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IgA deficiency: values below the thresholds established by the laboratory for age or < 0.2<span class="elsevierStyleHsp" style=""></span>g/L in children aged more than 3 years.</p> <p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">2. Ask the family not to initiate a low-gluten or gluten-free diet before the patient is evaluated in the Paediatric Gastroenterology department.</p> <p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">3. Convey the message that regardless of how the diagnosis is reached, treatment with a gluten-free diet is life-long.</p> <p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">4. In case of a positive anti-tTG IgA test with a low titre, confirm sufficient dietary gluten intake. Consider repeating serological tests adding the EMA test.</p> <p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">5. Consider: a. revision of biopsy results; b. false positive anti-tTG result and testing for EMA (if positive EMA<span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>potential CD); c. additional tests (HLA, anti-tTG deposits, cytometry, etc); d. consider followup and retesting ensuring normal gluten intake; e. assess the relevance of symptoms.</p> <p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">tTG<span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>tissue transglutaminase antibodies, EMA<span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>endomysial antibodies; DGP<span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>deamidated gliadin peptide antibodies, ULN<span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>upper limit of normal.</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "Enriqueta Román Riechmann, Gemma Castillejo de Villasante, M. 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"d" "identificador" => "aff0020" ] 4 => array:3 [ "entidad" => "Servicio de Pediatría, Cardiología Infantil, Hospital Universitario Príncipe de Asturias, Alcalá de Henares, Madrid, Spain" "etiqueta" => "e" "identificador" => "aff0025" ] 5 => array:3 [ "entidad" => "Cardiología Infantil, Hospital Universitari Vall d'Hebron, Barcelona, Spain" "etiqueta" => "f" "identificador" => "aff0030" ] 6 => array:3 [ "entidad" => "Unidad de Arritmias, Cardiopatías Familiares y Muerte Súbita, Hospital Sant Joan de Déu, Barcelona, Spain" "etiqueta" => "g" "identificador" => "aff0035" ] 7 => array:3 [ "entidad" => "Departamento de Ciencias Médicas, Facultad de Medicina, Universidad de Girona, Spain" "etiqueta" => "h" "identificador" => "aff0040" ] 8 => array:3 [ "entidad" => "Recerca Cardiovascular, Institut de Recerca, Fundació Sant Joan de Déu, Barcelona, Spain" "etiqueta" => "i" "identificador" => "aff0045" ] 9 => array:3 [ "entidad" => "Guard-Heart, European Reference Center, Spain" "etiqueta" => 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con cardiopatias conocidas y en la población pediatrica general, posicionamiento de la Asociación Española de Pediatria" ] ] "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Attention-deficit hyperactivity disorder (ADHD) is a neurodevelopmental disorder usually with onset in childhood characterised by a persistent pattern of symptoms of inattention, hyperactivity and impulsivity (DSM-5).<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> Broadly speaking, in children and adolescents pharmacological treatment is only recommended when cognitive-behavioural psychotherapy has failed or in case of moderate to severe symptoms.</p><p id="par0010" class="elsevierStylePara elsevierViewall">The drugs authorised in Spain for treatment of ADHD are methylphenidate, lisdexamfetamine, atomoxetine and guanfacine. Due to the potential cardiovascular adverse effects of these drugs, mainly increases in blood pressure (BP) and heart rate, their use in patients with known or undiagnosed congenital heart defects (CHDs) is controversial.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Objective</span><p id="par0015" class="elsevierStylePara elsevierViewall">To develop a consensus document of the Sociedad Española de Cardiología Pediátrica y Cardiopatías Congénitas (Spanish Association of Paediatric Cardiology and Congenital Heart Disease, SECPCC) in collaboration with experts from other societies and agencies useful to paediatric cardiologists and physicians managing children and adolescents with ADHD.</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Methodology</span><p id="par0020" class="elsevierStylePara elsevierViewall">Analysis of the scientific literature and international clinical practice guidelines, summary of product characteristics of drugs authorised by the Agencia Española del Medicamento y Productos Sanitarios (Spanish Agency of Medicines and Medical Devices) and the Guideline of the Spanish Ministry of Health.</p><p id="par0025" class="elsevierStylePara elsevierViewall">To this end, a working group was formed consisting of a coordinator, members of the Working Group on Clinical Cardiology and the Group on Arrhythmias of the SECPCC with relevant clinical experience on the subject. This group developed an initial version of the document that was revised by an external group of experts (<a class="elsevierStyleCrossRef" href="#sec0075">Appendix A</a>) and an internal group of experts of the SECPCC (<a class="elsevierStyleCrossRef" href="#sec0080">Appendix B</a>), eventually reaching a consensus on the final document.</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Recommendations of the Sociedad Española de Cardiología Pediátrica y Cardiopatías Congénitas on the cardiovascular evaluation preceding treatment</span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">In children and adolescents with unknown cardiovascular disease</span><p id="par0030" class="elsevierStylePara elsevierViewall">Based on the current literature,<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> and in agreement with the main international guidelines,<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">3–8</span></a> the SECPCC recommends performing a cardiovascular evaluation before initiating treatment for ADHD in children and adolescents with unknown cardiovascular disease by means of a history taking and physical examination. Routine performance of an electrocardiogram (ECG) is not recommended, but should be reserved for selected cases as described below.</p><p id="par0035" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">History taking:</span> emphasis should be placed on the identification of known heart diseases and the presence of warning signs such as syncope suggestive of a cardiac origin (<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>) or from a non-vasovagal cause, chest pain suggestive of a cardiac origin, palpitations or shortness of breath on exertion. It is also important to ask about the history of sudden death in relatives aged less than 40 years or the presence of heart disease in the family, including hypertrophic cardiomyopathy, long QT syndrome or other channelopathies, Wolff-Parkinson-White syndrome, bicuspid aortic valve, coarctation of the aorta, arterial hypertension (HTN) at an early age or renal disease. In case of warning signs or a reasonable suspicion of heart disease, the patient should be referred to a cardiologist before initiating pharmacological treatment.</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0040" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Physical examination:</span> It should include measurement of the weight and height of the patient. Particular attention should be paid to the detection of murmurs during auscultation and the identification of features of Marfan syndrome, such as tall final height relative to the predicted target height, tall and slender build, pectus carinatum or excavatum, long and narrow face, long and slender fingers, limited extension of the elbow or scoliosis, among others. In case of detection of a murmur or features of Marfan syndrome, the patient must be referred to a cardiologist prior to initiation of pharmacotherapy. Since several studies have found evidence of mild increases in heart rate and BP (both systolic and diastolic) in association with the use of stimulant and nonstimulant drugs for treatment of ADHD,<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a> we recommend including measurement of the heart rate and BP in the initial assessment prior to initiation of pharmacotherapy, with subsequent monitoring of both variables every 3–6 months.</p><p id="par0045" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Blood pressure:</span> we recommend adherence to the protocol for measurement of BP proposed by the European Society of Hypertension,<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a> using a cuff of appropriate size for the age of the patient, and calculating the percentiles of BP based on the height of the patient. If the initial BP value is high, the measurement should be repeated at least twice. If it remains high (> 95<span class="elsevierStyleSup">th</span> percentile), an evaluation of HTN should be performed by means of ambulatory blood pressure monitoring (ABPM), and if HTN is confirmed, this should be followed by an investigation of its aetiology and an evaluation of potential damage in target organs. If a high BP is detected in patients already undergoing pharmacological treatment for ADHD, the dose of medication could be reduced or medication suspended before starting the evaluation of HTN. Once a diagnosis is established, the management of the patient can include a combination of antihypertensive drugs and pharmacotherapy for ADHD with guanfacine, which is associated with hypotension, or the dosage of ADHD medication can be reduced or the medication discontinued altogether.</p><p id="par0050" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Heart rate:</span> in case of detection of a heart rate that is persistently above the 99<span class="elsevierStyleSup">th</span> percentile (<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>), potential psychological and medical causes should be explored, and an ECG performed to confirm that the patient has sinus tachycardia and not another form of arrhythmia. It is important to consider that patients with ADHD frequently experience anxiety symptoms that may in turn be associated with increased heart rate. It is possible, although rare, that the sinus tachycardia is severe enough to require adjustment or discontinuation of pharmacological treatment.</p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><p id="par0055" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Electrocardiogram:</span> performance of an ECG is not recommended as part of the routine cardiovascular assessment prior to initiating pharmacotherapy. In case of treatment with guanfacine and atomoxetine combined with other drugs that may prolong the QT interval (such as escitalopram or fluoxetine), or of treatment combining methylphenidate and risperidone,<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">11</span></a> monitoring of the QTc interval is advisable. An ECG should be performed if the patient requires referral to a cardiologist due to abnormal findings in the cardiovascular assessment, symptoms suggesting cardiovascular origin or a family history of sudden death.</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">In children and adolescents with known heart disease</span><p id="par0060" class="elsevierStylePara elsevierViewall">If the patient has a known cardiac disease, we recommend consultation with a paediatric cardiologist prior to initiating pharmacotherapy.</p><p id="par0065" class="elsevierStylePara elsevierViewall">The cardiologist and ADHD specialist should discuss the appropriate approach for pharmacotherapy with the family, engaging in shared decision-making after providing the family with adequate information and taking into account the risks and benefits of treatment.</p><p id="par0070" class="elsevierStylePara elsevierViewall">We recommend measurement of BP and heart rate before initiation of treatment with additional measurements every 3–6 months (<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>). In patients with CHDs and a circulatory physiology that could be compromised by tachycardia or increased BP, the BP and heart rate should be monitored every 1 or 2 months. In case of detection of tachycardia or a history indicative of arrhythmia, the patient should be evaluated by means of 24<span class="elsevierStyleHsp" style=""></span>-h Holter monitoring (<a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a>).</p><elsevierMultimedia ident="tbl0015"></elsevierMultimedia></span></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Recommendations of the Sociedad Española de Cardiología Pediátrica y Cardiopatías Congénitas on the use of medication for treatment of attention-deficit hyperactivity disorder in children and adolescents with cardiovascular disease</span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">Patients with cardiovascular symptoms and no evidence of heart disease</span><p id="par0415" class="elsevierStylePara elsevierViewall"><ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005"><span class="elsevierStyleLabel">•</span><p id="par0075" class="elsevierStylePara elsevierViewall">Children or adolescents with a diagnosis of neurocardiogenic syncope or symptoms suggestive of orthostatic hypotension can start pharmacotherapy for ADHD, avoiding the use of guanfacine due to its hypotensive effect.</p></li><li class="elsevierStyleListItem" id="lsti0010"><span class="elsevierStyleLabel">•</span><p id="par0080" class="elsevierStylePara elsevierViewall">Children or adolescents with a diagnosis of nonspecific chest pain or palpitations with a normal cardiological evaluation (ECG, echocardiogram, Holter ECG or cardiac stress test, as applicable), can start pharmacotherapy for ADHD using stimulant or nonstimulant drugs.</p></li><li class="elsevierStyleListItem" id="lsti0015"><span class="elsevierStyleLabel">•</span><p id="par0085" class="elsevierStylePara elsevierViewall">Children or adolescents with a family history of sudden death in the absence of evidence of inherited heart conditions, and with a normal cardiological evaluation (ECG, echocardiogram, Holter ECG or cardiac stress test, as applicable) and negative results of genetic testing or in who genetic testing is not indicated, can start pharmacotherapy for ADHD.</p></li><li class="elsevierStyleListItem" id="lsti0020"><span class="elsevierStyleLabel">•</span><p id="par0090" class="elsevierStylePara elsevierViewall">In children or adolescents with a family history of sudden death, a normal cardiological evaluation (ECG, echocardiogram, Holter ECG or cardiac stress test, as applicable) and positive results of genetic testing but a negative phenotype at the time of the evaluation, decisions regarding pharmacotherapy should be individualised.</p></li></ul></p></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0105">Congenital heart defects</span><p id="par0095" class="elsevierStylePara elsevierViewall">The following patients may receive medication for ADHD:<ul class="elsevierStyleList" id="lis0010"><li class="elsevierStyleListItem" id="lsti0025"><span class="elsevierStyleLabel">•</span><p id="par0100" class="elsevierStylePara elsevierViewall">Patients with mild and haemodynamically insignificant CHDs that had not undergone corrective surgery and do not require treatment for the heart disease.</p></li><li class="elsevierStyleListItem" id="lsti0030"><span class="elsevierStyleLabel">•</span><p id="par0105" class="elsevierStylePara elsevierViewall">Patients with simple or complex CHDs that have undergone successful corrective surgery, without residual lesions and not receiving treatment for the heart disease.</p></li></ul></p><p id="par0110" class="elsevierStylePara elsevierViewall">The use of pharmacological treatment for ADHD should be individualised in the following cases:<ul class="elsevierStyleList" id="lis0015"><li class="elsevierStyleListItem" id="lsti0035"><span class="elsevierStyleLabel">•</span><p id="par0115" class="elsevierStylePara elsevierViewall">Patients particularly sensitive to an increase in afterload due to an increase in BP secondary to stimulant therapy, such as patients with ventriculoarterial valve or systemic atrioventricular valve regurgitation.</p></li><li class="elsevierStyleListItem" id="lsti0040"><span class="elsevierStyleLabel">•</span><p id="par0120" class="elsevierStylePara elsevierViewall">Patients particularly sensitive to a decrease in afterload due to a potential decrease in BP secondary to treatment with guanfacine, such as patients with systemic ventricular outflow obstruction.</p></li><li class="elsevierStyleListItem" id="lsti0045"><span class="elsevierStyleLabel">•</span><p id="par0125" class="elsevierStylePara elsevierViewall">Patients particularly sensitive to potential tachycardias secondary to stimulant therapy, such as those with diastolic dysfunction or mitral stenosis in whom a shortening of the diastole should be avoided, or patients with systolic dysfunction in whom an increase in myocardial oxygen consumption secondary to tachycardia should be avoided.</p></li><li class="elsevierStyleListItem" id="lsti0050"><span class="elsevierStyleLabel">•</span><p id="par0130" class="elsevierStylePara elsevierViewall">Patients at risk of coronary failure: patients with Kawasaki disease, that have undergone coronary reimplantation (arterial switch procedure, Ross procedure, anomalous left coronary artery from the pulmonary artery), with anomalous origin or paths of coronary arteries, vasculitis, or early atherosclerosis of the coronary arteries. In these cases, it is important to ensure that the coronary flow reserve is sufficient in case of a potential increase in myocardial oxygen consumption secondary to the use of sympathomimetic drugs.</p></li><li class="elsevierStyleListItem" id="lsti0055"><span class="elsevierStyleLabel">•</span><p id="par0135" class="elsevierStylePara elsevierViewall">In all cases, we recommend clinical monitoring of the patient after treatment initiation, assessing changes in BP, heart rate and ECG features and the haemodynamic impact of these changes after initiating treatment and any increase in dosage. The frequency of these assessments should be established on a case-by-case basis.</p></li><li class="elsevierStyleListItem" id="lsti0060"><span class="elsevierStyleLabel">•</span><p id="par0140" class="elsevierStylePara elsevierViewall">Dose adjustments or discontinuation of ADHD medication should be considered in case of a haemodynamic response that can have a negative impact on the patient’s heart condition.</p></li></ul></p><p id="par0145" class="elsevierStylePara elsevierViewall">We recommend against initiating pharmacological treatment in:<ul class="elsevierStyleList" id="lis0020"><li class="elsevierStyleListItem" id="lsti0065"><span class="elsevierStyleLabel">•</span><p id="par0150" class="elsevierStylePara elsevierViewall">Patients with haemodynamically unstable CHD, before the haemodynamically or clinically significant lesion is corrected or treated.</p></li><li class="elsevierStyleListItem" id="lsti0070"><span class="elsevierStyleLabel">•</span><p id="par0155" class="elsevierStylePara elsevierViewall">Patients with CHD and residual HTN. Adequate management and control of BP must precede initiation of pharmacological treatment for ADHD.</p></li></ul></p></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0110">Cardiomyopathies</span><p id="par0160" class="elsevierStylePara elsevierViewall">The risks and benefits of ADHD treatment should be evaluated on a case-by-case basis in collaboration with the ADHD specialist (neurologist, psychiatrist or paediatrician).</p><p id="par0165" class="elsevierStylePara elsevierViewall">Initiation of pharmacotherapy is not recommended in patients with haemodynamically unstable cardiomyopathy.</p><p id="par0170" class="elsevierStylePara elsevierViewall">We recommend clinical monitoring of the patient after initiation of treatment, assessing changes in BP, heart rate and ECG features as well as the impact of these changes in the haemodynamic status of the patient. These variables should be assessed on treatment initiation and after each dose increase, if applicable.</p><p id="par0175" class="elsevierStylePara elsevierViewall">Dose adjustment or discontinuation of ADHD medication should be considered in patients exhibiting haemodynamic changes that may have a negative impact on the cardiomyopathy.</p></span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0115">Marfan syndrome and other aortopathies</span><p id="par0180" class="elsevierStylePara elsevierViewall">Patients with a normal aortic root diameter, with or without ongoing treatment, can start pharmacotherapy for ADHD with monitoring of BP and heart rate every month or 2 months and whenever the dose is increased.</p><p id="par0185" class="elsevierStylePara elsevierViewall">In patients with a dilated aorta undergoing treatment with beta-blockers or angiotensin II receptor blockers, it is particularly important to be prudent in the decision to initiate ADHD medication, as an increase in heart rate or BP could be highly detrimental. In any case, the drug with the least sympathomimetic activity available should be selected, for instance, guanfacine. Another important aspect to consider is that since these patients are receiving hypotensive treatment, they may not tolerate further increases in BP.</p><p id="par0190" class="elsevierStylePara elsevierViewall">In case of HTN, ADHD treatment should be suspended and BP controlled with pharmacotherapy before gradually reintroducing ADHD medication.</p><p id="par0195" class="elsevierStylePara elsevierViewall">In case of concomitant mitral valve regurgitation, treatment should also adhere to the recommendations given in the CHD section of this guideline.</p></span><span id="sec0060" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0120">High blood pressure</span><p id="par0200" class="elsevierStylePara elsevierViewall">Blood pressure should be measured following the technical recommendations and reference values of the European Society of Hypertension.<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">12</span></a></p><p id="par0205" class="elsevierStylePara elsevierViewall">The BP should be measured before initiating and during treatment with ADHD drugs at intervals to be determined on a case-by-case basis considering everything that has been discussed to this point. It is important to use a cuff size appropriate for the age of the patients and to calculate the BP percentiles based on height.<a class="elsevierStyleCrossRefs" href="#bib0060"><span class="elsevierStyleSup">12,13</span></a><ul class="elsevierStyleList" id="lis0025"><li class="elsevierStyleListItem" id="lsti0075"><span class="elsevierStyleLabel">•</span><p id="par0210" class="elsevierStylePara elsevierViewall">If the BP is below the 95th percentile, ADHD pharmacotherapy can be initiated/continued.</p></li><li class="elsevierStyleListItem" id="lsti0080"><span class="elsevierStyleLabel">•</span><p id="par0215" class="elsevierStylePara elsevierViewall">If the BP is above the 95th percentile, it must be measured 2 more times after intervals of 10<span class="elsevierStyleHsp" style=""></span>min of rest; if the BP continues to be high, the dose should be reduced or the ADHD medication suspended temporarily, with subsequent monitoring of BP.<ul class="elsevierStyleList" id="lis0030"><li class="elsevierStyleListItem" id="lsti0085"><span class="elsevierStyleLabel">a</span><p id="par0220" class="elsevierStylePara elsevierViewall">If the BP is below the 95th percentile in the next check up, treatment can continue or resume.</p></li><li class="elsevierStyleListItem" id="lsti0090"><span class="elsevierStyleLabel">b</span><p id="par0225" class="elsevierStylePara elsevierViewall">If the BP is above the 95th percentile in the next check up, the patient should be referred to a paediatric nephrologist for performance of an evaluation including a 24-h ABPM. If the findings of ABPM are abnormal, we also recommend performance of an ECG and an echocardiographic evaluation. A second ABPM should be performed, and in case of abnormal findings, HTN should be diagnosed and the required treatment initiated.. If the second ABPM does not confirm the diagnosis of HTN, ADHD treatment can be initiated.<ul class="elsevierStyleList" id="lis0035"><li class="elsevierStyleListItem" id="lsti0095"><span class="elsevierStyleLabel">○</span><p id="par0230" class="elsevierStylePara elsevierViewall">Once HTN has been diagnosed and relevant treatment initiated, if control of BP is achieved with sustained values below the 95<span class="elsevierStyleSup">th</span> percentile, it is possible to initiate or resume pharmacotherapy for ADHD.</p></li><li class="elsevierStyleListItem" id="lsti0100"><span class="elsevierStyleLabel">○</span><p id="par0235" class="elsevierStylePara elsevierViewall">It is important to recommend nonpharmacological lifestyle interventions in all patients with high blood pressure<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a>: physical activity, dietary recommendations (increased intake of fruit, vegetables and legumes, choosing low-fat dairy products, decreased intake of salt and sugars), weight loss as needed, and stress reduction.</p></li><li class="elsevierStyleListItem" id="lsti0105"><span class="elsevierStyleLabel">○</span><p id="par0240" class="elsevierStylePara elsevierViewall">In children with ADHD, the prevalence of anxiety is much higher compared to the general population, so any measure aimed at reducing stress should be considered, as well as specific treatment for anxiety, if the patient requires it. Anxiety is associated to increase both BP and heart rate.</p></li><li class="elsevierStyleListItem" id="lsti0110"><span class="elsevierStyleLabel">○</span><p id="par0245" class="elsevierStylePara elsevierViewall">We recommend against pharmacological treatment of ADHD (with stimulants or atomoxetine) in patients with moderate or severe HTN.<a class="elsevierStyleCrossRefs" href="#bib0025"><span class="elsevierStyleSup">5,14</span></a></p></li><li class="elsevierStyleListItem" id="lsti0115"><span class="elsevierStyleLabel">○</span><p id="par0250" class="elsevierStylePara elsevierViewall">In case of elevation of BP with psychostimulant drugs (methylphenidate and lisdexamfetamine), consider the addition of a beta-blocker on a case-by-case basis.</p></li><li class="elsevierStyleListItem" id="lsti0120"><span class="elsevierStyleLabel">○</span><p id="par0255" class="elsevierStylePara elsevierViewall">It is important to take into account that stimulants may reduce the effectiveness of antihypertensive drugs, and caution should be exerted when they are administered along with drugs that also increase BP.</p></li><li class="elsevierStyleListItem" id="lsti0125"><span class="elsevierStyleLabel">○</span><p id="par0260" class="elsevierStylePara elsevierViewall">In case of moderate HTN, treatment with guanfacine may be considered. It is important to remember that the dose of guanfacine should be tapered off before discontinuation to minimise the risk of rebound HTN.</p></li><li class="elsevierStyleListItem" id="lsti0130"><span class="elsevierStyleLabel">○</span><p id="par0265" class="elsevierStylePara elsevierViewall">If during treatment with guanfacine the patient develops sustained orthostatic hypotension or episodes of syncope, the dose should be reduced or the ADHD medication switched to a different drug.</p></li></ul></p></li></ul></p></li></ul></p></span><span id="sec0065" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0125">Arrythmia and arrhythmogenic disorders</span><p id="par0270" class="elsevierStylePara elsevierViewall">Treatment for ADHD with stimulant or nonstimulant drugs can be initiated in:<ul class="elsevierStyleList" id="lis0040"><li class="elsevierStyleListItem" id="lsti0135"><span class="elsevierStyleLabel">•</span><p id="par0275" class="elsevierStylePara elsevierViewall">Patients with incidental findings in ECG that are frequent in childhood and adolescence and are not pathological: incomplete right bundle branch block, respiratory sinus arrhythmia or wandering atrial pacemaker.</p></li><li class="elsevierStyleListItem" id="lsti0140"><span class="elsevierStyleLabel">•</span><p id="par0280" class="elsevierStylePara elsevierViewall">Patients with incidental finding in ECG of complete right bundle branch block or left anterior or posterior hemiblock, once structural heart disease has been ruled out.</p></li><li class="elsevierStyleListItem" id="lsti0145"><span class="elsevierStyleLabel">•</span><p id="par0285" class="elsevierStylePara elsevierViewall">Asymptomatic patients with incidental detection of infrequent (< 60/h) monomorphic premature supraventricular contractions after ruling out relevant associated disease. We recommend performance of 24<span class="elsevierStyleHsp" style=""></span>-h Holter monitoring after treatment initiation to assess for changes in the pattern of arrhythmia relative to baseline.</p></li><li class="elsevierStyleListItem" id="lsti0150"><span class="elsevierStyleLabel">•</span><p id="par0290" class="elsevierStylePara elsevierViewall">Patients with Brugada syndrome, as the highest risk in these patients corresponds to situation with increased vagal tone.</p></li><li class="elsevierStyleListItem" id="lsti0155"><span class="elsevierStyleLabel">•</span><p id="par0295" class="elsevierStylePara elsevierViewall">Patients with a history of supraventricular tachycardia currently not receiving antiarrhythmic drugs. In case of persistence or recurrence of tachycardia, consider the possibility of cardiac ablation for curative treatment.</p></li><li class="elsevierStyleListItem" id="lsti0160"><span class="elsevierStyleLabel">•</span><p id="par0300" class="elsevierStylePara elsevierViewall">Asymptomatic patients with infrequent (< 60/h) monomorphic premature ventricular contractions (PVCs) that are not complex, without underlying structural heart disease and with evidence of a decrease or disappearance of PVCs on exertion in the cardiac stress test. We recommend performance of 24<span class="elsevierStyleHsp" style=""></span>-h Holter monitoring after treatment initiation to assess for changes in the pattern of arrhythmia relative to baseline.</p></li><li class="elsevierStyleListItem" id="lsti0165"><span class="elsevierStyleLabel">•</span><p id="par0305" class="elsevierStylePara elsevierViewall">Asymptomatic patients with incidental finding of preexcitation in the ECG and evidence of disappearance of impulse conduction through the accessory pathway with development of a high heart rate in the cardiac stress test or 24-h Holter monitoring, in who it is not necessary to ablate the accessory pathway before initiating treatment.</p></li><li class="elsevierStyleListItem" id="lsti0170"><span class="elsevierStyleLabel">•</span><p id="par0310" class="elsevierStylePara elsevierViewall">Asymptomatic patients with incidental finding of first degree or second degree (Mobitz I) atrioventricular block, avoiding the use of guanfacine.</p></li></ul></p><p id="par0315" class="elsevierStylePara elsevierViewall">In the following cases, it is necessary to consult with a specialist in arrhythmias and individualise treatment:<ul class="elsevierStyleList" id="lis0045"><li class="elsevierStyleListItem" id="lsti0175"><span class="elsevierStyleLabel">•</span><p id="par0320" class="elsevierStylePara elsevierViewall">Patients with catecholaminergic polymorphic ventricular tachycardia. This is an infrequent disease with catecholamine-dependent features, so stimulant therapy is not recommended in these patients.</p></li><li class="elsevierStyleListItem" id="lsti0180"><span class="elsevierStyleLabel">•</span><p id="par0325" class="elsevierStylePara elsevierViewall">Asymptomatic patients with frequent (> 60/h) monomorphic PVCs, polymorphic PVCs or complex PVCs, or with underlying structural heart disease.</p></li><li class="elsevierStyleListItem" id="lsti0185"><span class="elsevierStyleLabel">•</span><p id="par0330" class="elsevierStylePara elsevierViewall">Asymptomatic patients with incidental finding of preexcitation on ECG and no evidence of disappearance of impulse conduction through the accessory pathway with development of a high heart rate in the cardiac stress test or 24<span class="elsevierStyleHsp" style=""></span>-h Holter monitoring.</p></li><li class="elsevierStyleListItem" id="lsti0190"><span class="elsevierStyleLabel">•</span><p id="par0335" class="elsevierStylePara elsevierViewall">Previous episode of aborted sudden cardiac death.</p></li><li class="elsevierStyleListItem" id="lsti0195"><span class="elsevierStyleLabel">•</span><p id="par0340" class="elsevierStylePara elsevierViewall">Previous history of arrhythmia requiring cardiopulmonary resuscitation, cardioversion, defibrillation or a pacemaker.</p></li><li class="elsevierStyleListItem" id="lsti0200"><span class="elsevierStyleLabel">•</span><p id="par0345" class="elsevierStylePara elsevierViewall">History de arrythmia associated with sudden death.</p></li></ul></p></span></span><span id="sec0070" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0130">Conflicts of interest</span><p id="par0350" class="elsevierStylePara elsevierViewall">The authors have no conflicts of interest to declare.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:11 [ 0 => array:3 [ "identificador" => "xres1308932" "titulo" => "Abstract" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Introduction" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Objective" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Method" ] 3 => array:2 [ "identificador" => "abst0020" "titulo" => "Results" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec1208408" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres1308931" "titulo" => "Resumen" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0025" "titulo" => "Introducción" ] 1 => array:2 [ "identificador" => "abst0030" "titulo" => "Objetivo" ] 2 => array:2 [ "identificador" => "abst0035" "titulo" => "Metodología" ] 3 => array:2 [ "identificador" => "abst0040" "titulo" => "Resultados" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec1208407" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:2 [ "identificador" => "sec0010" "titulo" => "Objective" ] 6 => array:2 [ "identificador" => "sec0015" "titulo" => "Methodology" ] 7 => array:3 [ "identificador" => "sec0020" "titulo" => "Recommendations of the Sociedad Española de Cardiología Pediátrica y Cardiopatías Congénitas on the cardiovascular evaluation preceding treatment" "secciones" => array:2 [ 0 => array:2 [ "identificador" => "sec0025" "titulo" => "In children and adolescents with unknown cardiovascular disease" ] 1 => array:2 [ "identificador" => "sec0030" "titulo" => "In children and adolescents with known heart disease" ] ] ] 8 => array:3 [ "identificador" => "sec0035" "titulo" => "Recommendations of the Sociedad Española de Cardiología Pediátrica y Cardiopatías Congénitas on the use of medication for treatment of attention-deficit hyperactivity disorder in children and adolescents with cardiovascular disease" "secciones" => array:6 [ 0 => array:2 [ "identificador" => "sec0040" "titulo" => "Patients with cardiovascular symptoms and no evidence of heart disease" ] 1 => array:2 [ "identificador" => "sec0045" "titulo" => "Congenital heart defects" ] 2 => array:2 [ "identificador" => "sec0050" "titulo" => "Cardiomyopathies" ] 3 => array:2 [ "identificador" => "sec0055" "titulo" => "Marfan syndrome and other aortopathies" ] 4 => array:2 [ "identificador" => "sec0060" "titulo" => "High blood pressure" ] 5 => array:2 [ "identificador" => "sec0065" "titulo" => "Arrythmia and arrhythmogenic disorders" ] ] ] 9 => array:2 [ "identificador" => "sec0070" "titulo" => "Conflicts of interest" ] 10 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2019-07-14" "fechaAceptado" => "2019-09-10" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec1208408" "palabras" => array:6 [ 0 => "Methylphenidate" 1 => "Atomoxetine" 2 => "Lisdexamphetamine" 3 => "Guanfacine" 4 => "Cardiovascular side effects" 5 => "Sudden death" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec1208407" "palabras" => array:7 [ 0 => "Atomoxetina" 1 => "Lisdexanfetamina" 2 => "Guanfacina" 3 => "Efectos secundarios cardiovasculares" 4 => "Muerte súbita" 5 => "Cardiopatías congénitas" 6 => "Cardiopatías adquiridas" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:3 [ "titulo" => "Abstract" "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Introduction</span><p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Approved drugs for attention deficit hyperactivity disorder (ADHD) in Spain are methylphenidate, lisdexamphetamine, atomoxetine and guanfacine. Due to adverse cardiovascular effects, mainly increased blood pressure and heart rate, its use in patients with known or undiagnosed heart disease may be controversial.</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Objective</span><p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">To obtain a consensus document from the Spanish Society of Paediatric Cardiology and Congenital Heart Diseases (SECPCC) and experts from other Agencies and Societies as a guide for the paediatric cardiologist and physicians who treat children and adolescents with ADHD.</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Method</span><p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">An analysis was performed on the bibliography and Clinical Practice Guidelines, technical data sheets approved by the Spanish Agency of Medicines and Health Devices, and the Spanish Ministry of Health Guidelines. A Working Group was formed, with a Coordinator, as well as members of the Clinical Cardiology Working Group and Arrhythmia Group of the SECPCC. This Group produced a preliminary document that was reviewed by a group of external experts (List 1) and a group of internal experts of the SECPCC (List 2) with a consensus being reached on the final document.</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Results</span><p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">The recommendations of the SECPCC and the group of experts are presented on cardiovascular evaluation prior to treatment in children and adolescents with unknown cardiovascular disease and with known cardiovascular disease.</p><p id="spar0065" class="elsevierStyleSimplePara elsevierViewall">The recommendations of the SECPCC and the group of experts are also presented on the use of medications for ADHD in children and adolescents with cardiological symptoms with no evidence of heart disease, congenital heart disease, cardiomyopathy, Marfan syndrome and other aortic diseases, hypertension, and arrhythmias.</p></span>" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Introduction" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Objective" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Method" ] 3 => array:2 [ "identificador" => "abst0020" "titulo" => "Results" ] ] ] "es" => array:3 [ "titulo" => "Resumen" "resumen" => "<span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Introducción</span><p id="spar0070" class="elsevierStyleSimplePara elsevierViewall">Los fármacos aprobados para el trastorno por déficit de atención con hiperactividad (TDAH) en España son: metilfenidato, lisdexanfetamina, atomoxetina y guanfacina. Debido a los efectos adversos cardiovasculares que pueden producir, principalmente aumento de la tensión arterial y la frecuencia cardiaca, su uso en pacientes con cardiopatías conocidas o no diagnosticadas puede ser controvertido.</p></span> <span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Objetivo</span><p id="spar0075" class="elsevierStyleSimplePara elsevierViewall">Realización de un documento de consenso de la Sociedad Española de Cardiología Pediátrica y Cardiopatías Congénitas (SECPCC) y expertos de otras Agencias y Sociedades como instrumento para el cardiólogo infantil y los médicos que tratan niños y adolescentes con TDAH.</p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Metodología</span><p id="spar0080" class="elsevierStyleSimplePara elsevierViewall">Análisis de la bibliografía y Guías de Práctica Clínica, fichas técnicas aprobadas por la Agencia Española del Medicamento y Productos Sanitarios y Guía del Ministerio de Sanidad español. Formación de un Grupo de trabajo con un Coordinador, miembros de los grupos de trabajo de Cardiología Clínica y Arritmias de la SECPCC. Este Grupo realizó un documento que fue revisado por un grupo de expertos externos (Anexo 1) y un grupo de expertos internos de la SECPCC (Anexo 2) llegando a un consenso para la obtención del documento final.</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Resultados</span><p id="spar0085" class="elsevierStyleSimplePara elsevierViewall">Se presentan las recomendaciones de la SECPCC y el grupo de expertos sobre la evaluación cardiovascular previa al tratamiento en niños y adolescentes sin enfermedad cardiovascular conocida y con enfermedad cardiovascular conocida. Se presentan las recomendaciones de la SECPCC y el grupo de expertos sobre el uso de medicamentos para el TDAH en niños y adolescentes con síntomas cardiológicos sin evidencia de cardiopatía, cardiopatías congénitas, miocardiopatías, síndrome de Marfan y otras aortopatías, hipertensión arterial y arritmias.</p></span>" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0025" "titulo" => "Introducción" ] 1 => array:2 [ "identificador" => "abst0030" "titulo" => "Objetivo" ] 2 => array:2 [ "identificador" => "abst0035" "titulo" => "Metodología" ] 3 => array:2 [ "identificador" => "abst0040" "titulo" => "Resultados" ] ] ] ] "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Picarzo JP-L, Malfaz FC, Marcos DC, Hernández RC, Soria TF, García BM. Recomendaciones de la Sociedad Española de Cardiologia Pediatrica y Cardiopatias Congenitas en relacion al uso de medicamentos en el trastorno por déficit de atención e hiperactividad en niños y adolescentes con cardiopatias conocidas y en la población pediatrica general, posicionamiento de la Asociación Española de Pediatria. An Pediatr (Barc). 2019. <span class="elsevierStyleInterRef" id="intr0005" href="https://doi.org/10.1016/j.anpedi.2019.09.002">https://doi.org/10.1016/j.anpedi.2019.09.002</span></p>" ] ] "apendice" => array:1 [ 0 => array:1 [ "seccion" => array:3 [ 0 => array:3 [ "apendice" => "<p id="par0355" class="elsevierStylePara elsevierViewall">Agencia Española del Medicamento y Productos Sanitarios (Spanish Agency of Medicines and Medical Devices). Almudena López Fando, Division of Pharmacoepidemiology and Pharmacosurveillance. Department of Medicinal Products for Human Use.</p> <p id="par0360" class="elsevierStylePara elsevierViewall">Sociedad Española de Cardiología (Spanish Cardiology Association). Inmaculada Sánchez, Paediatric Cardiology, Hospital Ramón y Cajal Madrid.</p> <p id="par0365" class="elsevierStylePara elsevierViewall">Sociedad Española de Psiquiatría (Spanish Psychiatric Association). José Antonio Ramos Quiroga, coordinator of the Programme on Attention-Deficit Hyperactivity Disorder and coordinator of the Psychiatric Emergency Department, Hospital Universitari Vall d’Hebron, Barcelona.</p> <p id="par0370" class="elsevierStylePara elsevierViewall">Sociedad Española de Farmacología Clínica (Spanish Society of Clinical Pharmacology). Belén Ruiz Antorán, Expert Group of the European Medicines Agency, Department of Clinical Pharmacology, Hospital Puerta de Hierro, Madrid.</p> <p id="par0375" class="elsevierStylePara elsevierViewall">Sociedad de Psiquiatría Infantil de la Asociación Española de Pediatría. Azucena Díez Suárez, Unidad de Psiquiatría Infantil y Adolescente, Clínica Universidad de Navarra.</p> <p id="par0380" class="elsevierStylePara elsevierViewall">Asociación Española de Pediatría (Spanish Association of Pediatrics), Working Group on Evidence-Based Paediatrics. Carlos Ochoa Sangrador, Hospital Virgen de la Concha, Zamora.</p> <p id="par0385" class="elsevierStylePara elsevierViewall">Sociedad Española de Neurología Pediátrica (Spanish Society of Paediatric Neurology). Francisco Javier López Pisón, Paediatric Neurology, Hospital Miguel Servet, Zaragoza.</p> <p id="par0390" class="elsevierStylePara elsevierViewall">Asociación Española de Pediatría de Atención Primaria (Spanish Association of Primary Care Paediatrics, AEPap). José Miguel García Cruz, coordinator of the Group on ADHD and Psychoeducational Development of the AEPap.</p> <p id="par0395" class="elsevierStylePara elsevierViewall">Sociedad Española de Pediatría Extrahospitalaria y Atención Primaria (Spanish Association of Outpatient and Primary Care Paediatrics). Adrián García Ron, Paediatric Neurology, Hospital Clínico San Carlos, Madrid.</p>" "etiqueta" => "Appendix A" "identificador" => "sec0075" ] 1 => array:3 [ "apendice" => "<p id="par0400" class="elsevierStylePara elsevierViewall">Sociedad Española de Cardiología Pediátrica y Cardiopatías Congénitas (Spanish Association of Paediatric Cardiology and Congenital Heart Disease). Miguel Ángel Granados Ruiz, Paediatric Cardiology, Hospital 12 Octubre, Madrid.</p> <p id="par0405" class="elsevierStylePara elsevierViewall">Sociedad Española de Cardiología Pediátrica y Cardiopatías Congénitas (Spanish Associatio of Paediatric Cardiology and Congenital Heart Disease). María del Mar Rodríguez Vázquez del Rey, Paediatric Cardiology, Hospital Virgen de las Nieves, Granada.</p> <p id="par0410" class="elsevierStylePara elsevierViewall">Sociedad Española de Cardiología Pediátrica y Cardiopatías Congénitas (Spanish Association of Paediatric Cardiology and Congenital Heart Disease). Elena Montañés Delmas, Paediatric Cardiology, Hospital 12 Octubre, Madrid.</p>" "etiqueta" => "Appendix B" "identificador" => "sec0080" ] 2 => array:4 [ "apendice" => "<p id="par9265" class="elsevierStylePara elsevierViewall"><elsevierMultimedia ident="upi0005"></elsevierMultimedia></p>" "etiqueta" => "Appendix" "titulo" => "Supplementary data" "identificador" => "sec9125" ] ] ] ] "multimedia" => array:4 [ 0 => array:8 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0005" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:2 [ "leyenda" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">SCD, sudden cardiac death.</p>" "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Presence of structural heart disease \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Family history of SCD \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Syncope on exertion, associated with emotional states or in supine position \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Palpitations or chest pain of sudden onset followed by syncope \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Presence of organic murmur \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Abnormal ECG \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab2243015.png" ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Syncope suggesting a cardiac origin.</p>" ] ] 1 => array:8 [ "identificador" => "tbl0010" "etiqueta" => "Table 2" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0010" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:2 [ "leyenda" => "<p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">bpm, beats per minute.</p><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Adapted from Fleming et al. Normal ranges of heart rate and respiratory rate in children from birth to 18 years of age: A systematic review of observational studies. Lancet 2011;377:1011.</p>" "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">p1 \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">p10-p90 \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">p99 \t\t\t\t\t\t\n \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">4 to < 6 years \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">65 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">81-117 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">131 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">6 to < 8 years \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">59 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">74-111 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">123 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">8 to < 12 years \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">52 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">67-103 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">115 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">12 to < 15 years \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">47 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">62-96 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">108 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">15-18 years \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">43 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">58-92 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">104 \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab2243017.png" ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Heart rate (bpm) by age group and percentile range.</p>" ] ] 2 => array:8 [ "identificador" => "tbl0015" "etiqueta" => "Table 3" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0015" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:2 [ "leyenda" => "<p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">bpm, beats per minute.</p><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">Adapted from Krasemann et al. Changes of the corrected QT interval in healthy boys and girls over day and night. Eur Heart J. 2009;30:202–208.</p>" "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Age (years) \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Male \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Female \t\t\t\t\t\t\n \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">5 to < 8 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">87<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>11 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">92<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>8 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">8 to < 12 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">83<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>9 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">85<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>8 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">12 to < 16 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">82<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>7 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">84<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>8 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">16 to < 18 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">77<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>7 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">80<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>2 \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab2243016.png" ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Mean heart rate (bpm) and standard deviation in 24-h Holter monitoring.</p>" ] ] 3 => array:5 [ "identificador" => "upi0005" "tipo" => "MULTIMEDIAECOMPONENTE" "mostrarFloat" => false "mostrarDisplay" => true "Ecomponente" => array:2 [ "fichero" => "mmc1.pdf" "ficheroTamanyo" => 446256 ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:14 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:1 [ "referenciaCompleta" => "Centers for Disease Control and Prevention (CDC). 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Year/Month | Html | Total | |
---|---|---|---|
2024 October | 211 | 31 | 242 |
2024 September | 351 | 40 | 391 |
2024 August | 358 | 66 | 424 |
2024 July | 395 | 49 | 444 |
2024 June | 291 | 34 | 325 |
2024 May | 282 | 62 | 344 |
2024 April | 207 | 38 | 245 |
2024 March | 184 | 32 | 216 |
2024 February | 153 | 25 | 178 |
2024 January | 156 | 37 | 193 |
2023 December | 163 | 31 | 194 |
2023 November | 105 | 42 | 147 |
2023 October | 131 | 36 | 167 |
2023 September | 77 | 62 | 139 |
2023 August | 67 | 29 | 96 |
2023 July | 61 | 38 | 99 |
2023 June | 76 | 37 | 113 |
2023 May | 48 | 35 | 83 |
2023 April | 64 | 42 | 106 |
2023 March | 79 | 41 | 120 |
2023 February | 43 | 24 | 67 |
2023 January | 43 | 27 | 70 |
2022 December | 65 | 56 | 121 |
2022 November | 70 | 44 | 114 |
2022 October | 59 | 61 | 120 |
2022 September | 40 | 49 | 89 |
2022 August | 36 | 58 | 94 |
2022 July | 57 | 59 | 116 |
2022 June | 40 | 54 | 94 |
2022 May | 46 | 56 | 102 |
2022 April | 48 | 43 | 91 |
2022 March | 42 | 77 | 119 |
2022 February | 53 | 42 | 95 |
2022 January | 42 | 69 | 111 |
2021 December | 38 | 69 | 107 |
2021 November | 44 | 45 | 89 |
2021 October | 55 | 99 | 154 |
2021 September | 32 | 41 | 73 |
2021 August | 28 | 39 | 67 |
2021 July | 29 | 24 | 53 |
2021 June | 32 | 37 | 69 |
2021 May | 29 | 44 | 73 |
2021 April | 94 | 184 | 278 |
2021 March | 55 | 29 | 84 |
2021 February | 57 | 40 | 97 |
2021 January | 128 | 36 | 164 |
2020 December | 65 | 22 | 87 |
2020 November | 36 | 30 | 66 |
2020 October | 52 | 21 | 73 |
2020 September | 43 | 33 | 76 |
2020 August | 13 | 14 | 27 |
2020 July | 39 | 16 | 55 |
2020 June | 34 | 18 | 52 |
2020 May | 35 | 14 | 49 |
2020 April | 49 | 18 | 67 |
2020 March | 78 | 26 | 104 |
2020 February | 159 | 43 | 202 |
2020 January | 31 | 6 | 37 |