Renal function is greatly important in risk stratification, pharmacologic therapy, and the prognosis of patients with heart failure (HF).
The deterioration of heart function can result in the worsening renal function (WRF) and vice versa.
Besides the heart function itself, the Pharmacologic Treatment of HF is closely related to renal function as regards initiation, titration, and discontinuation, making the situation more complex.
A case study on essential dosage adjustment in chronic renal insufficiencySriramNagarajan16
Renal disease alters the effects of many drugs. Drug doses of certain drugs have to be appropriately adjusted depending upon
the degree of renal impairment. Drug dosing errors in patients with renal impairment are common and can lead to
accumulation and toxicity leading to adverse effects and poor outcomes. A case of a 72 years old male patient with chronic
renal failure with other co morbid disease states like systemic hypertension, diabetes mellitus, osteoporosis and peripheral
artery disease has been discussed. Laboratory data revealed both elevated serum creatinine and urea levels. On the day of
admission the patient was in end stage renal disease as his calculated GFR was 12ml/min. Modified Diet for Renal Disease
equation was used to calculate the GFR and dose adjustments were made accordingly. Drugs prescribed to the patients
included ceftriaxone 1 g, Pentoxifylline 400 mg, Tapendadol 50 mg, Levocarnitine 500 mg, Alprazolam 0.5 mg, Alpha
calcidiol 0.25 mg, Atorvastatin 20 mg, Cilostazol 50 mg, Tramadol 50 mg, Esomeprazole 40mg, Calcium 250 mg, A
systematic medication chart review revealed that pentoxyfylline is the drug of choice with altered dosing recommendations in
this patient. Therapeutic duplication in the form of using pentoxyfylline and cilostazole to treat peripheral vascular disease
was also noted. Alprazolam was started at a higher dose for the geriatric patient.
A case study on essential dosage adjustment in chronic renal insufficiencySriramNagarajan16
Renal disease alters the effects of many drugs. Drug doses of certain drugs have to be appropriately adjusted depending upon
the degree of renal impairment. Drug dosing errors in patients with renal impairment are common and can lead to
accumulation and toxicity leading to adverse effects and poor outcomes. A case of a 72 years old male patient with chronic
renal failure with other co morbid disease states like systemic hypertension, diabetes mellitus, osteoporosis and peripheral
artery disease has been discussed. Laboratory data revealed both elevated serum creatinine and urea levels. On the day of
admission the patient was in end stage renal disease as his calculated GFR was 12ml/min. Modified Diet for Renal Disease
equation was used to calculate the GFR and dose adjustments were made accordingly. Drugs prescribed to the patients
included ceftriaxone 1 g, Pentoxifylline 400 mg, Tapendadol 50 mg, Levocarnitine 500 mg, Alprazolam 0.5 mg, Alpha
calcidiol 0.25 mg, Atorvastatin 20 mg, Cilostazol 50 mg, Tramadol 50 mg, Esomeprazole 40mg, Calcium 250 mg, A
systematic medication chart review revealed that pentoxyfylline is the drug of choice with altered dosing recommendations in
this patient. Therapeutic duplication in the form of using pentoxyfylline and cilostazole to treat peripheral vascular disease
was also noted. Alprazolam was started at a higher dose for the geriatric patient.
download link : https://www.dropbox.com/s/a8ug16pfkvv1bzp/Cardiorenal%20syndrome.ppt?m
Join us on our facebook group: NephroTube...............Follow our blog: www.nephrotube.blogspot.com
Updated Hypertension Management – ESH 2023.pdfDr. Nayan Ray
Hypertension is the most prevalent CV disorder in the world and according to the WHO, it affects 1.28 billion adults aged 30–79 years worldwide, two-thirds living in low-income and middle-income countries.
In 2019, the global age-standardized average prevalence of hypertension in adults aged 30–79 years was reported to be 34% in men and 32% in women.
At younger ages (<50 years), hypertension is more prevalent in men, whereas a steeper increase of SBP in women from their third decade (and more so following menopause) makes the prevalence of hypertension greater in women in older age categories (>65 years).
Rule of Halves
Half the people with high blood pressure are not known (“rule 1”),
Half of those known are not treated (“rule 2”) and
Half of those treated are not controlled (“rule 3”)'
Definition:
Hypertension is defined based on repeated office SBP values ≥ 140 mmHg and/or DBP ≥ 90 mmHg.
Cardiac arrest is the cessation of functional cardiac contraction and is the final common pathway in death from any pathology.
In the clinical context, cardiac arrest refers to the sudden loss of cardiac output that prompts an emergency response.
Pathogenesis, prognosis and management of in-hospital and out-of-hospital cardiac arrest are subtly different; however, the basic principles of cardiopulmonary resuscitation (CPR) are to maintain forward flow of oxygenated blood, correct the causative factor and restore spontaneous circulation.
download link : https://www.dropbox.com/s/a8ug16pfkvv1bzp/Cardiorenal%20syndrome.ppt?m
Join us on our facebook group: NephroTube...............Follow our blog: www.nephrotube.blogspot.com
Updated Hypertension Management – ESH 2023.pdfDr. Nayan Ray
Hypertension is the most prevalent CV disorder in the world and according to the WHO, it affects 1.28 billion adults aged 30–79 years worldwide, two-thirds living in low-income and middle-income countries.
In 2019, the global age-standardized average prevalence of hypertension in adults aged 30–79 years was reported to be 34% in men and 32% in women.
At younger ages (<50 years), hypertension is more prevalent in men, whereas a steeper increase of SBP in women from their third decade (and more so following menopause) makes the prevalence of hypertension greater in women in older age categories (>65 years).
Rule of Halves
Half the people with high blood pressure are not known (“rule 1”),
Half of those known are not treated (“rule 2”) and
Half of those treated are not controlled (“rule 3”)'
Definition:
Hypertension is defined based on repeated office SBP values ≥ 140 mmHg and/or DBP ≥ 90 mmHg.
Cardiac arrest is the cessation of functional cardiac contraction and is the final common pathway in death from any pathology.
In the clinical context, cardiac arrest refers to the sudden loss of cardiac output that prompts an emergency response.
Pathogenesis, prognosis and management of in-hospital and out-of-hospital cardiac arrest are subtly different; however, the basic principles of cardiopulmonary resuscitation (CPR) are to maintain forward flow of oxygenated blood, correct the causative factor and restore spontaneous circulation.
CVD Risk Managemnt- Focus on HTN & Dys.pdfDr. Nayan Ray
Cardiovascular disease is a major cause of disability and premature death throughout the world and contributes substantially to the escalating costs of health care.
The underlying pathology is atherosclerosis, which develops over many years and is usually advanced by the time symptoms occur, generally in middle age.
Acute coronary and cerebrovascular events frequently occur suddenly and are often fatal before medical care can be given.
Modification of risk factors has been shown to reduce mortality and morbidity in people with diagnosed or undiagnosed cardiovascular disease.
In patients with coronary artery disease (CAD), percutaneous coronary interventions (PCI) are the cornerstone of treatment for those presenting with an acute coronary syndrome (ACS); PCI has also been largely adopted in patients with chronic coronary syndromes (CCS).
Adjunctive pharmacotherapy, in particular antithrombotic therapy, has a pivotal role in optimising outcomes in patients undergoing PCI23. In fact, patients undergoing PCI may develop both acute and long-term ischaemic events.
Therefore, antithrombotic drugs, in particular antiplatelet agents, are key to the treatment and prevention of both local and systemic thrombotic complications.
Coronary Revascularization in Chronic Kidney Disease Patient.pptxDr. Nayan Ray
Chronic kidney disease (CKD) is an independent risk factor for the development of coronary artery disease, and for more severe coronary heart disease (CHD).
CKD is also associated with adverse outcomes in those with existing cardiovascular disease.
This includes increased mortality after an acute coronary syndrome, after percutaneous coronary intervention (PCI) with or without stenting, and after coronary artery bypass. In addition, patients with CKD are more likely to present with atypical symptoms, which may delay diagnosis and adversely affect outcomes.
Having more than two year experiences, presently anticoagulant is an essential component of management of COVID 19
Its role is recommended in moderate to severe to critically ill patients with different opinion in the dosage
Giving anticoagulants in asymptomatic or mild cases is still need to be validated though there are suggestions in favor.
There is recommendation for post discharge patients who had clinically suspected/established thromboembolism events
Dyslipidemia in Chronic Kidney Diseases.pdfDr. Nayan Ray
Dyslipidaemia in Chronic Kidney Disease: An Approach to Pathogenesis and Treatment
Slides Include:
1. Stages of CKD
2. Developments of atherogenesis
3. Lipoprotein in CKD
4. Drug Therapies
5.Summary KDIGO Guideline
Management of HTN according to gender. This slides will answer some questions such as
1. Why there is BP variability difference between male and female?
2. What's the regulatory mechanism of HTN in gender?
Flu Vaccine Alert in Bangalore Karnatakaaddon Scans
As flu season approaches, health officials in Bangalore, Karnataka, are urging residents to get their flu vaccinations. The seasonal flu, while common, can lead to severe health complications, particularly for vulnerable populations such as young children, the elderly, and those with underlying health conditions.
Dr. Vidisha Kumari, a leading epidemiologist in Bangalore, emphasizes the importance of getting vaccinated. "The flu vaccine is our best defense against the influenza virus. It not only protects individuals but also helps prevent the spread of the virus in our communities," he says.
This year, the flu season is expected to coincide with a potential increase in other respiratory illnesses. The Karnataka Health Department has launched an awareness campaign highlighting the significance of flu vaccinations. They have set up multiple vaccination centers across Bangalore, making it convenient for residents to receive their shots.
To encourage widespread vaccination, the government is also collaborating with local schools, workplaces, and community centers to facilitate vaccination drives. Special attention is being given to ensuring that the vaccine is accessible to all, including marginalized communities who may have limited access to healthcare.
Residents are reminded that the flu vaccine is safe and effective. Common side effects are mild and may include soreness at the injection site, mild fever, or muscle aches. These side effects are generally short-lived and far less severe than the flu itself.
Healthcare providers are also stressing the importance of continuing COVID-19 precautions. Wearing masks, practicing good hand hygiene, and maintaining social distancing are still crucial, especially in crowded places.
Protect yourself and your loved ones by getting vaccinated. Together, we can help keep Bangalore healthy and safe this flu season. For more information on vaccination centers and schedules, residents can visit the Karnataka Health Department’s official website or follow their social media pages.
Stay informed, stay safe, and get your flu shot today!
Ethanol (CH3CH2OH), or beverage alcohol, is a two-carbon alcohol
that is rapidly distributed in the body and brain. Ethanol alters many
neurochemical systems and has rewarding and addictive properties. It
is the oldest recreational drug and likely contributes to more morbidity,
mortality, and public health costs than all illicit drugs combined. The
5th edition of the Diagnostic and Statistical Manual of Mental Disorders
(DSM-5) integrates alcohol abuse and alcohol dependence into a single
disorder called alcohol use disorder (AUD), with mild, moderate,
and severe subclassifications (American Psychiatric Association, 2013).
In the DSM-5, all types of substance abuse and dependence have been
combined into a single substance use disorder (SUD) on a continuum
from mild to severe. A diagnosis of AUD requires that at least two of
the 11 DSM-5 behaviors be present within a 12-month period (mild
AUD: 2–3 criteria; moderate AUD: 4–5 criteria; severe AUD: 6–11 criteria).
The four main behavioral effects of AUD are impaired control over
drinking, negative social consequences, risky use, and altered physiological
effects (tolerance, withdrawal). This chapter presents an overview
of the prevalence and harmful consequences of AUD in the U.S.,
the systemic nature of the disease, neurocircuitry and stages of AUD,
comorbidities, fetal alcohol spectrum disorders, genetic risk factors, and
pharmacotherapies for AUD.
Explore natural remedies for syphilis treatment in Singapore. Discover alternative therapies, herbal remedies, and lifestyle changes that may complement conventional treatments. Learn about holistic approaches to managing syphilis symptoms and supporting overall health.
Lung Cancer: Artificial Intelligence, Synergetics, Complex System Analysis, S...Oleg Kshivets
RESULTS: Overall life span (LS) was 2252.1±1742.5 days and cumulative 5-year survival (5YS) reached 73.2%, 10 years – 64.8%, 20 years – 42.5%. 513 LCP lived more than 5 years (LS=3124.6±1525.6 days), 148 LCP – more than 10 years (LS=5054.4±1504.1 days).199 LCP died because of LC (LS=562.7±374.5 days). 5YS of LCP after bi/lobectomies was significantly superior in comparison with LCP after pneumonectomies (78.1% vs.63.7%, P=0.00001 by log-rank test). AT significantly improved 5YS (66.3% vs. 34.8%) (P=0.00000 by log-rank test) only for LCP with N1-2. Cox modeling displayed that 5YS of LCP significantly depended on: phase transition (PT) early-invasive LC in terms of synergetics, PT N0—N12, cell ratio factors (ratio between cancer cells- CC and blood cells subpopulations), G1-3, histology, glucose, AT, blood cell circuit, prothrombin index, heparin tolerance, recalcification time (P=0.000-0.038). Neural networks, genetic algorithm selection and bootstrap simulation revealed relationships between 5YS and PT early-invasive LC (rank=1), PT N0—N12 (rank=2), thrombocytes/CC (3), erythrocytes/CC (4), eosinophils/CC (5), healthy cells/CC (6), lymphocytes/CC (7), segmented neutrophils/CC (8), stick neutrophils/CC (9), monocytes/CC (10); leucocytes/CC (11). Correct prediction of 5YS was 100% by neural networks computing (area under ROC curve=1.0; error=0.0).
CONCLUSIONS: 5YS of LCP after radical procedures significantly depended on: 1) PT early-invasive cancer; 2) PT N0--N12; 3) cell ratio factors; 4) blood cell circuit; 5) biochemical factors; 6) hemostasis system; 7) AT; 8) LC characteristics; 9) LC cell dynamics; 10) surgery type: lobectomy/pneumonectomy; 11) anthropometric data. Optimal diagnosis and treatment strategies for LC are: 1) screening and early detection of LC; 2) availability of experienced thoracic surgeons because of complexity of radical procedures; 3) aggressive en block surgery and adequate lymph node dissection for completeness; 4) precise prediction; 5) adjuvant chemoimmunoradiotherapy for LCP with unfavorable prognosis.
Ozempic: Preoperative Management of Patients on GLP-1 Receptor Agonists Saeid Safari
Preoperative Management of Patients on GLP-1 Receptor Agonists like Ozempic and Semiglutide
ASA GUIDELINE
NYSORA Guideline
2 Case Reports of Gastric Ultrasound
Knee anatomy and clinical tests 2024.pdfvimalpl1234
This includes all relevant anatomy and clinical tests compiled from standard textbooks, Campbell,netter etc..It is comprehensive and best suited for orthopaedicians and orthopaedic residents.
NVBDCP.pptx Nation vector borne disease control programSapna Thakur
NVBDCP was launched in 2003-2004 . Vector-Borne Disease: Disease that results from an infection transmitted to humans and other animals by blood-feeding arthropods, such as mosquitoes, ticks, and fleas. Examples of vector-borne diseases include Dengue fever, West Nile Virus, Lyme disease, and malaria.
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Ve...kevinkariuki227
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Verified Chapters 1 - 19, Complete Newest Version.pdf
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Verified Chapters 1 - 19, Complete Newest Version.pdf
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Ve...
Renal Responses to HF Medication.pdf
1. Renal Responses to HF
Medication- How to Treat
Dr. Nayan Ray
MBBS
Mymensingh Medical College and Hospital
2. Introduction
• Renal function is greatly important in risk stratification,
pharmacologic therapy, and the prognosis of patients with heart
failure (HF).
• The deterioration of heart function can result in the worsening renal
function (WRF) and vice versa.
• Besides the heart function itself, the Pharmacologic Treatment of HF
is closely related to renal function as regards initiation, titration, and
discontinuation, making the situation more complex.
Int J Heart Fail. 2022 Apr;4(2):75-9 https://doi.org/10.36628/ijhf.2021.0039 pISSN 2636-154X·eISSN 2636-1558
NYN/DMA/BPL
3. Assessment of renal function
• Renal function evaluation helps
(i) to better understand the underlying cardio-renal physiology,
(ii) to improve initiation, adaptation or continuation of evidence-based heart
failure therapies,
(iii) to stratify patients at risk of adverse outcome, and
(iv) to identify the presence of systemic diseases or the coexistence of
independent renal disease.
European Journal of Heart Failure (2020) 22, 584–603 doi:10.1002/ejhf.1697
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4. Definition of changes in renal function in heart failure
European Journal of Heart Failure (2020) 22, 584–603 doi:10.1002/ejhf.1697
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5. Overview of laboratory and urinary renal biomarkers in heart failure
European Journal of Heart Failure (2020) 22, 584–603 doi:10.1002/ejhf.1697
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6. Distribution of estimated glomerular filtration rate (eGFR)
among 1216 patients with chronic stable heart failure.
Eur Heart J 2006;27:569–81
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7. Relationship between change in eGFR during hospitalisation and subsequent 60-day
hazard for adverse events
J Card Fail 2016;22:753–760. DOSE,
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8. Main factors influencing glomerular filtration rate (GFR) in patients with chronic heart failure
Archives of Cardiovascular Disease (2020) 113, 660—670
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9. Grading of CKD definitions based on baseline eGFR (KDIGO CKD definition)
European Journal of Heart Failure (2016) 18, 1508–1517 doi:10.1002/ejhf.609
NYN/DMA/BPL
10. Worsening Renal Function
Defined as ≥26.5μmol/L and ≥25% increase in
serum creatinine from baseline to 6 weeks
European Journal of Heart Failure (2016) 18, 1508–1517 doi:10.1002/ejhf.609
NYN/DMA/BPL
11. Relationship between heart failure and renal failure
The bidirectional link between cardiac and renal function can lead to
clinical presentations that are termed cardio-renal syndrome (CRS)
There are five types of CRS
• Type 1: Acute heart failure causes acute kidney injury (AKI)
• Type 2: Chronic heart failure causes CKD
• Type 3: AKI or acute renal failure causes acute cardiac failure
• Type 4: CKD causes chronic cardiac dysfunction, including heart failure
• Type 5: An acute or chronic systemic disorder causes both cardiac and
renal failure (e.g. sepsis, diabetes mellitus, systemic lupus erythematosus)
Br J Clin Pharmacol (2018) 84 5–17
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15. Characteristics of All Studies Reporting Sex-Specific Adverse Drug Reaction Data per Drug Class
J A C C : H E A R T F A I L U R E V O L . 7 , N O . 3 , 2 0 1 9
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16. Changes in kidney function after
initiation of drug treatment
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17. A decline in renal function is commonly seen in patients when they
start an ACEI, ARB or sacubitril/valsartan and is usually modest.
► A fall in eGFR (and rise in creatinine) is very common after initiation
of RAAS inhibitors but usually stabilises.
► A progressive fall in GFR on RAAS inhibition suggests primary renal
disease, including extrarenal and intrarenal vascular disease.
► For patients with HFrEF, the benefit of RAAS inhibitors is greater in
patients with worsening renal function during RAAS inhibition despite
their worse prognosis relative to those with no decline
► A moderate, asymptomatic decline in renal function is not an
indication to stop RAAS inhibitors.
Clark AL, Kalra PR, Petrie MC, et al. Heart 2019;105:904–910.
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18. Clark AL, Kalra PR, Petrie MC, et al. Heart 2019;105:904–910.
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20. Changes in kidney function during intercurrent illness
• Regardless of whether patients are treated with RAAS inhibitors,
changes in renal function are common during acute intercurrent
illness; the incidence of AKI is between 7% and 18% of hospitalised
patients.
• AKI is a powerful risk marker for poor outcome and is strongly
associated with an increase in the risk of subsequent admission for
heart failure.
• Renal function often does not to return to baseline level in survivors
of AKI, especially in those with pre-existing CKD.
Clark AL, Kalra PR, Petrie MC, et al. Heart 2019;105:904–910.
NYN/DMA/BPL
21. • In patients on a RAAS inhibitor, intercurrent illness commonly causes
AKI, but there is no evidence that stopping the RAAS inhibitor is
beneficial.
► If a patient with HFrEF develops hyperkalaemia
– Potassium ≥5.5 mmol/L, monitor closely, medication review and consider
suspending RAAS inhibitor(s).
– Potassium ≥6.0 mmol/L, stop RAAS inhibitor(s).
Clark AL, Kalra PR, Petrie MC, et al. Heart 2019;105:904–910.
NYN/DMA/BPL
22. ► If the patient with HFrEF has a rise in creatinine during intercurrent
illness:
– By less than 30%, continue RAAS inhibitor(s) but monitor closely.
– Stop any other medication that may worsen renal function, including diuretic
if clinically appropriate.
– If by ≥30%, RAAS inhibitor(s) should be stopped.
Clark AL, Kalra PR, Petrie MC, et al. Heart 2019;105:904–910.
NYN/DMA/BPL
23. Considerations when managing a patient with
heart failure who develops hyperkalaemia
Clark AL, Kalra PR, Petrie MC, et al. Heart 2019;105:904–910.
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24. Clark AL, Kalra PR, Petrie MC, et al. Heart 2019;105:904–910.
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25. Management of patients with AKI
or worsening renal function who
are receiving RAAS inhibitor
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27. End-of-life care
• When a patient with HF is approaching end of life, symptom control
overrides treatment with potential prognostic impact.
• Deteriorating renal function is common.
• Diuretics should be titrated to prevent distress from fluid overload,
irrespective of renal function.
• If there is symptomatic hypotension, discontinuation of RAAS
blockade is appropriate.
NYN/DMA/BPL
28. End-of-life care Management-
► Higher doses of diuretics than are commonly used are needed to
treat congestion in the fluid overloaded patient.
► A decline in renal function is not an indication to reduce diuretic
dose if the patient remains congested.
► Consider stopping RAAS inhibitors towards the end of life.
NYN/DMA/BPL
29. Summary
• The interaction between treatment for heart failure and decline in
renal function is frequently misunderstood and commonly used as a
reason to withhold potentially life-prolonging therapy.
• The misunderstanding is not helped by referring to RAAS inhibitors as
‘nephrotoxic’ drugs, which they most emphatically are not.
• The combination is, of course, of vital importance to patients with
symptomatic HFrEF; however, close monitoring of renal function and
potassium is vital when using MRA and other RAAS inhibitor together.
1. National Institute for Health and Care Excellence. Acute kidney injury: prevention, detection and management.
Clinical guideline [CG169]. London, 2013.
2. Sinnott SJ, Mansfield KE, Schmidt M, et al. Biochemical monitoring after initiation of aldosterone antagonist therapy
in users of renin-angiotensin system blockers: a UK primary care cohort study. BMJ Open 2017;7:e018153
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30. • There is a danger that concerns over renal function may prevent
patients receiving medication beneficial to their longterm outcome.
• While decline in renal function is important and may require drugs to
be stopped, that should only be after very careful consideration of the
risks and benefits to the individual patient.
1. National Institute for Health and Care Excellence. Acute kidney injury: prevention, detection and management.
Clinical guideline [CG169]. London, 2013.
2. Sinnott SJ, Mansfield KE, Schmidt M, et al. Biochemical monitoring after initiation of aldosterone antagonist therapy
in users of renin-angiotensin system blockers: a UK primary care cohort study. BMJ Open 2017;7:e018153
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