Skip to main content
SpringerLink
Log in

Glycemic Control in Coronary Revascularization

  • Coronary Artery Disease (D Feldman and V Voudris, Section Editors)
  • Published:
Current Treatment Options in Cardiovascular Medicine Aims and scope Submit manuscript

Opinion statement

Hyperglycemia in the setting of coronary revascularization is associated with increased adverse cardiovascular events in patients with or without diabetes mellitus. Data suggest that acute peri-procedural hyperglycemia causes an increase in inflammation, platelet activity, and endothelial dysfunction and is associated with plaque instability and infarct size. While peri-procedural blood glucose level is an independent predictor of adverse outcomes in patients undergoing coronary revascularization, treatment strategies remain uncertain. Randomized clinical trials of glucose-insulin-potassium infusions have consistently shown no benefit, while those comparing insulin therapy versus standard of care have demonstrated mixed results, likely due to the failure to reach euglycemia with these strategies. Although no glucose-lowering agent has been shown to be superior in peri-procedural glycemic control, the continuation of clinically prescribed long-acting glucose-lowering medications in patients with diabetes mellitus prior to coronary angiography and possible percutaneous coronary intervention may be the simplest and most effective approach to maintain euglycemia and decrease the associated increase in inflammation and platelet activity. However, alternative strategies such as therapies targeted at the underlying mechanism of harm (e.g., more potent anti-platelet therapy, anti-inflammatory therapy) should also be considered and warrant further investigation.

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

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Similar content being viewed by others

References and Recommended Reading

Papers of particular interest, published recently, have been highlighted as: • Of importance •• Of major importance

  1. http://www.diabetes.org/diabetes-basics/statistics/ (accessed 11/03/2015).

  2. Garcia MJ, McNamara PM, Gordon T, et al. Morbidity and mortality in diabetics in the Framingham population: sixteen year follow-up study. Diabetes. 1974;23:105–11.

    Article  CAS  PubMed  Google Scholar 

  3. Abizaid A, Kornowski R, Mintz GS, et al. The influence of diabetes mellitus on acute and late clinical outcomes following coronary stent implantation. J Am Coll Cardiol. 1998;32:584–9.

    Article  CAS  PubMed  Google Scholar 

  4. Elezi S, Kornowski R, Mintz GS, et al. Diabetes mellitus and the clinical and angiographic outcome after coronary stent placement. J Am Coll Cardiol. 1998;32:1866–73.

    Article  CAS  PubMed  Google Scholar 

  5. Chen PC, Chua SK, Hung HF, et al. Admission hyperglycemia predicts poorer short- and long-term outcomes after primary percutaneous coronary intervention for ST-elevation myocardial infarction. J Diabetes Investig. 2014;5:80–6. This single centered prospective observational study of 1035 patients undergoing primary PCI for STEMI demonstrates the association between acute hyperglycemia and poor short- and long-term outcome such as increased hospital stay, duration of ICU stay, increase morbidity and mortality, reinfarction and heart failure.

    Article  PubMed Central  PubMed  Google Scholar 

  6. Thiele RH, Hucklenbruch C, Ma JZ, Colquhoun, et al. Admission hyperglycemia is associated with poor outcome after emergent coronary bypass grafting surgery. J Crit Care. 2015;30:1210–6. This single centered retrospective analysis of admission hyperglycemia in 240 emergency CABG patients, demonstrates the association between peri-procedural hyperglycemia and increased in-hospital mortality in CABG patients.

    Article  CAS  PubMed  Google Scholar 

  7. Jneid H, Anderson JL, Wright RS, et al. 2012 ACCF/AHA focused update of the guideline for the management of patients with unstable angina/non–ST-elevation myocardial infarction (updating the 2007 guideline and replacing the 2011 focused update): a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. Circulation. 2012;126:875–910.

    Article  PubMed  Google Scholar 

  8. Malmberg K, Yusuf S, Gerstein HC, et al. Impact of diabetes on long-term prognosis in patients with unstable angina and non-Q-wave myocardial infarction: results of the OASIS (Organization to Assess Strategies for Ischemic Syndromes) Registry. Circulation. 2000;102:1014–9.

    Article  CAS  PubMed  Google Scholar 

  9. Franklin K, Goldberg RJ, Spencer F, et al. Implications of diabetes in patients with acute coronary syndromes. The Global Registry of Acute Coronary Events. Arch Intern Med. 2004;164:1457–63.

    Article  PubMed  Google Scholar 

  10. Singla A, Orshaw P, Boura J, et al. Glycosylated hemoglobin and outcomes in diabetic patients with acute myocardial infarction after successful revascularization with stent placement: findings from the Guthrie Health Off-Label Stent (GHOST) Investigators. J Interv Cardiol. 2012;25:262–9.

    Article  PubMed  Google Scholar 

  11. Norhammar A, Ryden L, Malmberg K, et al. Admission plasma glucose: independent risk factor for long term-prognosis after myocardial infarction even in nondiabetic patients. Diabetes Care. 1999;22:18–22.

    Article  Google Scholar 

  12. Straumann E, Kurz DJ, Muntwyler J, et al. Admission glucose concentrations independently predict early and late mortality in patients with acute myocardial infarction treated by primary or rescue percutaneous coronary intervention. Am Heart J. 2005;150:1000–6.

    Article  CAS  PubMed  Google Scholar 

  13. Celia T, Lylsoy A, Turban H, et al. Transient hyperglycemia in patients with acute myocardial infarction: time to define optimal glucose levels. Int J Cardiol. 2008;130:472–3.

    Article  Google Scholar 

  14. Lavi S, Kapelliovich M, Gruberg L, et al. Hyperglycemia during acute myocardial infarction in patients who are treated by primary percutaneous coronary intervention: impact on long-term prognosis. Int J Cardiol. 2008;123:117–22.

    Article  PubMed  Google Scholar 

  15. Ishihara M, Kojima S, Nakamoto T, et al. Comparison of blood glucose values on admission for acute myocardial infarction in patients with versus without diabetes mellitus. Am J Cardiol. 2009;104:769–74.

    Article  CAS  PubMed  Google Scholar 

  16. Cruz-Gonzalez I, Chia S, Raffel OC, et al. Hyperglycemia on admission predicts larger infarct size in patients undergoing percutaneous coronary intervention for acute ST-segment elevation myocardial infarction. Diabetes Res Clin Pract. 2010;88:97–102. The single-center prospective observational study of 347 STEMI patients undergoing primary PCI demonstrated that admission hyperglycemia is associated with increased infarct size as measured by SPECT imaging 5 days after PCI.

    Article  CAS  PubMed  Google Scholar 

  17. Nusca A, Patti G, Marino F, et al. Prognostic role of preprocedural glucose levels on short- and long-term outcome in patients undergoing percutaneous coronary revascularization. Catheter Cardiovasc Interv. 2012;80:377–84.

    Article  PubMed  Google Scholar 

  18. Capes SE, Hunt D, Malmberg K, et al. Stress hyperglycaemia and increased risk of death after myocardial infarction in patients with and without diabetes: a systematic overview. Lancet. 2000;355:773–8.

    Article  CAS  PubMed  Google Scholar 

  19. Székely A, Levin J, Miao Y, et al. Impact of hyperglycemia on perioperative mortality after coronary artery bypass graft surgery. J Thorac Cardiovasc Surgery. 2011;142:430–7.

    Article  Google Scholar 

  20. Stein B, Weintraub WS, Gebhart SP, et al. Influence of diabetes mellitus on early and late outcome after percutaneous transluminal coronary angioplasty. Circulation. 1995;91:979–89.

    Article  CAS  PubMed  Google Scholar 

  21. Laskey WK, Selzer F, Vlachos HA, et al. Comparison of in-hospital and one-year outcomes in patients with and without diabetes mellitus undergoing percutaneous catheter intervention (from the National Heart, Lung, and Blood Institute Dynamic Registry). Am J Cardiol. 2002;90:1062–7.

    Article  PubMed  Google Scholar 

  22. Shah B, Liou M, Grossi E, et al. Relation of elevated periprocedural blood glucose to long-term survival after percutaneous coronary intervention. Am J Cardiol. 2005;96:543–6.

    Article  CAS  PubMed  Google Scholar 

  23. Kauffman AB, Delate T, Olson KL, et al. Relationship between haemoglobin A1C values and recurrent cardiac events. Clin Drug Investig. 2008;28:501–7.

    Article  PubMed  Google Scholar 

  24. Lemesle G, Bonello L, de Labriolle A, et al. Prognostic value of hemoglobin A1C Levels in patients with diabetes mellitus undergoing percutaneous coronary intervention with stent implantation. Am J Cardiol. 2009;104:41–5.

    Article  CAS  PubMed  Google Scholar 

  25. Hasdai D, Rizza RA, Grill DE, et al. Glycemic control and outcome of diabetic patients after successful percutaneous coronary revascularization. Am Heart J. 2001;141:117–23.

    Article  CAS  PubMed  Google Scholar 

  26. Robertson BJ, Gaucho JA, Gabbay R, et al. Usefulness of hyperglycemia in predicting renal and myocardial injury in patients with diabetes mellitus undergoing percutaneous coronary intervention. Am J Cardiol. 2004;94:1027–9.

    Article  PubMed  Google Scholar 

  27. Lindsay J, Sharma AK, Canos D, et al. Preprocedure hyperglycemia is more strongly associated with restenosis in diabetic patients after percutaneous coronary intervention than is hemoglobin A1C. Cardiovasc Revasc Med. 2007;8:15–20.

    Article  PubMed  Google Scholar 

  28. Kuroda M, Shinke T, Sakaguchi K, et al. Effect of daily glucose fluctuation on coronary plaque vulnerability in patients pre-treated with lipid-lowering therapy: a prospective observational study. JACC Cardiovasc Interv. 2015;8:800–11. This prospective single-centered observational study of 70 CAD patients referred for PCI concluded that daily glucose fluctuation is associated with plaque vulnerability as measured by virtual histology intravascular ultrasound.

    Article  PubMed  Google Scholar 

  29. Nusca A, Lauria Pantano A, Melfi R, et al. Glycemic variability assessed by continuous glucose monitoring and short-term outcome in diabetic patients undergoing percutaneous coronary intervention: an observational pilot study. J Diabetes Res. 2015;2015:250201.

    Article  PubMed Central  PubMed  Google Scholar 

  30. Smith LR, Harrell Jr FE, Rankin JS, et al. Determinants of early versus late cardiac death in patients undergoing coronary artery bypass graft surgery. Circulation. 1991;84:III245–53.

    CAS  PubMed  Google Scholar 

  31. Calafiore AM, Di Mauro M, Di Giammarco G, et al. Effect of diabetes on early and late survival after isolated first coronary bypass surgery in multivessel disease. J Thorac Cardiovasc Surg. 2003;125:144–54.

    Article  PubMed  Google Scholar 

  32. McAlister FA, Man J, Bistriz L, et al. Diabetes and coronary artery bypass surgery: an examination of perioperative glycemic control and outcomes. Diabetes Care. 2003;26:1518–24.

    Article  PubMed  Google Scholar 

  33. Halkos ME, Lattouf OM, Puskas JD, et al. Elevated preoperative hemoglobin A1c level is associated with reduced long-term survival after coronary artery bypass surgery. Ann Thorac Surg. 2008;86:1431–7.

    Article  PubMed  Google Scholar 

  34. Ghosh P, Sahoo R, Vaidya A, et al. Role of complement and complement regulatory proteins in the complications of diabetes. Endocr Rev. 2015;36:272–88.

    Article  CAS  PubMed  Google Scholar 

  35. Qin X, Goldfine A, Krumrei N, et al. Glycation inactivation of the complement regulatory protein Cd59. Diabetes. 2004;53:2653–61.

    Article  CAS  PubMed  Google Scholar 

  36. Piga R, Naito Y, Kokura S, et al. Short-term high glucose exposure induces monocyte-endothelial cells adhesion and transmigration by increasing VCAM-1 and MCP-1 expression in human aortic endothelial cells. Atherosclerosis. 2007;193:328–34.

    Article  CAS  PubMed  Google Scholar 

  37. Morigi M, Angioletti S, Imberti B, et al. Leukocyte-endothelial interaction is augmented by high glucose concentrations and hyperglycemia in a NF-kB-dependent fashion. J Clin Invest. 1998;101:1905–15.

    Article  PubMed Central  CAS  PubMed  Google Scholar 

  38. Knudsen EC, Seljeflot I, Michael A, et al. Increased levels of CRP and MCP-1 are associated with previously unknown abnormal glucose regulation in patients with acute STEMI: a cohort study. Cardiovasc Diabetol. 2010;9:47.

    Article  PubMed Central  PubMed  Google Scholar 

  39. Fantin SD, Wainstein MV, Polanczyk CA, et al. Inflammatory and oxidative stress markers after intravenous insulin in percutaneous coronary intervention with stent in type 2 diabetes mellitus. J Clin Endocrinol Metab. 2015;96:478–85.

    Article  Google Scholar 

  40. Mellbin LG, Bjerre M, Thiel S, et al. Complement activation and prognosis in patients with type 2 diabetes and myocardial infarction: a report from the DIGAMI 2 trial. Diabetes Care. 2012;35:911–7.

    Article  PubMed Central  CAS  PubMed  Google Scholar 

  41. De La Cruz JP, Arrebola MM, Villalobos MA, et al. Influence of glucose concentration on the effects of aspirin, ticlopidine and clopidogrel on platelet function and platelet-subendothelium interaction. Eur J Pharmacol. 2004;484:19–27.

    Article  Google Scholar 

  42. Keating FK, Sobel BE, Schneider DJ. Effects of increased concentrations of glucose on platelet reactivity in healthy subjects and in patients with and without diabetes mellitus. Am J Cardiol. 2003;92:13–5.

    Article  Google Scholar 

  43. Yngen M, Norhammer A, Hjemdahl P, et al. Effects of improved metabolic control on platelet reactivity in patients with type 2 diabetes mellitus following coronary angioplasty. Diab Vasc Dis Res. 2006;3:52–6.

    Article  PubMed  Google Scholar 

  44. Davi G, Averna M, Catalano L, et al. Platelet functions in patients with type 2 diabetes mellitus; the effect of glycemic control. Diabetes Res. 1989;10:7–12.

    CAS  PubMed  Google Scholar 

  45. Shah B, Berger JS, Amoroso NS, et al. Periprocedural glycemic control in patients with diabetes mellitus undergoing coronary angiography with possible percutaneous coronary intervention. Am J Cardiol. 2014;113:1474–80. A single-centered randomized trial of 172 patients with type 2 DM undergoing coronary angiography with possible PCI that compared the effects of holding versus continuing long-acting glucose lowering medications. They concluded that continuing long-acting glucose lowering medication achieves euglycemia, seems safe, and lowers platelet activity prior to undergoing coronary angiography with possible PCI.

    Article  PubMed Central  PubMed  Google Scholar 

  46. Du XL, Edelstein D, Dimmeler S, et al. Hyperglycemia inhibits endothelial nitric oxide synthase activity by posttranslational modification at the Akt site. J Clin Invest. 2001;108:1341–048.

    Article  PubMed Central  CAS  PubMed  Google Scholar 

  47. La Sala L, Pujadas G, De Nigris V, et al. Oscillating glucose and constant high glucose induce endoglin expression in endothelial cells: The role of oxidative stress. Acta Diabetol. 2015;52:505–12.

    Article  PubMed  Google Scholar 

  48. De Nigris V, Pajamas G, La Sala L, et al. Short-term high glucose exposure impairs insulin signaling in endothelial cells. Cardiovasc Diabetol. 2015;14:114.

    Article  PubMed Central  PubMed  Google Scholar 

  49. Nakamura T, Ako J, Kadowaki T, et al. Impact of acute hyperglycemia during primary stent implantation in patients with ST-elevation myocardial infarction. J Cardiol. 2009;53:272–7.

    Article  PubMed  Google Scholar 

  50. Erdogan D, Akcay S, Yucel H, et al. The effects of good glycaemic control on left ventricular and coronary endothelial functions in patients with poorly controlled type 2 diabetes mellitus. Clin Endocrinol. 2015;82:388–96.

    Article  CAS  Google Scholar 

  51. Corpus RA, George P, House J, et al. Optimal glycemic control is associated with a lower rate of target vessel revascularization in treated type II diabetic patients undergoing elective percutaneous coronary intervention. J Am Coll Cardiol. 2004;43:8–14.

    Article  PubMed  Google Scholar 

  52. Aronson D, Bloomgarden Z, Rayfield EJ. Potential mechanisms promoting restenosis in diabetic patients. J Am Coll Cardiol. 1996;27:528–35.

    Article  CAS  PubMed  Google Scholar 

  53. Shah B, Burdowski J, Lobach I, et al. A risk score for prediction of hyperglycemia at coronary angiography. JACC Cardiovasc Interv. 2014;7:1199–201. A risk score assessment was developed in order to help predict the patient who will develop peri-procedural hyperglycemia at the time of coronary angiography.

    Article  PubMed Central  PubMed  Google Scholar 

  54. Sodi-Pallares D, Testelli MR, Fishkeder BL, et al. Effects of an intravenous infusion of potassium-glucose-insulin solution on electrocardiographic signs of myocardial infarction: a preliminary clinical report. Am J Cardiol. 1962;9:166–81.

    Article  CAS  PubMed  Google Scholar 

  55. Pentecost BL, Maybe NM, Lamb P, et al. Controlled trial of intravenous glucose, potassium, and insulin in acute myocardial infarction. Lancet. 1968;1:946–8.

    Article  CAS  PubMed  Google Scholar 

  56. Opie LH, Tansey M, Kennelly BM. Proposed metabolic vicious circle in patients with large myocardial infarction and high plasma free fatty acid concentrations. Lancet. 1977;2:890–2.

    Article  CAS  PubMed  Google Scholar 

  57. van der Horst IC, Zijlstra F, Van’t Hof AW, et al. Glucose-insulin-potassium infusion inpatients treated with primary angioplasty for acute myocardial infarction. J Am Coll Cardiol. 2003;42:784–91.

    Article  PubMed  Google Scholar 

  58. Yazici M, Demircan S, Durna K, et al. Effect of glucose-insulin-potassium infusion on myocardial damage due to percutaneous coronary revascularization. Am J Cardiol. 2005;96:1517–20.

    Article  CAS  PubMed  Google Scholar 

  59. Mehta SR, Yusuf S, Díaz R, et al. Effect of glucose-insulin-potassium infusion on mortality in patients with acute ST-segment elevation myocardial infarction: the CREATE-ECLA randomized controlled trial. JAMA. 2015;293:437–46. This international multicentered randomized clinical trial of 20,195 patients demonstrated that high-dose GIK in acute STEMI patients for 24 hours has a neutral effect on all-cause mortality at 30 day follow-up compared to the control group.

    Google Scholar 

  60. Mamas M, Neyses L, Fath-Ordoubadi F, et al. A meta-analysis of glucose-insulin-potassium therapy for treatment of acute myocardial infarction. Exp Clin Cardiol. 2010;15:30–24.

    Google Scholar 

  61. Lell WA, Nielsen VG, McGiffin DC, et al. Glucose-insulin-potassium infusion for myocardial protection during off-pump coronary artery surgery. Ann Thorac Surg. 2002;73:1246–51.

    Article  PubMed  Google Scholar 

  62. Wistbacka JO, Kaukoranta PK. Nuutinen. Prebypass glucose-insulin-potassium in elective nondiabetic coronary artery surgery patients. J Cardiothorac Vasc Anesth. 1992;6:521–7.

    Article  CAS  PubMed  Google Scholar 

  63. Ali-Hassan-Sayegh S, Mirhoseini SJ, Zeriouh M, et al. Safety and efficacy of glucose–insulin–potassium treatment in coronary artery bypass graft surgery and percutaneous coronary intervention. Interac Cardiovasc Thorac Surg. 2015;21:667–76. This meta-analysis reviewed the efficacy of low dose GIK treatment in 24,768 patients undergoing either CABG or PCI and concluded that there was no significant effect on re-MI, cardiogenic shock and cardiac arrest with low dose GIK.

    Article  Google Scholar 

  64. Ike A, Shirai K, Nishikawa H, et al. Associations between different types of hypoglycemic agents and the clinical outcome of percutaneous coronary intervention in diabetic patients—from the FU-Registry. J Cardiol. 2015;65:390–6.

    Article  PubMed  Google Scholar 

  65. Dangas GD, Farkouh ME, Sleeper LA, et al. Long-term outcome of PCI versus CABG in insulin and non-insulin-treated diabetic patients: results from the FREEDOM trial. J Am Coll Cardiol. 2014;64:1189–97. The multicenter, open label prospective randomized FREEDOM trial evaluated PCI versus CABG in 1,850 insulin treated diabetic patients and demonstrated that there was a higher rate of death, MI and stroke in patients treated with insulin than those not treated with insulin regardless of whether they undergo PCI or CABG.

    Article  CAS  PubMed  Google Scholar 

  66. Frye RL, August P, Brooks MM, et al. A randomized trial of therapies for type 2 diabetes and coronary artery disease. N Eng J Med. 2009;360:2503–15. This multicenter trial of 2368 patients with both stable CAD and type 2 DM randomized patients to either prompt revascularization with PCI or CABG or intensive medical therapy alone with insulin-sensitization or insulin-provision therapy, and demonstrated that there was no significant difference between initial treatment strategies.

    Article  CAS  Google Scholar 

  67. Malmberg K, Ryden L, Efendic S, et al. Randomized trial of insulin-glucose infusion followed by subcutaneous insulin treatment in diabetic patients with acute myocardial infarction (DIGAMI study): effects on mortality at 1 year. J Am Coll Cardiol. 1995;26:57–65. The multicenter randomized trial of 620 patients with DM and acute MI evaluated treatment with insulin-glucose infusion followed by subcutaneous insulin and demonstrated that higher admission blood glucose level predicted higher mortality and that patients randomized to the insulin treatment arm had a significantly lower rate of mortality.

    Article  CAS  PubMed  Google Scholar 

  68. Malmberg K, Rydén L, Wedel H, et al. Intense metabolic control by means of insulin in patients with diabetes mellitus and acute myocardial infarction (DIGAMI 2): effects on mortality and morbidity. Eur Heart J. 2005;26:650–61. Multicenter prospective randomized open trial of 1253 patients with DM and AMI assigned to either group 1, acute insulin-glucose infusion followed by insulin based long-term glucose control; group 2, insulin-glucose infusion followed by standard glucose control; or group 3, routine metabolic management according to local practice. This study did not show any benefit in the composite endpoint of death, non-fatal MI or stroke. However, it did show glucose level as a strong independent predictor in long term mortality in this patient population and the treatment groups never reached target glucose levels.

    Article  CAS  PubMed  Google Scholar 

  69. Shah B, Danoff A, Sedlis S, et al. Periprocedural management of the patient with diabetic patient undergoing coronary angiography: current practice. Arch Intern Med. 2012;172:1514–46. An anonymous electronic survey of cardiologists referring patients for coronary angiography concluded that there is considerable variability in the management of long-acting glucose-lowering medications prior to procedure in patients with DM.

    Article  PubMed Central  PubMed  Google Scholar 

Download references

Author information

Authors and Affiliations

  1. VA New York Harbor Healthcare System, Manhattan Campus, New York, NY, USA

    Francisco Ujueta MD, MS, Ephraim N. Weiss MD, Steven P. Sedlis MD & Binita Shah MD, MS

  2. New York University School of Medicine, New York, NY, 10016, USA

    Francisco Ujueta MD, MS, Ephraim N. Weiss MD, Steven P. Sedlis MD & Binita Shah MD, MS

Authors
  1. Francisco Ujueta MD, MS
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Ephraim N. Weiss MD
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Steven P. Sedlis MD
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Binita Shah MD, MS
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Binita Shah MD, MS.

Ethics declarations

Conflict of Interest

The authors declare that they have no competing interests.

Human and Animal Rights and Informed Consent

This article does not contain any studies with human or animal subjects performed by any of the authors.

Additional information

This article is part of the Topical Collection on Coronary Artery Disease

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Ujueta, F., Weiss, E.N., Sedlis, S.P. et al. Glycemic Control in Coronary Revascularization. Curr Treat Options Cardio Med 18, 12 (2016). https://doi.org/10.1007/s11936-015-0434-6

Download citation

  • Published:

  • DOI: https://doi.org/10.1007/s11936-015-0434-6

Keywords

Search

Navigation