Top

Current Cardiology Reports

Published in:

01-11-2018 | Hypertension (DS Geller and DL Cohen, Section Editors)

Dangers of Overly Aggressive Blood Pressure Control

Authors: Faisal Rahman, John W. McEvoy

Published in: Current Cardiology Reports | Issue 11/2018

Abstract

Purpose of Review

Recent US guidelines have changed the definition of hypertension to ≥ 130/80 mmHg and recommended more intense blood pressure (BP) targets. We summarize the evidence for intense BP treatment and discuss risks that must be considered when choosing treatment goals for individual patients.

Recent Findings

The SPRINT study reported that treating to a systolic BP target of 120 mmHg reduces cardiovascular outcomes in high-risk individuals, supporting more intensive BP reduction than previously recommended. However, recent observational studies have placed emphasis on the BP J-curve phenomenon, where low BPs are associated with adverse cardiovascular outcomes, suggesting that overly aggressive BP targets may sometimes be harmful. We attempt to reconcile these apparent contradictions for the clinician. We also review other potential dangers of aggressive BP targets, including syncope, renal impairment, polypharmacy, drug interactions, subjective drug side-effects, and non-adherence.

Summary

We suggest a personalized approach to BP drug management considering individual risks, benefits, and preferences when choosing therapeutic targets, recognizing that a goal of 130/80 mmHg should always be considered. Additionally, we recommend an intense focus on lifestyle changes and medication adherence.

Danaei G, Ding EL, Mozaffarian D, Taylor B, Rehm J, Murray CJ, et al. The preventable causes of death in the United States: comparative risk assessment of dietary, lifestyle, and metabolic risk factors. PLoS Med. 2009;6(4):e1000058.CrossRef

Forouzanfar MH, Liu P, Roth GA, Ng M, Biryukov S, Marczak L, et al. Global burden of hypertension and systolic blood pressure of at least 110 to 115 mm Hg, 1990–2015. JAMA. 2017;317(2):165–82.CrossRef

•• Group SR, Wright JT Jr, Williamson JD, Whelton PK, Snyder JK, Sink KM, et al. A Randomized trial of intensive versus standard blood-pressure control. N Engl J Med. 2015;373(22):2103–16. The largest randomized control trial supporting the benefit of aggressive systolic blood pressure control. CrossRef

Whelton PK, Carey RM, Aronow WS, Casey DE Jr, Collins KJ, Dennison Himmelfarb C, et al. 2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA Guideline for the prevention, detection, evaluation, and management of high blood pressure in adults: a report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. J Am Coll Cardiol. 2018;71(19):e127–248.CrossRef

Flack JM. Method of blood pressure measurement, interpretation of SPRINT, and the Atlantic divide. Curr Hypertens Rep. 2017;19(3):19.CrossRef

Johnson KC, Whelton PK, Cushman WC, Cutler JA, Evans GW, Snyder JK, et al. Blood Pressure measurement in SPRINT (Systolic Blood Pressure Intervention Trial). Hypertension. 2018;71(5):848–57.CrossRef

Muntner P, Carey RM, Gidding S, Jones DW, Taler SJ, Wright JT, et al. Potential US population impact of the 2017 American College of Cardiology/American Heart Association high blood pressure guideline. J Am Coll Cardiol. 2018;71(2):109–18.

Bakris G, Sorrentino M. Redefining hypertension - assessing the new blood-pressure guidelines. N Engl J Med. 2018;378(6):497–9.CrossRef

Yang JY, Chiu S, Krouss M. Overtreatment of asymptomatic hypertension—urgency is not an emergency: a teachable moment. JAMA Int Med. 2018;178(5):704–5.CrossRef

10.

Pfeffer MA, McMurray JJ. Lessons in uncertainty and humility - clinical trials involving hypertension. N Engl J Med. 2016;375(18):1756–66.CrossRef

11.

Staessen JA, Fagard R, Thijs L, Celis H, Arabidze GG, Birkenhager WH, et al. Randomised double-blind comparison of placebo and active treatment for older patients with isolated systolic hypertension. The Systolic Hypertension in Europe (Syst-Eur) Trial Investigators. Lancet. 1997;350(9080):757–64.CrossRef

12.

Beckett NS, Peters R, Fletcher AE, Staessen JA, Liu L, Dumitrascu D, et al. Treatment of hypertension in patients 80 years of age or older. N Engl J Med. 2008;358(18):1887–98.CrossRef

13.

ALLHAT Collaborative Research Group. Major cardiovascular events in hypertensive patients randomized to doxazosin vs chlorthalidone: the antihypertensive and lipid-lowering treatment to prevent heart attack trial (ALLHAT). JAMA. 2000;283(15):1967–75.

14.

Effects of treatment on morbidity in hypertension. Results in patients with diastolic blood pressures averaging 115 through 129 mm Hg. JAMA. 1967;202(11):1028–34.

15.

Effects of treatment on morbidity in hypertension. II. Results in patients with diastolic blood pressure averaging 90 through 114 mm Hg. JAMA. 1970;213(7):1143–52.

16.

Hypertension Detection and Follow-up Program Cooperative Group. Five-year findings of the hypertension detection and follow-up program. I. Reduction in mortality of persons with high blood pressure, including mild hypertension. JAMA. 1979;242(23):2562–71.

17.

Lewington S, Clarke R, Qizilbash N, Peto R, Collins R, Prospective SC. Age-specific relevance of usual blood pressure to vascular mortality: a meta-analysis of individual data for one million adults in 61 prospective studies. Lancet. 2002;360(9349):1903–13.CrossRef

18.

Huang Y, Wang S, Cai X, Mai W, Hu Y, Tang H, et al. Prehypertension and incidence of cardiovascular disease: a meta-analysis. BMC Med. 2013;11:177.CrossRef

19.

•• Thomopoulos C, Parati G, Zanchetti A. Effects of blood pressure lowering on outcome incidence in hypertension: 2. Effects at different baseline and achieved blood pressure levels--overview and meta-analyses of randomized trials. J Hypertens. 2014;32(12):2296–304. Meta-analysis using randomized control trial data to compare systolic blood pressure < 130 mmHg to > 130 mmHg. CrossRef

20.

Turnbull F, Blood Pressure Lowering Treatment Trialists C. Effects of different blood-pressure-lowering regimens on major cardiovascular events: results of prospectively-designed overviews of randomised trials. Lancet. 2003;362(9395):1527–35.CrossRef

21.

Thomopoulos C, Parati G, Zanchetti A. Effects of blood-pressure-lowering treatment on outcome incidence. 12. Effects in individuals with high-normal and normal blood pressure: overview and meta-analyses of randomized trials. J Hypertens. 2017;35(11):2150–60.CrossRef

22.

Bundy JD, Li C, Stuchlik P, Bu X, Kelly TN, Mills KT, et al. Systolic blood pressure reduction and risk of cardiovascular disease and mortality: a systematic review and network meta-analysis. JAMA Cardiol. 2017;2(7):775–81.CrossRef

23.

Brunstrom M, Carlberg B. Association of blood pressure lowering with mortality and cardiovascular disease across blood pressure levels: a systematic review and meta-analysis. JAMA Intern Med. 2018;178(1):28–36.CrossRef

24.

Davis EM, Appel LJ, Wang X, Greene T, Astor BC, Rahman M, et al. Limitations of analyses based on achieved blood pressure: lessons from the African American study of kidney disease and hypertension trial. Hypertension. 2011;57(6):1061–8.CrossRef

25.

Ceral J, Habrdova V, Vorisek V, Bima M, Pelouch R, Solar M. Difficult-to-control arterial hypertension or uncooperative patients? The assessment of serum antihypertensive drug levels to differentiate non-responsiveness from non-adherence to recommended therapy. Hypertens Res. 2011;34(1):87–90.CrossRef

26.

Strauch B, Petrak O, Zelinka T, Rosa J, Somloova Z, Indra T, et al. Precise assessment of noncompliance with the antihypertensive therapy in patients with resistant hypertension using toxicological serum analysis. J Hypertens. 2013;31(12):2455–61.CrossRef

27.

Tomaszewski M, White C, Patel P, Masca N, Damani R, Hepworth J, et al. High rates of non-adherence to antihypertensive treatment revealed by high-performance liquid chromatography-tandem mass spectrometry (HP LC-MS/MS) urine analysis. Heart. 2014;100(11):855–61.CrossRef

28.

Shapiro BP, Ambrosius WT, Blackshear JL, Cushman WC, Whelton PK, Oparil S, et al. Impact of intensive versus standard blood pressure management by tertiles of blood pressure in SPRINT (Systolic Blood Pressure Intervention Trial). Hypertension. 2018;71(6):1064–74.CrossRef

29.

Williamson JD, Supiano MA, Applegate WB, Berlowitz DR, Campbell RC, Chertow GM, et al. Intensive vs standard blood pressure control and cardiovascular disease Outcomes in adults aged >/=75 Years: a randomized clinical trial. JAMA. 2016;315(24):2673–82.CrossRef

30.

Abell JG, Kivimäki M, Dugravot A, Tabak AG, Fayosse A, Shipley M et al. Association between systolic blood pressure and dementia in the Whitehall II cohort study: role of age, duration, and threshold used to define hypertension. Eur Heart J. 2018;39(33):3119–25.CrossRef

31.

McEvoy JW, Chen Y, Rawlings A, Hoogeveen RC, Ballantyne CM, Blumenthal RS, et al. Diastolic blood pressure, subclinical myocardial damage, and cardiac events: implications for blood pressure control. J Am Coll Cardiol. 2016;68(16):1713–22.CrossRef

32.

Beddhu S, Chertow GM, Cheung AK, Cushman WC, Rahman M, Greene T, et al. Influence of baseline diastolic blood pressure on effects of intensive compared with standard blood pressure control. Circulation. 2018;137(2):134–43.CrossRef

33.

• Group AS, Cushman WC, Evans GW, Byington RP, Goff DC Jr, Grimm RH Jr, et al. Effects of intensive blood-pressure control in type 2 diabetes mellitus. N Engl J Med. 2010;362(17):1575–85. ACCORD is a large trial of BP control among diabetics which, while technically negative, provides tacit support to the findings of SPRINT. CrossRef

34.

• Perkovic V, Rodgers A. Redefining Blood-Pressure Targets--SPRINT Starts the Marathon. N Engl J Med. 2015;373(22):2175–8. Pooled analysis of the SPRINT and ACCORD trials showing benefit for aggressive systolic blood pressure control. CrossRef

35.

•• Lonn EM, Bosch J, Lopez-Jaramillo P, Zhu J, Liu L, Pais P, et al. Blood-pressure lowering in intermediate-risk persons without cardiovascular disease. N Engl J Med. 2016;374(21):2009–20. Randomized control trial consistent with the suggestion that benefits of intensive blood pressure control maybe related to patient specific risk. CrossRef

36.

Blood Pressure Lowering Treatment Trialists C, Sundstrom J, Arima H, Woodward M, Jackson R, Karmali K, et al. Blood pressure-lowering treatment based on cardiovascular risk: a meta-analysis of individual patient data. Lancet. 2014;384(9943):591–8.CrossRef

37.

Ikonomidis I, Makavos G, Lekakis J. Arterial stiffness and coronary artery disease. Curr Opin Cardiol. 2015;30(4):422–31.PubMed

38.

Lucas SJ, Tzeng YC, Galvin SD, Thomas KN, Ogoh S, Ainslie PN. Influence of changes in blood pressure on cerebral perfusion and oxygenation. Hypertension. 2010;55(3):698–705.CrossRef

39.

Hansson L, Zanchetti A, Carruthers SG, Dahlof B, Elmfeldt D, Julius S, et al. Effects of intensive blood-pressure lowering and low-dose aspirin in patients with hypertension: principal results of the Hypertension Optimal Treatment (HOT) randomised trial. HOT Study Group. Lancet. 1998;351(9118):1755–62.

40.

Rabkin SW, Waheed A, Poulter RS, Wood D. Myocardial perfusion pressure in patients with hypertension and coronary artery disease: implications for DBP targets in hypertension management. J Hypertens. 2013;31(5):975–82.CrossRef

41.

•• Farnett L, Mulrow CD, Linn WD, Lucey CR, Tuley MR. The J-curve phenomenon and the treatment of hypertension. Is there a point beyond which pressure reduction is dangerous? JAMA. 1991;265(4):489–95. Landmark document on the BP J-curve phenomenon. CrossRef

42.

•• Vidal-Petiot E, Ford I, Greenlaw N, Ferrari R, Fox KM, Tardif JC, et al. Cardiovascular event rates and mortality according to achieved systolic and diastolic blood pressure in patients with stable coronary artery disease: an international cohort study. Lancet. 2016;388(10056):2142–52. A large observational study demonstrating the systolic and diastolic blood pressure J-curve phenomenon where low and high blood pressures are associated with increased cardiovascular events. CrossRef

43.

Cruickshank JM. Antihypertensive treatment and the J-curve. Cardiovasc Drugs Ther. 2000;14(4):373–9.CrossRef

44.

Pepine CJ, Handberg EM, Cooper-DeHoff RM, Marks RG, Kowey P, Messerli FH, et al. A calcium antagonist vs a non-calcium antagonist hypertension treatment strategy for patients with coronary artery disease. The International Verapamil-Trandolapril Study (INVEST): a randomized controlled trial. JAMA. 2003;290(21):2805–16.CrossRef

45.

• Messerli FH, Mancia G, Conti CR, Hewkin AC, Kupfer S, Champion A, et al. Dogma disputed: can aggressively lowering blood pressure in hypertensive patients with coronary artery disease be dangerous? Ann Int Med. 2006;144(12):884–93. Landmark document on the BP J-curve phenomenon. CrossRef

46.

• Bohm M, Schumacher H, Teo KK, Lonn E, Mahfoud F, Mann JFE et al. Achieved diastolic blood pressure and pulse pressure at target systolic blood pressure (120–140 mmHg) and cardiovascular outcomes in high-risk patients: results from ONTARGET and TRANSCEND trials. Eur Heart J. 2018;39(33):3105–14. Post hoc analysis of the ONTARGET and TRANSCEND randomized control trials showing the dangers of low diastolic blood pressure.

47.

Duncker DJ, Bache RJ. Regulation of coronary blood flow during exercise. Physiol Rev. 2008;88(3):1009–86.CrossRef

48.

Sandesara PB, O’Neal WT, Kelli HM, Topel M, Samman-Tahhan A, Sperling LS. Diastolic Blood Pressure and Adverse Outcomes in the TOPCAT (Treatment of Preserved Cardiac Function Heart Failure With an Aldosterone Antagonist) Trial. J Am Heart Assoc. 2018;7(5).

49.

Tsujimoto T, Kajio H. Low diastolic blood pressure and adverse outcomes in heart failure with preserved ejection fraction. Int J Cardiol. 2018;263:69–74.CrossRef

50.

Rahman F, Al Rifai M, Blaha MJ, Nasir K, Budoff MJ, Psaty BM, et al. Relation of Diastolic Blood Pressure and Coronary Artery Calcium to Coronary Events and Outcomes (From the Multi-Ethnic Study of Atherosclerosis). Am J Cardiol. 2017;120(10):1797–803.CrossRef

51.

Cooper-DeHoff RM, Gong Y, Handberg EM, Bavry AA, Denardo SJ, Bakris GL, et al. Tight blood pressure control and cardiovascular outcomes among hypertensive patients with diabetes and coronary artery disease. JAMA. 2010;304(1):61–8.CrossRef

52.

Boshuizen HC, Izaks GJ, van Buuren S, Ligthart GJ. Blood pressure and mortality in elderly people aged 85 and older: community based study. BMJ. 1998;316(7147):1780–1784.CrossRef

53.

D’Agostino RB, Belanger AJ, Kannel WB, Cruickshank JM. Relation of low diastolic blood pressure to coronary heart disease death in presence of myocardial infarction: the Framingham Study. BMJ. 1991;303(6799):385–9.CrossRef

54.

• Park J-M, Kim BJ, Kwon SU, Hwang Y-H, Heo SH, Rha J-H et al. Intensive blood pressure control may not be safe in subacute ischemic stroke by intracranial atherosclerosis: a result of randomized trial. J Hypertens. 2018;36(9):1936–41. Small randomized trial showing risks of aggressive blood pressure control in patients with subacute ischemic stroke with carotid stenosis. CrossRef

55.

Group SPSS, Benavente OR, Coffey CS, Conwit R, Hart RG, McClure LA, et al. Blood-pressure targets in patients with recent lacunar stroke: the SPS3 randomised trial. Lancet. 2013;382(9891):507–15.CrossRef

56.

Croall ID, Tozer DJ, Moynihan B, Khan U, O’Brien JT, Morris RG, et al. Effect of Standard vs Intensive Blood Pressure Control on Cerebral Blood Flow in Small Vessel Disease: The PRESERVE Randomized Clinical Trial. In: JAMA Neurol; 2018.

57.

Shimbo D, Barrett Bowling C, Levitan EB, Deng L, Sim JJ, Huang L, et al. Short-Term Risk of Serious Fall Injuries in Older Adults Initiating and Intensifying Treatment With Antihypertensive Medication. Circ Cardiovasc Qual Outcomes. 2016;9(3):222–9.CrossRef

58.

Tinetti ME, Han L, Lee DS, McAvay GJ, Peduzzi P, Gross CP, et al. Antihypertensive medications and serious fall injuries in a nationally representative sample of older adults. JAMA Intern Med. 2014;174(4):588–95.CrossRef

59.

Gangavati A, Hajjar I, Quach L, Jones RN, Kiely DK, Gagnon P, et al. Hypertension, orthostatic hypotension, and the risk of falls in a community-dwelling elderly population: the maintenance of balance, independent living, intellect, and zest in the elderly of Boston study. J Am Geriatr Soc. 2011;59(3):383–9.CrossRef

60.

Lipsitz LA, Habtemariam D, Gagnon M, Iloputaife I, Sorond F, Tchalla AE, et al. Reexamining the Effect of Antihypertensive Medications on Falls in Old Age. Hypertension. 2015;66(1):183–9.CrossRef

61.

• Bromfield SG, Ngameni CA, Colantonio LD, Bowling CB, Shimbo D, Reynolds K, et al. Blood pressure, antihypertensive polypharmacy, frailty, and risk for serious fall injuries among older treated adults with hypertension. Hypertension. 2017;70(2):259–66. Analysis evaluating the risks of falls among older patients showing that frailty indicators main predictor of fall risk. CrossRef

62.

Deandrea S, Lucenteforte E, Bravi F, Foschi R, La Vecchia C, Negri E. Risk factors for falls in community-dwelling older people: a systematic review and meta-analysis. Epidemiology 2010;21(5):658–668.CrossRef

63.

Margolis KL, Palermo L, Vittinghoff E, Evans GW, Atkinson HH, Hamilton BP, et al. Intensive blood pressure control, falls, and fractures in patients with type 2 diabetes: the ACCORD trial. J Gen Intern Med. 2014;29(12):1599–606.CrossRef

64.

Stubbs B, Mueller C, Gaughran F, Lally J, Vancampfort D, Lamb SE, et al. Predictors of falls and fractures leading to hospitalization in people with schizophrenia spectrum disorder: A large representative cohort study. Schizophr Res. 2018. https://doi.org/10.1016/j.schres.2018.05.010.CrossRef

65.

Xie X, Atkins E, Lv J, Bennett A, Neal B, Ninomiya T, et al. Effects of intensive blood pressure lowering on cardiovascular and renal outcomes: updated systematic review and meta-analysis. Lancet. 2016;387(10017):435–43.CrossRef

66.

Beddhu S, Greene T, Boucher R, Cushman WC, Wei G, Stoddard G et al. Intensive systolic blood pressure control and incident chronic kidney disease in people with and without diabetes mellitus: secondary analyses of two randomised controlled trials. Lancet Diabetes Endocrinol. 2018;6(7):555–63.CrossRef

67.

Del Pinto R, Pietropaoli D, Ferri C. Diastolic blood pressure and risk profile in renal and cardiovascular diseases. Results from the SPRINT trial. J Am Soc Hypertens. 2018;12(7)513–23.

68.

Bress AP, Bellows BK, King JB, Hess R, Beddhu S, Zhang Z, et al. Cost-Effectiveness of Intensive versus Standard Blood-Pressure Control. N Engl J Med. 2017;377(8):745–55.CrossRef

69.

Cooney D, Pascuzzi K. Polypharmacy in the elderly: focus on drug interactions and adherence in hypertension. Clin Geriatr Med. 2009;25(2):221–33.CrossRef

70.

Mukete BN, Ferdinand KC. Polypharmacy in Older Adults With Hypertension: A Comprehensive Review. J Clin Hypertens (Greenwich). 2016;18(1):10–8.CrossRef

71.

Herr M, Sirven N, Grondin H, Pichetti S, Sermet C. Frailty, polypharmacy, and potentially inappropriate medications in old people: findings in a representative sample of the French population. Eur J Clin Pharmacol. 2017;73(9):1165–72.CrossRef

72.

Kandzari DE, Bohm M, Mahfoud F, Townsend RR, Weber MA, Pocock S, et al. Effect of renal denervation on blood pressure in the presence of antihypertensive drugs: 6-month efficacy and safety results from the SPYRAL HTN-ON MED proof-of-concept randomized trial. Lancet. 2018;391(10137):2346–55.CrossRef

73.

Azizi M, Schmieder RE, Mahfoud F, Weber MA, Daemen J, Davies J, et al. Endovascular ultrasound renal denervation to treat hypertension (RADIANCE-HTN SOLO): a multicentre, international, single-blind, randomized, sham-controlled trial. Lancet. 2018;391(10137):2335–45.CrossRef

74.

Selvaraj S, Steg PG, Elbez Y, Sorbets E, Feldman LJ, Eagle KA, et al. Pulse Pressure and Risk for Cardiovascular Events in Patients With Atherothrombosis: From the REACH Registry. J Am Coll Cardiol. 2016;67(4):392–403.CrossRef

75.

Savoia C, Volpe M, Grassi G, Borghi C, Agabiti Rosei E, Touyz RM. Personalized medicine-a modern approach for the diagnosis and management of hypertension. Clin Sci (Lond). 2017;131(22):2671–85.CrossRef

76.

McEvoy JW, Martin SS, Dardari ZA, Miedema MD, Sandfort V, Yeboah J, et al. Coronary Artery Calcium to Guide a Personalized Risk-Based Approach to Initiation and Intensification of Antihypertensive Therapy. In: Circulation. 2017;135(2):153–65.CrossRef

77.

Tamblyn R, Abrahamowicz M, Dauphinee D, Wenghofer E, Jacques A, Klass D et al. Influence of physicians’ management and communication ability on patients’ persistence with antihypertensive medication. Arch Intern Med 2010;170(12):1064–1072.CrossRef

Title: Dangers of Overly Aggressive Blood Pressure Control
Authors: Faisal Rahman
John W. McEvoy
Publication date: 01-11-2018
Publisher: Springer US
Published in: Current Cardiology Reports / Issue 11/2018
Print ISSN: 1523-3782
Electronic ISSN: 1534-3170
DOI: https://doi.org/10.1007/s11886-018-1063-y

ACC 2024 Congress Coverage

Year in Review: Heart failure and cardiomyopathies

Heart Failure Video

Watch this official video from ACC.24. Dr. Biykem Bozkurt discusses last year's major advances in heart failure and cardiomyopathies.

Watch now

At a glance: The STEP trials

Springer Medicine

Dangers of Overly Aggressive Blood Pressure Control

Abstract

Purpose of Review

Recent Findings

Summary

ACC 2024 Congress Coverage

Year in Review: Heart failure and cardiomyopathies

Semaglutide benefits people with type 2 diabetes and obesity-related heart failure

Incentivised to exercise

New intervention for STEMI-related cardiogenic shock

» View more highlights on the ACC 2024 congress hub page

At a glance: The STEP trials

Springer Medicine

Abstract

Purpose of Review

Recent Findings

Summary

Please log in to get access to this content

Other articles of this Issue 11/2018

The Clinical Dilemma of Anticoagulation Use in Patients with Cerebral Amyloid Angiopathy and Atrial Fibrillation

Role of Percutaneous Chronic Total Occlusion Interventions in Patients with Ischemic Cardiomyopathy and Reduced Left Ventricular Ejection Fraction

Transcatheter Mitral Valve Therapy: Defining the Patient Who Will Benefit

Echocardiography in Sarcoidosis

Type D Personality as a Risk Factor in Coronary Heart Disease: a Review of Current Evidence

Tumor Necrosis Factor-α in Heart Failure: an Updated Review

ACC 2024 Congress Coverage

Year in Review: Heart failure and cardiomyopathies

Semaglutide benefits people with type 2 diabetes and obesity-related heart failure

Incentivised to exercise

New intervention for STEMI-related cardiogenic shock

» View more highlights on the ACC 2024 congress hub page