1
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Rahhal A, Provan D, Shunnar K, Najim M, Ahmed AO, Rozi W, Al-Khabori M, Marashi M, AlRasheed M, Osman H, Yassin M. Concurrent coronary artery disease and immune thrombocytopenia: a systematic review. Front Med (Lausanne) 2023; 10:1213275. [PMID: 37886354 PMCID: PMC10598342 DOI: 10.3389/fmed.2023.1213275] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2023] [Accepted: 09/13/2023] [Indexed: 10/28/2023] Open
Abstract
Introduction Coronary artery disease (CAD) management in the setting of immune thrombocytopenia (ITP) remains very challenging to clinicians as a reasonable balance between bleeding and thrombosis risks needs to be achieved, and the evidence guiding such management is scarce. Methods We conducted a systematic review following the PRISMA guidelines to summarize the available literature on the management and outcomes of CAD coexisting with ITP. We searched PubMed and Embase for studies published in English exploring CAD and ITP management until 05 October 2022. Two independent reviewers screened and assessed the articles for inclusion. Patients' characteristics, CAD treatment modalities, ITP treatment, and complications were reported. Results We identified 32 CAD cases, among which 18 cases were revascularized with percutaneous coronary intervention (PCI), 12 cases underwent coronary artery bypass graft surgery (CABG), and two cases were managed conservatively. More than 50% were men, with a mean age of 61 ± 13 years and a mean baseline platelet count of 52 ± 59 × 109/L. Irrespective of the revascularization modality, most patients were treated with either corticosteroids alone, intravenous immunoglobulins (IVIG) alone, or in combination. Among those who underwent PCI, two patients had bleeding events, and one patient died. Similarly, among those with CABG, one patient developed bleeding, and one patient died. Conclusion We found that revascularization with either PCI or CABG with the concurrent use of corticosteroids and/or IVIG for ITP was feasible, with an existing non-negligible risk of bleeding and mortality.
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Affiliation(s)
- Alaa Rahhal
- Pharmacy Department, Hamad Medical Corporation, Doha, Qatar
| | - Drew Provan
- Barts and The London School of Medicine, Queen Mary University of London, London, United Kingdom
| | - Khaled Shunnar
- Cardiology Department, Hamad Medical Corporation, Doha, Qatar
| | - Mostafa Najim
- Internal Medicine Department, Rochester Regional Health—Unity Hospital, New York, NY, United States
| | - Ashraf Omer Ahmed
- Internal Medicine Department, Hamad Medical Corporation, Doha, Qatar
| | - Waail Rozi
- Internal Medicine Department, Hamad Medical Corporation, Doha, Qatar
| | | | - Mahmoud Marashi
- Dubai Academic Health Corporation and Mediclinic Hospital, Dubai, United Arab Emirates
| | | | - Hani Osman
- Hematology and Oncology Department, Tawam Hospital, Abu-Dhabi, United Arab Emirates
| | - Mohamed Yassin
- Hematology Department, National Centre for Cancer Care and Research, Hamad Medical Corporation, Doha, Qatar
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2
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Ali EA, Rasheed M, Al-sadi A, Awadelkarim AM, Saad EA, Yassin MA. Immune Thrombocytopenic Purpura and Paradoxical Thrombosis: A Systematic Review of Case Reports. Cureus 2022; 14:e30279. [DOI: 10.7759/cureus.30279] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/13/2022] [Indexed: 11/07/2022] Open
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3
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Davis M, Movahed MR, Hashemzadeh M, Hashemzadeh M. The presence of idiopathic thrombocytopenic purpura and incidence of acute non-ST elevation myocardial infarction. Ann Hematol 2021; 101:21-26. [PMID: 34596718 DOI: 10.1007/s00277-021-04668-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2021] [Accepted: 09/17/2021] [Indexed: 10/20/2022]
Abstract
Platelets play an integral role in the pathogenesis of acute coronary syndrome (ACS). The purpose of this study was to investigate any correlation between immune thrombocytopenia (ITP) and non-ST segment elevation myocardial infarction (NTSEMI), a common presentation of ACS. Using the large Nationwide Inpatient Sample (NIS) database, we studied any correlation between NSTEMI and ITP utilizing ICD-9 codes. We performed uni- and multivariate analysis adjusting for risk factors from the years 2002-2011. Data was extracted from 106,653 ITP patients and 79,636,090 controls. In multiple years of the study period (2002-2011), NSTEMI incidence was significantly higher in ITP patients when compared with non-ITP patients in the univariate analysis (odds ratio average 1.226). However, no significant association was found after adjusting for additional risk factors in multivariate analysis. Based on our large database study, ITP is not independently associated with NSTEMI incidence after adjusting for comorbidity.
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Affiliation(s)
- Mitchell Davis
- College of Medicine Phoenix, University of Arizona, 6119 North Pinchot, Phoenix, AZ, 85750, USA
| | - Mohammad Reza Movahed
- College of Medicine Phoenix, University of Arizona, 6119 North Pinchot, Phoenix, AZ, 85750, USA.,University of Arizona, Sarver Heart Center, Tucson, AZ, USA
| | - Mehrtash Hashemzadeh
- College of Medicine Phoenix, University of Arizona, 6119 North Pinchot, Phoenix, AZ, 85750, USA
| | - Mehrnoosh Hashemzadeh
- College of Medicine Phoenix, University of Arizona, 6119 North Pinchot, Phoenix, AZ, 85750, USA. .,Pima Community College, Tucson, AZ, USA.
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4
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Davis M, Movahed MR, Hashemzadeh M, Hashemzadeh M. The presence of idiopathic thrombocytopenic purpura correlates with lower rate of acute ST-elevation myocardial infarction. Future Cardiol 2021; 17:1327-1333. [PMID: 33988030 DOI: 10.2217/fca-2020-0183] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Background: Platelets are important in the pathogenesis of myocardial infarction (MI). We hypothesize that patients with acquired thrombocytopenia such as idiopathic thrombocytopenic purpura (ITP) may have lower MI rate. Materials & method: The Nationwide Inpatient Sample was used for this study. We analyzed the correlation between ST-elevation MI (STEMI) and ITP utilizing ICD-9 codes. Results: STEMI rate was lower in patients with ITP. We found that, in 2002, STEMI occurred in 0.64% of patients with ITP versus 0.89 (p < 0.007) and for 2011 0.30 versus 0.48 (p < 0.005). After adjusting for tobacco use, diabetes, hypertension, hyperlipidemia, gender and age, STEMI rate remained lower in ITP patients. Conclusion: ITP appears to be associated with lower STEMI rate suggesting low platelet count may exert protective effect from STEMI.
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Affiliation(s)
- Mitchell Davis
- College of Medicine Phoenix, University of Arizona, AZ 85004, USA
| | - Mohammad Reza Movahed
- College of Medicine Phoenix, University of Arizona, AZ 85004, USA.,CareMore, Tucson, AZ 85718, USA
| | | | - Mehrnoosh Hashemzadeh
- College of Medicine Phoenix, University of Arizona, AZ 85004, USA.,Pima Community College, Tucson, AZ 85709, USA
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5
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Chehab O, Abdallah N, Kanj A, Pahuja M, Adegbala O, Morsi RZ, Mishra T, Afonso L, Abidov A. Impact of immune thrombocytopenic purpura on clinical outcomes in patients with acute myocardial infarction. Clin Cardiol 2019; 43:50-59. [PMID: 31710764 PMCID: PMC6954382 DOI: 10.1002/clc.23287] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/06/2019] [Revised: 10/14/2019] [Accepted: 10/21/2019] [Indexed: 11/29/2022] Open
Abstract
Background Patients with immune thrombocytopenic purpura (ITP) admitted with acute myocardial infarction (AMI) may be challenging to manage given their increased risk of bleeding complications. There is limited evidence in the literature guiding appropriate interventions in this population. The objective of this study is to determine the difference in clinical outcomes in AMI patients with and without ITP. Methods Using the United States national inpatient sample database, adults aged ≥18 years, who were hospitalized between 2007 and 2014 for AMI, were identified. Among those, patients with ITP were selected. A propensity‐matched cohort analysis was performed. The primary outcome was in‐hospital mortality. Secondary outcomes were coronary revascularization procedures, bleeding and cardiovascular complications, and length of stay (LOS). Results The propensity‐matched cohort included 851 ITP and 851 non‐ITP hospitalizations for AMI. There was no difference in mortality between ITP and non‐ITP patients with AMI (6% vs7.3%, OR:0.81; 95% CI:0.55‐1.19; P = .3). When compared to non‐ITP patients, ITP patients with AMI underwent fewer revascularization procedures (40.9% vs 45.9%, OR:0.81; 95% CI:0.67‐0.98; P = .03), but had a higher use of bare metal stents (15.4% vs 11.3%, OR:1.43; 95% CI:1.08‐1.90; P = .01), increased risk of bleeding complications (OR:1.80; CI:1.36‐2.38; P < .0001) and increased length of hospital stay (6.14 vs 5.4 days; mean ratio: 1.14; CI:1.05‐1.23; P = .002). More cardiovascular complications were observed in patients requiring transfusions. Conclusions Patients with ITP admitted for AMI had a similar in‐hospital mortality risk, but a significantly higher risk of bleeding complications and a longer LOS compared to those without ITP. Further studies are needed to assess optimal management strategies of AMI that minimize complications while improving outcomes in this population.
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Affiliation(s)
- Omar Chehab
- Department of Internal Medicine, Wayne State University, Detroit, Michigan
| | - Nadine Abdallah
- Department of Internal Medicine, Wayne State University, Detroit, Michigan
| | - Amjad Kanj
- Department of Internal Medicine, Wayne State University, Detroit, Michigan
| | - Mohit Pahuja
- Department of Internal Medicine, Wayne State University, Detroit, Michigan
| | - Oluwole Adegbala
- Department of Internal Medicine, Wayne State University, Detroit, Michigan
| | - Rami Z Morsi
- Department of Internal Medicine, Brigham and Women's Hospital, Boston, Massachusetts
| | - Tushar Mishra
- Department of Internal Medicine, Wayne State University, Detroit, Michigan
| | - Luis Afonso
- Department of Internal Medicine, Wayne State University, Detroit, Michigan
| | - Aiden Abidov
- Department of Internal Medicine, Wayne State University, Detroit, Michigan.,Cardiology Section, Department of Internal Medicine, John D. Dingell VA Medical Center, Detroit, Michigan
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6
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Fujino S, Niwa S, Fujioka K, Mabuchi T, Noji Y, Yamaguchi M, Aoyama T. Primary Percutaneous Coronary Intervention by a Stentless Technique for Acute Myocardial Infarction with Idiopathic Thrombocytopenic Purpura: A Case Report and Review of the Literature. Intern Med 2016; 55:147-52. [PMID: 26781014 DOI: 10.2169/internalmedicine.55.4544] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
A 78-year-old man who had been diagnosed with idiopathic thrombocytopenic purpura (ITP) was admitted to our hospital with chest pain, cold sweating and nausea. An electrocardiogram and echocardiogram revealed an ST elevated acute lateral myocardial infarction. He underwent an immediate cardiac catheterization. An occluded left circumflex artery was detected by coronary angiography. Reperfusion was performed successfully by non-slip element balloon angioplasty alone, without stenting, to avoid prolonged dual anti-platelet therapy. In this report we discussed the management strategies of acute myocardial infarction in a patient with concomitant ITP.
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Affiliation(s)
- Susumu Fujino
- Department of Cardiology, Fukui Prefectural Hospital, Japan
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7
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Li-Sha G, Peng C, Yue-Chun L. Recurrent acute coronary syndrome and restenosis after percutaneous coronary intervention in a patient with idiopathic thrombocytopenic purpura: a case report and literature review. BMC Cardiovasc Disord 2015; 15:101. [PMID: 26385102 PMCID: PMC4574573 DOI: 10.1186/s12872-015-0092-3] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2014] [Accepted: 09/12/2015] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Platelets play a pivotal role in the pathogenesis of acute coronary syndrome (ACS) and acute and chronic complications following percutaneous coronary intervention (PCI). Platelet inhibition is a cornerstone in the management of these patients. Idiopathic thrombocytopenic purpura (ITP) is a bleeding disorder characterized by premature platelet destruction mediated by autoantibodies. The safety of antiplatelet therapy and PCI in patients who have ACS and ITP is unknown. The aim of the present study is to discuss the management strategies for patients who have ACS and ITP and to review limited data available in the literature. CASE PRESENTATION We report the case of a patient with ITP who underwent three separate coronary interventions. The first PCI with stenting was performed in the left anterior descending artery 5 years ago while the patient suffered an anterior acute myocardial infarction, and the platelet count at admission was 90 × 10(9)/L. The patient presented with recurrent ACS and severe in-stent restenosis 5 years after the first PCI, and the platelet count at admission was 18 × 10(9)/L, and elevated to 87 × 10(9)/L after platelets transfusion. He was treated successfully with cutting balloon angioplasty under anticoagulation with unfractionated heparin and antiagregation with acetylsalicylic acid and clopidogrel. Four months later after cutting balloon angioplasty, the patient received an intracoronary stent when he once again presented with recurrent ACS in the setting of restenosis. The patient has been observed for 1.5 years without restenosis after the third PCI. CONCLUSION We reviewed all the cases in the literature involving PCI and discussed the management strategies in patients with ITP and ACS. Available data suggest that PCI can be safe and feasible, and the risk-benefit equation of PCI procedures and antiplatelet therapies should be carefully evaluated, and the treatment should be individualized.
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Affiliation(s)
- Ge Li-Sha
- Department of Pediatric, Second Affiliated Hospital of Wenzhou Medical University, Wenzhou, 325000, China.
| | - Chen Peng
- Department of Cardiology, Second Affiliated Hospital of Wenzhou Medical University, 109 Xueyuan Road, Wenzhou, Zhejiang, China.
| | - Li Yue-Chun
- Department of Cardiology, Second Affiliated Hospital of Wenzhou Medical University, 109 Xueyuan Road, Wenzhou, Zhejiang, China.
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8
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Protective function of tocilizumab in human cardiac myocytes ischemia reperfusion injury. ASIAN PAC J TROP MED 2015; 8:48-52. [PMID: 25901924 DOI: 10.1016/s1995-7645(14)60186-3] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2014] [Revised: 11/15/2014] [Accepted: 12/20/2014] [Indexed: 11/22/2022] Open
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9
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Lee CH, Kim U. Revascularization for patients with idiopathic thrombocytopenic purpura and coronary artery disease. Korean Circ J 2014; 44:264-7. [PMID: 25089139 PMCID: PMC4117848 DOI: 10.4070/kcj.2014.44.4.264] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2014] [Revised: 04/24/2014] [Accepted: 06/12/2014] [Indexed: 11/11/2022] Open
Abstract
Idiopathic thrombocytopenic purpura (ITP) is an autoimmune disorder with a low platelet count characterized by premature platelet destruction and suppression of platelet production mediated by autoantibodies, which may predispose to bleeding. Although the prevalence of coronary artery disease (CAD) in ITP seems to be rare, their co-occurrence is not unusual. Patients with ITP have increased risks for thrombosis and atherosclerosis associated with hemostatic factors, endothelial damage, and the negative effects of steroid and immunoglobulin therapies. Thus, the coexistence of ITP and CAD presents complex problems requiring a balance between hemorrhagic risk and prevention of thrombosis. Here, the authors present two patients with ITP, who were revascularized in different ways for CAD. Although the optimal management of thrombocytopenic patients with CAD is uncertain, individualized treatment modalities can be useful in patients with ITP and CAD.
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Affiliation(s)
- Chan-Hee Lee
- Division of Cardiology, Yeungnam University Medical Center, Daegu, Korea
| | - Ung Kim
- Division of Cardiology, Yeungnam University Medical Center, Daegu, Korea
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10
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Demircelik B, Altinsoy M, Bozduman F, Gunes M, Cakmak M, Eryonucu B. Coronary intervention for acute coronary syndrome in a 51-year-old man with immune thrombocytopenic purpura: a case report. J Med Case Rep 2014; 8:214. [PMID: 24950596 PMCID: PMC4077221 DOI: 10.1186/1752-1947-8-214] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2014] [Accepted: 04/28/2014] [Indexed: 11/17/2022] Open
Abstract
Introduction Treatment of the rare cases of patients with chronic idiopathic thrombocytopenic purpura with acute coronary syndrome can be a significant problem. The patient in our case report was treated successfully with percutaneous coronary intervention. Case presentation A 51-year-old man of Turkish origin who had idiopathic thrombocytopenic purpura was admitted to our hospital with severe chest pain. His electrocardiography was normal on admission but dynamic ischemic changes were observed during follow-up. He underwent immediate coronary angiography. In his angiography, left anterior descending artery stenosis was 90% together with the diagonal ostium. Percutaneous coronary intervention was performed successfully. Bleeding complications were not observed after the procedure. Conclusions We report the presence of a rare case of chronic idiopathic thrombocytopenic purpura in a patient with acute coronary syndrome. In this situation a serious multidisciplinary approach is required before coronary intervention.
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Affiliation(s)
- Bora Demircelik
- Department of Cardiology, Faculty of Medicine, Turgut Ozal University, Ankara, Turkey.
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11
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Two cases and review of the literature: primary percutaneous angiography and antiplatelet management in patients with immune thrombocytopenic purpura. ISRN HEMATOLOGY 2013; 2013:174659. [PMID: 24459590 PMCID: PMC3888679 DOI: 10.1155/2013/174659] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 11/17/2013] [Accepted: 12/04/2013] [Indexed: 11/17/2022]
Abstract
We report two cases of immune thrombocytopenic purpura (ITP) associated with acute coronary artery syndrome highlighting the interventions done in every case along with the medications used during intervention and as outpatient. The first case is that of a woman with ITP exacerbation while on dual antiplatelet therapy and the second case is that of a male presenting with non-ST elevation myocardial infarction (NSTEMI) while in a thrombocytopenic crisis. In both cases antiplatelet therapy was held and thrombopoietic therapy was initiated before resuming full anticoagulation and coronary intervention. Given the paucity of data on ITP and antiplatelets treatment in the setting of acute coronary syndrome, no strict recommendations can be proposed, but antiplatelets appear to be safe acutely and in the long term in this category of patients as long as few measures are undertaken to minimize the risks of bleeding and thrombosis.
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12
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Girolami A, Vettore S, Vianello F, Berti de Marinis G, Fabris F. Myocardial infarction in two cousins heterozygous for ASN41HIS autosomal dominant variant of Bernard-Soulier syndrome. J Thromb Thrombolysis 2013; 34:513-7. [PMID: 22569901 DOI: 10.1007/s11239-012-0742-6] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
Bernard-Soulier Syndrome is characterized by thrombocytopenia with large platelets and defective aggregation to ristocetin. The bleeding tendency is variable but may be severe. The syndrome is due to genetic defects of the GPIb-V-IX complex and it has been maintained to be protective from thrombotic events. Here we present the first two cases of documented M.I. in two cousins, heterozygous for the Arg41His mutation which is responsible for a dominant form of Bernard-Soulier Syndrome. In one of the two patients an aneurysm of the aorta was also present. The patients had a mild bleeding tendency which was severely aggravated by treatment with antiplatelet drugs. These clinical observations are in contrast with experimental studies which demonstrate that Bernard-Soulier-like strains of mice show a decreased thrombus generation in several experimental settings.
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Affiliation(s)
- Antonio Girolami
- Department of Medical and Surgical Sciences, Padua University, Via Ospedale 105, 35128, Padua, Italy.
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13
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Matzdorff A, Beer JH. Immune Thrombocytopenia Patients Requiring Anticoagulation—Maneuvering Between Scylla and Charybdis. Semin Hematol 2013; 50 Suppl 1:S83-8. [DOI: 10.1053/j.seminhematol.2013.03.020] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
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14
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Girolami A, de Marinis GB, Bonamigo E, Treleani M, Vettore S. Arterial and venous thromboses in patients with idiopathic (immunological) thrombocytopenia: a possible contributing role of cortisone-induced hypercoagulable state. Clin Appl Thromb Hemost 2012; 19:613-8. [PMID: 22790661 DOI: 10.1177/1076029612452114] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Immunological thrombocytopenias, as other forms of thrombocytopenia, are associated with bleeding. Occasionally, these patients manifest thrombotic events. A total of at least 29 patients were reported to have had either arterial (20 cases) or venous (9 cases) thrombosis while platelet count was less than 50 × 10(3)/μL. The most frequent clinical manifestation was a myocardial infarction. Thrombosis occurred in the large majority of patients during prednisone therapy. Patients receiving cortisone or patients with Cushing syndrome show a hypercoagulable state characterized by elevated factor VIII levels, decreased fibrinolysis, and abnormal von Willebrand factor multimers composition. The same is probably true for prednisone-treated patients with thrombocytopenia. However, the 2 conditions are not identical since prednisone is a mainly glycoactive compound, whereas cortisol produced in excess in Cushing syndrome is mainly mineraloactive. The presence of large, young, hyperactive platelets may also play a role. Prednisone-treated patients with thrombocytopenia have to be considered as potentially thrombophilic.
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Affiliation(s)
- Antonio Girolami
- 1Department of Medical and Surgical Sciences, University of Padua Medical School, Padua, Italy
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15
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Management of myocardial infarction in immune thrombocytopenic purpura with anti-phospholipid antibodies. J Thromb Thrombolysis 2012; 35:115-8. [DOI: 10.1007/s11239-012-0763-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
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16
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Xu W, Wang TY, Becker RC. Enfermedades hematológicas: desde dentro del corazón. Rev Esp Cardiol 2011; 64:606-13. [DOI: 10.1016/j.recesp.2011.02.018] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2011] [Accepted: 02/22/2011] [Indexed: 10/18/2022]
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