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Cardiomyopathy

Diseases Myocardial

Cardiomyopathy refers to a clinical disease that involves the muscles of the heart. Cardiomyopathy usually causes the heart muscles to grow thicker, and more rigid than the normal myocardium. The progressive scarring of the heart muscle may sometimes replace the physiologic role of the normal myocardium.


Presentation

Patients diagnosed with Restrictive Cardiomyopathy will present with the following signs and symptoms:

Patients diagnosed with Dilated Cardiomyopathy will present with the following signs and symptoms:

Majority of patients with Hypertrophic Cardiomyopathy (HCM) are asymptomatic. The following symptomatology may be seen in patients with HCM:

Fatigue
  • These signs and symptoms include: Shortness of breath or trouble breathing, especially with physical exertion Fatigue (tiredness) Swelling in the ankles, feet, legs, abdomen, and veins in the neck Other signs and symptoms may include dizziness; light-headedness[web.archive.org]
  • Symptoms: Patients with cardiomyopathy will typically present with dyspnea, orthopnea, paroxysmal nocturnal dyspnea, bilateral edema, and fatigue.[symptoma.com]
  • Common symptoms of heart failure include shortness of breath, fatigue and swelling of the ankles, feet, legs, abdomen and veins in the neck.[heart.org]
  • Symptoms of DCM can occur at any age and may include: Heart failure symptoms ( shortness of breath and fatigue ). Swelling of the lower extremities. Fatigue (feeling overly tired). Weight gain .[medicinenet.com]
Amyloidosis
  • Cardiac amyloidosis can resemble HCM; symmetric LV thickening is typical of amyloidosis but also occurs in HCM, and restrictive physiology and poor compliance may be present in both diseases. [25] However, amyloidosis tissue may be characterized by its[emedicine.com]
  • […] cardiomyopathy, such as coronary heart disease , heart attack , or a viral infection that inflames the heart muscle Diabetes or other metabolic diseases, or severe obesity Diseases that can damage the heart, such as hemochromatosis , sarcoidosis , or amyloidosis[web.archive.org]
  • Amyloidosis. (A disease in which abnormal proteins build up in the body's organs, including the heart.)[heart.org]
  • […] cocaine and amphetamines, and some medicines used to treat cancer Infections, especially viral infections that inflame the heart muscle Restrictive Cardiomyopathy Certain diseases, conditions, and factors can cause restrictive cardiomyopathy, including: Amyloidosis[web.archive.org]
  • The most common causes of this type of cardiomyopathy are amyloidosis and scarring of the heart from an unknown cause. Peripartum cardiomyopathy occurs during pregnancy or in the first 5 months afterward.[medlineplus.gov]
Congestive Heart Failure
  • Unfortunately, some women never recover and go on to develop chronic congestive heart failure with a death rate of 85% within five years.[womensheart.org]
  • The three common cardiomyopathies are: Dilated cardiomyopathy : This results in left ventricular systolic dysfunction and clinical manifestations of congestive heart failure.[healio.com]
  • The goal of treatment is to control or prevent congestive heart failure, improve heart function and prevent complications, such as arrhythmias and blood clots.[ucsfbenioffchildrens.org]
  • The progressive stretch of the heart’s myocardium reduces the volume of the cardiac output contributing to the development of congestive heart failure.[symptoma.com]
  • Congestive Heart Failure This is a common feature of all late stage cardiomyopathies when the muscles of the heart become too weak to pump enough blood to the body for normal function.[childrenscardiomyopathy.org]
Pallor
  • Affected individuals may also experience excessive sweating, fatigue, wheezing, and paleness of the skin (pallor).[rarediseases.org]
Dyspnea
  • Symptoms: Patients with cardiomyopathy will typically present with dyspnea, orthopnea, paroxysmal nocturnal dyspnea, bilateral edema, and fatigue.[symptoma.com]
  • However, after 10 infusions the patient developed dyspnea, edema of the legs, ascites and a weight gain of 10 kg because of a decompensated heart insufficiency with a reduced ejection fraction from formerly 48%-50% to 15%.[ncbi.nlm.nih.gov]
  • The obstructive type is also notable for signs of reduced blood flow ( dyspnea , vertigo , syncope ).[amboss.com]
  • , angina, syncope, sudden death Systolic murmur mitral regurgitation murmur, S4 Bifid carotid pulse with a brisk upstroke and rapid downstroke Exertional dyspnea and fatigue LV RV failure Functional AV valve regurgitation ECG Nonspecific ST- and T-wave[merckmanuals.com]
Exertional Dyspnea
  • ) dyspnea Angina pectoris Vertigo , syncope Obstructive and nonobstructive type Cardiac arrhythmias and palpitations Sudden cardiac death (particularly during or after intense physical activity ) HOCM is an important cause of sudden cardiac death in young[amboss.com]
  • dyspnea, angina, syncope, sudden death Systolic murmur mitral regurgitation murmur, S4 Bifid carotid pulse with a brisk upstroke and rapid downstroke Exertional dyspnea and fatigue LV RV failure Functional AV valve regurgitation ECG Nonspecific ST- and[merckmanuals.com]
  • dyspnea. 2,3 Thus, a high index of suspicion is necessary for diagnosis.[scielo.mec.pt]
  • Suspicion may be raised by chest pain, exertional dyspnea, fatigue, syncope, palpitations, ventricular tachyarrhythmias, and conduction abnormalities or by acute congestive heart failure or cardiogenic shock associated with LV dilatation and/or segmental[web.archive.org]
Pleural Effusion
  • Associated pleural effusions may also be seen.[radiopaedia.org]
  • effusions Cardiac catheterization with pressure measurements Possible myocardial biopsy to identify underlying cause Treatment References: [1] [3] [16] [17] Arrhythmogenic right ventricular cardiomyopathy (ARVC) Epidemiology Especially young adults Etiology[amboss.com]
  • Pulmonary multi-detector computed tomography angiography excluded acute pulmonary embolism but revealed bilateral pulmonary infiltration and pleural effusion suggesting acute pulmonary edema. transthoracic echo-cardiography (TTE) revealed four-chamber[scielo.mec.pt]
  • Common abnormalities seen on the chest radiograph include cardiomegaly, interstitial edema, pleural effusion(s), and evidence of previous sternotomy (sternal wires).[clevelandclinicmeded.com]
Rales
  • Pulmonary auscultation showed bilateral rales and wheezing. Arterial gasometry revealed chronic respiratory alkalosis and oxygen saturation of 95%.[scielo.mec.pt]
Heart Disease
  • Understand Your Risk for Cardiomyopathy Symptoms and Diagnosis of Cardiomyopathy Prevention and Treatment of Cardiomyopathy Cardiomyopathy in Children Learn more: Family History and Heart Disease Alcohol and Heart Disease Cocaine, Marijuana and Other[heart.org]
  • From Wikidata Jump to navigation Jump to search A heart disease and a myopathy that is characterised by deterioration of the function of the heart muscle edit English cardiomyopathy A heart disease and a myopathy that is characterised by deterioration[wikidata.org]
  • This study aims to help train staff on a range of heart conditions by evaluating patients of all ages at the National Institutes of Health Clinical Center who have heart disease or are at risk of heart disease.[nhlbi.nih.gov]
Chest Pain
  • You develop chest pain, palpitations, faintness, or other new or unexplained symptoms.[medlineplus.gov]
  • pain, especially after physical exertion or heavy meals; and heart murmurs .[web.archive.org]
  • RATIONALE: The typical symptoms of stress cardiomyopathy include sudden-onset chest pain and breathlessness or collapse as well as classical symptoms of cardiovascular disease; however, rare reports have described nervous system symptoms as the initial[ncbi.nlm.nih.gov]
  • Symptoms can include chest pain , dizziness, shortness of breath, or fainting . Hypertrophic cardiomyopathy also can affect the heart's mitral valve, causing blood to leak backward through the valve.[heart.org]
Palpitations
  • Symptoms include palpitations and fainting after physical activity. Palpitations are feelings that your heart is skipping a beat, fluttering or beating too hard or too fast. ARVD usually affects teens or young adults.[heart.org]
  • At a clinic visit 5 months later, she had received no ICD shocks and reported no symptoms of severe palpitations.[nejm.org]
  • Palpitation Palpitation is an uncomfortable awareness of the heart beat. People may occasionally feel an extra beat or a skipped beat and this is usually normal. Sometimes an awareness of the heart beating does suggest and irregular heart rhythm.[ineaia.tripod.com]
  • You develop chest pain, palpitations, faintness, or other new or unexplained symptoms.[medlineplus.gov]
  • Illustration depicting the difference between a normal heart and hypertrophic cardiomyopathy Symptoms include shortness of breath, chest discomfort, palpitations, fatigue, dizziness or passing out.[barnesjewish.org]
Tachycardia
  • Case 2 presented isolated LVNC with nonsustained ventricle tachycardia. A cesarean section was performed at 36 weeks' gestation because of placenta previa. Case 3 presented dilated LVNC.[ncbi.nlm.nih.gov]
  • Most common mode of presentation was ventricular tachycardia (VT). Two patients had left ventricular (LV) systolic dysfunction. One patient had a splice site mutation in exon 12 of PKP2 gene and one patient died during follow-up.[ncbi.nlm.nih.gov]
  • A 68-year-old woman presented with symptoms of palpitations and was found to have frequent premature ventricular contractions and nonsustained ventricular tachycardia.[nejm.org]
  • Most commonly, ventricular tachycardia occurs. Sudden cardiac death is the main concern in ARVD. The classic ECG finding of Epsilon waves from early afterdepolarizations of the ventricles is actually rare.[healio.com]
  • Treat possible ventricular tachycardia or atrial fibrillation If there is high risk of sudden cardiac death ; : consider an implantable cardioverter defibrillator (ICD) If symptoms persist after medical therapy , or in cases of NYHA III/IV heart failure[amboss.com]
Heart Murmur
  • (Heart murmurs are extra or unusual sounds heard during a heartbeat.) Updated: June 22, 2016[web.archive.org]
  • Show More In some cases, cardiomyopathy is diagnosed when a heart murmur is detected at a routine doctor visit, although children with cardiomyopathy do not always have a heart murmur.[ucsfbenioffchildrens.org]
  • For example, the loudness, timing, and location of a heart murmur may suggest obstructive hypertrophic cardiomyopathy. A "crackling" sound in the lungs may be a sign of heart failure.[nhlbi.nih.gov]
Hepatomegaly
  • Additional symptoms may include fluid collection in the abdomen (ascites) and feet due to accumulation of fluid, congestion of the lungs, and an abnormally large liver (hepatomegaly).[rarediseases.org]
Stroke
  • During a median follow-up of 25.0 17.8 months, the primary end point of HF hospitalization, stroke or death occurred in 35 patients (21%).[ncbi.nlm.nih.gov]
  • KEYWORDS: drug misuse (including Addiction); ischaemic heart disease; stroke[ncbi.nlm.nih.gov]
  • RESULTS: Three (7.3%) patients in the metoprolol group and nine (24.3%) patients in the placebo group showed improved stroke volume (P 0.057).[ncbi.nlm.nih.gov]
  • Moreover, clinical and laboratory research shows that cardiac structural damage can occur in the presence of a normal heart, especially in the context of seizures, stroke, and traumatic brain injury or under conditions of psychological stress.[ncbi.nlm.nih.gov]
  • Whereas the pathogenesis of this disorder is not well understood, it usually occurs after an emotional or physical stress such as acute asthma, surgery, chemotherapy, and stroke. However, its occurrence in ileus patients is rarely reported.[ncbi.nlm.nih.gov]

Workup

The following laboratory work up and tests are done to investigate patients with impending cardiomyopathy:

  • Chest X-ray – Chest radiographs will show whether the heart is enlarged.
  • Echocardiography – This makes use of sound waves that determines size and functions of the heart. 
  • Electrocardiogram (ECG) – This diagnostic modality uses chest electrodes to determine the electrical activity of the heart. This can detect abnormal rhythms and enlargement by voltage.
  • Magnetic Resonance Imaging (MRI) – This makes use of magnetic fields and radio waves to determine a more detailed image of the heart [8].
  • Cardiac Catheterization – This procedure makes use of a slender flexible tube inserted in the major vessels to the heart where a sample biopsy of the heart tissue may be taken for laboratory examination.
  • Laboratory tests – blood test like the Beta-type natriuretic peptide (BNP) are tested for elevation due to heart failure which is seen as a common complication of cardiomyopathy. Troponin I may also be used to prognosticate heart failures in cardiomyopathy [9].
ST Elevation
  • […] ventricle Epidemiology : especially postmenopausal women 60 years Pathophysiology : emotional/physical stress massive catecholamine discharge ; cardiotoxicity, multi-vessel spasms and dysfunction myocardial stunning Clinical findings : Diagnostics ECG : ST[amboss.com]
  • Heart - infarction [# 5, median year 2009 (2008-2015)] Acute myocardial infarction with ST-elevation and spontaneous coronary artery dissection can occur in young patients with CD[ 3 , 136 ].[doi.org]
Right Bundle Branch Block
  • bundle branch block Echocardiography and/or cardiac MRI Right ventricular enlargement, wall motion abnormalities EF Treatment Avoid intense physical exertion Anti-arrhythmic treatment Pharmacologic: beta blockers (e.g., sotalol ), amiodarone , calcium[amboss.com]
  • First described in 1992, the syndrome is identified by a distinctive ECG pattern consisting of right bundle-branch block and coved ST-segment elevation in the anterior precordial leads (V 1 through V 3 ).[web.archive.org]
Ventricular Bigeminy
  • Frequent ventricular ectopics and ventricular bigeminy (seen with severe DCM). Ventricular dysrhythmias ( VT / VF ). ECG Examples Example 1 Ischaemic dilated cardiomyopathy: There is marked LVH (S wave in V2 35 mm) with dominant S waves in V1-4.[lifeinthefastlane.com]
T Wave Inversion
  • wave inversion, abnormal Q waves , nonspecific abnormalities Laboratory: troponin T ; , BNP Echocardiography : apical left ventricular ballooning , LVEF Coronary angiography : usually no pathological findings Treatment Prognosis : spontaneous recovery[amboss.com]
  • New electrocardiographic abnormalities either ST-segment elevation and/or T-wave inversion or modest elevation in cardiac troponin level. Absence of pheochromocytoma or myocarditis.[radiologyassistant.nl]
  • […] proteins such as plakoglobin, plakophilin-2, desmoplakin, desmocollin-2, and desmoglein-2. 56 , 57 Clinical diagnosis can be challenging but relies largely on familial occurrence, left bundle-branch pattern ventricular tachyarrhythmias, ECG findings of T-wave[doi.org]
  • ECGs most commonly show abnormal repolarization with T-wave inversion in leads V 1 through V 3 and small-amplitude potentials at the end of the QRS complex (epsilon wave); Brugada syndrome–like right bundle-branch block and right precordial ST-segment[web.archive.org]
Myocardial Fibrosis
  • KEYWORDS: diabetic cardiomyopathy; heart failure; inflammation; metabolic dysregulation; myocardial fibrosis[ncbi.nlm.nih.gov]
  • Myocardial fibrosis correlated with systolic function, and patients with poor outcomes had more extensive myocardial fibrosis.[jamanetwork.com]
  • Because localizing focal fibrosis with LGE involves "nulling" the signal of surrounding myocardium, the technique is unable to identify more diffuse interstitial myocardial fibrosis.[emedicine.com]
  • fibrosis Role in prognosis Differential diagnosis Nuclear imaging Endomyocardial biopsy Laboratory tests Genetic testing and family screening Counselling in probands Methods for molecular genetic screening in probands Indications for genetic testing[escardio.org]
  • Diffuse myocardial fibrosis may lead to reduced voltage QRS complexes, particularly in the limb leads. There may be a discrepancy of QRS voltages with signs of hypertrophy in V4-6 and relatively low voltages in the limb leads.[lifeinthefastlane.com]
Left Ventricular Hypertrophy
  • Example 3 Dilated cardiomyopathy: There is marked left ventricular hypertrophy with repolarisation abnormality (LV “strain” pattern) in V5-6.[lifeinthefastlane.com]
  • Association between diabetes mellitus and left ventricular hypertrophy in a multiethnic population. Am J Cardiol. 2008;101(12):1787–91. CrossRef PubMed Google Scholar 7.[doi.org]
  • ventricular hypertrophy (see Sokolow-Lyon criteria ) Left bundle branch block Ventricular tachycardia or atrial fibrillation Echocardiography Confirmatory test Asymmetrically thickened left ventricular wall 15 mm Septum thickness to inferoposterior wall[amboss.com]
  • Hypertensive cardiomyopathy often presents with left ventricular hypertrophy in association with features of dilated or restrictive cardiomyopathy with cardiac failure.[circ.ahajournals.org]
Biventricular Hypertrophy
  • The most common ECG abnormalities are those associated with atrial and ventricular hypertrophy — typically, left sided changes are seen but there may be signs of biatrial or biventricular hypertrophy. Interventricular conduction delays (eg.[lifeinthefastlane.com]
Pleural Effusion
  • Associated pleural effusions may also be seen.[radiopaedia.org]
  • effusions Cardiac catheterization with pressure measurements Possible myocardial biopsy to identify underlying cause Treatment References: [1] [3] [16] [17] Arrhythmogenic right ventricular cardiomyopathy (ARVC) Epidemiology Especially young adults Etiology[amboss.com]
  • Pulmonary multi-detector computed tomography angiography excluded acute pulmonary embolism but revealed bilateral pulmonary infiltration and pleural effusion suggesting acute pulmonary edema. transthoracic echo-cardiography (TTE) revealed four-chamber[scielo.mec.pt]
  • Common abnormalities seen on the chest radiograph include cardiomegaly, interstitial edema, pleural effusion(s), and evidence of previous sternotomy (sternal wires).[clevelandclinicmeded.com]

Treatment

For restrictive cardiomyopathy, therapeutic modalities are focused on the alleviation of the symptoms. Water and salt intake monitoring is paramount to prevent overload. In some case, patients are given diuretics to unload water retention in RCM. When heart failure become progressively worse, cardiac transplant may be the only option for RCM.

Dilated cardiomyopathy are medically treated with Angiotensin converting enzyme inhibitors, Angiotensin receptor blockers, beta blockers, digoxin, and diuretics [10]. A pacemaker may be installed in patients with DCM to synchronize any irregular cardiac rhythm. Hypertrophic cardiomyopathy are given medications to relax the heart muscles like beta blockers and calcium channel blockers. Cardiac surgeries like septal myectomy and septal ablation are some of the surgical options elected to debulk the thickened muscles of the heart.

Prognosis

In both children and adult population the outlook for restrictive cardiomyopathy is generally poor. Most patient progress to low output heart failure which may complicate to thromboembolism or cardiac cirrhosis. There is a higher mortality rate in dilated cardiomyopathy associated with severe congestive heart failure (CHF), male sex, and increasing age. About half of the patients with DCM presenting with CHF will die within the first 5 years from diagnosis [5]. Although patients with DCM having mild CHF carries a brighter outlook. Hypertrophic cardiomyopathy carries the best prognosis with only 1-3% mortality rating [6]. Majority of the mortality seen in HCM is due to sudden death caused by ventricular tachycardia and fibrillation. Morbidity and mortality improves with early diagnosis and intervention of the HCM disease [7].

Etiology

In the majority of cases of cardiomyopathy, the etiologic causation is often times unknown. The following pre-morbid causes has been implicated as the most common identifiable causes of cardiomyopathy in clinical practice:

Epidemiology

In the world wide scale, the reported incidence of cardiomyopathy is up to 400,000 to 550,000 diagnosed cases per annum prevailing in up to 5 million people. In the United States, the most common form of restrictive myocarditis is the idiopathic type. The prevalence of endomyocardial fibrosis (EMF) abounds in the subtropical areas of Africa among children and young adults [1]. Causing 25% of the deaths due to heart diseases in the same African regions.

Dilated cardiomyopathy can affect patients at any age but symptoms usually surface in the third and fourth decade of life. Hypertrophic cardiomyopathy (HCM) represents 0.5% of patient brought in for diagnostic echocardiography [2]. The worldwide prevalence rate of HCM is only 50 to 200 cases per 100,000 population [3]. HCM has a slight male predilection over the female population with a peak mean age of occurrence at the third decade of life. Although in the adult population, the majority of the diagnosed cases HCM are within the 30’s to 60’s age range.

Sex distribution
Age distribution

Pathophysiology

In restrictive cardiomyopathy (RCM), the stiffness in the myocardium can give rise to an increased intra ventricular pressure even in the light of a smaller stroke volume [4]. The restrictive effect on the ventricular volume can lead to diastolic heart failure because of the progressive loss of stroke volume due to the muscular restriction. Fibrotic changes in the heart muscles can cause cardiac scarring on the heart surface and cause bundle branch block in the electrophysiology of the heart.

In the dilated cardiomyopathy cases, the ventricle begins to enlarge due to the chronic left ventricular failure causing both systolic and diastolic type of heart failures. The progressive stretch of the heart’s myocardium reduces the volume of the cardiac output contributing to the development of congestive heart failure. The progressive dilatation of the ventricles can lead to the development of an acquired tricuspid and mitral valve regurgitation defects.

The progressive hypertrophy of the heart muscles in hypertrophic cardiomyopathy increases the pressure gradient in the outflow tracts of the circulating blood. Mitral valve dysfunction happens in hypertrophic cardiomyopathy when the hypertrophy involves the heart papillary muscles and the muscular septal hypertrophy displacing the outflow tract of the mitral valve. The thickening of the heart muscles can also impair the calcium channel physiology.

Prevention

In most cases, cardiomyopathy could not be prevented. Patients can only modify some activities that may result in heart failure with cardiomyopathy like abstaining from alcohol or recreational drugs. A balanced diet with adequate vitamins and minerals can actively prevent heart failure in some cases of cardiomyopathies.

Summary

Cardiomyopathy is a general term given to abnormal heart muscles. Clinically, there are basically three types of cardiomyopathies: Restrictive, Dilated, and Hypertrophic cardiomyopathy. This abnormalities seen in the heart muscles retards the normal delivery of blood throughout the organ systems of the body. Cardiomyopathy can progress to serious heart failure if left untreated. Treatment approaches to cardiomyopathy grossly depends on the type and could be therapeutically corrected by either surgical or medical means.

Patient Information

  • Definition: Cardiomyopathy refers to any clinical disease that involves the muscles of the heart that results in the alteration in the shape and size of the myocardium.
  • Cause: A number of pre-morbid causes can give rise to cardiomyopathy like hypertension, thyroid diseases, diabetes, cardiac scarring, and viral infections.
  • Symptoms: Patients with cardiomyopathy will typically present with dyspnea, orthopnea, paroxysmal nocturnal dyspnea, bilateral edema, and fatigue.
  • Diagnosis: Cardiomyopathy work up includes: Chest X-ray, ECG, MRI, Echocardiography, blood tests, and cardiac catheterizations.
  • Treatment and follow-up: Medical treatment of cardiomyopathy includes the usage of beta blocker, digoxin, ACE inhibitors, and calcium channel blockers. Surgical cardiac muscle myectomy and ablation may also be used to debulk the heart. 

References

Article

  1. Braunwald E, Abelmann WH. Atlas of Heart Diseases. Vol 2. 1994:53-61.
  2. Maron BJ, Peterson EE, Maron MS, Peterson JE. Prevalence of hypertrophic cardiomyopathy in an outpatient population referred for echocardiographic study. Am J Cardiol. Mar 15 1994; 73(8):577-80.
  3. Maron BJ, Gardin JM, Flack JM, et al. Prevalence of hypertrophic cardiomyopathy in a general population of young adults. Echocardiographic analysis of 4111 subjects in the CARDIA Study. Coronary Artery Risk Development in (Young) Adults. Circulation. Aug 15 1995; 92(4):785-9.
  4. Goldstein JA. Differentiation of constrictive pericarditis and restrictive cardiomyopathy. ACC Ed Highlights. Fall 1998; 14-22.
  5. McKee PA, Castelli WP, McNamara PM, Kannel WB. The natural history of congestive heart failure: the Framingham study. N Engl J Med. Dec 23 1971; 285(26):1441-6.
  6. Maron BJ. Hypertrophic cardiomyopathy: a systematic review. JAMA. Mar 13 2002; 287(10):1308-20.
  7. DeRose JJ Jr, Banas JS Jr, Winters SL. Current perspectives on sudden cardiac death in hypertrophic cardiomyopathy. Prog Cardiovasc Dis. May-Jun 1994; 36(6):475-84.
  8. Francone M. Role of cardiac magnetic resonance in the evaluation of dilated cardiomyopathy: diagnostic contribution and prognostic significance. ISRN Radiol. 2014; 2014:365404.
  9. La Vecchia L, Mezzena G, Zanolla L, Paccanaro M, Varotto L, Bonanno C, et al. Cardiac troponin I as diagnostic and prognostic marker in severe heart failure. J Heart Lung Transplant. Jul 2000; 19(7):644-52.
  10. Felker GM, Lee KL, Bull DA, Redfield MM, Stevenson LW, Goldsmith SR, et al. Diuretic strategies in patients with acute decompensated heart failure. N Engl J Med. Mar 3 2011; 364(9):797-805.

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Last updated: 2018-06-22 10:15