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cardio.cardiogenic-shock.acromegaly-cardiomyopathy.v1PRODUCTION
cardio.cardiogenic-shock.acromegaly-cardiomyopathy.v1

Cardiogenic shock — acromegaly-induced cardiomyopathy

cardiologyacuteadult
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11/12 authored

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Acromegaly cardiomyopathy with cardiogenic shock = end-stage manifestation of GH/IGF-1 excess (~30-40% of long-standing acromegaly develops cardiomyopathy; rare progression to shock); biventricular hypertrophy + diastolic + eventual systolic dysfunction + arrhythmia + accelerated CAD + valvular disease pattern; concurrent OSA in ~70%; preload-sensitive LV hypertrophy demands cautious volume management

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Acromegaly cardiomyopathy + SCAI C+ shock confirmed

Patient inputs (18)

Locates adenoma (macro >10 mm vs micro <10 mm); informs surgical approach; visual field assessment if macroadenoma (chiasm compression)

IGF-1 reference ranges are age-adjusted; older patients have lower normals; transplant candidacy assessment

Cardiomyopathy reversibility correlates with disease duration; long-standing (>10 yr) acromegaly more likely to have irreversible fibrosis

OSA in ~70% of acromegaly patients (anatomical + central); exacerbates HF and shock physiology; CPAP/BiPAP reduces RV strain

Tachycardia + arrhythmia surveillance; AF and VT/VF more common in acromegaly cardiomyopathy

Cardiorenal screen; pegvisomant + somatostatin analog dose adjustment if AKI; renal injury common in shock

DM common in acromegaly (GH-induced insulin resistance); dose-adjustment for SGLT2i; informs prognosis

Rules out ischemic cardiomyopathy / accelerated CAD (acromegaly accelerates atherosclerosis); high values prompt cath

Markedly elevated in acromegaly cardiomyopathy with shock; trends response to therapy

Best screening test for acromegaly — reflects 24-h GH secretion; age-adjusted; elevated >ULN suggests acromegaly per Endocrine Society 2014 (PMID 25356808)

TSH, ACTH/cortisol, prolactin, LH/FSH — panhypopituitarism may co-exist; hyponatremia from SIADH or adrenal insufficiency requires immediate replacement before any pituitary intervention

Biventricular concentric hypertrophy + LV systolic dysfunction + valvular disease (especially AR + MR) is characteristic; rules out other CS etiologies

LV hypertrophy voltage criteria; arrhythmia surveillance; rules out ischemia

SCAI 2022 staging baseline; SBP <90 with end-organ hypoperfusion = SCAI C+

Hypoxemia from pulmonary edema + concurrent OSA; guides NIPPV and CPAP/BiPAP strategy

SCAI 2022 staging; CardShock prognostication (Harjola PMID 26333869); ≥4 = SCAI D-E pattern

Subepicardial fibrosis pattern is characteristic of acromegaly cardiomyopathy; biventricular hypertrophy + late gadolinium enhancement; informs reversibility prognosis

Documents prior treatments; informs current GH/IGF-1 status; may have hypopituitarism requiring replacement

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Severity triggers (4)

4 need judgement
  • informationallife_threateningpituitary_apoplexy_with_adrenal_insufficiency
    Acromegaly patient with acute severe headache + vision loss + hemodynamic collapse + cortisol <5 µg/dL — pituitary apoplexy (infarction or hemorrhage of adenoma) with secondary adrenal crisis; STAT IV hydrocortisone 100 mg + emergent neurosurgery
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseveresevere_osa_exacerbating_acromegaly_cs
    Severe OSA (AHI >30 + nocturnal hypoxemia) untreated in acromegaly patient with cardiogenic shock — RV strain + nocturnal desaturation worsens shock physiology; STAT CPAP/BiPAP + sleep medicine consult
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseveresomatostatin_induced_severe_bradycardia_or_qt_prolongation
    Acromegaly patient on octreotide / lanreotide develops severe bradycardia (HR <40) OR QT prolongation (QTc >500) → torsades risk; reduce dose or hold; ECG surveillance
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmoderategh_resistant_disease_requiring_pegvisomant_decision
    Acromegaly patient with persistently elevated IGF-1 despite max-dose somatostatin analog (octreotide LAR 40 mg or lanreotide 120 mg q4 wk) — GH-resistant disease; consider pegvisomant transition; weigh risk-benefit (cost, LFT monitoring, daily SC injection)
    Trigger could not be auto-evaluated — needs clinician judgement.

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Recommended regimen

Acromegaly cardiomyopathy with CS — NE first-line + AVOID dopamine + cautious volume + somatostatin analog (octreotide / lanreotide) + pegvisomant if GH-resistant + concurrent OSA management + MCS bridge if refractory
axis: acromegaly_cs_phenotype
Selected axis "Acromegaly cardiomyopathy with CS — NE first-line + AVOID dopamine + cautious volume + somatostatin analog (octreotide / lanreotide) + pegvisomant if GH-resistant + concurrent OSA management + MCS bridge if refractory" by default fallback (first axis)
  • norepinephrine
    first line
    vasopressor_alpha
    0.05–0.5 µg/kg/min titrate MAP ≥65 • IV • continuous
    triggers: acromegaly_cs_with_sbp_lt_90, cs_scai_c_or_higher_in_acromegaly
    SOAP-II PMID 20200382 — NE first-line in CS; AVOID dopamine in acromegaly (paradoxical somatotroph stimulation worsens GH secretion)
    rxcui 7512
  • milrinone
    first line
    pde3_inhibitor
    0.125–0.5 µg/kg/min IV continuous (no bolus) • IV • continuous
    triggers: acromegaly_cs_with_low_cardiac_output_and_adequate_map
    Inodilator; reduces SVR + improves cardiac output; preferred in biventricular failure pattern of acromegaly cardiomyopathy; ACC/AHA 2022 HF (PMID 35363499)
    rxcui 52769
  • dobutamine
    second line
    inotrope_beta1
    2.5–10 µg/kg/min • IV • continuous
    triggers: inotropy_needed_when_milrinone_unavailable
    DOREMI PMID 33704937 — non-inferior to milrinone; cautious in hypertrophic LV (preload-sensitive)
    rxcui 3616
  • furosemide
    first line
    loop_diuretic
    20-40 mg IV bolus titrate cautiously (preload-sensitive LV) • IV • as scheduled
    triggers: acromegaly_cs_with_pulmonary_edema
    DOSE PMID 21366472; CAUTIOUS in hypertrophic LV (small volume changes cause large pressure shifts)
    rxcui 4603
  • octreotide
    first line
    somatostatin_analog
    50 µg IV bolus then 100-500 µg SC q8h; transition to octreotide LAR 20 mg IM monthly once stable • IV/SC/IM • q8h SC or monthly LAR
    triggers: acromegaly_with_elevated_igf1_and_cs, acromegaly_cardiomyopathy_acute_decompensation
    Endocrine Society 2014 PMID 25356808; reduces GH/IGF-1 within hours-days; may improve cardiac function over weeks per Colao 2004; first-line medical therapy for acromegaly
    rxcui 221130
  • lanreotide
    first line
    somatostatin_analog_depot
    120 mg SC q4 wk depot (Autogel formulation) • SC • q4 wk depot
    triggers: acromegaly_chronic_management_after_stabilization, octreotide_intolerance
    Endocrine Society 2014 PMID 25356808; depot somatostatin analog alternative to octreotide LAR; equivalent efficacy
    rxcui 236167
  • pegvisomant
    second line
    gh_receptor_antagonist
    10 mg SC daily, titrate to 30 mg daily based on IGF-1 • SC • daily
    triggers: gh_resistant_to_somatostatin_analog, somatostatin_analog_intolerance, igf1_persistently_elevated_despite_octreotide
    Trainer 2000 NEJM — normalizes IGF-1 in >90% per pivotal trial; second-line for GH-resistant or intolerant patients
    rxcui 278739
  • cabergoline
    add on
    dopamine_d2_agonist
    0.5 mg PO twice weekly, titrate to 3.5 mg/wk • PO • twice weekly
    triggers: acromegaly_with_co_secretion_of_prolactin, small_adenoma_with_mild_disease_after_stabilization
    Endocrine Society 2014 PMID 25356808; ADD-ON only — generally INEFFECTIVE in acute CS setting (long onset; only suppresses small adenomas); useful for prolactin co-secreting adenomas after stabilization
    rxcui 47579
  • hydrocortisone
    rescue
    glucocorticoid
    100 mg IV q8h then taper • IV • q8h
    triggers: adrenal_insufficiency_from_panhypopituitarism_or_pituitary_apoplexy
    STAT replacement before any pituitary intervention if cortisol <5 µg/dL or pituitary apoplexy suspected; Endocrine Society 2014 PMID 25356808
    rxcui 5492
  • carvedilol
    first line
    beta_alpha_blocker
    3.125 mg PO BID titrate (after off catecholamines ≥24 h) • PO • BID
    triggers: acromegaly_cs_recovery_phase_off_inotropes_with_systolic_dysfunction
    COPERNICUS PMID 11386262 / CAPRICORN PMID 11356436; AVOID during active shock (hypertrophic LV depends on atrial kick); start ONLY in recovery phase after off catecholamines
    rxcui 20352
  • sacubitril-valsartan
    first line
    arni
    24/26 mg PO BID titrate to 97/103 BID • PO • BID
    triggers: acromegaly_cs_recovery_phase_with_persistent_hfref
    PIONEER-HF PMID 30403955; recovery phase only; acromegaly cardiomyopathy with persistent HFrEF benefits from standard 4-pillar GDMT
    rxcui 1656328
  • spironolactone
    first line
    mra
    12.5–25 mg PO daily • PO • daily
    triggers: acromegaly_cs_recovery_phase_with_persistent_hfref_and_k_below_5
    RALES PMID 10471456; recovery phase only
    rxcui 9997
  • empagliflozin
    first line
    sglt2_inhibitor
    10 mg PO daily • PO • daily
    triggers: acromegaly_cs_recovery_phase_with_persistent_hfref_and_egfr_above_20
    EMPULSE PMID 35347356; particularly useful given DM common in acromegaly (GH-induced insulin resistance)
    rxcui 1545653

outpatient playbook — drug actions (3)

  1. 1. continue 4-pillar GDMT until LVEF normalized + stable ≥6-12 mo
    rxcui 1656328
    ARNI + BB + MRA + SGLT2i at max tolerated • PO • as scheduled
    trigger: Persistent HFrEF
    ACC/AHA 2022 HF; do not de-escalate prematurely (TRED-HF PMID 30429051 — withdrawal causes deterioration)
  2. 2. continue somatostatin analog or pegvisomant per remission status
    octreotide LAR or pegvisomant titrated to IGF-1 • IM/SC • monthly or daily
    trigger: Persistent disease activity post-surgery
    Endocrine Society 2014 — long-term medical therapy if surgery + radiation incomplete
  3. 3. add cabergoline if mild residual disease + small adenoma
    rxcui 17767
    0.5 mg PO twice weekly titrate to 3.5 mg/wk • PO • twice weekly
    trigger: Mild residual disease + small adenoma + no significant valvular disease
    Endocrine Society 2014 — useful for prolactin co-secreting adenomas; AVOID if valvular disease (ergot valvulopathy)

Auto-drafted A&P note

outpatient

Subjective

- Possible entry pathways: Cardiogenic shock (SBP <90 + lactate ≥2 + AKI / cool extremities) in patient with known acromegaly OR classic phenotype (frontal bossing, prognathism, enlarged hands/feet, soft-tissue swelling); Echo with biventricular concentric hypertrophy + LV systolic dysfunction (LVEF <35%) + shock physiology — acromegaly cardiomyopathy end-stage; Markedly elevated IGF-1 (age-adjusted >ULN) in shock patient with cardiomyopathy of unclear etiology — acromegaly screen.

Objective

- No vitals, labs, or imaging entered for this encounter.

Assessment

**Cardiogenic shock — acromegaly-induced cardiomyopathy** (cardio.cardiogenic-shock.acromegaly-cardiomyopathy.v1).
Scope: Acromegaly cardiomyopathy with cardiogenic shock = end-stage manifestation of GH/IGF-1 excess (~30-40% of long-standing acromegaly develops cardiomyopathy; rare progression to shock); biventricular hypertrophy + diastolic + eventual systolic dysfunction + arrhythmia + accelerated CAD + valvular disease pattern; concurrent OSA in ~70%; preload-sensitive LV hypertrophy demands cautious volume management

No severity triggers fired against current inputs.

Plan

Regimen axis: **Acromegaly cardiomyopathy with CS — NE first-line + AVOID dopamine + cautious volume + somatostatin analog (octreotide / lanreotide) + pegvisomant if GH-resistant + concurrent OSA management + MCS bridge if refractory**.
1. norepinephrine 0.05–0.5 µg/kg/min titrate MAP ≥65 IV continuous (vasopressor_alpha, first line) — SOAP-II PMID 20200382 — NE first-line in CS; AVOID dopamine in acromegaly (paradoxical somatotroph stimulation worsens GH secretion)
2. milrinone 0.125–0.5 µg/kg/min IV continuous (no bolus) IV continuous (pde3_inhibitor, first line) — Inodilator; reduces SVR + improves cardiac output; preferred in biventricular failure pattern of acromegaly cardiomyopathy; ACC/AHA 2022 HF (PMID 35363499)
3. dobutamine 2.5–10 µg/kg/min IV continuous (inotrope_beta1, second line) — DOREMI PMID 33704937 — non-inferior to milrinone; cautious in hypertrophic LV (preload-sensitive)
4. furosemide 20-40 mg IV bolus titrate cautiously (preload-sensitive LV) IV as scheduled (loop_diuretic, first line) — DOSE PMID 21366472; CAUTIOUS in hypertrophic LV (small volume changes cause large pressure shifts)
5. octreotide 50 µg IV bolus then 100-500 µg SC q8h; transition to octreotide LAR 20 mg IM monthly once stable IV/SC/IM q8h SC or monthly LAR (somatostatin_analog, first line) — Endocrine Society 2014 PMID 25356808; reduces GH/IGF-1 within hours-days; may improve cardiac function over weeks per Colao 2004; first-line medical therapy for acromegaly
6. lanreotide 120 mg SC q4 wk depot (Autogel formulation) SC q4 wk depot (somatostatin_analog_depot, first line) — Endocrine Society 2014 PMID 25356808; depot somatostatin analog alternative to octreotide LAR; equivalent efficacy
7. pegvisomant 10 mg SC daily, titrate to 30 mg daily based on IGF-1 SC daily (gh_receptor_antagonist, second line) — Trainer 2000 NEJM — normalizes IGF-1 in >90% per pivotal trial; second-line for GH-resistant or intolerant patients
8. cabergoline 0.5 mg PO twice weekly, titrate to 3.5 mg/wk PO twice weekly (dopamine_d2_agonist, add on) — Endocrine Society 2014 PMID 25356808; ADD-ON only — generally INEFFECTIVE in acute CS setting (long onset; only suppresses small adenomas); useful for prolactin co-secreting adenomas after stabilization
9. hydrocortisone 100 mg IV q8h then taper IV q8h (glucocorticoid, rescue) — STAT replacement before any pituitary intervention if cortisol <5 µg/dL or pituitary apoplexy suspected; Endocrine Society 2014 PMID 25356808
10. carvedilol 3.125 mg PO BID titrate (after off catecholamines ≥24 h) PO BID (beta_alpha_blocker, first line) — COPERNICUS PMID 11386262 / CAPRICORN PMID 11356436; AVOID during active shock (hypertrophic LV depends on atrial kick); start ONLY in recovery phase after off catecholamines
11. sacubitril-valsartan 24/26 mg PO BID titrate to 97/103 BID PO BID (arni, first line) — PIONEER-HF PMID 30403955; recovery phase only; acromegaly cardiomyopathy with persistent HFrEF benefits from standard 4-pillar GDMT
12. spironolactone 12.5–25 mg PO daily PO daily (mra, first line) — RALES PMID 10471456; recovery phase only
13. empagliflozin 10 mg PO daily PO daily (sglt2_inhibitor, first line) — EMPULSE PMID 35347356; particularly useful given DM common in acromegaly (GH-induced insulin resistance)

Setting playbook (outpatient) — Long-term acromegaly cardiomyopathy surveillance: serial IGF-1 every 3 mo until normalized then every 6-12 mo; serial echo at 3 mo + 6 mo + 12 mo for LVEF recovery; pituitary surgery + radiotherapy if needed; ICD/WCD if LVEF <35% on full GDMT; advanced HF + transplant if no recovery; cardiology + endocrinology + neurosurgery co-management; OSA management
14. continue 4-pillar GDMT until LVEF normalized + stable ≥6-12 mo ARNI + BB + MRA + SGLT2i at max tolerated PO as scheduled — Persistent HFrEF (ACC/AHA 2022 HF; do not de-escalate prematurely (TRED-HF PMID 30429051 — withdrawal causes deterioration))
15. continue somatostatin analog or pegvisomant per remission status octreotide LAR or pegvisomant titrated to IGF-1 IM/SC monthly or daily — Persistent disease activity post-surgery (Endocrine Society 2014 — long-term medical therapy if surgery + radiation incomplete)
16. add cabergoline if mild residual disease + small adenoma 0.5 mg PO twice weekly titrate to 3.5 mg/wk PO twice weekly — Mild residual disease + small adenoma + no significant valvular disease (Endocrine Society 2014 — useful for prolactin co-secreting adenomas; AVOID if valvular disease (ergot valvulopathy))

Non-pharmacologic actions:
- Long-term cardiology + endocrinology + neurosurgery co-management
- Stereotactic radiosurgery (Gamma Knife) if surgery fails or adenoma residual
- Cardiac rehab maintenance
- ICD/WCD evaluation if LVEF <35% at 3-6 mo on full GDMT
- Advanced HF / transplant evaluation if no recovery at 6-12 mo
- CPAP adherence
- DM + lipid + BP management — acromegaly accelerates atherosclerosis; rigorous secondary prevention
- Family history evaluation for MEN1 / familial isolated pituitary adenoma

AVOID / contraindication checks:
- AVOID_dopamine_in_acromegaly_cs (paradoxical somatotroph stimulation worsens GH secretion)
- Cautious_volume_resuscitation_in_lv_hypertrophy (preload sensitive; small changes cause large pressure shifts)
- AVOID_beta_blockers_in_active_shock (hypertrophic LV depends on atrial kick)
- Rule_out_adrenal_insufficiency_before_any_pituitary_intervention (panhypopituitarism may co exist)
- Hydrocortisone_100_mg_iv_stat_if_cortisol_below_5_or_pituitary_apoplexy_suspected (Endocrine Society 2014)
- Somatostatin_analog_can_cause_bradycardia_and_qt_prolongation (monitor ECG)
- Pegvisomant_monitor_lfts_q_4_to_6_weeks (transaminitis risk)
- Cabergoline_avoid_if_valvular_heart_disease (ergot vasoconstriction; dose dependent valvulopathy)
- Cpap_bipap_for_concurrent_osa_in_acromegaly_cs (~70% have concurrent OSA; worsens shock)
- No_dapt_de_escalation_during_active_acs_pattern_in_acromegaly_cad

Monitoring

Regimen monitoring:
- arterial line continuous BP (ACC/AHA 2022 Class I)
- central venous access large bore (ACC/AHA 2022)
- continuous telemetry for arrhythmia detection (AF + VT/VF more common in acromegaly cardiomyopathy)
- lactate q1-2h (CardShock; Harjola PMID 26333869)
- UOP hourly (SCAI 2019 end-organ perfusion marker)
- daily IGF1 trend (responsive in days to somatostatin analog initiation)
- daily glucose q4-6h (somatostatin analog can worsen DM via insulin suppression)
- daily echo for LVEF recovery trajectory
- pre discharge TSH ACTH cortisol prolactin (pituitary axis surveillance)
- ECG q24h during somatostatin initiation (bradycardia + QT prolongation surveillance)
- LFTs q4-6 weeks during pegvisomant (transaminitis risk)
- serial IGF1 q3mo until normalized then q6-12mo (treatment response)
- serial echo at 3mo 6mo 12mo postdischarge (LVEF recovery)
- cardiac MRI annual for fibrosis surveillance
- CPAP compliance review weekly if OSA
- visual fields q6 to 12 mo if macroadenoma

Setting (outpatient) monitoring:
- Quarterly cardiology + echo until stable
- Endocrine biochemical remission (IGF-1 normal + random GH <1 ng/mL)
- Annual pituitary MRI if residual adenoma
- Annual cardiac MRI for fibrosis
- Annual visual fields if macroadenoma

Follow-up plan: Endocrinology + cardiology co-management; pituitary surgery evaluation (transsphenoidal first-line) once stable; stereotactic radiosurgery if surgery fails / residual; long-term somatostatin analog or pegvisomant if surgery + radiation incomplete; serial IGF-1 every 3 mo until normalized then every 6-12 mo; serial echo at 3 mo + 6 mo + 12 mo for LVEF recovery; ICD/WCD evaluation if LVEF <35% on full GDMT; advanced HF + transplant if no recovery; OSA management (CPAP); annual cardiac MRI for fibrosis surveillance; visual field testing if macroadenoma
- Close-out criterion: Multidisciplinary follow-up + pituitary surgery + endocrine + transplant pathway booked

Monitoring phase: Continuous telemetry, A-line, central line; lactate q1-2 h; UOP hourly; daily echo for cardiac recovery trajectory; daily IGF-1 trend (responsive in days); daily BMP / NT-proBNP / troponin / glucose; BP cuff in non-affected arm if obvious hand changes; CPAP compliance if OSA

Disposition

Current setting: outpatient — Long-term acromegaly cardiomyopathy surveillance: serial IGF-1 every 3 mo until normalized then every 6-12 mo; serial echo at 3 mo + 6 mo + 12 mo for LVEF recovery; pituitary surgery + radiotherapy if needed; ICD/WCD if LVEF <35% on full GDMT; advanced HF + transplant if no recovery; cardiology + endocrinology + neurosurgery co-management; OSA management

Disposition criteria:
- Long-term continuation; cross-link to cardio.hfref.core.v1 if HFrEF persists; transplant if no recovery; biochemical remission goal (IGF-1 normal + random GH <1 ng/mL) per Endocrine Society 2014

Escalation triggers (move to higher acuity):
- Worsening LVEF despite GDMT → advanced HF + transplant evaluation
- New arrhythmia → urgent EP
- IGF-1 elevation despite therapy → escalate therapy or radiation
- New visual change → urgent neuro-ophthalmology + neurosurgery
- New ischemic event → cardiology cath

Earlier-Return Triggers

Return-precaution thresholds (watch for):
- [LIFE_THREATENING] Acromegaly patient with acute severe headache + vision loss + hemodynamic collapse + cortisol <5 µg/dL — pituitary apoplexy (infarction or hemorrhage of adenoma) with secondary adrenal crisis; STAT IV hydrocortisone 100 mg + emergent neurosurgery
- [SEVERE] Severe OSA (AHI >30 + nocturnal hypoxemia) untreated in acromegaly patient with cardiogenic shock — RV strain + nocturnal desaturation worsens shock physiology; STAT CPAP/BiPAP + sleep medicine consult
- [SEVERE] Acromegaly patient on octreotide / lanreotide develops severe bradycardia (HR <40) OR QT prolongation (QTc >500) → torsades risk; reduce dose or hold; ECG surveillance

Citations

- Endocrine Society 2014 Acromegaly Clinical Practice Guideline (Katznelson PMID 25356808) + 2022 ACC/AHA/HFSA HF Guideline (Heidenreich PMID 35363499) + SCAI 2022 CS staging (Naidu PMID 35718438) [PMID:25356808](https://pubmed.ncbi.nlm.nih.gov/25356808/)
- Cited evidence (PMID 35363499) [PMID:35363499](https://pubmed.ncbi.nlm.nih.gov/35363499/)
- Cited evidence (PMID 35718438) [PMID:35718438](https://pubmed.ncbi.nlm.nih.gov/35718438/)
- Cited evidence (PMID 38587234) [PMID:38587234](https://pubmed.ncbi.nlm.nih.gov/38587234/)
- Cited evidence (PMID 20200382) [PMID:20200382](https://pubmed.ncbi.nlm.nih.gov/20200382/)

Last reconciled with current guidelines: 2026-05-15.
References
  • Endocrine Society 2014 Acromegaly Clinical Practice Guideline (Katznelson PMID 25356808) + 2022 ACC/AHA/HFSA HF Guideline (Heidenreich PMID 35363499) + SCAI 2022 CS staging (Naidu PMID 35718438) — PMID:25356808
  • Cited evidence (PMID 35363499) — PMID:35363499
  • Cited evidence (PMID 35718438) — PMID:35718438
  • Cited evidence (PMID 38587234) — PMID:38587234
  • Cited evidence (PMID 20200382) — PMID:20200382