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Prevention Starts in the Womb: Opportunities for Addressing Cardiovascular Risk Factors During Pregnancy and Beyond Cover

Prevention Starts in the Womb: Opportunities for Addressing Cardiovascular Risk Factors During Pregnancy and Beyond

Open Access
|Sep 2021

References

  1. Bateman BT, Bansil P, Hernandez-Diaz S, Mhyre JM, Callaghan WM, Kuklina EV. Prevalence, trends, and outcomes of chronic hypertension: a nationwide sample of delivery admissions. Am J Obstet Gynecol. 2012 Feb;206(2):134.e1. doi: 10.1016/j.ajog.2011.10.878
  2. Seely EW, Ecker J. Chronic hypertension in pregnancy. Circulation. 2014 Mar 18;129(11):125461. doi: 10.1161/CIRCULATIONAHA.113.003904
  3. ACOG [Internet]. Washington, DC: American College of Obstetricians and Gynecologists; c2021. Catalano PM, Koutrouvelis GO. Obesity in Pregnancy; 2013 [cited 2021 Aug 12]. Available from: https://www.acog.org/clinical/clinical-guidance/practice-bulletin/articles/2015/12/obesity-in-pregnancy
  4. Vrijkotte TGM, Krukziener N, Hutten BA, Vollebregt KC, Van Eijsden M, Twickler MB. Maternal lipid profile during early pregnancy and pregnancy complications and outcomes: the ABCD study. J Clin Endocrinol Metab. 2012 Nov;97(11): 391725. doi: 10.1210/jc.2012-1295
  5. AHRQ [Internet]. Rockville, MD: Agency for Healthcare Research and Quality; c 2021. Fingar KR, Mabry-Hernandez I, Ngo-Metzger Q, Wolff T, Steiner CA, Elixhauser A. Delivery Hospitalizations Involving Preeclampsia and Eclampsia, 2005-2014. 2017 Apr [cited 2021 Aug 12]; Available from: https://hcup-us.ahrq.gov/reports/statbriefs/sb222-Preeclampsia-Eclampsia-Delivery-Trends.jsp
  6. H-CUP [Internet]. Rockville, MD: Agency for Healthcare Research and Quality; c2021. Wier LM, Witt E, Burgess J, Elixhauser A. Statistical Brief #102; Hospitalizations Related to Diabetes in Pregnancy; 2010 Dec [cited 2021 Aug 12]. Available from: https://www.hcup-us.ahrq.gov/reports/statbriefs/sb102.pdf
  7. CDC [Internet]. Atlanta, GA: Centers for Disease Control and Prevention; c2021. Martin JA, Hamilton BE, Osterman MJK. Births in the United States; Data from the National Vital Statistics System. 2019 Jul [cited 2021 Aug 12]; Available from: https://www.cdc.gov/nchs/products/databriefs/db346.htm
  8. CDC [Internet]. Atlanta, GA: Centers for Disease Control and Prevention; c2021. QuickStats: Percentage of Small-for-Gestational-Age Births By Race and Hispanic Ethnicity in the United States; 2008 Dec 19 [cited 2021 Aug 12]. Available from: https://www.cdc.gov/mmwr/preview/mmwrhtml/mm5750a5.htm
  9. H-CUP [Internet]. Rockville, MD: Agency for Healthcare Research and Quality; c2021. Elixhauser A, Wier LM. Complicating Conditions of Pregnancy and Childbirth, 2008; HCUP Statistical Brief #113; 2011 May [cited 2021 Aug 12]. Available from: http://www.hcup-us.ahrq.gov/reports/statbriefs/sb113.jsp
  10. Elgendy IY, Bukhari S, Barakat AF, Pepine CJ, Lindley KJ, Miller EC. American College of Cardiology Cardiovascular Disease in Women Committee. Maternal Stroke: A Call for Action. Circulation. 2021 Feb 16;143(7):727738. doi: 10.1161/CIRCULATIONAHA.120.051460
  11. Cho L, Davis M, Elgendy I, et al. Summary of Updated Recommendations for Primary Prevention of Cardiovascular Disease in Women: JACC State-of-the-Art Review. J Am Coll Cardiol. 2020 May 26;75(20):26022618. doi: 10.1016/j.jacc.2020.03.060
  12. Grandi SM, Filion KB, Yoon S, et al. Cardiovascular Disease-Related Morbidity and Mortality in Women with a History of Pregnancy Complications. Circulation. 2019 Feb 19;139(8):10691079. doi: 10.1161/CIRCULATIONAHA.118.036748
  13. Brown HL, Warner JJ, Gianos E, et al. Promoting risk identification and reduction of cardiovascular disease in women through collaboration with obstetricians and gynecologists: A presidential advisory from the American Heart Association and the American College of Obstetricians and Gynecologists. Circulation. 2018 Jun 12;137(24):e843e852. doi: 10.1161/CIR.0000000000000582
  14. Creanga AA, Syverson C, Seed K, Callaghan WM. Pregnancy-Related Mortality in the United States, 2011–2013. Obstet Gynecol. 2017 Aug;130(2): 366373. doi: 10.1097/AOG.0000000000002114
  15. Ananth CV, Duzyj CM, Yadava S, Schwebel M, Tita ATN, Joseph KS. Changes in the prevalence of chronic hypertension in Pregnancy, United States, 1970 to 2010. Hypertension. 2019 Nov;74(5):10891095. doi: 10.1161/HYPERTENSIONAHA.119.12968
  16. Wild R, Weedin EA, Wilson D. Dyslipidemia in Pregnancy. Endocrinol Metab Clin North Am. 2016 Mar;45(1):5563. doi: 10.1016/j.ecl.2015.09.004
  17. Harrington RA, Califf RM, Balamurugan A, et al. Call to Action: Rural health: A Presidential Advisory From the American Heart Association and American Stroke Association. Circulation. 2020 Mar 10;141(10):e615e644. doi: 10.1161/CIR.0000000000000753
  18. Cameron NA, Molsberry R, Pierce JB, et al. Pre-Pregnancy Hypertension Among Women in Rural and Urban Areas of the United States. J Am Coll Cardiol. 2020 Dec 1;76(22):26112619. doi: 10.1016/j.jacc.2020.09.601
  19. Shahul S, Tung A, Minhaj M, et al. Racial disparities in comorbidities, complications, and maternal and fetal outcomes in women with preeclampsia/eclampsia. Hypertens Pregnancy. 2015 Oct 2;34(4):506515. doi: 10.3109/10641955.2015.1090581
  20. Perak AM, Lancki N, Kuang A. HAPO Follow-Up Study Cooperative Research Group. Associations of Maternal Cardiovascular Health in Pregnancy With Offspring Cardiovascular Health in Early Adolescence. JAMA. 2021 Feb 16;325(7):658668. doi: 10.1001/jama.2021.0247
  21. Bramham K, Parnell B, Nelson-Piercy C, Seed PT, Poston L, Chappell LC. Chronic hypertension and pregnancy outcomes: Systematic review and meta-analysis. BMJ. 2014 Apr 15;348. g2301. doi: 10.1136/bmj.g2301
  22. Nabhan AF, Elsedawy MM. Tight control of mild-moderate pre-existing or non-proteinuric gestational hypertension. The Cochrane Database of Systematic Reviews. 2011 Jul 6;(7):CD006907. doi: 10.1002/14651858.CD006907.pub2
  23. Abalos E, Duley L, Steyn DW, Gialdini C. Antihypertensive drug therapy for mild to moderate hypertension during pregnancy. Cochrane Database Syst Rev. 2018 Oct 1;10(10):CD002252. doi: 10.1002/14651858.CD002252.pub4
  24. Sinkey RG, Oparil S. Lower blood pressure thresholds raise the bar in pregnancy. Circ Res. 2019 Jul 5;125(2):195197. doi: 10.1161/CIRCRESAHA.119.315384
  25. Tita ATN, Sibai BM, Oparil S. Less-Tight versus Tight Control of Hypertension in Pregnancy. New Engl J Med. 2015 Jun 11;372(24):23667. doi: 10.1056/NEJMc1503870
  26. American College of Obstetricians and Gynecologists’ Committee on Practice Bulletins—Obstetrics. ACOG Practice Bulletin No. 203: Chronic Hypertension in Pregnancy. Obstet Gynecol. 2019 Jan;133(1):e26e50. doi: 10.1097/AOG.0000000000003020
  27. Butalia S, Audibert F, Côté AM, et al. Hypertension Canada’s 2018 Guidelines for the Management of Hypertension in Pregnancy. Can J Cardiol. 2018 May;34(5):526531. doi: 10.1016/j.cjca.2018.02.021
  28. Webster K, Fishburn S, Maresh M, Findlay SC, Chappell LC. Diagnosis and management of hypertension in pregnancy: summary of updated NICE guidance. BMJ. 2019 Sep 9;366:l5119. doi: 10.1136/bmj.l5119
  29. Mehta LS, Warnes CA, Bradley E, et al.; American Heart Association Council on Clinical Cardiology; Council on Arteriosclerosis, Thrombosis and Vascular Biology; Council on Cardiovascular and Stroke Nursing; Stroke Council. Cardiovascular Considerations in Caring for Pregnant Patients: A Scientific Statement From the American Heart Association. Circulation. 2020 Jun 9;141(23):e884e903. doi: 10.1161/CIR.0000000000000772
  30. Bateman BT, Heide-Jørgensen U, Einarsdóttir K, et al. β-Blocker Use in Pregnancy and the Risk for Congenital Malformations: An International Cohort Study. Ann Intern Med. 2018 Nov 20;169(10):665673. doi: 10.7326/M18–;0338
  31. Davis MB, Arany Z, McNamara DM, Goland S, Elkayam U. Peripartum Cardiomyopathy: JACC State-of-the-Art Review. J Am Coll Cardiol. 2020 Jan 21;75(2): 207221. doi: 10.1016/j.jacc.2019.11.014
  32. Easterling T, Mundle S, Bracken H, et al. Oral antihypertensive regimens (nifedipine retard, labetalol, and methyldopa) for management of severe hypertension in pregnancy: an open-label, randomised controlled trial. Lancet. 2019 Sep 21;394(10203):10111021. doi: 10.1016/S0140–;6736(19)31282–6
  33. ACC.org [Internet]. Washington, DC: American College of Cardiology; c2021. Lundberg GP, Mehta LS. Familial Hypercholesterolemia and Pregnancy; 2018 May 14 [cited 2021 Aug27]. Available from: https://www.acc.org/latest-in-cardiology/articles/2018/05/10/13/51/familial-hypercholesterolemia-and-pregnancy
  34. ACC.org [Internet]. Washington, DC: American College of Cardiology; c2021. Mukherjee M. Dyslipidemia in Pregnancy; 2014 May 19 [cited 2021 Aug 27]. Available from: https://www.acc.org/latest-in-cardiology/articles/2014/07/18/16/08/dyslipidemia-in-pregnancy.
  35. Chen Q, Chen H, Xi F, et al. Association between maternal blood lipids levels during pregnancy and risk of small-for-gestational-age infants. Sci Rep. 2020 Nov 16;10(1):19865. doi: 10.1038/s41598–;020-76845–1
  36. ACOG.org [Internet]. Washington, DC: American College of Obstetricians and Gynecologists; 2021. Christopher BA, Pagidipati NJ. Evaluation and Management of Lipid Disorders; 2019 Mar [cited 2021 Aug 27]. Available from: https://www.acog.org/clinical/journals-and-publications/clinical-updates/2019/03/evaluation-and-management-of-lipid-disorders
  37. Grundy SM, Stone NJ, Bailey AL, et al. AHA/ACC/AACVPR/AAPA/ABC/ACPM/ADA/AGS/APhA/ASPC/NLA/PCNA Guideline on the Management of Blood Cholesterol: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. Circulation. 2019 Jun 18;139(25):e1082e1143. doi: 10.1161/CIR.0000000000000625
  38. Morton S, Thangaratinam S. Statins in pregnancy. Curr Opin Obstet Gynecol. 2013 Dec;25(6):43340. doi: 10.1097/GCO.0000000000000026
  39. Goldberg AC, Hopkins PN, Toth PP, et al. Familial hypercholesterolemia: screening, diagnosis and management of pediatric and adult patients: clinical guidance from the National Lipid Association Expert Panel on Familial Hypercholesterolemia. J Clin Lipidol. 2011 Jun;5(3 Suppl):S18. doi: 10.1016/j.jacl.2011.04.003
  40. Pfaller B, Siu SC, D’Souza R, et al. Impact of Obesity on Outcomes of Pregnancy in Women With Heart Disease. J Am Coll Cardiol. 2021 Mar 16;77(10):13171326. doi: 10.1016/j.jacc.2021.01.010
  41. Saucedo M, Esteves-Pereira AP, Pencolé L, et al. Understanding maternal mortality in women with obesity and the role of care they receive: a national case-control study. Int J Obes (Lond). 2021 Jan;45(1):258265. doi: 10.1038/s41366–;020-00691–4
  42. Ely DM, Gregory ECW, Drake P. Infant Mortality by Maternal Prepregnancy Body Mass Index: United States, 2017–2018. Natl Vital Stat Rep. 2020 Aug;69(9):111. PMID: 22054916
  43. Denison F, Aedla N, Keag O, et al. Care of Women with Obesity in Pregnancy: Green-top Guideline No. 72. BJOG. 2019 Feb;126(3):e62e106. doi: 10.1111/1471–;0528.15386
  44. Artal R. The role of exercise in reducing the risks of gestational diabetes mellitus in obese women. Best Pract Res Clin Obstet Gynaecol. 2015 Jan;29(1):12332. doi: 10.1016/j.bpobgyn.2014.05.013
  45. ACOG.org [Internet]. Washington, DC: American College of Obstetricians and Gynecologists; 2021. Birsner ML, Gyamfi-Bannerman C. Physical Activity and Exercise During Pregnancy and the Postpartum Period; 2020 Apr [cited 2021 Aug 27]. Available from: https://www.acog.org/clinical/clinical-guidance/committee-opinion/articles/2020/04/physical-activity-and-exercise-during-pregnancy-and-the-postpartum-period
  46. Berghella V, Saccone G. Exercise in pregnancy! Am J Obstet Gynecol. 2017 Apr;216(4):335337. doi: 10.1016/j.ajog.2017.01.023
  47. Health.gov [Internet]. Washington, DC: US Department of Health and Human Services; c 2021. Physical Activity Guidelines for Americans: 2nd edition; 2019 Sep [cited 2021 Aug 27]. Available from: https://health.gov/sites/default/files/2019–09/Physical_Activity_Guidelines_2nd_edition.pdf
  48. ACOG.org [Internet]. Washington, DC: American College of Obstetricians and Gynecologists; 2021. Valent AM, Choby B. Tobacco and Nicotine Cessation During Pregnancy; 2020 May [cited 2021 Aug 27]. Available from: https://www.acog.org/clinical/clinical-guidance/committee-opinion/articles/2020/05/tobacco-and-nicotine-cessation-during-pregnancy
  49. Pineles BL, Park E, Samet JM. Systematic review and meta-analysis of miscarriage and maternal exposure to tobacco smoke during pregnancy. Am J Epidemiol. 2014 Apr 1;179(7):80723. doi: 10.1093/aje/kwv301
  50. Pineles BL, Hsu S, Park E, Samet JM. Systematic Review and Meta-Analyses of Perinatal Death and Maternal Exposure to Tobacco Smoke During Pregnancy. Am J Epidemiol. 2016 Jul 15;184(2):8797. doi: 10.1093/aje/kwv301
  51. Maessen SE, Ahlsson F, Lundgren M, Cutfield WS, Derraik JGB. Maternal smoking early in pregnancy is associated with increased risk of short stature and obesity in adult daughters. Sci Rep. 2019 Mar 12;9(1):4290. doi: 10.1038/s41598–;019-39006–7
  52. US Preventive Services Task Force [Internet]. Rockville, MD: US Preventive Services Task Force; c2021. Tobacco Smoking Cessation in Adults, Including Pregnant Persons: Intervention; 2021 Jan 19 [cited 2021 Aug 27]; Available from: https://www.uspreventiveservicestaskforce.org/uspstf/recommendation/tobacco-use-in-adults-and-pregnant-women-counseling-and-interventions#fullrecommendationstart
  53. Parretti E, Lapolla A, Dalfrà MG, et al. Preeclampsia in lean normotensive normotolerant pregnant women can be predicted by simple insulin sensitivity indexes. Hypertension. 2006 Mar;47(3):44953. doi: 10.1161/01.HYP.0000205122.47333.7f
  54. Peng TY, Ehrlich SF, Crites Y, et al. Trends and racial and ethnic disparities in the prevalence of pregestational type 1 and type 2 diabetes in Northern California: 1996–2014. Am J Obstet Gynecol. 2017 Feb;216(2):177.e1177.e8. doi: 10.1016/j.ajog.2016.10.007
  55. ACOG.org [Internet]. Washington, DC: American College of Obstetricians and Gynecologists; 2021. Pregestational Diabetes Mellitus; 2018 Dec [cited 2021 Aug 27]. Available from: https://www.acog.org/clinical/clinical-guidance/practice-bulletin/articles/2018/12/pregestational-diabetes-mellitus
  56. Bentley-Lewis R, Powe C, Ankers E, Wenger J, Ecker J, Thadhani R. Effect of race/ethnicity on hypertension risk subsequent to gestational diabetes mellitus. Am J Cardiol. 2014 Apr 15;113(8):136470. doi: 10.1016/j.amjcard.2014.01.411
  57. Phipps EA, Thadhani R, Benzing T, Karumanchi SA. Pre-eclampsia: pathogenesis, novel diagnostics and therapies. Nat Rev Nephrol. 2019 May;15(5):275289. doi: 10.1038/s41581–;019-0119–6
  58. James AH, Jamison MG, Biswas MS, Brancazio LR, Swamy GK, Myers ER. Acute myocardial infarction in pregnancy: a United States population-based study. Circulation. 2006 Mar 28;113(12):156471. doi: 10.1161/CIRCULATIONAHA.105.576751
  59. American Diabetes Association. Management of Diabetes in Pregnancy: Standards of Medical Care in Diabetes- 2018. Diabetes Care. 2018 Jan;41(Suppl 1):S137S143. doi: 10.2337/dc18-S013
  60. Duley L, Meher S, Hunter KE, Seidler AL, Askie LM. Antiplatelet agents for preventing pre-eclampsia and its complications. Cochrane Database Syst Rev. 2019 Oct 30;2019(10):CD004659. doi: 10.1002/14651858.CD004659.pub3
  61. LeFevre ML. Low-dose aspirin use for the prevention of morbidity and mortality from preeclampsia: U.S. Preventive Services Task Force recommendation statement. Ann Intern Med. 2014 Dec 2;161(11):81926. doi: 10.7326/M14–;1884
  62. Ma’ayeh M, Rood KM, Kniss D, Costantine MM. Novel Interventions for the Prevention of Preeclampsia. Curr Hypertens Rep. 2020 Feb 12;22(2):17. doi: 10.1007/s11906–;020-1026–8
  63. ClinicalTrials.gov [Internet]. Bethesda, MD: US National Library of Medicine; c 2021. Indonesia Pravastatin to Prevent Preeclampsia Study (INOVASIA); 2018 Aug 28 [cited 2021 Aug 27]. Available from: https://clinicaltrials.gov/ct2/show/NCT03648970
  64. ClinicalTrials.gov [Internet]. Bethesda, MD: US National Library of Medicine; c 2021. Pravastatin for Prevention of Preeclampsia (Statin); 2020 Oct 27 [cited 2021 Aug 27]. Available from: https://clinicaltrials.gov/ct2/show/NCT01717586
  65. Seely EW, Celi AC, Chausmer J, et al. Cardiovascular Health After Preeclampsia: Patient and Provider Perspective. J Womens Health (Larchmt). 2021 Mar;30(3):305313. doi: 10.1089/jwh.2020.8384
  66. Wu P, Haththotuwa R, Kwok CS, et al. Preeclampsia and Future Cardiovascular Health: A Systematic Review and Meta-Analysis. Circ Cardiovasc Qual Outcomes. 2017 Feb;10(2):e003497. doi: 10.1161/CIRCOUTCOMES.116.003497
  67. Benschop L, Duvekot JJ, Roeters Van Lennep JE. Future risk of cardiovascular disease risk factors and events in women after a hypertensive disorder of pregnancy. Heart. 2019 Aug;105(16):12731278. doi: 10.1136/heartjnl-2018–;313453
  68. Hall PS, Nah G, Vittinghoff E, et al. Relation of Pregnancy Loss to Risk of Cardiovascular Disease in Parous Postmenopausal Women (From the Women’s Health Initiative). Am J Cardiol. 2019 May 15;123(10):16201625. doi: 10.1016/j.amjcard.2019.02.012
  69. Arnett DK, Blumenthal RS, Albert MA, et al. 2019 ACC/AHA Guideline on the Primary Prevention of Cardiovascular Disease: Executive Summary: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. J Am Coll Cardiol. 2019 Sep 10;74(10):13761414. doi: 10.1016/j.jacc.2019.03.009
  70. Kjerulff LE, Sanchez-Ramos L, Duffy D. Pregnancy outcomes in women with polycystic ovary syndrome: a metaanalysis. Am J Obstet Gynecol. 2011 Jun;204(6):558.e16. doi: 10.1016/j.ajog.2011.03.021
  71. Carmina E, Lobo RA. Is There Really Increased Cardiovascular Morbidity in Women with Polycystic Ovary Syndrome? J Womens Health (Larchmt). 2018 Nov;27(11):13851388. doi: 10.1089/jwh.2018.7162
  72. Osibogun O, Ogunmoroti O, Michos ED. Polycystic ovary syndrome and cardiometabolic risk: Opportunities for cardiovascular disease prevention. Trends Cardiovasc Med. 2020 Oct;30(7):399404. doi: 10.1016/j.tcm.2019.08.010
  73. Guzick DS. Cardiovascular Risk in PCOS. J Clin Endocrinol Metab. 2004 Aug;89(8):36945. doi: 10.1210/jc.2004–;1136
  74. ACOG.org [Internet]. Washington, DC: American College of Obstetricians and Gynecologists; 2021. Hoeger K, Vitek W. Polycystic Ovary Syndrome; 2016 Jul [cited 2021 Aug 27]. Available from: https://www.acog.org/clinical/journals-and-publications/clinical-updates/2016/07/polycystic-ovary-syndrome
  75. Mehta JL, Mcsweeney J, editors. Gender Differences in the Pathogenesis and Management of Heart Disease. Switzerland: Springer International Publishing; 2018. 359. doi: 10.1007/978–;3-319–71135-5
  76. Oliver-Williams C, Vassard D, Pinborg A, Schmidt L. Risk of cardiovascular disease for women with polycystic ovary syndrome: results from a national Danish registry cohort study. Eur J Prev Cardiol. 2020 Aug 2;2047487320939674. doi: 10.1177/2047487320939674
  77. Muka T, Oliver-Williams C, Kunutsor S, et al. Association of Age at Onset of Menopause and Time Since Onset of Menopause With Cardiovascular Outcomes, Intermediate Vascular Traits, and All-Cause Mortality: A Systematic Review and Meta-analysis. JAMA Cardiol. 2016 Oct 1;1(7):767776. doi: 10.1001/jamacardio.2016.2415
  78. ACOG.org [Internet]. Washington, DC: American College of Obstetricians and Gynecologists; 2021. Primary Ovarian Insufficiency in Adolescents and Young Women; 2014 Jul [cited 2021 Aug 27]. Available from: https://www.acog.org/clinical/clinical-guidance/committee-opinion/articles/2014/07/primary-ovarian-insufficiency-in-adolescents-and-young-women
  79. Honigberg MC, Zekavat SM, Aragam K, et al. Association of Premature Natural and Surgical Menopause With Incident Cardiovascular Disease. JAMA. 2019 Dec 24;322(24):24112421. doi: 10.1001/jama.2019.19191
  80. Zhu D, Chung HF, Dobson AJ, et al. Age at natural menopause and risk of incident cardiovascular disease: a pooled analysis of individual patient data. Lancet Public Health. 2019 Nov;4(11):e553e564. doi: 10.1016/S2468–;2667(19)30155–0
DOI: https://doi.org/10.14797/mdcvj.696 | Journal eISSN: 1947-6108
Language: English
Page range: 48 - 59
Submitted on: Sep 1, 2021
Accepted on: Sep 1, 2021
Published on: Sep 24, 2021
Published by: Houston Methodist DeBakey Heart & Vascular Center
In partnership with: Paradigm Publishing Services

© 2021 Lochan M. Shah, Alison Wand, Wendy Ying, Allison G. Hays, Roger S. Blumenthal, Lili A. Barouch, Sammy Zakaria, Garima Sharma, published by Houston Methodist DeBakey Heart & Vascular Center
This work is licensed under the Creative Commons Attribution-NonCommercial 4.0 License.