記住我
2020, Vol. 21 Issue (1): 31-39
DOI: 10.31083/j.rcm.2020.01.24
Special Issue:
Cardiovascular disorders in chronic kidney disease
Management of heart failure in patients with end-stage kidney disease on maintenance dialysis: a practical guide
Megan S. Joseph1, Maryse Palardy1, Nicole M. Bhave1, *(
)
1 University of Michigan Medical School and Michigan Medicine, Department of Internal Medicine, Division of Cardiovascular Medicine, 1500 East Medical Center Drive, Ann Arbor, Michigan, 48109, USA.
Abstract:End-stage kidney disease (ESKD) and heart failure (HF) often coexist and must be managed simultaneously. Multidisciplinary collaboration between nephrology and cardiology is critical when treating patients with such complicated physiology. There is no "one-size-fits-all" approach to the evaluation of patients with new left ventricular systolic dysfunction, and diagnostic testing should be adapted to an individual's risk factors. Guideline-directed medical therapy (GDMT) for systolic heart failure should be employed in these patients. While limited randomized data exist, observational data and post hoc analyses suggest that GDMT, including renin angiotensin aldosterone system inhibitors, is associated with improved cardiovascular outcomes and can be safely initiated at low doses with close monitoring of kidney function in this population. Volume status is typically managed through ultrafiltration, so close communication between cardiology and nephrology is necessary to achieve a patient's optimal dry weight and mitigate intradialytic hypotension. Patient education and engagement regarding sodium and fluid restriction is crucial, and symptom burden should be reassessed following changes to the dialysis regimen.
Submitted: 01 March 2020 Accepted: 05 March 2020 Published: 30 March 2020 *Corresponding Author(s): Nicole M. Bhave E-mail: nbhave@med.umich.edu Service
E-mail this article
Add to citation manager
E-mail Alert
RSS
Articles by authors
Megan S. Joseph
Maryse Palardy
Nicole M. Bhave
Table 1. Heart failure medications in end-stage kidney disease.
Medication classMedicationsDialyzabilityMinimum Dose*ACE inhibitorsCaptopril
Figure 1. Central illustration: Team approach to the management of Heart failure in End-Stage Kidney Disease
Box. Clinical vignettes highlighting diagnostic and therapeutic challenges encountered when managing patients with HF, HTN, and ESKD.
Case 1Mr. X is a 39-year-old man with ESKD secondary to hypertension, on HD via arteriovenous (AV) fistula for 5 years. He was referred to cardiology clinic after a TTE, which was obtained as part of his evaluation for a kidney transplant, showed left ventricular (LV) dilation and LV ejection fraction (LVEF) 40-45%. TTE was also notable for prominent apical trabeculations. Because of his TTE findings and risk factors, the differential diagnosis for his cardiomyopathy included non-compaction cardiomyopathy, ischemic heart disease, and hypertensive cardiomyopathy. The first therapeutic intervention made was that his HD regimen was adjusted to target a lower dry weight. He subsequently underwent cardiovascular magnetic resonance (CMR), which revealed LVEF 61%, hypertrabeculation of the LV apex not meeting criteria for non-compaction cardiomyopathy, and no late gadolinium enhancement of the myocardium. His coronary angiogram was normal. Ultimately, he was felt to have a non-ischemic cardiomyopathy attributable to hypertension and ESKD, with recovered LVEF in the setting of improved loading conditions. He subsequently underwent kidney transplant without complications. Though his antihypertensive regimen was de-escalated post-transplant, he continued on carvedilol and low-dose lisinopril, given his history of LV dysfunction.Commentary: The improvement in this patient’s LVEF was attributed to better volume management, highlighting the dynamic nature of LV dysfunction depending on volume status in ESKD. GDMT, including beta-blocker and angiotensin converting enzyme inhibitor, should be continued even after the LVEF has recovered. Finally, if his kidney function remains stable for at least 6-12 months after transplant, he may benefit from ligation of his AV fistula, as ligation has been associated with significant reduction in LV mass index by CMR and decrease in NT pro-B-type natriuretic peptide levels (Rao et al., 2019).
Case 2Mr. Y is a 48-year-old man patient with a history of a bicuspid aortic valve with associated ascending aortic aneurysm and ESKD secondary to an unknown autoimmune disease who underwent a kidney transplant but subsequently developed graft failure and adult-onset type I diabetes mellitus. He was referred to cardiology clinic for management of resistant hypertension while on HD. Given his ascending aortic aneurysm, blood pressure control was felt to be critically important. He was initially maintained on clonidine 0.1 mg/24 hour transdermally, metoprolol succinate 100 mg daily, and extended-release nifedipine 60 mg daily. In an effort to improve blood pressure control, his antihypertensive regimen was adjusted to include carvedilol 25 mg twice daily, hydralazine 100 mg three times daily, losartan 25 mg daily, amlodipine 5 mg daily, and clonidine 0.2 mg/24 hour transdermally. Despite these changes, his blood pressure remained elevated, often as high as 180/100 mmHg. The cardiologist contacted his nephrologist, who felt that the patient was volume overloaded and suggested increased ultrafiltration. However, ultrafiltration was limited by cramping during HD, so no significant progress was possible. The patient elected to switch to PD, as he had done well on PD prior to his first transplant. Several weeks after the transition, his dry weight was decreased by approximately 5 kg, and home blood pressures were averaging 120/80 mmHg. Finally, as part of his kidney transplant workup, an evaluation for myocardial ischemia was recommended, given his history of diabetes mellitus and relatively sedentary lifestyle. A vasodilator nuclear stress test was ordered rather than a dobutamine stress echocardiogram, given his history of ascending aortic aneurysm; no evidence of ischemia was present.Commentary: If a patient’s optimal dry weight is not identified and achieved, venous hypertension can be extremely challenging, if not impossible, to control. Modality for myocardial ischemia evaluation must be chosen based on an individual’s risk factors and comorbidities.
Table 2. Acute Dialysis Quality Initiative XI Workgroup’s proposed functional classification system of heart failure in patients with end-stage kidney disease (Chawla et al., 2014).
Heart Failure ClassSymptoms1Asymptomatic, with echocardiographic evidence of heart disease2RDyspnea on exertion that is relieved with RRT/UF to a NYHA Class I level2NRDyspnea on exertion that cannot be relieved with RRT/UF to a NYHA Class I level3RDyspnea with ADLs that is relieved by RRT/UF to a NYHA Class II level3NRDyspnea with ADLs that cannot be relieved by RRT/UF to a NYHA Class II level4RDyspnea at rest that is relieved by RRT/UF to a NYHA Class III level4NRDyspnea at rest that cannot be relieved by RRT/UF to a NYHA Class III level
Table 3. Strategies to mitigate intradialytic hypotension.
Lengthen hemodialysis runsIncrease frequency of hemodialysis from 3 times weekly to 4-6 times weekly (may schedule one or more ultrafiltration-only runs per week)Lower dialysate temperature (patient tolerability may be limited)Hold anti-hypertensives the morning before dialysis (GDMT drugs may be given post-dialysis if tolerated)Discontinuation of anti-hypertensives that have not been shown to provide mortality benefit in patients with heart failure (e.g., clonidine, minoxidil, calcium-channel blockers)Use of midodrine or fludrocortisone (note that midodrine is associated with worse outcomes following kidney transplantation)Switch from hemodialysis to peritoneal dialysis
[1]
ACR Committee on Drugs andContrast Media (2020).ACR manual on contrast media.Available at: https://www.acr.org/-/media/ACR/Files/Clinical-Resources/Contrast_Media.pdf
[2]
MERIT-HF Study Group. (1999)Effect of metoprolol CR/XL in chronic heart failure: metoprolol CR/XL randomised intervention trial in congestive heart failure (MERIT-HF).Lancet 353, 2001-2007.
[3]
Alhamad, T.,Brennan, D. C.,Brifkani, Z.,Xiao, H.,Schnitzler, M. A.,Dharnidharka, V. R.,Axelrod, D.,Segev, D. L. and Lentine, K. L (2016)Pretransplant midodrine use: a newly identified risk marker for complications after kidney transplantation.Transplantation 100, 1086-1093.
[4]
Assimon, M. M.,Brookhart, M. A.,Fine, J. P.,Heiss, G.,Layton, J. B. and Flythe, J. E (2018)A comparative study of carvedilol versus metoprolol initiation and 1-year mortality among individuals receiving maintenance hemodialysis.American Journal of Kidney Diseases: the Official Journal of the National Kidney Foundation 72, 337-348.
[5]
Bomback, A. S (2016)Mineralocorticoid receptor antagonists in end-stage renal disease: efficacy and safety.Blood Purif 41, 166-170.
[6]
Brar, S. S.,Aharonian, V.,Mansukhani, P.,Moore, N.,Shen, A. Y.,Jorgensen, M.,Dua, A.,Short, L. and Kane, K (2014)Haemodynamic-guided fluid administration for the prevention of contrast-induced acute kidney injury: the POSEIDON randomised controlled trial.Lancet 383, 1814-1823.
[7]
Brunelli, S. M.,Cohen, D. E.,Marlowe, G. and Van Wyck, D (2018)The impact of midodrine on outcomes in patients with intradialytic hypotension.American Journal of Nephrologyl 48, 381-388.
[8]
Chan, K. E.,Lazarus, J. M. and Hakim, R. M (2010)Digoxin associates with mortality in ESRD.Journal of the American Society of Nephrology 21, 1550-1559.
[9]
Charytan, D. M.,Himmelfarb, J.,Ikizler, T. A.,Raj, D. S.,Hsu, J. Y.,Landis, J. R.,Anderson, A. H.,Hung, A. M.,Mehrotra, R.,Sharma, S.,Weiner, D. E.,Williams, M.,DiCarli, M.,Skali, H.,Kimmel, P. L.,Kliger, A. S.,Dember, L. M. and Hemodialysis Novel Therapies, C (2019)Safety and cardiovascular efficacy of spironolactone in dialysis-dependent ESRD (SPin-D): a randomized, placebo-controlled, multiple dosage trial.Kidney Internationalernational 95, 973-982.
[10]
Chawla, L. S.,Herzog, C. A.,Costanzo, M. R.,Tumlin, J.,Kellum, J. A.,McCullough, P. A.,Ronco, C. and Workgroup, A. X (2014)Proposal for a functional classification system of heart failure in patients with end-stage renal disease: proceedings of the acute dialysis quality initiative (ADQI) XI workgroup.Journal of the American College of Cardiology 63, 1246-1252.
[11]
Chertow, G. M.,Levin, N. W.,Beck, G. J.,Daugirdas, J. T.,Eggers, P. W.,Kliger, A. S.,Larive, B.,Rocco, M. V.,Greene, T. and Frequent Hemodialysis Network Trials, G. (2016)Long-term effects of frequent in-center hemodialysis.Journal of the American Society of Nephrology 27, 1830-1836.
[12]
Chou, J. A. and Kalantar-Zadeh, K. (2017)Volume balance and intradialytic ultrafiltration rate in the hemodialysis patient.Current Heart Failure Reports 14, 421-427.
[13]
Cice, G.,Ferrara, L.,D'Andrea, A.,D'Isa, S.,Di Benedetto, A.,Cittadini, A.,Russo, P. E.,Golino, P. and Calabro, R (2003)Carvedilol increases two-year survivalin dialysis patients with dilated cardiomyopathy: a prospective, placebo-controlled trial.Journal of the American College of Cardiology 41, 1438-1444.
[14]
Damman, K.,Gori, M.,Claggett, B.,Jhund, P. S.,Senni, M.,Lefkowitz, M. P.,Prescott, M. F.,Shi, V. C.,Rouleau, J. L.,Swedberg, K.,Zile, M. R.,Packer, M.,Desai, A. S.,Solomon, S. D. and McMurray, J. J. V (2018)Renal effects and associated outcomes during angiotensin-neprilysin inhibition in heart failure.JACC Heart Fail 6, 489-498.
[15]
Digitalis Investigation Group(1997)The effect of digoxin on mortality and morbidity in patients with heart failure.The New England Journal 336, 525-533.
[16]
Foley, R. N.,Gilbertson, D. T.,Murray, T. and Collins, A. J (2011)Long interdialytic interval and mortality among patients receiving hemodialysis.The New England Journal 365, 1099-1107.
[17]
Grossekettler, L.,Schmack, B.,Meyer, K.,Brockmann, C.,Wanninger, R.,Kreusser, M. M.,Frankenstein, L.,Kihm, L. P.,Zeier, M.,Katus, H. A.,Remppis, A. and Schwenger, V (2019)Peritoneal dialysis as therapeutic option in heart failure patients.ESC Heart Fail 6, 271-279.
[18]
He, J.,Ogden, L. G.,Bazzano, L. A.,Vupputuri, S.,Loria, C. and Whelton, P. K (2001)Risk factors for congestive heart failure in US men and women: NHANES I epidemiologic follow-up study.Archives of Internal Medicine 161, 996-1002.
[19]
Hein, A. M.,Scialla, J. J.,Edmonston, D.,Cooper, L. B.,DeVore, A. D. and Mentz, R. J (2019)Medical management of heart failure with reduced ejection fraction in patients with advanced renal disease.JACC Heart Fail 7, 371-382.
[20]
Herzog, C. A.,Asinger, R. W.,Berger, A. K.,Charytan, D. M.,Diez, J.,Hart, R. G.,Eckardt, K. U.,Kasiske, B. L.,McCullough, P. A.,Passman, R. S.,DeLoach, S. S.,Pun, P. H. and Ritz, E (2011)Cardiovascular disease in chronic kidney disease. A clinical update from Kidney Disease: Improving Global Outcomes (KDIGO).Kidney International 80, 572-586.
[21]
Heywood, J. T.,Fonarow, G. C.,Yancy, C. W.,Albert, N. M.,Curtis, A. B.,Stough, W. G.,Gheorghiade, M.,McBride, M. L.,Mehra, M. R.,O'Connor, C. M.,Reynolds, D. and Walsh, M. N (2010)Influence of renal function on the use of guideline-recommended therapies for patients with heart failure.American Journal of Cardiology 105, 1140-1146.
[22]
Hillege, H. L.,Nitsch, D.,Pfeffer, M. A.,Swedberg, K.,McMurray, J. J.,Yusuf, S.,Granger, C. B.,Michelson, E. L.,Ostergren, J.,Cornel, J. H.,de Zeeuw, D.,Pocock, S.,van Veldhuisen, D. J.,Candesartan in Heart Failure: Assessment of Reduction in, M. and Morbidity, I (2006)Renal function as a predictor of outcome in a broad spectrum of patients with heart failure.Circulation 113, 671-678.
[23]
Kalantar-Zadeh, K.,Regidor, D. L.,Kovesdy, C. P.,Van Wyck, D.,Bunnapradist, S.,Horwich, T. B. and Fonarow, G. C (2009)Fluid retention is associated with cardiovascular mortality in patients undergoing long-term hemodialysis.Circulation 119, 671-679.
[24]
McCullough, P. A.,v, A. and Kale, P. (2016a)Goal-directed heart failure care in patients with chronic kidney disease and end-stage renal disease.JACC Heart Fail 4, 662-663.
[25]
McCullough, P. A.,Chan, C. T.,Weinhandl, E. D.,Burkart, J. M. and Bakris, G. L (2016b)Intensive hemodialysis, left ventricular hypertrophy, and cardiovascular disease.American Journal of Kidney Disease: the Official Journal of the National Kidney Foundation 68, S5-S14.
[26]
McMurray, J. J.,Packer, M.,Desai, A. S.,Gong, J.,Lefkowitz, M. P.,Rizkala, A. R.,Rouleau, J. L.,Shi, V. C.,Solomon, S. D.,Swedberg, K.,Zile, M. R.,Investigators, P.-H. andCommittees (2014)Angiotensin-neprilysin inhibition versus enalapril in heart failure.The New England Journal 371, 993-1004.
[27]
Murthy, V. L.,Naya, M.,Foster, C. R.,Hainer, J.,Gaber, M.,Dorbala, S.,Charytan, D. M.,Blankstein, R. and Di Carli, M. F (2012)Coronary vascular dysfunction and prognosis in patients with chronic kidney disease.JACC Cardiovasc Imaging 5, 1025-1034.
[28]
Nishimura, R. A.,Otto, C. M.,Bonow, R. O.,Carabello, B. A.,Erwin, J. P., 3rd,Fleisher, L. A.,Jneid, H.,Mack, M. J.,McLeod, C. J.,O'Gara, P. T.,Rigolin, V. H.,Sundt, T. M., 3rd andThompson, A (2017)2017 AHA/ACC focused update of the 2014 AHA/ACC guideline for the management of patients with valvular heart disease: a report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines.Journal of the American College of Cardiology 70, 252-289.
[29]
Nishimura, R. A.,Otto, C. M.,Bonow, R. O.,Carabello, B. A.,Erwin, J. P., 3rd,Guyton, R. A.,O'Gara, P. T.,Ruiz, C. E.,Skubas, N. J.,Sorajja, P.,Sundt, T. M., 3rd,Thomas, J. D. and American College of Cardiology/American Heart Association Task Force on Practice, G. (2014)2014 AHA/ACC guideline for the management of patients with valvular heart disease: executive summary: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines.Journal of the American College of Cardiology 63, 2438-2488.
[30]
Perkovic, V.,Hunt, D.,Griffin, S. V.,du Plessis, M. and Becker, G. J (2003)Accelerated progression of calcific aortic stenosis in dialysis patients.Nephron Clinical Practice 94, c40-45.
[31]
Ponikowski, P.,Voors, A. A.,Anker, S. D.,Bueno, H.,Cleland, J. G. F.,Coats, A. J. S.,Falk, V.,Gonzalez-Juanatey, J. R.,Harjola, V. P.,Jankowska, E. A.,Jessup, M.,Linde, C.,Nihoyannopoulos, P.,Parissis, J. T.,Pieske, B.,Riley, J. P.,Rosano, G. M. C.,Ruilope, L. M.,Ruschitzka, F.,Rutten, F. H.,van der Meer, P. and Group, E. S. C. S. D (2016)2016 ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure: The Task Force for the diagnosis and treatment of acute and chronic heart failure of the European Society of Cardiology (ESC) developed with the special contribution of the Heart Failure Association (HFA) of the ESC.European Heart Journal 37, 2129-2200.
[32]
Poole-Wilson, P. A.,Swedberg, K.,Cleland, J. G.,Di Lenarda, A.,Hanrath, P.,Komajda, M.,Lubsen, J.,Lutiger, B.,Metra, M.,Remme, W. J.,Torp-Pedersen, C.,Scherhag, A.,Skene, A. and Carvedilol Or Metoprolol European Trial, I. (2003)Comparison of carvedilol and metoprolol on clinical outcomes in patients with chronic heart failure in the Carvedilol Or Metoprolol European Trial (COMET): randomised controlled trial.Lancet 362, 7-13.
[33]
Pottebaum, A. A.,Hagopian, J. C.,Brennan, D. C.,Gharabagi, A. and Horwedel, T. A (2018)Influence of pretransplant midodrine use on outcomes after kidney transplantation.Clinical Transplantation 32, e13366.
[34]
Rangaswami, J. and McCullough, P. A (2018)Heart failure in end-stage kidney disease: pathophysiology, diagnosis, and therapeutic strategies.Seminars in Nephrology 38, 600-617.
[35]
Rao, N. N.,Stokes, M. B.,Rajwani, A.,Ullah, S.,Williams, K.,King, D.,Macaulay, E.,Russell, C. H.,Olakkengil, S.,Carroll, R. P.,Faull, R. J.,Teo, K. S. L.,McDonald, S. P.,Worthley, M. I. and Coates, P. T (2019)Effects of arteriovenous fistula ligation on cardiac structure and function in kidney transplant recipients.Circulation 139, 2809-2818.
[36]
Rihal, C. S.,Textor, S. C.,Grill, D. E.,Berger, P. B.,Ting, H. H.,Best, P. J.,Singh, M.,Bell, M. R.,Barsness, G. W.,Mathew, V.,Garratt, K. N. and Holmes, D. R., Jr (2002)Incidence and prognostic importance of acute renal failure after percutaneous coronary intervention.Circulation 105, 2259-2264.
[37]
Saran, R.,Robinson, B.,Abbott, K. C.,Agodoa, L. Y. C.,Bragg-Gresham, J.,Balkrishnan, R.,Bhave, N.,Dietrich, X.,Ding, Z.,Eggers, P. W.,Gaipov, A.,Gillen, D.,Gipson, D.,Gu, H.,Guro, P.,Haggerty, D.,Han, Y.,He, K.,Herman, W.,Heung, M.,Hirth, R. A.,Hsiung, J. T.,Hutton, D.,Inoue, A.,Jacobsen, S. J.,Jin, Y.,Kalantar-Zadeh, K.,Kapke, A.,Kleine, C. E.,Kovesdy, C. P.,Krueter, W.,Kurtz, V.,Li, Y.,Liu, S.,Marroquin, M. V.,McCullough, K.,Molnar, M. Z.,Modi, Z.,Montez-Rath, M.,Moradi, H.,Morgenstern, H.,Mukhopadhyay, P.,Nallamothu, B.,Nguyen, D. V.,Norris, K. C.,O'Hare, A. M.,Obi, Y.,Park, C.,Pearson, J.,Pisoni, R.,Potukuchi, P. K.,Repeck, K.,Rhee, C. M.,Schaubel, D. E.,Schrager, J.,Selewski, D. T.,Shamraj, R.,Shaw, S. F.,Shi, J. M.,Shieu, M.,Sim, J. J.,Soohoo, M.,Steffick, D.,Streja, E.,Sumida, K.,Kurella Tamura, M.,Tilea, A.,Turf, M.,Wang, D.,Weng, W.,Woodside, K. J.,Wyncott, A.,Xiang, J.,Xin, X.,Yin, M.,You, A. S.,Zhang, X.,Zhou, H. and Shahinian, V (2019)US renal data system 2018 annual data report: epidemiology of kidney disease in the United States.American Journal of Kidney Diseases: the Official Journal of the National Kidney Foundation 73, A7-A8.
[38]
Schwitter, J. and Arai, A. E (2011)Assessment of cardiac ischaemia and viability: role of cardiovascular magnetic resonance.European Heart Journal 32, 799-809.
[39]
Sheikine, Y. and Di Carli, M. F (2008)Integrated PET/CT in the assessment of etiology and viability in ischemic heart failure.Current Heart Failure Reports 5, 136-142.
[40]
Soulez, G.,Bloomgarden, D. C.,Rofsky, N. M.,Smith, M. P.,Abujudeh, H. H.,Morgan, D. E.,Lichtenstein, R. J.,Schiebler, M. L.,Wippold, F. J., 2nd,Russo, C.,Kuhn, M. J.,Mennitt, K. W.,Maki, J. H.,Stolpen, A.,Liou, J.,Semelka, R. C.,Kirchin, M. A.,Shen, N.,Pirovano, G. and Spinazzi, A (2015)Prospective cohort study of nephrogenic systemic fibrosis in patients with stage 3-5 chronic kidney disease undergoing mri with injected gadobenate dimeglumine or gadoteridol.AJR Am J Roentgenol 205, 469-478.
[41]
Swedberg, K.,Eneroth, P.,Kjekshus, J. and Snapinn, S (1990)Effects of enalapril and neuroendocrine activation on prognosis in severe congestive heart failure (follow-up of the consensus trial).Consensus Trial Study Group. Am J Cardiol 66, 40D-44D;discussion 44D-45D.
[42]
Swedberg, K.,Komajda, M.,Bohm, M.,Borer, J. S.,Ford, I.,Dubost-Brama, A.,Lerebours, G.,Tavazzi, L. and Investigators, S (2010)Ivabradine and outcomes in chronic heart failure (SHIFT): a randomised placebo-controlled study.Lancet (London, England) 376, 875-885.
[43]
Taylor, A. L.,Ziesche, S.,Yancy, C.,Carson, P.,D'Agostino, R.,Jr.,Ferdinand, K.,Taylor, M.,Adams, K.,Sabolinski, M.,Worcel, M.,Cohn, J. N. and African-American Heart Failure Trial, I (2004)Combination of isosorbide dinitrate and hydralazine in blacks with heart failure.The New England Journal 351, 2049-2057.
[44]
Wang, C. S.,FitzGerald, J. M.,Schulzer, M.,Mak, E. and Ayas, N. T (2005)Does this dyspneic patient in the emergency department have congestive heart failure?JAMA 294, 1944-1956.
[45]
Yancy, C. W.,Jessup, M.,Bozkurt, B.,Butler, J.,Casey, D. E.,Jr.,Colvin, M. M.,Drazner, M. H.,Filippatos, G.,Fonarow, G. C.,Givertz, M. M.,Hollenberg, S. M.,Lindenfeld, J.,Masoudi, F. A.,McBride, P. E.,Peterson, P. N.,Stevenson, L. W. and Westlake, C (2016)2016 ACC/AHA/HFSA focused update on new pharmacological therapy for heart failure: an update of the 2013 ACCF/AHA guideline for the management of heart failure: a report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines and the Heart Failure Society of America.Journal of the American College of Cardiology 68, 1476-1488.
[46]
Yancy, C. W.,Jessup, M.,Bozkurt, B.,Butler, J.,Casey, D. E.,Jr.,Drazner, M. H.,Fonarow, G. C.,Geraci, S. A.,Horwich, T.,Januzzi, J. L.,Johnson, M. R.,Kasper, E. K.,Levy, W. C.,Masoudi, F. A.,McBride, P. E.,McMurray, J. J.,Mitchell, J. E.,Peterson, P. N.,Riegel, B.,Sam, F.,Stevenson, L. W.,Tang, W. H.,Tsai, E. J.,Wilkoff, B. L.,American College of Cardiology, F. and American Heart Association Task Force on Practice, G. (2013)2013 ACCF/AHA guideline for the management of heart failure: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines.Journal of the American College of Cardiology 62, e147-239.
No Suggested Reading articles found!
Viewed
Full textCited
Shared Discussed
留言 (0)