Skip to main content
Key Specialties
Cardiology Diabetology Endocrinology Gastroenterology Geriatrics and Gerontology Gynecology and Obstetrics Hematology Infectious Disease Internal Medicine Nephrology Neurology Oncology Pediatrics Respiratory Medicine Rheumatology Surgery
Congress Coverage
2024 ACC Congress 2023 ESMO Congress 2023 EASD Congress 2023 ERS Congress 2023 ESC Congress
Clinical Collections
Advances in Alzheimer’s

Keynote webinar | Spotlight on medication adherence

LIVE: Thursday 27th June 2024, 18:00-19:30 (CEST)
Join our expert panel to discover why you need to understand the drivers of non-adherence in your patients, and how you can optimize medication adherence in your clinics to drastically improve patient outcomes.
ADVANCED SEARCH
Log in
Top
Antimicrobial Resistance & Infection Control
Published in: Antimicrobial Resistance & Infection Control 1/2018

Open Access 01-12-2018 | Research

Genome-based analysis of Carbapenemase-producing Klebsiella pneumoniae isolates from German hospital patients, 2008-2014

Authors: Laura Becker, Martin Kaase, Yvonne Pfeifer, Stephan Fuchs, Annicka Reuss, Anja von Laer, Muna Abu Sin, Miriam Korte-Berwanger, Sören Gatermann, Guido Werner

Published in: Antimicrobial Resistance & Infection Control | Issue 1/2018

Login to get access

Abstract

Background

By using whole genome sequence data we aimed at describing a population snapshot of carbapenemase-producing K. pneumoniae isolated from hospitalized patients in Germany between 2008 and 2014.

Methods

We selected a representative subset of 107 carbapenemase-producing K. pneumoniae clinical isolates possessing the four most prevalent carbapenemase types in Germany (KPC-2, KPC-3, OXA-48, NDM-1). Isolates were processed via illumina NGS. Data were analysed using different SNP-based mapping and de-novo assembly approaches. Relevant information was extracted from NGS data (antibiotic resistance determinants, wzi gene/cps type, virulence genes). NGS data from the present study were also compared with 238 genome data from two previous international studies on K. pneumoniae.

Results

NGS-based analyses revealed a preferred prevalence of KPC-2-producing ST258 and KPC-3-producing ST512 isolates. OXA-48, being the most prevalent carbapenemase type in Germany, was associated with various K. pneumoniae strain types; most of them possessing IncL/M plasmid replicons suggesting a preferred dissemination of blaOXA-48 via this well-known plasmid type. Clusters ST15, ST147, ST258, and ST512 demonstrated an intermingled subset structure consisting of German and other European K. pneumoniae isolates. ST23 being the most frequent MLST type in Asia was found only once in Germany. This latter isolate contained an almost complete set of virulence genes and a K1 capsule suggesting occurrence of a hypervirulent ST23 strain producing OXA-48 in Germany.

Conclusions

Our study results suggest prevalence of “classical” K. pneumonaie strain types associated with widely distributed carbapenemase genes such as ST258/KPC-2 or ST512/KPC-3 also in Germany. The finding of a supposed hypervirulent and OXA-48-producing ST23 K. pneumoniae isolates outside Asia is highly worrisome and requires intense molecular surveillance.
Appendix
Available only for authorised users
Literature
1.
ECDC. Antimicrobial resistance surveillance in Europe 2016; 5. Annual report of the European antimicrobial resistance surveillance network (EARS-net). In: Annual report of the European antimicrobial resistance surveillance network (EARS-net). Stockholm: European Centre for Disease Prevention and Control (ECDC); 2017.
2.
Pfennigwerth N. Report of the National Reference Centre for gram-negative nosocomial pathogens, 2016. Epidemiologisches Bull. 2017;26:5.
3.
Kaase M, Pfennigwerth N. Report from the National Reference Centre for gram-negative nosocomial pathogens, 2015. Epidemiologisches Bull. 2016;41(25):5.
4.
Kaiser T, Finstermeier K, Hantzsch M, Faucheux S, Kaase M, Eckmanns T, Bercker S, Kaisers UX, Lippmann N, Rodloff AC, et al. Stalking a lethal superbug by whole-genome sequencing and phylogenetics: influence on unraveling a major hospital outbreak of carbapenem-resistant Klebsiella pneumoniae. Am J Infect Control. 2017;46(1):54–59. https://​doi.​org/​10.​1016/​j.​ajic.​2017.​07.​022.
5.
Carstens A, Kepper U, Exner M, Hauri AM, Kaase M, Wendt C. Plasmid-mediated multispecies outbreak with carbapenemase-resistant Enterobacteriaceae. Epidemiologisches Bull. 2014;47:5.
6.
Kola A, Piening B, Pape UF, Veltzke-Schlieker W, Kaase M, Geffers C, Wiedenmann B, Gastmeier P. An outbreak of carbapenem-resistant OXA-48-producing Klebsiella pneumoniae associated to duodenoscopy. Antimicrob Resist Infect Control. 2015;4:8.PubMedPubMedCentral
7.
Steinmann J, Kaase M, Gatermann S, Popp W, Steinmann E, Damman M, Paul A, Saner F, Buer J, Rath P. Outbreak due to a Klebsiella pneumoniae strain harbouring KPC-2 and VIM-1 in a German university hospital, July 2010 to January 2011. Euro Surveill. 2011;16(33.
8.
Kaase M, Schimanski S, Schiller R, Beyreiss B, Thurmer A, Steinmann J, Kempf VA, Hess C, Sobottka I, Fenner I, et al. Multicentre investigation of carbapenemase-producing Escherichia coli and Klebsiella pneumoniae in German hospitals. Int J Med Microbiol. 2016;306(6):415–20.PubMed
9.
Bolger AM, Lohse M, Usadel B. Trimmomatic: a flexible trimmer for Illumina sequence data. Bioinformatics. 2014;30(15):2114–20.PubMedPubMedCentral
10.
Li H, Durbin R. Fast and accurate short read alignment with burrows-wheeler transform. Bioinformatics. 2009;25(14):1754–60.PubMedPubMedCentral
11.
Koboldt DC, Zhang Q, Larson DE, Shen D, McLellan MD, Lin L, Miller CA, Mardis ER, Ding L, Wilson RK. VarScan 2: somatic mutation and copy number alteration discovery in cancer by exome sequencing. Genome Res. 2012;22(3):568–76.PubMedPubMedCentral
12.
Stamatakis A. RAxML version 8: a tool for phylogenetic analysis and post-analysis of large phylogenies. Bioinformatics. 2014;30(9):1312–3.PubMedPubMedCentral
13.
Huang W, Li L, Myers JR, Marth GT. ART: a next-generation sequencing read simulator. Bioinformatics. 2012;28(4):593–4.PubMed
14.
Li H, Handsaker B, Wysoker A, Fennell T, Ruan J, Homer N, Marth G, Abecasis G, Durbin R, Genome Project Data Processing S. The sequence alignment/map format and SAMtools. Bioinformatics. 2009;25(16):2078–9.PubMedPubMedCentral
15.
Becker L, Fuchs S, Pfeifer Y, Semmler T, Eckmanns T, Korr G, Sissolak D, Friedrichs M, Zill E, Tung M-L et al: Whole genome sequence analysis of CTX-M-15 producing Klebsiella isolates allowed dissecting a polyclonal outbreak scenario. Front Microbiol 2018, (online first):14.
16.
Arndt D, Grant JR, Marcu A, Sajed T, Pon A, Liang Y, Wishart DS. PHASTER: a better, faster version of the PHAST phage search tool. Nucleic Acids Res. 2016;44(W1):W16–21.PubMedPubMedCentral
17.
Coil D, Jospin G, Darling AE. A5-miseq: an updated pipeline to assemble microbial genomes from Illumina MiSeq data. Bioinformatics. 2015;31(4):587–9.PubMed
18.
Zankari E, Hasman H, Cosentino S, Vestergaard M, Rasmussen S, Lund O, Aarestrup FM, Larsen MV. Identification of acquired antimicrobial resistance genes. J Antimicrob Chemother. 2012;67(11):2640–4.PubMedPubMedCentral
19.
Larsen MV, Cosentino S, Rasmussen S, Friis C, Hasman H, Marvig RL, Jelsbak L, Sicheritz-Ponten T, Ussery DW, Aarestrup FM, et al. Multilocus sequence typing of total-genome-sequenced bacteria. J Clin Microbiol. 2012;50(4):1355–61.PubMedPubMedCentral
20.
Brisse S, Passet V, Haugaard AB, Babosan A, Kassis-Chikhani N, Struve C, Decre D. wzi gene sequencing, a rapid method for determination of capsular type for Klebsiella strains. J Clin Microbiol. 2013;51(12):4073–8.PubMedPubMedCentral
21.
Kumabe A, Kenzaka T. String test of hypervirulent Klebsiella pneumonia. QJM. 2014;107(12):1053.PubMed
22.
Pichler C, Buchsel M, Rossen JW, Vavra M, Reuter S, Kern WV, Thimme R, Mischnik A. First report of invasive liver abscess syndrome with endophthalmitis caused by a K2 serotype ST2398 hypervirulent Klebsiella pneumoniae in Germany, 2016. New Microbes New Infect. 2017;17:77–80.PubMedPubMedCentral
23.
Siguier P, Perochon J, Lestrade L, Mahillon J, Chandler M. ISfinder: the reference Centre for bacterial insertion sequences. Nucleic Acids Res. 2006;34(Database issue):D32–6.PubMed
24.
Struve C, Roe CC, Stegger M, Stahlhut SG, Hansen DS, Engelthaler DM, Andersen PS, Driebe EM, Keim P, Krogfelt KA. Mapping the evolution of Hypervirulent Klebsiella pneumoniae. MBio. 2015;6(4):e00630.PubMedPubMedCentral
25.
Holt KE, Wertheim H, Zadoks RN, Baker S, Whitehouse CA, Dance D, Jenney A, Connor TR, Hsu LY, Severin J, et al. Genomic analysis of diversity, population structure, virulence, and antimicrobial resistance in Klebsiella pneumoniae, an urgent threat to public health. Proc Natl Acad Sci U S A. 2015;112(27):E3574–81.PubMedPubMedCentral
26.
Deleo FR, Chen L, Porcella SF, Martens CA, Kobayashi SD, Porter AR, Chavda KD, Jacobs MR, Mathema B, Olsen RJ, et al. Molecular dissection of the evolution of carbapenem-resistant multilocus sequence type 258 Klebsiella pneumoniae. Proc Natl Acad Sci U S A. 2014;111(13):4988–93.PubMedPubMedCentral
27.
Wendt C, Schutt S, Dalpke AH, Konrad M, Mieth M, Trierweiler-Hauke B, Weigand MA, Zimmermann S, Biehler K, Jonas D. First outbreak of Klebsiella pneumoniae carbapenemase (KPC)-producing K. pneumoniae in Germany. Eur J Clin Microbiol Infect Dis. 2010;29(5):563–70.PubMed
28.
Liapis E, Pantel A, Robert J, Nicolas-Chanoine MH, Cavalie L, van der Mee-Marquet N, de Champs C, Aissa N, Eloy C, Blanc V, et al. Molecular epidemiology of OXA-48-producing Klebsiella pneumoniae in France. Clin Microbiol Infect. 2014;20(12):O1121–3.PubMed
29.
Potron A, Poirel L, Rondinaud E, Nordmann P. Intercontinental spread of OXA-48 beta-lactamase-producing Enterobacteriaceae over a 11-year period, 2001 to 2011. Euro Surveill. 2013;18(31).
30.
Cuzon G, Ouanich J, Gondret R, Naas T, Nordmann P. Outbreak of OXA-48-positive carbapenem-resistant Klebsiella pneumoniae isolates in France. Antimicrob Agents Chemother. 2011;55(5):2420–3.PubMedPubMedCentral
31.
Kovacs K, Nyul A, Mestyan G, Melegh S, Fenyvesi H, Jakab G, Szabo H, Janvari L, Damjanova I, Toth A. Emergence and interhospital spread of OXA-48-producing Klebsiella pneumoniae ST395 clone in western Hungary. Infect Dis (Lond). 2017;49(3):231–3.PubMed
32.
Potron A, Kalpoe J, Poirel L, Nordmann P. European dissemination of a single OXA-48-producing Klebsiella pneumoniae clone. Clin Microbiol Infect. 2011;17(12):E24–6.PubMed
33.
De Laveleye M, Huang TD, Bogaerts P, Berhin C, Bauraing C, Sacre P, Noel A, Glupczynski Y, multicenter study g. Increasing incidence of carbapenemase-producing Escherichia coli and Klebsiella pneumoniae in Belgian hospitals. Eur J Clin Microbiol Infect Dis. 2017;36(1):139–46.PubMed
34.
Skalova A, Chudejova K, Rotova V, Medvecky M, Studentova V, Chudackova E, Lavicka P, Bergerova T, Jakubu V, Zemlickova H, et al. Molecular characterization of OXA-48-like-producing Enterobacteriaceae in the Czech Republic and evidence for horizontal transfer of pOXA-48-like plasmids. Antimicrob Agents Chemother. 2017;61(2):e01889–16.PubMedPubMedCentral
35.
Canton R, Akova M, Carmeli Y, Giske CG, Glupczynski Y, Gniadkowski M, Livermore DM, Miriagou V, Naas T, Rossolini GM, et al. Rapid evolution and spread of carbapenemases among Enterobacteriaceae in Europe. Clin Microbiol Infect. 2012;18(5):413–31.PubMed
36.
Wyres KL, Holt KE. Klebsiella pneumoniae population genomics and antimicrobial-resistant clones. Trends Microbiol. 2016;24(12):944–56.PubMed
37.
Zautner AE, Bunk B, Pfeifer Y, Sproer C, Reichard U, Eiffert H, Scheithauer S, Gross U, Overmann J, Bohne W. Monitoring microevolution of OXA-48-producing Klebsiella pneumoniae ST147 in a hospital setting by SMRT sequencing. J Antimicrob Chemother. 2017;72(10):2737–44.PubMed
38.
Stolle I, Prenger-Berninghoff E, Stamm I, Scheufen S, Hassdenteufel E, Guenther S, Bethe A, Pfeifer Y, Ewers C. Emergence of OXA-48 carbapenemase-producing Escherichia coli and Klebsiella pneumoniae in dogs. J Antimicrob Chemother. 2013;68(12):2802–8.PubMed
39.
Baraniak A, Izdebski R, Fiett J, Sadowy E, Adler A, Kazma M, Salomon J, Lawrence C, Rossini A, Salvia A, et al. Comparative population analysis of Klebsiella pneumoniae strains with extended-spectrum beta-lactamases colonizing patients in rehabilitation centers in four countries. Antimicrob Agents Chemother. 2013;57(4):1992–7.PubMedPubMedCentral
40.
Ito R, Shindo Y, Kobayashi D, Ando M, Jin W, Wachino J, Yamada K, Kimura K, Yagi T, Hasegawa Y, et al. Molecular epidemiological characteristics of Klebsiella pneumoniae associated with bacteremia among patients with pneumonia. J Clin Microbiol. 2015;53(3):879–86.PubMedPubMedCentral
41.
Maatallah M, Vading M, Kabir MH, Bakhrouf A, Kalin M, Naucler P, Brisse S, Giske CG. Klebsiella variicola is a frequent cause of bloodstream infection in the Stockholm area, and associated with higher mortality compared to K. pneumoniae. PLoS One. 2014;9(11):e113539.PubMedPubMedCentral
42.
Pantelidou IM, Galani I, Georgitsi M, Daikos GL, Giamarellos-Bourboulis EJ. Interactions of Klebsiella pneumoniae with the innate immune system vary in relation to clone and resistance phenotype. Antimicrob Agents Chemother. 2015;59(11):7036–43.PubMedPubMedCentral
43.
Xiao SZ, Wang S, Wu WM, Zhao SY, Gu FF, Ni YX, Guo XK, Qu JM, Han LZ. The resistance phenotype and molecular epidemiology of Klebsiella pneumoniae in bloodstream infections in shanghai, China, 2012-2015. Front Microbiol. 2017;8:250.PubMedPubMedCentral
44.
Zurfluh K, Poirel L, Nordmann P, Klumpp J, Stephan R. First detection of Klebsiella variicola producing OXA-181 carbapenemase in fresh vegetable imported from Asia to Switzerland. Antimicrob Resist Infect Control. 2015;4:38.PubMedPubMedCentral
45.
Di DY, Jang J, Unno T, Hur HG. Emergence of Klebsiella variicola positive for NDM-9, a variant of New Delhi metallo-beta-lactamase, in an urban river in South Korea. J Antimicrob Chemother. 2017;72(4):1063–7.PubMed
46.
Long SW, Linson SE, Ojeda Saavedra M, Cantu C, Davis JJ, Brettin T, Olsen RJ. Whole-genome sequencing of human clinical Klebsiella pneumoniae isolates reveals misidentification and misunderstandings of Klebsiella pneumoniae, Klebsiella variicola, and Klebsiella quasipneumoniae. mSphere. 2017;2(4):e00290–17.PubMedPubMedCentral
47.
Cubero M, Grau I, Tubau F, Pallares R, Dominguez MA, Linares J, Ardanuy C. Hypervirulent Klebsiella pneumoniae clones causing bacteraemia in adults in a teaching hospital in Barcelona, Spain (2007-2013). Clin Microbiol Infect. 2016;22(2):154–60.PubMed
48.
Shon AS, Bajwa RP, Russo TA. Hypervirulent (hypermucoviscous) Klebsiella pneumoniae: a new and dangerous breed. Virulence. 2013;4(2):107–18.PubMedPubMedCentral
49.
Gu D, Dong N, Zheng Z, Lin D, Huang M, Wang L, Chan EW, Shu L, Yu J, Zhang R, et al. A fatal outbreak of ST11 carbapenem-resistant hypervirulent Klebsiella pneumoniae in a Chinese hospital: a molecular epidemiological study. Lancet Infect Dis. 2017;
50.
Wei DD, Wan LG, Deng Q, Liu Y. Emergence of KPC-producing Klebsiella pneumoniae hypervirulent clone of capsular serotype K1 that belongs to sequence type 11 in mainland China. Diagn Microbiol Infect Dis. 2016;85(2):192–4.PubMed
51.
Yao B, Xiao X, Wang F, Zhou L, Zhang X, Zhang J. Clinical and molecular characteristics of multi-clone carbapenem-resistant hypervirulent (hypermucoviscous) Klebsiella pneumoniae isolates in a tertiary hospital in Beijing, China. Int J Infect Dis. 2015;37:107–12.PubMed
52.
Diago-Navarro E, Chen L, Passet V, Burack S, Ulacia-Hernando A, Kodiyanplakkal RP, Levi MH, Brisse S, Kreiswirth BN, Fries BC. Carbapenem-resistant Klebsiella pneumoniae exhibit variability in capsular polysaccharide and capsule associated virulence traits. J Infect Dis. 2014;210(5):803–13.PubMedPubMedCentral
53.
Wyres KL, Gorrie C, Edwards DJ, Wertheim HF, Hsu LY, Van Kinh N, Zadoks R, Baker S, Holt KE. Extensive capsule locus variation and large-scale genomic recombination within the Klebsiella pneumoniae clonal group 258. Genome Biol Evol. 2015;7(5):1267–79.PubMedPubMedCentral
54.
Chen L, Mathema B, Pitout JD, DeLeo FR, Kreiswirth BN. Epidemic Klebsiella pneumoniae ST258 is a hybrid strain. MBio. 2014;5(3):e01355–14.PubMedPubMedCentral
55.
Mathers AJ, Stoesser N, Chai W, Carroll J, Barry K, Cherunvanky A, Sebra R, Kasarskis A, Peto TE, Walker AS, et al. Chromosomal integration of the Klebsiella pneumoniae carbapenemase gene, blaKPC, in Klebsiella species is elusive but not rare. Antimicrob Agents Chemother. 2017;61(3):e01823–16.PubMedPubMedCentral
56.
Pfeifer Y, Schlatterer K, Engelmann E, Schiller RA, Frangenberg HR, Stiewe D, Holfelder M, Witte W, Nordmann P, Poirel L. Emergence of OXA-48-type carbapenemase-producing Enterobacteriaceae in German hospitals. Antimicrob Agents Chemother. 2012;56(4):2125–8.PubMedPubMedCentral
57.
Gomez-Simmonds A, Greenman M, Sullivan SB, Tanner JP, Sowash MG, Whittier S, Uhlemann AC. Population structure of Klebsiella pneumoniae causing bloodstream infections at a New York City tertiary care hospital: diversification of multidrug-resistant isolates. J Clin Microbiol. 2015;53(7):2060–7.PubMedPubMedCentral
58.
Bowers JR, Kitchel B, Driebe EM, MacCannell DR, Roe C, Lemmer D, de Man T, Rasheed JK, Engelthaler DM, Keim P, et al. Genomic analysis of the emergence and rapid global dissemination of the clonal group 258 Klebsiella pneumoniae pandemic. PLoS One. 2015;10(7):e0133727.PubMedPubMedCentral
59.
Conte V, Monaco M, Giani T, D'Ancona F, Moro ML, Arena F, D'Andrea MM, Rossolini GM, Pantosti A, pneumoniae A-ISGoC-PK. Molecular epidemiology of KPC-producing Klebsiella pneumoniae from invasive infections in Italy: increasing diversity with predominance of the ST512 clade II sublineage. J Antimicrob Chemother. 2016;71(12):3386–91.PubMed
Metadata
Title
Genome-based analysis of Carbapenemase-producing Klebsiella pneumoniae isolates from German hospital patients, 2008-2014
Authors
Laura Becker
Martin Kaase
Yvonne Pfeifer
Stephan Fuchs
Annicka Reuss
Anja von Laer
Muna Abu Sin
Miriam Korte-Berwanger
Sören Gatermann
Guido Werner
Publication date
01-12-2018
Publisher
BioMed Central
Published in
Antimicrobial Resistance & Infection Control / Issue 1/2018
Electronic ISSN: 2047-2994
DOI
https://doi.org/10.1186/s13756-018-0352-y

Other articles of this Issue 1/2018

Antimicrobial Resistance & Infection Control 1/2018 Go to the issue

Research

Enumerating the economic cost of antimicrobial resistance per antibiotic consumed to inform the evaluation of interventions affecting their use

Research

Mixed methods evaluation of the impact of a short term training program on sterile processing knowledge, practice, and attitude in three hospitals in Benin

Research

VIM-positive Pseudomonas aeruginosa in a large tertiary care hospital: matched case-control studies and a network analysis

Research

Risk for subsequent infection and mortality after hospitalization among patients with multidrug-resistant gram-negative bacteria colonization or infection

Letter to the Editor

Letter to the editor in response to estimating the burden of antimicrobial resistance: a systematic literature review

Research

Surface area wiped, product type, and target strain impact bactericidal efficacy of ready-to-use disinfectant Towelettes
Live Webinar | 27-06-2024 | 18:00 (CEST)

Keynote webinar | Spotlight on medication adherence

Reserve your place

Live: Thursday 27th June 2024, 18:00-19:30 (CEST)

WHO estimates that half of all patients worldwide are non-adherent to their prescribed medication. The consequences of poor adherence can be catastrophic, on both the individual and population level.

Join our expert panel to discover why you need to understand the drivers of non-adherence in your patients, and how you can optimize medication adherence in your clinics to drastically improve patient outcomes.

Prof. Kevin Dolgin
Prof. Florian Limbourg
Prof. Anoop Chauhan
Developed by: Springer Medicine
Obesity Clinical Trial Summary

At a glance: The STEP trials

Read more

A round-up of the STEP phase 3 clinical trials evaluating semaglutide for weight loss in people with overweight or obesity.

Developed by: Springer Medicine

Highlights from the ACC 2024 Congress

Year in Review: Pediatric cardiology

Pediatric Cardiology Video

Watch Dr. Anne Marie Valente present the last year's highlights in pediatric and congenital heart disease in the official ACC.24 Year in Review session.

Year in Review: Pulmonary vascular disease

Cardiopulmonary Comorbidity Video

The last year's highlights in pulmonary vascular disease are presented by Dr. Jane Leopold in this official video from ACC.24.

Year in Review: Valvular heart disease

Valvular Heart Disease Video

Watch Prof. William Zoghbi present the last year's highlights in valvular heart disease from the official ACC.24 Year in Review session.

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.

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

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

16-04-2024 Type 2 Diabetes News

Incentivised to exercise

11-04-2024 Lifestyle Modifications News

New intervention for STEMI-related cardiogenic shock

10-04-2024 Myocardial Infarction News

» View more highlights on the ACC 2024 congress hub page

Image Credits