Adult1 27 - 28

Chapter 27
Management of Patients With

Coronary Vascular Disorders
Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins

Coronary Atherosclerosis
• Atherosclerosis is the abnormal accumulation of lipid

deposits and fibrous tissue within arterial walls and
lumen.
• In coronary atherosclerosis, blockages and narrowing of
the coronary vessels reduce blood flow to the
myocardium.
• Cardiovascular disease is the leading cause of death in
the United States for men and women of all racial and
ethnic groups.
• Coronary artery disease (CAD) is the most prevalent
cardiovascular disease in adults.
Pathophysiology of Atherosclerosis

Coronary Arteries

Clinical Manifestations
• Symptoms are caused by myocardial ischemia

• Symptoms and complications are related to the location
and degree of vessel obstruction
• Angina pectoris (most common manifestation)
• Other symptoms: epigastria distress, pain that radiates
to jaw or left arm, SOB, atypical symptoms in women
• Myocardial infarction
• Heart failure
• Sudden cardiac death
Risk Factors for Coronary Artery Disease
(CAD)
• Refer to Chart 27-1

– Four modifiable risk factors cited as major
(cholesterol abnormalities, tobacco use, HTN, and
diabetes)
• Elevated LDL: primary target for cholesterol-lowering
medication
• Framingham risk calculator
• Metabolic syndrome
• hs-CRP (high-sensitivity C-reactive protein)

Prevention of CAD
• Control cholesterol
• Dietary measures
• Physical activity
• Medications
• Cessation of tobacco use
• Manage HTN
• Control diabetes

Cholesterol Medications
• Six types of lipid-lowering agents: affect the lipid

components somewhat differently (Table 27-2)
– 3-Hydroxy-3-methylglutaryl coenzyme A (HMG-CoA)
(or statins)
– Nicotinic acids
– Fibric acids (or fibrates)
– Bile acid sequestrants (or resins)
– Cholesterol absorption inhibitors
– Omega-3 acid-ethyl esters
Question
The nurse is caring for a patient with hypercholesterolemia

who has been prescribed atorvastatin (Lipitor). What
serum levels should be monitored in this patient?
A. Complete blood count (CBC)
B. Blood cultures
C. Na and K levels
D. Liver enzymes

Answer
D. Liver enzymes
Rationale: Atorvastatin (Lipitor) is an HMG-CoA reductase
inhibitor and is hepatotoxic. Therefore, liver enzymes
should be monitored in patients taking this medication.

Angina Pectoris
• A syndrome characterized by episodes or paroxysmal

pain or pressure in the anterior chest caused by
insufficient coronary blood flow
• Physical exertion or emotional stress increases
myocardial oxygen demand, and the coronary vessels are
unable to supply sufficient blood flow to meet the oxygen
demand
• Types of angina

Angina—Nursing Assessment
• May be described as tightness, choking, or a heavy
sensation
• Frequently retrosternal and may radiate to neck, jaw,
shoulders, back or arms (usually left)
• Anxiety frequently accompanies the pain
• Other symptoms may occur: dyspnea or shortness of
breath, dizziness, nausea, and vomiting
• The pain of typical angina subsides with rest or NTG
• Unstable angina is characterized by increased frequency
and severity and is not relieved by rest and NTG.
Requires medical intervention!

Gerontologic Considerations
• Diminished pain transition that occurs with aging may

affect presentation of symptoms
• “Silent” CAD
• Teach older adults to recognize their “chest pain–like”
symptoms (i.e., weakness)
• Pharmacologic stress testing; cardiac catheterization
• Medications should be used cautiously!

Treatment
• Treatment seeks to decrease myocardial oxygen demand

and increase oxygen supply
• Medications
• Oxygen
• Reduce and control risk factors
• Reperfusion therapy may also be done

Medications
• Nitroglycerin
• Beta-adrenergic blocking agents
• Calcium channel blocking agents
• Antiplatelet and anticoagulant medications
• Aspirin
• Clopidogrel and ticlopidine
• Heparin
• Glycoprotein IIB/IIIa agents

Question
The nurse is caring for a patient who has severe chest pain
after working outside on a hot day and is brought to the
emergency center. The nurse administers nitroglycerin to
help alleviate chest pain. What side effect should concern
the nurse the most?
A. Dry mucous membranes
B. Heart rate of 88 bpm
C. Blood pressure of 86/58 mm Hg
D. Complaints of headache

Answer
C. Blood pressure of 86/58 mm Hg

Rationale: Nitroglycerin dilates vessels in the body. Dilation
of the veins causes venous pooling of blood throughout the
body. As a result, less blood returns to the heart, and filling
pressure (preload) is reduced. If the patient is hypovolemic,
the decrease in filling pressure can cause a significant
decrease in cardiac output and blood pressure. This patient
was working outside on a hot day, and the possibility of
dehydration and hypovolemia should be considered. Dry
mucous membranes can cause poor absorption of sublingual
nitroglycerin but is not the most concerning. B and D are
insignificant findings.

Nursing Process: The Care of the Patient
With Angina Pectoris—Assessment
• Symptoms and activities, especially those that precede
and precipitate attacks
• Risk factors, lifestyle, and health promotion activities
• Patient and family knowledge
• Adherence to the plan of care

With Angina Pectoris—Diagnoses
• Risk for decreased cardiac tissue perfusion
• Anxiety related to cardiac symptoms and possible death
• Deficient knowledge about the underlying disease and
methods for avoiding complications
• Noncompliance, ineffective management of therapeutic
regimen related to failure to accept necessary lifestyle
changes

Collaborative Problems
• ACS, MI, or both

• Dysrhythmias and cardiac arrest (see Chapters 26 and
29)
• Heart failure (see Chapter 29)
• Cardiogenic shock (see Chapter 14)

With Angina Pectoris—Planning
• Goals
– Immediate and appropriate treatment of angina
– Prevention of angina
– Reduction of anxiety
– Awareness of the disease process
– Understanding of prescribed care and adherence to
the self-care program
– Absence of complications

With Angina Pectoris—Interventions
• Treat angina
• Reduce anxiety
• Prevent pain
• Educate patients about self-care
• Continuing care

Nursing Intervention—Treat Angina
• Priority!
• Patient is to stop all activity and sit or rest in bed (semi-
Fowler’s positing).
• Assess the patient while performing other necessary
interventions. Assessment includes VS, observation for
respiratory distress, and assessment of pain. In the
hospital setting, the ECG is assessed or obtained.
• Administer medications as ordered or by protocol, usually
NTG. Reassess pain and administer NTG up to three
doses.
• Administer oxygen 2 L/min by nasal cannula
Nursing Intervention: Reduce Anxiety
• Use a calm manner

• Stress-reduction techniques
• Patient teaching
• Addressing patient spiritual needs may assist in allaying
anxieties
• Address both patient and family needs

Nursing Intervention: Preventing Pain
• Identify level of activity that causes patients prodromal

S&S
• Plan activities accordingly
• Alternate activities with rest periods
• Teach patient and family

Nursing Intervention: Patient Teaching
• Balance activity with rest
• Follow prescribed exercise regimen
• Avoid exercising in extreme temperatures
• Use resources for emotional support (counselor)
• Avoid OTC medications that may increase HR or BP
before consulting with health care provider
• Stop using tobacco products (nicotine increases HR and
BP)
• Diet low in fat and high in fiber

Nursing Intervention: Patient Teaching
(cont’d)
• Medication teaching (carry NTG at all times!)
• Follow up with health care provider
• Report increase in S&S to provider
• Maintain normal BP and blood glucose levels

Acute Coronary Syndrome (ACS) and
Myocardial Infarction (MI)
• Emergent situation
• Characterized by an acute onset of myocardial ischemia
that results in myocardial death (i.e., MI) if definitive
interventions do not occur promptly.
• Although the terms coronary occlusion, heart attack, and
MI are used synonymously, the preferred term is MI.

Effects of Ischemia, Injury, and Infarction
on ECG

With ACS—Assessment
• Chest pain
– Occurs suddenly and continues despite rest and
medication
– Other S&S: SOB; C/O indigestion; nausea; anxiety;
cool, pale skin; increased HR, RR
• ECG changes
• ECG
• Lab studies: cardiac enzymes, troponin, creatine kinase,
myoglobin

With ACS—Diagnoses
• Acute pain related to increased myocardial oxygen
demand and decreased myocardial oxygen supply
• Risk for decreased cardiac tissue perfusion related to
reduced coronary blood flow
• Risk for imbalanced fluid volume
• Risk for ineffective peripheral tissue perfusion related to
decreased cardiac output from left ventricular
dysfunction
• Anxiety related to cardiac event and possible death
• Deficient knowledge about post-ACS self-care
Collaborative Problems
• Acute pulmonary edema (see Chapter 29)

• Heart failure (see Chapter 29)
• Cardiogenic shock (see Chapter 14)
• Dysrhythmias and cardiac arrest (see Chapters 26 and
29)
• Pericardial effusion and cardiac tamponade (see Chapter
29)

With ACS—Planning
• Goals:
– Relief of pain or ischemic signs (e.g., ST-segment
changes) and symptoms
– Prevention of myocardial damage
– Maintenance of effective respiratory function,
adequate tissue perfusion
– Adherence to the self-care program
– Early recognition of complications
With ACS—Nursing Interventions
• Relieve pain and S&S of ischemia
• Improve respiratory function
• Promote adequate tissue perfusion
• Reduce anxiety
• Monitor and manage potential complications
• Educate patient and family
• Provide continuing care

Nursing Management: ACS/MI
• Oxygen and medication therapy
• Frequent VS assessment
• Physical rest in bed with HOB elevated
• Relief of pain helps decrease workload of heart
• Monitor I&O and tissue perfusion
• Frequent position changes to prevent respiratory
complications
• Report changes in patient’s condition
• Evaluate interventions!

Invasive Coronary Artery Procedures
• Percutaneous transluminal coronary angioplasty (PTCA)

• Coronary artery stent
• Coronary artery bypass graft (CABG)
• Cardiac surgery

Percutaneous Coronary Intervention

Coronary Artery Bypass Grafts

Greater and Lesser Saphenous Veins Are
Commonly Used for Bypass Graft
Procedures

Cardiopulmonary Bypass System

Nursing Management: Patient Requiring
Invasive Cardiac Intervention
• Assessment of patient
• Reduce fear and anxiety
• Monitor and manage potential complications
• Provide patient education
• Maintain cardiac output
• Promote adequate gas exchange
• Maintain fluid and electrolyte balance
• Minimize sensory–perception imbalance

Nursing Management: Patient Requiring
Invasive Cardiac Intervention (cont’d)
• Relieve pain
• Maintain adequate tissue perfusion
• Maintain body temperature
• Promote health and community-based care

Question
The nurse is caring for a patient after cardiac surgery.

Which nursing intervention is appropriate to help prevent
complications arising from venous stasis?
A. Encourage crossing of legs.
B. Use pillows in the popliteal space to elevate the knees in
the bed.
C. Discourage exercising.
D. Apply sequential pneumatic compression devices as
prescribed.

Answer
D. Apply sequential pneumatic compression devices as

prescribed.
Rationale: Sequential pneumatic compression devices
should be used when prescribed to help prevent venous
stasis and clotting complications such as deep vein
thrombosis and pulmonary embolism. Patients should be
discouraged to cross their legs. Pillows should not be used
in the popliteal space to elevate the knees; rather, this
should be avoided. Exercises, passive and active, should be
encouraged.

Chapter 28
Management of Patients With

Structural, Infectious, and
Inflammatory Cardiac Disorders

Valvular Disorders
• Regurgitation: The valve does not close properly, and

blood backflows through the valve.
• Stenosis: The valve does not open completely, and blood
flow through the valve is reduced.
• Valve prolapse: The stretching of an atrioventricular
valve leaflet into the atrium during diastole

Valves of the Heart

Specific Valvular Disorders
• Mitral valve prolapse

• Mitral regurgitation
• Mitral stenosis
• Aortic regurgitation
• Aortic stenosis

Nursing Management: Valvular Heart
Disorders
• Patient education
• Monitor VS trends
• Monitor for complications
– Heart failure
– Dysrhythmias
– Other symptoms
• Medication schedule: education
• Daily weights: monitor for weight gain

Nursing Management: Valvular Heart
Disorders (cont’d)
• Plan activity with rest periods
• Sleep with HOB elevated

Question
The nurse is providing education for a client diagnosed with

mitral valve prolapse (MVP). What should be included in
the teaching plan? (Select all that apply.)
A. MVP is not hereditary.
B. Caffeine is tolerated in small amounts.
C. Avoid alcohol.
D. Stop use of tobacco products.
E. Prophylactic antibiotics are not prescribed before dental
procedures.

Answer
C. Avoid alcohol.
D. Stop use of tobacco products.
E. Prophylactic antibiotics are not prescribed before dental
procedures.
Rationale: MVP is hereditary, and caffeine should be
avoided.

Surgical Management:
Valvular Heart Disorders
• Valvuloplasty • Valve replacement
– Commissurotomy – Mechanical
– Balloon valvuloplasty – Tissue
– Annuloplasty – Bioprosthesis
– Leaflet repair – Homografts
– Chordoplasty – Autografts

Balloon Valvuloplasty

Annuloplasty Ring Insertion

Valve Leaflet Resection and Repair With
Ring Annuloplasty

Valve Replacement

Nursing Management: Valvuloplasty and
Valve Replacement
• Balloon valvuloplasty
– Monitor for heart failure and emboli
– Assess heart sounds every 4 hours
– Same care as after cardiac catheterization
• Surgical valvuloplasty or valve replacements
– Focus is hemodynamic stability and recovery from
anesthesia
– Frequent assessments with attention to neurologic,
respiratory, and cardiovascular systems
Nursing Management—Valvuloplasty and
Valve Replacement (cont’d)
• Patient education
– Anticoagulation therapy
– Prevention of infective endocarditis
– Follow up
– Repeat echocardiograms

Cardiomyopathy
• Cardiomyopathy is a series of progressive events that
culminates in impaired cardiac output and can lead to
heart failure, sudden death, or dysrhythmias.
• Types
– Restrictive cardiomyopathy
– Hypertrophic cardiomyopathy
– Arrhythmogenic cardiomyopathy
– Unclassified cardiomyopathies

Cardiomyopathies That Lead to
Congestive Heart Failure

Question
What is the main electrolyte involved in cardiomyopathy?

A. Calcium
B. Phosphorus
C. Potassium
D. Sodium

Answer
D. Sodium
Rationale: Sodium is the major electrolyte involved with
cardiomyopathy. Cardiomyopathy often leads to heart
failure, which develops, in part, from fluid overload. Fluid
overload is often associated with elevated sodium levels.

Nursing Process: The Patient With
Cardiomyopathy (Assessment)
• History (predisposing factors, family history)
• Chest pain
• Review of diet (Na reduction, vitamin supplements)
• Psychosocial history: impact on family, stressors,
depression
• Physical assessment: VS pulse pressure; pulsus
paradoxus; weight gain or loss; PMI; murmurs; S3 or S4;
pulmonary auscultation for crackles, JVD, and edema

Nursing Process: The Patient with
Cardiomyopathy (Nursing Diagnosis)
• Decreased cardiac output

• Risk for ineffective cardiac, cerebral, peripheral, and
renal tissue perfusion
• Impaired gas exchange
• Activity intolerance
• Anxiety
• Powerlessness
• Noncompliance with medication and diet therapies

Collaborative Problems and Potential
Complications
• Heart failure
• Ventricular dysrhythmias
• Atrial dysrhythmias
• Cardiac conduction defects
• Pulmonary or cerebral embolism
• Valvular dysfunction

Cardiomyopathy (Planning and Goals)
Goals
– Improvement or maintenance of cardiac output
– Increased activity tolerance
– Adherence to the self-care program
– Increased sense of power with decision making
– Absence of complications

Cardiomyopathy (Nursing Interventions)
• Improve cardiac output and peripheral blood flow
– Rest, positioning (legs down), supplemental O2,
medications, low Na diet, avoid dehydration
• Increase activity tolerance and improving gas exchange
– Cycle rest and activity, ensure patient recognizes
symptoms that indicate the need for rest
• Reduce anxiety
– Eradicate or alleviate perceived stressors, educate
family about diagnosis, assist with anticipatory
grieving
Cardiomyopathy (Nursing Interventions)
(cont’d)
• Decrease the sense of powerlessness
– Assist patients in identifying things that have been
lost (i.e., ability to play sports), assist patients in
identifying amount of control they still have left
• Promote home- and community-based care
– Educate patients about ways to balance lifestyle and
work while accomplishing therapeutic activities
– Assess patient and family and their adjustment to
lifestyle changes, educate family about CPR and
AEDs, establish trust
Cardiomyopathy (Evaluation)
• Maintain or improve cardiac function

– HR and RR WNL, decreased dyspnea and increased
comfort, maintain or improve gas exchange, absence
of weight gain, maintain or improve peripheral blood
flow
• Maintain or increase activity tolerance
– Carry out activities of daily living (e.g., brush teeth,
feed self), reports increased tolerance to activity

Cardiomyopathy (Evaluation) (cont’d)
• Reduce anxiety
– Discusses prognosis, verbalizes fears and concerns,
participates in support groups, demonstrates
appropriate coping mechanisms
• Decrease sense of powerlessness
– Identifies emotional response to diagnosis, discusses
control that he or she has
• Adhere to self-care program
– Takes medications as prescribed, modifies diet to
accommodate sodium and fluid recommendations,
modifies lifestyle, identifies S&S to be reported
Infectious Diseases of the Heart
• Any of the layers of the heart may be affected by an
infectious process.
• Diseases are named by the layer of the heart that is
affected.
• Diagnosis is made by patient symptoms and
echocardiogram.
• Blood cultures may be used to identify the infectious
agent and to monitor therapy.
• Treatment is with appropriate antimicrobial therapy.
Patients require teaching to complete the course of
appropriate antimicrobial therapy and require teaching
for infection prevention and health promotion.
Types of Infectious Disease of the Heart
• Rheumatic endocarditis
– Occurs most often in school-age children after group
A beta-hemolytic streptococcal pharyngitis; need to
promptly recognize and treat “strep” throat to
prevent rheumatic fever
• Infective endocarditis
– Usually develops in people with prosthetic heart
valves or structural cardiac defects; also occurs in
patients who are IV drug abusers and in those with
debilitating diseases, indwelling catheters, or
prolonged IV therapy

Types of Infectious Disease of the Heart
• Pericarditis
– Inflammation of the pericardium; many causes;
potential complications: pericardial effusion and
cardiac tamponade
• Myocarditis
– An inflammatory process involving the myocardium;
most common pathogens involved in myocarditis
tend to be viral; in endocarditis, they tend to be
bacterial; complications: cardiomyopathy and heart
failure

Clinical Manifestations: Infectious
Diseases of the Heart
• Fever
• New heart murmur, friction rub at left lower sternal
border (pericarditis)
• Osler nodes, Janeway lesions, Roth spots, and splinter
hemorrhages in nailbeds (Rheumatic)
• Cardiomegaly, heart failure, tachycardia, splenomegaly
• Fatigue, dyspnea, syncope, palpitations, chest pain
(myocarditis)
• Diagnostic tools: blood cultures, echocardiogram, CBC,
rheumatoid factor, ESR, CRP, urinalysis, ECG, cardiac
catheterization, CMR imaging, TEE, CT scan
Prevention
• Antibiotic prophylaxis before certain procedures

• Ongoing oral hygiene
• Female patients are advised NOT to use IUDs
• Meticulous care should be taken in patients “at risk” who
have catheters
• Catheters should be removed as soon as they are no
longer needed
• Immunizations

Question
A patient with restrictive cardiomyopathy taking digoxin

presents with symptoms of anorexia, nausea, vomiting,
headache, and malaise. What should the nurse expect to
be included in the plan of care for this patient?
A. The patient’s digoxin will be changed to nifedipine.
B. The patient’s digoxin dose will be decreased.
C. Nothing; these are signs of restrictive cardiomyopathy
that are expected.
D. The patient will be admitted to an ICU.

Answer
B. The patient’s digoxin dose will be decreased.
Rationale: Patients with restrictive cardiomyopathy are
sensitive to digitalis. Nurses must closely monitor these
patients for digitalis toxicity, which is evidenced by
dysrhythmia, anorexia, nausea, vomiting, headache, and
malaise. This patient presents with symptoms of digoxin
toxicity, so a decrease in dosage should be anticipated.
These patients should avoid nifedipine, and they do not
need to be admitted to the ICU.

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Chapter 27

Management of Patients With

Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins

• Atherosclerosis is the abnormal accumulation of lipid

Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins

Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins

• Symptoms are caused by myocardial ischemia

• Refer to Chart 27-1

Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins

Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins

• Six types of lipid-lowering agents: affect the lipid

The nurse is caring for a patient with hypercholesterolemia

Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins

Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins

• A syndrome characterized by episodes or paroxysmal

Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins

Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins

• Diminished pain transition that occurs with aging may

Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins

• Treatment seeks to decrease myocardial oxygen demand

Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins

Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins

Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins

C. Blood pressure of 86/58 mm Hg

Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins

Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins

Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins

• ACS, MI, or both

Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins

Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins

Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins

• Use a calm manner

Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins

• Identify level of activity that causes patients prodromal

Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins

Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins

Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins

Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins

Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins

Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins

• Acute pulmonary edema (see Chapter 29)

Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins

Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins

Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins

• Percutaneous transluminal coronary angioplasty (PTCA)

Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins

Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins

Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins

Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins

Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins

Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins

Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins

The nurse is caring for a patient after cardiac surgery.

Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins

D. Apply sequential pneumatic compression devices as

Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins

Management of Patients With

Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins

• Regurgitation: The valve does not close properly, and

Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins

Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins

• Mitral valve prolapse

Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins