Skip to main content
SpringerLink
Log in

Inpatient Pain Medicine Considerations in Patients with Heart Failure, Cardiac Arrhythmias, and Other Cardiac Conditions

  • Chapter
  • First Online:
Guide to the Inpatient Pain Consult

  • 799 Accesses

Abstract

Heart failure, cardiac arrhythmias, and other cardiovascular conditions are a significant cause of morbidity and mortality in the world. These patients represent a sizeable proportion of hospitalized individuals and can be challenging to treat from a pain management standpoint. Cardiac patients often have multiple comorbidities and are on many different medications prone to drug interactions that must be taken into consideration when developing a treatment plan. This chapter will provide a general overview of heart failure and cardiac arrhythmias, as well as the importance of pain control in this population. The pathophysiology of pain, patient specific risk factors, and diagnostic considerations will also be outlined. This chapter will cover treatment strategies for cardiac patients in the inpatient setting including pharmacological management, pain assessment tools, and potential medications to use with caution. Lastly, there will be a brief discussion on discharge planning and follow-up considerations.

This is a preview of subscription content, log in via an institution to check access.

Access this chapter

Log in via an institution
Chapter
USD 29.95
Price excludes VAT (USA)
  • Available as PDF
  • Read on any device
  • Instant download
  • Own it forever
eBook
USD 84.99
Price excludes VAT (USA)
  • Available as EPUB and PDF
  • Read on any device
  • Instant download
  • Own it forever
Softcover Book
USD 109.99
Price excludes VAT (USA)
  • Compact, lightweight edition
  • Dispatched in 3 to 5 business days
  • Free shipping worldwide - see info
Hardcover Book
USD 159.99
Price excludes VAT (USA)
  • Durable hardcover edition
  • Dispatched in 3 to 5 business days
  • Free shipping worldwide - see info

Tax calculation will be finalised at checkout

Purchases are for personal use only

Institutional subscriptions

Similar content being viewed by others

References

  1. Udeoji D, Shah A, Bharadwaj P, Katsiyiannis P, Schwarz E. Evaluation of the prevalence and severity of pain in patients with stable chronic heart failure. World J Cardiol. 2012;4:250–5. https://doi.org/10.4330/wjc.v4.i8.250.

    Article  PubMed  PubMed Central  Google Scholar 

  2. Alemzadeh-Amsari MJ, Ansari-Ramandi, Naderi N. Chronic pain in chronic heart failure: a review article. J Tehran Univ Heart Cent. 2017;12(2):49–56.

    Google Scholar 

  3. Roger V. Epidemiology of heart failure. Circ Res. 2013;113:649–59. https://doi.org/10.1161/CIRCRESAHA.113.300268.

    Article  CAS  Google Scholar 

  4. Yancy CW, Jessup M, Bozkurt B, Butler J, Casey DE Jr, Drazner MH, Fonarow GC, Geraci SA, Horwich T, Januzzi JL, Johnson MR, Kasper EK, Levy WC, Masoudi FA, McBride PE, McMurray JJV, Mitchell JE, Peterson PN, Riegel B, Sam F, Stevenson LW, Tang WHW, Tsai EJ, Wilkoff BL. 2013 ACCF/AHA guideline for the management of heart failure: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol. 2013;62:e147–239.

    Article  Google Scholar 

  5. Habal MV, Garan AR. Long-term management of end-stage heart failure. Best Pract Res Clin Anaesthesiol. 2017;31:153–66. https://doi.org/10.1016/j.bpa.2017.07.003.

    Article  PubMed  PubMed Central  Google Scholar 

  6. Metra M, Teerlink JR. Heart failure. Lancet. 2017;390:1981–95. https://doi.org/10.1016/S0140-6736(17)31071-1.

    Article  PubMed  Google Scholar 

  7. Khurshid S, Choi SH, Weng LC, Wang E, Trinquart L, Benjamin EJ, Ellinor PT, Lubitz SA. Frequency of cardiac rhythm abnormalities in a half million adults. Circ Arrhythm Electrophysiol. 2018;11:e006273. https://doi.org/10.1161/CIRCEP.118.006273.

    Article  PubMed  PubMed Central  Google Scholar 

  8. Fu D. Cardiac arrhythmias: diagnosis, symptoms, and treatments. Cell Biochem Biophys. 2015;73:291–6. https://doi.org/10.1007/s12013-015-0626-4.

    Article  CAS  PubMed  Google Scholar 

  9. Ehret GB, Voide C, Gex-Fabry M, et al. Drug-induced long QT syndrome in injection drug users receiving methadone: high frequency in hospitalized patients and risk factors. Arch Intern Med. 2006;166:1280–7. https://doi.org/10.1001/archinte.166.12.1280.

    Article  CAS  PubMed  Google Scholar 

  10. Shaiova L, Berger A, Blinderman CD, Eduardo B, Davis MP, Derby S, Inturrisi C, Kalman J, Mehta D, Pappagallo M, Perlov E. Consensus guideline on parenteral methadone use in pain and palliative care. Palliat Support Care. 2008;6:165–76. https://doi.org/10.1017/S1478951508000254.

    Article  PubMed  Google Scholar 

  11. Gan Q, Zhang FR, Zhou QF, Dai LY, Liu YH, Chai XC, Wu F, Shen WF. Clinical significance of pain in patients with chronic heart failure. Chin Med J. 2012;125(18):3223–7. https://doi.org/10.3760/cma.j.issn.0366-6999.2012.18.005.

    Article  CAS  PubMed  Google Scholar 

  12. Godfrey CM, Harrison MB, Friedberg E, Medves JM, Tranmer JE. The symptom of pain in individuals recently hospitalized for heart failure. J Cardiovasc Nurs. 2007;22(5):368–74.

    Article  Google Scholar 

  13. Evangelista LS, Berg J, Dracup K. Relationship between psychosocial variables and compliance in patients with heart failure. Heart Lung. 2001;30(4):294–301. https://doi.org/10.1067/mhl.2001.116011.

    Article  CAS  PubMed  Google Scholar 

  14. Schäfers M, Sommer C, Geis C, Hagenacker T, Vandenabeele P, Sorkin LS. Selective stimulation of either tumor necrosis factor receptor differentially induces pain behavior in vivo and ectopic activity in sensory neurons in vitro. Neuroscience. 2008;157:414–23. https://doi.org/10.1016/j.neuroscience.2008.08.067.

    Article  CAS  PubMed  Google Scholar 

  15. Figueroa-Romero C, Sadidi M, Feldman EL. Mechanisms of disease: the oxidative stress theory of diabetic neuropathy. Rev Endocr Metab Disord. 2008;9(4):301–14. https://doi.org/10.1007/s11154-008-9104-2.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  16. Tennant F. Treat the pain…save a heart. In: Practical pain management. 2011. https://www.practicalpainmanagement.com/pain/other/co-morbidities/treat-pain-save-heart. Accessed 25 Apr 2019.

  17. Liu W, Wang X, Mei Z, Gong J, Gao X, Zhao Y, Ma J, Xie F, Qian L. Chronic stress promotes the progression of pressure overload-induced cardiac dysfunction through inducing more apoptosis and fibrosis. Physiol Res. 2015;64:325–34.

    Article  CAS  Google Scholar 

  18. Goodlin S, Wingate S, Albert NM, Pressler SJ, Houser J, Kwon J, Chiong J, Storey P, Quill T, Teerlink J. Investigating pain in heart failure patients: the pain assessment, incidence, and nature in heart failure (PAIN-HF) study. J Card Fail. 2012;18(10):776–83. https://doi.org/10.1016/j.cardfail.2012.07.007.

    Article  PubMed  Google Scholar 

  19. Hongjie F, Weidong Y, Qiang Z, Hui C, Jun L, Junpeng W, Yang S, Xinhua H. Depression after heart failure and risk of cardiovascular and all-cause mortality: a meta-analysis. Prev Med. 2014;63:36–42. https://doi.org/10.1016/j.ypmed.2014.03.007.

    Article  Google Scholar 

  20. Merskey H, Bogduk N. IASP terminology. Part III: pain terms, a current list with definitions and notes on usage. In: Classification of chronic pain. 2nd ed. Washington: IASP; 1994. p. 209–14.

    Google Scholar 

  21. Light-McGroary KA, Goodlin SJ. The challenges of understanding and managing pain in the heart failure patient. Curr Opin Support Palliat Care. 2013;7:14–20. https://doi.org/10.1097/SPC.0b013e32835c1f2f.

    Article  PubMed  Google Scholar 

  22. Gilron I, Baron R, Jensen T. Neuropathic pain: principles of diagnosis and treatment. Mayo Clin Proc. 2015;90(4):532–45. https://doi.org/10.1016/j.mayocp.2015.01.018.

    Article  CAS  PubMed  Google Scholar 

  23. Lewis KS, Whipple JK, Michael KA, Quebbeman EJ. Effect of analgesic treatment on the physiological consequences of acute pain. Am J Health Syst Pharm. 1994;51:1539–54.

    Article  CAS  Google Scholar 

  24. Deyo RA, Tsui-Wu Y-J. Descriptive epidemiology of low-back pain and its related medical care in the United States. Spine. 1987;12:264–8.

    Article  CAS  Google Scholar 

  25. Jaffe RA, Schmiesing CA, Golianu B. Anesthesiologists manual of surgical procedures. Philadelphia: Wolters Kluwer; 2020.

    Google Scholar 

  26. Quibell R, Prommer EE, Mihalyo M, Twycross R, Wilcock A. Ketamine∗. J Pain Symptom Manag. 2011;41:640–9.

    Article  CAS  Google Scholar 

  27. Buvanendran A, Kroin K. Multimodal analgesia for controlling acute postoperative pain. Acute Pain. 2009;11:145–6.

    Article  Google Scholar 

  28. Kandil E, Melikman E, Adinoff B. Lidocaine infusion: a promising therapeutic approach for chronic pain. J Anesth Clin Res. 2017;08:697. https://doi.org/10.4172/2155-6148.1000697.

    Article  CAS  Google Scholar 

  29. Farag E, Ghobrial M, Sessler DI, Dalton JE, Liu J, Lee JH, Zaky S, Benzel E, Bingaman W, Kurz A. Effect of perioperative intravenous lidocaine administration on pain, opioid consumption, and quality of life after complex spine surgery. Anesthesiology. 2013;119:932–40.

    Article  CAS  Google Scholar 

  30. Mcdaid C, Maund E, Rice S, Wright K, Jenkins B, Woolacott N. Paracetamol and selective and non-selective non-steroidal anti-inflammatory drugs (NSAIDs) for the reduction of morphine-related side effects after major surgery: a systematic review. Health Technol Assess. 2010;14:1–153, iii–iv. https://doi.org/10.3310/hta14170.

  31. Cronin B, Kaplan JA, Maus T. Kaplans essentials of cardiac anesthesia for cardiac surgery. Philadelphia: Elsevier; 2018.

    Google Scholar 

  32. Galvagno SM Jr, Smith CE, Varon AJ, Hasenboehler EA, Sultan S, Shaefer G, To KB, Fox AD, Alley DE, Ditillo M, Joseph BA, Robinson BR, Haut ER. Pain management for blunt thoracic trauma: A joint practice management guideline from the Eastern Association for the Surgery of Trauma and Trauma Anesthesiology Society. J Trauma Acute Care Surg. 2016;81(5):936–51.

    Google Scholar 

  33. Wink J, Veering BT, Aarts LPHJ, Wouters PF. Effects of thoracic epidural anesthesia on neuronal cardiac regulation and cardiac function. Anesthesiology. 2019;130:472–91.

    Article  Google Scholar 

  34. Kim MC, et al. Refractory angina pectoris: mechanism and therapeutic options. J Am Coll Cardiol. 2002;39(6):923–34.

    Article  Google Scholar 

  35. Lo J(C-C), et al. Usefulness of stellate ganglion block for refractory angina pectoris. Baylor Univ Med Cent Proc. 2018;31(3):370–1. https://doi.org/10.1080/08998280.2018.1463040.

    Article  Google Scholar 

  36. Moore R, et al. Temporary sympathectomy in the treatment of chronic refractory angina. J Pain Symptom Manag. 2005;30(2):183–91. https://doi.org/10.1016/j.jpainsymman.2005.02.016.

    Article  Google Scholar 

  37. 2016 AHA/ACC guideline on the management of patients with lower extremity peripheral artery disease: a report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. Circulation;135(12):e791-e792. https://doi.org/10.1161/cir.0000000000000502.

  38. Reilly MP, Mohler ER. Cilostazol: treatment of intermittent claudication. Ann Pharmacother. 2001;35:48–56.

    Article  CAS  Google Scholar 

  39. Pilowsky I, Hallett EC, Bassett DL, Thomas PG, Penhall RK. A controlled study of amitriptyline in the treatment of chronic pain. Pain. 1982;14:169–79.

    Article  CAS  Google Scholar 

  40. Godfrey RG. A guide to the understanding and use of tricyclic antidepressants in the overall management of fibromyalgia and other chronic pain syndromes. Arch Intern Med. 1996;156:1047–52.

    Article  CAS  Google Scholar 

  41. Dworkin RH, O’Connor AB, Backonja M, et al. Pharmacologic management of neuropathic pain: evidence-based recommendations. Pain. 2007;132(3):237–51. https://doi.org/10.1016/j.pain.2007.08.033.

    Article  CAS  PubMed  Google Scholar 

  42. Feng MR, Turluck D, Burleigh J, Lister R, Fan C, Middlebrook A, Taylor C, Su T. Brain microdialysis and PK/PD correlation of pregabalin in rats. Eur J Drug Metab Pharmacokinet. 2001;26:123–8.

    Article  CAS  Google Scholar 

  43. Freynhagen R, Bennett MI. Diagnosis and management of neuropathic pain. BMJ. 2009. 2009;339:b3002. https://doi.org/10.1136/bmj.b3002.

    Article  CAS  PubMed  Google Scholar 

  44. Barr J, et al. Clinical practice guidelines for the management of pain, agitation, and delirium in adult patients in the intensive care unit. Crit Care Med. 2013;41:263–306.

    Article  Google Scholar 

  45. Ivankovich AD, Miletich DJ, Reimann C, Albrecht RF, Zahed B. Cardiovascular effects of centrally administered ketamine in goats. Surv Anesthesiol. 1975;19:510–1. https://doi.org/10.1097/00132586-197512000-00010.

    Article  Google Scholar 

  46. Pagel PS, Kampine JP, Schmeling WT, Warltier DC. Ketamine depresses myocardial contractility as evaluated by the preload Recruitable stroke work relationship in chronically instrumented dogs with autonomic nervous system blockade. Anesthesiology. 1992;76:564–72.

    Article  CAS  Google Scholar 

  47. Zafirova Z, Rubin L. Anesthesia for patients with pulmonary hypertension or right heart failure. https://www.uptodate.com/contents/anesthesia-for-patients-with-pulmonary-hypertension-or-right-heart-failure. 2019.

  48. Murray MJ, Harrison BA, Mueller JT, Rose SH, Wass CT, Wedel DJ. Fausts anesthesiology review. Amsterdam: Elsevier Health Sciences; 2014.

    Google Scholar 

  49. Erdoan G, Ceyhan D, Güleç S. Possible heart failure associated with pregabalin use: case report. ARI. 2011;23(2):80–3. https://doi.org/10.5505/agri.2011.35119.

  50. Murphy N, Mockler M, Ryder M, Ledwidge M, McDonald K. Decompensation of chronic heart failure associated with pregabalin in patients with neuropathic pain. J Card Fail. 2007;13(3):227–9. https://doi.org/10.1016/j.cardfail.2006.11.006.

    Article  PubMed  Google Scholar 

  51. De Smedt RHE, Jaarsma T, van den Broek SAJ, Haaijer-Ruskamp FM. Decompensation of chronic heart failure associated with pregabalin in a 73-year-old patient with postherpetic neuralgia: a case report. Br J Clin Pharmacol. 2008;66(2):327–8. https://doi.org/10.1111/j.1365-2125.2008.03196.x.

    Article  PubMed  PubMed Central  Google Scholar 

  52. Page RL, Cantu M, Lindenfeld J, Hergott LJ, Lowes BD. Possible heart failure exacerbation associated with pregabalin: case discussion and literature review. J Cardiovasc Med. 2008;9:922–5.

    Article  Google Scholar 

  53. Gallagher R, Apostle N. Peripheral edema with pregabalin. CMAJ. 2013;185(10):E506. https://doi.org/10.1503/cmaj.121232.

    Article  PubMed  PubMed Central  Google Scholar 

  54. Page RL, O’Bryant CL, Cheng D, Dow TJ, Ky B, Stein CM, Spencer AP, Trupp RJ, Lindenfield J. Drugs that may cause or exacerbate heart failure. Circulation. 2016;134:e32–69. https://doi.org/10.1161/CIR/0000000000000426.

    Article  CAS  PubMed  Google Scholar 

  55. Colucci VJ, Berry BD. Heart failure worsening and exacerbation after venlafaxine and duloxetine therapy. Ann Pharmacother. 2008;42:882–7.

    Article  CAS  Google Scholar 

  56. Siepmann T, Ziemssen T, Mueck-Weymann M, Kirch W, Siepmann M. The effects of venlafaxine on autonomic functions in healthy volunteers. J Clin Psychopharmacol. 2007;27(6):687–91. https://doi.org/10.1097/jcp.0b013e31815a255b.

    Article  CAS  PubMed  Google Scholar 

  57. Howell C, Wilson AD, Waring WS. Cardiovascular toxicity due to venlafaxine poisoning in adults: a review of 235 consecutive cases. Br J Clin Pharmacol. 2007;64(2):192–7. https://doi.org/10.1111/j.1365-2125.2007.02849.x.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  58. Batista M, Dugernier T, Simon M, Haufroid V, Capron A, Fonseca S, Bonbled F, Hantson P. The spectrum of acute heart failure after venlafaxine overdose. Clin Toxicol. 2013;51:92–5. https://doi.org/10.3109/15563650.2012.763133.

    Article  CAS  Google Scholar 

  59. Vinetti M, Haufroid V, Capron A, Classen J, Marchandise S, Hantson P. Severe acute cardiomyopathy associated with venlafaxine overdose and possible role of CYP2D6 and CYP2C19 polymorphisms. Clin Toxicol. 2011;49:865–9. https://doi.org/10.3109/15563650.2011/626421/.

    Article  CAS  Google Scholar 

  60. Johnson EM, Whyte E, Mulsant BH, Pollock BG, Weber E, Begley AE, Reynolds CF. Cardiovascular changes associated with venlafaxine in the treatment of late-life depression. Am J Geriatr Psychiatry. 2006;14(9):796–802.

    Article  Google Scholar 

  61. Letsas K, Korantzopoulos P, Pappas L, Evangelou D, Efremidis M, Kardaras F. QT interval prolongation associated with venlafaxine administration. Int J Cardiol. 2006;109:116–7. https://doi.org/10.1016/j.ijcard.2005.03.065.

    Article  PubMed  Google Scholar 

  62. Reznik I, Rosen Y, Rosen B. An acute ischaemic event associated with the use of venlafaxine: a case report and proposed pathophysiological mechanisms. J Psychopharmacol. 1999;13(2):193–5.

    Article  CAS  Google Scholar 

  63. Wernicke J, Lledó A, Raskin J, Kajdasz D, Raskin J, Wang F. An evaluation of the cardiovascular safety profile of duloxetine. Drug Saf. 2007;30(5):437–55. https://doi.org/10.2165/00002018-200730050-00007.

    Article  CAS  PubMed  Google Scholar 

  64. Cymbalta-epar-scientific-discussion. In: EMEA. 2005. https://www.ema.europa.eu/en/documents/scientific-discussion/cymbalta-epar-scientific-discussion_en.pdf. Accessed 21 Sept 2019.

  65. Caughey GE, Cleland LG, Penglis PS, Gamble JR, James MJ. Roles of cyclooxygenase (COX)-1 and COX-2 in prostanoid production by human endothelial cells: selective up-regulation of prostacyclin synthesis by COX-2. J Immunol. 2001;167:2831–8.

    Article  CAS  Google Scholar 

  66. Cheng Y. Role of prostacyclin in the cardiovascular response to thromboxane A2. Science. 2002;296:539–41.

    Article  CAS  Google Scholar 

  67. Brown R. Methadone: applied pharmacology and use as adjunctive treatment in chronic pain. Postgrad Med J. 2004;80:654–9.

    Article  CAS  Google Scholar 

  68. Eap CB, Buclin T, Baumann P. Interindividual variability of the clinical pharmacokinetics of methadone. Clin Pharmacokinet. 2002;41:1153–93.

    Article  CAS  Google Scholar 

  69. Chou R, Cruciani RA, Fiellin DA, et al. Methadone safety: a clinical practice guideline from the American Pain Society and College on Problems of Drug Dependence, in collaboration with the Heart Rhythm Society. J Pain. 2014;15:321–37.

    Article  CAS  Google Scholar 

  70. Badulak A. Trends in reporting methadone-associated cardiac arrhythmia, 1997–2011: an analysis of registry data. J Emerg Med. 2013;45:483–4.

    Article  Google Scholar 

  71. Berul CI. Acquired long QT syndrome: Definitions, causes, and pathophysiology. https://www.uptodate.com/contents/acquired-long-qt-syndrome-definitions-causes-and-pathophysiology

  72. Thomas D, Karle C, Kiehn J. The cardiac hERG/IKr potassium channel as pharmacological target: structure, function, regulation, and clinical applications. Curr Pharm Des. 2006;12:2271–83.

    Article  CAS  Google Scholar 

  73. Nachimuthu S, Assar MD, Schussler JM. Drug-induced QT interval prolongation: mechanisms and clinical management. Ther Adv Drug Saf. 2012;3:241–53.

    Article  Google Scholar 

  74. Khan IA. Long QT syndrome: diagnosis and management. Am Heart J. 2002;143:7–14.

    Article  Google Scholar 

  75. Yang T, Roden DM. Extracellular potassium modulation of drug block of I Kr. Circulation. 1996;93:407–11.

    Article  CAS  Google Scholar 

  76. Groban L. Central nervous system and cardiac effects from long-acting amide local anesthetic toxicity in the intact animal model. Reg Anesth Pain Med. 2003;28:3–11.

    Article  CAS  Google Scholar 

  77. Morgan GE, Mikhail MS, Murray MJ. Clinical anesthesiology. New York: Lange Medical Books/McGraw-Hill; 2006.

    Google Scholar 

  78. Royse. A review of local anesthetic cardiotoxicity and treatment with lipid emulsion. Local Reg Anesth. 2010;3:11.

    Article  Google Scholar 

  79. Gitman M, Fettiplace MR, Weinberg G, Neal JM, Barrington MJ. Local anesthetic systemic toxicity. Plast Reconstr Surg. 2019;1.

    Google Scholar 

  80. Fernandes HS. Clonidine in anesthesiology: a brief review. Biomed J Sci Tech Res. 2018. https://doi.org/10.26717/bjstr.2018.07.001481.

  81. See S, Ginzburg R. Choosing a skeletal muscle relaxant. Am Fam Physician. 2008;78(3):365–70.

    PubMed  Google Scholar 

Download references

Author information

Authors and Affiliations

  1. University of Virginia Health System, Charlottesville, VA, USA

    Patrick Oley, Eryn Thiele & Lynn R. Kohan

Authors
  1. Patrick Oley
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Eryn Thiele
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Lynn R. Kohan
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Lynn R. Kohan .

Editor information

Editors and Affiliations

  1. Department of Anesthesiology, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA

    Alaa Abd-Elsayed

Rights and permissions

Reprints and permissions

Copyright information

© 2020 Springer Nature Switzerland AG

About this chapter

Check for updates. Verify currency and authenticity via CrossMark

Cite this chapter

Oley, P., Thiele, E., Kohan, L.R. (2020). Inpatient Pain Medicine Considerations in Patients with Heart Failure, Cardiac Arrhythmias, and Other Cardiac Conditions. In: Abd-Elsayed, A. (eds) Guide to the Inpatient Pain Consult. Springer, Cham. https://doi.org/10.1007/978-3-030-40449-9_6

Download citation

  • DOI: https://doi.org/10.1007/978-3-030-40449-9_6

  • Published:

  • Publisher Name: Springer, Cham

  • Print ISBN: 978-3-030-40448-2

  • Online ISBN: 978-3-030-40449-9

  • eBook Packages: MedicineMedicine (R0)

Publish with us

Policies and ethics

Search

Navigation