Top

Current Treatment Options in Cardiovascular Medicine

Published in:

01-06-2017 | Cerebrovascular Disease and Stroke (N Rost, Section Editor)

Critical Care Management of Acute Ischemic Stroke

Authors: Matthew B. Bevers, MD, PhD, W. Taylor Kimberly, MD, PhD

Published in: Current Treatment Options in Cardiovascular Medicine | Issue 6/2017

Opinion statement

Ischemic stroke accounts for approximately 85% of all strokes. Although severe strokes constitute a minority of cases, they are associated with a majority of the subsequent disability and death. Reperfusion therapy with intravenous tissue plasminogen activator (tPA) and/or endovascular thrombectomy is a mainstay of acute stroke management. Intensive care management of stroke is focused on reducing complications of reperfusion, such as hemorrhagic transformation, and minimizing secondary brain injury, including brain edema and progressive stroke. Additionally, severe stroke patients frequently need ventilatory or hemodynamic support provided in an intensive care unit (ICU) setting. Here, we discuss the current medical and surgical ICU management aspects of acute ischemic stroke and identify areas where ongoing studies may reveal new treatments to improve neurological recovery.

Mozaffarian D, Benjamin EJ, Go AS, et al. Heart disease and stroke statistics-2016 update a report from the American Heart Association. Circulation. 2016; doi:10.1161/CIR.0000000000000350.

Adeoye O, Hornung R, Khatri P, Kleindorfer D. Recombinant tissue-type plasminogen activator use for ischemic stroke in the united states: a doubling of treatment rates over the course of 5 years. Stroke. 2011;42:1952–5.CrossRefPubMedPubMedCentral

Saver JL, Goyal M, Bonafe A, et al. Stent-retriever thrombectomy after intravenous t-PA vs. t-PA alone in stroke. N Engl J Med. 2015;372:2285–95.CrossRefPubMed

Goyal M, Demchuk AM, Menon BK, et al. Randomized assessment of rapid endovascular treatment of ischemic stroke. N Engl J Med. 2015;372:1019–30.CrossRefPubMed

Campbell BC, Mitchell PJ, Kleinig TJ, et al. Endovascular therapy for ischemic stroke with perfusion-imaging selection. N Engl J Med. 2015;372:1009–18.CrossRefPubMed

Jovin TG, Chamorro A, Cobo E, et al. Thrombectomy within 8 hours after symptom onset in ischemic stroke. N Engl J Med. 2015;372:2296–306.CrossRefPubMed

Berkhemer OA, Fransen PSS, Beumer D, et al. A randomized trial of tntraarterial treatment for acute ischemic stroke. New Engl J Med. 2015;372:11–20.CrossRefPubMed

Ropper A, Kennedy S, Zervas N. Neurological and neurosurgical intensive care. Baltimore, MD: University Park Press; 1983.

Kramer AH, Zygun DA. Do neurocritical care units save lives? Measuring the impact of specialized ICUs. Neurocrit Care. 2011;14:329–33.CrossRefPubMed

10.

Mirski M, Chang C, Cowan R. Impact of a neuroscience intensive care unit on neurosurgical patient outcomes and cost of care: evidence-based support for an intensivist-directed specialty ICU model of care. J Neurosurg Anesthesiol. 2001;13:83–92.CrossRefPubMed

11.

Stroke Unit Trialists’ Collaboration (2013) Organised inpatient (stroke unit) care for stroke. Cochrane Database Syst Rev 2013–2015.

12.

Kalil AC, Metersky ML, Klompas M, et al. Management of adults with hospital-acquired and ventilator-associated pneumonia: 2016 clinical practice guidelines by the Infectious Diseases Society of America and the American Thoracic Society. Clin Infect Dis. 2016;63:e61–e111.CrossRefPubMed

13.

Mandell LA, Wunderink RG, Anzueto A, et al. Infectious diseases society of America/American Thoracic Society consensus guidelines on the management of community-acquired pneumonia in adults. Clin Infect Dis. 2007;44:S27–72.CrossRefPubMed

14.

Wendell LC, Raser J, Kasner S, Park S. Predictors of extubation success in patients with middle cerebral artery acute ischemic stroke. Stroke Res Treat. 2011;2011:248789.PubMedPubMedCentral

15.

Guru PK, Singh TD, Pedavally S, Rabinstein AA, Hocker S. Predictors of extubation success in patients with posterior fossa strokes. Neurocrit Care. 2016;25:117–27.CrossRefPubMed

16.

Anderson CD, Bartscher JF, Scripko PD, Biffi A, Chase D, Guanci M, Greer DM. Neurologic examination and extubation outcome in the neurocritical care unit. Neurocrit Care. 2011;15:490–7.CrossRefPubMed

17.

Walcott BP, Kamel H, Castro B, Kimberly WT, Sheth KN. Tracheostomy after severe ischemic stroke: a population-based study. J Stroke Cerebrovasc Dis. 2014;23:1024–9.CrossRefPubMed

18.

Bösel J, Schiller P, Hook Y, et al. Stroke-related early tracheostomy versus prolonged orotracheal intubation in neurocritical care trial (SETPOINT): a randomized pilot trial. Stroke. 2013;44:21–8.CrossRefPubMed

19.

Schönenberger S, Niesen W-D, Fuhrer H, Bauza C, Klose C, Kieser M, Suarez JI, Seder DB, Bösel J. Early tracheostomy in ventilated stroke patients: study protocol of the international multicentre randomized trial SETPOINT2 (stroke-related early tracheostomy vs. prolonged orotracheal intubation in neurocritical care trial 2). Int J Stroke. 2016;11:368–79.CrossRefPubMed

20.

Oliveira-Filho J, Silva S, Trabuco C, Pedreira B, Sousa E, Bacellar A. Detrimental effect of blood pressure reduction in the first 24 hours of acute stroke onset. Neurology. 2003;61:1047–51.CrossRefPubMed

21.

Castillo J, Leira R, García MM, Serena J, Blanco M, Dávalos A. Blood pressure decrease during the acute phase of ischemic stroke is associated with brain injury and poor stroke outcome. Stroke. 2004;35:520–7.CrossRefPubMed

22.

• Jauch EC, Saver JL, Adams HP, et al. Guidelines for the early management of patients with acute ischemic stroke: a guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke. 2013;44:870–947. This publication enumerates the current guidelines from the American Stroke Association on the initial inpatient management of ischemic strokeCrossRefPubMed

23.

Chalela JA, Dunn B, Todd JW, Warach S. Induced hypertension improves cerebral blood flow in acute ischemic stroke. Neurology. 2005;64:1979.CrossRefPubMed

24.

Georgiadis AL, Al-kawi A, Janjua N, Kirmani JF. Cerebral angiography can demonstrate changes in collateral flow during induced hypertension. Radiol Case Reports. 2007;2:3–5.CrossRef

25.

Koenig MA, Geocadin RG, de Grouchy M, Glasgow J, Vimal S, Restrepo L, Wityk RJ. Safety of induced hypertension therapy in patients with acute ischemic stroke. Neurocrit Care. 2006;4:3–7.CrossRefPubMed

26.

Hillis AE, Ulatowski JA, Barker PB, Torbey M, Ziai W, Beauchamp NJ, Oh S, Wityk RJ. A pilot randomized trial of induced blood pressure elevation: effects on function and focal perfusion in acute and subacute stroke. Cerebrovasc Dis. 2003;16:236–46.CrossRefPubMed

27.

• Hacke W, Kaste M, Fieschi C, et al. Intravenous thrombolysis with recombinant tissue plasminogen activator for acute hemispheric stroke. The European cooperative acute stroke study (ECASS). JAMA. 1995;274:1017–25. This landmark trial demonstrated the efficacy of intravenous tPA in treating acute ischemic strokeCrossRefPubMed

28.

• The National Institute of Neurological Disorders and Stroke rt-PA Stroke Study Group. Tissue plasminogen activator for acute ischemic stroke. N Engl J Med. 1995;333:1581–7. This landmark trial demonstrated the efficacy of intravenous tPA in treating acute ischemic strokeCrossRef

29.

Battey TW, Karki M, Singhal AB, Wu O, Sadaghiani S, Campbell BC, Davis SM, Donnan GA, Sheth KN, Kimberly WT. Brain edema predicts outcome after nonlacunar ischemic stroke. Stroke. 2014;45:3643–8.CrossRefPubMedPubMedCentral

30.

• Wijdicks EFM, Sheth KN, Carter BS, Greer DM, Kasner SE, Kimberly WT, Schwab S, Smith EE, Tamargo RJ, Wintermark M. Recommendations for the management of cerebral and cerebellar infarction with swelling: a statement for healthcare professionals from the American Heart Association/American Stroke Association. Stroke. 2014;45:1222–38. These are the guidelines from the American Stroke Association on the management of post-stroke cerebral edema, a common stroke complication managed in the ICUCrossRefPubMed

31.

Wijdicks EF, Diringer MN. Middle cerebral artery territory infarction and early brain swelling: progression and effect of age on outcome. Mayo Clin Proc. 1998;73:829–36.CrossRefPubMed

32.

Krieger DW, Demchuk A, Kasner SE, Jauss M, Hantson L. Early clinical and radiological predictors of fatal brain swelling in ischemic stroke. Stroke. 1999;30:287–92.CrossRefPubMed

33.

Cucchiara BL, Kasner SE, Wolk DA, Lyden PD, Knappertz VA, Ashwood T, Odergren T, Nordlund A. Early impairment in consciousness predicts mortality after hemispheric ischemic stroke. Crit Care Med. 2004;32:241–5.CrossRefPubMed

34.

Kasner SE, Demchuk AM, Berrouschot J, et al. Predictors of fatal brain edema in massive hemispheric ischemic stroke. Stroke. 2001;32:2117–23.CrossRefPubMed

35.

Thomalla G, Hartmann F, Juettler E, et al. Prediction of malignant middle cerebral artery infarction by magnetic resonance imaging within 6 hours of symptom onset: a prospective multicenter observational study. Ann Neurol. 2010;68:435–45.CrossRefPubMed

36.

Kruetzelmann A, Hartmann F, Beck C, et al. Combining magnetic resonance imaging within six-hours of symptom onset with clinical follow-up at 24 h improves prediction of “malignant” middle cerebral artery infarction. Int J Stroke. 2014;9:210–4.CrossRefPubMed

37.

Bevers MB, Vaishnav NH, Pham L, Battey TW, Kimberly WT (2016) Hyperglycemia is associated with more severe cytotoxic injury after stroke. J Cereb Blood Flow Metab 0271678X16671730

38.

Helbok R, Olson DM, Le Roux PD, Vespa P. Intracranial pressure and cerebral perfusion pressure monitoring in non-TBI patients: special considerations. Neurocrit Care. 2014;21(Suppl 2):S85–94.CrossRefPubMed

39.

Paldor I, Rosenthal G, Cohen JE, Leker R, Harnof S, Shoshan Y, Itshayek E. Intracranial pressure monitoring following decompressive hemicraniectomy for malignant cerebral infarction. J Clin Neurosci. 2015;22:79–82.CrossRefPubMed

40.

Parienti J-J, Mongardon N, Mégarbane B, et al. Intravascular complications of central venous catheterization by insertion site. N Engl J Med. 2015;373:1220–9.CrossRefPubMed

41.

Ryu JH, Walcott BP, Kahle KT, Sheth SA, Peterson RT, Nahed BV, Coumans JVCE, Simard JM. Induced and sustained hypernatremia for the prevention and treatment of cerebral edema following brain injury. Neurocrit Care. 2013;19:222–31.CrossRefPubMed

42.

Fisher LA, Ko N, Miss J, Tung PP, Kopelnik A, Banki NM, Gardner D, Smith WS, Lawton MT, Zaroff JG. Hypernatremia predicts adverse cardiovascular and neurological outcomes after SAH. Neurocrit Care. 2006;5:180–5.CrossRefPubMed

43.

Kamel H, Navi BB, Nakagawa K, Hemphill JC, Ko NU. Hypertonic saline versus mannitol for the treatment of elevated intracranial pressure—a meta-analysis of randomized clinical trials. Crit Care Med. 2011;39:554–9.CrossRefPubMed

44.

Jüttler E, Schwab S, Schmiedek P, Unterberg A, Hennerici M, Woitzik J, Witte S, Jenetzky E, Hacke W. Decompressive surgery for the treatment of malignant infarction of the middle cerebral artery (DESTINY): a randomized, controlled trial. Stroke (00392499). 2007;38:2518–25.CrossRef

45.

• Vahedi K, Hofmeijer J, Juettler E, et al. Early decompressive surgery in malignant infarction of the middle cerebral artery: a pooled analysis of three randomised controlled trials. Lancet Neurol. 2007;6:215–22. This is a pooled analysis of three trials of hemicraniectomy for malignant middle cerebral artery infarction demonstrating survival and outcome benefit of decompressive surgeryCrossRefPubMed

46.

Hofmeijer J, Kappelle LJ, Algra A, Amelink GJ, van Gijn J, van der Worp HB. Surgical decompression for space-occupying cerebral infarction (the hemicraniectomy after middle cerebral artery infarction with life-threatening edema trial [HAMLET]): a multicentre, open, randomised trial. Lancet Neurol. 2009;8:326–33.CrossRefPubMed

47.

Jüttler E, Unterberg A, Woitzik J, et al. Hemicraniectomy in older patients with extensive middle-cerebral-artery stroke. N Engl J Med. 2014;370:1091–100.CrossRefPubMed

48.

St Louis EK, Wijdicks EF, Li H. Predicting neurologic deterioration in patients with cerebellar hematomas. Neurology. 1998;51:1364–9.CrossRefPubMed

49.

St Louis EK, Wijdicks EF, Li H, Atkinson JD. Predictors of poor outcome in patients with a spontaneous cerebellar hematoma. Can J Neurol Sci. 2000;27:32–6.PubMed

50.

Sheth KN, Elm JJ, Molyneaux BJ, et al. Safety and efficacy of intravenous glyburide on brain swelling after large hemispheric infarction (GAMES-RP): a randomised, double-blind, placebo-controlled phase 2 trial. Lancet Neurol. 2016;15:1160–9.CrossRefPubMed

51.

Terruso V, D’Amelio M, Di Benedetto N, et al. Frequency and determinants for hemorrhagic transformation of cerebral infarction. Neuroepidemiology. 2009;33:261–5.CrossRefPubMed

52.

Turner RJ, Sharp FR. Implications of MMP9 for blood brain barrier disruption and hemorrhagic transformation following ischemic stroke. Front Cell Neurosci. 2016;10:56.CrossRefPubMedPubMedCentral

53.

Piccardi B, Palumbo V, Nesi M, et al. Unbalanced metalloproteinase-9 and tissue inhibitors of metalloproteinases ratios predict hemorrhagic transformation of lesion in ischemic stroke patients treated with thrombolysis: results from the MAGIC study. Front Neurol. 2015;6:1–7.CrossRef

54.

Levy JH, Welsby I, Goodnough LT. Fibrinogen as a therapeutic target for bleeding: a review of critical levels and replacement therapy. Transfusion. 2014;54:1389–405.CrossRefPubMed

55.

Sarode R, Milling TJ, Refaai MA, Mangione A, Schneider A, Durn BL, Goldstein JN. Efficacy and safety of a 4-factor prothrombin complex concentrate in patients on vitamin K antagonists presenting with major bleeding: a randomized, plasma-controlled, phase IIIb study. Circulation. 2013;128:1234–43.PubMed

56.

Frontera J a., Gordon E, Zach V, Jovine M, Uchino K, Hussain MS, Aledort L (2014) Reversal of coagulopathy using prothrombin complex concentrates is associated with improved outcome compared to fresh frozen plasma in warfarin-associated intracranial hemorrhage. Neurocrit Care 397–406

57.

Pollack CV, Reilly P a, Eikelboom J, et al. Idarucizumab for dabigatran reversal. N Engl J Med. 2015:1–10.

58.

Frontera JA, Lewin JJ, Rabinstein AA, et al. Guideline for reversal of antithrombotics in intracranial hemorrhage: a statement for healthcare professionals from the Neurocritical Care Society and Society of Critical Care Medicine. Neurocrit Care. 2016;24:6–46.CrossRefPubMed

59.

Antihypertensive Treatment of Acute Cerebral Hemorrhage (ATACH) Investigators. Antihypertensive treatment of acute cerebral hemorrhage. Crit Care Med. 2010;38:637–48.CrossRef

60.

Anderson CS, Huang Y, Wang JG, et al. Intensive blood pressure reduction in acute cerebral haemorrhage trial (INTERACT): a randomised pilot trial. Lancet Neurol. 2008;7:391–9.CrossRefPubMed

61.

Mendelow AD, Gregson BA, Fernandes HM, Murray GD, Teasdale GM, Hope DT, Karimi A, Shaw MD, Barer DH. Early surgery versus initial conservative treatment in patients with spontaneous supratentorial Intracerebral hematomas in the international surgical trial in Intracerebral hemorrhage (STICH): a randomized trial. Lancet. 2005;14:41.

62.

Mendelow AD, Gregson BA, Rowan EN, Murray GD, Gholkar A, Mitchell PM. Early surgery versus initial conservative treatment in patients with spontaneous supratentorial lobar intracerebral haematomas (STICH II): a randomised trial. Lancet. 2013;382:397–408.CrossRefPubMedPubMedCentral

63.

• Chinese Acute Stroke Trial Collaborative Group (1997) CAST: randomised placebo-controlled trial of early aspirin use in 20 000 patients with acute ischaemic stroke. 349:1641–1649. One of two key trials establishing the efficacy of aspirin to prevent recurrent stroke

64.

• The International Stroke Trial Collaborative Group. The international stroke trial (IST): a randomised trial of aspirin, subcutaneous heparin, both, or neither among 19 435 patients with acute ischaemic stroke. Lancet. 1997;349:1569–81. One of two key trials establishing the efficacy of aspirin to prevent recurrent strokeCrossRef

65.

Howard G, McClure L a, Krakauer JW, Coffey CS. Stroke and the statistics of the aspirin/clopidogrel secondary prevention trials. Curr Opin Neurol. 2007;20:71–7.PubMed

66.

Johnston SC, Amarenco P, Albers GW, et al. Ticagrelor versus aspirin in acute stroke or transient ischemic attack. New Engl J Med. 2016;375:35–43.CrossRefPubMed

67.

Wang YY, Zhao X, Liu L, et al. Clopidogrel with aspirin in acute minor stroke or transient ischemic attack. N Engl J Med. 2013;369:11–9.CrossRefPubMed

68.

Derdeyn CP, Chimowitz MI, Lynn MJ, et al. Aggressive medical treatment with or without stenting in high-risk patients with intracranial artery stenosis (SAMMPRIS): the final results of a randomised trial. Lancet. 2014;383:333–41.CrossRefPubMed

69.

Berge E, Abdelnoor M, Nakstad PH, Sandset PM. Low molecular-weight heparin versus aspirin in patients with acute ischaemic stroke and atrial fibrillation: a double-blind randomised study. Lancet. 2000;355:1205–10.CrossRefPubMed

70.

The TOAST Investigators. Low molecular weight heparinoid, ORG 10172 (danaparoid), and outcome after acute ischemic stroke: a randomized controlled trial. The publications Committee for the Trial of ORG 10172 in acute stroke treatment (TOAST) investigators. JAMA. 1998;279:1265–72.CrossRef

71.

Markus HS, Hayter E, Levi C, et al. Antiplatelet treatment compared with anticoagulation treatment for cervical artery dissection (CADISS): a randomised trial. Lancet Neurol. 2015;14:361–7.CrossRefPubMed

72.

Molina CA, Alvarez-Sabín J, Schonewille W, Montaner J, Rovira A, Abilleira S, Codina A. Cerebral microembolism in acute spontaneous internal carotid artery dissection. Neurology. 2000;55:1738–40.CrossRefPubMed

73.

Leung TW, Wabnitz M, Miao Z, Chimowitz I. Angioplasty and Stenting. 2016;40:152–63.

74.

Schonewille WJ, Wijman CAC, Michel P, et al. Treatment and outcomes of acute basilar artery occlusion in the basilar artery international cooperation study (BASICS): a prospective registry study. Lancet Neurol. 2009;8:724–30.CrossRefPubMed

75.

Prasad K, Krishnan PR. Fever is associated with doubling of odds of short-term mortality in ischemic stroke: an updated meta-analysis. Acta Neurol Scand. 2010;122:404–8.CrossRefPubMed

76.

Bruno A, Biller J, Adams HP, Clarke WR, Woolson RF, Williams LS, Hansen MD. Acute blood glucose level and outcome from ischemic stroke. Neurology. 1999;52:280.CrossRefPubMed

77.

Capes SE, Hunt D, Malmberg K, Pathak P, Gerstein HC. Stress hyperglycemia and prognosis of stroke in nondiabetic and diabetic patients: a systematic overview. Stroke. 2001;32:2426–32.CrossRefPubMed

78.

Murros K, Fogelholm R, Kettunen S, Vuorela AL, Valve J. Blood-glucose, glycosylated hemoglobin, and outcome of ischemic brain infarction. J Neurol Sci. 1992;111:59–64.CrossRefPubMed

79.

Weir CJ, Murray GD, Dyker AG, Lees KR. Is hyperglycaemia an independent predictor of poor outcome after acute stroke? Results of a long term follow up study. BMJ. 1997;314:1303.CrossRefPubMedPubMedCentral

80.

Stead LG, Gilmore RM, Bellolio MF, Mishra S, Bhagra A, Vaidyanathan L, Decker WW, Brown RD. Hyperglycemia as an independent predictor of worse outcome in non-diabetic patients presenting with acute ischemic stroke. Neurocrit Care. 2009;10:181–6.CrossRefPubMed

81.

Bruno A, Kent TA, Coull BM, Shankar RR, Saha C, Becker KJ, Kissela BM, Williams LS. Treatment of hyperglycemia in ischemic stroke (THIS): a randomized pilot trial. Stroke. 2008;39:384–9.CrossRefPubMed

82.

Gray CS, Hildreth AJ, Sandercock PA, O’Connell JE, Johnston DE, Cartlidge NEF, Bamford JM, James OF, Alberti KGMM. Glucose-potassium-insulin infusions in the management of post-stroke hyperglycaemia: the UK glucose insulin in stroke trial (GIST-UK). Lancet Neurol. 2007;6:397–406.CrossRefPubMed

83.

Johnston KC, Hall CE, Kissela BM, Bleck TP, Conaway MR. Glucose regulation in acute stroke patients (GRASP) trial: a randomized pilot trial. Stroke. 2009;40:3804–9.CrossRefPubMedPubMedCentral

84.

Bruno A, Durkalski VL, Hall CE, Juneja R, Barsan WG, Janis S, Meurer WJ, Fansler A, Johnston KC. The stroke hyperglycemia insulin network effort (SHINE) trial protocol: a randomized, blinded, efficacy trial of standard vs. intensive hyperglycemia management in acute stroke. Int J Stroke. 2014;9:246–51.CrossRefPubMed

85.

NICE-SUGAR Study Investigators. Intensive versus conventional glucose control in critically ill patients. N Engl J Med. 2009;360:1283–97.CrossRef

Title: Critical Care Management of Acute Ischemic Stroke
Authors: Matthew B. Bevers, MD, PhD
W. Taylor Kimberly, MD, PhD
Publication date: 01-06-2017
Publisher: Springer US
Published in: Current Treatment Options in Cardiovascular Medicine / Issue 6/2017
Print ISSN: 1092-8464
Electronic ISSN: 1534-3189
DOI: https://doi.org/10.1007/s11936-017-0542-6

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

Keynote webinar | Spotlight on medication adherence

Springer Medicine

Critical Care Management of Acute Ischemic Stroke

Opinion statement

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

Keynote webinar | Spotlight on medication adherence

Springer Medicine

Opinion statement

Please log in to get access to this content

Other articles of this Issue 6/2017

Invasive Hemodynamic Assessment of Patients with Heart Failure and Pulmonary Hypertension

Pulmonary Hypertension and Cancer: Etiology, Diagnosis, and Management

Cardiovascular Disease Prevention: The Role of Policy Interventions

Venous Compression Syndromes: a Review

Update on Treatment in Cardiac Sarcoidosis

Role of Imaging in Cardio-Oncology

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