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

Cardiogenic shock — peripartum cardiomyopathy (PPCM, severe)

cardiologyacuteadultpregnancy
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11/12 authored

Canonical 12-phase frame with authored status for this dossier.

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Frame

Detailed

PPCM with cardiogenic shock = HFrEF (LVEF <30% in severe variant) in peripartum window + SCAI C+ shock physiology; pregnancy status drives drug selection (ACEi/ARB/SGLT2i/DOAC teratogenic; bromocriptine postpartum-only adjunct); ~5–10% of PPCM progresses to shock; very high maternal + fetal mortality

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PPCM-CS pattern confirmed (peripartum window + LVEF <30 + SCAI C+ physiology)

Patient inputs (14)

Age >30 increases PPCM risk; informs future-pregnancy counseling and transplant candidacy

PPCM defined window: last month pregnancy through 5 mo postpartum; trimester drives ACEi/ARB/SGLT2i/DOAC teratogenicity decisions and delivery-decision urgency

Multiparity + multiple gestation + pre-eclampsia + prior PPCM are risk factors; prior PPCM with recurrence carries up to 20% mortality

Tachycardia + arrhythmia surveillance; PPCM-CS has elevated VT/VF risk if LVEF <35%

Cardiorenal screen; LMWH dosing; ACEi-postpartum dose adjustment; renal injury common in shock

Rules out ischemic CMP differential; mildly elevated in PPCM but high values prompt SCAD/MI workup (postpartum SCAD common)

NT-proBNP markedly elevated in PPCM-CS; trends response to therapy and recovery

Echo LVEF <30% + dilated LV + global hypokinesis is the diagnostic pattern; RV function + valvular assessment; rules out other CS etiologies (PE, tamponade, valvular emergency)

Rules out SCAD-related ischemia, arrhythmia, conduction disease; documents baseline rhythm

PPCM is diagnosis of exclusion — must rule out pre-existing CMP, valvular, ischemic, viral myocarditis

SCAI 2022 staging baseline; SBP <90 with end-organ hypoperfusion = SCAI C+; preserves uteroplacental perfusion if antepartum

Hypoxemia from pulmonary edema; guides NIPPV vs intubation decision in pregnant patient

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

African ancestry confers 4× higher PPCM incidence and worse recovery profile per AHA 2020 PPCM Scientific Statement (PMID 32362133)

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Severity triggers (4)

4 need judgement
  • informationallife_threateningantepartum_ppcm_cs_requiring_urgent_delivery_and_mcs
    Antepartum PPCM-CS (SBP <90, lactate ≥4, SCAI C-E) + fetal distress or maternal compromise — urgent delivery (vaginal vs C-section per fetal/maternal status) often improves maternal hemodynamics; concurrent MCS bridge (Impella CP / VA-ECMO) if refractory; pregnancy heart team mobilization
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationallife_threateningrecurrent_ppcm_cs_in_subsequent_pregnancy
    Patient with prior PPCM-CS + LVEF that did not normalize + new pregnancy presenting with shock — recurrence rate 30-50%, mortality up to 20%; urgent termination discussion if LVEF <35%
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseveretransplant_listing_in_young_mother_with_no_recovery
    Young postpartum patient (often <40 yo) with PPCM-CS who fails to recover at 6-12 mo despite full GDMT + bromocriptine + AC — advanced HF + transplant evaluation; LVAD bridge to transplant if needed; ethical complexity given age + family
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseverebromocriptine_bleed_or_thrombosis_complication
    PPCM-CS patient on bromocriptine with active bleeding (peripartum hemorrhage, AC-related bleed) OR thrombosis (LV thrombus, stroke, PE) despite prophylactic AC — hold bromocriptine; manage bleed vs thrombosis per phenotype; reassess risk-benefit of completing 8-wk course
    Trigger could not be auto-evaluated — needs clinician judgement.

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Recommended regimen

PPCM-CS pregnancy-aware shock regimen — NE first-line + milrinone preferred over dobutamine in pregnancy + bromocriptine 8-wk postpartum per IPAC + LMWH peripartum + MCS bridge to recovery (Impella CP / VA-ECMO)
axis: ppcm_cs_pregnancy_aware_phenotype
Selected axis "PPCM-CS pregnancy-aware shock regimen — NE first-line + milrinone preferred over dobutamine in pregnancy + bromocriptine 8-wk postpartum per IPAC + LMWH peripartum + MCS bridge to recovery (Impella CP / VA-ECMO)" by default fallback (first axis)
  • norepinephrine
    first line
    vasopressor_alpha
    0.05–0.5 µg/kg/min titrate MAP ≥65 • IV • continuous
    triggers: ppcm_cs_with_sbp_lt_90, cs_scai_c_or_higher_peripartum
    SOAP-II PMID 20200382 — NE first-line in CS; preserves uteroplacental perfusion; preferred vasopressor in pregnancy
    rxcui 7512
  • milrinone
    first line
    pde3_inhibitor
    0.125–0.5 µg/kg/min IV continuous (no bolus to avoid hypotension) • IV • continuous
    triggers: ppcm_cs_with_low_cardiac_output_and_adequate_map, pregnancy_with_inotropy_need
    Inodilator preferred over dobutamine in pregnancy (better arrhythmia profile despite OPTIME-CHF PMID 12759322 caution); 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_or_renal_failure
    DOREMI PMID 33704937 — non-inferior to milrinone; used cautiously in pregnancy due to arrhythmogenic potential
    rxcui 3616
  • furosemide
    first line
    loop_diuretic
    40 mg IV bolus then 5–10 mg/h infusion or 40–80 mg IV q6–8h • IV • as scheduled
    triggers: ppcm_cs_with_pulmonary_edema
    DOSE PMID 21366472 high-dose IV bolus arm; safe in pregnancy and lactation
    rxcui 4603
  • hydralazine
    first line
    arteriolar_vasodilator
    10–25 mg PO TID OR 5–10 mg IV q4–6h prn • PO/IV • TID
    triggers: ppcm_cs_antepartum_afterload_reduction_off_pressors
    Pregnancy-safe afterload reducer; substitute for ACEi/ARB during pregnancy (ESC pregnancy 2018 PMID 30165544)
    rxcui 5470
  • isosorbide dinitrate
    first line
    venous_vasodilator_nitrate
    20–40 mg PO TID • PO • TID
    triggers: ppcm_cs_antepartum_preload_afterload_reduction_off_pressors
    Combine with hydralazine (A-HeFT analog) for pregnancy-safe afterload + preload reduction
    rxcui 6058
  • carvedilol
    first line
    beta_alpha_blocker
    3.125 mg PO BID titrate (after off catecholamines ≥24 h) • PO • BID
    triggers: ppcm_cs_postpartum_recovery_phase_off_inotropes
    CAPRICORN PMID 11356436 + COPERNICUS PMID 11386262; preferred postpartum (limited lactation data but acceptable per AAP); start AFTER inotrope wean
    rxcui 20352
  • sacubitril-valsartan
    first line
    arni
    24/26 mg PO BID titrate to 97/103 BID • PO • BID
    triggers: ppcm_cs_postpartum_recovery_phase_not_breastfeeding
    PIONEER-HF PMID 30403955; POSTPARTUM ONLY (TERATOGENIC); AAP advises against during lactation
    rxcui 1656328
  • enalapril
    first line
    acei
    2.5 mg PO BID titrate • PO • BID
    triggers: ppcm_cs_postpartum_recovery_phase_breastfeeding
    POSTPARTUM ONLY; enalapril and captopril are AAP-approved during lactation
    rxcui 203123
  • spironolactone
    first line
    mra
    12.5–25 mg PO daily • PO • daily
    triggers: ppcm_cs_postpartum_recovery_phase_with_k_below_5
    POSTPARTUM ONLY (potential antiandrogenic teratogen); RALES PMID 10471456
    rxcui 9997
  • empagliflozin
    first line
    sglt2_inhibitor
    10 mg PO daily • PO • daily
    triggers: ppcm_cs_postpartum_recovery_phase_egfr_above_20_not_breastfeeding
    EMPULSE PMID 35347356; POSTPARTUM ONLY; not recommended during pregnancy or breastfeeding
    rxcui 1545653
  • bromocriptine
    add on
    dopamine_d2_agonist_prolactin_inhibitor
    2.5 mg PO BID × 2 weeks then 2.5 mg PO daily × 6 weeks (8 weeks total) • PO • BID then daily
    triggers: ppcm_cs_postpartum_lvef_below_35, severe_ppcm_postpartum_seeking_recovery
    IPAC RCT (Sliwa 2017 PMID 28637825): 8-wk regimen improved LVEF recovery 27→58% at 6 mo; POSTPARTUM ONLY (suppresses lactation — counsel patient); ADD prophylactic AC during therapy due to thrombosis risk
    rxcui 142426
  • enoxaparin
    comorbidity specific
    lmwh
    1 mg/kg SC q12h (therapeutic) OR 40 mg SC daily (prophylactic) • SC • q12h or daily
    triggers: ppcm_antepartum_with_chads2vasc_above_2_and_lvef_below_35, ppcm_postpartum_during_bromocriptine_therapy, ppcm_cs_with_lv_thrombus
    LMWH preferred peripartum (warfarin teratogenic 6–12 wks gestation + fetal bleeding third trimester); ESC pregnancy 2018 PMID 30165544
    rxcui 67108
  • warfarin
    comorbidity specific
    vitamin_k_antagonist
    5 mg PO daily; INR target 2-3 • PO • daily
    triggers: ppcm_postpartum_chronic_ac_indication, lactation_with_chronic_ac_need
    POSTPARTUM transition from LMWH; safe in lactation (no significant breast milk transfer)
    rxcui 11289
  • apixaban
    comorbidity specific
    doac_factor_xa_direct
    5 mg PO BID • PO • BID
    triggers: ppcm_postpartum_chronic_ac_not_breastfeeding
    POSTPARTUM alternative to warfarin; NOT recommended during breastfeeding (limited data)
    rxcui 1364430

outpatient playbook — drug actions (2)

  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. maintain GDMT at least 12 months even after LVEF recovery
    rxcui 1656328
    maintain • PO • as scheduled
    trigger: LVEF recovered but recent
    TRED-HF PMID 30429051; AHA 2020 PPCM scientific statement (PMID 32362133) suggests indefinite GDMT in PPCM

Auto-drafted A&P note

outpatient

Subjective

- Possible entry pathways: Peripartum patient (last month pregnancy through 5 mo postpartum) with SBP <90 + severe LV dysfunction (LVEF <30%) on bedside echo — PPCM-CS clinical pattern (SCAI C+); Echo LVEF <30% + dilated LV + global hypokinesis in peripartum window with shock physiology — PPCM with cardiogenic shock; Patient with prior PPCM + persistent LV dysfunction + new pregnancy presenting with shock — recurrence with severe presentation (mortality up to 20%).

Objective

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

Assessment

**Cardiogenic shock — peripartum cardiomyopathy (PPCM, severe)** (cardio.cardiogenic-shock.peripartum-cardiomyopathy.v1).
Scope: PPCM with cardiogenic shock = HFrEF (LVEF <30% in severe variant) in peripartum window + SCAI C+ shock physiology; pregnancy status drives drug selection (ACEi/ARB/SGLT2i/DOAC teratogenic; bromocriptine postpartum-only adjunct); ~5–10% of PPCM progresses to shock; very high maternal + fetal mortality

No severity triggers fired against current inputs.

Plan

Regimen axis: **PPCM-CS pregnancy-aware shock regimen — NE first-line + milrinone preferred over dobutamine in pregnancy + bromocriptine 8-wk postpartum per IPAC + LMWH peripartum + MCS bridge to recovery (Impella CP / VA-ECMO)**.
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; preserves uteroplacental perfusion; preferred vasopressor in pregnancy
2. milrinone 0.125–0.5 µg/kg/min IV continuous (no bolus to avoid hypotension) IV continuous (pde3_inhibitor, first line) — Inodilator preferred over dobutamine in pregnancy (better arrhythmia profile despite OPTIME-CHF PMID 12759322 caution); 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; used cautiously in pregnancy due to arrhythmogenic potential
4. furosemide 40 mg IV bolus then 5–10 mg/h infusion or 40–80 mg IV q6–8h IV as scheduled (loop_diuretic, first line) — DOSE PMID 21366472 high-dose IV bolus arm; safe in pregnancy and lactation
5. hydralazine 10–25 mg PO TID OR 5–10 mg IV q4–6h prn PO/IV TID (arteriolar_vasodilator, first line) — Pregnancy-safe afterload reducer; substitute for ACEi/ARB during pregnancy (ESC pregnancy 2018 PMID 30165544)
6. isosorbide dinitrate 20–40 mg PO TID PO TID (venous_vasodilator_nitrate, first line) — Combine with hydralazine (A-HeFT analog) for pregnancy-safe afterload + preload reduction
7. carvedilol 3.125 mg PO BID titrate (after off catecholamines ≥24 h) PO BID (beta_alpha_blocker, first line) — CAPRICORN PMID 11356436 + COPERNICUS PMID 11386262; preferred postpartum (limited lactation data but acceptable per AAP); start AFTER inotrope wean
8. sacubitril-valsartan 24/26 mg PO BID titrate to 97/103 BID PO BID (arni, first line) — PIONEER-HF PMID 30403955; POSTPARTUM ONLY (TERATOGENIC); AAP advises against during lactation
9. enalapril 2.5 mg PO BID titrate PO BID (acei, first line) — POSTPARTUM ONLY; enalapril and captopril are AAP-approved during lactation
10. spironolactone 12.5–25 mg PO daily PO daily (mra, first line) — POSTPARTUM ONLY (potential antiandrogenic teratogen); RALES PMID 10471456
11. empagliflozin 10 mg PO daily PO daily (sglt2_inhibitor, first line) — EMPULSE PMID 35347356; POSTPARTUM ONLY; not recommended during pregnancy or breastfeeding
12. bromocriptine 2.5 mg PO BID × 2 weeks then 2.5 mg PO daily × 6 weeks (8 weeks total) PO BID then daily (dopamine_d2_agonist_prolactin_inhibitor, add on) — IPAC RCT (Sliwa 2017 PMID 28637825): 8-wk regimen improved LVEF recovery 27→58% at 6 mo; POSTPARTUM ONLY (suppresses lactation — counsel patient); ADD prophylactic AC during therapy due to thrombosis risk
13. enoxaparin 1 mg/kg SC q12h (therapeutic) OR 40 mg SC daily (prophylactic) SC q12h or daily (lmwh, comorbidity specific) — LMWH preferred peripartum (warfarin teratogenic 6–12 wks gestation + fetal bleeding third trimester); ESC pregnancy 2018 PMID 30165544
14. warfarin 5 mg PO daily; INR target 2-3 PO daily (vitamin_k_antagonist, comorbidity specific) — POSTPARTUM transition from LMWH; safe in lactation (no significant breast milk transfer)
15. apixaban 5 mg PO BID PO BID (doac_factor_xa_direct, comorbidity specific) — POSTPARTUM alternative to warfarin; NOT recommended during breastfeeding (limited data)

Setting playbook (outpatient) — Long-term PPCM-CS surveillance: serial LVEF at 3 mo + 6 mo + 12 mo; ICD eligibility re-evaluation if LVEF <35% at 3-6 mo on full GDMT; advanced HF + transplant pathway if no recovery at 6-12 mo; future-pregnancy counseling; cross-link to chronic HF if no recovery
16. 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))
17. maintain GDMT at least 12 months even after LVEF recovery maintain PO as scheduled — LVEF recovered but recent (TRED-HF PMID 30429051; AHA 2020 PPCM scientific statement (PMID 32362133) suggests indefinite GDMT in PPCM)

Non-pharmacologic actions:
- Future-pregnancy counseling — recurrence rate 30-50% if LVEF did not normalize; counsel against pregnancy if persistent LV dysfunction
- Reliable contraception — counsel re: progestin-only or IUD (combined oral contraceptives raise thrombosis risk + are not preferred)
- 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
- Family screening if familial CMP suspected

AVOID / contraindication checks:
- Avoid_acei_arb_arni_during_pregnancy_teratogenic (FDA Pregnancy Category D — fetal renal dysgenesis, oligohydramnios)
- Avoid_spironolactone_during_pregnancy (antiandrogenic — feminization of male fetus theoretical)
- Avoid_warfarin_pregnancy_weeks_6_to_12 (warfarin embryopathy)
- Avoid_warfarin_third_trimester (fetal intracranial hemorrhage at delivery)
- Avoid_sglt2i_during_pregnancy_or_breastfeeding (animal teratogenicity + limited human data)
- Bromocriptine_postpartum_only_suppresses_lactation (counsel patient; informed consent re: lactation cessation)
- Add_prophylactic_anticoagulation_during_bromocriptine_therapy (increased thrombosis risk per IPAC)
- Avoid_doac_during_pregnancy_or_breastfeeding (insufficient data)
- Milrinone_preferred_over_dobutamine_in_pregnancy (better arrhythmia profile)
- Hold_bromocriptine_if_active_bleeding_or_uncontrolled_HTN (thrombosis vs bleed balance; ergot vasoconstriction)
- Obstetric_team_must_co_manage_delivery_decision_in_severe_ppcm_cs (urgent C section if fetal distress + maternal compromise)
- Carvedilol_arni_after_off_catecholamines_24h (avoid β blockade during active inotrope/pressor support)

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 (PPCM-CS has elevated VT/VF risk if LVEF <35%)
- lactate q1-2h (CardShock; Harjola PMID 26333869)
- UOP hourly (SCAI 2019 end-organ perfusion marker)
- continuous fetal monitoring if antepartum (continuous if SBP <100 or on inotrope)
- daily echo for LVEF recovery trajectory
- pre discharge NT proBNP BMP INR if warfarin
- echo at 1 week then 6 weeks then 3 months then 6 months postpartum (LVEF recovery surveillance)
- lactation consult if bromocriptine planned (irreversible lactation suppression)
- INR q week during warfarin titration postpartum (target 2-3)
- anti xa monitoring during lmwh in pregnancy (target 0.6-1.0 U/mL therapeutic)

Setting (outpatient) monitoring:
- Quarterly clinic visits + echo
- Annual BNP/NT-proBNP
- INR if on warfarin

Follow-up plan: PPCM clinic at 2 wks, 6 wks, 3 mo, 6 mo, 12 mo postpartum; serial echo for LVEF recovery; ICD/WCD evaluation if LVEF <35% at 3–6 mo on full GDMT; advanced HF + transplant pathway if no recovery at 6–12 mo; future-pregnancy counseling (recurrence 30–50% if LVEF did not normalize); contraception counseling (avoid combined oral contraceptives — thrombosis risk; prefer progestin-only or IUD)
- Close-out criterion: PPCM clinic + transplant pathway + future-pregnancy + contraception counseling booked

Monitoring phase: Continuous telemetry, A-line, central line, possibly PA catheter; lactate q1–2 h; UOP hourly; daily echo for cardiac recovery trajectory; continuous fetal monitoring if antepartum; daily BMP / NT-proBNP / troponin

Disposition

Current setting: outpatient — Long-term PPCM-CS surveillance: serial LVEF at 3 mo + 6 mo + 12 mo; ICD eligibility re-evaluation if LVEF <35% at 3-6 mo on full GDMT; advanced HF + transplant pathway if no recovery at 6-12 mo; future-pregnancy counseling; cross-link to chronic HF if no recovery

Disposition criteria:
- Long-term continuation; cross-link to cardio.hfref.core.v1 if HFrEF persists past 12 mo; transplant if no recovery

Escalation triggers (move to higher acuity):
- New pregnancy in patient with persistent LV dysfunction → urgent MFM + cardiology + advanced HF eval (termination discussion if LVEF <35%)
- Worsening LVEF despite GDMT → advanced HF + transplant evaluation
- ICD therapy delivered → urgent EP

Earlier-Return Triggers

Return-precaution thresholds (watch for):
- [LIFE_THREATENING] Antepartum PPCM-CS (SBP <90, lactate ≥4, SCAI C-E) + fetal distress or maternal compromise — urgent delivery (vaginal vs C-section per fetal/maternal status) often improves maternal hemodynamics; concurrent MCS bridge (Impella CP / VA-ECMO) if refractory; pregnancy heart team mobilization
- [LIFE_THREATENING] Patient with prior PPCM-CS + LVEF that did not normalize + new pregnancy presenting with shock — recurrence rate 30-50%, mortality up to 20%; urgent termination discussion if LVEF <35%
- [SEVERE] Young postpartum patient (often <40 yo) with PPCM-CS who fails to recover at 6-12 mo despite full GDMT + bromocriptine + AC — advanced HF + transplant evaluation; LVAD bridge to transplant if needed; ethical complexity given age + family

Citations

- 2022 ACC/AHA/HFSA HF Guideline (Heidenreich PMID 35363499) + AHA 2020 PPCM Scientific Statement (Davis PMID 32362133) + ESC pregnancy 2018 (Regitz-Zagrosek PMID 30165544) + IPAC bromocriptine RCT (Sliwa 2017 PMID 28637825) + SCAI 2022 CS staging (Naidu PMID 35718438) [PMID:28637825](https://pubmed.ncbi.nlm.nih.gov/28637825/)
- Cited evidence (PMID 32362133) [PMID:32362133](https://pubmed.ncbi.nlm.nih.gov/32362133/)
- Cited evidence (PMID 30165544) [PMID:30165544](https://pubmed.ncbi.nlm.nih.gov/30165544/)
- Cited evidence (PMID 28612476) [PMID:28612476](https://pubmed.ncbi.nlm.nih.gov/28612476/)
- Cited evidence (PMID 17320504) [PMID:17320504](https://pubmed.ncbi.nlm.nih.gov/17320504/)

Last reconciled with current guidelines: 2026-05-15.
References
  • 2022 ACC/AHA/HFSA HF Guideline (Heidenreich PMID 35363499) + AHA 2020 PPCM Scientific Statement (Davis PMID 32362133) + ESC pregnancy 2018 (Regitz-Zagrosek PMID 30165544) + IPAC bromocriptine RCT (Sliwa 2017 PMID 28637825) + SCAI 2022 CS staging (Naidu PMID 35718438) — PMID:28637825
  • Cited evidence (PMID 32362133) — PMID:32362133
  • Cited evidence (PMID 30165544) — PMID:30165544
  • Cited evidence (PMID 28612476) — PMID:28612476
  • Cited evidence (PMID 17320504) — PMID:17320504