Cardiogenic shock other diagnostic studies: Difference between revisions

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{{Cardiogenic shock}}
{{Cardiogenic shock}}
{{CMG}}; {{AE}} {{JS}}
{{CMG}}; {{AE}} {{JS}} {{sali}}


==Overview==
==Overview==
Attending to the catastrophic [[outcome]] of cardiogenic shock in a very short time span, its [[diagnosis]] must be reached as early as possible in order for proper [[therapy]] to be started. This period until [[diagnosis]] and [[therapy|treatment]] initiation is particularly important in the case of cardiogenic shock since the [[mortality rate]] of this condition complicating acute-[[MI]] is very high, along with the fact that the ability to revert the damage caused, through [[reperfusion]] techniques, declines considerably with [[diagnostic]] delays. Therefore and due to the unstable state of these patients, the [[diagnostic]] evaluations are usually performed as supportive measures are initiated. The [[diagnostic]] measures should start with the proper [[medical history|history]] and [[physical examination]], including [[blood pressure]] measurement, followed by an [[EKG]], [[echocardiography]], [[chest x-ray]] and collection of [[blood]] samples for evaluation. The physician should keep in mind the common features of [[shock]], irrespective of the type of [[shock]], in order to avoid delays in the [[diagnosis]]. Although not all [[shock]] patients present in the same way, these features include: abnormal [[mental status]], [[cool extremities]], [[clammy skin]], manifestations of [[hypoperfusion]], such as [[hypotension]] and [[oliguria]], as well as evidence of [[metabolic acidosis]] on the [[blood]] results.<ref>{{Cite book  | last1 = Longo | first1 = Dan L. (Dan Louis) | title = Harrison's principles of internal medici | date = 2012 | publisher = McGraw-Hill | location = New York | isbn = 978-0-07-174889-6 | pages =  }}</ref>
The [[Swan-ganz catheter]], [[right heart catheter]] or [[pulmonary artery catheter]] has been gradually replaced by [[echocardiography]] with [[color Doppler]] throughout the years, however, it is still common practice in some centers. It may be used for different situations, such as: confirming the [[diagnosis]] of [[cardiogenic shock]] following clinical evaluation, ensuring adequacy of filling pressures, establishing the relationship between these [[filling pressures]] and [[cardiac output]] as well as helping in possible adjustments in [[therapy]]. It is still a very important tool for the assessment of [[hemodynamic]] parameters, such as [[cardiac]] power and [[stroke]] work index, which are important data for short-term prognosis.It may also be helpful in distinguishing [[cardiogenic shock]] from [[septic shock]] and in optimizing the patient's [[left ventricular filling pressures]]. The presence of significant [[V waves]] (greatly exceeding the [[pulmonary capillary wedge pressure]]) on the [[pulmonary artery]] tracing suggests either [[acute mitral regurgitation]] or a [[ventricular septal defect]]. The [[revascularization]] procedure may consist of [[percutaneous coronary intervention]] procedure or [[coronary artery bypass graft]] [[surgery]]. Patients who have undergone [[reperfusion]] procedures with either [[percutaneous coronary intervention]] or [[fibrinolytic therapy]], experiencing new symptoms, should also be evaluated for failure of the initial treatment.


==Other Diagnostic Studies==
==Other Diagnostic Studies==
=== Swan Ganz Catheter ===
=== Swan Ganz Catheter ===
The [[Swan-ganz catheter]] or [[pulmonary artery catheter]] has been gradually replaced by [[echocardiography]] with color [[Doppler]] throughout the years, however, it is still common practice in some centers. It may be used for different situations, such as: confirming the [[diagnosis]] of cardiogenic shock following clinical evaluation, ensuring adequacy of filling pressures, establishing the relationship between  these filling pressures and [[cardiac output]] as well as helping in possible adjustments in [[therapy]].<ref name="ReynoldsHochman2008">{{cite journal|last1=Reynolds|first1=H. R.|last2=Hochman|first2=J. S.|title=Cardiogenic Shock: Current Concepts and Improving Outcomes|journal=Circulation|volume=117|issue=5|year=2008|pages=686–697|issn=0009-7322|doi=10.1161/CIRCULATIONAHA.106.613596}}</ref> It is still a very important tool for the assessment of [[hemodynamic]] parameters, such as ''cardiac power'' and ''stroke work index'', which are important data for short-term [[prognosis]].<ref name="pmid15261929">{{cite journal| author=Fincke R, Hochman JS, Lowe AM, Menon V, Slater JN, Webb JG et al.| title=Cardiac power is the strongest hemodynamic correlate of mortality in cardiogenic shock: a report from the SHOCK trial registry. | journal=J Am Coll Cardiol | year= 2004 | volume= 44 | issue= 2 | pages= 340-8 | pmid=15261929 | doi=10.1016/j.jacc.2004.03.060 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=15261929  }} </ref> It may also be helpful in distinguishing cardiogenic shock from [[septic shock]] and in optimizing the patient's left ventricular filling pressures. The presence of significant V waves (greatly exceeding the pulmonary [[capillary wedge pressure]]) on the [[pulmonary artery]] tracing suggests either acute [[mitral regurgitation]] or a [[ventricular septal defect]].
*The [[Swan-ganz catheter]], right [[heart]] [[catheter]] or [[pulmonary artery catheter]] has been gradually replaced by [[echocardiography]] with color [[Doppler]] throughout the years, however, it is still common practice in some centers.  
 
*It may be used for different situations, such as: confirming the [[diagnosis]] of cardiogenic shock following clinical evaluation, ensuring adequacy of filling pressures, establishing the relationship between  these filling pressures and [[cardiac output]] as well as helping in possible adjustments in [[therapy]].<ref name="ReynoldsHochman2008">{{cite journal|last1=Reynolds|first1=H. R.|last2=Hochman|first2=J. S.|title=Cardiogenic Shock: Current Concepts and Improving Outcomes|journal=Circulation|volume=117|issue=5|year=2008|pages=686–697|issn=0009-7322|doi=10.1161/CIRCULATIONAHA.106.613596}}</ref>  
*In cardiogenic shock complicating [[right ventricle myocardial infarction|RV infarct]], the PA catheter may help in the diagnosis, when the following criteria are found:<ref name="NgYeghiazarians2011">{{cite journal|last1=Ng|first1=R.|last2=Yeghiazarians|first2=Y.|title=Post Myocardial Infarction Cardiogenic Shock: A Review of Current Therapies|journal=Journal of Intensive Care Medicine|volume=28|issue=3|year=2011|pages=151–165|issn=0885-0666|doi=10.1177/0885066611411407}}</ref><ref>{{cite book | last = Topol | first = Eric | title = Textbook of cardiovascular medicine | publisher = Lippincott Williams & Wilkins | location = Philadelphia | year = 2007 | isbn = 0781770122 }}</ref><ref name="pmid6092446">{{cite journal| author=Dell'Italia LJ, Starling MR, Crawford MH, Boros BL, Chaudhuri TK, O'Rourke RA| title=Right ventricular infarction: identification by hemodynamic measurements before and after volume loading and correlation with noninvasive techniques. | journal=J Am Coll Cardiol | year= 1984 | volume= 4 | issue= 5 | pages= 931-9 | pmid=6092446 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=6092446  }} </ref><ref name="pmid8139631">{{cite journal| author=Kinch JW, Ryan TJ| title=Right ventricular infarction. | journal=N Engl J Med | year= 1994 | volume= 330 | issue= 17 | pages= 1211-7 | pmid=8139631 | doi=10.1056/NEJM199404283301707 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=8139631  }} </ref>
*It is still a very important tool for the assessment of [[hemodynamic]] parameters, such as ''cardiac power'' and ''stroke work index'', which are important data for short-term [[prognosis]].<ref name="pmid15261929">{{cite journal| author=Fincke R, Hochman JS, Lowe AM, Menon V, Slater JN, Webb JG et al.| title=Cardiac power is the strongest hemodynamic correlate of mortality in cardiogenic shock: a report from the SHOCK trial registry. | journal=J Am Coll Cardiol | year= 2004 | volume= 44 | issue= 2 | pages= 340-8 | pmid=15261929 | doi=10.1016/j.jacc.2004.03.060 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=15261929  }} </ref>  
*It may also be helpful in distinguishing cardiogenic shock from [[septic shock]] and in optimizing the patient's [[left ventricular]] filling pressures.  
*The presence of significant V waves (greatly exceeding the [[pulmonary capillary wedge pressure]]) on the [[pulmonary artery]] tracing suggests either acute [[mitral regurgitation]] or a [[ventricular septal defect]].
*In cardiogenic shock complicating [[right ventricle myocardial infarction|RV infarct]], the [[PA catheter]] may help in the [[diagnosis]], when the following criteria are found:<ref name="NgYeghiazarians2011">{{cite journal|last1=Ng|first1=R.|last2=Yeghiazarians|first2=Y.|title=Post Myocardial Infarction Cardiogenic Shock: A Review of Current Therapies|journal=Journal of Intensive Care Medicine|volume=28|issue=3|year=2011|pages=151–165|issn=0885-0666|doi=10.1177/0885066611411407}}</ref><ref>{{cite book | last = Topol | first = Eric | title = Textbook of cardiovascular medicine | publisher = Lippincott Williams & Wilkins | location = Philadelphia | year = 2007 | isbn = 0781770122 }}</ref><ref name="pmid6092446">{{cite journal| author=Dell'Italia LJ, Starling MR, Crawford MH, Boros BL, Chaudhuri TK, O'Rourke RA| title=Right ventricular infarction: identification by hemodynamic measurements before and after volume loading and correlation with noninvasive techniques. | journal=J Am Coll Cardiol | year= 1984 | volume= 4 | issue= 5 | pages= 931-9 | pmid=6092446 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=6092446  }} </ref><ref name="pmid8139631">{{cite journal| author=Kinch JW, Ryan TJ| title=Right ventricular infarction. | journal=N Engl J Med | year= 1994 | volume= 330 | issue= 17 | pages= 1211-7 | pmid=8139631 | doi=10.1056/NEJM199404283301707 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=8139631  }} </ref>
:*[[RA]] pressure >10 mm Hg
:*[[RA]] pressure >10 mm Hg
:*Ratio [[RA]]:[[PCWP]] ≥0.8
:*Ratio [[RA]]:[[PCWP]] ≥0.8
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*In cardiogenic shock complicating '''acute [[MR]]''', [[PA catheter]] may reveal:<ref name="NgYeghiazarians2011">{{cite journal|last1=Ng|first1=R.|last2=Yeghiazarians|first2=Y.|title=Post Myocardial Infarction Cardiogenic Shock: A Review of Current Therapies|journal=Journal of Intensive Care Medicine|volume=28|issue=3|year=2011|pages=151–165|issn=0885-0666|doi=10.1177/0885066611411407}}</ref><ref name="pmid7643642">{{cite journal| author=Reeder GS| title=Identification and treatment of complications of myocardial infarction. | journal=Mayo Clin Proc | year= 1995 | volume= 70 | issue= 9 | pages= 880-4 | pmid=7643642 | doi=10.1016/S0025-6196(11)63946-3 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=7643642  }} </ref>
*In cardiogenic shock complicating '''acute [[MR]]''', [[PA catheter]] may reveal:<ref name="NgYeghiazarians2011">{{cite journal|last1=Ng|first1=R.|last2=Yeghiazarians|first2=Y.|title=Post Myocardial Infarction Cardiogenic Shock: A Review of Current Therapies|journal=Journal of Intensive Care Medicine|volume=28|issue=3|year=2011|pages=151–165|issn=0885-0666|doi=10.1177/0885066611411407}}</ref><ref name="pmid7643642">{{cite journal| author=Reeder GS| title=Identification and treatment of complications of myocardial infarction. | journal=Mayo Clin Proc | year= 1995 | volume= 70 | issue= 9 | pages= 880-4 | pmid=7643642 | doi=10.1016/S0025-6196(11)63946-3 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=7643642  }} </ref>
:*large V wave in [[PCWP]] tracing
:*large V wave in [[PCWP]] tracing
:*severity of [[MR]], given by [[Left ventriculogram quality grades|left ventriculogram]] executed during [[cardiac catheterization]]
:*severity of [[MR]], given by [[Left ventriculogram quality grades|left ventriculogram]] carried out during [[cardiac catheterization]]
 
*In cardiogenic shock complicating '''[[VSR]]''', [[PA catheter]] may reveal:<ref name="NgYeghiazarians2011">{{cite journal|last1=Ng|first1=R.|last2=Yeghiazarians|first2=Y.|title=Post Myocardial Infarction Cardiogenic Shock: A Review of Current Therapies|journal=Journal of Intensive Care Medicine|volume=28|issue=3|year=2011|pages=151–165|issn=0885-0666|doi=10.1177/0885066611411407}}</ref><ref name="pmid3728312">{{cite journal| author=Hillis LD, Firth BG, Winniford MD| title=Variability of right-sided cardiac oxygen saturations in adults with and without left-to-right intracardiac shunting. | journal=Am J Cardiol | year= 1986 | volume= 58 | issue= 1 | pages= 129-32 | pmid=3728312 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=3728312  }} </ref>
*In cardiogenic shock complicating '''[[VSR]]''', [[PA catheter]] may show:
:*large V wave in [[PCWP]] tracing
:*large V wave in PCWP tracing
:*confirmation of [[diagnosis]]
:*confirmation of diagnosis
:*calculation of [[shunt]] fraction
:*calculation of shunt fraction
:*rise of ≥8% of [[oxygen saturation]] between [[RA]] and [[PA]]
:*rise of 8-9% of oxygen saturation between RA and PA
:*location and size of [[VSR]], given by [[Left ventriculogram quality grades|left ventriculogram]], carried out during [[cardiac catheterization]]
:*evaluation of location and size of VSR, given by [[Left ventriculogram quality grades|left ventriculogram]], perfumed during cardiac catheterization
*In cardiogenic shock complicating '''[[free wall rupture]] and [[tamponade]]''', [[PA catheter]] may reveal:<ref name="NgYeghiazarians2011">{{cite journal|last1=Ng|first1=R.|last2=Yeghiazarians|first2=Y.|title=Post Myocardial Infarction Cardiogenic Shock: A Review of Current Therapies|journal=Journal of Intensive Care Medicine|volume=28|issue=3|year=2011|pages=151–165|issn=0885-0666|doi=10.1177/0885066611411407}}</ref>
 
:*in the presence of [[tamponade]], equalization of right-sided [[diastolic]] pressures
*In cardiogenic shock complicating '''[[free wall rupture]] and [[tamponade]]''', [[PA catheter]] may be useful in:
*This technique is recommended for [[MI]] patients who are severely [[hypotensive]], however, several centers are gradually switching to a less [[invasive]] approach, managing cardiogenic shock patients by their clinical status, complemented by [[echocardiography]], instead of using the [[PA catheter]]. <ref name="ReynoldsHochman2008">{{cite journal|last1=Reynolds|first1=H. R.|last2=Hochman|first2=J. S.|title=Cardiogenic Shock: Current Concepts and Improving Outcomes|journal=Circulation|volume=117|issue=5|year=2008|pages=686–697|issn=0009-7322|doi=10.1161/CIRCULATIONAHA.106.613596}}</ref><ref name="Antman2004">{{cite journal|last1=Antman|first1=E. M.|title=ACC/AHA Guidelines for the Management of Patients With ST-Elevation Myocardial Infarction--Executive Summary: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the 1999 Guidelines for the Management of Patients With Acute Myocardial Infarction)|journal=Circulation|volume=110|issue=5|year=2004|pages=588–636|issn=0009-7322|doi=10.1161/01.CIR.0000134791.68010.FA}}</ref>
:*


This technique is recommended for [[MI]] patients who are severely [[hypotensive]], however, several centers are gradually switching to a less [[invasive]] approach, managing cardiogenic shock patients by their clinical status, complemented by [[echocardiography]], instead of using the [[PA catheter]]. <ref name="ReynoldsHochman2008">{{cite journal|last1=Reynolds|first1=H. R.|last2=Hochman|first2=J. S.|title=Cardiogenic Shock: Current Concepts and Improving Outcomes|journal=Circulation|volume=117|issue=5|year=2008|pages=686–697|issn=0009-7322|doi=10.1161/CIRCULATIONAHA.106.613596}}</ref><ref name="Antman2004">{{cite journal|last1=Antman|first1=E. M.|title=ACC/AHA Guidelines for the Management of Patients With ST-Elevation Myocardial Infarction--Executive Summary: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the 1999 Guidelines for the Management of Patients With Acute Myocardial Infarction)|journal=Circulation|volume=110|issue=5|year=2004|pages=588–636|issn=0009-7322|doi=10.1161/01.CIR.0000134791.68010.FA}}</ref>
===Coronary Angiography===
*This method is indicated for patients with cardiogenic shock in whom [[myocardial infarction]] is suspected and that have indication for [[revascularization]] procedures.
*The [[revascularization]] procedure may consist of [[percutaneous coronary intervention]] procedure or [[coronary artery bypass graft surgery]].<ref name="pmid15289388">{{cite journal| author=Antman EM, Anbe DT, Armstrong PW, Bates ER, Green LA, Hand M et al.| title=ACC/AHA guidelines for the management of patients with ST-elevation myocardial infarction--executive summary: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the 1999 Guidelines for the Management of Patients With Acute Myocardial Infarction). | journal=Circulation | year= 2004 | volume= 110 | issue= 5 | pages= 588-636 | pmid=15289388 | doi=10.1161/01.CIR.0000134791.68010.FA | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=15289388  }} </ref> Patients who have undergone reperfusion procedures with either [[percutaneous coronary intervention]] or [[fibrinolytic therapy]], experiencing new [[symptoms]], should also be evaluated for failure of the initial treatment.


=== Biopsy ===
=== Biopsy ===

Latest revision as of 18:26, 8 January 2020

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: João André Alves Silva, M.D. [2] Syed Musadiq Ali M.B.B.S.[3]

Overview

The Swan-ganz catheter, right heart catheter or pulmonary artery catheter has been gradually replaced by echocardiography with color Doppler throughout the years, however, it is still common practice in some centers. It may be used for different situations, such as: confirming the diagnosis of cardiogenic shock following clinical evaluation, ensuring adequacy of filling pressures, establishing the relationship between these filling pressures and cardiac output as well as helping in possible adjustments in therapy. It is still a very important tool for the assessment of hemodynamic parameters, such as cardiac power and stroke work index, which are important data for short-term prognosis.It may also be helpful in distinguishing cardiogenic shock from septic shock and in optimizing the patient's left ventricular filling pressures. The presence of significant V waves (greatly exceeding the pulmonary capillary wedge pressure) on the pulmonary artery tracing suggests either acute mitral regurgitation or a ventricular septal defect. The revascularization procedure may consist of percutaneous coronary intervention procedure or coronary artery bypass graft surgery. Patients who have undergone reperfusion procedures with either percutaneous coronary intervention or fibrinolytic therapy, experiencing new symptoms, should also be evaluated for failure of the initial treatment.

Other Diagnostic Studies

Swan Ganz Catheter

  • This technique is recommended for MI patients who are severely hypotensive, however, several centers are gradually switching to a less invasive approach, managing cardiogenic shock patients by their clinical status, complemented by echocardiography, instead of using the PA catheter. [1][9]

Coronary Angiography

Biopsy

In case of suspected cardiomyopathy a biopsy of heart muscle may be of benefit in establishing a definitive diagnosis.

References

  1. ↑ 1.0 1.1 Reynolds, H. R.; Hochman, J. S. (2008). "Cardiogenic Shock: Current Concepts and Improving Outcomes". Circulation. 117 (5): 686–697. doi:10.1161/CIRCULATIONAHA.106.613596. ISSN 0009-7322.
  2. ↑ Fincke R, Hochman JS, Lowe AM, Menon V, Slater JN, Webb JG; et al. (2004). "Cardiac power is the strongest hemodynamic correlate of mortality in cardiogenic shock: a report from the SHOCK trial registry". J Am Coll Cardiol. 44 (2): 340–8. doi:10.1016/j.jacc.2004.03.060. PMID 15261929.
  3. ↑ 3.0 3.1 3.2 3.3 Ng, R.; Yeghiazarians, Y. (2011). "Post Myocardial Infarction Cardiogenic Shock: A Review of Current Therapies". Journal of Intensive Care Medicine. 28 (3): 151–165. doi:10.1177/0885066611411407. ISSN 0885-0666.
  4. ↑ Topol, Eric (2007). Textbook of cardiovascular medicine. Philadelphia: Lippincott Williams & Wilkins. ISBN 0781770122.
  5. ↑ Dell'Italia LJ, Starling MR, Crawford MH, Boros BL, Chaudhuri TK, O'Rourke RA (1984). "Right ventricular infarction: identification by hemodynamic measurements before and after volume loading and correlation with noninvasive techniques". J Am Coll Cardiol. 4 (5): 931–9. PMID 6092446.
  6. ↑ Kinch JW, Ryan TJ (1994). "Right ventricular infarction". N Engl J Med. 330 (17): 1211–7. doi:10.1056/NEJM199404283301707. PMID 8139631.
  7. ↑ Reeder GS (1995). "Identification and treatment of complications of myocardial infarction". Mayo Clin Proc. 70 (9): 880–4. doi:10.1016/S0025-6196(11)63946-3. PMID 7643642.
  8. ↑ Hillis LD, Firth BG, Winniford MD (1986). "Variability of right-sided cardiac oxygen saturations in adults with and without left-to-right intracardiac shunting". Am J Cardiol. 58 (1): 129–32. PMID 3728312.
  9. ↑ Antman, E. M. (2004). "ACC/AHA Guidelines for the Management of Patients With ST-Elevation Myocardial Infarction--Executive Summary: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the 1999 Guidelines for the Management of Patients With Acute Myocardial Infarction)". Circulation. 110 (5): 588–636. doi:10.1161/01.CIR.0000134791.68010.FA. ISSN 0009-7322.
  10. ↑ Antman EM, Anbe DT, Armstrong PW, Bates ER, Green LA, Hand M; et al. (2004). "ACC/AHA guidelines for the management of patients with ST-elevation myocardial infarction--executive summary: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the 1999 Guidelines for the Management of Patients With Acute Myocardial Infarction)". Circulation. 110 (5): 588–636. doi:10.1161/01.CIR.0000134791.68010.FA. PMID 15289388.


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