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cardio.nstemi.diabetic-silent.v1PRODUCTION
cardio.nstemi.diabetic-silent.v1

NSTEMI — diabetic silent / atypical (autonomic neuropathy; anginal-equivalent presentation)

cardiologyacuteadult
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Detailed

Confirm NSTEMI in diabetic patient with atypical / anginal-equivalent presentation per Canto JAMA 2012 PMID 22340557 + Pop-Busui PMID 28522672 CAN framework. Anchor to three drivers: (1) cardiac autonomic neuropathy blunting pain perception, (2) microvascular dysfunction + accelerated diffuse CAD, (3) anginal equivalents (dyspnea, fatigue, nausea, syncope, unexplained hypoglycemia)

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Diabetic silent NSTEMI confirmed + CAN context framed

Patient inputs (13)

Bedside echo for new RWMA — particularly important in diabetics where pain perception is blunted and clinical exam may underestimate ischemic burden

Diabetic patients with longer disease duration and higher A1c have higher CAN prevalence; age + diabetes duration interact

Microalbuminuria, retinopathy, peripheral neuropathy markers correlate with CAN; presence raises silent ischemia probability and lowers cath threshold

A1c at admission documents glycemic control history + drives long-term diabetes management; elevated A1c worsens ACS outcomes per DIGAMI

Metformin HOLD peri-cath (contrast nephropathy → lactic acidosis); SGLT2i HOLD if DKA risk (NPO, sepsis); insulin titration plan; GLP-1 RA continuation per ADA 2026

T2DM > T1DM for silent ischemia; duration ≥10 y and A1c ≥7 raise CAN probability per DCCT/EDIC + Pop-Busui PMID 28522672

ESC 2023 0/1-h hsTn algorithm — lower threshold for serial trop in any diabetic with anginal-equivalent presentation; chronic elevation common in diabetic nephropathy + HFpEF — dynamic delta required

Confirm absence of STE (this is NSTEMI variant); detect ST depression, T inversion, dynamic changes; baseline ECG abnormalities common in diabetes (LVH, pre-existing T-wave changes) confound

Hyperglycemia >180 worsens ACS outcomes per DIGAMI/HI-5; hypoglycemia drives counter-regulatory failure during ischemia; target 140-180 in critically-ill ACS per ADA 2026

Diabetic nephropathy common; CKD-EPI 2021 race-free eGFR gates contrast, DOAC, gabapentinoid dosing; KDIGO 2026 pre-hydration if cath proceeds

Hypotension as both red flag (silent shock) and trigger consideration; orthostatic SBP drop ≥20 a CAN marker

Resting tachycardia >100, orthostatic SBP drop ≥20, abnormal heart rate variability, gastroparesis, sexual dysfunction — clinical CAN markers per Pop-Busui PMID 28522672

Microalbuminuria marker for diabetic nephropathy + microvascular disease + CAN association; raises silent ischemia probability

* = hard-required. Engine cannot meaningfully run until these are filled.

Severity triggers (6)

6 need judgement
  • informationallife_threateningsilent_cardiogenic_shock_in_diabetic_nstemi
    SBP <90 + lactate ≥2 + hypoperfusion in diabetic NSTEMI patient — pain perception blunted by CAN; may present as unexplained hypotension + organ dysfunction without classic chest pain; lower threshold for shock workup
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationallife_threateninghyperosmolar_hyperglycemic_state_overlap_with_nstemi
    Glucose >600 + osmolality >320 + altered mental status in diabetic NSTEMI patient — HHS overlap; high mortality without aggressive volume + insulin + electrolyte management
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationallife_threateningmechanical_complication_in_diabetic_nstemi
    New murmur, pulmonary edema, RV failure in diabetic NSTEMI — papillary muscle rupture, VSD, free-wall rupture; mortality >50% without surgical correction
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseveresevere_hypoglycemia_with_concerning_features_in_diabetic_nstemi
    Glucose <54 + altered mental status / seizure / cardiac event in diabetic NSTEMI patient — counter-regulatory failure during ischemia; may itself be presenting feature of silent MI
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmoderatepersistent_hyperglycemia_above_180_in_critical_acs
    Glucose >180 mg/dL persistent in critically-ill diabetic NSTEMI patient — worsens outcomes per DIGAMI/HI-5; insulin infusion indicated
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmoderatecontrast_nephropathy_risk_in_diabetic_with_ckd
    eGFR <60 + diabetic with planned cath in NSTEMI window — high CIN-AKI risk; KDIGO 2026 pre-hydration + contrast minimization mandatory
    Trigger could not be auto-evaluated — needs clinician judgement.

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Recommended regimen

Diabetic silent NSTEMI phenotype — standard NSTE-ACS bundle plus diabetes-specific glycemic management, peri-procedural metformin/SGLT2i hold, and post-stabilization SGLT2i + GLP-1 RA cardio-renal benefit
axis: diabetic_silent_nstemi_phenotype
Selected axis "Diabetic silent NSTEMI phenotype — standard NSTE-ACS bundle plus diabetes-specific glycemic management, peri-procedural metformin/SGLT2i hold, and post-stabilization SGLT2i + GLP-1 RA cardio-renal benefit" by default fallback (first axis)
  • aspirin
    first line
    antiplatelet_cox1
    162-325 mg load → 81 mg • PO chewed • load once → 81 mg daily lifelong
    triggers: diabetic_silent_nstemi_confirmed
    Universal — ACC/AHA 2025 ACS Class I; ISIS-2 mortality benefit; lifelong post-MI
    rxcui 243670
  • ticagrelor
    first line
    P2Y12_inhibitor
    180 mg load → 90 mg BID • PO • BID × 12 mo
    triggers: diabetic_silent_nstemi_pci_planned
    PLATO PMID 19717846 — net benefit preserved/amplified in DM subgroup; preferred P2Y12 in DM-ACS per ACC/AHA 2025
    rxcui 1116632
  • clopidogrel
    second line
    P2Y12_inhibitor
    300-600 mg load → 75 mg • PO • daily × 12 mo
    triggers: ticagrelor_intolerance, high_bleed_risk_cohort
    Alternative if ticagrelor intolerance or HBR; CURE trial backbone
    rxcui 32968
  • unfractionated_heparin
    first line
    parenteral_anticoagulant
    60 U/kg IV bolus + 12 U/kg/h infusion • IV • bolus + infusion at PCI; aPTT 50-70
    triggers: diabetic_silent_nstemi_pci_planned
    AHA 2025 ACS Class I peri-PCI AC; UFH preferred for short half-life + reversibility
    rxcui 5224
  • enoxaparin
    second line
    LMWH
    1 mg/kg SC q12h (1 mg/kg q24h if CrCl 15-30; HOLD if CrCl <15) • SC • q12h or q24h per CrCl until cath or end of hospitalisation
    triggers: conservative_path, pci_not_imminent
    ESSENCE; renal dose-adjust mandatory in diabetic nephropathy; switch to UFH at PCI
    rxcui 67108
  • atorvastatin
    first line
    statin_high_intensity
    80 mg daily • PO • daily lifelong
    triggers: diabetic_silent_nstemi_confirmed
    PROVE-IT PMID 15007110 — high-intensity statin lifelong; LDL target <70 (or <55 very-high-risk per ESC 2023)
    rxcui 83367
  • lisinopril
    first line
    acei
    5 mg daily titrate • PO • daily
    triggers: diabetic_nephropathy_or_microalbuminuria, ef_below_40, htn
    HOPE PMID 10639539 — ramipril CV benefit in DM; ACEi reduces albuminuria + slows nephropathy progression; ACC/AHA 2025 + ADA 2026 Class I in DM-ACS
    rxcui 29046
  • metoprolol_tartrate
    first line
    beta_blocker_cardioselective
    25 mg BID titrate (start lower if EF reduced) • PO • BID
    triggers: diabetic_silent_nstemi_post_event
    CAPRICORN + ACC/AHA 2025 Class I post-MI BB; cardioselective preferred to minimize hypoglycemia masking
    rxcui 6918
  • dapagliflozin
    first line
    sglt2_inhibitor
    10 mg daily (HOLD peri-procedural and if NPO/sepsis — DKA risk) • PO • daily post-stabilization
    triggers: diabetic_silent_nstemi_post_stabilization, t2dm_with_ckd, ef_below_40
    DAPA-MI PMID 38320150 — SGLT2i post-MI cardio-renal benefit; DECLARE PMID 30415602 + EMPA-REG PMID 26378978; ADA 2026 Class I in DM with CV/renal disease; HOLD if NPO/sepsis (DKA risk)
    rxcui 1488564
  • liraglutide
    add on
    glp1_agonist
    0.6 mg SC daily titrate to 1.2-1.8 mg • SC • daily
    triggers: t2dm_with_high_cv_risk_or_obesity, inadequate_glycemic_control_on_metformin_+_sglt2i
    LEADER PMID 27295427 — liraglutide CV benefit in T2DM; ADA 2026 + ACC/AHA 2025 Class I in T2DM-ACS post-stabilization; weight + CV benefit
    rxcui 475968
  • metformin
    comorbidity specific
    biguanide
    HOLD peri-cath × 48 h; resume 500 mg BID titrate to 1000 mg BID if eGFR ≥30 stable post-cath • PO • BID
    triggers: t2dm_post_stabilization_eGFR_above_30
    FDA label — HOLD peri-contrast (lactic acidosis risk); resume post-cath if renal stable; first-line T2DM agent per ADA 2026
    rxcui 6809
  • insulin_regular
    rescue
    short_acting_insulin
    IV infusion 0.05-0.1 U/kg/h titrate to glucose 140-180 • IV • continuous
    triggers: glucose_above_180_in_critical_acs, persistent_hyperglycemia_during_admission
    DIGAMI PMID 9099043 + HI-5 PMID 16936138 — insulin glucose-control improves DM-ACS outcomes; ADA 2026 inpatient target 140-180 in critically ill
    rxcui 253182
  • sacubitril-valsartan
    add on
    arni
    24/26 mg BID titrate (start at ≥36 h post-ACEi, SBP ≥100) • PO • BID
    triggers: diabetic_silent_nstemi_with_ef_below_40_post_event
    PIONEER-HF PMID 30403955 + ACC/AHA 2022 HF Class I — initiate ARNI if HFrEF persists post-MI
    rxcui 1656328
  • eplerenone
    add on
    mineralocorticoid_receptor_antagonist
    25 mg daily (HOLD if K >5 or eGFR <30) • PO • daily
    triggers: ef_below_40_post_mi, k_below_5, egfr_above_30
    EPHESUS post-MI MRA Class I; particular benefit in DM substrate
    rxcui 298869

outpatient playbook — drug actions (4)

  1. 1. continue ASA + ticagrelor 12 mo, then ASA monotherapy
    rxcui 321208
    aspirin 81 + ticagrelor 90 BID × 12 mo • PO • daily/BID
    trigger: Post-NSTEMI standard
    ACC/AHA 2025 Class I; PRECISE-DAPT for shortening if HBR
  2. 2. maintain GDMT
    rxcui 83367
    atorvastatin 40-80 + BB low + ACEi low + MRA per renal/K • PO • daily
    trigger: Post-MI maintenance
    ACC/AHA 2025 Class I
  3. 3. continue SGLT2i + GLP-1 RA cardio-renal benefit
    rxcui 1488564
    dapagliflozin 10 + liraglutide 1.2-1.8 mg • PO/SC • daily
    trigger: T2DM with CV/renal disease
    EMPA-REG PMID 26378978 + LEADER PMID 27295427 + DECLARE PMID 30415602; ADA 2026 + ACC/AHA 2025 Class I lifelong in T2DM with CV disease
  4. 4. add PCSK9i if LDL >70 on max statin
    evolocumab 140 mg SC q2w • SC • q2w
    trigger: LDL >70 on max statin
    FOURIER PMID 28304224

Auto-drafted A&P note

outpatient

Subjective

- Possible entry pathways: Unexplained dyspnea or fatigue in T2DM patient with microalbuminuria, retinopathy, or peripheral neuropathy — anginal-equivalent silent NSTEMI suspect; low threshold for serial hsTn + ECG; Nausea, diaphoresis, or syncope in diabetic patient — anginal-equivalent presentation per Canto JAMA 2012 PMID 22340557; women with diabetes even more likely atypical; Unexplained hypoglycemia in diabetic patient (counter-regulatory failure during ischemia) — silent MI consideration.

Objective

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

Assessment

**NSTEMI — diabetic silent / atypical (autonomic neuropathy; anginal-equivalent presentation)** (cardio.nstemi.diabetic-silent.v1).
Phenotype framing: Type-1 NSTEMI (plaque rupture in accelerated CAD) — most likely in this engine; Type-2 NSTEMI (demand from sepsis/anemia/HFpEF decompensation in diabetic substrate); diabetic ketoacidosis with secondary trop bump; HFpEF decompensation with chronic trop; PE with strain pattern + trop; aortic dissection (diabetic vasculopathy)
Scope: Confirm NSTEMI in diabetic patient with atypical / anginal-equivalent presentation per Canto JAMA 2012 PMID 22340557 + Pop-Busui PMID 28522672 CAN framework. Anchor to three drivers: (1) cardiac autonomic neuropathy blunting pain perception, (2) microvascular dysfunction + accelerated diffuse CAD, (3) anginal equivalents (dyspnea, fatigue, nausea, syncope, unexplained hypoglycemia)

No severity triggers fired against current inputs.

Plan

Regimen axis: **Diabetic silent NSTEMI phenotype — standard NSTE-ACS bundle plus diabetes-specific glycemic management, peri-procedural metformin/SGLT2i hold, and post-stabilization SGLT2i + GLP-1 RA cardio-renal benefit**.
1. aspirin 162-325 mg load → 81 mg PO chewed load once → 81 mg daily lifelong (antiplatelet_cox1, first line) — Universal — ACC/AHA 2025 ACS Class I; ISIS-2 mortality benefit; lifelong post-MI
2. ticagrelor 180 mg load → 90 mg BID PO BID × 12 mo (P2Y12_inhibitor, first line) — PLATO PMID 19717846 — net benefit preserved/amplified in DM subgroup; preferred P2Y12 in DM-ACS per ACC/AHA 2025
3. clopidogrel 300-600 mg load → 75 mg PO daily × 12 mo (P2Y12_inhibitor, second line) — Alternative if ticagrelor intolerance or HBR; CURE trial backbone
4. unfractionated_heparin 60 U/kg IV bolus + 12 U/kg/h infusion IV bolus + infusion at PCI; aPTT 50-70 (parenteral_anticoagulant, first line) — AHA 2025 ACS Class I peri-PCI AC; UFH preferred for short half-life + reversibility
5. enoxaparin 1 mg/kg SC q12h (1 mg/kg q24h if CrCl 15-30; HOLD if CrCl <15) SC q12h or q24h per CrCl until cath or end of hospitalisation (LMWH, second line) — ESSENCE; renal dose-adjust mandatory in diabetic nephropathy; switch to UFH at PCI
6. atorvastatin 80 mg daily PO daily lifelong (statin_high_intensity, first line) — PROVE-IT PMID 15007110 — high-intensity statin lifelong; LDL target <70 (or <55 very-high-risk per ESC 2023)
7. lisinopril 5 mg daily titrate PO daily (acei, first line) — HOPE PMID 10639539 — ramipril CV benefit in DM; ACEi reduces albuminuria + slows nephropathy progression; ACC/AHA 2025 + ADA 2026 Class I in DM-ACS
8. metoprolol_tartrate 25 mg BID titrate (start lower if EF reduced) PO BID (beta_blocker_cardioselective, first line) — CAPRICORN + ACC/AHA 2025 Class I post-MI BB; cardioselective preferred to minimize hypoglycemia masking
9. dapagliflozin 10 mg daily (HOLD peri-procedural and if NPO/sepsis — DKA risk) PO daily post-stabilization (sglt2_inhibitor, first line) — DAPA-MI PMID 38320150 — SGLT2i post-MI cardio-renal benefit; DECLARE PMID 30415602 + EMPA-REG PMID 26378978; ADA 2026 Class I in DM with CV/renal disease; HOLD if NPO/sepsis (DKA risk)
10. liraglutide 0.6 mg SC daily titrate to 1.2-1.8 mg SC daily (glp1_agonist, add on) — LEADER PMID 27295427 — liraglutide CV benefit in T2DM; ADA 2026 + ACC/AHA 2025 Class I in T2DM-ACS post-stabilization; weight + CV benefit
11. metformin HOLD peri-cath × 48 h; resume 500 mg BID titrate to 1000 mg BID if eGFR ≥30 stable post-cath PO BID (biguanide, comorbidity specific) — FDA label — HOLD peri-contrast (lactic acidosis risk); resume post-cath if renal stable; first-line T2DM agent per ADA 2026
12. insulin_regular IV infusion 0.05-0.1 U/kg/h titrate to glucose 140-180 IV continuous (short_acting_insulin, rescue) — DIGAMI PMID 9099043 + HI-5 PMID 16936138 — insulin glucose-control improves DM-ACS outcomes; ADA 2026 inpatient target 140-180 in critically ill
13. sacubitril-valsartan 24/26 mg BID titrate (start at ≥36 h post-ACEi, SBP ≥100) PO BID (arni, add on) — PIONEER-HF PMID 30403955 + ACC/AHA 2022 HF Class I — initiate ARNI if HFrEF persists post-MI
14. eplerenone 25 mg daily (HOLD if K >5 or eGFR <30) PO daily (mineralocorticoid_receptor_antagonist, add on) — EPHESUS post-MI MRA Class I; particular benefit in DM substrate

Setting playbook (outpatient) — 3-12 mo follow-up — DAPT-duration decision (12 mo default), long-term GDMT optimisation with cardio-renal SGLT2i + GLP-1 RA, A1c target 7-7.5% individualized per ADA 2026, intensified secondary prevention with PCSK9 if LDL >70, annual diabetes complication screening
15. continue ASA + ticagrelor 12 mo, then ASA monotherapy aspirin 81 + ticagrelor 90 BID × 12 mo PO daily/BID — Post-NSTEMI standard (ACC/AHA 2025 Class I; PRECISE-DAPT for shortening if HBR)
16. maintain GDMT atorvastatin 40-80 + BB low + ACEi low + MRA per renal/K PO daily — Post-MI maintenance (ACC/AHA 2025 Class I)
17. continue SGLT2i + GLP-1 RA cardio-renal benefit dapagliflozin 10 + liraglutide 1.2-1.8 mg PO/SC daily — T2DM with CV/renal disease (EMPA-REG PMID 26378978 + LEADER PMID 27295427 + DECLARE PMID 30415602; ADA 2026 + ACC/AHA 2025 Class I lifelong in T2DM with CV disease)
18. add PCSK9i if LDL >70 on max statin evolocumab 140 mg SC q2w SC q2w — LDL >70 on max statin (FOURIER PMID 28304224)

Non-pharmacologic actions:
- Cardiac rehab maintenance phase
- Annual flu + COVID + pneumococcal vaccination per CDC
- Smoking cessation reinforcement
- Mediterranean / DASH diet counseling
- BP + glucose home log review at every visit
- Diabetes self-management education

AVOID / contraindication checks:
- HOLD_metformin_peri_cath_x_48h (FDA label — contrast/lactic acidosis)
- HOLD_sglt2i_if_npo_sepsis_peri_proc (DKA risk)
- Beta_blocker_cardioselective_preferred_in_DM (avoid hypoglycemia masking)
- NEVER_target_glucose_below_140_in_critical_acs (hypoglycemia worsens outcomes per NICE SUGAR + ADA 2026)
- Enoxaparin_renal_dose_adjust_if_crcl_15_30 (FDA label)
- Enoxaparin_avoid_if_crcl_below_15 (FDA label)
- Contrast_minimisation_egfr_below_30 (KDIGO 2026)
- NSAID_avoid_in_dm_with_ckd (renal + bleed amplification)
- Gabapentinoid_for_diabetic_neuropathy_renal_dose_adjust (FDA label)

Monitoring

Regimen monitoring:
- serial troponin q3-6h during initial workup then q12h to confirm correction
- serial ecg q15min x 1h if concerning features then daily
- glucose q4h with insulin sliding scale or basal bolus (ADA 2026 target 140-180)
- echo at 5-7d for lv function + thrombus screen
- creatinine q24h x 72h for CIN-AKI surveillance (KDIGO 2026)
- a1c at admission and at 3 mo post discharge (target 7-7.5% individualized per ADA 2026)
- urine albumin creatinine ratio annually (microalbuminuria progression)
- hgb + plt q12h x 24h then q24h during anticoagulation
- lipid panel at 4-12 weeks post event (LDL <70 or <55 very-high-risk)
- orthostatic vitals to track CAN progression

Setting (outpatient) monitoring:
- BMP every 3 mo on ACEi/MRA
- A1c every 3-6 mo (target 7-7.5% individualized per ADA 2026)
- Lipid panel every 6-12 mo
- UACR annually
- Bleeding signs check at every visit through DAPT duration
- Echo at 1 yr if EF<40

Follow-up plan: Cardiology + endocrinology joint follow-up at 1, 4, 12 wks; LVEF re-echo at 40-90 d for ICD eligibility (MADIT-II EF ≤30); cardiac rehab Class I per ACC/AHA 2025 with diabetes-specific glycemic monitoring; intensified secondary prevention (high-intensity statin lifelong, BP <130/80, A1c 7-7.5% individualized per ADA 2026, SGLT2i/GLP-1 RA cardio-renal); annual eye + foot + microalbuminuria screening
- Close-out criterion: Long-term joint follow-up + cardiac rehab booked

Monitoring phase: Telemetry; serial trop to confirm trend; daily ECG; glucose q4h with insulin sliding scale or basal-bolus per ADA 2026 inpatient targets 140-180; BMP daily on AC + ACEi/ARB; renal trajectory (CIN-AKI surveillance); CAN markers reassessed; falls precautions if orthostatic

Disposition

Current setting: outpatient — 3-12 mo follow-up — DAPT-duration decision (12 mo default), long-term GDMT optimisation with cardio-renal SGLT2i + GLP-1 RA, A1c target 7-7.5% individualized per ADA 2026, intensified secondary prevention with PCSK9 if LDL >70, annual diabetes complication screening

Disposition criteria:
- Long-term continuation; cross-link to chronic CAD + diabetes engines; geriatrics co-management if frail

Escalation triggers (move to higher acuity):
- Recurrent chest pain or anginal-equivalent → ED + reassess
- BARC 2+ bleed → de-escalate DAPT immediately
- NYHA worsening to III+ → expedite cardiology re-eval + echo
- Functional decline / new neurologic deficit → comprehensive re-eval
- Worsening A1c → endo + regimen escalation

Earlier-Return Triggers

Return-precaution thresholds (watch for):
- [LIFE_THREATENING] SBP <90 + lactate ≥2 + hypoperfusion in diabetic NSTEMI patient — pain perception blunted by CAN; may present as unexplained hypotension + organ dysfunction without classic chest pain; lower threshold for shock workup
- [LIFE_THREATENING] Glucose >600 + osmolality >320 + altered mental status in diabetic NSTEMI patient — HHS overlap; high mortality without aggressive volume + insulin + electrolyte management
- [LIFE_THREATENING] New murmur, pulmonary edema, RV failure in diabetic NSTEMI — papillary muscle rupture, VSD, free-wall rupture; mortality >50% without surgical correction

Citations

- 2025 ACC/AHA ACS Guideline (Rao) — diabetes ACS subgroup; ADA 2026 Standards of Care; ESC 2023 NSTE-ACS (Byrne, PMID 37622670); 4th UDMI 2018 (Thygesen Circulation 2018, PMID 30153967) [PMID:37622670](https://pubmed.ncbi.nlm.nih.gov/37622670/)
- Cited evidence (PMID 30153967) [PMID:30153967](https://pubmed.ncbi.nlm.nih.gov/30153967/)
- Cited evidence (PMID 18539917) [PMID:18539917](https://pubmed.ncbi.nlm.nih.gov/18539917/)
- Cited evidence (PMID 9099043) [PMID:9099043](https://pubmed.ncbi.nlm.nih.gov/9099043/)
- Cited evidence (PMID 16936138) [PMID:16936138](https://pubmed.ncbi.nlm.nih.gov/16936138/)

Last reconciled with current guidelines: 2026-05-15.
References
  • 2025 ACC/AHA ACS Guideline (Rao) — diabetes ACS subgroup; ADA 2026 Standards of Care; ESC 2023 NSTE-ACS (Byrne, PMID 37622670); 4th UDMI 2018 (Thygesen Circulation 2018, PMID 30153967) — PMID:37622670
  • Cited evidence (PMID 30153967) — PMID:30153967
  • Cited evidence (PMID 18539917) — PMID:18539917
  • Cited evidence (PMID 9099043) — PMID:9099043
  • Cited evidence (PMID 16936138) — PMID:16936138