-terminal probrain natriuretic peptide predicts cardiovascular events in patients with hypertension and left ventricular hypertrophy&#58; a LIFE study"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [
                            0 => "M&#46;H&#46; Olsen"
                            1 => "K&#46; Wachtell"
                            2 => "C&#46; Tuxen"
                            3 => "E&#46; Fossum"
                            4 => "L&#46;E&#46; Bang"
                            5 => "C&#46; Hall"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "J Hypertens"
                        "fecha" => "2004"
                        "volumen" => "22"
                        "paginaInicial" => "1597"
                        "paginaFinal" => "1604"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/15257184"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            16 => array:3 [
              "identificador" => "bib17"
              "etiqueta" => "17&#46;"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "N-terminal pro-brain natriuretic peptide for detection of cardiovascular stress in patients with obstructive sleep apnea syndrome"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [
                            0 => "E&#46; Vartany"
                            1 => "M&#46; Imevbore"
                            2 => "M&#46; O&#8217;Malley"
                            3 => "C&#46; Manfredi"
                            4 => "C&#46; Pasquarella"
                            5 => "L&#46; Scinto"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1111/j.1365-2869.2006.00551.x"
                      "Revista" => array:6 [
                        "tituloSerie" => "J Sleep Res"
                        "fecha" => "2006"
                        "volumen" => "15"
                        "paginaInicial" => "424"
                        "paginaFinal" => "429"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/17118099"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            17 => array:3 [
              "identificador" => "bib18"
              "etiqueta" => "18&#46;"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Alteraciones ecocardiogr&#225;ficas asociadas al s&#237;ndrome de apnea-hipopnea del sue&#241;o en funci&#243;n de su gravedad"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:6 [
                            0 => "J&#46;A&#46; Moro"
                            1 => "L&#46; Almenar"
                            2 => "E&#46; Fern&#225;ndez-Fabrellas"
                            3 => "S&#46; Ponce"
                            4 => "R&#46; Blanquer"
                            5 => "A&#46; Salvador"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "Rev Esp Cardiol"
                        "fecha" => "2007"
                        "volumen" => "60"
                        "paginaInicial" => "589"
                        "paginaFinal" => "596"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/17580047"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            18 => array:3 [
              "identificador" => "bib19"
              "etiqueta" => "19&#46;"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "An&#225;lisis de las alteraciones ecocardiogr&#225;ficas del s&#237;ndrome de apnea e hipopnea del sue&#241;o y su modificaci&#243;n con la presencia de hipertensi&#243;n arterial"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:6 [
                            0 => "J&#46;A&#46; Moro"
                            1 => "L&#46; Almenar"
                            2 => "E&#46; Fern&#225;ndez-Fabrellas"
                            3 => "S&#46; Ponce"
                            4 => "R&#46; Blanquer"
                            5 => "A&#46; Salvador"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "Rev Esp Cardiol"
                        "fecha" => "2008"
                        "volumen" => "61"
                        "paginaInicial" => "49"
                        "paginaFinal" => "57"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/18221691"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            19 => array:3 [
              "identificador" => "bib20"
              "etiqueta" => "20&#46;"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "The nocturnal secretion of cardiac natriuretic peptides during obstructive sleep apnoea and its response to therapy with nasal continuous positive airway pressure"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [
                            0 => "H&#46; Kita"
                            1 => "M&#46; Ohi"
                            2 => "K&#46; Chin"
                            3 => "T&#46; Noguchi"
                            4 => "N&#46; Otsuka"
                            5 => "T&#46; Tsuboi"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "J Sleep Res"
                        "fecha" => "1998"
                        "volumen" => "7"
                        "paginaInicial" => "199"
                        "paginaFinal" => "207"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/9785275"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            20 => array:3 [
              "identificador" => "bib21"
              "etiqueta" => "21&#46;"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Plasma brain natriuretic peptide in obstructive sleep apnea"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:6 [
                            0 => "A&#46; Svatikova"
                            1 => "A&#46;S&#46; Shamsuzzaman"
                            2 => "R&#46; Wolk"
                            3 => "B&#46;G&#46; Phillips"
                            4 => "L&#46;J&#46; Olson"
                            5 => "V&#46;K&#46; Somers"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1016/j.amjcard.2004.05.010"
                      "Revista" => array:6 [
                        "tituloSerie" => "Am J Cardiol"
                        "fecha" => "2004"
                        "volumen" => "94"
                        "paginaInicial" => "529"
                        "paginaFinal" => "532"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/15325948"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            21 => array:3 [
              "identificador" => "bib22"
              "etiqueta" => "22&#46;"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Utility of B-natriuretic peptide in detecting diastolic dysfunction&#58; comparison with Doppler velocity recordings"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [
                            0 => "E&#46; Lubien"
                            1 => "A&#46; deMaria"
                            2 => "P&#46; Krishnaswamy"
                            3 => "P&#46; Copton"
                            4 => "J&#46; Koon"
                            5 => "R&#46; Kazanegra"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "Circulation"
                        "fecha" => "2002"
                        "volumen" => "105"
                        "paginaInicial" => "595"
                        "paginaFinal" => "601"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/11827925"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            22 => array:3 [
              "identificador" => "bib23"
              "etiqueta" => "23&#46;"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "NTproBNP in obstructive sleep apnea syndrome is decreased by nasal continuous positive airway pressure"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [
                            0 => "S&#46; Tasci"
                            1 => "R&#46; Manka"
                            2 => "S&#46; Scholtyssek"
                            3 => "S&#46; Lentini"
                            4 => "C&#46; Troatz"
                            5 => "B&#46; Stoffel-Wagner"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1007/s00392-006-0315-9"
                      "Revista" => array:6 [
                        "tituloSerie" => "Clin Res Cardiol"
                        "fecha" => "2006"
                        "volumen" => "95"
                        "paginaInicial" => "23"
                        "paginaFinal" => "30"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/16598442"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            23 => array:3 [
              "identificador" => "bib24"
              "etiqueta" => "24&#46;"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "NTproBNP is not elevated in patients with obstructive sleep apnea"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [
                            0 => "R-H&#46; H&#252;bner"
                            1 => "N&#46;E&#46; El Mokhtari"
                            2 => "S&#46; Freitag"
                            3 => "T&#46; Rausche"
                            4 => "R&#46; G&#246;der"
                            5 => "A&#46; Tiroke"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1016/j.rmed.2007.07.023"
                      "Revista" => array:6 [
                        "tituloSerie" => "Respir Med"
                        "fecha" => "2008"
                        "volumen" => "102"
                        "paginaInicial" => "134"
                        "paginaFinal" => "142"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/17892929"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            24 => array:3 [
              "identificador" => "bib25"
              "etiqueta" => "25&#46;"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Prevalence of left ventricular diastolic dysfunction in the community&#46; Results from a Doppler echocardiographic-based survey of a population sample"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [
                            0 => "M&#46; Fischer"
                            1 => "A&#46; Baessler"
                            2 => "H&#46;W&#46; Hense"
                            3 => "C&#46; Hengstemberg"
                            4 => "M&#46; Muscholl"
                            5 => "S&#46; Holmer"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "Eur Heart J"
                        "fecha" => "2003"
                        "volumen" => "24"
                        "paginaInicial" => "320"
                        "paginaFinal" => "328"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/12581679"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            25 => array:3 [
              "identificador" => "bib26"
              "etiqueta" => "26&#46;"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Practice parameters for the indications for polysomnography and related procedures&#58; an update for 2005"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [
                            0 => "C&#46;A&#46; Kushida"
                            1 => "M&#46;R&#46; Littner"
                            2 => "T&#46; Morgenthaler"
                            3 => "C&#46;A&#46; Alessi"
                            4 => "D&#46; Bailey"
                            5 => "J&#46; Coleman Jr"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "Sleep"
                        "fecha" => "2005"
                        "volumen" => "28"
                        "paginaInicial" => "499"
                        "paginaFinal" => "521"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/16171294"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            26 => array:3 [
              "identificador" => "bib27"
              "etiqueta" => "27&#46;"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Diagnosis and initial management of obstructive sleep apnea without polysomnography&#46; A randomized validation study"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:4 [
                            0 => "A&#46;T&#46; Mulgrew"
                            1 => "N&#46; Fox"
                            2 => "N&#46;Y&#46; Ayas"
                            3 => "F&#46; Ryan"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:7 [
                        "tituloSerie" => "Ann Intern Med"
                        "fecha" => "2007"
                        "volumen" => "146"
                        "paginaInicial" => "157"
                        "paginaFinal" => "166"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/17283346"
                            "web" => "Medline"
                          ]
                        ]
                        "itemHostRev" => array:3 [
                          "pii" => "S147330991170007X"
                          "estado" => "S300"
                          "issn" => "14733099"
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            27 => array:3 [
              "identificador" => "bib28"
              "etiqueta" => "28&#46;"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Obstructive sleep apnea syndrome&#58; more insights on structural and functional cardiac alterations&#44; and the effects of treatment with continuous positive airway pressure"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [
                            0 => "B&#46; Shivalkar"
                            1 => "C&#46; van de Heyning"
                            2 => "M&#46; Kerremans"
                            3 => "D&#46; Rinkevich"
                            4 => "J&#46; Verbraecken"
                            5 => "W&#46; de Backer"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1016/j.jacc.2005.11.054"
                      "Revista" => array:6 [
                        "tituloSerie" => "J Am Coll Cardiol"
                        "fecha" => "2006"
                        "volumen" => "47"
                        "paginaInicial" => "1433"
                        "paginaFinal" => "1439"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/16580533"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
          ]
        ]
      ]
    ]
  ]
  "idiomaDefecto" => "en"
  "url" => "/15792129/0000004500000004/v1_201305150418/S1579212909710171/v1_201305150418/en/main.assets"
  "Apartado" => array:4 [
    "identificador" => "9374"
    "tipo" => "SECCION"
    "en" => array:2 [
      "titulo" => "Original Articles"
      "idiomaDefecto" => true
    ]
    "idiomaDefecto" => "en"
  ]
  "PDF" => "https://static.elsevier.es/multimedia/15792129/0000004500000004/v1_201305150418/S1579212909710171/v1_201305150418/en/main.pdf?idApp=UINPBA00003Z&text.app=https://www.archbronconeumol.org/"
  "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S1579212909710171?idApp=UINPBA00003Z"
]
Share
Journal Information
Vol. 45. Issue 4.
Pages 173-180 (April 2009)
Share
Share
Download PDF
More article options
Vol. 45. Issue 4.
Pages 173-180 (April 2009)
Original article
Full text access
Usefulness of the N-Terminal Fraction of Brain Natriuretic Peptide for Deciding When to Refer Patients With Sleep Apnea-Hypopnea Syndrome to the Cardiologist
¿Cuándo remitir al cardiólogo al paciente con síndrome de apneas-hipopneas durante el sueño? Utilidad del NT-proBNP
Visits
4187
Estrella Fernández Fabrellasa,
Corresponding author
fernandez_est@gva.es

Corresponding author.
, Luis Almenar Bonetb, Silvia Ponce Péreza, José Antonio Moro Lópezb, Rafael Blanquer Olivasa, Antonio Salvador Sanzc
a Servicio de Neumología, Hospital Universitario Dr. Peset, Valencia, Spain
b Servicio de Cardiología, Hospital Universitario La Fe, Valencia, Spain
c Servicio de Cardiología, Hospital Universitario Dr. Peset, Valencia, Spain
This item has received
Article information
Abstract
Bibliography
Download PDF
Statistics
Abstract
Introduction and objective

When sleep apnea-hypopnea syndrome (SAHS) and cardiovascular disease occur concurrently, prognosis is affected. Echocardiography can detect structural cardiac abnormalities but using this technique in all patients would place a heavy burden on resources. The objective of this study was to investigate whether the N-terminal fraction of brain natriuretic peptide (NT-proBNP) can be used as a marker for silent heart disease.

Patients and methods

NT-proBNP concentration was measured in the 114 consecutive patients with SAHS who underwent echocardiography before starting treatment. Left and right ventricular systolic and diastolic function, as well as structural abnormalities, were studied. Correlations between NT-proBNP concentration and the abnormalities detected were investigated. A receiver operating characteristics (ROC) curve was plotted for NT-proBNP concentration and cardiac abnormalities.

Results

Data for 98 patients were finally analyzed. NT-proBNP concentration was significantly correlated with ventricular septal thickness (r=0.63), posterior wall thickness (r=0.45), and left ventricular enddiastolic diameter (r=0.51) (P<.0001 for all correlations). The area under the ROC curve was significant (0.870; 95% confidence interval, 0.801-0.939; P<.0001). Assuming that specificity would be more useful for clinical practice, we calculated that NT-proBNP concentrations below 100 and 200 pg/mL could rule out structural abnormalities with a reliability of 90% and 100%, respectively.

Conclusions

NT-proBNP concentration was strongly correlated with echocardiographic abnormalities and so could be a useful tool for identifying patients who should be referred to the cardiologist.

Keywords:
Sleep apnea-hypopnea syndrome
Doppler echocardiography
Natriuretic peptides
Resumen
Introducción y objetivo

La comorbilidad cardiovascular del síndrome de apneas-hipopneas durante el sueño (SAHS) condiciona su pronóstico. La ecocardiografía detecta alteraciones estructurales, pero realizarla a todos los pacientes ocasionaría un gran consumo de recursos. El objetivo de este trabajo ha sido estudiar el papel de la fracción N-terminal del péptido natriurético cerebral (NT-proBNP) para detectar cardiopatía silente.

Pacientes y métodos

Se seleccionó a 114 pacientes consecutivos con SAHS, a quienes se les determinó la concentración de NT-proBNP y se les realizó una ecocardiografía antes de que recibieran tratamiento. Se estudiaron las funciones sistólica y diastólica de ambos ventrículos, así como las alteraciones morfológicas. Se analizaron las correlaciones existentes entre el NT-proBNP y las alteraciones halladas. Se realizó una curva de eficacia diagnóstica entre el NT-proBNP y la presencia de alteración cardíaca.

Resultados

Finalmente se estudió a 98 pacientes. El NT-proBNP se correlacionó de forma significativa (p<0,0001) con el grosor del tabique interventricular (r=0,63), con el de la pared posterior (r=0,45) y con el diámetro telediastólico del ventrículo izquierdo (r=0,51). La curva de eficacia diagnóstica calculó un área bajo la curva significativa (0,870; intervalo de confianza del 95%, 0,801-0,939; p<0,0001). Se consideró más útil para la práctica clínica el valor de especificidad. Así, unos valores de NT-proBNP inferiores a 100 y 200 pg/ml descartan que haya alteraciones morfológicas cardíacas con una fiabilidad del 90 y el 100%, respectivamente.

Conclusiones

El NT-proBNP tiene correlaciones relevantes con la presencia de alteraciones ecocardiográficas y podría ser una herramienta útil para identificar a los pacientes que deberían ser remitidos para estudio cardiológico.

Palabras clave:
Síndrome de apneas-hipopneas durante el sueño
Ecocardiografía Doppler
Péptidos natriuréticos
Full text is only aviable in PDF
References
[1.]
S. Redline.
Epidemiology of sleep-disordered breathing.
Semin Respir Crit Care Med, 19 (1998), pp. 113-122
[2.]
T. Young, M. Palta, J. Dempsey, J. Skatrud, S. Weber, S. Badr.
The occurrence of sleepdisordered breathing among middle-aged adults.
N Engl J Med, 328 (1993), pp. 1230-1235
[3.]
W.T. McNicholas, M.R. Bonsignore, The Management Committee of EU COST ACTION B26.
Eur Respir J, 29 (2007), pp. 156-178
[4.]
E. Shahar, C.W. Whitney, S. Redline, E.T. Lee, A.B. Newman, F.J. Nieto, et al.
Sleepdisordered breathing and cardiovascular disease: cross-sectional results of the Sleep Heart Health Study.
Am J Respir Crit Care Med, 163 (2001), pp. 19-25
[5.]
H.E. Dincer, W. O’Neill.
Deleterious effects of sleep-disordered breathing on the heart and vascular system.
Respiration, 73 (2006), pp. 124-130
[6.]
L. Almenar Bonet, L. Martínez-Dolz.
Péptidos natriuréticos en insuficiencia cardíaca.
Rev Esp Cardiol, (2006), pp. 15F-26F
[7.]
K. Dingli, E.L. Coleman, M. Vennelle, S.P. Finch, P.K. Wraith, T.W. McKay, et al.
Evaluation of a portable device for diagnosing the sleep apnoea/hypopnoea syndrome.
Eur Respir J, 21 (2003), pp. 253-259
[8.]
Consenso Español sobre el síndrome de apneas-hipopneas del sueño (SAHS). Grupo Español de Sueño.
Arch Bronconeumol, 41 (2005), pp. 51-67
[9.]
Chobanian AV, Bakris GL, Black HR, Cushman WC, Green LA, Izzo JL, et al. Seventh report of the Joint National Committee in Prevention, Detection, Evaluation and Treatment of High Blood Pressure. Hypertension. 2003;42:1206-52.
[10.]
Global Initiative for Chronic Obstructive Lung Disease. Update 2007. Available from: http://www.goldcopd.com
[11.]
P. Lavie, P. Herer, L. Lavie.
Mortality risk factors in sleep apnoea: a matched casecontrol study.
J Sleep Res, 16 (2007), pp. 128-134
[12.]
J. Hedner, H. Ejnell, K. Caidahl.
Left ventricular hypertrophy independent of hypertension in patients with obstructive sleep apnoea.
J Hypertens, 8 (1990), pp. 941-946
[13.]
J.P. Laaban, S. Pascal-Sebaouns, E. Bloch, E. Orvoen-Frija, J.M. Oppert, G. Huchon.
Left ventricular systolic dysfunction in patients with obstructive sleep apnea syndrome.
Chest, 122 (2002), pp. 1133-1138
[14.]
J.W. Fung, T.S. Li, D.K. Choy, W. Yip, F.W. Ko, J.E. Sandersen, et al.
Severe obstructive sleep apnea is associated with left ventricular diastolic dysfunction.
Chest, 121 (2002), pp. 422-429
[15.]
J.A. de Lemos, D.A. Morrow, J.H. Bentley, T. Omland, M.S. Sabatine, C.H. McCabe, et al.
The prognostic value of B-type natriuretic peptide in patients with acute coronary syndromes.
N Engl J Med, 345 (2001), pp. 1014-1021
[16.]
M.H. Olsen, K. Wachtell, C. Tuxen, E. Fossum, L.E. Bang, C. Hall, et al.
N-terminal probrain natriuretic peptide predicts cardiovascular events in patients with hypertension and left ventricular hypertrophy: a LIFE study.
J Hypertens, 22 (2004), pp. 1597-1604
[17.]
E. Vartany, M. Imevbore, M. O’Malley, C. Manfredi, C. Pasquarella, L. Scinto, et al.
N-terminal pro-brain natriuretic peptide for detection of cardiovascular stress in patients with obstructive sleep apnea syndrome.
J Sleep Res, 15 (2006), pp. 424-429
[18.]
J.A. Moro, L. Almenar, E. Fernández-Fabrellas, S. Ponce, R. Blanquer, A. Salvador.
Alteraciones ecocardiográficas asociadas al síndrome de apnea-hipopnea del sueño en función de su gravedad.
Rev Esp Cardiol, 60 (2007), pp. 589-596
[19.]
J.A. Moro, L. Almenar, E. Fernández-Fabrellas, S. Ponce, R. Blanquer, A. Salvador.
Análisis de las alteraciones ecocardiográficas del síndrome de apnea e hipopnea del sueño y su modificación con la presencia de hipertensión arterial.
Rev Esp Cardiol, 61 (2008), pp. 49-57
[20.]
H. Kita, M. Ohi, K. Chin, T. Noguchi, N. Otsuka, T. Tsuboi, et al.
The nocturnal secretion of cardiac natriuretic peptides during obstructive sleep apnoea and its response to therapy with nasal continuous positive airway pressure.
J Sleep Res, 7 (1998), pp. 199-207
[21.]
A. Svatikova, A.S. Shamsuzzaman, R. Wolk, B.G. Phillips, L.J. Olson, V.K. Somers.
Plasma brain natriuretic peptide in obstructive sleep apnea.
Am J Cardiol, 94 (2004), pp. 529-532
[22.]
E. Lubien, A. deMaria, P. Krishnaswamy, P. Copton, J. Koon, R. Kazanegra, et al.
Utility of B-natriuretic peptide in detecting diastolic dysfunction: comparison with Doppler velocity recordings.
Circulation, 105 (2002), pp. 595-601
[23.]
S. Tasci, R. Manka, S. Scholtyssek, S. Lentini, C. Troatz, B. Stoffel-Wagner, et al.
NTproBNP in obstructive sleep apnea syndrome is decreased by nasal continuous positive airway pressure.
Clin Res Cardiol, 95 (2006), pp. 23-30
[24.]
R-H. Hübner, N.E. El Mokhtari, S. Freitag, T. Rausche, R. Göder, A. Tiroke, et al.
NTproBNP is not elevated in patients with obstructive sleep apnea.
Respir Med, 102 (2008), pp. 134-142
[25.]
M. Fischer, A. Baessler, H.W. Hense, C. Hengstemberg, M. Muscholl, S. Holmer, et al.
Prevalence of left ventricular diastolic dysfunction in the community. Results from a Doppler echocardiographic-based survey of a population sample.
Eur Heart J, 24 (2003), pp. 320-328
[26.]
C.A. Kushida, M.R. Littner, T. Morgenthaler, C.A. Alessi, D. Bailey, J. Coleman Jr, et al.
Practice parameters for the indications for polysomnography and related procedures: an update for 2005.
Sleep, 28 (2005), pp. 499-521
[27.]
A.T. Mulgrew, N. Fox, N.Y. Ayas, F. Ryan.
Diagnosis and initial management of obstructive sleep apnea without polysomnography. A randomized validation study.
Ann Intern Med, 146 (2007), pp. 157-166
[28.]
B. Shivalkar, C. van de Heyning, M. Kerremans, D. Rinkevich, J. Verbraecken, W. de Backer, et al.
Obstructive sleep apnea syndrome: more insights on structural and functional cardiac alterations, and the effects of treatment with continuous positive airway pressure.
J Am Coll Cardiol, 47 (2006), pp. 1433-1439
Copyright © 2009. Sociedad Española de Neumología y Cirugía Torácica
Archivos de Bronconeumología
Article options
Tools

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