1
|
Li YT, Wang Y, Hu XJ, Chen JH, Li YY, Zhong QY, Cheng H, Mohammed BH, Liang XL, Hernandez J, Huang WY, Wang HHX. Association between Systolic Blood Pressure and Diabetic Retinopathy in Both Hypertensive and Normotensive Patients with Type 2 Diabetes: Risk Factors and Healthcare Implications. Healthcare (Basel) 2021; 9:580. [PMID: 34068355 PMCID: PMC8153301 DOI: 10.3390/healthcare9050580] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2021] [Revised: 04/28/2021] [Accepted: 05/07/2021] [Indexed: 11/26/2022] Open
Abstract
A common diabetes-related microvascular complication is diabetic retinopathy (DR), yet associations between blood pressure (BP) and risks for DR in diabetic patients with normal BP received inadequate attention. This may lead to 'clinical inertia' in early DR prevention. We aimed to assess whether the extent to which systolic BP levels were associated with DR in patients with type 2 diabetes (T2DM) and normal BP were similar to that in those with concurrent hypertension. Data were collected from patients with T2DM attending ophthalmic check-up with primary care referral (n = 2510). BP measurements, clinical laboratory tests, and dilated fundus examination were conducted according to gold standard of diagnosis and routine clinical procedure. Of all subjects, over 40% were normotensive and one fifth were clinically diagnosed with DR. Systolic BP levels increased across DR categories of escalated severity irrespective of the coexistence of hypertension. Ordinal logistic regression analysis showed that an increased systolic BP was independently and significantly associated with DR (adjusted odds ratio [aOR] = 1.020, p < 0.001 for hypertensives; aOR = 1.019, p = 0.018 for normotensives), after adjusting for diabetes duration, sex, lifestyles, and haemoglobin A1c levels. Regular monitoring of systolic BP should not be neglected in routine diabetes management even when BP falls within the normal range. (200 words).
Collapse
Affiliation(s)
- Yu-Ting Li
- State Key Laboratory of Ophthalmology, Zhongshan Ophthalmic Center, Sun Yat-Sen University, Guangzhou 510060, China; (Y.-T.L.); (X.-L.L.)
| | - Yi Wang
- School of Public Health, Sun Yat-Sen University, Guangzhou 510080, China; (Y.W.); (X.-J.H.); (J.-H.C.); (Y.-Y.L.); (Q.-Y.Z.); (H.C.)
| | - Xiu-Jing Hu
- School of Public Health, Sun Yat-Sen University, Guangzhou 510080, China; (Y.W.); (X.-J.H.); (J.-H.C.); (Y.-Y.L.); (Q.-Y.Z.); (H.C.)
| | - Jia-Heng Chen
- School of Public Health, Sun Yat-Sen University, Guangzhou 510080, China; (Y.W.); (X.-J.H.); (J.-H.C.); (Y.-Y.L.); (Q.-Y.Z.); (H.C.)
| | - Yun-Yi Li
- School of Public Health, Sun Yat-Sen University, Guangzhou 510080, China; (Y.W.); (X.-J.H.); (J.-H.C.); (Y.-Y.L.); (Q.-Y.Z.); (H.C.)
| | - Qi-Ya Zhong
- School of Public Health, Sun Yat-Sen University, Guangzhou 510080, China; (Y.W.); (X.-J.H.); (J.-H.C.); (Y.-Y.L.); (Q.-Y.Z.); (H.C.)
| | - Hui Cheng
- School of Public Health, Sun Yat-Sen University, Guangzhou 510080, China; (Y.W.); (X.-J.H.); (J.-H.C.); (Y.-Y.L.); (Q.-Y.Z.); (H.C.)
| | - Bedru H. Mohammed
- School of Public Health, LKS Faculty of Medicine, The University of Hong Kong, Hong Kong, China;
| | - Xiao-Ling Liang
- State Key Laboratory of Ophthalmology, Zhongshan Ophthalmic Center, Sun Yat-Sen University, Guangzhou 510060, China; (Y.-T.L.); (X.-L.L.)
| | - Jose Hernandez
- EDU, Digital Education Holdings Ltd., KKR-1320 Kalkara, Malta;
- Green Templeton College, University of Oxford, Oxford OX2 6HG, UK
| | - Wen-Yong Huang
- State Key Laboratory of Ophthalmology, Zhongshan Ophthalmic Center, Sun Yat-Sen University, Guangzhou 510060, China; (Y.-T.L.); (X.-L.L.)
| | - Harry H. X. Wang
- School of Public Health, Sun Yat-Sen University, Guangzhou 510080, China; (Y.W.); (X.-J.H.); (J.-H.C.); (Y.-Y.L.); (Q.-Y.Z.); (H.C.)
- JC School of Public Health and Primary Care, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong, China
- General Practice and Primary Care, Institute of Health and Wellbeing, University of Glasgow, Glasgow G12 9LX, UK
| |
Collapse
|
2
|
Sabuncu T, Sonmez A, Eren MA, Sahin I, Çorapçioğlu D, Üçler R, Akin Ş, Haymana C, Demirci İ, Atmaca A, Ersöz HÖ, Satman I, Bayram F. Characteristics of patients with hypertension in a population with type 2 diabetes mellitus. Results from the Turkish Nationwide SurvEy of Glycemic and Other Metabolic Parameters of Patients with Diabetes Mellitus (TEMD Hypertension Study). Prim Care Diabetes 2021; 15:332-339. [PMID: 33277201 DOI: 10.1016/j.pcd.2020.11.001] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/03/2020] [Revised: 10/05/2020] [Accepted: 11/02/2020] [Indexed: 12/19/2022]
Abstract
BACKGROUND The present survey aimed to find out the demographical and clinical characteristics of patients with hypertension in a population with type 2 diabetes mellitus (T2DM) in Turkey. METHODS Patients with T2DM who were followed-up in tertiary endocrine units for at least last one year were recruited. Demographic, clinical and biochemical data of the patients were collected. Hypertension was defined as taking anti-hypertensive medications or having office arterial blood pressure (ABP) ≥140/90 mmHg or home ABP ≥ 130/80 mmHg. RESULTS A total of 4756 (58.9% women) diabetic patients were evaluated. The percentage of patients with hypertension was 67.5% (n = 3212). Although 87.4% (n = 2808) of hypertensive patients were under treatment, blood pressure was on target in 52.7% (n = 1479) of patients. Hypertension proportions were higher in woman (p = 0.001), older, more obese, and those who had longer diabetes duration, lower education levels, higher frequency of hypoglycemic events (all p < 0.001) and higher triglyceride levels (p = 0.003). LDL cholesterol level and the percentage of smokers were lower in hypertensive group than in non-hypertensive group (both p < 0.001). The percentage of macro and microvascular complications was higher in the hypertensive group than in the normotensive one (both p < 0.001). In multivariate logistic regression analysis, being a woman (OR: 1.26, 95% CI: 1.04-1.51, p = 0.016), smoking (OR: 1.38, 95% CI: 1.05-1.80, p = 0.020), regular physical activity (OR: 1.24, 95% CI: 1.01-1.53, p = 0.039) and the presence of macrovascular complications (OR: 1.38 95% CI: 1.15-1.65, p = 0.001) were the significant predictors of good ABP regulation. The ratios of masked and white coat hypertension were 41.2% and 5.7%, respectively. CONCLUSION Our findings indicate that two-thirds (67.5%) of adult patients with T2DM have hypertension. Co-existence of hypertension increases the frequency of macro and microvascular diabetic complications in these patients. Despite the critical role of hypertension in morbidity and mortality, only half of the patients have favorable ABP levels. Masked hypertension seems to be another important issue in this population.
Collapse
Affiliation(s)
- Tevfik Sabuncu
- Harran University, Faculty of Medicine, Department of Endocrinology and Metabolism, Sanliurfa, Turkey
| | - Alper Sonmez
- Health Sciences University, Gulhane Faculty of Medicine, Department of Endocrinology and Metabolism, Ankara, Turkey
| | - Mehmet Ali Eren
- Harran University, Faculty of Medicine, Department of Endocrinology and Metabolism, Sanliurfa, Turkey.
| | - Ibrahim Sahin
- Inonu University, Faculty of Medicine, Department of Endocrinology and Metabolism, Malatya, Turkey
| | - Demet Çorapçioğlu
- Ankara University, Faculty of Medicine, Department of Endocrinology and Metabolism, Ankara, Turkey
| | - Rıfkı Üçler
- Van Yüzüncü Yıl University, Faculty of Medicine, Department of Endocrinology and Metabolism, Van, Turkey
| | - Şafak Akin
- Ankara Memorial Hospital, Ankara, Turkey
| | - Cem Haymana
- Health Sciences University, Gulhane Faculty of Medicine, Department of Endocrinology and Metabolism, Ankara, Turkey
| | - İbrahim Demirci
- Health Sciences University, Gulhane Faculty of Medicine, Department of Endocrinology and Metabolism, Ankara, Turkey
| | - Ayşegül Atmaca
- On Dokuz Mayıs University, Faculty of Medicine, Department of Endocrinology and Metabolism, Samsun, Turkey
| | - Halil Önder Ersöz
- Karadeniz Teknik University, Faculty of Medicine, Department of Endocrinology and Metabolism, Trabzon, Turkey
| | - Ilhan Satman
- Istanbul University, Faculty of Medicine, Department of Endocrinology and Metabolism, Istanbul, Turkey
| | - Fahri Bayram
- Erciyes University, Faculty of Medicine, Department of Endocrinology and Metabolism, Kayseri, Turkey
| |
Collapse
|
3
|
Piskorz D. Hypertension and metabolic disorders, a glance from different phenotypes. Am J Prev Cardiol 2020; 2:100032. [PMID: 34327456 PMCID: PMC8315388 DOI: 10.1016/j.ajpc.2020.100032] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2020] [Revised: 06/04/2020] [Accepted: 06/04/2020] [Indexed: 12/28/2022] Open
Abstract
The extraordinary expansion of cardiometabolic risk factors, the impact they generate in the development of hypertension and its specific phenotypes, and its implications in cardiovascular risk and therapeutic decision-making deserve an extensive and careful reflection. The aim of this review is to analyze the available evidence and gaps in the relationship between cardiometabolic risk factors and hypertension phenotypes. Overweight or obese patients, dyslipidemic, carbohydrate intolerant and type 2 diabetic patients have a significantly higher probability of suffering from high blood pressure than subjects without metabolic disorders. Masked hypertension should be systematically suspected in subjects with type 2 diabetes or metabolic disorders and borderline hypertension independently of the debate on the reproducibility of blood pressure phenotypes diagnosis. Some minor difficulties emerge to understand the phenotypes of hypertension in diabetic individuals, since clinical practice guidelines are not homogeneous in their postulates regarding the blood pressure targets at office and ambulatory and home blood pressure monitoring. The small number of diabetic hypertensive patients included in epidemiological studies, and the presence of confounding factors, such as the duration of diabetes, the quantity and type of drugs indicated for the treatment of both hypertension and diabetes, or the level of diabetes control, undermine the possibilities to draw conclusions of value for the clinical practice.
Collapse
|
4
|
Chan KS, Lai KPL, Chan PF, Luk MHM, Chao VKD. Evaluation of the applicability of deep breathing test in the diagnosis of hypertension with white-coat effect in Chinese patients in primary care. Clin Hypertens 2019; 25:2. [PMID: 30774977 PMCID: PMC6357457 DOI: 10.1186/s40885-018-0106-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2018] [Accepted: 12/19/2018] [Indexed: 01/01/2023] Open
Abstract
Purpose The current gold standard for the diagnosis of white-coat effect is by the 24-h ambulatory blood pressure monitoring (ABPM) which may not be readily available in every primary care setting. Previous studies had shown that deep breathing, through modulating the baroreceptor reflex sensitivity to vagal stimulation over 30 to 60 s, was useful in detection of the white-coat effect. The aim of our study was to evaluate the diagnostic accuracy of the deep breathing test (DBT) as compared with the gold standard of ABPM in the diagnosis of hypertension with white-coat effect in Chinese patients in primary care. Methods This cross sectional study recruited 178 consecutive, eligible, consented, hypertensive patients receiving treatment at a local public primary care Hypertension Clinic. The diagnostic accuracy of the DBT in all recruited patients, patients not taking beta-adrenergic blockers and patients with different clinic SBP cut-off before the DBT by means of area under the receiver operating characteristic (ROC) curve, sensitivity, specificity, positive and negative predictive values was evaluated. Results The results for the ROC curves for systolic and diastolic BP changes after the DBT were statistically insignificant. The ROC curve was statistically significant for SBP change in patients not taking beta-adrenergic blockers and with pre-DBT clinic SBP ≥ 165 mmHg (ROC curve area of 0.719, 95% CI 0.53 to 0.91, p = 0.04). The corresponding sensitivity and specificity of the DBT were 40.9 and 90.9% respectively if SBP drop was > 30 mmHg. Conclusion The DBT, even though could not be clinically applied to all patients, was proven to be a potential screening and diagnostic test for white-coat effect in Chinese hypertensive patients with a pre-test SBP of ≥165 mmHg and who were not taking beta-adrenergic blockers. Trial registration This study was approved by Kowloon East Cluster/ Kowloon Central Cluster Research Ethics Committee/Institutional Review Board of Hospital Authority of Hong Kong under the registration KC/KE-16-0084/ER-3.
Collapse
Affiliation(s)
- Kam Sum Chan
- Department of Family Medicine and Primary Health Care, United Christian Hospital and Tseung Kwan O Hospital, Kowloon East Cluster, Hospital Authority, Tseung Kwan O, Hong Kong, China
| | - Kit Ping Loretta Lai
- Department of Family Medicine and Primary Health Care, United Christian Hospital and Tseung Kwan O Hospital, Kowloon East Cluster, Hospital Authority, Tseung Kwan O, Hong Kong, China
| | - Pang Fai Chan
- Department of Family Medicine and Primary Health Care, United Christian Hospital and Tseung Kwan O Hospital, Kowloon East Cluster, Hospital Authority, Tseung Kwan O, Hong Kong, China
| | - Man Hei Matthew Luk
- Department of Family Medicine and Primary Health Care, United Christian Hospital and Tseung Kwan O Hospital, Kowloon East Cluster, Hospital Authority, Tseung Kwan O, Hong Kong, China
| | - Vai Kiong David Chao
- Department of Family Medicine and Primary Health Care, United Christian Hospital and Tseung Kwan O Hospital, Kowloon East Cluster, Hospital Authority, Tseung Kwan O, Hong Kong, China
| |
Collapse
|
5
|
C-reactive protein and blood pressure variability in type 2 hypertensive diabetic patients. Blood Press Monit 2019; 24:52-58. [PMID: 30640739 DOI: 10.1097/mbp.0000000000000362] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE Increased blood pressure (BP) variability and inflammation are included among the factors recognized as potential predictors of cardiovascular events in type 2 diabetes and hypertension. This study aimed to evaluate whether C-reactive protein (CRP) is associated with increased BP variability in diabetic-hypertensive patients. PATIENTS AND METHODS We carried out a cross-sectional study with 285 diabetic-hypertensive patients, evaluating laboratory characteristics and 24-h ambulatory BP monitoring. SD, coefficient of variation (CV%), time-rate index of 24-h systolic BP (SBP), and 24-h BP patterns were evaluated. Pearson's χ-test, Student's t-test, and the Mann-Whitney test were used to compare the groups. Groups were defined by CRP of up to 3 mg/l (low) and more than 3 mg/l (high). RESULTS The age of the patients was 59 (54-62) years; 101 (35%) were men. There was an increase in office SBP [137 (127-148) vs. 145 (130-157) mmHg] and DBP [79 (73-86) vs. 82 (76-91) mmHg] in the high CRP group. Blood pressure variability indexes were not different among groups [SD: 11.2 (9-15) vs. 12.2 (10-15) mmHg; CV%: 8.6 (7-11) vs. 9.4 (7-12); time rate: 0.55±0.12 vs.12.2 (10-15) mmHg/min]. In addition, BMI (29.3±3.8 vs. 30.9±3.6 kg/m), total cholesterol [166 (148-190) vs. 177 (156-210) mg/dl], and HbA1c [7.5% (6.6-8.9) vs.8.3% (7.1-9.9)] were higher in the high CRP group. CONCLUSION In patients with diabetes and hypertension, higher CRP levels are linked to cardiometabolic derangements, although they are not associated with increased BP variability.
Collapse
|
6
|
Masked uncontrolled hypertension in patients on maintenance hemodialysis. Hypertens Res 2017; 40:819-824. [PMID: 28381875 DOI: 10.1038/hr.2017.48] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2016] [Revised: 01/18/2017] [Accepted: 02/17/2017] [Indexed: 11/08/2022]
Abstract
Masked uncontrolled hypertension (MUCH) has been proven to be associated with increased cardiovascular risk in the general population. We performed the current analysis to determine its prevalence in dialysis patients and its association with pulse wave velocity (PWV). From 368 participants of another cohort study, we selected 145 subjects with controlled predialysis blood pressure (BP). All subjects underwent ambulatory BP monitoring and PWV measurement. MUCH was defined as controlled predialysis BP with daytime BP⩾135/85 mm Hg (definition-1); total ambulatory BP⩾130/80 mm Hg (definition-2); and either daytime BP⩾135/85 mm Hg or nighttime BP⩾120/70 mm Hg (definition-3). The prevalence of MUCH was 43.4% (definition-1), 55.9% (definition-2) and 74.5% (definition-3). Multivariable logistic regression analysis showed that the use of antihypertensive medication was the most consistent predictor of MUCH within all 3 definitions (all odds ratio (OR)⩾4.28, P<0.001). Predialysis systolic BP (both OR>1, P⩽0.04), predialysis diastolic BP (both OR>1, P⩽0.001) and hemoglobin (both OR<1, P=0.02) were all significantly associated with MUCH in two models. Interdialytic weight gain (OR=0.52, P=0.02) was associated with MUCH under definition-2, and BMI (OR=0.86, P=0.03) was associated with MUCH under definition-3. Patients with MUCH had significantly elevated PWV compared with their counterparts according to all three definitions with or without adjusting for covariates (all P⩽0.03). In conclusion, MUCH affects a large proportion of dialysis patients with controlled predialysis BP and is associated with increased PWV. Patients on antihypertensive medications and with higher predialysis BP are more likely to have MUCH.
Collapse
|
7
|
Massierer D, Leiria LF, Severo MD, Ledur PDS, Becker AD, Aguiar FM, Lima E, Freitas VC, Schaan BD, Gus M. Blood pressure variability and its association with echocardiographic parameters in hypertensive diabetic patients. BMC Cardiovasc Disord 2016; 16:4. [PMID: 26747793 PMCID: PMC4706684 DOI: 10.1186/s12872-015-0183-1] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2015] [Accepted: 12/31/2015] [Indexed: 01/07/2023] Open
Abstract
BACKGROUND Blood pressure (BP) variability is associated with target organ damage in hypertension and diabetes. The 24 h ambulatory blood pressure monitoring (24 h-ABPM) has been proposed as an evaluation for BP variability using several indexes [standard deviation (SD) of mean BP, coefficient of variation (CV), BP variation over time (time-rate index)]. METHODS We evaluated the association between BP variability measured by 24 h-ABPM indexes and echocardiographic variables in a cross-sectional study in 305 diabetic-hypertensive patients. RESULTS Two groups were defined by the median (0.55 mmHg/min) of time-rate systolic BP (SBP) index and classified as low or high variability. Age was 57.3 ± 6.2 years, 196 (64.3%) were female. Diabetes duration was 10.0 (5.0-16.2) years, HbA1c was 8.2 ± 1.9%. Baseline clinical characteristics were similar between low (n = 148) and high (n = 157) variability groups. Office SBP and systolic 24 h-ABPM were higher in the high variability group (139.9 mmHg vs 146.0 mmHg, P = 0.006; 128.3 mmHg vs 132.9 mmHg, P = 0.019, respectively). Time-rate index, SD and CV of SBP, were higher in high variability group (P < 0.001; P < 0.001 and P = 0.003, respectively). Time-rate index was not independently associated with the echocardiography's variables in multiple linear model when adjusting for age, 24 h-ABPM, diabetes duration and HbA1c. The multiple linear regression model revealed that the significant and independent determinants for septum thickness, relative wall thickness and posterior wall thickness (parameters of left ventricular hypertrophy) were: age (p = 0.025; p = 0.010; p = 0.032, respectively) and 24 h-SBP (p < 0.001 in the three parameters). CONCLUSION BP variability estimated by 24 h-ABPM is not independently associated with echocardiographic parameters in diabetic-hypertensive patients.
Collapse
Affiliation(s)
- Daniela Massierer
- Cardiology, Hospital de Clínicas de Porto Alegre, Rua Ramiro Barcelos 2350, sala 2061, 90035-003, Porto Alegre, RS, Brazil. .,Postgraduate Studies Program in Cardiology, School of Medicine, Universidade Federal do Rio Grande do Sul, Rua Ramiro Barcelos, 2400 - 2° andar, Porto Alegre, RS, Brazil.
| | - Liana Farias Leiria
- Endocrine Division, Hospital de Clínicas de Porto Alegre, Rua Ramiro Barcelos 2350, sala 2061, 90035-003, Porto Alegre, RS, Brazil. .,Postgraduate Studies Program in Cardiology, School of Medicine, Universidade Federal do Rio Grande do Sul, Rua Ramiro Barcelos, 2400 - 2° andar, Porto Alegre, RS, Brazil.
| | - Mateus Dorneles Severo
- Endocrine Division, Hospital de Clínicas de Porto Alegre, Rua Ramiro Barcelos 2350, sala 2061, 90035-003, Porto Alegre, RS, Brazil.
| | - Priscila Dos Santos Ledur
- Endocrine Division, Hospital de Clínicas de Porto Alegre, Rua Ramiro Barcelos 2350, sala 2061, 90035-003, Porto Alegre, RS, Brazil.
| | - Alexandre Dalpiaz Becker
- Endocrine Division, Hospital de Clínicas de Porto Alegre, Rua Ramiro Barcelos 2350, sala 2061, 90035-003, Porto Alegre, RS, Brazil. .,Faculty of Medicine, Universidade Federal do Rio Grande do Sul, Rua Ramiro Barcelos, 2400, Porto Alegre, RS, Brazil.
| | - Fernanda Mus Aguiar
- Universidade Federal de Ciências da Saúde de Porto Alegre, Rua Sarmento Leite, 245, 90050-170, Porto Alegre, RS, Brazil.
| | - Eliandra Lima
- Endocrine Division, Hospital de Clínicas de Porto Alegre, Rua Ramiro Barcelos 2350, sala 2061, 90035-003, Porto Alegre, RS, Brazil. .,Faculty of Medicine, Universidade Federal do Rio Grande do Sul, Rua Ramiro Barcelos, 2400, Porto Alegre, RS, Brazil.
| | - Valéria Centeno Freitas
- Cardiology, Hospital de Clínicas de Porto Alegre, Rua Ramiro Barcelos 2350, sala 2061, 90035-003, Porto Alegre, RS, Brazil.
| | - Beatriz D Schaan
- Endocrine Division, Hospital de Clínicas de Porto Alegre, Rua Ramiro Barcelos 2350, sala 2061, 90035-003, Porto Alegre, RS, Brazil. .,Faculty of Medicine, Universidade Federal do Rio Grande do Sul, Rua Ramiro Barcelos, 2400, Porto Alegre, RS, Brazil.
| | - Miguel Gus
- Cardiology, Hospital de Clínicas de Porto Alegre, Rua Ramiro Barcelos 2350, sala 2061, 90035-003, Porto Alegre, RS, Brazil. .,Postgraduate Studies Program in Cardiology, School of Medicine, Universidade Federal do Rio Grande do Sul, Rua Ramiro Barcelos, 2400 - 2° andar, Porto Alegre, RS, Brazil.
| |
Collapse
|