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Weigel F, Nudy M, Krakowski G, Ahmed M, Foy A. Meta-Analysis of Nonrandomized Studies to Assess the Optimal Timing of Coronary Artery Bypass Grafting After Acute Myocardial Infarction. Am J Cardiol 2022; 164:44-51. [PMID: 34815058 DOI: 10.1016/j.amjcard.2021.10.033] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/23/2021] [Revised: 09/27/2021] [Accepted: 10/04/2021] [Indexed: 12/20/2022]
Abstract
The optimal timing of coronary artery bypass grafting (CABG) in patients after an acute myocardial infarction (MI) is unknown. We performed a systematic review and meta-analysis of studies comparing mortality rates in patients who underwent CABG at different time intervals after acute MI. Bias assessments were completed for each study, and summary of proportions of all-cause mortality were calculated based on CABG at various time intervals after MI. A total of 22 retrospective studies, which included a total of 137,373 patients were identified. The average proportion of patients who died when CABG was performed within 6 hours of MI was 12.7%, within 6 to 24 hours of MI was 10.9%, within 1 day of MI was 9.8%, any time after 1 day of MI was 3.0%, within 7 days of MI was 5.9%, and any time after 7 days of MI was 2.7%. Interstudy heterogeneity, assessed using I2 values, showed significant heterogeneity in death rates within subgroups. Only 1 study accounted for immortal time bias, and there was a serious risk of selection bias in all other studies. Confounding was found to be a serious risk for bias in 55% of studies because of a lack of accounting for type of MI, MI severity, or other verified cardiac risk factors. The current publications comparing timing of CABG after MI is at serious risk of bias because of patient selection and confounding, with heterogeneity in both study populations and intervention time intervals.
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The Pharmacological Approach to Oncologic Patients with Acute Coronary Syndrome. J Clin Med 2020; 9:jcm9123926. [PMID: 33287336 PMCID: PMC7761724 DOI: 10.3390/jcm9123926] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2020] [Revised: 11/26/2020] [Accepted: 11/28/2020] [Indexed: 01/03/2023] Open
Abstract
Among acute coronary syndrome (ACS) patients, 15% have concomitant cancer, especially in the first 6 months after their diagnosis, as well as in advanced metastatic stages. Lung, gastric, and pancreatic cancers are the most frequent malignancies associated with ACS. Chemotherapy and radiotherapy exert prothrombotic, vasospastic, and proinflammatory actions. The management of cancer patients with ACS is quite challenging: percutaneous revascularization is often underused, and antiplatelet and anticoagulant pharmacological therapy should be individually tailored to the thrombotic risk and to the bleeding complications. Sometimes oncological patients also show different degrees of thrombocytopenia, which further complicates the pharmacological strategies. The aim of this review is to summarize the current evidence regarding the treatment of ACS in cancer patients and to suggest the optimal management and therapy to reduce the risk of adverse coronary events after ACS in this high-risk population.
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Benefits and risks of P2Y12 inhibitor preloading in patients with acute coronary syndrome and stable angina. J Thromb Thrombolysis 2017; 44:303-315. [DOI: 10.1007/s11239-017-1529-6] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
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Diercks DB, Kontos MC, Hollander JE, Mumma BE, Holmes DN, Wiviott S, Saucedo JF, de Lemos JA. ED administration of thienopyridines in non-ST-segment elevation myocardial infarction: results from the NCDR. Am J Emerg Med 2013; 31:1005-11. [PMID: 23702070 PMCID: PMC4045403 DOI: 10.1016/j.ajem.2013.03.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2013] [Revised: 02/14/2013] [Accepted: 03/01/2013] [Indexed: 01/23/2023] Open
Abstract
OBJECTIVE American Heart Association/American College of Cardiology guidelines recommend that patients with definite unstable angina or non-ST-segment elevation myocardial infarction (NSTEMI) receive dual antiplatelet therapy on presentation to the hospital when undergoing early invasive management or "as soon as possible" after admission when being managed conservatively. The guidelines do not specify whether these medications should be administered in the emergency department (ED). Our aim was to determine whether ED administration of a thienopyridine was associated with clinical outcomes among patients with NSTEMI. METHODS We examined thienopyridine use in 39454 patients with NSTEMI who received a thienopyridine within 24 hours of presentation in the National Cardiovascular Data Registry's Acute Coronary Treatment and Intervention Outcomes Network-Get With The Guidelines Registry from January 2007 to June 2010. Patients who were not seen initially in the ED, were transferred in, or were missing time data were excluded. We analyzed the association between ED administration of thienopyridines and outcomes and patient demographics. RESULTS Of the cohort receiving a thienopyridine within 24 hours, 9534 (24.2%) received it in the ED. Emergency department administration of a thienopyridine was not associated with in-hospital major bleeding (multivariable adjusted odds ratio, 0.99; 95% confidence interval, 0.91-1.09) or in-hospital mortality (adjusted 1.02; 95% confidence interval, 0.86-1.20). Independent predictors most strongly associated with ED thienopyridine administration were elevated troponin, ED length of stay, prior percutaneous coronary intervention, and initial electrocardiogram showing ischemic changes. CONCLUSIONS There was no association between ED thienopyridine administration and in-hospital major bleeding or mortality. Emergency department length of stay, electrocardiographic changes, and elevated troponin were associated with ED thienopyridine administration.
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Affiliation(s)
- Deborah B. Diercks
- From the Department of Emergency Medicine, University of California Davis Medical Center, Sacramento
| | - Michael C. Kontos
- Division of Cardiology, Virginia Commonwealth University, Richmond, VA
| | - Judd E. Hollander
- Department of Emergency Medicine, University of Pennsylvania, Philadelphia, PA
| | - Bryn E. Mumma
- From the Department of Emergency Medicine, University of California Davis Medical Center, Sacramento
| | | | - Stephen Wiviott
- Division of Cardiology, Brigham and Women’s Hospital, Boston, MA
| | - Jorge F. Saucedo
- Division of Cardiology, University of Oklahoma Health Sciences Center, Oklahoma City, OK
| | - James A. de Lemos
- Division of Cardiology, University of Texas Southwestern, Dallas, TX
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Van de Werf F, Ardissino D, Bueno H, Collet JP, Gershlick A, Kolh P, Kristensen SD, Silber S, Verheugt F, Wojakowski W. Acute coronary syndromes: considerations for improved acceptance and implementation of management guidelines. Expert Rev Cardiovasc Ther 2012; 10:489-503. [PMID: 22458581 DOI: 10.1586/erc.12.20] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
The management of acute coronary syndrome in Europe is covered by various European Society of Cardiology guidelines, which although valuable, are complex and may not always provide clear guidance in everyday clinical practice. Consequently, implementation of the guideline recommendations is frequently suboptimal. To complicate matters further, a wealth of new data from large trials examining novel anti-thrombotic agents will become or are already available, necessitating guideline updates. This article summarizes the gaps between current guideline-recommended treatment of acute coronary syndrome and daily practice as dictated by the evidence base, including recent trials. Reasons for the suboptimal implementation of the current European Society of Cardiology guidelines and possible solutions to making these more practice oriented are presented.
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Affiliation(s)
- Frans Van de Werf
- Department of Cardiology, University Hospitals Leuven, Herestraat 49, B-3000 Leuven, Belgium.
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Early clopidogrel use in non-ST elevation acute coronary syndrome and subsequent coronary artery bypass grafting. Am Heart J 2011; 161:832-41. [PMID: 21570511 DOI: 10.1016/j.ahj.2011.01.020] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/18/2010] [Accepted: 01/21/2011] [Indexed: 11/21/2022]
Abstract
Clopidogrel use is associated with a significant decrease in major adverse cardiac events when used in patients with non-ST elevation acute coronary syndromes (NSTE-ACS), and guidelines give a class I level of evidence A recommendation for the use of clopidogrel in these patients. The optimal timing of clopidogrel use has not been conclusively determined, but nearly all data available support early use in patients with NSTE-ACS. Despite this, clopidogrel usage is far less than expected based on current guidelines because of concern for bleeding at the time of possible subsequent coronary artery bypass grafting (CABG). Clopidogrel use has been associated with increased perioperative bleeding at the time of CABG, but data are mixed. Numerous studies have conclusively shown that this bleeding risk is confined to those patients receiving clopidogrel within 5 days of CABG. The absolute number of patients exposed to this possible bleeding risk is very small relative to the >1 million patients who present annually with NSTE-ACS and is estimated to be <0.8% of these patients. Recent data have shown that (1) holding clopidogrel for 5 days before CABG is safe in patients with NSTE-ACS and (2) clopidogrel use in patients with NSTE-ACS decreases ischemic events in patients referred for CABG compared to patients who are not given clopidogrel. These data strongly challenge the notion that clopidogrel should be withheld until it is determined if the patient will be referred for CABG.
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Brown C, Joshi B, Faraday N, Shah A, Yuh D, Rade JJ, Hogue CW. Emergency cardiac surgery in patients with acute coronary syndromes: a review of the evidence and perioperative implications of medical and mechanical therapeutics. Anesth Analg 2011; 112:777-99. [PMID: 21385977 DOI: 10.1213/ane.0b013e31820e7e4f] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
Patients with acute coronary syndromes who require emergency cardiac surgery present complex management challenges. The early administration of antiplatelet and antithrombotic drugs has improved overall survival for patients with acute myocardial infarction, but to achieve maximal benefit, these drugs are given before coronary anatomy is known and before the decision to perform percutaneous coronary interventions or surgical revascularization has been made. A major bleeding event secondary to these drugs is associated with a high rate of death in medically treated patients with acute coronary syndrome possibly because of subsequent withholding of antiplatelet and antithrombotic therapies that otherwise reduce the rate of death, stroke, or recurrent myocardial infarction. Whether the added risk of bleeding and blood transfusion in cardiac surgical patients receiving such potent antiplatelet or antithrombotic therapy before surgery specifically for acute coronary syndromes affects long-term mortality has not been clearly established. For patients who do proceed to surgery, strategies to minimize bleeding include stopping the anticoagulation therapy and considering platelet and/or coagulation factor transfusion and possibly recombinant-activated factor VIIa administration for refractory bleeding. Mechanical hemodynamic support has emerged as an important option for patients with acute coronary syndromes in cardiogenic shock. For these patients, perioperative considerations include maintaining appropriate anticoagulation, ensuring suitable device flow, and periodically verifying correct device placement. Data supporting the use of these devices are derived from small trials that did not address long-term postoperative outcomes. Future directions of research will seek to optimize the balance between reducing myocardial ischemic risk with antiplatelet and antithrombotics versus the higher rate perioperative bleeding by better risk stratifying surgical candidates and by assessing the effectiveness of newer reversible drugs. The effects of mechanical hemodynamic support on long-term patient outcomes need more stringent analysis.
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Affiliation(s)
- Charles Brown
- Department of Anesthesiology and Critical Care Medicine, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
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Kosuge M, Ebina T, Hibi K, Morita S, Endo M, Maejima N, Iwahashi N, Okada K, Ishikawa T, Umemura S, Kimura K. An early and simple predictor of severe left main and/or three-vessel disease in patients with non-ST-segment elevation acute coronary syndrome. Am J Cardiol 2011; 107:495-500. [PMID: 21184992 DOI: 10.1016/j.amjcard.2010.10.005] [Citation(s) in RCA: 56] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/28/2010] [Revised: 10/01/2010] [Accepted: 10/01/2010] [Indexed: 12/23/2022]
Abstract
Clopidogrel should be initiated as soon as possible in patients with non-ST-segment elevation acute coronary syndrome (NSTE-ACS) except those who urgently require coronary artery bypass grafting (CABG). The present study assessed the ability to predict severe left main coronary artery and/or 3-vessel disease (LM/3VD) that would most likely require urgent CABG based on only clinical factors on admission in 572 patients with NSTE-ACS undergoing coronary angiography. Severe LM/3VD was defined as ≥75% stenosis of LM and/or 3VD with ≥90% stenosis in ≥2 proximal lesions of the left anterior descending coronary artery and other major epicardial arteries. Patients were divided into the 3 groups according to angiographic findings: no LM/3VD (n = 460), LM/3VD but not severe LM/3VD (n = 57), and severe LM/3VD (n = 55). Severe LM/3VD was associated with a higher rate of urgent CABG compared to no LM/3VD and LM/3VD but not severe LM/3VD (46%, 2%, and 2%, p <0.001). On multivariate analysis, degree of ST-segment elevation in lead aVR was the strongest predictor of severe LM/3VD (odds ratio 29.1, p <0.001), followed by positive troponin T level (odds ratio 1.27, p = 0.044). ST-segment elevation ≥1.0 mm in lead aVR best identified severe LM/3VD with 80% sensitivity, 93% specificity, 56% positive predictive value, and 98% negative predictive value. In conclusion, ST-segment elevation ≥1.0 mm in lead aVR on admission electrocardiogram is highly suggestive of severe LM/3VD in patients with NSTE-ACS. Selected patients with this finding might benefit from promptly undergoing angiography, withholding clopidogrel to allow early CABG.
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Affiliation(s)
- Masami Kosuge
- Division of Cardiology, Yokohama City University Medical Center, Yokohama, Japan.
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Gilchrist IC. It is standard practice, but is it really best practice or clinical biocreep? Catheter Cardiovasc Interv 2010; 76:525-6. [PMID: 20882656 DOI: 10.1002/ccd.22775] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
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Rastan AJ, Thiele H, Schuler G, Mohr FW. Stellenwert der koronaren Bypass operation in der Therapie der akuten Koronarsyndrome. Herz 2010; 35:70-8. [DOI: 10.1007/s00059-010-3327-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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Banihashemi B, Goodman SG, Yan RT, Welsh RC, Mehta SR, Montalescot G, Kornder JM, Wong GC, Gyenes G, Steg PG, Yan AT. Underutilization of clopidogrel and glycoprotein IIb/IIIa inhibitors in non-ST-elevation acute coronary syndrome patients: the Canadian global registry of acute coronary events (GRACE) experience. Am Heart J 2009; 158:917-24. [PMID: 19958857 DOI: 10.1016/j.ahj.2009.09.016] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/19/2009] [Accepted: 09/29/2009] [Indexed: 12/22/2022]
Abstract
BACKGROUND There are limited contemporary data on the early use of clopidogrel or glycoprotein (Gp) IIb/IIIa inhibitors, alone versus combination therapies, in non-ST-elevation acute coronary syndrome (NSTE-ACS). METHODS This study included 5,806 Canadian NSTE-ACS patients with elevated cardiac biomarker and/or ST deviation on presentation in the prospective GRACE between 2003-2007. We stratified the study population according to the management strategy (non-invasive vs invasive) and into low-(GRACE risk score <or=108), intermediate- (109-140), and high-risk groups (>or=141). RESULTS Overall, 3,893 patients (67.1%) received early (<or=24 hours of admission) antiplatelet therapy; the rates of use were 76%, 73%, and 57% in the low-, intermediate-, and high-risk groups, respectively (P for trend < .001). Only 54% of the conservatively managed patients and 12% of the invasively managed patients received early clopidogrel and GpIIb/IIIa inhibitors, respectively. High-risk patients were less likely (adjusted odds ratio = 0.48, 95% CI 0.39-0.59, P < .001) to receive early clopidogrel or GpIIb/IIIa inhibitors, whereas in-hospital catheterization was an independent positive predictor (adjusted odds ratio = 2.02, 95% CI 1.74-2.34, P < .001) of use. CONCLUSIONS In this contemporary NSTE-ACS population, both clopidogrel and GpIIb/IIIa inhibitors were targeted toward patients treated with an invasive strategy but paradoxically toward the lower-risk group. In particular, clopidogrel appeared to be underused among conservatively managed patients despite its proven efficacy, whereas GpIIb/IIIa inhibitors were administered to only a minority of the high-risk patients with elevated cardiac biomarkers. Our findings emphasize the ongoing need to promote the optimal use of evidence-based antiplatelet therapies among high-risk patients with NSTE-ACS.
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Saucedo JF. Oral antiplatelet therapy in unstable angina/non-ST-segment elevation myocardial infarction, ST-segment elevation myocardial infarction, and percutaneous coronary intervention: is it time for a guideline update? Am J Cardiol 2009; 104:4C-8C. [PMID: 19695354 DOI: 10.1016/j.amjcard.2009.06.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Oral antiplatelet drugs are central in the management of acute coronary syndromes, including unstable angina/non-ST-segment elevation myocardial infarction, ST-segment elevation myocardial infarction, and percutaneous coronary intervention. However, the mechanisms that confer the benefits of these agents also increase bleeding risk. Thus, the selection of appropriate pharmacotherapy requires close attention to the delicate balance between reducing the risk of ischemic events and minimizing bleeding risk. A critical review of the 2007 guidelines in these areas and new clinical data with currently available and soon-to-be-approved antiplatelet agents are presented.
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Affiliation(s)
- Jorge F Saucedo
- University of Oklahoma Health Sciences Center, 920 Stanton L. Young Boulevard, Oklahoma City, OK 73190, USA.
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Reply. J Am Coll Cardiol 2009. [DOI: 10.1016/j.jacc.2009.03.041] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
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Rao RV, Goodman SG, Yan RT, Spencer FA, Fox KA, DeYoung JP, Rose B, Grondin FR, Gallo R, Gore JM, Yan AT. Temporal trends and patterns of early clopidogrel use across the spectrum of acute coronary syndromes. Am Heart J 2009; 157:642-50.e1. [PMID: 19332190 DOI: 10.1016/j.ahj.2009.01.002] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/06/2008] [Accepted: 01/05/2009] [Indexed: 12/01/2022]
Abstract
BACKGROUND Randomized trials have established efficacy of clopidogrel in various types of acute coronary syndromes (ACS). The objective of this study was to examine the temporal trends and patterns of early clopidogrel use (within the first 24 hours of hospitalization) across the spectrum of patients with ACS in Canada. METHODS Using the multinational, prospective GRACE (Global Registry of Acute Coronary Events) and GRACE(2), we identified 11,177 patients who were admitted for ACS from January 2003 to December 2007 in Canada. Demographic information, clinical features, and treatment were recorded. We examined the early use of clopidogrel over time and in relation to the type of ACS, clinical features on presentation, and the mode of reperfusion therapy. RESULTS Of the 11,177 patients with ACS, 3,091 (27.7%) had ST-elevation myocardial infarction (STEMI), 5,194 (46.5%) had non-STEMI, and 2,892 (25.9%) had unstable angina; the rates of early clopidogrel administration were 63.0%, 66.6%, and 57.2%, respectively (P < .001). Overall, there was a significant increase in clopidogrel use over the period studied (P for trend < .001). In patients with non-ST-elevation ACS (non-STEMI and unstable angina), clopidogrel use was higher among those with positive cardiac biomarkers compared to those without (67.1% vs 59.8%, P < .001) but similar in the groups with and without ST deviation. There was an inverse relationship between GRACE risk score and rates of early clopidogrel administration. In patients with STEMI receiving fibrinolytic therapy, only 55.7% of patients <65 years old received clopidogrel compared with 47.0% and 42.6% of patients 65 to 74 and >75 years old, respectively (P for trend < .001). CONCLUSIONS Although early use of clopidogrel therapy has increased over time across the spectrum of ACS, a significant proportion of eligible patients still do not receive this evidence-based therapy. There is a need to optimize the use of proven antiplatelet therapies to improve clinical outcome.
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Affiliation(s)
- Rajeev V Rao
- Terrence Donnelly Heart Centre, St. Michael's Hospital, University of Toronto, and The Canadian Heart Research Centre, Ontario, Canada
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Kosuge M, Ebina T, Hibi K, Morita S, Komura N, Hashiba K, Kiyokuni M, Nakayama N, Umemura S, Kimura K. Early, Accurate, Non-Invasive Predictors of Left Main or 3-Vessel Disease in Patients With Non-ST-Segment Elevation Acute Coronary Syndrome. Circ J 2009; 73:1105-10. [DOI: 10.1253/circj.cj-08-1009] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Affiliation(s)
- Masami Kosuge
- The Division of Cardiology, Yokohama City University Medical Center
| | - Toshiaki Ebina
- The Division of Cardiology, Yokohama City University Medical Center
| | - Kiyoshi Hibi
- The Division of Cardiology, Yokohama City University Medical Center
| | - Satoshi Morita
- The Division of Cardiology, Yokohama City University Medical Center
| | - Naohiro Komura
- The Division of Cardiology, Yokohama City University Medical Center
| | | | | | - Naoki Nakayama
- The Division of Cardiology, Yokohama City University Medical Center
| | - Satoshi Umemura
- The Division of Cardiology, Yokohama City University Medical Center
| | - Kazuo Kimura
- The Division of Cardiology, Yokohama City University Medical Center
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Bibliography. Current world literature. Diseases of the aorta, pulmonary, and peripheral vessels. Curr Opin Cardiol 2008; 23:646-7. [PMID: 18830082 DOI: 10.1097/hco.0b013e328316c259] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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