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Pons I, Jeréz A, Espinosa G, Rodríguez-Pintó I, Erkan D, Shoenfeld Y, Cervera R. Cardiac involvement in the catastrophic antiphospholipid syndrome (CAPS): Lessons from the "CAPS registry". Semin Arthritis Rheum 2024; 66:152439. [PMID: 38552300 DOI: 10.1016/j.semarthrit.2024.152439] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2023] [Revised: 02/28/2024] [Accepted: 03/25/2024] [Indexed: 05/14/2024]
Abstract
OBJECTIVE To analyze the demographic, clinical, and laboratory characteristics of catastrophic antiphospholipid syndrome (CAPS) patients with cardiac involvement, and to identify the factors associated with this cardiac involvement. MATERIAL AND METHODS Based on the analysis of the "CAPS Registry", the demographic, clinical, and serological characteristics of patients with cardiac involvement were analyzed. Cardiac involvement was defined as heart failure, valvular disease, acute myocardial infarction, pericardial effusion, pulmonary arterial hypertension, systolic dysfunction, intracardiac thrombosis, and microvascular disease. Univariate and multivariate analysis was used for multiple comparisons. RESULTS 749 patients (293 [39 %] women and mean age 38.1 ± 16.2 years) accounting for 778 CAPS events were included, of them 404 (52 %) had cardiac involvement. The main cardiac manifestations were heart failure in 185/377 (55 %), valve disease in 116/377 (31 %), and acute myocardial infarction in 104/378 (28 %). Of 58 patients with autopsy/biopsy, 48 (83 %) had cardiac thrombotic microangiopathy, Stroke (29% vs. 21 %, p = 0.012), transient cerebral vascular accident (2% vs. 1 %, p = 0.005), pulmonary infarction (26% vs. 3 %, p = 0.017), renal infarction (46% vs. 35 %, p = 0.006), acute kidney injury (70% vs. 53 %, p < 0.001), and livedo reticularis (24% vs. 17 %, p = 0.016) were significantly more frequent during CAPS events with versus without heart involvement. Multivariate analysis identified acute kidney injury (OR 1.068, IC 95 % 1.8-4.8, p < 0.001) as the only clinical characteristics that were, independently, associated with cardiac involvement in CAPS events. Cardiac involvement was not related to higher mortality. CONCLUSIONS Cardiac involvement is frequent in CAPS, with association with kidney involvement, and it is not related to higher mortality. The presence of cardiac microthrombosis was demonstrated in most biopsies/autopsies performed.
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Affiliation(s)
- Isaac Pons
- Department of Autoimmune Diseases, Reference Centre for Systemic Autoimmune Diseases (UEC/CSUR) of the Catalan and Spanish Health Systems-Member of ERNReCONNET, Hospital Clínic, Universitat de Barcelona, Barcelona, Catalonia, Spain; Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Catalonia, Spain; Department of Internal Medicine, Althaia Xarxa Assistencial Universitària de Manresa, Facultat de Medicina, Universitat de Vic-Universitat Central de Catalunya (uVic-UCC), Manresa, Catalonia, Spain
| | - Alba Jeréz
- Department of Autoimmune Diseases, Reference Centre for Systemic Autoimmune Diseases (UEC/CSUR) of the Catalan and Spanish Health Systems-Member of ERNReCONNET, Hospital Clínic, Universitat de Barcelona, Barcelona, Catalonia, Spain; Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Catalonia, Spain; Department of Internal Medicine, Systemic Autoimmune Diseases Unit, Hospital Mútua de Terrassa, Terrassa, Catalonia, Spain
| | - Gerard Espinosa
- Department of Autoimmune Diseases, Reference Centre for Systemic Autoimmune Diseases (UEC/CSUR) of the Catalan and Spanish Health Systems-Member of ERNReCONNET, Hospital Clínic, Universitat de Barcelona, Barcelona, Catalonia, Spain; Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Catalonia, Spain.
| | - Ignasi Rodríguez-Pintó
- Department of Autoimmune Diseases, Reference Centre for Systemic Autoimmune Diseases (UEC/CSUR) of the Catalan and Spanish Health Systems-Member of ERNReCONNET, Hospital Clínic, Universitat de Barcelona, Barcelona, Catalonia, Spain; Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Catalonia, Spain
| | - Doruk Erkan
- Barbara Volcker Center for Women and Rheumatic Diseases, Hospital for Special Surgery, Weill Cornell Medicine, New York, NY, USA
| | - Yehuda Shoenfeld
- Zabludowicz Center for Autoimmune Diseases, Sheba Medical Center, Tel-Hashomer, Reichman University, Herzelya, Israel
| | - Ricard Cervera
- Department of Autoimmune Diseases, Reference Centre for Systemic Autoimmune Diseases (UEC/CSUR) of the Catalan and Spanish Health Systems-Member of ERNReCONNET, Hospital Clínic, Universitat de Barcelona, Barcelona, Catalonia, Spain; Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Catalonia, Spain
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Lai AC, Feinman J, Oates C, Parikh A. A case report of acute heart failure and cardiogenic shock caused by catastrophic antiphospholipid syndrome and lupus myocarditis. Eur Heart J Case Rep 2022; 6:ytac446. [PMID: 36504504 PMCID: PMC9728516 DOI: 10.1093/ehjcr/ytac446] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2022] [Revised: 04/28/2022] [Accepted: 11/18/2022] [Indexed: 11/23/2022]
Abstract
Background Catastrophic antiphospholipid syndrome and lupus myocarditis are two rare life-threatening conditions. Case summary We present a case of a 47-year-old woman admitted in profound cardiogenic shock due to catastrophic antiphospholipid syndrome and lupus myocarditis requiring advanced heart failure therapies, including early mechanical circulatory support. She improved with steroids, immunoglobulins, mycophenolate, and eculizumab. Discussion This case highlights the importance of early identification of cardiogenic shock secondary to catastrophic antiphospholipid syndrome and lupus myocarditis, the arrhythmogenic complications of myocarditis, and the subsequent management of the disease progression with mechanical and medical support.
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Affiliation(s)
- Ashton C Lai
- Corresponding author. Tel: 855-674-3278, Fax: 212-426-6376,
| | - Jason Feinman
- Icahn School of Medicine, Mount Sinai Medical Center, 1190 5th Avenue, New York, NY 10029-6574, USA
| | - Connor Oates
- Icahn School of Medicine, Mount Sinai Medical Center, 1190 5th Avenue, New York, NY 10029-6574, USA
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Eculizumab use in catastrophic antiphospholipid syndrome (CAPS): Descriptive analysis from the “CAPS Registry”. Clin Exp Rheumatol 2022; 21:103055. [DOI: 10.1016/j.autrev.2022.103055] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2022] [Accepted: 01/21/2022] [Indexed: 02/07/2023]
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Al-Akchar M, Sawalha K, Al-Khadra Y, Kittleson M, Missula V, Sundararajan T, Koester C, Salih M, Bhattarai M, Ibrahim A, Chami Y, DeMartini T, Hafiz AM. Outcomes of cardiogenic shock with autoimmune rheumatological disorders. CARDIOVASCULAR REVASCULARIZATION MEDICINE 2021; 38:70-74. [PMID: 34426085 DOI: 10.1016/j.carrev.2021.08.007] [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: 06/13/2021] [Revised: 08/02/2021] [Accepted: 08/05/2021] [Indexed: 11/29/2022]
Abstract
AIMS Data on cardiogenic shock (CS) in autoimmune diseases (AID) is limited. Our study aims to evaluate in-hospital outcomes of CS in hospitalized patients with underlying AID compared with patients without AID. METHODS The National Inpatient Sample (NIS) database years 2011-17 was used to identify hospitalizations for CS. We retrospectively compared in-hospital outcomes of CS in patients with underlying AID versus non-AID. RESULTS Of 863,239 patients diagnosed with CS, 23,127 (2.7%) had underlying AID. The AID population was older with more women and African American patients (P < 0.001 for all). There was a significant increase in in-hospital mortality in patients with AID vs non-AID that persisted after adjustment for demographics, comorbidities, insurance, socioeconomic status and hospital characteristics (38.3% vs 36.3%, aOR 1.06; 95% CI: 1.02-1.09, P = 0.001). Patients with AID had a lower rate of respiratory complications (11.5% vs 13.1%), acute stroke (6.0% vs 6.8%), use of mechanical circulatory support (12.0% vs 14.5%) and discharge to an outside facility (29.1% vs 28.8%) (P ≤ 0.001 for all). Using multivariable logistic regression, we identified female gender, Native American ethnicity, heart failure, coagulopathy, pulmonary circulation disorders, metastatic cancer, and fluid and electrolytes disorders as independent predictors of mortality in patients with AID who were diagnosed with CS. CONCLUSION Patients with AID hospitalized with CS have increased mortality which may be related to their underlying disease process and lack of effective disease-directed therapy for CS related to AID.
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Affiliation(s)
- Mohammad Al-Akchar
- Division of Cardiology, Department of Internal Medicine, Southern Illinois University School of Medicine, Springfield, IL, United States of America
| | - Khalid Sawalha
- Department of Internal Medicine, University of Massachusetts Medical School-Baystate Medical Center, Springfield, MA, United States of America.
| | - Yasser Al-Khadra
- Division of Cardiology, Department of Internal Medicine, Southern Illinois University School of Medicine, Springfield, IL, United States of America
| | - Michelle Kittleson
- Department of Cardiology, Smidt Heart Institute, Cedars Sinai Medical Center, Los Angeles, CA, United States of America
| | - Venkata Missula
- Department of Internal Medicine, Southern Illinois University School of Medicine, Springfield, IL, United States of America
| | - Tharani Sundararajan
- Department of Internal Medicine, Southern Illinois University School of Medicine, Springfield, IL, United States of America
| | - Cameron Koester
- Department of Internal Medicine, Southern Illinois University School of Medicine, Springfield, IL, United States of America
| | - Mohsin Salih
- Division of Cardiology, Department of Internal Medicine, Southern Illinois University School of Medicine, Springfield, IL, United States of America
| | - Mukul Bhattarai
- Division of Cardiology, Department of Internal Medicine, Southern Illinois University School of Medicine, Springfield, IL, United States of America
| | - Abdisamad Ibrahim
- Division of Cardiology, Department of Internal Medicine, University of Minnesota, Minneapolis, MN, United States of America
| | - Youssef Chami
- Division of Cardiology, Department of Internal Medicine, Southern Illinois University School of Medicine, Springfield, IL, United States of America
| | - Tony DeMartini
- Division of Cardiology, Department of Internal Medicine, Southern Illinois University School of Medicine, Springfield, IL, United States of America
| | - Abdul Moiz Hafiz
- Division of Cardiology, Department of Internal Medicine, Southern Illinois University School of Medicine, Springfield, IL, United States of America
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Rato IR, Barbosa AR, Afonso DJ, Beça S. Catastrophic antiphospholipid syndrome presented as ruptured papillary muscle during puerperium in a patient with systemic lupus erythematosus. Lupus 2021; 30:1017-1021. [PMID: 33736518 DOI: 10.1177/09612033211002273] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
INTRODUCTION Catastrophic antiphospholipid syndrome (CAPS) is a rare and serious phenomenon that requires prompt recognition and treatment. CASE PRESENTATION The authors present the case of a puerperal woman with systemic lupus erythematosus (SLE) admitted to the emergency room with headache, blurred vision, thoracic pain, and purpuric lesions on both ears. Echocardiogram revealed global decrease in left ventricular function while cardiac and inflammatory markers were elevated. Three days after admission she developed cardiogenic shock due to rupture of mitral papillary muscle which required emergent cardiac surgery, with replacement of the mitral valve; treatment with anticoagulation, high-dose glucocorticoids, and intravenous immunoglobulins were initiated. Cardiac and brain MRI revealed signs of ischemic lesions in both organs. Histopathology analysis of the placenta and papillary muscle showed signs of ischemia secondary to microvascular thrombosis. Based on the clinical demonstration of thrombosis in three organs, and the presence of lupus anticoagulant antibodies, a diagnosis of probable CAPS was established. CONCLUSION This case highlights the importance of a high level of suspicion of CAPS, particularly in patients with risk factors, and the value of immediate adequate treatment. Moreover, the rupture of a papillary muscle with histologically consistent signs of antiphospholipid syndrome expands the spectrum of involvement of this disease and should be considered as a rare but life-threatening possibility in patients with myocardial injury.
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Affiliation(s)
- Inês Rueff Rato
- Department of Internal Medicine, Centro Hospitalar de Vila Nova de Gaia/Espinho, Vila Nova de Gaia, Portugal
| | - Ana Rita Barbosa
- Department of Internal Medicine, Centro Hospitalar Baixo Vouga, Aveiro, Portugal
| | - David João Afonso
- Department of Anatomic Pathology, Centro Hospitalar de Vila Nova de Gaia/Espinho, Vila Nova de Gaia, Portugal
| | - Sara Beça
- Department of Internal Medicine, Centro Hospitalar de Vila Nova de Gaia/Espinho, Vila Nova de Gaia, Portugal
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Abstract
Lupus myocarditis is a serious, potentially deadly disease. When it presents as an acute or fulminant myocarditis in a patient without an established diagnosis of lupus, lupus as an etiology of the condition is not commonly suspected. Meanwhile, it has a distinct treatment which may be lifesaving. Review of the literature can shed more light as current management is mostly based on clinical experience and case reports rather than randomized control trials. In this review we are discussing this diagnostic entity, focusing on cardiogenic shock as a manifestation of lupus myocarditis, and discussing management including aggressive immunosuppression, mechanical circulatory support, and cardiac transplantation.
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Gawalkar AA, Bahl A, Ahluwalia J, Sood A, Sharma A, Sharma S, Dhir V. Prevalence of antiphospholipid antibodies in patients with overt myocardial dysfunction in systemic lupus erythematosus. A case-control study. Lupus 2020; 29:1503-1508. [DOI: 10.1177/0961203320947784] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Background Small case-series have reported overt myocardial dysfunction to be associated with positive antiphospholipid antibodies in patients of systemic lupus erythematosus (SLE). However, there is no case-control study that has examined this association. Methods This case-control study recruited patients of SLE (fulfilling SLICC criteria) with overt myocardial dysfunction as cases and those without this as controls. Overt myocardial dysfunction was defined by echocardiography as global left ventricular dysfunction and reduced ejection fraction (<50%). Those patients with a prior diagnosis of anti-phospholipid antibody syndrome, coronary artery disease, rheumatic heart disease or severe pulmonary artery hypertension were excluded. Antibodies tested included lupus anticoagulant, anticardiolipin antibodies (IgM and IgG) and anti-beta 2 glycoprotein 1 antibodies (IgM and IgG). Patients with positive tests underwent repeat testing for persistent positivity after 12 weeks. Results This study included 51 patients (21 cases and 30 controls) having a mean (SD) age of 33 (13.3) years, and disease duration (median, IQR) of 28 months (12−38 months). The mean ejection fraction of cases was 31.7 (9.3)% while that of controls was 55.7 (1.7)% (p = 0.03). The frequency (percentage) of positive antiphospholipid antibodies was not significantly different between cases and controls (43%, 40%, p = 0.8). The frequency (percentage) of anti-cardiolipin antibody was also not significant between the groups (38%, 37%, p = 0.57). Serositis and leucopenia were more prevalent in SLE patients with myocardial dysfunction (p = 0.005). Conclusion This study did not find any significant association of anti-phospholipid antibodies with overt myocardial dysfunction in patients of SLE.
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Affiliation(s)
| | - Ajay Bahl
- Department of Cardiology, PGIMER, Chandigarh, India
| | | | - Ashwani Sood
- Department of Nuclear Medicine, PGIMER, Chandigarh, India
| | - Aman Sharma
- Department of Internal Medicine, PGIMER, Chandigarh, India
| | - Shefali Sharma
- Department of Internal Medicine, PGIMER, Chandigarh, India
| | - Varun Dhir
- Department of Internal Medicine, PGIMER, Chandigarh, India
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Battisha A, Sawalha K, Altibi AM, Madoukh B, Al-Akchar M, Patel B. Cardiogenic shock in autoimmune rheumatologic diseases: an insight on etiologies, management, and treatment outcomes. Heart Fail Rev 2020; 27:93-101. [PMID: 32562022 DOI: 10.1007/s10741-020-09990-4] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Autoimmune rheumatological disorders are known to have an increased risk for cardiovascular diseases including coronary artery disease (CAD), myocarditis, pericarditis, valvulopathy, and in consequence cardiogenic shock. Data on cardiogenic shock in rheumatological diseases are scarce; however, several reports have highlighted this specific entity. We sought to review the available literature and highlight major outcomes and the management approaches in each disease. Systematic literature search, including PubMed, Ovid/Medline, Cochrane Library, and Web of Science, was conducted between January 2000 and December 2009. We reviewed all cases reporting cardiogenic shock with rheumatologic conditions, including systemic lupus erythematosus (SLE), rheumatoid arthritis (RA), Takayasu's arteritis (TA), granulomatosis with polyangiitis (GPA), giant cell arteritis (GCA), and antiphospholipid syndrome (APS). We selected 45 papers reporting a total of 48 cases. Mean age was 39 ± 7.3 years and 68.8% were females. Most common rheumatologic conditions associated with cardiogenic shock were SLE (31%), GPA (23%), TA (14.6%), APA (10.4%), and RA (8.3%). Cardiogenic shock was found to be caused by eosinophilic myocarditis in 58% of cases, CAD in 19% of cases, and valvulopathy in 6% of cases. Most patient required high-dose steroids and second immunosuppressant therapy. Mechanical circulatory supported was required in 23 cases, IABP in 16 cases, and ECMO in 12 cases. Complete recovery occurred in 37 patients while 9 patients died and 2 required heart transplant. Responsible for two-thirds of cases, eosinophilic myocarditis should be suspected in young cardiogenic shock patients with underlying rheumatologic conditions. Lupus and GPA are the two most common conditions.
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Affiliation(s)
- Ayman Battisha
- University of Massachusetts Medical School - Baystate, Springfield, MA, USA
| | - Khalid Sawalha
- University of Massachusetts Medical School - Baystate, Springfield, MA, USA
| | - Ahmed M Altibi
- Harvard T.H. Chan School of Public Health, Harvard University, Boston, MA, USA.,Henry Ford Health System (HFHS), Jackson, MI, USA
| | - Bader Madoukh
- Overland Park Regional Medical Center - HCA Midwest Health, Kansas City, MO, USA
| | | | - Brijesh Patel
- Heart and Vascular Institute, West Virginian University, 1 Medical Center Dr., Morgantown, WV, 26505, USA.
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Dhooria A, Gawalkar A, Santosh K, Bahl A, Mb A, Naidu G, Sharma S, Sharma A, Jain S, Dhir V. Acute myocardial dysfunction in lupus: outcomes in Asian Indians. Clin Rheumatol 2020; 39:3661-3667. [PMID: 32445088 DOI: 10.1007/s10067-020-05177-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2019] [Revised: 05/07/2020] [Accepted: 05/15/2020] [Indexed: 12/23/2022]
Abstract
BACKGROUND Acute myocardial dysfunction is an uncommon but potentially fatal complication in systemic lupus erythematosus (SLE). We describe the outcome in a small series of Asian Indian patients and examine associated factors. METHODS SLE patients who fulfilled the 2012 SLICC criteria and developed new-onset myocardial dysfunction were included in this retrospective case series. Acute myocardial dysfunction was defined as global hypokinesia and left ventricular ejection fraction (LVEF)<50% on echocardiography (with or without symptoms) in patients with SLE. Survival was assessed using Kaplan-Meier survival analysis and Cox regression. RESULTS This study included 37 patients with mean age 28.2 ± 11.2 years and median (range) LVEF of 35% (18-48%) at presentation. A majority had active disease, with SLEDAI-2k ≥ 5 in 26 (of 28). All patients received oral corticosteroids and a majority received additional immunosuppression, including pulse methylprednisolone in 28 and cyclophosphamide in 27. Nine patients died during hospitalisation (25%), a majority due to infections. Death was significantly associated with elevated procalcitonin at presentation (p = 0.05), elevated white cell count (p = 0.02) and low complement C3 (p = 0.03). In those who survived, long-term outcomes were good, with complete myocardial recovery in 14 (64%). A higher ejection fraction at presentation was associated with complete recovery. CONCLUSIONS In this small series of patients of SLE with acute myocardial dysfunction, we report a significant in-hospital mortality due to infections. Many of the patients who died had elevated procalcitonin at presentation. A diligent search for infection seems prudent in lupus patients who present with acute myocardial dysfunction. Key Points • In patients of SLE with acute myocardial dysfunction who were treated with immunosuppression, there was significant short-term mortality due to infections. • This mortality was associated with elevated procalcitonin at baseline and may suggest some of them had pre-existing hidden sepsis. • A prudent search for infections in these patients before immunosuppression may help to decrease short-term mortality.
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Affiliation(s)
- Aadhaar Dhooria
- Department of Internal Medicine, Post Graduate Institute of Medical Education and Research, Chandigarh, 160012, India
| | - Atit Gawalkar
- Department of Cardiology, Post Graduate Institute of Medical Education and Research, Chandigarh, 160012, India
| | - Krishna Santosh
- Department of Cardiology, Post Graduate Institute of Medical Education and Research, Chandigarh, 160012, India
| | - Ajay Bahl
- Department of Cardiology, Post Graduate Institute of Medical Education and Research, Chandigarh, 160012, India
| | - Adarsh Mb
- Department of Internal Medicine, Post Graduate Institute of Medical Education and Research, Chandigarh, 160012, India
| | - Gsrsnk Naidu
- Department of Internal Medicine, Post Graduate Institute of Medical Education and Research, Chandigarh, 160012, India
| | - Shefali Sharma
- Department of Internal Medicine, Post Graduate Institute of Medical Education and Research, Chandigarh, 160012, India
| | - Aman Sharma
- Department of Internal Medicine, Post Graduate Institute of Medical Education and Research, Chandigarh, 160012, India
| | - Sanjay Jain
- Department of Internal Medicine, Post Graduate Institute of Medical Education and Research, Chandigarh, 160012, India
| | - Varun Dhir
- Department of Internal Medicine, Post Graduate Institute of Medical Education and Research, Chandigarh, 160012, India.
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Abdou N, Shoeib SAA, Zahran ES. Antiphospholipid Syndrome: Nephrologists’ Perspective. OPEN JOURNAL OF INTERNAL MEDICINE 2020; 10:112-120. [DOI: 10.4236/ojim.2020.102012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 09/01/2023]
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