FOUR CASES OF HYPOVOLEMIC RENIN-ALDOSTERONE AXIS DEFICIENCY WITHOUT HYPERKALEMIA FOLLOWING UNILATERAL ADRENALECTOMY FOR PRIMARY ALDOSTERONISM
|
|
- Bathsheba Simmons
- 6 years ago
- Views:
Transcription
1 Case Report FOUR CASES OF HYPOVOLEMIC RENIN-ALDOSTERONE AXIS DEFICIENCY WITHOUT HYPERKALEMIA FOLLOWING UNILATERAL ADRENALECTOMY FOR PRIMARY ALDOSTERONISM Marion Vallet, MD 1 *; Alexandre Martin, MD 1 *; Eric Huyghe, MD 2 ; Jacques Amar, MD 3 ; Bernard Chamontin, MD 3 ; Jean Baptiste Kantambadouno 3 ; Ivan Tack, MD 1 ; Béatrice Bouhanick, MD 3 ABSTRACT Objective: Hyperkalemia can occur following unilateral adrenalectomy for primary aldosteronism due to hypoaldosteronism. We hereby report the cases of 4 male patients exhibiting prolonged failure of the renin-aldosterone (RA) axis in association with normal-to-high kalemia or labile blood pressure and, most significantly, a decrease in extracellular fluid volume (ECFV). Methods: Prior to surgery, all patients exhibited hypokalemic hypertension, with documented primary aldosteronism. Within a few weeks of undergoing unilateral adrenalectomy, the patients developed either mild hyperkalemia or labile blood pressure. Complementary investigations revealed a decrease in measured ECFV with inappropriate normal renal sodium excretion, low supine plasma renin activity, and insufficient orthostatic-related aldosterone production. The adrenocorticotropic hormone (ACTH) stimulation test demonstrated no glucocorticoid deficiency, along with responsive aldosterone secretion. Results: The discrepancy between the aldosterone response in the orthostatic position versus the ACTH stimulation test suggested that the aldosterone deficiency Submitted for publication June 17, 2015 Accepted for publication November 24, 2015 From 1 Explorations Fonctionnelles Physiologiques, 2 Département d Urologie, and 3 HTA et THÉRAPEUTIQUE, Hôpital de Rangueil, Toulouse, France. * These authors contributed equally to the work. Address correspondence to Dr. Béatrice Bouhanick, CHU de Rangueil, Service d HTA et THÉRAPEUTIQUE, 1 avenue du Professeur Jean Poulhès - TSA F Toulouse cedex 9, France. duly-bouhanick.b@chu-toulouse.fr. DOI: /EP15874.CR To purchase reprints of this article, please visit: was largely due to RA axis depression. Recovery was confirmed between 3 and 18 months in all but one patient, the latter still requiring mineralocorticoid substitution 23 months later. Conclusion: Following unilateral adrenalectomy for primary aldosteronism, the occurrence of mild hyperkalemia prompted a functional evaluation of the RA system using an orthostatic stimulation test, rather than simply measuring baseline values and evaluating the glucocorticoid axis. In such cases, where RA depression is confirmed to cause latent hypovolemia, all treatments likely to further decrease plasma volume should be avoided, while mineralocorticoid substitution may be required. (AACE Clinical Case Rep. 2016;2:e311-e315) Abbreviations: ACTH = adrenocorticotropic hormone; AVS = adrenal vein sampling; BP = blood pressure; CT = computed tomography; ECFV = extracellular fluid volume; PA = primary aldosteronism; RA = renin-aldosterone INTRODUCTION Primary aldosteronism (PA) is the most common cause of secondary hypertension (1). The current treatment consists of removing the adrenal gland responsible for aldosterone hypersecretion (2). Numerous studies have reported post-unilateral adrenalectomy complications, which can consist of severe hyperkalemia related to adrenal insufficiency (3-9). We hereby report the cases of 4 patients who, despite subnormal kalemia, developed not only temporary aldosterone deficiency, but also prolonged depression of the renin-aldosterone (RA) axis resulting in a decrease in extracellular fluid volume (ECFV) following unilateral adrenalectomy for adenoma or hyperplasia. These observa- AACE CLINICAL CASE REPORTS Vol 2 No. 4 Autumn 2016 e311
2 e312 Renin-Aldosterone Axis Deficiency, AACE Clinical Case Rep. 2016;2(No. 4) tions highlight the value of performing biological followups following surgical PA treatment that include dynamic evaluation of the RA axis. CASE REPORT All but one patient were referred for hypertension to the Department of Internal Medicine and Hypertension of Toulouse University Hospital. All patients exhibited hypokalemia with or without resistant hypertension. PA diagnosis was established according to the ratio of plasma aldosterone concentration (PAC) to active renin, confirmed by either the captopril test (Patients 2 and 3) and/or the intravenous saline infusion test (Patients 3 and 4). Computed tomography (CT) was used to confirm adenoma. Two patients underwent adrenal vein sampling (AVS), and all patients underwent unilateral laparoscopic adrenalectomy. Histological analysis confirmed the presence of an aldosterone-producing adenoma in each patient. We performed postoperative explorations including ECFV measurement using inulin (10) and based our analysis on normal values ranging from 180 to 210 ml/kg (personal data from 10 healthy subjects). This also enabled us to obtain inulin plasma clearance rates. Patient Characteristics Patient 1 This 49-year-old asymptomatic hypertensive male consulted his physician for poor blood pressure (BP) control. Given his hypokalemia, the physician prescribed spironolactone and amlodipine. Hyperaldosteronism was suspected due to his increased aldosterone values, and CT imaging revealed a small right adrenal nodule (Table 1). Surgery was performed but did not resolve the patient s hypertension and hypokalemia, requiring a course of potassium supplementation and treatment with the combination of amiloride plus amlodipine. On Day 15 postsurgery, the patient presented with diarrhea and vomiting, exhibiting acute kidney injury (plasma creatinine = 294 µmol/l) and hyperkalemia (plasma potassium = 6 mmol/l), requiring hospitalization for rehydration and discontinuation of amiloride. His BP was measured at 130/90 mm Hg without any orthostatic symptoms or salt craving. The hyperkalemia persisted at approximately 5.3 mmol/l. At day 49, without any further treatment, significant hypovolemia (ECFV = 108 ml/kg) with an insufficient basal renin level and low PAC were observed (Table 2). Following orthostatic stimulation, the RA system was found to be deficient, whereas a short adrenocorticotropic hormone (ACTH) test demonstrated a mild response regarding aldosterone secretion. The patient was started on 50 μg fludrocortisone per day. At day 98, investigations revealed persistent hypovolemia (ECFV = 137 ml/kg) under fludrocortisone, still with inadequate renin response (supine: 12.3 mui/l; upright: 9.2 mui/l). The fludrocortisone dosage was then increased to 100 µg per day. On day 265, however, the patient suffered a heart attack due to poor adherence to the amlodipine. On day 686, though the fludrocortisone dosage was reduced to 50 µg per day, the investigation revealed no recovery of the RA axis (Table 2) and persistent hypovolemia (ECFV = 121 ml/kg). The fludrocortisone dosage was increased back up to 100 µg per day, at which point the patient was lost to follow-up. Patient 2 This 67-year-old male presented with poor BP control that gradually worsened despite tritherapy with ramipril, bisoprolol, and amlodipine. Hypokalemia and PA were diagnosed (Table 1). An abdominal CT scan revealed a right adrenal mass. Spironolactone (aldactone) was added preoperatively then discontinued for surgery. In the days following the operation, the patient continued to exhibit hypertension, requiring amlodipine and bisoprolol. A few weeks later, hyperkalemia at 6 mmol/l was detected. The patient remained asymptomatic without asthenia or vertigo and his clinostatic and orthostatic BPs were 130/75 and 130/85 mm Hg, respectively. Glucocorticoid deficiency was suspected and hydrocortisone substitution was initiated, despite the short ACTH stimulation test coming back normal. On day 51 postsurgery, our examinations revealed hypovolemia (ECFV = 165 ml/kg) with low supine renin, inadequate renin response, and low aldosterone (Table 2). Hydrocortisone was progressively phased out. On day 238, his ECFV remained slightly low (163 ml/kg), yet the RA axis had returned to normal, and his BP was efficiently controlled with dual therapy (amlodipine and bisoprolol). Patient 3 This 55-year-old male displayed resistant hypertension despite undergoing a course of 5 antihypertensive drugs: valsartan, hydrochlorothiazide, atenolol, nitrendipine, and urapidil. Hypokalemia was discovered on later tests and PA was diagnosed (Table 1). CT imaging revealed a left adrenal node, while AVS confirmed lateralization of secretion. Spironolactone was added to the treatment course prior to surgery and withdrawn for the operation. No electrolyte disorders requiring medication occurred following surgery, and his BP normalized to around 125/85 mm Hg without requiring any treatment. The patient was completely asymptomatic. On day 61, moderate hypovolemia (ECFV = 166 ml/kg) and an inadequate RA response were observed (Table 2). He was not treated with fludrocortisone, but was advised to avoid diuretics and renin-angiotensin blockers, and was instructed to follow a normal saline diet. The day 527 exploration revealed normovolemia, complete recovery of the RA axis, and normal BP that did not require treatment. Patient 4 This 42-year-old male exhibited hypertension and hypokalemia and was started on verapamil, lercanidip-
3 Renin-Aldosterone Axis Deficiency, AACE Clinical Case Rep. 2016;2(No. 4) e313 Table 1 Preoperative Patient Characteristics Patient 1 Patient 2 Patient 3 Patient 4 Normal values Age (years) Male/Female (M/F) M M M M - Duration of hypertension (years) Office SBP/DBP (mm Hg) 150/90 160/90 135/70 160/ hour ABPM SBP/DBP (mm Hg) MD 143/86 155/95 132/85 - Plasma creatinine (µmol/l) egfr (ml/min/1.73 m 2 ) >90 Plasma sodium (mmol/l) Plasma potassium (mmol/l) Supine/upright plasma renin 1-hour (mui/l) Supine/upright plasma aldosterone 1-hour (ng/l) Supine plasma aldosterone/renin ratio (ng/l per mui/l) MD 2.2 / / / / / MD 206 / / / / MD <23 Histopathology A A + H A A - Abbreviations: A = adenoma; ABPM = ambulatory blood pressure monitoring; DBP = diastolic blood pressure; egfr = estimated glomerular filtration rate using the Chronic Kidney Disease Epidemiology Collaboration formula; H = hyperplasia; MD = missing data; SBP = systolic blood pressure. ine, and amiloride. PA was diagnosed (Table 1) and a CT scan revealed a right adrenal node. Surgery was scheduled following confirmation of aldosterone secretion lateralization by AVS. The patient s BP rapidly improved as a result, requiring only verapamil, and his kalemia normalized. On day 42, he developed alternating episodes of hypotension and hypertension. As a result of what we had learned from Patient 1 s history, this symptom prompted us to measure ECFV. Hypovolemia was discovered (ECFV = 167 ml/ kg), along with an inadequate RA response (Table 2). As with Patient 3, no fludrocortisone was started and the same dietary and medication advice was offered. The day 93 tests revealed regressed hypovolemia (ECFV = 193 ml/kg) and a fully-recovered RA axis (Table 2), with verapamil still required for BP control. DISCUSSION In the context of unilateral adrenalectomy for PA, the discovery of normal to high plasma potassium (4.5 mmol/l) or labile BP could indicate a temporarily insufficient adaptation of the remaining adrenal gland. Such a situation has been reported in previous studies and has been attributed to a transient or prolonged hypoaldosteronism associated with a discrepancy between plasma renin levels and a lack of information concerning volemic status (3-8). We have hereby reported the cases of 4 patients presenting with normal to high kalemia associated with transient (n = 3) or prolonged (n = 1) failure of the RA axis. In these cases, subnormal kalemia and labile BP manifested within a few weeks of surgery, leading us to initiate complementary investigations. Our main findings were as follows: (1) a constant decrease in the ECFV with persistent inappropriate renal excretion of sodium was responsible for reversible impaired renal function in one case, (2) insufficient supine plasma-renin concentration was poorly stimulated in response to the upright position, (3) low baseline plasma aldosterone was unstimulated in an orthostatic test but was responsive to the ACTH stimulation test, and (4) in contrast, normal baseline plasma cortisol levels were found in all but one patient, and were shown to be normally increased by a short ACTH stimulation test. The discrepancy in the aldosterone response, namely pertaining to the orthostatic position versus the ACTH stimulation test, suggests that hypoaldosteronism primarily results from the lack of angiotensin II stimulation as a result of hyporeninism. These findings also indicate that PA can induce prolonged RA axis depression without systematic glucocorticoid deficiency. All 4 patients were male, supporting the belief that this gender is predisposed to such conditions as suggested by Chiang et al (8). The influence of postoperative treatments, such as beta-blockers or fludrocortisone, on the status of the RA axis cannot be ruled out. Nevertheless, the patient receiving fludrocortisone exhibited persistent decreased ECFV along with normal to high kalemia, indicating a persistent mineralocorticoid deficiency as opposed to an excess of fludrocortisone inhibiting the RA axis. Although the risk of postoperative hyperkalemia
4 e314 Renin-Aldosterone Axis Deficiency, AACE Clinical Case Rep. 2016;2(No. 4) Table 2 First and Last Postoperative Explorations Patient 1 Patient 2 Patient 3 Patient 4 Exploration First Last First Last First Last First Last Normal values Days postsurgery egfr (ml/min/1.73m 2 ) >90 mgfr (ml/min/1.73m 2 ) >90 ECFV (ml/kg) Plasma Na (mmol/l) Plasma K (mmol/l) Arterial HCO 3 (mmol/l) MD - Plasma glucose (mmol/l) Urinary Na (mmol/24 h) Urinary K (mmol/24 h) Fasting urinary Na/K ratio Supine/upright plasma renin 1-hour (mui/l) Supine/upright plasma aldosterone 1-hour (ng/l) Plasma aldosterone pre-/ post-acth (ng/l) Plasma cortisol pre-/post- ACTH (µ/100ml) 5.5 / / / MD 17.3 / / / / / / / <11 18 / 26 <10 / / / / / / / / 41 MD <20 / / 107 <20 / 48 MD 19 / / / / / / / / / / Abbreviations: ACTH = adrenocorticotropic hormone; ECFV = extracellular fluid volume; egfr = estimated glomerular filtration rate using the Chronic Kidney Disease Epidemiology Collaboration formula; h = hour; HCO 3 = bicarbonate; K = potassium; MD = missing data; mgfr = measured glomerular filtration rate; Na = sodium.
5 Renin-Aldosterone Axis Deficiency, AACE Clinical Case Rep. 2016;2(No. 4) e315 has been clearly related to the duration of hypertension and pre- or postoperative impaired renal function (6,8,9) as reported in Patient 1, we found that the RA axis can be deficient, even in patients with normal renal function and in the absence of hyperkalemia. The 4 patients reported herein represent 15% of the patients that underwent surgery for PA in our department during the study period. However, since ECFV measurement and postoperative RA axis explorations were not performed systematically, we cannot exclude the possibility that the prevalence of temporary RA axis deficiency was underestimated, as progressive and moderate decreases in ECFV are almost undetectable by clinical examination (11). We believe it possible that ACTH-stimulated aldosterone secretion could play a role in these cases, as the ACTH stimulation test was slightly responsive in these patients. However, the concomitant lack of aldosterone response during the orthostatic tests suggests that ACTH was probably not recruited in our patients when in the upright position. Such a discrepancy could result from an inadequate orthosympathetic response, as described in other studies of diabetic patients with hyporeninemic hypoaldosteronism (12,13). In conclusion, RA system depression can occur following unilateral adrenalectomy and should be investigated not only in hyperkalemic patients, but also in those with normal to high kalemia ( 4.5 mmol/l). As a result, actions with the potential to further decrease plasma volume (i.e., diuretic therapy or sodium-restricted diets) must be avoided so as to prevent symptomatic hypovolemia and functional renal insufficiency. We propose that, rather than an ACTH test, the RA axis should be functionally challenged by means of an orthostatic stimulation test. ACKNOWLEDGMENT The manuscript was written by M.V., A.M., I.T., and B.B., with all coauthors approving the final version. E.H. performed the surgeries. J.B.K., J.A., and B.C. recruited the patients. DISCLOSURE REFERENCES 1. Ganguly A. Primary aldosteronism. N Engl J Med. 1998;339: Funder JW, Carey RM, Fardella C, et al. Case detection, diagnosis, and treatment of patients with primary aldosteronism: an endocrine society clinical practice guideline. J Clin Endocrinol Metab. 2008;93: Taniguchi R, Koshiyama H, Yamauchi M, et al. A case of aldosterone-producing adenoma with severe postoperative hyperkalemia. Tohoku J Exp Med. 1998;186: Huang WT, Chau T, Wu ST, Lin SH. Prolonged hyperkalemia following unilateral adrenalectomy for primary hyperaldosteronism. Clin Nephrol. 2010;73: Gadallah MF, Kayyas Y, Boules F. Reversible suppression of the renin-aldosterone axis after unilateral adrenalectomy for adrenal adenoma. Am J Kidney Dis. 1998;32: Fischer E, Hanslik G, Pallauf A, et al. Prolonged zona glomerulosa insufficiency causing hyperkalemia in primary aldosteronism after adrenalectomy. J Clin Endocrinol Metab. 2012;97: Hibi Y, Hayakawa N, Hasegawa M, et al. Unmasked renal impairment and prolonged hyperkalemia after unilateral adrenalectomy for primary aldosteronism coexisting with primary hyperparathyroidism: report of a case. Surg Today. 2015;45: Chiang WF, Cheng CJ, Wu ST, et al. Incidence and factors of post-adrenalectomy hyperkalemia in patients with aldosterone producing adenoma. Clin Chim Acta. 2013;424: Park KS, Kim JH, Ku EJ, et al. Clinical risk factors of postoperative hyperkalemia after adrenalectomy in patients with aldosterone-producing adenoma. Eur J Endocrinol. 2015;172: Bröchner-Mortensen J, Giese J, Rossing N. Renal inulin clearance versus total plasma clearance of 51Cr-EDTA. Scand J Clin Lab Invest. 1969;23: Chung HM, Kluge R, Schrier RW, Anderson RJ. Clinical assessment of extracellular fluid volume in hyponatremia. Am J Med. 1987;83: Kuhlmann U, Vetter W, Fischer E, Siegenthaler W. Control of plasma aldosterone in diabetic patients with hyporeninemic hypoaldosteronism. Klin Wochenschr. 1978;56: Elisaf MS, Tomos PP, Milionis HJ, Siamopoulos KC. Prerenal azotemia in a diabetic patient with hyporeninemic hypoaldosteronism and autonomic neuropathy. Diabetes Metab. 1999;25: The authors have no multiplicity of interest to disclose.
Endocrine. Endocrine as it relates to the kidney. Sarah Elfering, MD University of Minnesota
Endocrine Sarah Elfering, MD University of Minnesota Endocrine as it relates to the kidney Parathyroid gland Vitamin D Endocrine causes of HTN Adrenal adenoma PTH Bone Kidney Intestine 1, 25 OH Vitamin
More informationYear 2004 Paper two: Questions supplied by Megan 1
Year 2004 Paper two: Questions supplied by Megan 1 QUESTION 96 A 32yo woman if found to have high blood pressure (180/105mmHg) at an insurance medical examination. She is asymptomatic. Clinical examination
More informationVolemic status estimation in clinical practice
Volemic status estimation in clinical practice Marion VALLET, Pierre-Yves CHARLES, Acil JAAFAR, Françoise PRADDAUDE, Ivan TACK Service des Explorations Fonctionnelles Physiologiques ; Hôpital de Rangueil,
More informationUpdates in primary hyperaldosteronism and the rule
Updates in primary hyperaldosteronism and the 20-50 rule I. David Weiner, M.D. Professor of Medicine and Physiology and Functional Genomics University of Florida College of Medicine and NF/SGVHS The 20-50
More informationPrimary Aldosteronism: screening, diagnosis and therapy
Primary Aldosteronism: screening, diagnosis and therapy Jacques W.M. Lenders, internist DEPT. OF INTERNAL MEDICINE, RADBOUD UNIVERSITY NIJMEGEN MEDICAL CENTER, NIJMEGEN,THE NETHERLANDS DEPT. OF INTERNAL
More informationUpdates in primary hyperaldosteronism and the rule
Updates in primary hyperaldosteronism and the 20-50 rule I. David Weiner, M.D. C. Craig and Audrae Tisher Chair in Nephrology Professor of Medicine and Physiology and Functional Genomics University of
More informationUpon completion, participants should be able to:
Learning Objectives Upon completion, participants should be able to: Describe the causes of secondary hypertension and the prevalence of primary aldosteronism Discuss the diagnostic approach to primary
More informationMineralocorticoids: aldosterone Angiotensin II/renin regulation by sympathetic tone; High potassium will stimulate and ACTH Increase in aldosterone
Disease of the Adrenals 1 Zona Glomerulosa Mineralocorticoids: aldosterone Angiotensin II/renin regulation by sympathetic tone; High potassium will stimulate and ACTH Increase in aldosterone leads to salt
More informationAbout 20% of the Canadian population
Mineralocorticoid Hypertension: Common and Treatable Hypertension is the most common chronic disease treated by the primary-care physician. It is now evident that mineralocorticoid hypertension, which
More informationThe endocrine system is made up of a complex group of glands that secrete hormones.
1 10. Endocrinology I MEDCHEM 535 Diagnostic Medicinal Chemistry Endocrinology The endocrine system is made up of a complex group of glands that secrete hormones. These hormones control reproduction, metabolism,
More informationHow to Recognize Adrenal Disease
How to Recognize Adrenal Disease CME Away India & Sri Lanka March 23 - April 7, 2018 Richard A. Bebb MD, ABIM, FRCPC Consultant Endocrinologist Medical Subspecialty Institute Cleveland Clinic Abu Dhabi
More informationClarification of hypertension Diagnosis of primary hyperaldosteronism
Nr. 1/2010 Clarification of hypertension Diagnosis of primary hyperaldosteronism Marc Beineke The significance of the /renin ratio (ARR) in the diagnosis of normoalaemic and hypokalaemic primary hyperaldosteronism,
More informationPrimary Aldosteronism
Primary Aldosteronism Odelia Cooper, MD Assistant Professor of Medicine Division of Endocrinology, Diabetes, and Metabolism Cedars-Sinai Medical Center HYPERTENSION CENTER Barriers to diagnosing primary
More information4/23/2015. Objectives DISCLOSURES
2015 PENS Conference Savannah, GA Novel Cases of Congenital Hyperreninemic Hypaldosteronism Jan M. Foote DISCLOSURES I have no actual or potential conflicts of interest in relation to this presentation.
More informationA case of DYSELECTROLYTEMIA. Dr. Prathyusha Dr. Lalitha janakiraman s unit
A case of DYSELECTROLYTEMIA Dr. Prathyusha Dr. Lalitha janakiraman s unit CASE SUMMARY 4 month old, female infant 1 st born to NC parents, term, b.wt: 3.25kg No neonatal hospitalization Attained head control
More informationHow to approach resistant hypertension. Teh-Li Huo, M.D., Ph.D.
How to approach resistant hypertension Teh-Li Huo, M.D., Ph.D. BP goals No risk factors:
More informationClinical Guideline. SPEG MCN Protocols Sub Group SPEG Steering Group
Clinical Guideline SECONDARY CARE MANAGEMENT OF SUSPECTED ADRENAL CRISIS IN CHILDREN AND YOUNG PEOPLE Date of First Issue 24/01/2015 Approved 28/09/2017 Current Issue Date 16/06/2017 Review Date 01/09/2019
More informationYounger adults with a family history of premature artherosclerotic disease should have their cardiovascular risk factors measured.
Appendix 2A - Guidance on Management of Hypertension Measurement of blood pressure All adults from 40 years should have blood pressure measured as part of opportunistic cardiovascular risk assessment.
More informationByvalson. (nebivolol, valsartan) New Product Slideshow
Byvalson (nebivolol, valsartan) New Product Slideshow Introduction Brand name: Byvalson Generic name: Nebivolol, valsartan Pharmacological class: Beta-blocker + angiotensin II receptor blocker (ARB) Strength
More informationRESISTENT HYPERTENSION. Dr. Helmy Bakr Professor and Head of Cardiology Dept. Mansoura University
RESISTENT HYPERTENSION Dr. Helmy Bakr Professor and Head of Cardiology Dept. Mansoura University Resistant Hypertension Blood pressure remaining above goal in spite of concurrent use of 3 antihypertensive
More informationHeart Failure (HF) Treatment
Heart Failure (HF) Treatment Heart Failure (HF) Complex, progressive disorder. The heart is unable to pump sufficient blood to meet the needs of the body. Its cardinal symptoms are dyspnea, fatigue, and
More informationDiseases of the Adrenal gland
Diseases of the Adrenal gland Adrenal insufficiency Cushing disease vs syndrome Pheochromocytoma Hyperaldostronism What are the layers of the adrenal gland?? And what does each layer produce?? What are
More informationNATURAL HISTORY AND SURVIVAL OF PATIENTS WITH ASCITES. PATIENTS WHO DO NOT DEVELOP COMPLICATIONS HAVE MARKEDLY BETTER SURVIVAL THAN THOSE WHO DEVELOP
PROGNOSIS Mortality rates as high as 18-30% are reported for hyponatremic patients. High mortality rates reflect the severity of underlying conditions and are not influenced by treatment of hyponatremia
More informationPotassium A NNA VINNIKOVA, M. D.
Potassium A NNA VINNIOVA, M. D. DIVISION OF NEPHROLOGY Graphics by permission from The Fluid, Electrolyte and Acid-Base Companion, S. Faubel and J. Topf, http://www.pbfluids.com Do you want to hear a Sodium
More informationResistant hypertension is defined as blood. Primary Hyperaldosteronism Decoded: A Case of Curable Resistant Hypertension.
Case Review Primary Hyperaldosteronism Decoded: A Case of Curable Resistant Hypertension Timothy R. Larsen, DO, Wadie David, Susan Steigerwalt, MD, Shukri David, MD Department of Internal Medicine, Section
More informationCOMPLEX HYPERTENSION. Anita Ralstin, FNP-BC Next Step Health Consultant, LLC
COMPLEX HYPERTENSION Anita Ralstin, FNP-BC Next Step Health Consultant, LLC Incidence Of Hypertension About 70 million American adults have high blood pressure. About 33% of the population Only 52% have
More informationCOMPOSITION. A film coated tablet contains. Active ingredient: irbesartan 75 mg, 150 mg or 300 mg. Rotazar (Film coated tablets) Irbesartan
Rotazar (Film coated tablets) Irbesartan Rotazar 75 mg, 150 mg, 300 mg COMPOSITION A film coated tablet contains Active ingredient: irbesartan 75 mg, 150 mg or 300 mg. Rotazar 75 mg, 150 mg, 300 mg PHARMACOLOGICAL
More informationAVS and IPSS: The Basics and the Pearls
AVS and IPSS: The Basics and the Pearls William F. Young, Jr., MD, MSc Professor of Medicine Mayo Clinic College of Medicine Rochester, MN, USA 2018 Mayo Foundation for Medical Education and Research.
More informationPrimary aldosteronism clinical practice guidelines: a re-appraisal The Management of Primary Aldosteronism
Primary aldosteronism clinical practice guidelines: a re-appraisal The Management of Primary Aldosteronism Prof. FRANCO MANTERO Division of Endocrinology University of Padua Italy Case Detection, Diagnosis
More informationDISCLOSURES OUTLINE OUTLINE 9/29/2014 ANTI-HYPERTENSIVE MANAGEMENT OF CHRONIC KIDNEY DISEASE
ANTI-HYPERTENSIVE MANAGEMENT OF CHRONIC KIDNEY DISEASE DISCLOSURES Editor-in-Chief- Nephrology- UpToDate- (Wolters Klewer) Richard J. Glassock, MD, MACP Geffen School of Medicine at UCLA 1 st Annual Internal
More informationEndocrine hypertensionmolecules. Marie Freel Caledonian Endocrine Society Meeting 29 th November 2015
Endocrine hypertensionmolecules and genes Marie Freel Caledonian Endocrine Society Meeting 29 th November 2015 Plan Mineralocorticoid hypertension Myths surrounding Primary Aldosteronism (PA) New developments
More informationCPY 605 ADVANCED ENDOCRINOLOGY
CPY 605 ADVANCED ENDOCRINOLOGY THE ADRENAL CORTEX PRESENTED BY WAINDIM NYIAMBAM YVONNE HS09A187 INTRODUCTION Two adrenal glands lie on top of each kidney. Each gland between 6 and 8g in weight is composed
More informationkeyword: diuretics Drug monitoring Monitoring diuretics in primary care 2 March 2009 best tests
www.bpac.org.nz keyword: diuretics Drug monitoring Monitoring diuretics in primary care 2 March 2009 best tests Why do we monitor patients taking diuretics and what do we monitor? Monitoring a person on
More informationAldosterone Antagonism in Heart Failure: Now for all Patients?
Aldosterone Antagonism in Heart Failure: Now for all Patients? Inder Anand, MD, FRCP, D Phil (Oxon.) Professor of Medicine, University of Minnesota, Director Heart Failure Program, VA Medical Center 111C
More informationDiabetes and Hypertension
Diabetes and Hypertension M.Nakhjvani,M.D Tehran University of Medical Sciences 20-8-96 Hypertension Common DM comorbidity Prevalence depends on diabetes type, age, BMI, ethnicity Major risk factor for
More informationAntihypertensive Agents Part-2. Assistant Prof. Dr. Najlaa Saadi PhD Pharmacology Faculty of Pharmacy University of Philadelphia
Antihypertensive Agents Part-2 Assistant Prof. Dr. Najlaa Saadi PhD Pharmacology Faculty of Pharmacy University of Philadelphia Agents that block production or action of angiotensin Angiotensin-converting
More informationAdrenal Gland Disorders
1 Adrenal Gland Disorders Adrenal cortex steroid hormones (corticosteroids) 1. Glucocorticoids Regulate metabolism and blood glucose Critical to physiologic stress response 2. Mineralocorticoids Regulate
More informationReframe the Paradigm of Hypertension treatment Focus on Diabetes
Reframe the Paradigm of Hypertension treatment Focus on Diabetes Paola Atallah, MD Lecturer of Clinical Medicine SGUMC EDL monthly meeting October 25,2016 Overview Physiopathology of hypertension Classification
More informationDiuretic Agents Part-2. Assistant Prof. Dr. Najlaa Saadi PhD Pharmacology Faculty of Pharmacy University of Philadelphia
Diuretic Agents Part-2 Assistant Prof. Dr. Najlaa Saadi PhD Pharmacology Faculty of Pharmacy University of Philadelphia Potassium-sparing diuretics The Ion transport pathways across the luminal and basolateral
More informationThe P&T Committee Lisinopril (Qbrelis )
Situation Background Assessment The P&T Committee Lisinopril (Qbrelis ) Qbrelis, 1 mg/ml lisinopril oral solution, has recently become an FDA- approved formulation. Current practice at UK Chandler Medical
More information0BCore Safety Profile. Pharmaceutical form(s)/strength: Film-coated tablet 40, 80, 160, 320 mg SE/H/PSUR/0024/003 Date of FAR:
0BCore Safety Profile Active substance: Valsartan Pharmaceutical form(s)/strength: Film-coated tablet 40, 80, 160, 320 mg P-RMS: SE/H/PSUR/0024/003 Date of FAR: 28.02.2013 4.2 Posology and method of administration
More informationPatients with primary aldosteronism (PA) are at a higher
ORIGINAL ARTICLE Endocrine Care Predictors of Decreasing Glomerular Filtration Rate and Prevalence of Chronic Kidney Disease After Treatment of Primary Aldosteronism: Renal Outcome of 213 Cases Yoshitsugu
More informationSpectrum of Hypertension & Hypokalemia
Spectrum of Hypertension & Hypokalemia Farheen K. Dojki, PGY-6 Hypertension Fellow, ASH Hypertension Center Dr. Dojki does not have any relevant financial relationships with any commercial interests. OBJECTIVES:
More informationPancreatic Insulinoma Presenting. with Episodes of Hypoinsulinemic. Hypoglycemia in Elderly ---- A Case Report
2008 19 432-436 Pancreatic Insulinoma Presenting with Episodes of Hypoinsulinemic Hypoglycemia in Elderly ---- A Case Report Chieh-Hsiang Lu 1, Shih-Che Hua 1, and Chung-Jung Wu 2,3 1 Division of Endocrinology
More informationA 64 year old man referred for evaluation of suspected hyperaldosteronism
A 64 year old man referred for evaluation of suspected hyperaldosteronism Dr. Dickens does not have any relevant financial relationships with any commercial interests. ENDORAMA: 64 year old man referred
More informationNIH Public Access Author Manuscript Transplant Proc. Author manuscript; available in PMC 2010 July 14.
NIH Public Access Author Manuscript Published in final edited form as: Transplant Proc. 1990 February ; 22(1): 17 20. The Effects of FK 506 on Renal Function After Liver Transplantation J. McCauley, J.
More informationManagement of Hypertension
Clinical Practice Guidelines Management of Hypertension Definition and classification of blood pressure levels (mmhg) Category Systolic Diastolic Normal
More informationAdrenocortical Insufficiency: Addison's Disease
280 PHYSIOLOGY CASES AND PROBLEMS Case 49 Adrenocortical Insufficiency: Addison's Disease Susan Oglesby is a 41-year-old divorced mother of two teenagers. She has always been in excellent health. She recently
More informationSpironolactone has not been demonstrated to elevate serum uric acid, to precipitate gout or to alter carbohydrate metabolism.
SPIRONE Composition Each tablet contains Spironolactone 100 mg. Tablets Action Spironolactone is a specific pharmacologic antagonist of aldosterone, acting primarily through competitive binding of receptors
More informationSupplementary Appendix
Supplementary Appendix This appendix has been provided by the authors to give readers additional information about their work. Supplement to: Wanner C, Inzucchi SE, Lachin JM, et al. Empagliflozin and
More informationHyperaldosteronism: Conn's Syndrome
RENAL AND ACID-BASE PHYSIOLOGY 177 Case 31 Hyperaldosteronism: Conn's Syndrome Seymour Simon is a 54-year-old college physics professor who maintains a healthy lifestyle. He exercises regularly, doesn't
More informationThe Work-up and Treatment of Adrenal Nodules
The Work-up and Treatment of Adrenal Nodules Lawrence Andrew Drew Shirley, MD, MS, FACS Assistant Professor of Surgical-Clinical Department of Surgery Division of Surgical Oncology The Ohio State University
More informationKingdom of Bahrain Arabian Gulf University College of Medicine and Medical Sciences. Endocrinology. (Review) Year 5 Internal Medicine
Kingdom of Bahrain Arabian Gulf University College of Medicine and Medical Sciences Endocrinology (Review) Year 5 Internal Medicine Presented by: Dr. Mona Arekat Prepared by: Ali Jassim Alhashli Case (1):
More informationVirtual Mentor American Medical Association Journal of Ethics April 2007, Volume 9, Number 4:
Virtual Mentor American Medical Association Journal of Ethics April 2007, Volume 9, Number 4: 295-299. Clinical pearl Hyperkalemia: newer considerations by Amar D. Bansal and David S. Goldfarb, MD Maintenance
More informationΚΑΡΔΙΑΚΗ ΑΝΕΠΑΡΚΕΙΑ ΚΑΙ ΑΝΤΑΓΩΝΙΣΤΕΣ ΑΛΔΟΣΤΕΡΟΝΗΣ ΣΠΥΡΟΜΗΤΡΟΣ ΓΕΩΡΓΙΟΣ MD, FESC. E.Α Κ/Δ Γ.Ν.ΚΑΤΕΡΙΝΗΣ
ΚΑΡΔΙΑΚΗ ΑΝΕΠΑΡΚΕΙΑ ΚΑΙ ΑΝΤΑΓΩΝΙΣΤΕΣ ΑΛΔΟΣΤΕΡΟΝΗΣ ΣΠΥΡΟΜΗΤΡΟΣ ΓΕΩΡΓΙΟΣ MD, FESC. E.Α Κ/Δ Γ.Ν.ΚΑΤΕΡΙΝΗΣ Aldosterone is a mineralocorticoid hormone synthesized by the adrenal glands that has several regulatory
More informationPatterns of Sodium Excretion During Sympathetic Nervous System Arousal. Gregory A. Harshfield, Derrick A. Pulliam, and Bruce S.
1156 Patterns of Sodium Excretion During Sympathetic Nervous System Arousal Gregory A. Harshfield, Derrick A. Pulliam, and Bruce S. Alpert The purpose of this study was to examine Na + handling and regulation
More informationSecondary Hypertension: A Real World Approach
Secondary Hypertension: A Real World Approach Evan Brittain, MD December 7, 2012 Kingston, Jamaica Disclosures None Real World Causes Renovascular Hypertension Endocrine Obstructive Sleep Apnea Pseudosecondary
More informationPatient details GP details Specialist details Name GP Name Dr Specialist Name Dr R. Horton
Rationale for Initiation, Continuation and Discontinuation (RICaD) Sacubitril/Valsartan (Entresto) For the treatment of symptomatic heart failure with reduced ejection fraction (NICE TA388) This document
More informationAddison s Disease. How it affects your dog. ZYCORTAL SUSPENSION (desoxycorticosterone pivalate injectable suspension)
Addison s Disease How it affects your dog ZYCORTAL Recognize the signs of Addison s disease Addison s disease is rare and the symptoms often mimic more common diseases. Symptoms are vague, and can wax
More information5.2 Key priorities for implementation
5.2 Key priorities for implementation From the full set of recommendations, the GDG selected ten key priorities for implementation. The criteria used for selecting these recommendations are listed in detail
More informationAdult Blood Pressure Clinician Guide June 2018
Kaiser Permanente National CLINICAL PRACTICE GUIDELINES Adult Blood Pressure Clinician Guide June 2018 Adult Blood Pressure Clinician Guide June 2018 Introduction This Clinician Guide is based on the 2018
More informationDr Narender Goel MD (Internal Medicine and Nephrology) Financial Disclosure: None, Conflict of Interest: None
Dr Narender Goel MD (Internal Medicine and Nephrology) drnarendergoel@gmail.com Financial Disclosure: None, Conflict of Interest: None 12 th December 2013, New York Visit us at: http://kidneyscience.info/
More informationDECLARATION OF CONFLICT OF INTEREST
DECLARATION OF CONFLICT OF INTEREST Novel approaches in hypertension Aldosterone-synthase inhibitors. Faiez Zannad Nancy, France Disclosures Dr Zannad reports receiving Speaker/consultant honoraria from
More informationAssistant Professor of Endocrinology
Pathophysiology Of Adrenal Disorder Dr.Rezvan Salehidoost Assistant Professor of Endocrinology Pathophysiology Of Adrenal Disorder The adrenal glands lie at the superior pole of each kidney and are composed
More informationHypertension Management Controversies in the Elderly Patient
Hypertension Management Controversies in the Elderly Patient Juan Bowen, MD Geriatric Update for the Primary Care Provider November 17, 2016 2016 MFMER slide-1 Disclosure No financial relationships No
More informationBasic Fluid and Electrolytes
Basic Fluid and Electrolytes Chapter 22 Basic Fluid and Electrolytes Introduction Infants and young children have a greater need for water and are more vulnerable to alterations in fluid and electrolyte
More informationELECTROLYTES RENAL SHO TEACHING
ELECTROLYTES RENAL SHO TEACHING Metabolic Alkalosis 2 factors are responsible for generation and maintenance of metabolic alkalosis this includes a process that raises serum bicarbonate and a process that
More informationHypertension (JNC-8)
Hypertension (JNC-8) Southern California University of Health Sciences Physician Assistant Program Management and Treatment of Hypertension April 17, 2018, presented by Ezra Levy, Pharm.D.! The 8 th Joint
More informationRaised aldosterone to renin ratio predicts antihypertensive efficacy of spironolactone: a prospective cohort follow-up study
Raised aldosterone to renin ratio predicts antihypertensive efficacy of spironolactone: a prospective cohort follow-up study P. O. Lim, R. T. Jung & T. M. MacDonald Hypertension Research Centre, Department
More informationHypertensionTreatment Guidelines. Michaelene Urban APRN, MSN, ACNS-BC, ANP-BC
HypertensionTreatment Guidelines Michaelene Urban APRN, MSN, ACNS-BC, ANP-BC Objectives: Review the definition of the different stages of HTN. Review the current guidelines for treatment of HTN. Provided
More informationRENAL TUBULAR ACIDOSIS An Overview
RENAL TUBULAR ACIDOSIS An Overview UNIVERSITY OF PNG SCHOOL OF MEDICINE AND HEALTH SCIENCES DISCIPLINE OF BIOCHEMISTRY & MOLECULAR BIOLOGY CLINICAL BIOCHEMISTRY PBL MBBS IV VJ. Temple 1 What is Renal Tubular
More informationHypertension diagnosis (see detail document) Diabetic. Target less than 130/80mmHg
Hypertension diagnosis (see detail document) Non-diabetic Diabetic Very elderly (older than 80 years) Target less than 140/90mmHg Target less than 130/80mmHg Consider SBP target less than 150mmHg Non-diabetic
More informationPotassium, Aldosterone, and Hypertension: How Physiology Determines Treatment. Jamie Johnston, MD University of Pittsburgh School of Medicine
Potassium, Aldosterone, and Hypertension: How Physiology Determines Treatment Jamie Johnston, MD University of Pittsburgh School of Medicine No Disclosures Acknowledgements: Evan Ray, MD, PhD Objectives
More informationOutpatient Fludrocortisone Suppression Test: A Safe and Effective Alternative to Inpatient
Outpatient Fludrocortisone Suppression Test: A Safe and Effective Alternative to Inpatient Testing/ Original Article Author Information Dr Walter van der Merwe MBChB, FRACP, Consultant Nephrologist, Renal
More informationSystolic Blood Pressure Intervention Trial (SPRINT)
09:30-09:50 2016.4.15 Systolic Blood Pressure Intervention Trial (SPRINT) IN A NEPHROLOGIST S VIEW Sejoong Kim Seoul National University Bundang Hospital Current guidelines for BP control Lowering BP
More informationManagement of Hypertension. M Misra MD MRCP (UK) Division of Nephrology University of Missouri School of Medicine
Management of Hypertension M Misra MD MRCP (UK) Division of Nephrology University of Missouri School of Medicine Disturbing Trends in Hypertension HTN awareness, treatment and control rates are decreasing
More informationAdrenocorticotropic Hormone-Independent Cushing Syndrome with Bilateral Cortisol-Secreting Adenomas
Case Report Endocrinol Metab 2013;28:133-137 http://dx.doi.org/10.3803/enm.2013.28.2.133 pissn 2093-596X eissn 2093-5978 Adrenocorticotropic Hormone-Independent Cushing Syndrome with Bilateral Cortisol-Secreting
More informationHypertension Update. Sarah J. Payne, MS, PharmD, BCPS Assistant Professor, Department of Pharmacotherapy UNT System College of Pharmacy
Hypertension Update Sarah J. Payne, MS, PharmD, BCPS Assistant Professor, Department of Pharmacotherapy UNT System College of Pharmacy Introduction 1/3 of US adults have HTN More prevalent in non-hispanic
More informationDifficult-to-Control & Resistant Hypertension. Anthony Viera, MD, MPH, FAHA Professor and Chair
Difficult-to-Control & Resistant Hypertension Anthony Viera, MD, MPH, FAHA Professor and Chair Objectives Define resistant hypertension Discuss evaluation strategy for patient with HTN that appears difficult
More informationJared Moore, MD, FACP
Hypertension 101 Jared Moore, MD, FACP Assistant Program Director, Internal Medicine Residency Clinical Assistant Professor of Internal Medicine Division of General Medicine The Ohio State University Wexner
More informationThe CARI Guidelines Caring for Australasians with Renal Impairment. ACE Inhibitor and Angiotensin II Antagonist Combination Treatment GUIDELINES
ACE Inhibitor and Angiotensin II Antagonist Combination Treatment Date written: September 2004 Final submission: September 2005 Author: Kathy Nicholls GUIDELINES No recommendations possible based on Level
More informationIntroductory Clinical Pharmacology Chapter 41 Antihypertensive Drugs
Introductory Clinical Pharmacology Chapter 41 Antihypertensive Drugs Blood Pressure Normal = sys
More informationADRENAL GLAND. Introduction 4/21/2009. Among most important and vital endocrine organ. Small bilateral yellowish retroperitoneal organ
Introduction Among most important and vital endocrine organ ADRENAL GLAND D.Hammoudi.MD Small bilateral yellowish retroperitoneal organ Lies just above kidney in gerota s fascia 2 1 The Adrenal Gland Anatomy
More informationPHARMACEUTICAL INFORMATION AZILSARTAN
AZEARLY Tablets Each Tablet Contains Azilsartan 20/40/80 mg PHARMACEUTICAL INFORMATION AZILSARTAN Generic name: Azilsartan Chemical name: 2-Ethoxy-1-{[2'-(5-oxo-2,5-dihydro-1,2,4-oxadiazol-3-yl)-4-biphenylyl]methyl}-
More informationDECLARATION OF CONFLICT OF INTEREST
DECLARATION OF CONFLICT OF INTEREST TAKE HOME MESSAGES FROM RECENT HEART FAILURE CLINICAL TRIALS How to use aldosterone blockers? Faiez Zannad INSERM, U961 and Clinical Investigation Center CHU, Heart
More informationBlood Pressure Treatment in 2018
Blood Pressure Treatment in 2018 Jay D. Geoghagan, MD, FACC Disclosures: None 1 2017 ACC/AHA/AAPA/ABC/ACPM/AGS/ APhA/ASH/ASPC/NMA/PCNA Guideline for the Prevention, Detection, Evaluation, and Management
More informationSTANDARD treatment algorithm mmHg
STANDARD treatment algorithm 130-140mmHg (i) At BASELINE, If AVERAGE SBP 1 > 140mmHg If on no antihypertensive drugs: Start 1 drug: If >55 years old / Afro-Caribbean: Calcium channel blocker (CCB) 2 If
More informationHeart Failure Clinician Guide JANUARY 2018
Kaiser Permanente National CLINICAL PRACTICE GUIDELINES Heart Failure Clinician Guide JANUARY 2018 Introduction This evidence-based guideline summary is based on the 2018 National Heart Failure Guideline.
More informationRenal-Related Questions
Renal-Related Questions 1) List the major segments of the nephron and for each segment describe in a single sentence what happens to sodium there. (10 points). 2) a) Describe the handling by the nephron
More informationNew Treatment Options for Diabetic Nephropathy patients. Prof. M. Burnier, Service of Nephrology and Hypertension CHUV, Lausanne, Switzerland
New Treatment Options for Diabetic Nephropathy patients Prof. M. Burnier, Service of Nephrology and Hypertension CHUV, Lausanne, Switzerland Diabetes and nephropathy Diabetic nephropathy is the most common
More informationALLHAT RENAL DISEASE OUTCOMES IN HYPERTENSIVE PATIENTS STRATIFIED INTO 4 GROUPS BY BASELINE GLOMERULAR FILTRATION RATE (GFR)
1 RENAL DISEASE OUTCOMES IN HYPERTENSIVE PATIENTS STRATIFIED INTO 4 GROUPS BY BASELINE GLOMERULAR FILTRATION RATE (GFR) 6 / 5 / 1006-1 2 Introduction Hypertension is the second most common cause of end-stage
More informationHeart Failure Clinician Guide JANUARY 2016
Kaiser Permanente National CLINICAL PRACTICE GUIDELINES Heart Failure Clinician Guide JANUARY 2016 Introduction This evidence-based guideline summary is based on the 2016 National Heart Failure Guideline.
More informationHyperkalemia a silent killer? PD Dr. med. Andreas Kistler Kantonsspital Frauenfeld
Hyperkalemia a silent killer? PD Dr. med. Andreas Kistler Kantonsspital Frauenfeld andreas.kistler@stgag.ch www.nephrologie-thurgau.ch Mr. Hyper K. Lemia charged with serial murder Bild entfernt (copyright)
More informationEndocrine Hypertension
Endocrine Hypertension 1 No Disclosures Endocrine Hypertension Objectives: 1. Understand Endocrine disorders causing hypertension 2. Understand clinical presentation of Pheochromocytoma and Hyperaldosteronism
More informationHYPERTENSION IN CKD. LEENA ONGAJYOOTH, M.D., Dr.med RENAL UNIT SIRIRAJ HOSPITAL
HYPERTENSION IN CKD LEENA ONGAJYOOTH, M.D., Dr.med RENAL UNIT SIRIRAJ HOSPITAL Stages in Progression of Chronic Kidney Disease and Therapeutic Strategies Complications Normal Increased risk Damage GFR
More informationNew Hypertension Guideline Recommendations for Adults July 7, :45-9:30am
Advances in Cardiovascular Disease 30 th Annual Convention and Reunion UERM-CMAA, Inc. Annual Convention and Scientific Meeting July 5-8, 2018 New Hypertension Guideline Recommendations for Adults July
More informationDIURETICS-4 Dr. Shariq Syed
DIURETICS-4 Dr. Shariq Syed AIKTC - Knowledge Resources & Relay Center 1 Pop Quiz!! Loop diuretics act on which transporter PKCC NKCC2 AIKTCC I Don t know AIKTC - Knowledge Resources & Relay Center 2 Pop
More informationEplerenon Medical Valley + Eplerenon Stada
VI.2 Elements for a Public Summary VI.2.1 Overview of disease epidemiology Heart failure is a complex syndrome, clinically characterized by signs and symptoms secondary to abnormal cardiac function. It
More information